The Ultimate Pilates Guide to Hip and Knee Replacements

Pilates protocol to rehabilitate clients after knee and hip replacements

The number of hip and knee replacements has increased by 84% in the past decade making these surgeries the 12th most common inpatient procedures in 2010. Due to the nature of a Pilates workout, it is the perfect program to facilitate recovery after hip/knee surgery.

Osteoarthritis is the most common reason for a total or partial hip and knee replacement. Just in the United States alone osteoarthritis affects 13.9% of adults ages 25 and up and 33.6% of those 65 and up (according to CDC statistics.)

In general, 9 out of 10 people experience dramatic pain relief after a replacement but living with an artificial joint poses new challenges. Some people going in for surgery expect that they will be able to use their new artificial joint just like a natural one but without all the pain. After working with several clients both before and after a replacement I can see that getting used to a new joint takes time and a whole new approach to movement.

Pilates is the ultimate rehabilitation workout for these clients. Prior to surgery they lived with pain for many years, sometimes even decades. This pain created compensation strategies in their bodies that won’t be fixed by simply replacing the joint. Even though the pain is gone now, the body is still used to moving as if it were protecting the painful area. Plus the limited range of motion in the joint as well as the “unnatural” sensation experienced by some of the post-replacement population makes regular daily activities as well as traditional exercise more challenging and sometimes even dangerous.

Pilates offers just the right approach to rebuild balanced movement patterns in the body as well as maximize the benefits of the artificial joint.

Several experienced Pilates instructors and studio owners share their advice on working with the clients before and after hip and knee surgeries. These answers will be of particular interest to Pilates instructors working with this population as well as to Pilates students who experience hip/knee problems or are rebuilding their strength after a replacement.

1. What unique benefits does Pilates offer after a knee/hip replacement?

Katherine and Kimberly Corp, the owners of Pilates On Fifth in New York City say,

1. “Pilates restores the alignment of the body. It is an ideal forum to both ensure that the joints in question are in optimal position and to correct imbalances or faults that could exacerbate the condition that caused the problem in the first place.
2. Muscles are strengthened in the optimal alignment after surgery. Muscle fibers will form along the lines of force that they are given, meaning that if alignment is faulty while exercises are performed, the muscles will lay down new fibers in that faulty pattern. Pilates, under the watchful eye of a skilled instructor, will ensure that the alignment is optimal so the new fibers form in a way that is beneficial to the joint.
3. Core strength is a vital component for anyone recovering from any knee or hip surgery, and the Pilates protocol will automatically include core strengthening along with exercises specific to the joint.
4. With Pilates, a skilled instructor can also see and identify “coping mechanisms”: habits that might have inadvertently developed after the surgery due to an avoidance of pain and/or a need to get around and function. We will look to correct those and restore proper alignment of the whole body.”
5. “Pilates helps speed up recovery along with making sure we strengthen and lengthen the area to help with the scar tissue,” says Jessie Zamer from Sculpt Fitness Studio in Houston.

2. Why is it ideal to do Pilates before surgery?

1. “I find it beneficial to do Pilates before surgery since many exercises assist hip/ knee issues to maintain range of motion and strengthen the surrounding tissue,” says Heike Yates of HEYlifetraining Pilates & Wellness. “Due to the no- to low-impact form of Pilates joints can be exercised very gently and surrounding tissue is strengthened even when range of motion is diminished, for instance, the lack of cartilage in the knee or deterioration of the femur in the hip.
2. Addressing the core is helpful for balance before and after surgery as it makes the clients much more confident and less afraid of falling. [in my experience] clients taking Pilates recovered faster and were not as afraid of movement after. Also they returned faster to exercise once cleared by the doctor. In some cases surgery can be delayed, as one of my clients was able to delay knee surgery due to osteoarthritis by one year.”
3. Pilates helps to “undo” poor compensation habits prior to surgery. “In some cases, students have developed poor muscular and compensation habits that have contributed to the need for the knee replacement. We can begin to “undo” some of these problems prior to surgery and then retrain the muscles after surgery to work in the proper manner,” says Julie Erickson of Endurance Pilates.
4. Strong core enhances and facilitates recovery especially in the early days after surgery. “The orthopedic doctors I work with all recommend Pilates before surgery. It is important to have a strong core, which greatly enhances and facilities recovery. Especially in the early days after surgery, when a patient is on a walker, crutches or a can, core strength and shoulder stability can make all the difference in being able to get around,” says Laura Phillips, the founding president of the Houston Pilates Association.
5. Strengthening muscles around the affected joint speeds up recovery time. “The stronger and more well-balanced the muscles before surgery, the faster the recovery period. Some atrophy is to be expected after-surgery given post-operative rest, etc., but if the client begins the process from a stronger place, the net result will be much better than if no preparation was done at all,” share Katherine and Kimberly Corp.

