Pilates for knee maintenance post competitive sport training.

Melanie Schoeman

7th January 2019

Comprehensive Teacher Training Course

Body Arts & Science International

Mooikloof, Pretoria, South Africa

Abstract

Often we ignore injuries we receive from competing in competitive sports, & the consequence we

will inevitably suffer later in life. Those who continue to reap the benefits of sports inevitably think

sacrificing the body is worth the risk. There is a high majority of sportsmen who have suffered one

too many injuries, facing the consequences later in life.

The knee being the biggest joint in the body, bridging the ground & us. It holds you up, constantly

absorbing shocks, any involuntary actions can damage & deteriorate such a valuable joint. Effecting

our mobility for the rest of our lives. The knee requires correct alignment from the hip all the way to

the toes, strength in both the supporting muscles: quadriceps, hamstrings.

Pilates offers a controlled environment to improve the alignment, control, strength of not only the

knee but all joints.

Contents

Anatomy of the knee 4

Common sports injuries 5

Treatment & Injury prevention 6

Knee anatomical diagrams 7

Introduction 8

Case studies 9

Program 1 11

Program 2 13

Conclusion 15

Bibliography 16

Anatomy of the knee

Function: The knee is part of the lower extremities. The knees support the body in an upright position without the need

for muscles to work, helps to lower & raise the body, provides stability, acts as a shock absorber, allows twisting of the

leg, makes walking more efficient, helps propel the body forward. The knee joint bears most of the weight of the body.

The knee joint is a synovial joint which connects the femur & to the tibia. When we’re sitting, the tibia & femur barely

touch; standing they lock together to form a stable unit.

The knee is one of the largest & most complex joints in the body. The knee joins the thigh bone (femur) to the shin bone

(tibia). It’s also the most vulnerable because it bears enormous weight & pressure loads while providing flexible

movement. When we walk, our knees support 1.5 times our body weight; climbing stairs is about 3-4 times our body

weight & squatting about 8 times.

The Bones: Four bones make up the knee,

Tibia —commonly name, shin bone, runs from the knee to the ankle. The top of the tibia is made of two plateaus

& a knuckle-like protuberance called the tibial tubercle. Attached to the top of the tibia on each side of the tibial

plateau are two crescent-shaped shock-absorbing cartilages called menisci which help stabilize the knee.

Patella—the kneecap is a flat, triangular bone; the patella moves when the leg moves. Its function is to relieve

friction between the bones & muscles when the knee is bent or straightened & to protect the knee joint. The

kneecap glides along the bottom front surface of the femur between two protuberances called femoral condyles.

These condyles form a groove called the patellofemoral groove.

Femur—commonly name, thigh bone; it’s the largest, longest & strongest bone in the body. The round knobs

at the end of the bone are called condyles.

Fibula—long, thin bone in the lower leg on the lateral side, & runs alongside the tibia from the knee to the ankle.

The cartilage: There are two types of cartilage in the knee.

Articular cartilage: found on the femur, the top of the tibia, & the back of the patella; it is a thin, shiny layer of cartilage.

It acts as a shock absorber & helps bones move smoothly over one another. Meniscus: these are crescent-shaped

discs that act shock absorbers that let the bones of the knee can move through their range of motion without rubbing

directly against each other. The menisci also contain nerves that help improve balance & stability & ensure the correct

weight distribution between the femur & tibia. The knee has two menisci:

Medial - on the inner side of the knee, this is largest of the two & attached to the tibia.

Lateral - on the outer side of the knee & attached to the tibia.

The Ligaments: are tough & fibrous tissues; they act like strong ropes to connect bones to other bones, preventing too

much motion & promoting stability. The knee has four:

ACL (anterior cruciate ligament) - attaches the tibia & the femur in the centre of your knee; prevents the femur

from sliding backward on the tibia, & the tibia from sliding forward on the femur.

PCL (posterior cruciate ligament) - is the strongest ligament & attaches the tibia & the femur. Prevents the femur

from sliding forward on the tibia, or the tibia from sliding backward on the femur.

MCL (medial collateral ligament) - attaches the medial side of the femur to the medial side of the tibia. Limits

side to side movement of the femur.

