Practical Assessment and Rehabilitation of the Dancer Case Study

Original Editor - Carin Hunter based on the course by Michelle Green-Smerdon
Top Contributors - Carin Hunter and Jess Bell

Introduction[edit | edit source]

This case study forms part of the Practical Assessment and Rehabilitation of the Dancer Course.

Assessment[edit | edit source]

Ms E is a 20-year-old dancer. She has been dancing for 17 years and does ballet, tap, modern, and contemporary dance and musical theatre.

She presents with a 7/9 score on the Beighton Scale[1] which shows she is hypermobile.[2] Her Beighton score is as follows:

LEFT RIGHT
1. Passive dorsiflexion and hyperextension of the fifth MCP joint beyond 90° 1 1
2. Passive apposition of the thumb to the flexor aspect of the forearm 0 0
3. Passive hyperextension of the elbow beyond 10° 1 1
4. Passive hyperextension of the knee beyond 10° 1 1
5. Active forward flexion of the trunk with the knees fully extended so that the palms of the hands rest flat on the floor 1 1  
TOTAL  7  / 9


Ms E's main complaint is pain on the top of both feet when going up onto pointe, doing a rollover and in roll-ups.

Pre-Pointe Assessment[edit | edit source]

1. Airplane Test[3]

The dancer must be in the correct starting position and be given the appropriate cues to complete the test. Detailed instructions for this test are available here. Always remember to test and compare both the right and left sides. When conducting this test, it is important to observe: pelvic control, knee alignment, coordination, control of movements and the ability to maintain square, level hips. It is advisable to take a video of this test. This enables the assessor to analyse the movement in detail and provides feedback to the dancer.

Ms E completed the test on both her left and right sides. On her left side, she demonstrates a slight lift of the hip on her raised limb. She does, however, present with good alignment, control and balance. Her alignment and control are better on her right side than her left.

2. Single Leg Heel Raise Test[3]

When Ms E completes the single leg heel raise test on her left side, she rolls between her toes while going up and down and demonstrates slight sickling of her foot. When testing the right side, the alignment of Ms E's foot is incorrect and she lifts her big toe up completely. She also has clawing of her toes. As is discussed here, the most important role of the intrinsic foot muscles for ballet dancers is to oppose the clawing effect of the long flexors of the toes.[4] When repeating the test, Ms E's bottom leg moves away from her other leg. This compensation is an attempt to gain control and stability. Moreover, Ms E is rolling over and cannot stay as centered / aligned as she does on her left leg.

3. Topple Test[5]

The topple test assesses a dancer’s ability to perform a single clean pirouette.[6] Like the airplane test, it is vital to take a video recording of this test because the movement is performed very quickly. Thus, it is too difficult to check all the points required for a "pass mark" with the naked eye. A video also enables the assessor to give feedback to the dancer.

When Ms E completes this test, her placement and landing are slightly off and need to be more centered. She rolls over her toes and is unable to maintain her alignment when on pointe.

4. Single Leg Sauté Test[7]

When conducting an assessment, it is beneficial to avoid performing the single leg heel raise test and the sauté test back-to-back as both tests evaluate calf endurance. Therefore, results will not be accurate if the tests are performed one after the other as the dancer may be affected by fatigue. The sauté test is a series of 16 consecutive jumps.[6] The test is described in detail here.

When testing her left side, Ms E begins to flex her hips and lean forwards. She is unable to get as high up onto her pointe as she completes more repetitions. On her right side, Ms E cannot jump as high and her landings are significantly more erratic; she is unable to land in one spot. As she tires, her upper body begins to sway as a compensation.

5. Pencil Test[8]

The pencil test assesses the overall plantar flexion range of the ankle-foot complex.[9] Because of Ms E's hypermobility (evidenced by her Beighton score), one would expect her to have good plantar flexion range. In the pencil test, the pencil lies flat on top of Ms E's foot.

These five tests are all discussed in more detail on the Pre Pointe Assessment page.

Quick Point Shoe Assessment[edit | edit source]

The pointe shoe is discussed in detail here.

Ms E dances in a Grishkho's pointe shoe. As discussed above, Ms E is hypermobile. Therefore, an ideal pointe shoe for Ms E would offer more strength, support and structure. However, when assessing her shoes, both have very flexible shanks.

On subjective assessment, Ms E reveals that her shoes were broken in by normal walking, and her usual ballet and barre classes.

On initial assessment, it appears that she has had an incorrect pointe shoe fitting:

1. Rise

The patient begins in parallel, which makes it easier to compare the left and right sides. She moves from flat on the floor up into pointe. This is a quick test to check alignment and it assesses the level of effort required to move onto pointe. When conducting this assessment, it is most effective if the patient moves through a demi-plié and then onto pointe, and then reverses the movement.[4]

When Ms E performs this test, her left knee is locked into hyperextension. Her transition onto pointe is jerky and comprises of two movements rather than one fluid movement. At the end of the movement, she collapses onto pointe instead of rising up and controlling the movement.

When she is up on pointe, Ms E knuckles over or falls forward onto pointe. She overshoots getting onto the box, and is unable to control / hold her foot up. There is give, or collapse, in her foot. This results in an overstretching of the ligaments and tendons in the front.

2. Pointe

During the pointe assessment, Ms E over-collapses into a wing or a sickle on her right side. Her left side is slightly better aligned.

