The one-legged squat

August 12, 2016 by KJK Leave a Comment

One legged squat, left leg is weight-bearing. Posture should be as straight-backed as possible with head up looking forward. I have a tendency to lean forward from the hips as I get fatigued which is evident here in a slightly rounded back

When I first began rehab I was told that the one legged squat is the most useful exercise for recovery. That has certainly been the case and I have done a lot of one legged squats in all sorts of different formats. An easily achievable one is shown below. I can do three sets of squats where each set consists of 10 to 12 repetitions.

The one legged squat. This not only strengthens the weight bearing leg but also stretches the hip flexor tendons in the non-weight bearing leg

Right leg weight bearing. The one legged squat second movement. This not only strengthens the weight bearing leg but also stretches the hip flexor tendons in the non-weight bearing leg

The one legged squat at the starting position with one leg raised behind and all the weight bearing on one leg. Note the square shouldered upright position. Left leg here is weight bearing

It is important to try and touch the nonweight bearing knee almost to the floor in the squat before driving straight up with the weight bearing leg. Back must stay straight.

Exercises at the 18 month mark

August 11, 2016 by KJK Leave a Comment

As I have not published for awhile, many people have written to me asking what sort of exercises do you do after 18 months of rehab. Obviously they are very different from what I did at the beginning and have been in constant evolution driven by three factors:

1) Increasing strength in the injured leg

2) Increasing confidence in attempting new and more difficult exercises

3) Return of balance when using the injured leg

4) Change in exercise methodology after changing trainers. For approximately the last six months I have had a male trainer, Paul Birtles, who took over after Belinda went to another job. While Paul continued the recovery work on my leg, he also identified other problem areas which needed attention viz:

Chronically tight hamstrings and hip flexor tendons which I have always had but possibly exacerbated by the injury

Stiffness and lack of flexibility in the lower back

Constant stiffness and soreness in the shoulders and scapular caused by strenuous repetitive exercise i.e swimming.

He attempted to address all these issues with appropriate exercises while maintaining focus on my injured leg aimed at preparing me for skiing in early 2017. In the following post are shown some of the exercises at the 18 month mark.

In the second year of rehabilitation I spent 20 to 30 minutes on an exercise bike before each gym session. This was necessary to warm up muscles for the stretching exercises and more advanced gym program undertaken in the second year. Due to an old injury in my lumbar spine I found it difficult to achieve correct posture on the bike.

Paul showing how it’s done, with correct seat height, seat position and posture

Warming up on an exercise bike is the best way to avoid injury during a gym based rehab session, especially in the second year as the exercises get progressively more difficult

The 18 month milestone

August 10, 2016 by KJK 6 Comments

It’s a big day in my rehabilitation program – 18 months since surgery. Why is this significant? All the literature surrounding tibial plateau fracture and surgery says that
improvement is most noticeable in the first 12 months of rehabilitation and can continue for up to 18 months. There is no suggestion anywhere in the research that recovery
continues after 18 months. So what I have now is what I will have for the rest of my life. It’s worth a review to see where you get to after 18 months of continuous
rehabilitation, involving weekly sessions with a personal trainer concentrating solely on post-surgical recovery.

In essence I can:

Walk continuously, climb up and down hills, climb up and down stairs and hike carrying a heavy backpack with no sign of pain or discomfort. I have tested my climbing ability on a very steep cliff near the Grand Canyon and found no noticeable difference in strength either going up or going down in either leg. There was no noticeable difference in fatigue in either leg
Perform sophisticated gym exercises including heavy leg presses, one legged squats and numerous sets on a leg extension machine without any pain or excessive fatigue
Perform exercises that require balancing on the broken leg while performing other exercises. My balance on the broken leg is now almost as good as on the unbroken leg although it has not recovered completely to where it was before the accident
Get shoes and boots on and off with no difficulty or discomfort.
Get comfortably on and off an escalator leading with either leg.

Most significantly, I am not in any pain. In this sense, being pain-free, I have made a complete recovery. [Read more…]

TPF rehabilitation – year two

March 26, 2016 by KJK Leave a Comment

So it’s Saturday, March 26 and I’m back in the gym at Frenchs Forest. It hasn’t got any more interesting than last time I was here. Unfortunately. It was depressing to think of all the Saturdays I spent here in 2015 and now I have to do it all again. It’s really hard to be motivated. I arrived back in Australia on Wednesday, March 9, a bit over two weeks ago, very tired after a delayed flight out of Sun Valley, Idaho, a bus trip to Boise, and a flight to Los Angeles via Seattle in Washington State. A day’s layover in LA, then home.

