Pilates Injuries: Back, Neck, Hips, Wrists and Knees

Every Pilates injury, by body part

Start from where it hurts. Each row links to the page that covers that injury in full.

Not on the list, or not sure which row is yours? That is what the first visit is for.

The common ones, in more depth

The neck in the hundred and roll-ups

The hundred, chest lifts and roll-ups all hold the head up off the mat against gravity. The small, deep muscles at the front of the neck are meant to hold it there. When they tire, the larger muscles at the side of the neck take over, the chin pokes forward, and the neck ends the class stiff and sore at the base of the skull. We time how long you can hold the head lifted with the chin tucked before it pokes forward, and test the deep neck muscles lying down. Rest the head on the mat or a small cushion for the hundred, or support it with your hands for chest lifts. The abdominal work carries on while the neck builds endurance. Pain, numbness or pins and needles down an arm is a different problem, covered in cervical radiculopathy.

Back pain after Pilates

Low back pain after Pilates is usually a load problem rather than damage. When the legs are held low in the hundred or the double leg stretch, the abdominals have to stop the lower back arching off the mat. When they run out, the back arches and takes the strain. Mid back pain is often the other way round: a stiff upper back in a roll-up hands the bending to a few segments, or swan and back extensions go further than the back can hold. The muscles between the ribs can complain after side bends and twists. We look at how the spine bends, one segment at a time, in a slow roll-down, test back extensor endurance, and find which exercise in your class brings it on.

Two exceptions are worth knowing. Pain down a leg with pins and needles points to a nerve root, often from a disc, covered in slipped disc. And bones thinned by osteoporosis tolerate loaded forward bending poorly. In a small 1984 study of women with spinal osteoporosis, new spinal fractures were far more common in the group given flexion exercises than in the group given extension exercises.² If you have osteoporosis or low bone density, ask your doctor and your therapist before roll-ups, rolling like a ball and rollover.

Hamstrings and the front of the hip

Feet in straps puts the hamstrings at length under a spring, and front splits on the reformer can take them further than they have been in years. A sudden pull in the back of the thigh is a hamstring strain. The front of the hip works the other way. Leg circles, scissors and the teaser keep the hip flexors working with the legs long, and a deep ache or a catch at the front of the hip can follow. A click or clunk there as the leg circles is usually a tendon flicking over the joint, covered in snapping hip. We test hamstring and hip flexor strength on both sides, and watch the leg circle for where the catch starts.

Wrists in plank and long stretch

Wrists and hands are seen by our hand therapy team.

Plank, long stretch, up stretch and side plank all put body weight through a wrist bent back near the end of its range. The tissue at the back of the wrist can pinch, which is pain across the back of the wrist as you press into the mat or the footbar. A ganglion can ache in the same position. Side support on one hand loads the little-finger side, where the TFCC sits. Tingling in the thumb, index and middle fingers after long holds, or at night, points to the carpal tunnel. We measure how far each wrist bends back, grip and pinch strength on both hands, and how long you can hold a plank before symptoms start. Fists, forearms, or a folded mat under the heel of the hand all reduce the bend. A wrist that is swollen, out of shape or too painful to grip after a fall needs an X-ray first. After that, a hand therapist manages the splint, the stiffness and the grip.

The shoulder in reformer arm work

Arm work in the straps takes the shoulder overhead and behind the body against a spring, often kneeling or lying with little support from the rest of the body. On springs heavier than the rotator cuff is ready for, the pattern is an ache at the side of the shoulder, worse reaching up or lying on that side at night. We test rotation strength against the other shoulder, and look at how the shoulder blade moves with the arm overhead. A lighter spring and a smaller range for a few weeks usually lets the arm work continue while the cuff is strengthened outside class.

Knees in footwork and barre, and falls off the carriage

Footwork presses the carriage out against the springs with the knees bending and straightening, and barre adds pliés and small pulses with the knee held bent. Pain around the kneecap that comes on with deep bends and heavier springs is usually patellofemoral pain. Pain just below the kneecap that builds with the jumpboard is the patellar tendon. We test single-leg squats and step-downs on both sides, and the spring setting the knee tolerates without pain the next morning.

