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BASIPilates

Case Study in Using of Pilates Training for Instability of Ankle

HyunJu Yoo, Physical Therapist, MS, DPT, Comprehensive – Brooklyn March 2018

CaseStudyinUsingofPilatesTrainingforInstabilityofAnkle

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Abstract As generally we know, ankle sprain and instability are one of the most common injuries in

sports activity. More than 3 million per year in “at risk population” and 25,000 people sprain

their ankles every day in the U.S (2018, WebMD base). “One of the most common injuries” in

ankle indicates of that ankle joint is used tremendously in daily activities and reflects the

importance for functional movements. When I work as physical therapist for patients with

chronic pain, ankle rarely seems like the way to figure out the symptoms or pain is connected to

ankle function and position with ease. For instance, the client with neck or shoulder pain has

poor alignment of body or dysfunction, most of them have ankle problems. Because when we

walk or move our legs, it occurs with pelvis’ movement, which is affecting movement pattern of

upper body and upper extremity such as trunk rotation and arm swing. Also, core muscles and

pelvis that we generally mention as body stabilizers are strongly related to ankle stability. In this

page, I aim to focus on why ankles are important in our functional movement and how it is

linked to the body anatomically and functionally. Also I will mention what body factors are

involved with injury and dysfunction and how they can be healed.

Pilates is whole body exercise that focused on core muscles and balance of the body, using

effective resistance with spring aiming not only to develop stretching but also to build muscle

strengthening without injury. When I consider connection between ankle and whole body, Pilates

would give positive effect for the people with ankle instability.

Key words: Ankle instability, Imbalance, Pilates, Balance Training,


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BASI Pilates Instructor Program Abstract ------------------------------------------------------------------------------------------------------- 2

Contents of Table -------------------------------------------------------------------------------------------- 3

Background --------------------------------------------------------------------------------------------------- 4

Case Study ---------------------------------------------------------------------------------------------------- 9

Result ------------------------------------------------------------------------------------------------------- 11

Discussion --------------------------------------------------------------------------------------------------- 13

References --------------------------------------------------------------------------------------------------- 15

Attachment -------------------------------------------------------------------------------------------------- 16


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Background

Ankle is the critical functional joint among the body joints that bearing whole body weight

and spreading the weigh to feet equally and functionally in order to use energy efficiently in

upright posture and ambulation. Ankle and foot are consisted of 7 ankle bones, 5 metatarsal

bones, and 14 phalangeal bones and those bones are connected to leg bones through ankle bones.

Basically, foot can move on pronation, supination, eversion, inversion, dorsiflexion, and

plantar flexion. Those motions are linked to balance of bone structures and soft structures. Once

the balance is ruined, we can see misalignments like pes cavus (high feet), pes planus (flat feet),

forefoot eversion or inversion, hind foot inversion or eversion, big toe adduction, hallux valgus

(bunion), and other deformation of metatarsophalangeal joints. As we mentioned above, ankle

joint is mostly used in ambulation. Gait pattern in composed with approximately 60% of stance,

40% of swing. In gait, pelvis that is connected to lower extremity shows small amount of

movement. In moving forward and backward of the leg, pelvis has 4 degrees of anterior and

posterior rotation on horizontal plane, and 4 degrees of tilt (up and down) in swing phase, pelvis

is shifted over stance limb. Also, 15 degrees of knee flexion is presented on heel stride phase to


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absorb shock on heel strike, to reduce center of gravity (COG), and knee extension on mid-

stance phase as the ankle plantar flexion and foot supination to restore leg’s original length to

reduce fall of ankle on opposite heel strike.

Muscles used in each phase of the gait are as below.

