Treatment of Knee Injuries

It is time to move into treatment of the knee injuries that we just spoke about. And as I mentioned in the beginning of this series, how important the education is and the individual that we're treating is, or that we're working with or ourselves in many of your cases. How do we know what the right intervention is at the right time with the right person? So that's what we're gonna talk about in this module, and we're gonna move right into it. So when we look at treatment of knee injuries, we've talked about ligament injuries, we've talked about internal derangements of things like meniscal tears.

We've talked about degenerative changes, and we've also talked about alignment issues, like the patellofemoral. And so I wanna keep them in these four categories of ligament instabilities, internal derangements, degenerative changes, and alignment issues. And this will help us to understand which tools of all the tools we have in Pilates do we use to be able to bring about the greatest outcome. In order to do this effectively I want to incorporate the Polestar Principles of movement strategies to the application of these knee injuries. And I've broken them down into four areas.

So the first one is restrictions or lack of mobility. And we're gonna talk about each one of these in depth, but we're now just looking at, is there movement in the knee? So if you think, or you have knee pain or you have clients that have pain, do they have a loss in their range of motion? Right now we're talking about the Osteokinematics, so flexion and extension of their knee. The next principle of movement in Polestar is dynamic alignment.

And this has to do with, you know, in my movement, in my walking, in my kicking, open chain activities, am I aligned in my optimal position? And what that means is typically hip joint over knee joint, over ankle, over second toe for most human movement. And then there are variations of that based on the individual. So some individuals might have a tibial torsion and their tibia is actually rotated a little bit and the foot goes out. Some might have torsions in their neck of their femur.

And that could cause some to stand with more external rotation, some to stand with more introverted internal rotation of the hip. So these are all things that we have to take into consideration is, what is the optimal dynamic alignment for that individual? We'll go into some detail on that. The next one is control of instabilities. So remember when I mentioned that if there is a ligamentous laxity, so let's say we strained the ligament, or we sprained our ankle for example, and we've lost some of that ligament or non-contractile stability, we're going to need to replace that with control of the neuromuscular system.

So how do we reeducate the muscles, for example, the ankle? Maybe the home exercise is that they're doing a TheraBand around their ankle and they're doing their exercises every day. They stand on uneven surfaces like a wobble board or an Oov or a pillow or a AIREX mat to be able to challenge the motor control of that and bring a heightened awareness and stability to that. So we talk about this as the control of instability. As it pertains to the knee, we're talking typically about medial collateral ligaments, or lateral collateral ligaments.

We're talking about anterior and posterior cruciate ligaments. So these are the four areas that we might lose stability in that anterior slide or glide plane. We might also lose stability in the medial or the lateral motion of the knees. So we would have to substitute those with neuromuscular control if we are not pursuing a surgical intervention. So again, looking at mobility, dynamic alignment and control, and the last one being movement integration, and I am a huge fan of restoring function, everything to me has to be about function.

And that function is very particular and unique to the individual. One of the important questions that I ask individuals is, "What do you believe you should be participating in right now? What do you wanna participate in? What activities do you want to be able to do?" So depending on the individual, if they say, "Well, I just wanna be able to get around my house. I'm, you know, 85 years old and I'm content.

I need to be able to drive. I need to go to the grocery store." You can put together, the activities could be, they need to walk. They need to be able to sit, stand, get out of a car, twist a little bit, need to be able to push a cart, need to be able to get up and down off of the toilet seat, need to be able to put their socks on their feet. Those become sort of the normal functional task that they're gonna need to be able to do. If I had that same person tell me that they believe that they should be able to play golf, they should be able to go hiking in the mountains and to go skiing, now I have to raise that bar a little bit of what task, what functional movement do they need to have in their life to be content.

And this is often a big disparity that exists for a lot of our clients, and even for ourselves when we have impairments in our bodies. So the ultimate goal in our sort of Polestar Principles is to restore function. And we have to know what task they want to participate in, in order to restore that function. So what I'd like to do now is I'm gonna go through each one of these with a couple demonstrations, and I wanna make it clear here that I'm not gonna be teaching a whole class. As a matter of fact, I've asked my colleague, Shelly Power to teach a number of classes that are geared towards these different areas and principles, if not all of them, in her classes for knee pathologies, knee rehabilitation, and also some classes that she has put together for knee health and prevention.

