Practical Assessment and Rehabilitation of the Dancer Case Study: Difference between revisions

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== Introduction ==
== Introduction ==
This case study forms part of the '''Practical Assessment of The Ballet Dancer''' Course
This case study forms part of the '''Practical Assessment and Rehabilitation of the Dancer''' Course.


== Assessment ==
== Assessment ==
Ms E is a 20 year old ballet dancer. She has been dancing for 17 years and does ballet, tap, modern, contemporary and musical theatre.
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 score|beightons scale]] which shows she is hypermobile<ref>Biernacki JL, Stracciolini A, Fraser J, Micheli LJ, Sugimoto D. [https://journals.lww.com/cjsportsmed/Abstract/2021/03000/Risk_Factors_for_Lower_Extremity_Injuries_in.13.aspx?context=LatestArticles 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.</ref>.
She presents with a 7/9 score on the [[Beighton score|Beighton Scale]]<ref>Alter M. Science of Flexibility. Sheridan books 2004 (third edition); page 89</ref> which shows she is hypermobile.<ref>Biernacki JL, Stracciolini A, Fraser J, Micheli LJ, Sugimoto D. [https://journals.lww.com/cjsportsmed/Abstract/2021/03000/Risk_Factors_for_Lower_Extremity_Injuries_in.13.aspx?context=LatestArticles 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.</ref> Her Beighton score is as follows:
 
Beightons Scale<ref>Alter M. Science of Flexibility. Sheridan books 2004 (third edition); page 89</ref>:
{| cellspacing="1" cellpadding="1" border="1" width="684"
{| cellspacing="1" cellpadding="1" border="1" width="684"
| rowspan="2" |'''Movement tested'''
| colspan="2" |'''Score'''
|-
|-
|
|LEFT
|LEFT
|RIGHT
|RIGHT
|-
|-
|1. Passive dorsiflexion and hyperextension of the fifth MCP joint beyond 90°
|1.Passive dorsiflexion and hyperextension of the fifth MCP joint beyond 90°
|1
|1
|1
|1
|-
|-
|2. Passive apposition of the thumb to the flexor aspect of the forearm
|2.Passive apposition of the thumb to the flexor aspect of the forearm
|0
|0
|0
|0
|-
|-
|3. Passive hyperextension of the elbow beyond 10°
|3.Passive hyperextension of the elbow beyond 10°
|1
|1
|1
|1
|-
|-
|4. Passive hyperextension of the knee beyond 10°
|4.Passive hyperextension of the knee beyond 10°
|1
|1
|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
|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
| colspan="2" |1
|1&nbsp;&nbsp;
|-
|-
|'''TOTAL'''
|'''TOTAL'''
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Her main complaint is "pain top of foot left and right when going up onto pointe and when doing a roll over".
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-Point Assessment ==
== Pre-Pointe Assessment ==
'''1. Airplane Test<ref>DeWolf A, McPherson A, Besong K, Hiller C, Docherty C. [https://www.ingentaconnect.com/content/jmrp/jdms/2018/00000022/00000004/art00005 Quantitative measures utilized in determining pointe readiness in young ballet dancers.] Journal of Dance Medicine & Science. 2018 Dec 1;22(4):209-17.</ref>'''
'''1. Airplane Test'''<ref name=":0">DeWolf A, McPherson A, Besong K, Hiller C, Docherty C. [https://www.ingentaconnect.com/content/jmrp/jdms/2018/00000022/00000004/art00005 Quantitative measures utilized in determining pointe readiness in young ballet dancers.] Journal of Dance Medicine & Science. 2018 Dec 1;22(4):209-17.</ref>


Make sure the starting position is correct for their Airplane test and give the patient the cue to complete the test. Always remember to test and compare left and right. When conducting this test try and observe the pelvic control, knee alignment, coordination control of movements and maintaining square, level hips. It is advised to video this test as this makes for an easier analysis after the test is complete and feedback can be shown to the dancer.
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 [[Pre Pointe Assessment|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 the left and the right. The left showed slight hip lifting of the raised limb, although she did present with good alignment, control and balance. When conducting the test on the right, the alignment and control was better than the opposite side
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'''
'''2. Single Leg Heel Raise Test'''<ref name=":0" />


