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Pilates Program Design for Acetabular Labral Rehab

Last Updated Dec 2013

By: Kristine Reynolds

pilates programOne of the most frequent diagnoses of hip and groin pain is acetabular labral tear, often attributed to biomechanical symptoms of snapping hip syndrome. The mechanism of injury for labral tear may involve repetitive twisting, cutting, pivoting, or hip flexion. Read on to find out how a pilates program may help lessen the pain.

Many individuals report insidious groin pain, clicking, locking, and buckling that can be attributed to femoral acetabular impingement (FAI), joint hypermobility, developmental hip dysplasia, and joint degeneration. These patients are typically 20-40 years of age and complain of sharp pain in the anterior thigh and groin, especially when pivoting, and catching or “locking.” Affected individuals might indicate the location of pain by gripping the lateral hip, known as "the C sign". This is located just above the greater trochanter and between the abducted thumb and index finger. Clicking can be audible and palpated when the hip is extended, adducted, and externally rotated and impingement can be provoked by flexing the hip to 90 degrees, then adducting and internally rotating.

Common findings in postural analysis include:

  • Excessive lumbar lordosis
  • Anterior pelvic tilt
  • Femoral internal or external rotation
  • Leg length discrepancy (usually the long side is symptomatic)
  • Weight bearing avoidance on affected lower extremity
  • Genu recurvatum
  • Knee flexion contracture
  • Overpronation of the foot

An official diagnosis is established via either arthroscopy, magnetic resonance imaging (MRI), or arthrography (MRA). Pediatric and adult patients are considered good candidates for labral repair or debridement via arthroscopic surgery if they present with signs and symptoms of hip pain lasting longer than one month in conjunction with indicative findings of a labral tear via MRI or MRA.

Arthroscopy of the hip joint has become a common technique in the past decade to diagnose and to treat hip pain, but a recent case study demonstrated how physical therapy and pilates exercise can improve function with labral pathology (Edelstein, J. Rehabilitating Psoas Tendinitis: A Case Report. HSSJ (2009) 5: 78–82).

Edelstein examines a 43-year old female with a history of low back pain referred to physical therapy program for insidious left hip pain. MRI demonstrated bilateral labral tears and ruled out hip dysplasia and FAI. Considering the atraumatic nature of the injury and a negative physical therapy lumbar screen, the author concluded that this condition was a result of impaired neuromuscular control associated with psoas inhibition. The function of the psoas muscle changes when pathology is present in the lumbar spine creating muscle imbalance between the lumbar spine and hip, which imparts abnormal forces through the hip joint and places it at risk for injury.

The therapeutic exercise program is designed by the physical therapist focused on maintaining neutral spine while moving from the lower extremities, including the Pilates Reformer Footwork Series. The patient reported a 75% improvement in symptoms with complete resolution of her left hip pain at the fifth visit. Although this study demonstrates positive outcomes with Pilates for labral tear prior to surgical intervention, it provides the notion that the Pilates method positively impacts neuromuscular re-education to this anatomic region.

Additional research has shown that Pilates exercise prescription to be successful in enhancing flexibility in agreement with the exercise prescription set forth by the American College of Sports Medicine. The Pilates method combines static and dynamic stretching with principles of flow and whole body movement to achieve a point of soft tissue restriction at range of motion without discomfort elicits a mechanical response of both contractile and non-contractile tissues and neurophysiological response to specific volumes of Pilates exercise prescription. This study promotes a frequency of 5 repetitions per exercise for 10-15 seconds, twice per week, for a 10 week period to develop flexibility, particurly in the hip flexors, adductors, and low back. (Phrompaet, S. Paungmali A, Pirunsan U, Sitilertpisan P. Effects of Pilates Training on Lumbo-Pelvic Stability and Flexibility. Asian Journal of Sports Medicine, 2(1), March 2011, 16-22.)

Regarding abdominal strength, a 2005 laboratory research using electromyography electrodes showed that the Roll Up produced high amounts of rectus abdominis activity.In this study, the electromyography electrodes were used on the rectus abdominis and external obliques of 12 test subjects. They measured the amout of electrical output elicited by these muscles during 10 reps of the Hundred, Double Leg Stretch, Criss-Cross, Roll Up and the Teaser with a traditional crunch used as the control.

labral tearWith respect to external oblique activity, all four Pilates exercises beat out the crunch- especially Roll Up and Criss Cross. Double Leg Stretch and Teaser need to be used with caution in this population because it is very easy to overuse hip flexors. The EMG results indicate that the Teaser is relatively tough on the hip flexors, registering three times more activity in this area than the crunch. (Olson M, Smith CM. Pilates Exercise: Lessons From the Lab. IDEA Fitness Journal. November–December 2005)

Using this evidence, personal knowledge and clinical experience, I have drafted the table below to present traditional physical therapy exercises used for pre- and post-op labral tears and a pilates program as a complementary alternative to this protocol.

Traditional Protocol Pilates Equivalent
PROM/Circumduction Standingnone
Resisted ankle pumpsReformer Tendon Stretching and Running
Stationary bikenone
Supine hip IR/ER/knee extendedCoordinate with supine hip extension
Glut/Quad/Ham setsCadillac Breathing, Prone Long Box Exercise
Heel slidesSupine hip extension
Supine hip flexion marchKnee folds
Uninvolved knee to chestUninvolved knee stirs
Standing quad stretchThigh Stretch (Reformer or Cadillac)
Hamstring/gastroc stretch supineLeg Springs, Reformer Straps, or Tower Bar Reformer Elephant
Water walkingWalking in Leg Springs
Quadruped rocking Cat 1, Cat 2, Childʼs Pose
Seated knee extensionModified Hip Twist/Tick Tock
Seated Footwork on Chair
Prone hamstring curlSingle Leg Kick
BridgingBridging with articulation
Reformer FootworkLeg press or wall slide
Supine hip IR/ER/knee flexedBent Knee Fall Out
Oblique side raise Mat Side Banana > Plank
Cadillac Oblique Lift, Chair Seated Mermaid
Crunch with twistCriss Cross, Spinal Twist, Saw
CrunchesC-curve and imprinting, Roll Up,
Rolling Back on Reformer or Cadillac
Reformer Knee Stretch Round and Flat

Phase 2: Intermediate Exercise

Double 1/3 Knee Bends

Reformer Footwork (increased resistance)
Reformer Side Splits (include 1/3 squat)

Supine hip flexor stretch off tableModified Reformer Lunges (stance foot on
floor, stretching leg on carriage)
Standing ITB stretchMonkey with ITB bias on each leg
3 Way Leg Lifts Lying ABD/Ext

Modified Toss Up and Circles
Side Kick (pendulum) and Bicycle
Leg Pull and Leg Pull Front

Lifts Standing ABD/Ext/FlexMagic Circle Series

Balance exercisesReformer Splits Chair Standing Leg Pump Front and Side
Bridging with marchesReformer Pelvic Lift
Sidelie hip internal rotationClam with feet together
Sidelie hip external rotationClam progression with foot lifting/knees
Side stepping Reformer Side Splits and Sidelying Footowork
Step ups Chair Standing Leg Pump
Reformer Single Leg Footwork
EllipticalPrancing on Reformer

Phase 3: Advanced Exercises

Chair Forward, Side, Russian
Water runningSingle Leg Stretch on Jumpboard
Side to side agilitiesSide Kicks on Jumpboard
Forward and backward runningPendulum & Supine Scissors on Jumpboard
Running progressionReformer Jumpboard interval training

Phase 4: Sport Specific Training

CariocasChair Standing Leg Pump Crossover
Sport specific drillsrepertoire will vary by patient

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