Hang around enough physical therapy places in New York City, and you’ll eventually hear a cyclist—and now patient—telling his story of the car that T-boned him at an intersection. Race director of the Westchester Triathlon and avid cyclist Jason Twedt was that unlucky biker just one week following the 2017 event. According to Jason, he had been “left crossed” by an oncoming minivan.
“I was on my way home from a hard training ride,” he said. “I was tired, glycogen-depleted, grumpy, and I really just wanted to get home and have a beer. It happened in slow motion. I had the lane and a green light, and then a blue minivan driving the other direction made a left turn directly into me. I went flying. The driver was a woman about my age who got out the car and stood over me saying, ‘Oh my god, oh my god, oh my god.’ I was like: ‘Oh my god! You hit me!’ My first thoughts were, Am I okay? Can I move my fingers and toes? And man, the rest of this ride is going to be annoying! But then I looked down and saw my knee, couldn’t move my big toe, and was like, Oh crap. It’s also difficult to ride a bike that is in two pieces! Being laid out on the pavement on your back is a lonely place after your life flashes in front of you. I had never felt so alone.”
Jason had sustained an ACL tear in his left knee and crushed the bones in his left big toe. He was sidelined from cycling, and had to take time away from his bike shop, which he had just opened in Bethel, CT. He had two separate surgeries, one to fuse together the bones in his toe and another to repair the torn ligament in his knee. His initial progression through the typical ACL rehab timeline was slow because he couldn’t bear weight on his healing left toe. Nonetheless, he was aggressive with the exercises he was able to perform, and once his toe could bear weight, his program advanced.
Eventually Jason was able to get back on his bike trainer indoors, though not without pain and stiffness. He had a screw in his toe that made walking and cycling painful, and running impossible. He had also developed excessive scar tissue in the knee joint that limited his motion, caused pain and swelling, and inhibited his quadriceps muscles. Together, this further added to the obstacles of running.
According to Jason’s physical therapist, Bridget Dungan, DPT, “Scar tissue and swelling in the knee has an inhibitory effect on the quadriceps muscles, which decreases muscle fiber activation and makes it really hard to build strength,” she said. This is why even basic everyday tasks had become difficult to Jason because of his decreased range of motion and inefficient quads.
“Stepping over the ledge of a bathtub and going down stairs was really tough,” Jason said. “What once had been simple everyday motions became challenging. I was beginning to learn what old age must feel like!”
Back ‘under the knife’ once again
Jason is not only a cyclist, but also a triathlete, so returning to running was a priority. The only option to fix the toe pain and improve his knee bending was to go “under the knife” again. One year after the accident, Jason was back on the operating table to remove the screw from his toe and clean out the scar tissue from his knee. And once again he was back in physical therapy. This time, the priority was knee range of motion and then strengthening his left leg. Despite his three-day-a-week treatment program after the first surgeries, he never fully regained his quadriceps muscle strength due to inhibition from scar tissue and pain. He had a lot of catching up to do. Luckily, the second surgery didn’t involve any repairs, so he could be relatively aggressive with his therapy right from the start. And with the screw out of his toe, he was no longer held back by pain from the hardware.
“Getting Jason’s knee to bend to its full potential after that second knee surgery was a delicate balance between pushing his limits but not over stressing the joint and causing it to swell,” Bridget explained. “It was important to regain and maintain his motion within the first two weeks after surgery, otherwise scar tissue could form again.”
Jason finally felt he had hit the home stretch, but was then faced with another unexpected trip to the operating room. He had been feeling some neck and arm pain since the accident, which gradually started to worsen. A minor surgery fixed the problem, but sidelined him for a few more days, giving his knee some unwelcomed—thought probably beneficial—rest. If you see Jason running around at the Westchester Triathlon, you know he doesn’t take well to sitting still!
A long-awaited shift in focus to full recovery, followed by training
Finally back on track, Jason could focus his energies on his physical therapy. His rehab approach was comprehensive: Bridget performed manual (hands-on) therapy for range of motion—which included Active Release Technique, Graston Technique, and joint mobilization—three times a week, and Jason performed self-stretching and range of motion exercises (including time on the stationary bike) several times a day. He was on a progressive strengthening program targeting his legs and core muscles, with a focus on his left quadriceps. Strengthening his hip muscles was also important, so that he would have a stable pelvic base when he eventually returned to running.
One key element of his strengthening program was the use of blood flow restriction (BFR) training, which is beneficial for building muscle strength after surgery. It involves the use of a controlled tourniquet system that occludes a percentage of blood to the limb while performing exercises, so that the muscles are working in a deprived oxygen state. This makes the muscles work harder, without having to load the joint. Jason used BFR training in the leg press with a very low weight, which taxed the muscles but not his knee, and helped him to quickly regain his quadriceps strength.
Retraining Jason’s balance and proprioception was also a priority, since these are usually impaired after joint injuries. Emphasis was placed on single-leg functional tasks with careful attention to using proper form. When the strength of his left leg returned, he was ready to start agility training and plyometrics, and is now on a return-to-run program. Soon, his workouts will be less about rehab and more about training, as he prepares for his first race back.
“I’m a better athlete now,” Jason said. “Going through rehab and basically starting over forced me to look at old habits and really address weaknesses. It made me do things I probably should have done from the beginning, and that’s made me even stronger. I take a much more defensive approach to riding. It made me think about what was important in life. But the most rewarding and important lesson was when I finally realized I had the courage to let go of what I can’t change. I might never be as fast, run a marathon again, or probably see the podium in a race…or perhaps I will. But regardless, I am still here to enjoy the ride!”
Jason is the Race Director of the Westchester Triathlon, which will be held this year on September 22. For more information, visit www.westchestertriathlon.org.