So how do we work with our children, our healthy adults, to be able to maintain the proper mobility, the proper dynamic alignment, the proper stability and control so that these individuals can function at their highest level? So I would defer classes if you're dealing with knee injuries or you have clients that have knee injuries that were developed by Shelly Power that are also on Pilates Anytime. So let's jump right in and let's take a look first at mobility. So we're gonna get onto the reformer, or we could also do some of these exercises on the mat looking at range of motion. I wanna make a sort of disclaimer here first.

One is that when we talk about range of motion in knee injuries, typically we're talking about the end of range. So that means that they don't have enough flexion, or they don't have full extension of their knee. When we deal with restrictions in midrange, in midrange. So somewhere in the middle of their knee, they're having pain that they can't move or gets locked. That requires typically medical attention.

So I just wanted to put a little precaution out there for you that you would refer that to, you know, their doctor or to their therapist, to be able to look at. We're typically talking about mobility as it pertains to the knee as a loss of end range, end of range flexion or end of range extension. And so we're looking at ways that we can start doing exercises to increase that mobility. So one of the first ones I wanna show that we do all the time in our mat work, our reformer on the trapeze table, is the bridge. And I'm gonna get in the position.

As we look at the bridge, what we can play with is the distance at which the feet are in relationship to the hips. So the further the feet are away from the hips, the less flexion range of motion they have. So I could start with somebody with the feet a little further out doing their bridge and teaching them to sort of that idea of reaching out through the knees, lengthening across the hips. This has a lot of benefits. From the idea of using the backside of the leg, the hamstrings, the glutes, to get the reach, to get the hip extension, to relieve the hip flexors.

And also now posting on top of that knee. So if I want to start increasing the range of motion, I can bring the feet closer. And the actual mobility of the exercise is on the descend. 'Cause I come down, my femur is actually approximating to the calf or the tibia. So I'm getting some sort of nice, gentle increase in range of motion for flexion.

And again, I could even bring that a little bit closer, and you'll see now that I'm sending my knees over my feet, and as I roll down, I'm really reaching my sit bones towards my heels to be able to increase that range of motion. And the nice thing about this exercise is that the load is not too great on the flexion moment. Even though we're increasing flexion, it's not like I'm cranking the foot towards the thigh, I'm allowing the thigh to come down towards the foot or towards the calf, okay? The next one is a modified sidekick. So in sidekick we can vary the length of the leg, right?

So if I want to start working on, typically a lot of the restriction in the knee is the inflection is gonna be the quadricep and the hip flexor. So if we're working on the exercise of hip extension in our sidekick, we can just keep the knee bent actually, and we get more extensibility of the muscles in the quadriceps and the hip flexors. We also can grab the knee in the sidekick and just sort of hold it there and you can even bring it forward and back in that same exercise we do all the time. And just keeping the heel nice and close to the bottom in that exercise as we move it, to be able to increase the suppleness and the flexibility in front of the knee. This one I do almost every morning for myself, just because I have my own knee pathologies.

We'll talk about a little bit later in the total knee question workshop, but this is what I do to be able to maintain and just really open up the front of my hips. So it's a very important exercise for me. The last one that I'm gonna show you, that would be a mat exercise that you could do anywhere is gonna be the leg kick. So if I'm laying on my stomach, and this one is, what's great as well for a hip problem and a hip replacement is just as valuable to the knee. And that's just doing an active contraction of the knee flexors to cause a reflexive inhibition of the knee extensors, right?

That's what's gonna allow that range of motion. Typically when the quadriceps are in spasms or restricted from the surgeries, especially around the patella tendon and quadricep tendon, this is a great exercise to cause a reciprocal inhibition and that in itself can really increase that flexion range of motion. So those are three mat exercises that I really like when we're dealing with sort of acute knee range of motion in loss of flexion, the ways that we can increase the flexion. I wanna move into the trapeze table exercise, where we're gonna be doing knee extensions and footwork with the tower bar sprung from below. So I have the tower bar sprung from below with a safety strap in place, and I'm using two long purple springs.

