The Roof, The Fall, 2 Broken Legs

Reformer Exercises for Rehabilitating a Shattered Tibia and Fibula at the Ankle Joint

Emma Johnson May 2018

Course year: 2016 Portland, OR

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Abstract The BASI Block System on the reformer offers an over-all conditioning program for all,

as well as helps restore fitness after experiencing devastating injuries. The BASI

repertoire on the reformer, with adjusted spring tension, can work to continue the healing

process without exacerbating the original wound—especially when falling off a roof and

incurring 2 broken legs at the ankle joint, including a shattered tibia. Multiple surgeries—

inserting a plethora of metal plates, rods and screws, plus being confined to bed and a

wheelchair for weeks/months, causes leg/ankle and feet muscles to atrophy. Continuing

to rehabilitate broken legs, after physical therapy, is essential for several reasons: to

ensure building muscle strength and mobility in the legs, ankles, feet and core; to achieve

optimal gait and posture post injury and PT; and to foster a holistic routine to restore the

client’s body and mind while still in physical pain.

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Table of Contents Abstract 2 Anatomy of the Ankle 4-6 Introduction 7 Case Study 8 Conclusion 10 Bibliography 11

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Ankle Anatomy The ankle joint acts like a hinge and its unique design offers stability to withstand 1.5

times the body weight when walking and 8 times that when running. Normal ankle

function is needed to walk with a smooth gait as the muscles, tendons, and ligaments that

support the ankle joint work together to propel the body. Injuries that inhibit normal

ankle/gait functioning can make everyday activities, including simply walking, riddled

with pain.

For the purpose of this paper, the ankle can be divided into a few relevant categories:

Bones and joints; Ligaments and tendons; Muscles.

Bones & Joints

The ankle joint is formed by the connection of three bones. The anklebone is called the

Talus, and its top fits inside a socket that is formed by the lower end of the tibia and

fibula. The bottom of the talus sits on the calcaneus.

The talus works like a hinge inside the socket, allowing the foot to move up—

dorsiflexion, and down—plantar flexion, while distally, the tibia and fibula clasp the

talus—the uppermost tarsal bone—which increases the stability of the ankle joint.

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The distal tibofibular joint is a fibrous joint, connecting the two bones with ligaments and

fibrous tissue.

Ligaments and Tendons Ligaments are the soft tissues attaching bones to bones, and tendons attach muscles to

bones. A series of ligaments support the lower end of the leg where it forms a hinge for

the ankle where the bottom end of the fibula meets the tibia. The ankle joint is also

supported by the tendons—the Achilles tendon—, which help with walking/running, and

the posterior tibial tendon that attaches a smaller muscle of the calf to the underside of the

foot.

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Muscles Most of the motion of the ankle is by way of the stronger muscles in the lower leg with

tendons passing by the ankle and connecting in the foot. Contraction of the muscles in the

leg is the main way we walk and run. The peroneals—longus and brevis—are located on

the outside of the ankle and foot, bending the ankle down and out. The gastrocnemius and

soleus connect to the calcaneus by the Achilles tendon, while the posterior tibialis muscle

supports the arch and helps turn the foot inward, and the anterior tibialis pulls the ankle

upward.

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Introduction According to a study done by the Center for Construction Research from 1992 to 2009,

falls accounted for 1/3 of the construction industry’s fatalities. And, tragically, roofers are

3 times more likely to die than any other type of construction worker. Regarding

homeowners, 34% of all falls happen at residential home projects.

It takes but a moment for everything to change.

Falling from a tall ladder or rooftop proffers myriad results: death, a life sentence in a

wheelchair due to paralysis, and/or broken bones. All are catastrophic and life changing.

Subsequent surgeries, nerve and bone pain and subsidiary pain from inactivity, and loss

of life-style—such as the ability to walk, drive, and independence, weight and muscle

loss, severe pain—at times may appear monumental to overcome. And, once Physical

Therapy is over, what can a survivor do to proceed with healing?