LCL (lateral collateral ligament) - attaches the lateral side of the femur to the lateral side of the fibula. Prevents

side to side movement of the femur.

Patellar ligament – attaches the kneecap to the tibia

The tendons: serve to stabilize the knee. There are two major tendons in the knee—the quadriceps & patellar.

The muscles: that strengthen the leg & help flex the knee are, the quadriceps are four muscles that straighten the knee

& the hamstrings are three muscles at the back of the thigh that bend the knee. Finally the gluteal muscles - gluteus

medius & minimus - also known as the glutes are in the buttocks; these are also important in positioning the knee.

Joint capsule: The joint capsule is a membrane bag that surrounds the knee joint. It is filled with a liquid called synovial

fluid, which lubricates & nourishes the joint.

Bursae There are approximately 14 of these small fluid-filled sacs within the knee joint. They reduce friction between

the tissues of the knee & prevent inflammation. The prepatellar bursa is one of the most significant bursa & is located

on the front of the knee just under the skin. It protects the kneecap. In addition to bursae, there is an infra patellar fat

pad that helps cushion the kneecap.

Plicae: Plicae are folds in the synovium. Plicae rarely cause problems but sometimes they can get caught between the

femur & kneecap & cause pain.

Common sport related injuries: The knee doesn’t have much protection from trauma or stress (pressure or force).

Knees are most often injured during sports activities, exercising, or as a result of a fall. The most common sport injuries

include:

Sprains & strains: These injuries usually happen in sports where the knee might experience a sudden force,

twisting motion, a rapid change in direction, or an incorrect landing technique. They injuries to the ligaments.

The ACL & MCL are the ligaments most often injured.

Meniscus tear: happens when the knee twists, pivots, or an individual is tackled. Daily life can wear down the

meniscus, then it can tear with a simple awkward turn during normal day to day activities.

Fractures: most often caused by high impact traumatic sports-related contact.

Overuse: most common overuse injury is "runner's knee," a term that refers to several Problems including

patellofemoral pain syndrome (PFPS). These painful conditions are common among athletes.

Symptoms of knee problems/injuries include:

Swelling

Stiffness

Locking (or Catching)

Difficulty with weight bearing

Instability

Snaps, Crackles & Pops

Pain & Tenderness (Tenderness along the joint

line/ Pain behind/ around the kneecap & can

travel to the thigh or shin.)

Decreased range of motion.

Examples of Repetitive Knee injuries are:

Patellofemoral Syndrome (Runner’s Knee)

Tendonitis

Bursitis (Housemaid’s Knee)

Iliotibial Band Syndrome

Osgood-Schlatter Disease

Patellar tendonitis

Treatment & rehabilitation: All knee injuries should be evaluated by a doctor as soon as possible. Basic treatment for

common knee injuries includes rest, ice, elevation, & an over-the-counter pain reliever such as Ibuprofen.

It is also important to begin strengthening & stretching exercises 24-48 hours after minor injuries, or as advised. There

should be a gradual return to normal activities. In some cases, such as an ACL tear, arthroscopic surgery is necessary

to repair the damage.

Additionally, short-term rest & avoiding putting weight on the leg may be necessary for proper healing. Without adequate

rehabilitation, a person will tend to have ongoing problems with an injured knee. The goal of treatment is to restore

stability, strength, & mobility.

Injury prevention:

Warm up by walking & stretching gently before & after playing sports.

Keep the leg muscles strong by using stairs, riding a stationary bicycle, or working out with weights.

Avoid sudden changes in the intensity of exercise.

Replace worn out shoes. Choose ones that fit properly & provide good traction.

Maintain a healthy weight to avoid added pressure on the knees.

Always wear a seatbelt.

Use knee guards in sports where knees could get injured.

Introduction

Knee maintenance, there are more than 2.5 million sports related knee injuries a year. In 2012 a study by Gage

et al reported that there were 6 million documented knee injuries. 62% of those injuries in males occurred from

sports. Men age 5-24 experienced the highest percentage of knee injuries playing sports. Female’s athletes

however have a higher rate of knee injuries. They are 4 to 6 times more likely to sustain a major knee injury in there

athletic career.

