More Than a Fad

Pilates has taken the fitness world by storm in recent years, but it may also have a place in the athletic training room. This article explains how Pilates techniques can be implemented into a traditional rehab program.

By Christine Romani-Ruby

Christine Romani-Ruby, MPT, ATC, is an Assistant Professor in the Physical Therapy Assistant Program at California University of Pennsylvania, where she also teaches in the Athletic Training Education Program. She is a co-founder of PowerHouse Pilates in Monongahela, Pa.

Training & Conditioning, 14.6, September 2004,

Odds are, you have heard about Pilates as a core conditioning and rehabilitation method. You have heard of professional athletes such as Jason Kidd, Tiger Woods, Curt Schilling, and Ruben Brown, giving some of the credit for their success to Pilates. You have seen the unusual equipment or watched athletes perform the advanced gymnastics-like movements.

Still, you’ve been wondering how Pilates relates to you as an athletic trainer. Though Pilates may seem like just another fitness trend, it is also becoming a popular method for rehabilitating athletes.

The Pilates method is based on a set of principles that incorporate many familiar concepts of athletic training and sports conditioning. For many athletic trainers, Pilates simply takes a slightly different approach to things they’re already doing. Pilates centers on a series of exercises, and most of these exercises mirror or build on techniques athletic trainers are familiar with. The Pilates machines are designed to enhance those exercises.

But machines are not required to utilize Pilates. Many of the exercises and movements can be taught on a mat with props simulating the effects of the Pilates machine. As a result, athletic trainers can blend Pilates into their therapeutic exercise regimen as they feel comfortable, choosing the exercises that make the most sense for them and their athletes.

Pilates exercises can easily be incorporated into traditional rehabilitation programs. Without abandoning other methods, Pilates exercises can be used as additional tools for reaching the goals your athletes have. Many times, the precision learned in Pilates will give traditional rehab exercises a whole new dimension.

As a certified athletic trainer and a Pilates instructor, I have seen the many ways these two disciplines interact. In this article, I look at some ways athletic trainers can incorporate Pilates exercises into their work by understanding the principles behind them and adapting some of their current procedures.

Pilates 101
The first Pilates principle is centering, which parallels the idea of core strengthening. Back in 1920, Joseph Pilates, founder of this method of exercise, concluded that all movement comes from a stable center, which he called the Powerhouse. He included the shoulder girdle, spine, and pelvic girdle in this Powerhouse, making these areas the focus of every Pilates exercise. These core areas are also a focus of many rehab efforts overseen by athletic trainers.

Concentration is the second principle. In Pilates theory, visualizing and engaging the mind should occur with every movement. Athletes gain kinesthetic, proprioceptive, and postural awareness through concentration. Pilates allows continued practice of these skills through its exercises and equipment.

The third principle is control. Pilates states that all physical motion must be controlled by the mind. Motion without control leads to a haphazard and counterproductive exercise regimen. To the athlete, this is motor learning. Skills can be as simple as mastering the ability to manage the body’s momentum or as advanced as learning the footwork used by a defensive back.

The fourth principle is flow. Pilates instructs athletes to move smoothly and evenly outward from a strong center, as seen in the movements of a gymnast, golfer, or professional dancer. Pilates exercise develops the grace found in the best athletes—movements you admire in any sport.

The fifth principle is precision: concentrating on the right movements every time you exercise. The idea is the same as an athlete meticulously isolating one muscle for re-training or strengthening to produce a certain effect.

The remaining principle is breathing, and in Pilates a diaphragmatic breath is coordinated with every movement. The breath ensures relaxation and increased flexibility, and also engages the deep core muscles. (See "Say ‘Ha’" below.)

Although not spelling them out as principles, Joseph Pilates underscored the importance of two other concepts: relaxation and stamina. He said his goal was for people to "learn to move without tenseness," which is vital for athletes. Endurance at the end of the game is crucial in preventing injury and maintaining performance levels. Through Pilates, athletes can develop the ability to use only the muscles required and to relax all others.

New Movement Patterns
Pilates can be especially useful when athletes have adapted to certain stretches and exercises. It may be difficult for them to change the way they perform ingrained movements, and they may even resist efforts to do so. By using Pilates, an athletic trainer can get an athlete to perform desired movements in a new way. I have found that if I introduce a new stretch or exercise, athletes often want to prove their mastery of it. This way, old habits can be broken and new movement patterns learned.

Pilates uses a lot of visual cues to help people perform the exercises correctly. I’ll tell students, "draw you ribs in and down," "draw your shoulder blades down your back," or "reach out of the top back of your head." When I can, I try to relate these ideas in ways athletes may better understand by connecting them to their sport. Even silly examples can work, such as telling them to reach out of Pebbles’ ponytail (from the Flintstones) to help maintain the proper posture with the back of the head reaching toward the ceiling.

Each exercise in the Pilates repertoire may (although it doesn’t have to) be performed on one of eight pieces of equipment that provide a specialized effect. Equipment resistance is provided by springs, which sometimes resist but often assist the movement. The body is directed to resist not only on the concentric movement against the springs, but also to resist the recoil of the springs on the eccentric return. In some Pilates exercises, the springs are used to re-align the body and provide consistent proprioceptive feedback.

Treating Shoulder Problems
The conditions that benefit most from Pilates are those that seem to defy diagnosis and leave athletic trainers searching for effective treatment methods. Many of these result from muscle imbalance and faulty posture. Too often, athletes adopt postures characteristic of their sport because of muscle imbalances. An example of this is the swimmer who develops a round-shouldered posture from the strength gained in the pectoralis major/minor and latissimus dorsi. This often leads to symptoms of thoracic outlet syndrome or impingement syndrome.