Fortunately, the BASI Pilates block system on the reformer offers a positive strategy for:

regaining mobility and strengthening the ankle joints after months in bed or a wheelchair,

strengthening—plus gaining—muscle mass in the feet, legs and entire body conditioning,

plus re-aligning the psychological impact from becoming suddenly incapacitated due to

multiple broken bones, thus experience and suddenly and irrevocable loss of

independence.

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Case Study Dirk is a 63-year-old male—and my husband—an electric guitarist by trade, who fell off

our new studio—former garage—roof when the tarpaper ripped and sent him bolting

toward the earth. He remembers consciously trying to get his feet down first during the

fall, which he succeeded at. By the time I heard him calling for help, his left foot’s

metatarsals were smack up against his shin. He broke the tibia (shattered) and fibula in

the left leg, along with metatarsals, and the fibula in the right leg. After a week in the

OHSU trauma ward he was sent home with an external fix on the left leg since it was too

swollen to operate on for a few weeks.

Dirk in the OHSU trauma ward, smiling due to a consider amount of drugs. During the second surgery, metal plates, rods and screws were inserted to help restore his

shattered tibia and fibula in the left leg.

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X-ray of Dirk’s left ankle after the 2nd surgery. It’s difficult to see the shattered bones floating about. Luckily the actual ankle joint was not broken.

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And, though he’s still swollen weeks after the 2nd surgery, both his feet flattened out. Insurance covered Physical Therapy—2 times a week—for several months. Once the

insurance ran out and PT was no longer an option financially, Dirk was mobile, and

hobbling with a cane, to work on the reformer with his PT’s blessing. He began a 12-

week Pilates practice on the reformer that evolved every 4 weeks since, initially, he was

weak and it took time for him to incorporate the breath work with the movements. He

also has kyphosis in his upper thoracic spine, as well as hypermobility in the knee

joints—all of which took time for him to feel and to be able to re-educate himself to work

with control and precision.

For the first 4-week regimen—3 times per/week—Dirk did the following with modified

spring tension due to nerve pain and general weakness in the body:

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• Warm up: Pelvic Curl, Spine Twist Supine, Chest lift and Chest lift w/ rotation

• Foot work—1 red spring

• Abdominal work: Hundred Prep—1 red spring

• Hip Work: Frog, Circles, Openings—1 red spring

• Spinal Articulation: on heels—2 red/1 blue spring

• Stretches: Standing Lunge—1 red spring

• Full Body Integration: Knee Stretch Round + Flat Back—1 red spring

• Arm work: Supine Series—1 red spring

• Leg work: Hamstring Curl—1 red spring

• Lateral Flexion/Rotation: Mermaid—1 red spring

• Back Extension: Breaststroke Prep—1 blue spring

• Child’s pose: on the mat

It was challenging working with Dirk at first: he was still experiencing immense pain and

his pain medications made him unfocused and uncoordinated (“Gabapetin” especially),

he wanted to talk during the sessions and describe everything he was feeling—rather than

focusing on the breathing, and he felt discouraged noticing how weak he was compared

to before falling. Plus, the Pilates instructor was his wife—telling him what to do—not an

easy situation.

After his sessions he felt exhausted and his pain level was higher. And yet after every

session he said felt better moving and though he had trouble with the breathing, he was

doing it enough to feel the benefits. By week 3 he was able to stay connected to his

breath and he began to notice he was getting stronger, especially his hamstrings and

quads which helped .