I’ve seen Belinda, my personal trainer at Virgin Gym in Pitt Street twice since I arrived back. She was keen to know how I went in America. Her synopsis, basically, was that I had probably tried to do too much, too soon and the soft tissues, ligaments and tendons in my knee just couldn’t stand it. She made the observation that there is only so much you can do in a gym to recover from TPF and I guess I have to agree. She also thought I didn’t have a properly structured skiing plan. I do now. Anyway she has outlined the program for the coming year which will be a lot like the previous year as far as I can see.

March has been a rough month. I came back from the US with badly infected sinuses, bad bronchitis and following a CAT scan of my chest, two nodules in my right lung. These may be a spin-off from my melanomas years ago. The sinus problem, caused by a broken nose and deviated septum when I was younger, will probably require surgery. The situation with my lungs is going to be determined shortly by a bronchial physician. It may also require surgery. So at the moment my leg is the least of my worries.

Nevertheless, I’m here at Virgin Gym French’s Forest on Saturday afternoon among the hairdryers and the shitty music.

Leg Press………………….

3 sets x 10 reps x 60kg = 30 presses

3 sets x 10 reps x 70kg = 30 presses

3 sets x 10 reps x 80kg = 30 presses

1 sets x 10 reps x 90kg = 10 presses

100 leg presses all up

Leg Extension…………….

7 sets x 35kg x 10 reps both legs = 70 extensions

1 sets x 40kg x 10 reps both legs = 10 extensions

80 leg extensions all up

Not a bad session just doing strength work over and over. Shoulders sore from all the swimming I’ve been doing since I got back.

Thank you letter

February 18, 2016 by KJK Leave a Comment

This is a copy of a letter sent to my personal trainer Belinda Van de Venn, at the Virgin Active Gym in Pitt St in Sydney, after my second day of skiing at Big Sky in Montana.

Village Centre
Big Sky
Montana
USA

Wednesday, February 18, 2016

Belinda,
Just got through day 2 so thought I should give you an update. Day 1 was interesting as it was like an exam day. I had a very capable female, American guide, Laura Herr, who was just back on the slopes after a broken fibula and ankle so she knew just what I was going through. She took it very slowly and we stuck to moderate runs. As you can imagine on the first run I was waiting for the pain to arrive but it didn’t. Thankfully. After about an hour the patella tendon just below my kneecap started to ache. Remember you said it would probably hurt. It wasn’t that painful or discomforting I just knew it was there. During the second hour the two tendons/muscles just above my knee started to ache but not for long.

knee I think these are the quadriceps muscles shown in the picture above. The quadriceps tendon in the picture wasn’t hurting. The patella tendon was hurting just where the arrow is. Into the third hour neither was hurting much. Significantly nothing was hurting behind the kneecap or at the site of the plate. I ended up skiing for five hours. No residual pain at the end. Steady pace on medium slopes. No rampaging. Most significantly my quads,which are normally stuffed for the first couple of days, weren’t tired. At all. That’s a first for me. I put it down to all the exercises you gave me.

Today was much the same. All the muscles around the knee, but not the knee itself, ached for about the first five minutes but then it went away. I skiied for four hours today without any pain at all.

Late this afternoon, I spied from the chair, a beautiful looking run called The Bowl, a single black diamond coming off Lone Mountain, which is the dominant peak here. I’d only been on the greens and blues but thought, “Bugger it! Why not!” Went at a steady pace but didn’t stop top to bottom. Because it was steeper I had to lean out further and push harder on the broken leg. No reaction. I couldn’t feel the plate at all. I was very pleased.

Anyway, much is now clear about the rehab you gave me. The flex and range of movement part I always got, ditto the strength part with the leg press and extension and flexion machines. What often puzzled me were all those exercises you said were to fire up the muscles around the knee – One legged balance on the Bosu ball, one legged dead lifts and that exercise standing sideways on one leg and holding the resistance against a Kinesis machine. I get all that now. Rehab from a broken leg isn’t about fixing bones. That’s probably over in the first eight weeks. It’s mending the buggered tendons and ligaments and getting them all working together that takes the time.