When Ms E completed the single leg heel raise test on the left, she rolls between her toes going up and down and slightly sickling a little. On the right the alignment of her foot is incorrect and she lifts her big toe up completely with clawing of the toes .On repeating the test the bottom leg moves away from the other leg. This compensation can help to gain control and stability. The clawing of the toes indicates the intrinsic muscles are gripping on the floor. She is rolling over and not staying as centered and aligned as on the left leg.
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 [[Biomechanics of the Dancer’s Ankle and Foot#Three Key Elements in a .22Good.22 Ballet Foot|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.<ref name=":1">Green-Smerdon M. Biomechanics of the Dancer’s Ankle and Foot Course. Plus , 2022.</ref> 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<ref>Altmann C, Roberts J, Scharfbillig R, Jones S. [https://www.ingentaconnect.com/content/jmrp/jdms/2019/00000023/00000001/art00006 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.</ref>'''
'''3. Topple Test'''<ref>Altmann C, Roberts J, Scharfbillig R, Jones S. [https://www.ingentaconnect.com/content/jmrp/jdms/2019/00000023/00000001/art00006 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.</ref>  


The topple test is also known as a Pirouette. A video recording of this test is vital because the dancer will perform the test very quickly and to be able to check all the points is too difficult with the naked eye. It also helps with giving feedback to the dancer.
The topple test assesses a dancer’s ability to perform a single clean pirouette.<ref name=":2">Hewitt S, Mangum M, Tyo B, Nicks C. [https://www.ingentaconnect.com/content/jmrp/jdms/2016/00000020/00000004/art00003 Fitness testing to determine pointe readiness in ballet dancers]. Journal of Dance Medicine & Science. 2016 Dec 15;20(4):162-7.</ref> 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 completed the test her placement and landing was slightly off and needs to be a little bit more centered. She was rolling over her toes and not keeping alignment when on pointe.  
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 Saute<ref>Lynn Batalden PT. [https://www.proquest.com/openview/d70eb2979a20a874508323e2a67e1fed/1?pq-origsite=gscholar&cbl=5425112 Pointe-Readiness Screening and Exercise for the Young Studio Dancer]. Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.</ref>'''
'''4. Single Leg Sauté Test'''<ref>Batalden L. [https://www.proquest.com/openview/d70eb2979a20a874508323e2a67e1fed/1?pq-origsite=gscholar&cbl=5425112 Pointe-Readiness Screening and Exercise for the Young Studio Dancer]. Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.</ref>


When conducting a PrePointe Assessment, try and split the Single Leg Heel Raise and the Sauté because they both work and calf endurance, therefore results will not be accurate as there will be a component of fatigue. The Sauté Test is a series of 16 consecutive jumps. On the left, Ms E begins to flex her hips and lean forwards. she also does not get as high up onto her pointe ad the jumps proceed. On the right, Ms E doesn't jump as high and the landings are significantly more erratic instead of in one spot. As she tires, her upper body begins to sway as compensation.
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.<ref name=":2" /> The test is described in detail [[Pre Pointe Assessment|here]].


'''5. Pencil Test<ref>Bonham K. [https://scholarcommons.sc.edu/cgi/viewcontent.cgi?article=1397&context=senior_theses The Prevalence and Efficacy of Cross-training in a Professional Ballet Environment: A Literature Review.] (2021). ''Senior Theses''. 397</ref>'''
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.


The pencil lie flat on top of her foot when conducting this test. She should perform well on this test as we know she is hypermobile.  
'''5. Pencil Test'''<ref>Bonham K. [https://scholarcommons.sc.edu/cgi/viewcontent.cgi?article=1397&context=senior_theses The Prevalence and Efficacy of Cross-training in a Professional Ballet Environment: A Literature Review.] (2021). ''Senior Theses''. 397</ref>
 
The pencil test assesses the overall plantar flexion range of the ankle-foot complex.<ref>Richardson M, Liederbach M, Sandow E. [https://www.ingentaconnect.com/content/jmrp/jdms/2010/00000014/00000003/art00002 Functional criteria for assessing pointe-readiness]. Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.</ref> 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 ==
== Quick Point Shoe Assessment ==
Ms E dances in a Grishkho's pointe shoe. On testing, Ms E hypermobile, this means her shoe should offer more strength and support and structure. When assessing the shoe, she appears to have a very flexible shank on both the left and the right.  
The pointe shoe is discussed in detail [[Anatomy of the Pointe Shoe|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 she revealed the shoes had been broken in by normal walking, normal ballet class and barre class.
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, she has an incorrect pointe shoe fitting.
On initial assessment, it appears that she has had an incorrect pointe shoe fitting:


'''1. Rise'''
'''1. Rise'''


The patient begins in parallel, which makes it easier to compare left and right, and moves from flat on the floor up into pointe. This is a quick test to check alignment and the effort to move onto Pointe. When conducting this assessment, it is most effective if the patient moves through a demi-plié and then onto a pointe, and then reverse it.  
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.<ref name=":1" />


When Ms E performs this test her left knee is locked into hyperextension. The transition onto pointe is jerky and comprises of two movements where as it should be one fluid movement. At the end of the movement she collapses onto pointe instead of rising up and controlling the movement.  
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, she is knuckling over or falling forward onto pointe. She has overshot getting onto the box, is not able to control and hold her foot up. There is give, or collapse in the foot. This is resulting in an overstretching these ligaments and tendons in the front.
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. Point'''
'''2. Pointe'''


On conducting a point assessment, Ms E over-collapses into a wing or a sickle on the right. The left is slightly better aligned.  
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. Plie'''
'''3. Plié'''


When Ms E performs a plié she slightly rolls in on her feet, creating a collapse in her turnout. If the therapist offers correction, this increases the difficulty for Ms E, although it can be maintained.
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 her heels are not 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.   
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 ==
== Objective Assessment and Findings ==
'''1. Showed roll over'''
'''1. Observe Pain Provocating Movement - The Rollover'''
 
On observation of Ms E's rollover, her foot collapses out and loses alignment.


Emma has taken her shoes off. So the two points where she said she had pain was in her rise onto her pointe on the lower front of her foot and also on the rollover. So I'm going to show you what a rollover looks like now. So take this is a side view. So have a quick look. I'm going to scoot out the way so she doesn't land on top of me. Just show them what a rollover is. So that is a rollover. Very hard to do and it is as uncomfortable as it looks. Yes. Right. So when she was doing her rollover, I'm not gonna ask her to do it again, her alignment. So when you do a rollover you should be completely aligned, your foot should to be a hundred percent in line doing your rollover. Quickly swing and face that way. So you would be in that position rolling over. So what's happening with Emma is that she's rolling over and she's collapsing, she's collapsing out. So, what are we going to do? He was going to just check her alignment. So again, the two points lateral and medial malleolus. Pop a marker in the middle and then draw your straight line down through to your second toe, which is next to your big toe. And that's your straight line that you're looking for. I'm going to do it on both. So middle between your malleoli and then straight line through to your your second toe over there. All right. So what we are looking for, just stand for me for two seconds, come scoot a little bit closer. So we're looking for, so if you look yet, she's got a nice little line straight through. So if you're going to point, so point this one for me, what you are looking for in a point is that all of this lines up in a line and you're not sitting with your sickling or your over-winging on that side. So put your feet together and just do a little demi, demi-rise. So again, you need to have this nice and straight. All right. Roll down for me, open up slightly and then do your demi like that. And you'll see what happens there, at the very end she shifts and comes back with with her alignment. Do one more again. That's a better alignment, is that much harder to work way, way harder. When you've got ....., this is a really nice cue for them to watch, especially if they're working in front of a mirror to make sure that that is nice and aligned. So, drawing this on and getting her to do rollovers while watching that alignment is straight. And also then teaching her where the correct alignment is will help significantly with those rollovers.
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.<ref name=":1" />


'''2. Checked alignment of foot'''<ref>Bronner S, Lassey I, Lesar JR, Shaver ZG, Turner C. [https://www.ingentaconnect.com/content/scimed/mppa/2020/00000035/00000001/art00004 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.</ref><ref>Khan K, Brown J, Way S, Vass N, Crichton K, Alexander R, Baxter A, Butler M, Wark J. [https://link.springer.com/article/10.2165/00007256-199519050-00004 Overuse injuries in classical ballet]. Sports Medicine. 1995 May;19(5):341-57.</ref> (pts problem that needed to be corrected) in pre pointe and in roll over)
'''2. Drawing Alignment Markers and Checking''' '''Alignment of the Foot''' <ref>Bronner S, Lassey I, Lesar JR, Shaver ZG, Turner C. [https://www.ingentaconnect.com/content/scimed/mppa/2020/00000035/00000001/art00004 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.</ref><ref>Khan K, Brown J, Way S, Vass N, Crichton K, Alexander R, Baxter A, Butler M, Wark J. [https://link.springer.com/article/10.2165/00007256-199519050-00004 Overuse injuries in classical ballet]. Sports Medicine. 1995 May;19(5):341-57.</ref>