The second 4-week regimen for 3 times per/week, I had Dirk doing the following with

little modification to spring tension:

• Warm up: Pelvic Curl, Spine Twist Supine, Chest lift and Chest lift w/ rotation

• Foot work—1 red/1 blue spring

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• Abdominal work: Hundreds—1 red/1 blue spring

• Hip Work: Frog, Circles, Openings—1 red/1 blue spring

• Spinal Articulation: Bottom Lift + w/Extensions on arches—2 red/1 blue spring

• Stretches: Standing Lunge—1 red spring

• Full Body Integration: Up Stretch 1 + Elephant—1 red spring

• Arm work: Arm Sitting Series—1 red spring

• Leg work: Side Split—1 red spring

• Lateral Flexion/Rotation: Mermaid—1 red spring

• Back Extension: Pulling Straps 1—1 blue spring

• Child’s pose: on the mat

This second round of work found Dirk tuned into his breath and the movement and he

understood and liked the flow of the sessions. During footwork we both noticed that he

was gaining more flexion in his ankle joint, plus his Achilles Tendon had stopped

“slipping around” as Dirk described it. When he practiced walking without his cane, he

found a new lengthening in his spine. Although going upstairs proved most challenging,

he could—one-by-one—climb stairs again. A new—albeit diminutive—triumph! In

addition, his mood was noticeable better and he was able to curtail his pain medications

through his doctor.

I noticed more stability in Dirk’s hips and knees, while Dirk noticed a change in his

quadriceps and hamstrings and often commented on how his feet were “waking up.” As

his PT had mentioned, the more blood flow we could get going—especially in his

gastrocnemius—the more functionality he’d find for walking.

For the final 4-week regimen, 3 times per/week, Dirk performed the following with little

change to the spring tension:

• Warm up: Pelvic Curl, Spine Twist Supine, Chest lift and Chest lift w/ rotation

• Foot work—2 red springs

• Abdominal work: Hundreds, Coordination—1 red/1 blue spring

• Hip Work: Frog, Extended Frog, Extended Frog Reverse—1 red/1 blue spring

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• Spinal Articulation: Bottom Lift + w/Extensions—2 red/1 blue spring

• Stretches: Standing Lunge—1 red spring

• Full Body Integration: Elephant—1 red spring; Reverse Knee Stretch—1 blue

spring; Down Stretch—1 red spring

• Arm work: Rowing Front 1&2 Series—1 red spring

• Leg work: Side Split—1 red spring

• Lateral Flexion/Rotation: Mermaid—1 red spring

• Back Extension: Pulling Straps 1 & 2—1 blue spring

• Child’s pose: on the mat

We maintained a close regimen to the 4 prior weeks because Dirk liked it and felt

comfortable doing it. We tried to do Single Leg Skate, but it was too demanding for his

balance as well as overwhelming with the pressure on his foot pushing the carriage. And

he wasn’t able to tolerate more than 2 red springs on his feet due to nerve pain in his feet.

Conclusion Over the 12-week program, Dirk experienced tremendous change in his feet, legs, core

muscles and his attitude toward life. His left ankle did not make as much progress in

flexion as his right ankle, due to the amount of hardware inserted in his Tibia and Fibula.

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The surgeon has suggested it may be possible to remove some of the metal in a year or

two so he can regain additional flexion.

On the plus side, Dirk’s awareness expanded as he learned to use his breath to not only

facilitate movement but to engage his core—truly experiencing BASI’s “mind-body form

of conditioning.” He grew significantly centered and focused during the sessions. It

reached the point where he’d “forget” to bring his cane when he left the house for doctor

appointments. He also stopped his pain medication—although his doctor still has him

taking Gabapentin, Tylenol, Ibuprofen daily—which has helped his mind-set, too.

Our goal to help him continue to rehabilitate his body by building muscle strength and

mobility once PT ended was more positive than expected—for both of us. He’s able to

walk, climb a ladder (no higher than 5 feet!), and he now has a breathing practice with

our continuing reformer work that not only restores

his body, but his heart and mind as well.

Bibliography Calais-Germain, Blandine. Anatomy of Movement. Eastland Press, Seattle, 1993. Print.

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Houston Methodist. Ankle Anatomy. https://www.houstonmethodist.org Isacowitz, Rael. Body Arts & Sciences International

• Study Guide/Comprehensive Course • Reformer/ Movement Analysis Workbook • Pilates for injuries & Pathologies

ScienceDirect. Falls From Roofs. https://www.sciencedirect.com/science/article/pii/S0022437512001247 by XS Dong - ‎2013