In these postural problems, the scapular force couple is disrupted. The levator scapulae and the rhomboids shorten, while the upper trapezius and the serratus anterior lengthen, creating poor scapulo-humeral rhythm. The pectoralis minor and the latissimus dorsi shorten, disrupting the glenohumeral joint axis and creating an anterior tilt of the scapula. To stand up straight, the athlete then lifts the entire ribcage, causing a lengthening of the external oblique. This can begin a downward spiral leading to very poor shoulder mechanics and chronic, unexplained pain. Key identifying factors of these syndromes are the previously described posture problems and an early and excessive elevation of the shoulder girdle during forward flexion or abduction of the shoulder.

Several Pilates exercises are extremely effective in correcting and preventing the poor mechanics associated with these postural problems. The first uses the Pilates ring to stretch the pectoralis minor without any risk of stress to the capsule. The Pilates ring—which is 15 inches in diameter and has a spring-like resistance—serves as a proprioceptive device to create the desired effect. The athlete is asked to stand in the Pilates posture holding the ring behind his or her back. He or she squeezes and releases the ring with light force while maintaining the Pilates posture and breathing. The athlete inhales on the squeeze to open the ribcage and then exhales on the release. Athletes with a tight pectoralis minor will tremble on the squeeze and feel like they can barely produce any force, which shows that the pectoralis minor is resisting the stretch.

A second exercise is used to increase the length of the latissimus dorsi, increase the strength of the external oblique, and retrain the serratus anterior. The athlete maintains a Pilates posture and holds the ring in front of his or her body. The upper extremities are relaxed and positioned in slight external rotation to engage the scapular stabilizers and recruit the serratus anterior. The round shape of the ring assists with this position, as does the cue to grip the ring more with the pinky fingers, which also helps to increase external rotation.

To complete the exercise, the athlete performs bilateral forward flexion to a point where there is no scapular elevation. When the scapulae elevate, the athlete stops and starts again. The use of a mirror is often beneficial with this exercise, since the results are rapid and very visual.

The athlete then progresses to a closed-chain exercise, such as side-lying on one elbow and lifting the ribcage away from the floor until the scapula is in neutral alignment. Positioning the ribcage on a fixed upper extremity encourages the proper scapular position. It is easiest to start on one elbow and then progress to being on an outstretched arm. The challenge can be easily increased by adding partial and full body weight. Further progression is attained by using an unstable surface, such as that of the Reformer, one of the Pilates machines.

Knee Injuries
Some other common conditions of muscle imbalance experienced by athletes include iliotibial band syndrome, patellofemoral syndrome, and chondromalacia. These all involve faulty mechanics due to muscle imbalance and poor posture. Surgeries for these are not very successful and treatment is often determined through trial and error. Pilates offers some exercise techniques that have proven to be extremely beneficial.

The first is side-lying abduction for strengthening of the gluteus medius. This exercise is not new to athletic trainers, but the precision used in the Pilates method is. The exercise is done with the top leg extended into a leg spring to align the pelvis not only in the saggital plane, but also in the transverse plane. The anterior/superior iliac spine (ASIS) is aligned, creating the appropriate length of the gluteus medius and adductors prior to and during the motion. The goal is to extend the muscles to the length they will reach during athletic activity.

The athlete is encouraged to keep stretching the leg into the spring throughout the entire motion of abduction. The spring resistance can be replaced by using rubber tubing or providing appropriate verbal cueing on the mat.

The second exercise used for these postural syndromes is leg circles, which stretch the iliotibial band and teach proximal stability and distal mobility. The athlete lies supine with one leg extended to the ceiling and the pelvis in a neutral position. He or she then performs a leg circle motion with the hip in neutral position. The goal is to hold the pelvis still. If the pelvis moves, the size and speed of the circle must be reduced.

A third exercise for these conditions requires a piece of Pilates equipment called a Reformer. The balls of the feet are placed on the footbar with the athlete supine. The athlete does a leg press, a heel-cord stretch, and a toe raise before returning the carriage by flexing the knees. This exercise not only strengthens and stretches the lower extremities, it also allows a comprehensive evaluation of the mechanics of the hip, knee, ankle, and foot. The athletic trainer can stand above the athlete and cue him or her into proper mechanics.

For example, a common dysfunction occurs when the femur internally rotates on full extension. With the Reformer and some verbal cueing, the athlete can learn to eliminate this improper motion from the action of extension. With the disappearance of the rotation there often comes a disappearance of pain.

As you can see, knowledge of the Pilates repertoire can be an asset to athletic trainers. Learning just a few of the exercises or being introduced to a few pieces of equipment will give the athletic trainer many additional exercise options. The underlying principles of athletic training and Pilates are similar—a strong core and proper posture improve performance and provide rapid return after injury.

Say "Ha"
To take a Pilates breath, inhale through the nose, imagining the ribcage expanding to the sides and the air going into the lower lobes of the lungs. Exhale through the mouth, making a "ha" sound and drawing the navel to the spine to engage the transverse abdominis. This breath is often practiced as if pumping up and deflating a tire. Inhale five times and then exhale five times, for as many as 10 pumps.

Pilates Posture
Stand with the legs in external rotation and heels together so that the second toe and patella point in the same direction. The outsides of the thighs are imagined to wrap outward and the backs of the thighs zip together. The anterior triangle of the pelvis, made up of the anterior/superior iliac spine (ASIS) and the pubic symphysis, is positioned in the frontal plane. The anterior angle of the 10th rib is stacked directly over the ASIS with the ribcage in the frontal plane. The scapulae are drawn down the back and the chest is open. The top back of the head reaches toward the ceiling so that the back of the neck is long.