3. What muscle imbalances are most common after hip/knee surgery?

One of the amazing parts of the Pilates method is that it addresses body as a whole. It doesn’t only strengthen a particular group of muscles or increases range of motion in one joint, it trains the whole body as an integrated system.

After surgery it would seem logical that only the affected side of the body needs extra attention. In reality we see that the entire body bares the consequences of surgery and any pre-surgical condition.

1. There is an overall imbalance between the right and left sides of the body that is exacerbated by the compensation mechanisms developed prior to surgery.
2. The muscles in the back of the leg are generally weakened and not actively utilized.
3. There is an overall imbalance around both the joint and the place of incision.

4. What are the main areas of focus of a Pilates workout?

Pilates works the entire body with emphasis on core strength and two way stretch. “Pilates builds a suit of armor from within and begins with teaching students to use the muscles of the core to support all of the movements of the body,” explains Julie Erickson.

Perhaps the best way to understand the true focus of a Pilates workout is to listen to Joseph Pilates himself as he says that

[The focus of any Pilates workout is] the attainment and maintenance of a uniformly developed body with a sound mind fully capable of naturally, easily and satisfactorily performing our many and varied tasks with spontaneous zest and pleasure.

5. When is it safe to start a Pilates-based rehabilitation program?

It is important to obtain clearance from the surgeon to start a Pilates program. Some patients can start doing Pilates just 6 weeks post-op while others need several months before they can come to the studio.

A lot of physical therapists now use Pilates equipment to further facilitate recovery of their patients. Many Pilates studios (like Pilates on Fifth in New York) also have PTs working at their facilities.

The number of physical therapy sessions covered by insurance differs from patient to patient and it has great impact on how soon a client can come back to Pilates. Pilates proves to be an effective and cost-efficient way to facilitate recovery after the initial PT sessions are over.

It is important to obtain exercise guidelines from the PT or from the surgeon before starting a Pilates program.

6. General precautions after hip/knee surgery

6. How does Pilates therapy compare/differ from PT?

Katherine and Kimberly Corp probably have the best explanation of differences between physical therapy and Pilates.

“Pilates naturally looks at the whole body working in concert, and does not isolate itself to one joint, even though more attention might be given to that joint at a given time. We like to explain it in terms of music: the PT works on an individual instrument at a time, while the Pilates professional works on the whole orchestra in concert. One instrument, or even a section of instruments, might receive more attention at times, but the goal is a harmonious blend of the orchestra working as one. In our case, the orchestra is the body!”

7. What are REAL people saying about the results of a Pilates-based rehabilitation program for hip and knee conditions?

A recent study looked at the benefits of Pilates Training for Use in Rehabilitation after Total Hip and Knee Arthroplasty. While the study group was small, the authors of the study concluded that Pilates Therapy was a helpful and viable rehabilitation technique for the clients recovering after hip and knee replacements (detailed study summary can be found here.) It is probably more helpful to hear what real people are saying about their success with Pilates.

1. Katherine Corp asked a client who has “bad knees” from surgery on one of them how her knees were doing and she said “Amazing, actually! I’ve been working on the reformer and then at home with the band and they’re so much stronger now they don’t even hurt!”
2. Kim Wallis who works with pro athletes and has several NHL clients said, “Many of my NHL players come in with “heavy legs”. They say they feel “lighter” on the ice after a Pilates session, that their muscles can “breathe” or that they have better circulation. I work with a rookie NFL player who secured a starting position because coaches saw such a marked improvement in speed and flexibility.”
3. “Pilates for Athletes is the perfect solution for any professional athlete looking to gain an edge. I began Pilates with Kim in 2002 after a potentially career threatening injury and I went on to play another 11 years in the NHL in large part to this regimen. Pilates will make you stronger, more in tune with your body and recover faster!” -Jamal Mayers, NHL Stanley Cup Champion who works with Kim Wallis.
4. “My clients love that they can do almost all the exercises they did before surgery. They feel strong and confident in their everyday activities, as they are no longer in pain after surgery; they actually move better, are able to play sports again, or play with their grand kids. My athletes can’t wait to get back to their regular training and apply what they “had” to learn during the injured phase, which usually is to slow down and focus on their core and flexibility,” shares Heike Yates.
5. “I have worked with many clients in preparation to their knee replacement and hip replacement surgeries and their recovery was indeed a lot faster compared to people that did not have such Pilates based programs prior to their surgeries. The clients themselves commented on how they felt and how much faster their recovery process was. They all agree that having started Pilates months or years before the surgery was needed, made their bodies stronger, more supple and better equipped to withstand such an invasive procedure. The speed of their recovery was so noticeable, that even their surgeons commented on their fast recovery process,” Rucsandra Mitrea.
6. “I mainly hear how Pilates has given them greater body awareness. Having that body awareness and being able to take that outside of the class and use it in everyday life is key to a healthier and productive lifestyle,” Jessie Zamer.
7. “I have several students that credit their Pilates program with adding significant yards to their golf drives post knee surgery! I also have hip replacement students who credit Pilates and the Pilates focus on proper movement patterning with their ability to move through their regular exercise regimen without pain.” Julie Erickson
8. “I’ve had numerous clients come back after hip and knee replacements, and I’d say the overall response is a sense of joy and release at being able to move again with freedom, without pain.” Laura Phillips
9. “Clients say they feel alive! They feel flexible and strong. Their wastes shrink in size and their posture is improved. Their moods are improved and they are able to do all the activities that they love.” Stephanie Perry