'''3. Drew alignment markers''' – helped pt A LOT to correct alignment
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.<ref name=":1" />


== Intervention and Outcome ==
== Intervention and Outcome ==
This patient was given five simple exercises to help strengthen intrinsic muscles, and foot control and awareness.
Ms E is given five simple exercises to help strengthen her muscles, and improve foot control and awareness:<ref name=":1" />


'''1. Doming'''
'''1. Doming'''


All right. Do you want to sit on the side and let's show them your exercises. Okay. So if we want to check her doming very quickly. So she was gripping and clawing in a lot of those movements. So this is where doming comes in as a really nice exercise. It lifts up the metatarsal heads and it works on that transverse arch over there. The point of the doming is as you lift up, you want to create that nice little dome. So you don't want clawing of the toes. So let's show to how you would do it. So, there we go. You might need to turn around and face the camera, so that they can see scoot a little bit back. There we go. All right. So if we dome you dome up, what you're looking for is was nice, flat, straight toes over here, and I should be able to get my finger in on the side over here. And if I slide through there, it should come through out on the other side, there, so if you look at Emma's doming, and you can see this side is quite good, this side, she's almost getting a little bit stuck into this little joint over here. So that's when would go and have a look and just see mobility-wise, what is the mobility looking like there? Because even though you have a hypermobile or or a flexible foot, there might be some parts where you are a little bit stiff and stuck, and that's probably one of the parts where she is.
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.
 
{{#ev:youtube|Wc6Zdgeq7ZU}}
All right. So doming is definitely one of the ones we want a give to her. 
 
'''2. Big Toe Up'''  
'''2. Big Toe Up'''  


Then the other one is big toe up, so separating them, so big toes and keeping the other toes on the ground and beautifully done on this one. This one. Oh, there we go. Got it, beautiful, and down.
The four small toes are kept comfortable on the ground while the big toe is lifted up. This exercise targets the [[Extensor Hallucis Longus|extensor hallucis longus]].  


'''3.''' '''Big Toe Down'''  
'''3.''' '''Big Toe Down'''
 
Now keep your big toes down and your other toes up. And this is the where she battles. Can you see those big toes are coming up as well? And also, when you look is the height, put your big toe down. So she's battling keeping her big toe down on this side and the other toes up. You want to have nice equal height up here and equal height up here. Alright, and 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|extensor digitorum longus]].
{{#ev:youtube|9koRqQhN8QE}}
'''4. Piano-ing'''  
'''4. Piano-ing'''  


Now, piano-ing. Can we try piano-ing? Do you want to stand and do the piano-ing? Okay. So standing and piano-ing is much nicer than sitting because with the standing, you get the weight through it and you get the feel of the movement and it's just much easier. And to be honest, they need to do it while they are standing and dancing. All right. So let's do piano-ing. So here lifting up and then she's doing baby toes down and she's piano-ing them all the way down to the last. And there, you can see she's starting to grip a little bit. So that's what you want to fix. No gripping, no clawing. So I don't want to see any clawing taking place, and reverse it. And the reverse is quite hard for you, hey. So piano-ing is really, really hard. You've really got to stare at your toes quite a lot in order to get this. And this does take practice. This is not something which you're going to get today or tomorrow. It is strengthening muscles. So it's going to take time. So when you piano, the essence of it is to be able to lift all the toes up individually and reverse them all the way back down left and right.  
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.
 
'''5. Big toe abduction'''


And then the last exercise that we've given her is the abduction of these two big toes. So we want to lift them up, pull them towards each other and down. Which were, ah, this one also you've got to stare at your toes for quite a long time. And again, clawing on that side over there, and then reverse it, lift up, put them back. Good. This one definitely behaves a lot better than that one. Try one more time, lift up and pull them in towards each other. Good. That's nice, that was as much better, less clawing on that side. So her feet, her intrinsics, are working really, really super hard over here. And again, this is not something that you're going to get today or tomorrow. You really have to stare at your toes to get them to move. And normally one side is better than the other side. So we've got to make sure that the clawing is one of the big things with Emma is that she doesn't claw and aligns all of that quite nicely.
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. {{#ev:youtube|Ai7eUHLr1G0}}
'''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).
{{#ev:youtube|IhmAFuP73Pw}}
== Outcome ==
== Outcome ==
– no pain in roll over provided she does her exercises, taken off pointe until can get properly fitted with correct shoes
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.
 
outcome was that as long as she does these exercises, she has no more pain on the forefoot in the rollover. And we've actually stopped her in doing the pointe until she can get a proper fitting assessment done with a professional fitter for her pointe shoes. Because continuing in the pointe shoes that she does have is going to be more detrimental to her and it's gonna be harder and it's going to create a lot more injuries later down the line.