-Initial contact (heel strike): hip extensor, quadriceps, anterior tibialis, -Double limb support: Anterior tibialis, Quadriceps -Sing limb stance (middle stance): hip extensor, quadriceps -Terminal stance: toe flexsors, posterior tibialis -Pre-swing phase: hip flexor -Initial swing (toe off): hip flexor -Mid-swing (foot cleanings?): dorsi flexors -Terminal swing: hamstrings

Abnormal alignment can be triggered from tiny joint and muscles in foot. For example, hallux

valgus (bunion toes) starts from deformity of flexor hallucis abductor and adductor hallucis. In

that case, those small muscles lose their own function of foot support, collapsing of the medial

arch would appear which are pronated feet. Once foot became hallux valgus with decreased arch,

tibia and femur turn to internally rotate and when body weight bears on the foot in gait, big toe

gets more pressure from lower arch to be deviated laterally and it causes more pronation on the

foot. Furthermore, this symptoms worsen body alignment even more.


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This is because, foot posture and body posture influences each other as they are connected in

anatomy, biomechanics, and the interconnectedness from the foot to top of the body. Abnormal

alignment, started from foot, directly connects to the hip joint which connected to pelvis through

thigh. In natural standing, when toe line is excessively inward then the other, leg turns internally

and then leads pelvis to rotate internally and tilt a bit anteriorly. On the contrary, if toe line is

facing outside, pelvis is tilted posteriorly slightly. External rotation of hip joint can lead more

stress and friction in the hip joint. This hip joint is also neighbor to sacroiliac joint (SIJ) that is

connected to spine then it generates direct effects on the spine raising other problems. Once SIJ

shows dysfunction such as arthritis, spondylitis and the other diseases, it is likely to lead other

problems as we commonly known as herniated disc, degenerated disc disease, spondylosis,

spondylitis, scoliosis, and many others.

When the femur is tilted due to dysfunction of muscles and joints, pelvis asymmetrically

rotates leading torso rotation to opposite side and shoulder blades become imbalance between

right and left. Shoulder complex and joint can effect abnormal position like kyphosis of thoracic

and it makes limited range of motion of shoulder with forward head, accompanying neck pain

and limited of motion in neck. Those symptoms generate impingement syndrome, biceps tendon

injury, thoracic outlet syndrome, tendinitis, bursitis, tear of ligaments, frozen shoulder,

osteoarthritis that we can face with ease. However, there are some cases that some people can

move without pain as adaption or compensation while the other complains of pain in same

condition (Evan Osar, 2017).

According a study about gait, person with chronic ankle instability (CIA) tends to use other

muscles as compensation relatively others without CIA. When investor conducted EMG test for

those people, it revealed that they used peroneus longus which role in pronation and dynamic


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stability and activated medial gastrocnemius and gluteus medius more, generating circumduction

gait as compensation of supination feet. Also, they presented 43% wider base of support than

health people during phase of stance to pre-swing. Meanwhile, activation of anterior tibialis has

decreased in the gait. As I mentioned earlier, this muscles plays a critical role in gait to prevent

foot drop in swing to initial stance (heel strike) phase and to align body over the ankle in stance

phase of gait. In this case, inverted foot position can be presented, leading more pressure on

lateral side of foot during weight activities.

Hence, foot and ankle stability is the most important in our body alignment and in

rehabilitation process. In this page, the Pilates program will be focused on rebuilding of body

alignment and normal posture by using proper regime from Pilate’s concept and based on the

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used muscles.


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Many people say that physical screening should be conducted before initiating exercise often

display undiagnosed problems that could be aggravated by physical activity (Gary cook, 2011).

Screening provides reliable perspective for specific testing and assessment to refine the most

pertinent information (Gary cook, 2011). In this page, I used Single Leg Balance (SLB) Test*,

Wet test*, and Foot Pictures which are easily assessable to screen body to identify deficiency.


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Case Study The 28 years old female has history of right ankle sprain 6 months ago and complains of

stiffness and discomfort in ambulation and stair negotiation. According to the body screening,

she has shown several specific symptoms.

[Body Screening]

During SLB test, client presented positive with Trendrendburg sign* that indicates of

weakness of Glutes medius on left hip joint which can impact of instability of hip joint. This

muscle is the key muscle to hold pelvis parallel in horizontal line on standing leg while the other

leg in swing phase.