The reformer carriage moves. Most of the falls we see happen getting on or off, or standing on the carriage, and end in a turned ankle or a hand put out to break the fall. A finger can also be caught between the carriage and the frame. Any of these is worth a doctor first if the joint is out of shape or too painful to use, listed below.

Return on tests, not dates

Pain going away is the first sign, not the last. These are the checks we use before your usual class:

• Neck: the head held lifted with the chin tucked for a full hundred, with no neck pain that evening.
• Back: a slow roll-down and roll-up without pain, and back extensor endurance close to what it was before.
• Hamstrings and hip: single-leg bridges and leg circles without pain or a catch, counted on both sides and close to each other.
• Wrists: a plank on flat hands without pain at the back of the wrist, and grip strength close to the other hand.
• Shoulder: rotation strength close to the other side, and arm work in the straps without pain the next morning.
• Knees: single-leg squats and step-downs without kneecap pain, compared with the other leg.

Then load comes back in steps: lighter springs and fewer repetitions first, then your usual class, then the harder level or the jumpboard. This is Stage 4, Return & Perform, of The Phoenix Recovery Protocol. Pain is the first thing to leave. Strength is the last to train and recover.

Is this normal?

Sore abdominals, inner thighs or glutes for a day or two after a new class or a harder level, on both sides, is usual and settles in 24 to 72 hours. So is muscle shaking during a long hold. A stiff neck or back the morning after a class that settles as you move is common, and is a reason to adjust the load, not to panic. Pain at one spot, on one side, that is there at the start of the next class, that makes you skip an exercise, tingling or numbness, or pain still there after a lighter week, is worth getting checked.

When to see a doctor first

• Call 995 for chest pain, collapse or severe breathlessness in class. Also after a fall from the reformer with a knock to the head followed by confusion, vomiting, a worsening headache or drowsiness, or neck pain after a fall or a rollover with numbness, tingling or weakness in the arms or legs. Do not move someone with a suspected neck injury.
• Emergency department now if a wrist or finger is visibly out of shape after a fall or after being caught in the carriage, or a crushed finger has a deep cut; if back pain comes with numbness between the legs or new problems passing urine or stool; or if you are pregnant and have vaginal bleeding, fluid leaking or regular painful tightening during or after class.
• Doctor the same day for sudden sharp back pain during a roll-up or a forward bend if you have osteoporosis or low bone density, which can be a spinal compression fracture; a pop at the sit bone with bruising down the back of the thigh, which can be a hamstring tendon tear; or new weakness in an arm or a leg.
• Doctor soon for pain, numbness or pins and needles spreading down an arm or a leg; tingling in the hand that wakes you or does not go; a wrist still painful at the base of the thumb after a fall, even if it looked normal; or a hip that locks or gives way.

Questions people ask

What are the most common reformer Pilates injuries?

Reformer Pilates injuries most often involve the lower and middle back, the neck, the hamstrings and hip flexors, the wrists in plank and long stretch, the shoulders in strap work, and the knees in footwork. Most come from springs, repetitions or level increased faster than the body has adapted. A smaller number come from falls off a moving carriage.

Why does my back hurt after Pilates?

Back pain after Pilates usually comes from load rather than damage. Common causes are the lower back arching when the legs are held low in the hundred, and roll-ups done with a stiff mid back. Pain down a leg with pins and needles needs assessment, and sudden sharp pain with osteoporosis needs a doctor the same day.

Why does my neck hurt during Pilates?

In the hundred, chest lifts and roll-ups, the head is held up against gravity. When the deep neck muscles tire, the larger muscles at the side of the neck take over and the chin pokes forward. Resting the head on the mat or supporting it with the hands keeps the abdominal work going while the neck builds endurance.

Can I do Pilates with a knee injury?

Often, yes. Pilates is commonly used in knee rehabilitation because spring resistance can be set light and the depth of knee bend can be limited. Kneecap pain may flare with heavy footwork, deep bends and barre pliés. After knee surgery, the surgeon’s protocol comes first, and a therapist sets which exercises suit each stage.