Needless to say I’m enormously grateful for your efforts in my rehab. It’s one year and one week since surgery and I’m skiing comfortably down a black run. That’s all down to you. My daughters are also very appreciative of your skill and professionalism. If you want something to add to your rehab program, you might consider that routine I worked out on the bike – doing five sprints to 100 rpm at levels increasing progressively from nine to thirteen on a recumbent bike, all within a half hour. It’s really boring but it may also have helped with recovery.

Anyway, so far so good. I’m telling everyone here about my miracle personal trainer back in Australia. Will be fully rampaging on the double blacks by the end of the week. Look out. Hope married life is going well – the first month is the hardest.

Regards

Kieran Kelly

Success in gym based rehabilitation

December 23, 2015 by KJK Leave a Comment

As I’m now more than 11 months into a rehab program for a tibial plateau fracture I often wonder what are the keys to successful recovery. As most rehabilitation is based in a gymnasium, it is evident that if you are not properly directed or do not apply yourself in the gym, you will not get better. Part of this is having someone to assist you and guide you through the process. I noticed today in my fortnightly session with Belinda Van De Venn, my personal trainer, that it is more enjoyable doing gym rehab with someone. Just having someone to talk to while you’re doing the exercises, makes a difference. This is before consideration of the expert input that someone like that can provide. Doing exercises on your own in a gym and trying to design your own program over an extended period of time would, at least for me, be impossible.

Some people may be able to do it but I couldn’t.

Balancing on my broken leg on a Bosu ball. This is a lot harder than it looks

Today was one of the most difficult days I have had. The exercises are getting more and more advanced and increasingly difficult to do, although they are not particularly painful. The pain in my broken leg has now largely abated but it still seems weak when subjected to particular exercises. I did my usual warmup on the bike. When Belinda arrived at 1:15 PM she immediately got me doing one leg balancing stands on a Bosu ball. This was particularly difficult when I had to balance on my broken leg – much easier with the left leg. This is not due to pain but merely weakness and lack of coordination.

We then did a series of step ups onto a low gym bench before doing a series of jumps onto and off the same bench.

A two footed jump from the floor onto a small bench. I also did two footed jumps off the same bench as part of this exercise.

Landing during a two footed jump. The key is to land with both feet simultaneously and to keep your knees bent. This is a low impact exercise designed to strengthen the muscles around the knee.

Belinda then had me running backwards across the gym, stopping, then doing 5 one-legged hops forward on the broken leg and 10 on the unbroken leg. Hopping on one leg, especially after the fracture and surgery is psychologically very difficult, particularly as hopping imparts an impact (albeit low) to the broken knee and psychologically the reaction is to try and protect it. I also found this hard on my lower back which started to ache.

After that, it was the cyclist’s or skier’s squat on the small wedge – 20 times. This is a really great exercise. Stretches everything.

The cyclist’s or skier’s squat off a small, wedge-shaped bench.

But true to form, she saved the best till last. This involved standing on the bench and jumping off, not landing on 2 feet but landing on one and immediately going into a one legged squat. On my sound, left leg this was no problem. My brain just did not want any part of this on my broken leg. Strangely it didn’t hurt – it’s just that my brain didn’t want to experience all my weight landing on that one weak knee. As it turned out there were no ill effects from this session other than it made my back ache. My knees were fine.

The relationship the relationship between the postsurgical patient and their advisors such as physiotherapists and personal trainers are crucial to successful recovery. They are also critical in avoiding injury during rehabilitation. I was magically fortunate in encountering Belinda vendor then at the virgin gym in Sydney. As of December 2015 she has been supervising my recovery for nine months. This photo was taken in the gym after our last session before Christmas in 2015

The relationship between the post-surgical patient and their advisors, such as physiotherapists and personal trainers, is crucial to successful recovery. They are also critical in avoiding injury during rehabilitation. I was fortunate in encountering Belinda Van de Venn at the Virgin gym in Pitt St, Sydney. As of December 2015 she has been supervising my recovery for ten months. This photo was taken in the gym after our last session before Christmas in 2015

CAUTION: The exercises described above come 11 months after surgery for a tibial plateau fracture and about 9 1/2 months since rehabilitation began. These exercises are advanced and involve pressure on the broken knee and some impact. They should only be attempted under expert supervision. They should also not be attempted by anyone who has not had a sustained and progressive exercise program over many months. The risk of injury in these exercises is significant. Jumping backwards and downwards off the bench may cause injury if you do not land squarely with both feet. It is even harder when landing in the one-legged squat position after jumping from a bench. The above description of exercises should not be taken as a recommendation that this course of rehabilitation should be followed. You should consult your own expert medical and rehabilitation consultants.