You could also use one short red spring if you wanted to have a little more tension, but the goal here is to work on knee extension. So I really like the weight coming down into the leg as the knee is pushing into extension. So I'm going to get into position and push the bar up and we can use just the one leg. And let's say I wanna work on my left knee extension. And just feeling that pressure coming down from the springs really gives me a nice stretch into extension.

I can also work a little bit through that ankle dorsiflexion that we talked about earlier as being essential for knee health. So I'm not worried about coming in too deep. You know, it's always a little shaky here as we come into that angle. I'm more interested in the extension in this exercise and then working a little bit on that dorsiflexion so that whole posterior chain is being challenged to loosen up a little bit. And really even sometimes I'll push my client's knee through a little bit, holding their foot to the bar so it doesn't slip.

Just like that. And rather than holding in a stretch, little pulses is often a great way of getting again, an inhibition or a relaxation of those tissues. So that pressure coming down from the spring, the repetition going into extension and the dorsiflexion through the foot. So the next piece of apparatus I wanna show a couple demonstrations on is the chair. And the combo chair is a great piece of equipment to work on, particularly flexion in that knee, that end of range.

Now we do a lot using things like moon box and things to limit the amount of knee flexion. I'm actually trying to use the chair now without the box to really challenge that knee flexion, to really try to get into that deeper range of motion, closer to a 125, a 130 degrees that would allow somebody to squat to the floor. So that's my intention here. And I just wanted to make it clear. A lot of times on the exercise I'm demonstrating in this section are tweaks to existing exercises to be able to really focus on things like mobility, dynamic alignment, et cetera.

So the first one is just the single leg press. And typically we work on the idea of just having a very nice organized body, very efficient, a slightly lean forward, and working on the control of the knee. But here also, I can lean forward a little bit more and I can really let that knee flex up. I let the springs bring the foot up and the knee into its sort of end range flexion. So this is a nice way, again, there's an active load on the lower extremity, and at the same time, I'm eccentrically lengthening the quadriceps to get that deeper flexion in the knee.

And to do that, I also have to have the springs up all the way to get the range of motion on the pedal. The next one is a more advanced exercise, and this is the lunge. And typically we would modify this as well, but here not so much about going up. I wanna use this as a way of actually going forward into that knee. And the springs that are just helping me a little bit with my arms to be able to load down into that ankle dorsiflexion and the knee flexion and the hip flexion.

So all three of them, hip, knee, ankle, necessary for full range of motion. We talked about the idea of things like running, squatting, jumping, needing these ranges of motion. So we can start up high. And I think, you know, even if you wanted to put a box underneath the pedal to start so that they can't go too far, but eventually working them again with load to be able to come all the way into that deep ankle dorsiflexion, knee flexion, and hip flexion. The last one that I'll show you is the seated knees on the chair.

And just, again, these are all normal exercises that we do in our equipment. But from here now I have, and especially with my longer legs, the pedals again are mobilizing me into a really nice axis where the pedal is coming back up towards vertical. So it's sort of bringing my shins or my tibias underneath my knees and it's taken me into hip flexion. So again, you could make the springs lighter, heavier, depending on how much mobility you wanted through that knee. These are all very safe ways.

I could also remove a leg out of the picture or I could pull the bar out and just do one pedal. I could also do alternating, but here I'm really focusing on restoring that mobility and end of range flexion. So that concludes our section on mobility. I do wanna bring your attention to many of our exercises can focus on terminal knee extension as well as knee flexion. Footwork is one of our best exercises for flexion on the reformer, feet and straps.

So the list goes on and on. Hopefully you'll try Shelly Powers class that will also address a lot of these mobility issues for knee pathologies. So for this next principle, dynamic alignment, I wanna demonstrate the bone rhythms or the Arthrokinematics, and I've asked Shelly to help me so that you can look at my hands also doing the tactile queuing to facilitate the bone rhythm, particularly the one of spiral that we talked about in the earlier module. And I wanna use the reformer to help us with the footwork, because it's a very safe, very easy way to work. And if you remember, when we talked about, when we bend our knees in a closed chain, the femur is going to spiral out and the tibia spirals in.