Also, client has rotated toward front in right of pelvis, knock knee (genu valgus), hyper extended

knee (genu recurvatum), and elevated shoulder in right side. During ambulation, client presented

decreased foot arch in both sides accompanying possibility of stage of 1 of hallux rigidus.

In summaries, her problems list as below;

Flat foot Inversion Ankle Genu-Valgus

Instability of Ankles Imbalance of Pelvis Trunk rotation forward left side

Elevated of Right Shoulders

Target muscles as below;

Tibialis Anteior/Posterior Plantaris Posterior tibialis/Gastrocnemius/Soleus Hamstrings Hip External rotators Hip extensors and abductor Trunk rotator Iliotibial band (ITB) Tensor fascia latae (TFL) Hip flexors Hip adductors Shoulder/shoulder girdle muscles

For those muscle groups, strengthening and stretching exercise will be conducted for whole body

balance.


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[Pilates Program]

All exercises were based on client’s symptoms and selected according to basic concepts from

BASI Block System also, informed knowledge from Sport Pilates Book (Paul Massey, 2004).

Exercise phase are divided into 4 weeks for 3 each phase total 12 weeks. Exercise were

conducted twice a week and all exercise program were consisted of based on all BASI block

systems.

*See Attachment 1


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Result Client complained less pain and discomfort during ambulation and working place. 1. Single Leg Balance (SLB) test

Before After Single Leg Stance Eyes Open (EO) Eyes Close (EC) Eyes Open (EO) Eyes Close (EC) On Right Leg 15 sec 5 sec 23 sec 11sec On Left Leg 8 sec <1 sec 14 sec 7 sec Practically, SLB test indicates risk of ankle sprain in the future when standing on single leg no

longer than 10 seconds. Client even wasn’t able to lift right leg, standing on left leg in closed eye

(CE) condition, presenting body sway and stepping down right away. After all sessions of

exercise, one leg standing time increased up to 7 seconds from less than 1 second. Even though,

being able to hold lifted leg only under 10 seconds on left leg still, generally all stability time

significantly increased in stable maintaining time.

2. Foot Arch Wet Test Before After

Foot Arch

Client had relatively lower arch on left foot and high arch on right foot before starting this

program.

1) When comparing diameters between medial side and lateral side of arch, there was more

difference between left foot and right foot in previous pictures. It seems that her body

weight was shifted to right side especially on lateral side of the right foot, making high

arch on right side of foot. After program, difference of diameter between both feet is

reduced.

L R L R


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2) On left foot, we can see wider contact surface in <Before> picture than <After> picture

while more contact surface is presenting on right foot in <After> picture than <Before>

picture. It can be considered as body weight distribution has changed almost equally in

each foot after exercise.

3) The line crossed from the center of the heel through medial side of arch shows different

angle. On left foot, line cross same point of second toe but total line is tilted to vertical

line from right side. On right foot, the angle of total line is shifted to the left side slightly

and the point, passing toes, is moved from lateral side to medial side of the third toe.

3. Pictures of Foot Before After

Posterior View of foot

In the posterior view of feet, decreased arch was seen significantly. When it compares to Arch

Pictures (bottom), displacement of navicular bone in left foot can be assumed, presenting with

decreased arch. Also, the cross line from the center of the heel along Achilles tendon shows


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deviated foot line from the center of the line. After program, the cross line moved to center and

also arch increased from the floor.

Discussion Before starting program, client had decreased arch and shown typical knock knee, internal

rotation in hip joint in standing position. Even in the pictures, right foot seemed to have lower

arch too however, according to the result of wet test, right foot showed higher arch which can be

assumed that the body weight is shifted to right side. Most of body weight was distributed on

heel than metatarsal bones however, the client’s body weight was weighed on outside on right

foot and it indicates total body weight is probably shifted to right side as adaptation for decreased

arch on left side. Also, during open kinetic position that foot is in the air such as table top

position, single leg stretch, single leg foot work, client had more inverted right foot. Again, in

swing phase of gait, foot should be in dorsiflexion to prepare heel strike phase however, she

probably lost the function of dorsiflexion due to the weakness in dorsi flexors or shortness of

plantar flexors. I assume that’s the reason why she has a history of sprain in right ankle , not in

the left ankle with more instability. Plus, client presented 3/4 grade of tenderness* on left side of

posterior tibialis tendon with light palpation during exercise. As the role of the posterior tibialis

as agonist muscles in plantar flexion and inversion of the foot, stretching and strengthening

exercise were required for the muscle. After program, tenderness grade has been decreased to 1/4

grade.

