From Ex-Fix to FKT Part 1

For Christmas 2018, her gift was an ex fix holding her pelvis together.

Hi! 👋  It’s me, Dr. Kelly Sadauckas. 🙂 I am one of a handful of Doctors of Physical Therapy IN THE WORLD who are double board certified in Pelvic Health and Orthopedics.  Today, I want to share with you about one of my REAL clients, Kaitlyn Boyle. 

In 2018, Kaitlyn set two course records in ultra-endurance mountain bike races, established herself as one of the fastest ultra-racers in the country, male or female, and Won the 24-hour Mountain Bike WORLD CHAMPIONSHIPS in Scotland. This is her.  She’s SUCH a bad-ass!

Kait Boyle winning 24-Hour Mountain Biking World Title in October 2018. 2 months later, she would be in a pelvic ex fix, following a car accident. 

At the end of 2018, Kaitlyn was on top of the world.

And just like that, everything changed

Kaitlyn's Car, the evening of Dec 24, 2018.

It was Christmas Eve, just 2 months after winning the World Champion title.  Kaitlyn was stuck in her crumpled truck without feeling in her legs and the deepest burning sensation in her pelvis.

The car accident resulted in Kait suffering a fractured pelvis, requiring an ex fix to stabilize; ruptured bladder; broken fibula and questions about her future as a pro athlete.

Kaitlyn had a quadruple fractured pelvis [that would require an ex fix (pieces of metal drilled into her pelvis from the outside) to stabilize], fractured sacrum, ruptured bladder, and a fractured fibula.

In laymans terms: She broke nearly every bone in her pelvis, had to have them screwed together from the inside and out, ruptured her bladder, and broke her fibula (outer lower leg bone).

Everyone ignored the fibula.

Kaitlyn woke up in the ICU, after emergency transportation from being extracted from her truck to Eastern Idaho Regional Medical Center (EIRMC) for an emergency trauma operation on her bladder in the earliest hours of Christmas morning.

Kaitlyn Was in the Hospital For 9 Days

During her 9-day stay in EIRMC, she had an emergency bladder surgery which resulted in an 8-inch vertical incision through her lower abdomen and insertion of a catheter.  Because of the presence of urine in her abdomen from the ruptured bladder, there was an infection risk, and she was not a candidate for full "internal fixation" of the pelvis. So five days later, she had surgery to stabilize her pelvis with an external fixator, in addition two long internal screws in her sacrum.

Here’s what it looks like from the inside:

Um....OW!

And here’s what it looked like from the outside:

The metal pieces you see held her pelvis together so it could heal. It had to be stabilized from the outside, because the infection risk of “just” screwing it together on the inside was too great, due to her ruptured bladder.

She spent 6 days completely immobilized in a hospital bed.

Following the placement of the ex-fix, had a "non-weight bearing" order for 5 weeks. This means she has to be in a wheelchair for 5-weeks, and isn’t allowed to put any weight through her legs. 

After those first 5 weeks in the wheelchair, she would be allowed to bear weight only through her right leg for another 6 weeks.

When She Started PT, The 31-Year Old World Champion was in a Wheelchair...with a catheter and an ex-fix.

Wheelchair: mobility device that you have to sit in, and is challenging to maneuver through tight places, over stairs, and over snow.  And it’s January, in a Mountain Town at 6,000ft of elevation. 

Catheter: tube that goes into your bladder to empty it…all the pee is held in a bag around your leg. 

Ex-fix: the metal rods that were drilled into the inside of the front of her pelvis, and also sticking out the front of her pelvis  (like an exo-skeleton that a super-hero or evil villain would have)

Kait was understandably uncertain at that first visit. Dr. Kelly wasn’t.

I greeted Kait at her first appointment with a huge smile, didn’t bat an eye at the catheter hanging from her wheelchair, or her 'alien contraption', the external fixator (she called it her 'towel rack'), coming out of her pelvis. We talked about how Kait was feeling, what re-learning to pee would be like, how Kait would start to move her legs again. We even discussed what Kait's journey back to first walking, then riding her bike might look like.

Regarding the plan for return to biking after pelvic fracture:

It was not: This is now, and there is the finish line.

It was: This is now, and here is your next step.

We started with simple movements - laying on the couch and sliding her legs back and forth in each direction. First side to side, like a windshield wiper, then back and forth, dragging her heels up to have bent knees. There was a huge focus on retraining the muscles of the deep core to stabilize the pelvis while the muscles of the hips moved the leg...all while breathing and (trying) to have a relatively relaxed pelvic floor!!  For the healthy, able body, those movements are easy. For Kait, the exercises were as hard as any interval work she'd ever done. 

I (Dr. Kelly), also did some fun and rather unique things, like dry needling, and having Kait do simple circulation exercises with Virtual Reality Goggles on, displaying a 1st person video of riding down a mountain bike trail. With athletes, I am big into visualization and 'the whole picture' of the athlete in eventual return to life, and not just the isolated, individual parts of rehab. There's good articles about that, actually...I'll do blogs on them, eventually ;)

How do you exercise with a pelvic ex fix? Here's one variant of a clamshell, to strengthen your gluteus medius. Just mind the metal and don't tear the mat table or couch, please.

