One 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.
With 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|
|Resisted ankle pumps||Reformer Tendon Stretching and Running|
|Supine hip IR/ER/knee extended||Coordinate with supine hip extension|
|Glut/Quad/Ham sets||Cadillac Breathing, Prone Long Box Exercise|
|Heel slides||Supine hip extension|
|Supine hip flexion march||Knee folds|
|Uninvolved knee to chest||Uninvolved knee stirs|
|Standing quad stretch||Thigh Stretch (Reformer or Cadillac)|
|Hamstring/gastroc stretch supine||Leg Springs, Reformer Straps, or Tower Bar Reformer Elephant|
|Water walking||Walking in Leg Springs|
|Quadruped rocking ||Cat 1, Cat 2, Childʼs Pose|
|Seated knee extension||Modified Hip Twist/Tick Tock|
Seated Footwork on Chair
|Prone hamstring curl||Single Leg Kick|
|Bridging||Bridging with articulation|
|Reformer Footwork||Leg press or wall slide|
|Supine hip IR/ER/knee flexed||Bent Knee Fall Out|
|Oblique side raise|| Mat Side Banana > Plank|
Cadillac Oblique Lift, Chair Seated Mermaid
|Crunch with twist||Criss Cross, Spinal Twist, Saw|
|Crunches||C-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 table||Modified Reformer Lunges (stance foot on|
floor, stretching leg on carriage)
|Standing ITB stretch||Monkey 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/Flex||Magic Circle Series|
|Balance exercises||Reformer Splits Chair Standing Leg Pump Front and Side|
|Bridging with marches||Reformer Pelvic Lift|
|Sidelie hip internal rotation||Clam with feet together|
|Sidelie hip external rotation||Clam progression with foot lifting/knees|
|Side stepping|| Reformer Side Splits and Sidelying Footowork|
|Step ups ||Chair Standing Leg Pump
Reformer Single Leg Footwork
|Elliptical||Prancing on Reformer|
Phase 3: Advanced Exercises
Chair Forward, Side, Russian
|Water running||Single Leg Stretch on Jumpboard|
|Side to side agilities||Side Kicks on Jumpboard|
|Forward and backward running||Pendulum & Supine Scissors on Jumpboard|
|Running progression||Reformer Jumpboard interval training|
Phase 4: Sport Specific Training
|Cariocas||Chair Standing Leg Pump Crossover|
|Sport specific drills||repertoire will vary by patient|
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