And then when the knee extends, just the opposite is gonna happen. The femur spirals in, the tibia spirals out. And the way we know, let's just keep repeating that, Shelly, the way we know that that's working correctly is because the foot does stay in alignment with the knee and with the thigh. If she turned both the femur and the tibia out, she would be going into an external rotation of her hip. And if she turned them both in, she'd be going into an internal rotation and a valgus knee, which we definitely don't want.

That's what we're trying to prevent. So just simple overhand pressure facilitating that rhythm. And we know we're doing it right when we're able to maintain that dynamic alignment of the ankle, the hip and the knee. And the reformer's a great place to practice that, because you can do lots of repetitions. We could use the footboard, we can use both legs.

We can work in different orientations of interactional rotation of the hips and still maintain that ideal alignment that we need for things like squatting activities. Remember, as we go into more functional activities, we need to be able to maintain that alignment in something like a jump or a single leg repeated jumping if we're gonna go run, or if we wanna walk or hike long distances. The next demonstration I wanna do for bone rhythms is on the chair. And this is one I talked about in one of the stories of the professional basketball player that gave him the accessory motion he needed to be able to find his power or his blow, as he referred to it, and able to jump. And I'm gonna let Shelly again, demonstrate the exercise of lunge, and I'm gonna show you the hand overlays to it to be able to really facilitate a nice fluid movement in the relationship of the knee and the surrounding bones.

So remember, we said that when she's in flexion like this, that the femur is spiraling out and the tibia is spiraling in, right? So this is going this way, this is going that way. As she straightens her knees back up, it's just the opposite, right? So she's going up. Tibia is spiraling out, as she goes down, tibia spirals in, and a lot of times with the knee pathologies I'll even use the tibia as the directive or the image, because a lot of times it's distracting enough that they forget about the knee and they're thinking about the tibia.

I can also take this a step further and I can do the same exact thing, the tibia stays the same and get the relationship into the ankle or the foot, again, explaining as she straightens up, she's going to spiral the tibia out and the talus in or the proximal foot in. And these are just nice ways to give them feedback. Again, 'cause a lot of times what'll happen is, they'll go up in the load and they'll go into a valgus stress, they'll collapse their foot, right? Or they'll often turn out to be able to avoid going over the big toe with the ankle. And these are just little ways that we can slow it down a little bit, make sure that they have the proper bone rhythm in their knees, in their lower extremity to really increase the function of their legs.

So as we continue the theme of bone rhythms or Arthrokinematics, I wanna finish up with a full normal weightbearing position in standing. I'm having Shelly stand a little abducted and a little turned out, because it makes it a little bit easier for me to use my hands in this position, but also a little bit easier for her. So again, the idea of as she squats down, femur spirals out, tibia spirals in, and the opposite going up. And what's interesting is, a lot of time in this position, allow it to keep coming down, let the hips keep coming down. Yeah, there you go, good, and then back up.

Now I can bring it into the hips. I could also follow that same pattern. So femur spirals out, pelvis spirals in, and the opposite, sit bones widen as the femur spirals out, and working our way down into the tibia and down into the foot and ankle and just trying to get a very functional range of motion for them, reeducating their squat to take away unwanted stress. So a lot of times, for example, even in the ballet world, when people go into their squat, they're taught to tuck underneath, which puts abnormal stress and changes the tracking on the patellofemoral joint. So if you're used to working with a lot of dancers or you're a dancer yourself, this is a faulty movement technique or strategy that's going to cause a lot of problems potentially in the knee and also over the toe and other parts of the body like the back.

So one of the things we try to do here is to really educate not just the knee dynamics, but also the pelvis. So as the femur spirals out, the pelvis has to spiral in, in the front, and sit bones are gonna widen in the back and that's gonna drop her down into a nice straight position and then come back up into a straight position. So these are the little tricks that we use all the time in our normal Pilates education. And then we bring 'em into a functional position, like standing or a plié for a dancer to be able to see if they can really capture what the Arthrokinematics are in their knee. Even I have children that are nine, 10 years old learning how to dance that can understand this concept of the bone rhythms.

So that concludes this section on dynamic alignment. I just wanna bring to your attention again, the idea of our ability to coach people to use not only the Osteokinematic or flexion extension as we did in mobility section, but also the dynamic alignment as it pertains to Arthrokinematics or bone rhythms. And just to reiterate that you can use these bone rhythms on any of the apparatus that's either closed or pseudo-closed chain activities to be able to reeducate that proper alignment and function. And this is particularly effective with things that have to do with patellofemoral pain, reeducating after surgery, any of the just behavioral changes that happen from knee pain. So you'll see how people change the way they walk.

