Reformer Pilates for Knee Pain: The Complete Guide

Important medical notice: this article is for information only and does not replace diagnosis or treatment by your orthopaedic surgeon, physiotherapist, rehabilitation doctor or any other healthcare professional. Knee pain has many causes with very different approaches. What is safe and beneficial for one person can be harmful for another, depending on the specific diagnosis, the stage of the injury and the clinical history. Before starting any exercise programme with knee pain, consult your doctor and obtain express clearance. The exercises described in this article are a guide and must be adapted to your situation under the supervision of a qualified instructor who knows your diagnosis.

The knee is the largest joint in the body and also one of the most vulnerable. It bears three to five times body weight going down stairs, and up to eight times when running. When it hurts, any physical activity becomes a question mark.

Reformer Pilates appears more and more often in the recommendations of physiotherapists and orthopaedic surgeons as a complement during rehabilitation or as a form of long-term maintenance. But as with any tool, the key is knowing how, when and for whom.

At Pinar Pilates we have spent years working with students who arrive after a diagnosis of chondromalacia, after an arthroscopy or with chronic knee pain without a clear cause. This guide gathers what we have learned, together with what the available scientific research says.

Why the Reformer Is Especially Suitable for the Knee

Low Impact and Controlled Axial Load

The characteristic that makes the Reformer especially useful for people with knee problems is the possibility of working unloaded or with a controlled, progressive axial load. Exercising lying down or reclining, the knee does not have to bear full body weight. The Reformer springs regulate the resistance precisely, which makes it possible to start with very little load and increase it gradually as the joint tolerates it.

This contrasts with activities such as running, jumping or even walking uphill, where the impact and load on the joint are hard to modulate.

Supervised Range of Movement

One of the critical factors in knee rehabilitation is controlling range of movement (ROM). There are positions within the flexion arc that put more stress on the cartilage, the menisci or the ligaments, depending on the condition. On the Reformer, the instructor can define exactly up to what angle the student works, something impossible in many floor exercises or gym machines with fixed stops.

For example, in cases of chondromalacia, the range of 0 to 30 degrees of flexion is usually the most problematic. A good Pilates instructor works above that angle or adapts the exercise to avoid it.

Strengthening Without Joint Stress

Quadriceps atrophy is an almost universal consequence of chronic knee pain. When it hurts, the body stops recruiting those muscles efficiently, which creates a vicious circle: less muscle, less joint support, more pain. Recovering the strength of the quadriceps, hamstrings and hip abductors is essential to protect the knee in the long term.

The Reformer lets you strengthen all these muscle groups with far less mechanical stress on the joint than traditional closed-chain exercises such as barbell squats or heavily loaded leg presses.

Knee Conditions That Benefit from Reformer Pilates

Chondromalacia Patellae (Patellofemoral Syndrome)

Chondromalacia patellae is a deterioration of the cartilage on the back of the kneecap. It shows as pain at the front of the knee that gets worse going down stairs, sitting for a long time with the knee bent (the “cinema sign”) or squatting.

Reformer Pilates addresses three of the factors that most contribute to this condition: weakness of the vastus medialis obliquus (VMO, the inner part of the quadriceps), the imbalance between the lateral and medial thigh muscles, and the lack of neuromuscular control of the kneecap during movement. Footwork exercises on the Reformer, correctly loaded and aligned, are a first-choice tool in the rehabilitation of patellofemoral syndrome.

A randomised controlled trial by Khayambashi et al. (2014) published in The American Journal of Sports Medicine showed that strengthening the hip muscles (abductors and external rotators) notably reduces patellofemoral pain, without needing to work directly on the knee in the early phases. The Reformer lets you work precisely these muscle groups with high precision and control.

Meniscus Injury (After Conservative Rehabilitation)

The menisci are two fibrocartilage structures that act as shock absorbers and stabilisers inside the knee. Meniscal injuries can be traumatic (a sudden twist) or degenerative (progressive wear, more common from the age of 40).

In the acute phase, exercise is not indicated. But once that phase has passed and with medical or physiotherapy clearance, Reformer Pilates lets you retrain knee coordination and strength with a load that does not compress the damaged meniscus. Unloaded exercises (lying down, working in chain extension) are the safest in these phases.

It is key that the instructor knows the location of the injury (anterior horn, posterior horn, root) and whether there was surgery, in order to adapt the range of movement appropriately.

Anterior Cruciate Ligament Injury (After Rehabilitation)

Rupture of the anterior cruciate ligament (ACL) is one of the most frequent injuries in sport. After reconstruction surgery (the most common option in active people) and the rehabilitation protocol with a physiotherapist, Reformer Pilates can be a very effective complement for regaining confidence in the joint, neuromuscular control and functional strength before returning to sport.

The Reformer does not replace physiotherapist-led rehabilitation; it complements it. Proprioceptive exercises (awareness of the joint’s position in space) are especially relevant in ACL recovery, and the Reformer integrates them naturally into almost all its exercises.