Limits of postsurgical rehabilitation

November 29, 2015 by KJK Leave a Comment

Today I started to find the limits of where you get to in recovery from surgery for a tibial plateau fracture.

As on many Sundays, the day began with a swim at Balmoral. I didn’t feel too bad after the swim yesterday and had a reasonable night’s sleep. That means I only woke up three or four times. That is a reasonable night’s sleep for me at present.

It was only a 1 km race and I waited till virtually everybody else had left and tagged along at the back of the field. I didn’t want to enter the race proper, as I was concerned about kicking people in the face with a flippers. I hate this when it happens to me so didn’t want to inflict it on other club members. I got round easily enough and at least I felt like I was participating again.

At lunchtime I attended my good friend and client David Ingham’s 70th birthday party at Manly Skiff club. I wasn’t able to get away until after 3 PM and had to rush to Virgin gym at French’s Forest to get the weekend’s gym session in. I would have preferred to stay at David’s function at in much pain and the company was agreeable. Nevertheless, I had made the commitment to myslef all those months ago and that is why discipline and determination are so important in recovery.

I did the standard warm-up on the bike: ………..5 mins on resistance 9, 10, 11, 12 and 13 – about 27 minutes all told. Sprinted to 100rpm, five times on levels 10, 11, 12 and 13. Struggled at level 13. Sweating like a pig as the gym seemed very warm and very tired at the end of this session. Interestingly, my heart rate got up to 142 bpm during the last five minutes. I can’t ever remember my heart rate getting this high, in nay form of exercise. I guess that means people with any sort of heart condition have to to be very careful about this type of graduated resistance exercise routine on a bicycle involving sprints. If you have a heart condition don’t do it.

Also of interest, I burnt only 300 cal of energy during the session on the bike. By way of comparison, two standard glasses of red or white wine (175ml) with 13% ABV would contain about 320 calories which is similar to a slice of Madeira cake. All that exercise on the bike would have only made up for two glasses of wine or a slice of cake. I’m not doing this exercise to lose weight, but it’s enlightening how hard you have to work to shift even a little of the energy produced by eating the wrong sort of food.

The rest of the session was:

Leg Extension…………….10 reps x 30kg x 2 sets both legs

Adductor……………………10 x 40kgs

Adductor……………………10 x 45kgs

Leg Curl …………………..10 x 35kg x 2 both legs

Leg Press………………….10 reps x 50kg x 2 both legs warm up

Leg Press………………….10 reps x 60kg both legs

Leg Press………………….10 reps x 70kg both legs

Leg Press………………….10 reps x 80kg x 2 both legs

And that was at for the day. It wasn’t a very big session but I couldn’t do any more. I’m feeling really tired. I don’t know if it’s work and the long process of rehabilitation or the neck pain and a lack of sleep, but I would love a holiday and a break for a while from this endless routine. I am reaching my limits. Maybe that’s what an increasing resistance exercise programme will ultimately do.

LIMITS: For almost 10 months I have been in a rehab programme involving progressive resistance exercise on a stationary bike, a leg press machine and various other gym equipment. This has been successful but I’ve felt recently that I’m reaching my physical limits. During the week, I asked Belinda about setting new limits and goals eg if I should continue to progress beyond level 13 on the bike? She said no. I then asked should I continue pushing on beyond 80 kg on the leg press machine and she said no. She had already said that I should not do leg extensions past 30 kg.

So I guess, as I approach 10 months post surgery, these are my limits. At least at this stage. I think fatigue is definitely starting to set in. Also tomorrow is my 63rd birthday so age must have something to do with capacity to keep pushing up the resistance.