This can make a big difference very fast in your client's performance and behavior. The next section I wanna cover as a tutorial is control of instability. And this again is the concept of when there are ligament impairments and there are a loss of stability in a joint, we have to supplement that with neuromuscular reeducation. We have to think about alignment. We have to think about mobility.

All those things come to play, but it really is about control. And this can happen when somebody has a meniscectomy, when somebody has a ligament injury that has resulted in some laxity in that joint, that we need to bring some control, some stability and some neuromuscular awareness. So the next couple things I wanna show you are activities that we can do, and that are also good home exercises to increase that strength and that control. And if you remember when we talked about what are things that help us with the healthy knee, right? Well, the healthy knee needs a healthy hip.

If the hip is not able to maintain the rotation in the rotators and the abductors, then it's very hard for any activity that uses deceleration through the knee. And this is where we talked about alignment in the last section. If we lose alignment, that's a problem, bone rhythms can help us. Here we're looking at actually exercises that are testing that strength in our single leg to be able to do a mini squat or decelerate when we move into walking or running activities. So the first one I wanna do is using a small box to be able to step down.

So I've asked Shelly to join me and help me with the step up and step down on a small box. And the goal here is to start working on some functional patterns. We're gonna go nice and slow. And what I'm looking for is I wanna make sure that she's shifting her weight and gonna be able to keep that knee in alignment as she comes up, and more importantly, as she goes down. This is one of the hardest things to teach following a knee injury.

And I know, it's a very challenging one for my knee as well. So let's give it a try, and things that I'm looking for, and you can just start stepping up and stepping down, and I'll talk through it is, how much tilt is there in the pelvis? Does the foot, the heel come up as they go down? It should, right? They should be able to allow themselves to decelerate through that knee moving forward and back.

So we're seeing Shelly does a nice job, obviously. As we come up into that position, again, I'm looking to see if the pelvis is maintaining itself, you know, is she tilting? Is she losing her knee alignment in a valgus or varus position? And just seeing if she has the ability to do five to 10 repetitions of stepping up and stepping down. This also will talk a little bit more about in the functional, but it is a great exercise at home.

They can do it on a step. They can do it on a small box, a phone book even, and we can always grade it. You can relax. We can always grade it to where we can do smaller heights. So for example, when somebody's coming off of a total knee replacement, we start working on small up and down for that ability to start getting used to allowing, and it's a very important word, allowing the joints to move through space.

When you're fearful and you have pain, the last thing you wanna do is move that joint. And so, you'll, I see people that walk, you know, with stiff legs or they they go up a step and they lift up with their hip and they come up this way or pull up with their hand, trying to avoid the whole idea of using their knee and passing weight through. I also know, Shelly and I worked with a number of patients together that have had knee pathologies. And one of the things we spend a lot of time on is really getting that weight to shift forward in that process. So looking much bigger than just the knee is looking at where's the torso, where's the hip, where's the ankle and foot?

And if we put a little more emphasis on other parts of the body than the knee, the knee does much better going up and down steps. The next exercise, and I adore this exercise. It was something I was taught right after I had my hip replacement. And now I use it every day in preparation for a knee replacement, which we'll talk about in another section of the training here. But the idea is using a Tai Chi stance coming down into just a small squat, not real big, not real deep, not uncomfortable.

And being able to maintain the standing leg in its normal dynamic alignment while we pick up the other leg and rotate the pelvis around that leg. So notice that this leg still stays relatively straight. And my pelvis now is on a 45 degree angle. I pick that leg back up and I bring it in place. And then I switch it to the other side, right?

And just stay in that position. And this is a great exercise. You'll do four or five of these, and all of a sudden you're feeling like, "Oh my gosh, my piriformis and my rotators are screaming at me." And which is a nice screaming, by the way, that I need to be stronger in those muscles in my body to be able to handle the deceleration for walking, going upstairs and eventually running. So there's an exercise I give to a lot of my patients. They can even pass the weight through, come back, pick up, bring the legs together.