3. Plié

When Ms E performs a plié, she slightly rolls in on her feet, creating a collapse in her turnout. When the therapist offers a correction, Ms E finds the movement more difficult, but can maintain the position.

Ms E is then asked to perform a grande plié, and it is apparent that her heels are not at the same height. As she moves out of her grande plié, she falls slightly out of alignment, which could be indicative of weak intrinsic muscles.

Objective Assessment and Findings[edit | edit source]

1. Observe Pain Provocating Movement - The Rollover

On observation of Ms E's rollover, her foot collapses out and loses alignment.

In order to help correct this, alignment markers can be drawn on. The dancer can also be asked to repeat the movement in front of a mirror. This provides visual input until the dancer has the strength and proprioception to complete the task without assistance. Teaching the correct alignment can also help with rollovers.[4]

2. Drawing Alignment Markers and Checking Alignment of the Foot [10][11]

Place a marker on the point between the lateral and medial malleolus, draw a straight line down to the the second toe. When the dancer points her toe, the line should be straight. She should not sickle or over-wing. The dancer can also place her feet together in parallel and rise onto demi-pointe and the marker should create a vertical line.[4]

Intervention and Outcome[edit | edit source]

Ms E is given five simple exercises to help strengthen her muscles, and improve foot control and awareness:[4]

1. Doming

Doming is a good exercise for Ms E as she was gripping and clawing with her toes on the ground, which indicates weak intrinsic muscles. This exercise encourages lifting of the metatarsal heads and the transverse arch. The toes should be flat / straight while the metatarsal head is lifted.

2. Big Toe Up

The four small toes are kept comfortable on the ground while the big toe is lifted up. This exercise targets the extensor hallucis longus.

3. Big Toe Down

The four small toes are lifted up while the big toe is kept comfortable on the ground. This exercise targets the extensor digitorum longus.

4. Piano-ing

With this exercise, all ten toes are lifted up. The goal is to place each toe down, in order, beginning with the small toe and ending with the big toe. This is then completed in reverse order, beginning with the big toe and ending with the small toe.

If there is any sign of gripping or clawing with the toes, as Ms E demonstrated, this exercise needs to be practised until the toes are comfortable and remain relaxed / straight.

5. Big Toe Abduction

The last exercise recommended for Ms E is big toe abduction. The feet are placed parallel on the floor. The big toes are lifted up, moved away from the other toes on the foot (i.e. abduction) and placed down on the floor. The movement is then reversed by lifting the big toe up and returning it to the start position (i.e. adduction).

Outcome[edit | edit source]

Ms E is asked not to practise pointe work until: she has done her exercises; has no pain in her forefoot during the rollover; and has been for a pointe shoe fitting assessment with a professional fitter.

Treatment Recommendations[edit | edit source]

1. Ball rolling

2. Intrinsic stretching and massage

3. Theraband exercises - in all these exercises, alignment and control are crucial:

  • Plantar flexion strengthens the gastrocnemius and soleus. It is important to hinge at the ankle, keeping the toes completely straight, following through with pointing the toes, and avoiding clawing
  • Dorsiflexion strengthens the tibialis anterior
  • Inversion with flat foot and pointed foot
  • Eversion with flat foot and pointed foot

 References[edit | edit source]

  1. Alter M. Science of Flexibility. Sheridan books 2004 (third edition); page 89
  2. Biernacki JL, Stracciolini A, Fraser J, Micheli LJ, Sugimoto D. Risk factors for lower-extremity injuries in female ballet dancers: a systematic review. Clinical journal of sport medicine. 2021 Mar 1;31(2):e64-79.
  3. 3.0 3.1 DeWolf A, McPherson A, Besong K, Hiller C, Docherty C. Quantitative measures utilized in determining pointe readiness in young ballet dancers. Journal of Dance Medicine & Science. 2018 Dec 1;22(4):209-17.
  4. 4.0 4.1 4.2 4.3 4.4 Green-Smerdon M. Biomechanics of the Dancer’s Ankle and Foot Course. Physioplus, 2022.
  5. Altmann C, Roberts J, Scharfbillig R, Jones S. Readiness for en pointe work in young ballet dancers are there proven screening tools and training protocols for a population at increased risk of injury?. Journal of Dance Medicine & Science. 2019 Mar 15;23(1):40-5.
  6. 6.0 6.1 Hewitt S, Mangum M, Tyo B, Nicks C. Fitness testing to determine pointe readiness in ballet dancers. Journal of Dance Medicine & Science. 2016 Dec 15;20(4):162-7.
  7. Batalden L. Pointe-Readiness Screening and Exercise for the Young Studio Dancer. Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.
  8. Bonham K. The Prevalence and Efficacy of Cross-training in a Professional Ballet Environment: A Literature Review. (2021). Senior Theses. 397
  9. Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.
  10. Bronner S, Lassey I, Lesar JR, Shaver ZG, Turner C. Intra-and inter-rater reliability of a ballet-based dance technique screening instrument. Medical Problems of Performing Artists. 2020 Mar 1;35(1):28-34.
  11. Khan K, Brown J, Way S, Vass N, Crichton K, Alexander R, Baxter A, Butler M, Wark J. Overuse injuries in classical ballet. Sports Medicine. 1995 May;19(5):341-57.