Serious rehab

November 25, 2015 by KJK Leave a Comment

Still too sore to join the Wednesday group and go for a swim this morning. Have decided I will not swim at all this week to give my neck a rest and hopefully alleviate the pain. Still the show must go on and so I presented myself at the Virgin gym in town to see what Belinda had in store for me. I arrived half an hour early and warmed up on the bike. I was a bit tired and sweating profusely before the session even started. We did a whole lot of new things including:

1) Running on the spot with very high leg lift. This was pretty difficult at first but I got used to it. The broken leg didn’t want to have anything to do with this at first and my coordination was terrible. It actually got better the faster I ran.

2) Walking lunges. This was really hard – back and forth across the gym. Instead of a normal lunge where you go forward then stand up again then lunge on the other leg, this was a succession of lunges in a walking motion with one knee almost touching the floor. Very difficult at first. I think this was trying to load up my knee while at the same time making it move. This seems to be a holy Grail for Belinda – putting load on the broken knee while it is in motion.

3) Jump turns. This is a straight skiing exercise where the body stays facing forward while the feet are together and about 45° to one side. I then had to jump up and land with my feet together and facing 45° the other way. This was also really hard until I got used to it, but strangely enough, once I tried it a few times it wasn’t so bad. This is a pure replication of the manoeuvre on a very steep skiing slope where the terrain does not allow a normal carved turn. The turn is initiated by jumping slightly, getting the skis off the ground and pointing them in a different direction. It was weird trying to do it in the gym. I felt stupid, but I know what she was aiming at.

TThe coach the bag arch using the free-form board the back arch using the free-form board was introduced into my routine a couple of weeks ago. This is a very difficult exercise but cried a satisfying one. The key is to keep the board under your backside as you lift your hips off the floor. This is difficult as your feet want to push out as your back arches. This is now a regular part of my routine with Belinda – part stretch and part leg strengthening exercise.

Belinda introduced the back-arch using the Freeform board into my exercise routine a couple of weeks ago. This is a very difficult exercise but a satisfying one. The key is to keep the board under your backside as you lift your hips off the floor. This is difficult as your feet want to push out as your back arches. This is now a regular part of my routine with Belinda – part stretch and part leg strengthening exercise.

We also did repetitions of the back arch using the Freeform board. Even though I find this exercise difficult, I asked her could we do it this week as I find it a really excellent stretch for muscles that I hardly ever use. For some reason, I sense that this is an excellent exercise for office-bound workers who sit at a desk every day. As usual, we completed numerous sets of speed skating on the Freeform board. All of this is about trying to get me skiing again. Belinda is now presuming that I am responsible for all the strength work and she is concentrating on the balance, coordination, stretching and range of movement that I will need to ski again. I see Matt Lyons the surgeon next week for the sign off. Here’s hoping.

At the gym

November 11, 2015 by KJK Leave a Comment

Intended to get up this morning and join the 630 swimming group at Manly. When the alarm went off I just couldn’t do it. That elusive sleep. Went straight into work. Saw Belinda today for the first time in a fortnight. This is the new gym session I’ve organised once a fortnight, rather than once a week. I guess that is some sort of milestone.

Belinda Van de Ven, my personal trainer was vital to my rehab programme. Originally from New Zealand and a specialist in gym based recovery from surgery, Belinda provided a disciplined and graduated approach to recovery. I saw her once a week for the first 9 months post surgery. An investment in a personal trainer is vital if you can afford it.

It was a very taxing session. I started off with half an hour on the bike, cranking up to 100rpms, so by the time she arrived at 1.15 I was a lather of sweat. She immediately got me going on the Freeform board doing a thing called the “ice skater.” This involves one foot on the board, but staying in a crouch and driving out and back with one leg, in a rhythm like a speed skater does at the Olympics. It’s a version of the one legged squat.

We then did a series of jumps off a gym block landing square on both feet into a squat position. We then did the sideways skipping up and over the same box. I’ve done this numerous times on the Bosu ball.

I got very tired but my leg didn’t hurt even after jumping off the box about 30 times. Then I made the mistake of telling Belinda how much it hurt when I broke into a run for the ferry last Friday. She asked me to jog up and down the gym. Apparently it is not good as I run with a very stiff right leg and swing from the hip trying to take the weight off the broken knee. It immediately hurt.

“That there is a little bit of pain there doesn’t surprise me, as you haven’t tried to do it before,” she said.

