The SIJ is the joint between the lower segments of the spine, the sacrum, and the illium bone of the pelvis. The SIJ is given structural support by strong ligaments and muscular support gives the SIJ some degree of dynamic stability. Movements of the SIJ are subtle and can be confusing; however the main movements which occur at this joint are nutation and counter-nutation. Basically speaking, nutation refers to the top end of the sacrum tilting forward relative to the Illium and counter-nutation refers to the top end of the sacrum tilting backwards relative to the Illium.
What is Pelvic Instability?
Pelvic instability refers to uncontrolled counter-nutation of the SIJ. This puts direct stretch on the long dorsal ligament which is highly innervated with nerves and can cause pain often felt in the buttock and down the leg. The combined actions of several muscles are critical to achieve stability of the SIJ, including trasverse abdominus, multifidus, pelvic floor muscles, the gluteal muscles, latissimus dorsi, obliques and erector spinae. Weakness or poor neuromuscular recruitment of these muscles can cause sustained counter-nutation of the sacrum, increasing the risk of SIJ irritation.
Treating Pelvic Instability and SIJ Pain
Assessment to determine which muscles are deficient in stabilising the pelvis is critical for the treatment of SIJ pain. For acute SIJ pain, any exercise or movement which brings the sacrum into nutation should reduce pain. This includes SIJ mobilisations, stretching the hamstrings to inhibit them from pulling the sacrum into counter-nutation, taping across the SIJ or into nutation as well as traction in line of the SIJ to reduce stretch on the long dorsal ligament. Initially to achieve further pelvic stability, exercises to improve the strength and control of transverse abdominus are key. To then achieve dynamic control of the pelvis, strengthening the other muscles which stabilise the pelvis (Most commonly gluteus maximus and latissimus dorsi) is required.
Written By Jack Hickey Exercise Physiologist at MD Health Pilates
Demystifying Pilates – Why do we do a Full Body Assessment (FBA) before you start Pilates
At MD Health Pilates, we always start your Clinical or Personalised Pilates program with a Full Body Assessment. What this means is that we assess all your major body parts, starting with your neck, shoulders, back, pelvis, hips, knees and ankles so that each program can specifically and individually tailored to each individual.
Why is it so important to start a Pilates program with a Full Body Assessment ?
We are not able to customise a Clinical or Personalised Pilates program, without assessing each body part specifically. In particular, we need to know more about any injuries you describe (commonly back pain) and any underlying injuries that will affect your program, that you may not be aware of (very often we find knee pain such as PFJ injuries). This will make a big difference in whether the program will be effective or not
How was the Full Body Assessment developed ?
The Full Body Assessment was developed by looking at all the potential tests we could do for each major body part, summarising them and determining which combination of tests will allow us to determine all the major injuries that can affect each body part (roughly 190 tests). Over the last 10 years we have refined this process and as new research and technology has emerged, we have refined the process even further to be more accurate. We continue to further refine and improve this process.
What does a Full Body Assessment involve ?
It involves assessing 1) Posture ( as well as specific foot posture) 2) Neck 3) Thoracic Spine 4) Lower Back 5) Pelvis 6) Hips 7) Knees 8) Ankles The process takes 1 hour. After we finish testing, the physiotherapist/exercise physiologist will again analyse the results and determine any particular injuries present and write the program based on your goals, injuries, strengths and weaknesses
The knee is primarily a hinge joint which allows for flexion and extension movements. The patello-femoral-joint is the joint between the patella (knee cap) and the intercondylar notch of the femur, where the patella tracks during flexion and extension of the knee. This tracking of the patella is largely influenced by the balance between lateral and medial forces acting upon it. The majority of the lateral force acting on the PFJ come from the vastus lateralis (VL) component of the quadriceps muscle and the ilio-tibial-band (ITB). The medial forces acting upon the PFJ are controlled by the vastus medialis (VM) muscle, particularly the oblique portion of this muscle referred to as VMO.
What is PFJ Knee Pain?
PFJ knee pain is an umbrella term used to describe pain underneath or around the patella. It is a very common issue which affects a wide range of people and can be quite non-specific in nature. PFJ pain is often aggravated by activities such as running, going up and down stairs or any activity which loads the PFJ such as squatting down.
What causes PFJ Knee Pain?
The lateral structures of the PFJ are anatomically much stronger than the medial structures and imbalances in these forces can cause abnormal patella tracking during knee flexion and extension. This abnormal patella tracking causes pain and irritation under and around the patella. Imbalances between medial and lateral PFJ forces are commonly a result of poor neuromuscular control of the quadriceps especially delay in timing of activation of VMO compared to VL; as we as tightness in the lateral structures of the PFJ, especially the ITB. There are also some biomechanical factors which contribute to abnormal patella tracking including increased femoral internal rotation, knee valgus and excessive foot pronation. Excessive loads being placed on the PFJ through training overload can also be a contributing factor to PFJ pain.