These injures can be cause by a multitude of movements & situation, that are easily to come across when playing sport,

you can move & stop too quickly, jump, turn, pivot, sudden changes of direction, overstretching. Then there is the worst

case scenario athlete to athlete contact, traumatic blows. Most injuries however have been described as occurring

without athlete-athlete contact.

The vulnerability of female knees has been attributed to a number of factors including anatomical, environmental,

hormonal, neuromuscular, & biomechanical differences. However all athletes who choose to disregard the side effects

to sport, willingly sacrificing their body to reap the benefits. They will eventually come to terms with the fact that, they

now need to maintain, what (little) joint mobility they have left.

In recent years research is suggesting that Injuries to a critical ligaments in the knee are becoming more common in

children & teens. Greater demand is being placed on youth athletes to increase training, younger sports specialization

& focus is placed on year-round competitive play. With knee injuries on the rise, there is a very simple solution that is

often overlooked as it is recommend that youth cross-train to prevent these injuries, however this isn’t always promoted

by schools, clubs & much of the time youth can be single minded in their focus.

Those in charge of training youth “should” promote health control of the body & multi muscular focus. Parents should

also be made aware of what early sports specialization, early competition will do to their child as they age. Athletes were

7 times more likely to sustain injuries in competition than in practice.

More than half of all high school students participate in some form of athletics. That makes sports one of the most

popular extracurricular activities among Youth. Injuries can exact emotional, physical, social, & economic tolls. Knee

injuries are among the most common serious injuries, accounting for 60% of high school sport-related surgeries.

Case Studies: I have decided to do a quick overview of 3 cases in which my clients have mild knee

issues, each have underlying route cases from youth/ adolescence sport participation. I haven’t

focused on one type of injury because even though the sports may differ & the injuries may differ,

they have all reached the same questions. How do I not let this get the better of me? & how do I

keep my knees supporting me well into my old age? How do I maintain what I have left?

Case study 1 (Male, 52 Y/O)

Sports history:

• Rugby uncontract 5Y/O barefoot till 12/ full contact 9+, last game was at 28 years old.

• Ice hockey 13-17. Rollerblade hockey (30+) 4 years.

• Sprinting 100/200m

• Cross country

Significant injuries to the knee, ankle or hips: Right ankle has tendency to sprain.

Repercussions: Stagnant knee stiffness, easily fatigued, hip flexors

Pilate’s level: Beginner.

Notes: Lacks alignment from the hips, tends to abduct the knees. Is showing good concentration in sessions.

Has 2/3 private session a week. Never felt any knee pain within the sessions. He is responsive to alignment

correction, specifically needing to control the knees & keep them in line with the ankles. There is a great

focus on controlling the directionality of the knee & slowing some movements down, to create opportunities

that coerce control.

Case study 2 (Male, 23 Y/O)

Sports history:

• Competitive track, sprinting (60/100/200/400) 8Y/O to current day.

• Javelin 14Y/O to present day

• Social football though teen years.

Significant injuries to the knee, ankle or hips: Tackled (Social football), impact medial of the right knee.

Repercussion: Pain in Right knee when sprinting. Runners knee (Patellofemoral Syndrome)

Pilate’s level: Beginner/ Intermediate

Notes before: joints below the hips lock up, low flexibility. High muscle mass, decreased range of motion.

Goal to teach movements that would help him strengthen & mobilize the lower extremities, for training

purposes as he doesn’t wish to discontinue nor take time off training, he wishes to prevent injury, in such a

case it was necessary to teach mat movements that he could use daily & create a personal program that he

could move locations with.

Case study 3 (Female 24 Y/O)

Sports history:

Rugby: no contact 6-11, full contact 11-13.

Competitive football 8-12.

Various other social sports through teen years.

Jazz dance 7-13

Ballet & contemporary 15-17.

Significant injuries to the knee, ankle or hips: Patellar subluxation Left knee.

Repercussions: Knee sensitivity to cold weather. Stationary stiffness. Dull pain.