And try to keep it slow, especially the challenge of that bringing the leg back. And try it right now, if you want. And just seeing if we can do that multiple times and trying to get it so that that knee stays straight. The most common error with its exercise is, as soon as you turn, people turn through their leg, so they don't have the rotation here. That's how we sort of cheat.

This applies to functional movement like getting in and out of a car or getting in a bathtub, or being able to get dressed. We need these kind of movements without the collapse of the knee, right? As soon as that knee collapses, we've lost that deceleration. And now we've exposed everything on the inside medial aspect of the knee. Great exercise for home.

So, another great prop or tool that we use in Pilates that's come along afterwards by Daniel Vladeta is the Oov. And the Oov has found many, many uses inside of our clinic, inside of our studio. And we often think of the Oov as something that we would lie on, or that we would lay on our side or sit on. But Daniel also has come up with a lot of exercises in standing. One of the ones that I really like that create a lot of unstable surfaces, is standing one foot on the neck of the Oov, and the other foot on the body of the Oov.

And it's unstable in multiple directions, which is the design of it, and try to find your balance and then squatting down, trying to keep the pelvis nice and even, coming up and down. So this one really challenges all of the dynamic awareness and control, spontaneous control of the body. And the reason why I like this so much is that because you can't predict what muscle has to be contracted to be able to maintain the control and stability, and then you turn around and try it on the other side. And again, this is always a fun challenge. Here we go.

Find the balance and then coming down into your squat, again, trying to maintain the pelvis even, and just squatting down. So my feet are going all different directions and I'm trying to stay on top of it. And it provides for stability training, abduction and abduction, flexion extension, and also in the rotation angle of the hip. Give that one a try. I will suggest that you have something to stick or next to the trapeze table when you first start mounting up onto the Oov.

You can also work on the Oov in the long position. And that's a little more challenging to get on top of, but also just getting on top of it this way, doing the same thing, working on your squats and more symmetrical with the instability, then sideways. So there's a couple challenges for you to give to your clients to work on their control. Another application of the OOV as it pertains to working on control and stability of the knee is lay on your back. And again, I've asked Shelly Power to join me and help me with this one.

The Oov itself laying on her back creates a lot of instability in a lot of different directions. So, it's meant to provide instability, anterior and posterior, side to side, and also diagonal. And the purpose of that design according to Daniel Vladeta is to be able to facilitate spontaneous organization in our body and control. And we know that a lot of times we get so hung up on telling people what muscles to use, that they get in the way of spontaneous organization, which is our ultimate goal and desire with our clients. So again, we're gonna assume that maybe Shelly has some problems with her right knee, and I'm gonna place the ball underneath the right knee.

So now I've even increased that instability a little bit more, and I am gonna have you bring this leg up just to hold it in position there, right? So now I've created a posterior instability, depending on what I have her do with her hands now is forcing her to create that contraction around the knee very spontaneously, because things are moving too much for her. She thinks, "Oh, I'm gonna use my quadriceps, or I'm gonna grab with my hamstring, or I'm gonna squeeze my glutes." She'll fall off the Oov, right? Especially as we start bringing the diagonal in. So right now, taking the hands into the knife hand position.

Right, good. And if we were to keep the diagonal of the left hand down that creates the stability through the right shoulder and just bring her right arm up. So now she has an instability on that diagonal, okay? And if I have her take this right hand out to the side, it creates the challenge or the perturbation that I want to be able to challenge her, right? These are the challenges that are taking place.

The same thing if I had her take her leg out to the side or move it around, creates the challenge. And you don't have to move it very far to get that challenge, right? And then let's bring this down for a second. Let's bring both arms up, right? And let's just feel this sensation of taking the arms overhead and back up to the ceiling.

So you're familiar with that one. And then let's bring this leg back up again, and we're gonna really challenge. She has to really find, I'm gonna give her a finger touch stability through the left foot and have her take her arms over her head again. And again, it's just connecting things you think of if she was paying volleyball or if she was playing tennis, what kind of stability would be demanded of her spontaneously? And that's why I love using the Oov.

Now, maintain the arms right there. Reach the right foot, roll that ball out a little bit, if you can, and bring it back. So now I'm starting to work on getting that extension inflection through the lower extremity with full load, everywhere, all different directions. Bring the arms back up to the ceiling. Take just the left arm out to the side and try the same thing with that right foot.