Exercise was focused on core and foot muscles, guiding her to maintain foot in proper position.

To do this, I gave her direction to lift toes during standing exercise so that arch can be lifted

equally and to align her body to the center. For healthy arch in standing position, short-foot

exercise was proven as effective exercise in the study (Lee, 2019) thus, continuous verbal cue

was given during standing exercise to keep arch high. According to another study, dorsiflexion

action in standing position benefits to stimulate pelvic floor muscles that core muscles (Lee,

2018). Based on the evidence, any exercise in standing position could affect to core muscles and

foot stability. In BASI block system, stretching group and full body integration block in reformer

are could be in the group and were conducted in most of sessions with correction of feet.

As a result, client presented with better foot posture and arch in single leg stance. Increased

arch was attained probably because of the repetitive and continuous verbal cues to correct her


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foot position and alignment, helping her automatically control her foot muscles during taking the

AFTER pictures, which affected more than actual strength she got from the program. To prove

this point, longitudinal observation in nature is required.

However, overall, client was satisfied with the result of the program, complaining less fatigue

in daily activities such as prolonged standing and walking in working environment. Also, her

balance time objectively increased with less body sway in single leg balance test. Thus, I would say

Pilates is effective exercise for improving ankle instability and balance.


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References Anne Krause. Neuromuscular and Kinematic Adaptation in Response to Reactive Balance Training – a Randomized Controlled Study Regarding Fall Prevention. Frontiers Physiology, https://doi.org/10.3389/fphys.2018.01075, 2018 Eunsang Lee. Short-Foot Exercise Promotes Quantitative Somatosensory Function in Ankle Instability: A Randomized Controlled Trial. Medical Science, DOI: 10.12659/MSM.912785, 2019 Evan Osar. The Psoas Solution: The Practitioner's Guide to Rehabilitation, Corrective Exercise, and Training for Improved Function (1 edition). England. North Atlantic Books, 2017 “Gait Cycle”, Orthobullets.com, https://www.orthobullets.com/foot-and-ankle/7001/gait-cycle Web. 10/06/2016 Gray Cook, Movement: Functional Movement Systems: Screening, Assessment, Corrective Strategies (1st Edition). Lotus Publishers, 2011 Hallux rigidus, Wikipedia https://en.m.wikipedia.org/wiki/Hallux_rigidus Web. “How foot and leg posture influence each other and cause pain.” Oregon Exercise Therapy, Web. 10/17/2017 Kyeongjin Lee. Activation of Pelvic Floor Muscle During Ankle Posture Change on the Basis of a Three Dimensional Motion Analysis System. Medical Science, 24: 7223-7230 DOI: 10.12659/MSM.912689, 2018 Thomas W. Myers. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists (3rd Edition). Churchill Livingstone, 2014

T H Trojian. Single leg balance test to identify risk of ankle sprains, Br J Sports Med ; 40(7): 610–613. Published online 2006 May 10. doi: 10.1136/bjsm.2005.024356, 2006

Paul Massey. Sports Pilates – How to prevent and Overcome Sports Injuries, Great Britain: Cico Books, 2004 Rael Isacowitz, Pilates Anatomy (1 edition). U.S.: Human Kinetics Publishers, 2011 Rael Isacowitz, BASI Pilates guide books Ramona Ritzmann, High Intensity Jump Exercise Preserves Posture Control, Gait, and Functional Mobility During 60 Days of Bed-Rest: An RCT Including 90 Days of Follow-Up. Frontiers Physiology, https://doi.org/10.3389/fphys.2018.01713, 2018