8. Best Apparatus/Reformer exercises for this population

9. What is the best Pilates homework after surgery?

1. “Mostly it is a focus on their bad habits. Trying to take what we learn in class to undo all the bad habits we tend to over look in our everyday routine. I think it really helps – when people remember to do their homework, that is!” says Jessie Zamer.
2. “Matwork and an additional stretch to work on during the week,” says Julie Erickson.
3. “The trick with homework is giving our clients something they’ll actually do!!! Realistically, 2-3 exercises is usually infinitely more manageable than 10… or even 5. We try to give clients a little routine that does not last more than FIVE minutes…. and then possibly, for the motivated, a routine that lasts 10-15 that they can do 2-3 times a week, just not every day,” share Katherine and Kimberly Corp.

10. Best Pilates mat exercises after hip/knee replacement

1. Breathing in supine position. Focus on expanding the ribcage to the sides and into the floor feeling that you are filling up the lowest pockets of your lungs with air. Exhale through a wide mouth letting all the air escape from the lungs. Practice core activation on each breath to create the feeling of a seatbelt tightened across the hipbones.
2. Leg Slides. Focus on keeping the pelvis from rocking as the leg slides forward. Imagine that you are dragging the leg through the mud.
3. The Hundred (legs on the floor or in tabletop.) Focus on keeping the lower back in neutral position and the neck and shoulders relaxed.
4. Arm circles with focus on ribcage stability. You can add therabands to increase the challenge.
5. Single Leg Circles. The bottom leg can be bent to assist with tight hamstrings. If recovering after hip surgery the range of motion should be small and any movement past the midline should be avoided. Focus on keeping the hips still while the leg is creating a controlled circle in the air.
6. Single Leg Stretch focusing on the straightening of the knee.
7. Spine twist while keeping the hips glued firmly to the floor. If hamstrings and lower back are tight, Spine twist can be performed standing or while sitting on a chair or a bench.
8. Side Kicks:
   – Clam
   – Front and back
   – Leg Lifts
   – Bicycle
   – Bend and Stretch with theraband.
9. Swimming (can be modified to slowly lift the opposite arm and leg.)
10. Modified Swan with focus on opening the chest as the shoulder blades slide down the back. The extension is happening only in the upper thoracic region as the lower back remains in neutral position, legs are actively lengthening.

11. Additional Resources

• Pilates for Hip and Knee Syndromes and Arthroplasties by Beth Kaplanek
• Pilates Training for Use in Rehabilitation after Total Hip and Knee Arthroplasty: A Preliminary Report, contains a Pilates mat program after hip/knee surgeries
• Ultimate Pilates Workouts:
  Lean Legs, and Butt
  Energize & Elongate
  Dynamic Stretch & Tone

Special Thanks and Credits

I want to thank personally all wonderful Pilates instructors who have contributed to the creation of this guide.

1. Katherine and Kimberly Corp, creators of the Ultimate Pilates Workouts and the owners of Pilates on Fifth in New York City.
2. Julie Erickson, the owner and the instructor at Endurance Pilates and Yoga Studio in Boston.
3. Jessie Zamer, STOTT cetified Pilates instructor at Sculpt Fitness Studio in Houston.
4. Laura Phillips, a Master Instructor for Peak Pilates and the founding president of the Houston Pilates Association.
5. Kim Wallis, the Director of Pilates at NutriFormance in St Louis, MO.
6. Heike Yates, the CEO/owner of HEYlifetraining Pilates & Wellness in Maryland.
7. Darleen Hutchins, corporate wellness program instructor (pilatesforcorporate.com), and contemporary Pilates Class instructor at www.Sobefitbody.com in Miami Beach, FL.
8. Rucsandra Mitrea, the owner and founder of the innovative Mitrea Wellness Centre, located in Toronto, Canada.
9. Stephanie Daulton Perry, the founder and creator of D Method and a Pilates instructor at Abundio’s Studio in Fort Worth, TX.

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