Like with anything that you practice with patience, and show up every day to try your best, life in the ex fix grew easier with each day.

As Kait improved, I progressed her onto more advanced movements like lifting her leg straight off the couch and doing a mini crunch. I taught Kait what movements were great to do within the confines of the ex fix, which were okay, and which should be avoided at all costs. Of course, we focused significantly on learning to isolate the diaphragm, apart from the abdomen, apart from the pelvic floor. We learned when it was okay to use them together, and when it wasn't. (side note, Vag Lab teaches that separation, and the Signature Series includes the exact rehab progression that Kaitlyn used to get out of the ex-fix and onto a bike!)

In addition to the exercises, there was also a bit of wound care to manage, which I outsourced, but in general, learned that 'granulation tissue' (fancy word for healing skin), if it can't close together (like if there's a piece of metal blocking it from sealing a hole in the skin), it will start to climb the metal to try to close the hole. COOL! (& and a little gross...but mostly cool). If this happens to you, don't freak out, just talk to your doctor, and they'll clean up the extra tissue (numb it and cut it away). It will heal fine when the metal is removed.

Within a couple weeks, Kaitlyn had the catheter removed and began re-training her bladder. 

Around that same time, we received the blessing from her surgeon to try a stationary bike, with zero resistance on the pedals.  Getting on the bike while still not able to bear weight normally through both legs, was a challenge, but not an insurmountable one. Through a combination of core strength, arm strength, a pivot transfer, patience and a milk carton, we were able to get Kaitlyn on a stationary bike, while still in her ex-fix.

Her first ride was 5 minutes, and she said it was one of the best rides of her life!

Kait could see her future of riding a bike outside again someday.

For the last three weeks in her wheelchair, Kait got on her indoor stationary bike nearly every day to spin her legs. The exercise, while it never raised her heart rate notably, got blood moving through her legs, gave her mind the meditative movement she craved, and fueled her inspiration for continuing the simple, but challenging, physical therapy exercises.

Still in the ex fix, Kait progresses from wheelchair to crutches

Around 8 weeks after surgery, while still partial weight bearing through one of her legs, Kaitlyn was cleared to transition from the wheelchair to crutches.

While crutches are generally viewed as limiting,
for Kait, they felt like freedom sticks!

She could finally stand upright. With her new capabilities from standing on one leg, she could more easily get in and out of bed, more easily to the bathroom, get in and out of the car, reach cabinets, climb stairs, cook, shower standing, go into stores, etc. These, often taken for granted human capabilities, were liberating and greatly helped Kaitlyn's outlook during this time.

At this point, when Kaitlyn was cleared for weight bearing as tolerated on one leg, and partial weight bearing on the other, in physical therapy we finally were able to progress to standing balance & strengthening exercises to keep her challenged and engaged. Remember those VR goggles? Now we're standing on the one leg we're allowed to, practicing on maintaining balance while watching a Roller Coaster Video. NOT EASY.

Meanwhile, Kait was making slow but steady progress in increasing her time and resistance pedaling on the bike.

Truth: She was also getting tired of physical therapy and healing.

All goals take focus, but motivation is a muscle and it can get tired.

As the weeks turned to months, Kait started to fatigue mentally from the focus and daily dedication to physical therapy and healing. Kait used journaling of her intentions, setting mini daily goals, and allocating days off to just rest and be unmotivated to keep her going.

"You get to..." was inscribed on her ex fix, and was a regular mantra to focus on the positives.

Smiles on the outside, ex fix on the outside, but getting tired on the inside.

Finally, three months after her surgery, her external fixator was removed and she was cleared to bear weight on her other leg. She quickly transitioned from crutches to a cane, added strength and balancing exercises, now with both legs, and marched into Kelly’s office ready to ditch the cane.

The Infamous Cane Toss. Ex Fix is now removed, and Kait is cleared for walking without a cane by Dr. Kelly! Woot-Woot!  And yes, that is a WORS shirt that I have on. I was a runner up in my age division in Citizen Class a few years ago...bet you didn't know I was also a 'big time' cycling star, did you ;) Kaitlyn & I in one room?!? Now you're impressed :)

After weaning from the crutches and cane, I would regularly test Kait's functional strength, balance and mobility, to advance her prescribed "PT exercises" so that they complemented her functional strength training in the best way possible. We also guided her in a specific "return to cycling progression", and while she wasn't "cleared" to "just return to strength training with a coach without restrictions", at this point, we did have her working with a strength coach again, with the strength coach and I collaborating closely.  It was important for her mental health, and physical health, to see that "PT wasn't forever" and that we were on the road to her feeling like a full human again. 

All of Kaitlyn's hard work, patience, vision and the support from her medical team, family and partner had paid off. She was healthy and functional again.

Her next chapter would be rebuilding from "no longer in a wheelchair" to return to racing again, and then eventually to "healthy and elite mountain bike athlete".

Tell you about it soon. In the meanwhile, visit her sponsors, Pivot, Industry Nine, and Ride With GPS. They have all been amazing and supported her through this journey.

And click here to check out The Signature Series, which includes all of the rehab exercises and guidance that Kaitlyn used to transition from ex-fix to athlete again!!

Thanks for Reading!

xoxo, Dr. Kelly

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