In the summer I had a moto-x rider come to me after having surgery to repair MCL, PCL and meniscus injuries caused by getting his leg trapped under his bike. What was different with this case was that he came to me one year after the operation. He had completed the prescribed rehab program post-op and had returned to his job (which included manual labour) but had some residual pain and stiffness on the medial side of the knee and hadn’t returned to sport.
One battered knee.
We ran through some basic movement patterns (squat, lunge etc.) to assess his movement, whichis where the first piece of technology came in- I used an iPad with the Hudle Technique app to record and play back his exercises. By playing the left and right lunges side by side we could see that he actually had less deviation in the frontal plane in the operated leg than the other side. This was the first step in restoring his confidence in his knee.
A screenshot from Hudl Technique
Whilst performing squats he reported that he felt as if he was putting more weight on the un-injured leg. Unfortunately I don’t have access to force plates, but instead used a balance system which reports the centre of gravity of a patient (Gleichgewicht-Koordination-System). This showed that his C-o-G was central whilst standing with both his eyes open and closed, but did indeed start to drift towards the un-injured leg as he performed some mini-squats. I decided that in order to shift his focus away from which leg was injured we would play some games on the computer.
The Gleichgewicht-Koordination-System
I used the BalensoSenso system (LINK), which is a small 3-axis tilt sensor which can be attached to pretty much any piece of equipment and comes with a selection of games that can be played using it. In this case it was attached to a balance board and we played games where he had to control the character by standing on the board and leaning left/right/forwards/backwards. This way he couldn’t avoid loading the injured leg (albeit only slightly, the only movement being a weight shift) whilst his concentration lay on the game and not his leg.
Away from the computer we performed various balance exercises and walking with mixed gait patterns, again challenging him to trust his leg and the feedback he was getting from it.
The next step was commence a more traditional strength based rehab program. Deadlifts and Romanian deadlifts were performed with Kettlebells, squats were performed with varying foot positions etc. etc. Lunges were progressed to include different directions and trunk rotations etc. Side lying abduction exercises and glute bridges were prescribed as home exercises and this is where he asked me if he could ride a bicycle. I said of course - one year post-op, with full flexion and having performed manual labour tasks every day in work of course he could ride a bicycle!
Once again it came down to confidence in his knee - he needed somebody to say that it was OK.
After a couple of sessions we retested his C-o-G during squats and it showed an improvement, but more importantly the patient himself reported an improvement in his symptoms - he had muscle aches after not having trained for so long but less of the pain and stiffness that he had initially reported.
I saw the patient for four 45 minute sessions over three weeks. There is evidence to suggest that strength gains can be made rapidly when initially starting a training program, due to neurological changes, but I believe in this case the biggest gains were made in addressing the patient’s confidence in his knee. Getting him out on a bike again was a win for me (though he still says his motorbike days are over).
I picked this case to write about because of the slightly different case history, but what provided the stimulus was a recent Pacey Performance Podcast with Philip Graham-Smith (LINK) where Phil talks about how long it used to take him to digitise video footage and how complicated the high speed cameras were to set up (LINK). Now your phone can take 240fps video. When I was doing athletics my parents were brilliant and bought a video camera and a VHS payer with 4 play heads for better frame-by-frame playback. Then when I went to university in 1999 I had access to video players with jog wheels to finely control what we were looking at and the ability to rewind a little bit at a time! Digitising the footage for my dissertation took months. Now I use an iPad which displays side by side 240fps footage and can be annotated instantly!
Today I use an iPad nearly every day in the clinic. If you haven’t tried them yet I highly recommend the following apps:
Hudl Technique (LINK) - as described above, for technique analysis and athlete feedback.
Complete Anatomy - for helping to explain anatomy to a patient.
With each of these I highly recommend an Apple Pencil (LINK) to increase the accuracy of your annotations.
I also wrote a blog post about using video feedback when teaching Olympic weightlifting, the basic principle of which will also carry over to using video in a clinical setting, you can read the post HERE