Pilate’s level: Intermediate

Notes: Knee cap had fluid motion, instability. Has gained control, & lessened fluidity. Does 3 sessions a

week to maintain & strengthen the knee joints. Although the left knee had suffered Patellar subluxation, the

right knee had compensated for the left knee & balanced needed to be restored & now maintained. Strength

has become a focus as she has advanced & regained control.

Conditioning Program: Below you will find a 1-12 week program designed to correct alignment,

strengthen & condition the knee joint. My main focus when designing programs for such clientele is

to focus on strengthening the hamstrings, quadriceps, hip adductors, gluteal muscles while

maintaining control, alignment & adequately stretching. I aim to achieve each cases individual goals,

via following the Basi method. While developing core strength & an awareness for what has, & what

they need to focus on. For the Programmes I have commented on specific exercises that

challenges & lessons learnt from the three cases.

Basi Block Week 1-4 Comment Week 5-8 Comment Week 9-12 Comment

Warm up Basic: The pelvic curl is a very good place to start with control. Making sure to engage the correct muscles to pull the knees into the correct position. Use an assist to gain control & keep pressure to grow strength. (Case 3)

Basic: please see week 1 Intermediate: We focus on reaching trough the legs in the same diagonal line. Fully extending the knees. Warming up the hip flexors & core simultaneously.

· Roll up · Roll up · Roll up

· Pelvic Curl · Pelvic Curl · Supine spine twist

· Spine twist supine · Spine twist supine · Double leg Stretch

· Chest lift · Chest lift · Single leg Stretch

· Chest lift with rotation

· Chest lift with rotation

· Criss Cross

Foot Work Reformer: Being in the supine position allows us as instructors to monitor how the alignment is being controlled. When you work with an athlete you realise other than there technic for their sport, they have little control over motion. During footwork cue that pressure from both feet must be equal, & the client must move through the full range of motion in the knees.

Cadillac: Wunda chair: Continuing on with the work, focus on keeping the knees aligned with toes. Keeping the spine straight. And working through the motions.

· Parallel heels · Parallel heels As the client builds strength this series offers a great range of motion in the knee joint. I started teaching this series spring-less, then once motions are learnt we build the strength into movement.

· Parallel heels

· Parallel toes · Parallel toes · Parallel toes

· V position Toes · V position Toes · V position Toes

· Open V heels · Open V heels · Open V heels

· Open V toes · Open V toes · Open V toes

· Calf Raises · Calf Raises · Calf Raises

· Prances · Prances · Single leg heel

· Single leg heel · Single leg heel · Single leg toes

· Single leg toes · Single leg toes

· Hip opener

Abdominals Reformer: Maintaining the legs position in table top is great for building up stability, while building core strength. Creating the focus on maintaining good positioning will factor through into daily life.

Cadillac: Legs straight. Wunda chair: Keep the legs stable, engage the quads, and keep legs activated.

· Hundred prep · Roll up with roll up bar

· Torso press sit

Hip Work Reformer: Working through the motions of hip work, focusing, on external rotation, coming from the hips & not the knees. Case 1 and 2 both have equally weak hips, started on lighter springs.

Cadillac: If there are any asymmetrical imbalances, Here is where we work on them strengthening individually, making sure the proper control is used to correct the imbalances.

Avalon barrel Build up the knee extensor strength, adding the resistance keeps us progressing.

· Frog · Supine single leg series

· Openings

· Frog · Scissors

· Down circles · Down circles · Helicopter

· Up circles · Up circles · Hip Abduction

· Hip extension · Hip abduction with extension · Openings · Bicycle & reverse

Spinal Articulation Reformer: Building on an already learnt exercise creates a goal. Allows subtle challenge. Case 3 does well with additional challenge, concentration. This exercise is adjusted for Case 1 as he needs a small Pilate’s ball to focus on keeping his knees in alignment.

Cadillac: Keep cueing simultaneous articulation of the spine & bending of the knees. Case 3 has more flexibility so finds this exercise easier. Case 2 however has to be cued all the way through as it takes much more concentration.

Avalon barrel control the hamstrings, keep core strength, · Bottom lift · Tower Prep · Roll over

· Tower

Stretches Reformer: Supply knee pillow if needed.