Reformer Pilates in the post-rehabilitation phase (not in the acute phase or in the first weeks after surgery) is documented as beneficial for restoring strength symmetry between the two legs, a key indicator for returning to sport.

Knee Osteoarthritis

Knee osteoarthritis is the deterioration of the knee’s joint cartilage. It is the most frequent cause of chronic knee pain in people over 50. The idea that exercise “wears out” the arthritic knee further is a myth that research has consistently disproved.

A systematic review and meta-analysis by Fransen et al. (2015) published in the Cochrane Database of Systematic Reviews, which included 54 controlled trials and more than 3,000 patients, concluded that supervised physical exercise produces moderate, clinically significant improvements in both pain and physical function in people with knee osteoarthritis, with no relevant differences by type of exercise.

Reformer Pilates fits this evidence well: supervised, low-impact, progressive exercise with attention to joint alignment. In addition, the joint warm-up produced by gentle movement improves the production of synovial fluid, which lubricates the joint and reduces friction between the joint surfaces.

6 Knee-Safe Reformer Pilates Exercises

All the exercises described below must be performed under the supervision of a qualified instructor who knows your diagnosis. The progression of resistance (springs) is individual and not determined by general standards.

1. Parallel Footwork (Feet on the Footbar)

Parallel footwork is the base Reformer exercise for the knee. It is performed lying on your back with the feet on the bar, pushing the carriage out (extension) and controlling the return (flexion). The key is alignment: knee over the second toe, with no valgus or varus, and weight spread evenly across the whole sole.

In people with chondromalacia, work is preferably done in the range of 30 to 90 degrees (avoiding the last degrees of full extension where patellar compression is greatest) or according to individual tolerance. Initial resistance should be minimal (one light spring) to reduce joint load as much as possible.

2. V Footwork (Heels Together, Toes Apart)

This variation preferentially activates the VMO (vastus medialis obliquus), the medial component of the quadriceps that is usually weakened in people with patellofemoral syndrome and plays a key role in correct tracking of the kneecap.

Execution is identical to parallel footwork in terms of carriage control and breathing, but with a slight external rotation of the hip that places the foot in a V position. It is important that the rotation comes from the hip and not the knee, which must stay in line with the second toe.

3. Single-Leg Press

Unilateral work (one leg at a time) lets you detect and correct strength imbalances between the injured leg and the healthy one. In ACL recovery, the goal is for both legs to reach 90% symmetry or higher before returning to high-impact activities.

The single-leg press on the Reformer lets you work the weaker leg with less total load than standing (since the leg is not bearing body weight) and with precise range control. It is performed with the same attention to alignment as bilateral footwork.

4. Bridging with Feet on the Bar or Platform

Bridging on the Reformer works the posterior chain (hamstrings, glutes, lower back muscles) effectively and with little compression on the knee. The knee is in a position of minimal load for most of the exercise.

Besides strengthening the hamstrings, bridging improves pelvic stabilisation, which has an indirect effect on knee mechanics: a stable pelvis reduces the torsional forces transmitted to the patellofemoral joint.

The variations (single-leg bridge, bridge with raised pelvis, bridge with carriage slide) let you progress the difficulty in a controlled way.

5. Side-Lying Abductors and Adductors

Side-lying hip exercises work the abductors (gluteus medius and minimus) and adductors with no load at all on the knee. This makes them especially useful in early phases of rehabilitation or when any loaded exercise is still limited.

As mentioned above, there is solid evidence that strengthening the hip abductors significantly improves patellofemoral pain. On the Reformer, these exercises are performed with the foot in a strap or with the leg free, depending on the exercise.

6. Unloaded Hamstring and Psoas Stretch

Tight hamstrings alter knee mechanics by increasing the load on the kneecap. Active stretching of these muscles, integrated into the Reformer session (for example, with the leg in the strap), improves flexibility in a controlled way and without sudden traction on the joint.

Likewise, a tight psoas can affect the position of the pelvis and, by chain effect, the knee. Hip-opening exercises on the Reformer (lunge on the carriage) work this pattern very effectively.

When NOT to Do Pilates with Knee Pain

Reformer Pilates is not suitable in every situation. There are conditions in which starting or continuing the practice can be counterproductive or even harmful.

The acute phase of any injury. If your knee is swollen, hot, with visible effusion or with pain that appeared in the last 24-72 hours after a trauma, the body needs rest, not loaded movement. Ice, elevating the leg and a medical consultation are the priority, not the Reformer.

After surgery without medical clearance. After a meniscus arthroscopy, an ACL reconstruction, a knee replacement or any other surgery, there is a rehabilitation protocol that defines what can be done and when. Reformer Pilates can be part of that protocol in advanced phases, but only with the explicit go-ahead of the surgeon or the physiotherapist responsible for the case. Starting earlier can compromise tissue healing or graft integration.

Pain that gets worse during exercise. If during the Pilates session the pain increases significantly (beyond the mild, tolerable discomfort usual in therapeutic exercise), stop the exercise, tell the instructor and consult your doctor. Pain is a signal that should not be ignored.