“Everything hurts the first time you do it after knee surgery. Remember when you were trying to step backwards over the Bosu ball? You’ve forgotten how much that hurt, ” she said.

I haven’t forgotten how much it hurt. I won’t ever forget that.

“If the pain is a 4/10, I’m not concerned. If it goes away I’m not concerned. If it was a 6 or 7/10 we wouldn’t be doing it. If it was painful the following day, I’d also be concerned but it’s not, so I’m not too worried,” she said.

Good session. Tomorrow is 9 months since surgery. That’s half way through the rehab program. Except for my neck I think I’m in good shape. My left hand burned all the way through the session today.

Friends and rehabilitation

October 30, 2015 by KJK Leave a Comment

One of the things which will aid your recovery is having friends around you who care for your welfare. Luckily I’m blessed in this regard. If I want to understand life’s complexities I speak to Barry Feyder; if I want to understand the intricacies of how women think, I go to Margaret Carney. If I need enlightenment on the roots of American blues music or the differential calculus, Tony Smuts is the man. For nutrition, I consult Alison Maunder, although she is not to be trusted as she made me give up Milo and refuses to acknowledge its medicinal qualities. For questions about the stock market I consult God, but He says there are some things that even He, with His all-knowing wisdom, does not understand.

Allan Bolton, exercise guru and computer pointy head

For exercise physiology or anything to do with maintaining a blog I speak to Allan Bolton. The former champion triathlete is also a computer pointy head who spent much of his career in the fitness industry.While discussing the blog at a meeting with him last weekend, he happened to notice that I was using leg extension machines as part of my gym rehabilitation. He explained that a leg extension machine puts a lot of pressure on the kneecap.

“It grinds away against the back of the kneecap,” were his exact words. When I explained I was only using 30 kg on the machine, he remained unconvinced and suggested I ask my physiotherapist whether the leg extension machine was a wise move, given that I had broken my tibia high up. This was advice I couldn’t afford to ignore.

Personal trainer Belinda Van De Ven.

After the exercise session on Wednesday I asked Belinda, my personal trainer, whether Al’s comments were true.
“Yes, I agree with him. Definitely. If you had broken your kneecap or there was some abnormality in the joint you wouldn’t be on the leg extension machine. I also don’t allow you to use extreme leverage on the machine which cuts down on the amount of pressure underneath the kneecap. I also don’t allow you to use a heavy weight. Thirty kgs is within your range,” she said. She was referring here to the way a leg extension machine is set up with the bottom bar placed across the shin or just above the ankle but never on the foot. This lessens the leverage and impact on your knee cap.

Dave Sheppard MGS Physiotherapy Manly.

“But you should ask Dave Sheppard his opinion anyway,”she said.

Good old Dave Sheppard, the Sage of Whistler Street, the Harry Potter wizard from MGS Physiotherapy got the following email:

_______________________________________________________________________________________________________

From: Kieran Kelly [mailto:kkelly20@bigpond.com]
Sent: Tuesday, 27 October 2015 1:33 PM
To: ‘MGS Admin’
Subject: RE: Attention David Sheppard

Dave,

Hope all is well with you.

My rehab is going well. However, a friend of mine who has had long experience with broken limbs, was looking at my workout schedule on the weekend and noticed I was doing leg extensions on a gym machine and was up to 30kgs (using both legs). He suggested this was not a good idea. He believes the leg extension machine puts too much weight on the underside of the kneecap. He said I should check with you.

What do you think?

__________________________________________________________________________________________________________________________

Hi Kieran

Your friend is correct about leg extension placing more pressure under the knee cap. 30kg on both legs is not however too much for you. Given (or assuming) that you do not have pain behind the knee cap at the moment then it actually becomes a good exercise to do. People that have trouble with their knee cap are often told not to do leg extensions. This should only be for the time that they are having trouble. I would say keep doing them although increasing them is not necessary. The body weight exercises (squats) and leg press are the ones to increase over time because they are more function al and set you up better for the things you want to do.

Keep the bike up as well. Level 10 at 100 rpm is a good workout.

Cheers

Dave

________________________________________________________________________________________________________________________

So that settles it. Harry Potter has spoken. These are three separate opinions – all valid. You can’t have too many people around to consult. Don’t be frightened of doing it. You don’t have to recover on your own.