Reformer Range through the knee, from bent to fully extended does take time and to not tense up in other places as you struggle with the full extension. Is the key. Even if it’s not perfect.

Avalon barrel I find these lunges and even the ladder barrel stretches highly beneficial with the maintenance and creating the balance. Always make sure the client knows that they should not only think about building strength.

· Kneeling lunge · Full lunge · Kneeling lunge

Ladder barrel

Gluteal / hamstrings

Adductors/ hip flexors

Full Body Integration Reformer: Showing clients the link between muscles is imperative. Especially when they have competed in sports. They have a preconceived notion of the connections. Assert

Reformer: Use the resistance, do not speed up. Keep the knee in line with the hip and ankle. Case 1. Separate the spines alignment from the action of the knee.

Reformer: cue full extension of legs, through full range of motion of the knees at this point torso should be maintained with only minor adjustments

· Scooter Knee stretch group Stomach massage

· Round back · Round back

· Flat back · Flat back

· Reaching

if the knee is amply supported.

Arm Work Wunda chair: Gives the chance to rest the knees if need be. Focus on the hips not join in the action keeping the body upright, (Case 1) finds it difficult to sustain table top.

Reformer: Once you can maintain legs at table top, strengthen the core.

Reformer: Keeping the legs fully extended & cue the client to not allow the legs to hinder the position off the upper body. Case 1 is currently unable to fully extend his legs & keep them extended. But every time this arm work gets brought up.

· Shrugs Arm supine series Arm sitting series

· Triceps press sit · Extension · Chest expansion

· Adduction · Biceps

/ped-a-pull arm standing series

· Up circles/Down circles

· Rhomboids

· Triceps · Hug a tree

· Salute

Full Body Integration 2 NA NA Avalon Barrel Keep the leg controlled, stabilizing the pelvis. · Leg Pull Front

Leg Work Wunda Chair: Focusing individually on each legs motions allows me to see if there is any imbalance & to cue focus on legs individually to even them out.

Reformer: Building Strength in, thighs, knees &core. Case 1 tries to speed this exercise. Cue slow motion, use resistance on the way back

Wunda Chair: Advancing the building the muscles that support the knees, keep torso aligned, abs engaged.

· Leg press standing • Single leg skating · Forward Lunge

· Hamstring curl · // Backwards step down

Lateral Flexion/Rotation Step barrel: Continue working on maintaining table top

Reformer: The stretch felt in mermaid all three case studies find this stretch relaxing. Originally they didn’t believe their lower extremities had that rage of motion/ flexibility.

Wunda Chair: Good assist, leaning on the pedal allows mental support. Can actively correct the alignment of the floor contact leg. Cueing to keep alignment.

· Spine Twist Supine Mermaid · Side over

Back Extension Mat: Relax the glutes as much as possible. (Case 2) Finds it difficult, dissociation.

Reformer: Keeping the glutes, thighs, the rest of the legs activated shows such improvement from where we started. (Case1)

Wunda Chair: Cue keep alignment of the legs, check misalignment. At this stage micro corrections keep core engaged, keep legs strong, quads engaged. Be present

· Back extension Brest stroke · single arm back extension

Conclusion

Knees are one, if not the most used joint of the body. Even without complications they wear & tear.

They deserve your utmost care & concern. With the Gentle isometric, static, strengthening &

stretching exercises that you get in Pilate’s greatly improves your mobility & strength. It’s hard to

ignore the benefits. With the increasing statistics on youth knee injuries, & the effects they carry are

for a life time, it’s necessary to keep supporting leg muscles strong & practicing injury prevention,

such as cross training, we should all try to keep our knees healthy & improve its lifespan even if only

so they can carry you into your old age.

Case 1, has greatly improved mobility in his hips allowing the alignment of the knees to happen

more naturally. Enjoying seeing the improvement in his strength, awareness. Case 2, Pilates has

given him a more mindful approach to how he deals with sprinting train & warming up, Case 3, is

impressed by the stability that has been returned to the knee cap by strengthening the quadriceps

& hamstrings.

There is nothing greater in the world than a little bit more knowledge & if I can help people who have

suffered a similar fate as I, passing on this knowledge that the knee can be maintained. I will.

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