Severe joint instability without a diagnosis. A knee that gives way, that “fails” or has notable instability without a clear diagnosis should not be subjected to loaded exercise until the cause is known. Instability can indicate a ligament injury that requires assessment before starting any exercise programme.

You can find a fuller guide to situations in which Reformer Pilates is not indicated in our article on contraindications of Reformer Pilates.

Scientific Evidence: What the Studies Say

Research on Pilates and knee pain, although less extensive than that on back pain, produces consistently positive results.

Donzelli et al. (2006) in Europa Medicophysica compared the McKenzie method with Pilates in patients with chronic knee pain and found equivalent improvements in both groups for pain and function, which positions Pilates as a valid alternative to more established interventions.

Lim et al. (2019) in PLOS ONE published a systematic review and meta-analysis of 21 studies that examined the effects of Pilates on pain and function in various musculoskeletal conditions. The analysis showed significant positive effects on pain reduction (SMD = -0.80) and functional improvement (SMD = 0.50), with a favourable safety profile.

In the specific field of patellofemoral syndrome, research consistently supports hip muscle training as a therapeutic strategy. Rathleff et al. (2015), in a trial published in the British Journal of Sports Medicine, showed that adding hip exercises to the quadriceps strengthening protocol sped up recovery from patellofemoral syndrome compared with quadriceps training alone.

At Pinar Pilates we work from this evidence, adapting each session to the student’s specific clinical condition. To find out how we approach work with other injuries, read our articles on Pilates for back pain and Pilates for a herniated disc.

What a Reformer Pilates Session at Pinar Pilates Is Like If You Have Knee Pain

Our classes have a maximum of 8 people, which lets the instructor supervise each student’s technique and adapt the exercises to their specific needs. This ratio is incompatible with the crowded classes at some studios, where individual attention is simply impossible.

Before your first class, we ask you to tell us your diagnosis and the current state of your injury. Not to rule you out, but to prepare an adapted session from the start. If you have no diagnosis but you have pain, the first class will also let the instructor assess how your body responds to the exercises.

Our instructors, Giuliana Di Giovanni, Gabriela Seminara, Camila T., Montserrat Sierra and Abel Gomez, have specific training in adaptations for injuries and work with people with conditions, beyond the generic Pilates certification.

If you are unsure whether your situation is compatible with Reformer Pilates, call +34 611 994 729 and we will talk before you book.

Frequently Asked Questions about Reformer Pilates and Knee Pain

Can I do Pilates if I have chondromalacia patellae?

Yes, in most cases and with the right adaptations. Reformer Pilates is one of the most recommended exercise options for chondromalacia precisely because it lets you strengthen the quadriceps (especially the VMO) and the hip muscles with minimal stress on the patellar cartilage. The instructor must know your diagnosis to adjust the range of movement and the workload.

How long after a knee arthroscopy can I start Reformer Pilates?

Your surgeon sets the timeframe. In general terms, after a diagnostic arthroscopy or a partial meniscectomy, the return to controlled exercise can happen between 4 and 8 weeks. In ligament reconstructions, the timeframe is longer (3 to 6 months before progressive loaded exercises). In every case, the Reformer is a tool for the intermediate and advanced phases of rehabilitation, not the first weeks.

Is Reformer Pilates enough as a treatment for knee pain, or do I need physiotherapy?

It depends on the diagnosis and the stage. In acute phases or when there is a structural injury that requires specific physiotherapy treatment (drainage, manual techniques, electrotherapy), physiotherapy is the primary approach. Reformer Pilates is a complement during rehabilitation and a tool for long-term maintenance and prevention. In some cases of mild chronic pain or in people who have already completed their rehabilitation, the Reformer can be enough as a maintenance practice.

Which Pilates exercises should I avoid if I have knee problems?

Exercises that combine deep knee flexion with load (above 90 degrees in many cases of chondromalacia), those that create torsion on the joint (some rotation exercises with the feet fixed) and standing exercises with impact are the ones that most often need to be modified or avoided. The exact list depends on your specific diagnosis. A good instructor will adapt each exercise to your situation, not apply a generic list of prohibitions.

How many classes does it take to notice improvement in knee pain?

Most students with chronic knee pain report noticeable improvements between 6 and 10 sessions of regular practice (two or three times a week). Study results are usually measured at 6-8 weeks into a programme. Consistency matters more than intensity: a few very intense sessions have less effect than regular, moderate practice.

Start with Your First Class at Pinar Pilates

Pinar Pilates is at Calle del Pinar 8, Madrid (Salamanca district), five minutes’ walk from Gregorio Marañón metro (lines 7 and 10) and less than a hundred metres from the Serrano-María de Molina bus stop. We have more than 490 Google reviews (average 4.9 out of 5) and more than 40 classes a week so you can find the time that best fits your schedule.

You can read about what your first Reformer Pilates class is like before booking, or explore our complete guide to Reformer Pilates exercises to get an idea of the work we do.

If you are starting from scratch or have not exercised for a while, the article on Reformer Pilates for beginners can help you know what to expect.

For any question about your specific case, call +34 611 994 729.

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