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* Attachment 1 <Pilates Program>

Block system 1-4 Weeks 5-8 Weeks 9-12 Weeks

Warm up

-Mat- Pelvic curl Spine Twist Supine Chest lift Chest lift with Rotation

-Mat- Roll up Spine Twist Supine Double/Single leg Stretch Criss Cross

-Mat- Hamstring pull 1,2,3 Shoulder Bridge Spine Twist Spine

Foot work Combined -Reformer- Foot work Series

-Cadillac- Foot Work Series

-Wunda Chair- Foot Work Series

Abdominals

-Reformer- Hundred Prep/Hundred Coordination Short Box Series

-Wunda Chair- Standing Pike/Reverse

-Reformer- Hundred Doubled leg/ with rotation Long box: Teaser /prep

-Wunda Chair- Cat stretch kneeling Pike Standing

-Reformer- Round about Climb-A-Tree Teaser

-Wunda Chair- Full pike Torso Press

Hip

-Reformer- Spine leg Series

-Cadillac- Supine single leg series


-Cadillac- Supine single leg series


-Cadillac- Side lying single leg series

Spine Articulation

-Reformer- Bottom lift / w/ extension

-Cadillac- Monkey original Tower Prep

-Mat- Rolling, Open leg rocker

-Reformer- Short / long spine Semi-Circle

-Mat- Roll over, control balance

Stretch -Reformer- Standing Lunge, Kneeling Lunge, Full Lunge

Full Body Integration

-Reformer- Knee Stretch Group Up Stretch 1,2 Elephant

-Reformer- Stomach Massage Series Up stretch 1,2,3 Long stretch

-Reformer- Long Back stretch

-Cadillac- Push through Group

Arm

-Reformer- Arms Supine Series Arms Sitting Series

-Wunda Chair- Shrugs Triceps Press Sit

-Reformer- Arms Kneeling Series Rowing Series

-Wunda Chair- Side kneeling Arm Frog back

-Reformer- Arms Kneeling Side Series

-Cadillac- Arms standing series

Full Body Integration - - -

Leg

-Wunda Chair- Leg Press standing Hip Opener

-Wunda Chair- Forward lunge Backward Step Down Frog Front

-Reformer- Jumping Series Side Splint

Lateral /Rotation

-Mat- Side lift, Side Kick Spine Twist

-Mat- Saw , Spine Twist, Corkscrew, Side kick kneeling

-Mat- Side Bend, Twist

-Wunda Chair- Side pike

Back Extension

-Wunda Chair- Swan Basic

-Mat- Back extension Single/Double leg kick

-Reformer- Pulling Strap 1,2 Breaststroke / prep

-Cadillac- Prone 1,2

-Wunda Chair- Back extension single arm


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* Single Leg Balance Test Process 1. Stand with the hands placed on the hips in order to prevent use of arms for balance. 2. Lift one leg and measure the length of time the subject can maintain their balance each side in open eyes and closed eye condition. The SLB test is considered positive and a good predictor of a future ankle sprain if the time held is less than 10 seconds for either eyes open or eyes closed. (Trojian 2006) * Wet Test Process 1. Pour water in to a shallow pan, 2. Well the sole of the foot 3. Step on to a piece of paper, 4. Check the imprint

* Trendelenburg Sign When lift one leg off the floor, if the pelvis on the lifted leg is dropping, it indicates muscles weakness of the opposite pelvic.

* Tenderness grade Grade 1/4: Tenderness with no physical response Grade 2/4: Tenderness with grimace, wince, and/or flinch Grade 3/4: Tenderenss with withdrawal (positive jump sign) Grade 4/4: Non-noxious stimuli (e.g., superficial palpation, gentle percussion) results in patient withdrawal or patient refusal to be palpated due to pain file:///C:/Users/HoneyJu/Downloads/Tenderness_Grading.pdf

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