And I'm giving her just a little bit of touch guard on that foot. This is challenging. Her whole insides are trying to figure things out, and she's very good with this, you can imagine a novice. But these are the kind of challenges, and relax. Bring the hands down, again, feet down.

There you go. These are the kind of challenges that actually do happen in our body when we're walking, getting on uneven surfaces. You step on a curve, you step on a stone, trying to create the idea for spontaneous control, spontaneous stability of the knee coming back from an injury. So this concludes the part on control and instability. Just a couple examples, ways you can look at even some functional stability, looking at dynamic stability, looking at spontaneous stability.

These are the kind of words that we're looking for in movement reeducation. So as our clients are able to tolerate different perturbations from many different directions, creates a lot of stability inside of the knee, and more importantly, inside the whole body. And as they feel more integrated and more awareness of that leg in space, using challenges like we did with the Oov, like we did with the step as we did with the Tai Chi move, these are always to increase control, which is what Joseph Pilates talked about as Contrology or the science of control. And this really does bring home, you know, how important it is for us to be able to have that stability and that awareness and that spontaneous reaction. Another part of this that's very important is load management.

So I wanted to just talk for a second on load management. When we talk about control, we often have to have enough strength, or power or spontaneous power to handle the perturbation or the challenge of the movement. That would be for example, an uneven surface or stepping off a curb that you weren't expecting or being pushed in a crowd or a sport that is involving other people that you have to adapt to their movement and their forces or the movement of a ball. All of these require a certain amount of load management and control. And so I always like to bring up that in Pilates, we have the ideal playground for load manipulation.

We manipulate load by length of levers, where we put the strap on the leg. We control it by orientation to gravity. We control it with the springs that we use to create assistance in movement. We control it with changing the orientation of gravity, not just the amount of gravity. We also can manipulate things like tempo.

We can manipulate things like endurance. We can manipulate things that have to do with rhythm, and all of these play into the idea of control. So the question that I'm gonna pose to you is, going back to, "What do our clients, or what do we want to participate in, and what kind of load does that activity require? And if we are not up to par with that kind of load for that activity today, then we start doing these exercises that can modify the load and create a successful movement experience. Particularly today we're talking about knee injuries with that knee injury.

And so they start building confidence back up in their ability to move. So again, control, load modulation, trying to get organization, the body, to be at a spontaneous and subconscious level is our goal. The last principle that I want to cover in the tutorials for this knee section is movement integration. I picked three really fundamental movements that we do as humans. One is gate walking, couple ideas on that.

The second is running. I do believe running is a human right, and the last one is going up and downstairs. So we're gonna tackle, these are three things that are often the biggest complaints of people who suffer from knee pain. And we want to be able to show that our intervention is actually improving their ability to walk, possibly even run, and definitely to go up and down stairs or inclines. So the first thing I wanna talk about is gait training.

And one of the things that happens quite often to us is we catch ourselves back on our heels. So we go back on our heels and we tend to turn our feet out a little bit. And that's the way that we sort of pull ourselves through when we're walking, right? And one of the things that I want you to do as an exercise is to bring your legs relatively parallel, not everybody can get perfectly parallel, but where your knees and your hips are parallel, even if your feet are a little turned out. And explore the idea of leaning forward and coming back on your heels, and we call this the 60/40 split, right?

And we wanna find more or less where that 60% of the weight is on the front of the feet, 40% on the heels. So the heels aren't coming off the ground, we're not toe walking. And we're also not 80% of the weight back on the heels. We wanna find that space where we're about 60% there. And we should be very easily, just barely lean forward and feel the heels pop up.

That's what it tells you that you're in a position to walk. And another definition of walking is controlled falling, right? So we literally are leaning forward in a healthy gait, to the point about three degrees, that it just is very easy for us to take that first step. And that leads us to the second exercise that I like going from 60/40 is the step through. So if I leave my left foot as the main foot that I'm working on in its gait pattern, I'm going to rock through that step.

So a heel, ball, toe, heel comes off. And I'm just feeling that feeling of weight transfer, trying to get it. So my body weight is forward, even in that motion. So I'm not back here trying to pull myself through, right? I'm actually leaning forward and getting over that foot.