Treating PFJ Knee Pain
Thorough assessment is required to determine the underlying cause of PFJ pain as there are a number of factors which influence it. For the majority of cases of PFJ pain, addressing the imbalance between medial and lateral PFJ forces is required. This includes Improving the neuromuscular control and timing of muscle activation of VMO with specific exercises, as well as reducing tightness in the lateral PFJ structures with stretches and releases for the ITB and VL muscle. Patella taping is also often beneficial to assist in correcting patella tracking before neuromuscular control has improved in early stages of rehabilitation. Assessing and addressing any biomechanical abnormalities that may be contributing to PFJ pain is also vital, such reducing femoral internal rotation by strengthening the hip external rotator muscles and reducing foot pronation by strengthening the stabilising muscles around the foot and ankle.
By Jack Hickey Exercise Physiologist at MD Health Pilates
Demystifying Pilates: Who is Clinical Pilates for and when is the best time to start Pilates if I have an injury?
The most common reason for Clinical Pilates is when someone has an injury. The most common is back pain, however, we see a range, including pelvic pain, neck pain, shoulder pain and knee pain to just scratch the surface, all which can be addressed with Clinical Pilates. Again, to best demonstrate how Clinical Pilates works when you have an injury, will give an example with a fictional client
Clinical Pilates for Roger, 55 year old man, who has knee pain, which interferes with his weekly bike ride (Yes he does wear Lycra)
Roger is also a typical client that comes to see us to start Clinical Pilates to address a specific injury. Roger works as a partner in a large accounting firm and spends his weekends riding around the bay from St Kilda to Port Melbourne. Roger has slowly developed knee pain over the last 6 months. Although it was originally there occasionally, it is now there after every ride and usually the next day. Roger also has difficult going down stairs. He occasionally gets back pain, but he is not really concerned about this and can deal with it
Where does the Clinical Pilates Process start
As always, we start with a Full Body Assessment to find out the aims of his program and any major issues that we need to address during his program. Roger wants to • Get rid of his knee pain • Improve his cycling if possible From Roger’s Full body Assessment, it was clearly determined that his pain was coming from patella-femoral joint pain (PFJ pain), due to poor tracking of his knee cap. This occurs due to a number of factors, including weakness and slow contraction of the major stabiliser of the knee cap, the VMO muscle (Vastus Medialis Oblique), a particular portion of the quadriceps muscle. Although Roger rides every weekend, his quadriceps are weaker than they should be for the activity that he undertakes. Other factors included pelvic instability and poor gluteal strength and control. This has a major contributing factor to Roger’s knee pain as weakness in these muscles means more load on the quadriceps, which ultimately puts more strain on the PFJ. Pelvic instability is probably the major cause of Roger’s back pain. (Pelvic instability is very common during pregnancy, but is also very common in the general population due to muscle weakness). There were no other major concerns from his assessment
Roger’s Clinical Pilates Program
Roger began his 13 week Pilates program with a strong focus on improving the strength and control of this quadriceps and gluteal muscles. We assessed his core stability on ultrasound on the first day and surprisingly is was already very good (8 out of 12 on both sides). We start with exercises demonstrating the correct contraction of the quadriceps and particularly the VMO portion. Roger gets to feel how the muscle should work and what the sensation should feel like. We follow this with an exercise for the gluteal muscles and then return to exercises for the VMO. Again, we start simple and particular as we have a very direct goal for Roger’s program. Over then next few weeks we continue to reinforce activation of the VMO muscle, but start progressing the load and weight in Roger’s Clinical Pilates exercises as strength is a major factor in reducing Roger’s knee pain.
At Roger’s week 7 re-assessment, Roger’s knee pain is better, but not gone. When he rides it hurts at the start, but does not continue and is not present the next day. His gluteal and quadriceps strength have improved significantly and VMO activation is much better, however, we still need a bit more strength for Roger to achieve his goals. Pelvic instability is much better as Roger has much more gluteal strength and better activation.
In the next 6 weeks of Roger’s program, we again strongly focus on Roger’s strength. We progress to more complicated quadriceps and gluteal exercises, particularly focussed on eccentric strength of the muscles.
At Roger’s 13 week re-assessment, his knee pain is barely present. His gluteal and quadriceps strength is good and where it should be for bike riding. VMO and gluteal activation is now very good. Roger even mentioned that the occasional back pain that was present no longer bothers him at all. Roger has also noticed that he finds riding easier and is a bit faster than his riding companions now. Roger finishes our 13 week program and decides he want to continue the rest of his training at the gym on his own. We write an exercise program Roger can follow at the gym and he knows he can contact us if he needs help again
(Although this is a fictional example, this is a very typical example of our Pilates clients)