== Treatment Recommendations ==
== Treatment Recommendations ==
Right. Okay. So how are we going to do some foot and ankle exercises. We're going to start with the muscles on the top of the foot. So here, first one is you want to try and get your big toe up. This is for your extensor hallucis longus. So, big toe up and then big toe down, big toe up and big toe down. That's your first exercise. Your second one is to try and keep your big toe down and lift all your other toes up. And that's for your extensor digitorum longus. Good job. Right, and then your last one in this is to try and piano the toes. So big toe up and then one by one lifting all the other toes up and then reverse it to piano-ing down. Some people do call these yoga toes. Really, really good to do.
1. '''Ball rolling'''
 
{{#ev:youtube|clTHavpjZ8U}}
So now if we go straight into intrinsics. Doming is one of the most important exercises that we do. So with doming, I'm going to come in here. You want to be here, this is where you want to be lifting up those knuckles. And you want to make sure that these toes remain straight. So just crinkle your toes for me as you dome up. So this is what we don't want. This is not correct doming. So doming strengthens the intrinsic muscles. And what that means is that these toes need to remain straight. So you're lifting up more into the transverse arch. So you can lift up transverse arch and you can lift up at the back over here so that you've got a nice little, just to show I can put my hand right in underneath, over there, rounding over here with straight toes. So that's doming. Doming is quite hard to do, and it does take some practice.
2. '''Intrinsic stretching and massage'''
 
Right. Really nice one too, ball rolling. So just popping a ball down and just rolling the muscles underneath for those beautiful intrinsic foot muscles that often get neglected over there. And you can play around with balls. You can do big balls, small balls, whichever ball works for you. Right. And that you can do how long as you like.
 
All right. Then we are looking for, so if you place your feet together, place them slightly apart from each other. Now we're looking for big toe abduction, which means trying to see, can you get your big toes to go meet each other in the middle? This one is really hard. And often we have a very dodgy side and a not so dodgy side. It's often one of those exercises where you kind of need to stare at your toes quite a lot and just make them move magically until you do get it right. So this one helps quite nice for bunions. Although it is the trickiest exercise we have ever come across, as you can tell.
 
All right. And then you also want to be stretching these intrinsics. So often here, you want to just get your fingers in and you want to get them in between each of these and just give them a nice, good stretch. So this is where those toe spacers from manicures come into play. And they work really nicely with stretching all of these toes open from each other. Remember intrinsics work so hard and they're such small, tiny muscles that we often forget to stretch them. So they really do love to be stretched. Because often when we work, we want to be working with splay toes rather than bunched up toes. And you must also remember then that your ballet dancer they are sitting in shoes and pointe shoes where they are busy crimping and tightening over here. So getting that stretch in between, oh, they just absolutely, absolutely love it. And you can also sit and massage in between each of those toes. They will really, really, really love you for that.
 
We're going to go through a few TheraBand exercises for strengthening for the ankle and foot for the ballet dancer. So we're going to start with your plantar flexion, which is for your gastrocs and your soleus. So the biggest thing over here when you're doing your plantar flexion is we want to make sure that we are hinging at the ankle and that we are not working the rest of the foot. And then we are isolating, so you dissociating movement. So when you are plantar flexing or pointing your toe, you want to make sure that these toes stay dead straight. And when you're coming up, you want to make sure those toes stay dead straight. So often what they teaching is to go through demi onto your pointe. So going through and then pointing your toes at the end and then reversing it. What we would like is actually not to do that because we want to be able to be working the hinge at the ankle joint while maintaining these straight toes and that'll help in any movement, especially your faster plyometric movements in your dancing and in your choreography. So you want to aim to keep these toes dead still, don't move them. It's really, really, really hard to do if you've been moving them your whole life. Keeping them dead still and just moving from the ankle joint and coming back up. So if they can do that, fantastic, we'll bring in a TheraBand. If they can't do that, let them learn and get hold of that movement first, before you start bringing in TheraBands. So when we do bring in your TheraBand, we're going to pop it through like that and then you can hold. So you are covering the toes and the ball of the foot. And again, same thing, you're going to point keeping these toes dead straight, you've got to watch these toes are dead straight and reverse. What we are you looking for as nice control down and a control up, even movement. And again, when she's pointing, you want to make sure that this alignment is dead straight. So again, good idea to mark that between the two malleoli and the line going down to that second toe. As she is pointing here that line must be dead straight. If she is sickling. We're going to end up doing that and your line's going to be broken or winging. She's going to be going in that direction. So a really nice visual cue is to get that alignment going and going up again, keep that line nice and straight.
 