And you can feel the tensegrity that we've talked about, that tensegrity model creates that elasticity that propels us. It pushes us through space. And that's really the key that we're trying to reproduce with this walking through exercise, just to step through. And we do it on both legs equally, where we just rock through, and the idea is getting the eyes up. A lot of times in gait they're looking down because they're afraid that they'll fall again or they'll hurt.

And that brings all the energy down. It loses the elasticity of our body from being up here, right? And so working through, and then we switch legs, rolling through that foot. And trying to get it so the step comes closer and closer on each step, right? And almost more in line, like a tandem line, not quite tandem.

But feeling the roll through the foot, applying the lean, filling the toe off right over that second toe, and just becoming familiar so that when we do go for a walk, we have that reference of a little bit of anterior lean. We're rolling through the feet. We're allowing the tendons to be very elastic in their properties to propel us in movement. And remember, we said that proper alignment with the tensegrity model gives us propulsion and elasticity. And this is something that somebody coming back from a knee injury has lost.

They no longer feel that sense of propulsion or elasticity. It feels very heavy, very painful. They're often back on their legs, on their weight. Their head is down. So we wanna work on the functional idea of coming up into a nice, beautiful posture, weight forward 60/40, and then learning to work through that elasticity in a nice, tall posture.

The second one is running. So we have a whole library of exercises in our business called Runity at Polestar. We also have them on the Pilates anytime library with Juanito from Spain. And one of the exercises we do that I wanna talk about is a single leg hopping. And single leg hopping really is about checking to see if we are ready, or if our clients are ready to start running again.

So we should be able to do a hop like that for a minute on one leg. That would tell me that that person can go out and run. I'm not a runner, especially not with my current knee condition, but would tell me that I could go out running safely, maybe half a mile, and then walk a mile, run a half a mile, walk a mile, and start gradually building up a very healthy endurance. There was a old saying where people would say, "I'm gonna go run to get in shape." And then run until we say, "You need to get in shape to go running." So we take our Pilates training very seriously as the pre-conditioning, posture, mobility, dynamic alignment, control, endurance, functional reeducation. We're talking about here the movement integration is, can you hop on that one foot for a minute?

And when you're hopping, is that knee collapsing every time you come down on that foot, or is it able to track correctly? And what we often find is that they can do correct alignment for the first 20, 30 seconds. And then by the time they get to 45, 50, 60 seconds, they're collapsing. And that tells me, you have the right idea. You have the ability, but you don't have the endurance yet to run more than maybe 50 seconds, 60 seconds at a time.

And so that's where we would start them with a small, you're gonna run for 30 seconds and then walk for a minute, run for 30 seconds, walk for a minute, and gradually build up that endurance until they're able to do the hop. The last one that I wanna talk about is stairs and incline. Stairs and inclines tend to be a major challenge functionally to people that have knee pathology. We already talked a little bit with the chair and we showed the exercises with Shelly of going up and down. The stepping, looking at bone rhythms for dynamic alignment, looking at assistive ranges of motion.

The one that actually is the most challenging though, is going down steps, going downstairs, going down inclines. It's the deceleration of the step. So what I wanna do is show you another one that we use with the trapeze table and assisted springs. Using the trapeze table and those springs is a great way to restore function. And a lot of times we have our standing exercises at the end of the trapeze table.

This is one that I sort of made up using a step to be able to do, just like we would do with our spring assisted squats is now to do a spring assisted step. So you get the tension just about right. And we're gonna focus on assistance to go up on a step and down on a step. And this allows the client to get a little more confidence. It's a little challenging on the proprioception, but it does give them the assistance and the balance that we get from the springs going up and down.

And so just again, you can get creative. Eventually, as we showed in the beginning of just with Shelly on the control one, looking at the bone rhythms, is the same thing coming up and being able to come down off that step. So using the springs to help, nice way, provides a sort of in-between step where you're getting assistance, but it's unstable, and you have to rely a lot more on your body. And then eventually the ultimate one is the functional one of them going up and down steps on their own. And that concludes the section on the tutorials.

And I'll be back to finish up with those who might need surgery. And what does that look like and how do we make that decision?