All right. So that's your plantar flexion, then you've got your dorsiflexion, which is your tib anterior. And again, only if they can sit and do this straight. So you're just going to hook it through this way. And then you're going to had a hold onto this side over here. And then she's going to go up, keeping these toes dead straight, as much as she can. And coming back, down and up again. And it's quite hard keeping these toes nice and straight because they want to immediately knuckle over when you are bringing that up into a dorsiflexion over there.
 
All right. So then we can go to the, we'll come to the inversion eversion just now, so we'll change angle for you. Right now let's work on the big toes and the toes. We like to work on them separately because otherwise the big toe takes over for everything. So we would pop them in separately. And again, you're just popping through that big toe, over there. All right. Okay. And again, so now you're going to do your flexion, right now we are going to be. So here you want to start into a pointe and then going to be working the big toe up and down in your pointe. Good. And up. That's it. And at the same time you want to keep these other toes dead still, no movement and gently up, making sure that your alignment is correct. Good. That's really nice. So the reason you want to do it in the pointe is because your ballet dancer spends a lot of time in the pointe. If you are doing this in a dorsiflexion, that's great, but that's not functional in any ballet dancer whatsoever. So make sure when you do this, that you are in a pointe already, toes are not clawing. And big toe is being worked up and down. And then again, you're going to then do the same, excluding the big toe and getting in those baby toe over there. Again, working in the pointe and making sure that your alignment is straight. And here you want to make sure that this toe stays down as much as it can and you're working on these other toes. They're groing up and down with the big toe remains.
 
Good job! And these are your, so one of the muscles, the two muscles that you're working on here are your flexor digitorum longus, and your flexor hallucis longus. Your hallucis is your big toe toe and your digitorum is all the rest of your other toes. It's quite hard when you isolate them and you work with them. Very nice, good job.
 
All right. Okay. So now if we go to the, inversion and everson. Can we get you more to an angle? So again, that's your in an out. And again, we want to be we working in a pointe, not in a dorsiflexion. So from here you want point and again, you just going to then wrap this nicely around, attach it somewhere or use your other foot. So where you want to start, you want to start in this neutral and then you going to wing out. Thats it. And you're going to go very, very slowly back to the original and here you're looking for control. You're not looking for a swing back. So again, and very slowly coming back to, and again, making sure these toes are not bunching and crinkling up into there. Right, and that is strengthening your inversion. And then your eversion. Or what you can do is you can just tie it and hook it around it.


All right. And again, starting in neutral and then you are going to the outside, making sure that the movement takes place in this forefoot, not in their entire leg. Again, keeping, making sure that those are straight over here. All right. So let's do your eversion, which is your peroneus brevis and then your inversion is your tib posterior.
3. '''Theraband exercises''' - in all these exercises, alignment and control are crucial:


So in all of these alignment is quite important and you'll see that what's really helpful is just move this here so that we can see it. We've kept this alignment. So we've kept her marking over here and that's really useful guide for the dancer in order to where are they? Are they in alignment as they're doing these exercises. So that's probably a really good idea to pop that there, or get them to pop it in every time they do their exercises. All right. So those are a few of the TheraBand exercises for the foot and the ankle .
* Plantar flexion strengthens the [[Gastrocnemius|gastro]]<nowiki/>[[Gastrocnemius|c]][[Gastrocnemius|nemius]] 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|tibialis anterior]]
* Inversion with flat foot and pointed foot
* Eversion with flat foot and pointed foot
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==  References ==
==  References ==
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Latest revision as of 15:36, 3 September 2022

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

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:

Movement tested Score
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
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. Plus , 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.
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