Practical Assessment and Rehabilitation of the Dancer Case Study
Top Contributors - Carin Hunter, Jess Bell and Kim Jackson
Introduction[edit | edit source]
This case study forms part of the Practical Assessment of The Ballet Dancer Course
Assessment[edit | edit source]
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.
She presents with a 7/9 score on the beightons scale which shows she is hypermobile.
Beightons Scale[1]:
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 |
Her main complaint is "pain top of foot left and right when going up onto pointe and when doing a roll over
Pre-Point Assessment[edit | edit source]
Airplane Test
So, just to go back, is she ready, or is it incorrect shoe fitting. Let's quickly run through all of those pre-pointe assessment tests. So we're going to start with the aeroplane. So if you can do the aeroplane for me. Remember aeroplane sides and your start position is making sure you're parallel. So we want you to a little bit further down over here, and then she's going to go bend your knee, touch the ground and come back up. Right. So already on this side, we need to watch out from this hip over here that's already lifting up. Her alignment and control is not bad. Remember watching this front knee over here and her balance is actually very good. And you showed on the other side for me. So don't forget to always compare the left and the right. And start position, again a little bit further down, cool, and there you go. Good. And up, this one is much better, better alignment, better control. Thank you. So for what we're looking for there is pelvic control, alignment of the knee, coordination control coming down, hip square, not opening up, she scored quite well. Again, watch this on a video. So that you can go through all those tick points.
Single leg heel raise
If we go into the second test, which is the single leg heelraise test, and then down. So already balance is good in the aeroplane. Falling out of this one over here, do two more on this side. And down, one last one. As you can see, she rolls between her toes going up and down and slightly sickling a little bit there. Show us the other side. She's at an angle here, so you can see her alignment of her foot. Again, here, lifts big toe up completely. And we have clawing of the toes. Good. One more. Also, if you saw this bottom leg flying away from the other leg in order to help gain that control and that stability over there. So here we were looking at intrinsics that were gripping on the floor over here, rolling over and not staying as centred and aligned.
Topple test
If we go into the third one, which is the topple test, which is your pirouette. So, this one definitely need to videotape because, see if you can pick up everything on this. That's very fast, a lot of things to watch out for. So just quickly from what we've seen, placement and landing was slightly off, the turn wasn't bad, just slightly needs to be a little bit more centered. And again, rolling over those toes. She's not keeping that alignment when she's actually up onto her pointe. Onto a demi-pointe over there. Right.
Single leg Saute
The last one is the sauté one. So did you also note that we split the single leg and the sauté so that they weren't next to each other because they both work and calf endurance. So we've left the sauté for the last, because it's going to be 16 consecutive jumps. Which is a lot. Right. Go for it.
16. Good job. All right. I'm gonna get Emma to do it slightly to the side, so face me on the next one, because as she tires you'll see, she starts sticking her bum out quite a lot and starts leaning forward a little bit, and she's not getting as high up onto her pointe. Off you go. And this one, not jumping up as high and jumping all over the place, you can see how much she's moving. And she's tiring very quickly on this one and upper body starting to sway and move, and a lot of cardiovascular fitness is needed for this one.
Pencil Test
So the pencil test is also some thing, we know she's hypermobile, so I expect in the pencil test to be absolutely a hundred percent. So all it is is just pointing the foot and making sure that the pencil can lie on the top, here, I'll scoot out of the way, without any gaps. Because if we've got someone who isn't having a good pointe, the pencil will either fall off, or they will have this massive gap over here, so they're not getting it, but generally it would fall off. So what we're looking for is that pencil to be lying on the top there, and that's your pencil tests for your pre-pointe assesment.
Quick Point Shoe Assessment[edit | edit source]
These are a Grishkho's, and we already know that Emma is hypermobile. So what we would expect from a pointe shoe, that it would have a little bit more strength and support and structure for her hypermobility. So, already if we're looking over here, I understand why she's having a problem going up on pointe, because this is far too flexible of a shank for Emma and her hypermobility. This is her other one. So this is, that was the right, this is the left. Again, far too flexible. So these pointe shoes have just been broken in by normal walking, normal ballet class, barre class. So already I can see we're going to have a bit of a problem here. This already starting to look like an incorrect pointe shoe fitting.
Rise
Pointe
Plie
Emma now has her pointe shoes on, I've brought the camera a little bit closer, so you can actually see what's happening at the pointe shoes. So her pain that she was complaining of was at the top of the ankle and the top of the foot on both left and right. All right. So we can already just placement over here. We want to check that they're in parallel. So this is what we call a parallel. If we go into a first, a first is a turnout like that. We're going to work in parallel. Just, it's a position where we like to start them with pointe shoes just to see alignment and how well they can get up onto their pointe. Right. So we are going through a demi-plié and then onto a pointe, and then reverse it. All right. Did you guys see that? Okay, so go up on, for me, it stop there, go back down, go up a little bit more. There, all right. Here we already see the one hyperextension of the knee is completely locked into hyperextension. If I were to push back there, she's fine. Here she would completely collapse. So already there she's locking her one knee. As we're going up, you can see, now watch how she goes up onto full pointe. So go up into full pointe. It's almost a one, two, and there's no smooth transmission. And then the last little section, she almost falls and collapses into her pointe. Go up again. And here, you can see there, she's completely collapsing over so I can just get you to swing around. Where you are onto your pointe. You can see she's actually completely knuckling over on this. So she's more onto the front of her pointe than she's onto the back of the pointe. So again, the shank is far too weak to support her hypermobility in her feet, completely knuckling over there. So overstretching these ligaments and tendons in the front here, and probably not working very well over there. So if we gave her a little bit more support, pull her back, that's where she should be. How does that feel? A lot better. Feels much better and it looks, alignment wise, it looks way better than what you were doing. So go back to what you were doing there. So this is what we call falling forward through onto our pointe, not getting, she's completely overshot getting over onto the box and here not able to control and hold this up over here, and you can see there's a complete give, a collapse in the foot, over here. Come down for me.
All right, so if we just get you to face front and just do a point through to the front for me. Again over here, you can see she's got that over-collapse. So if we get you to turn and do it on an angle and then, that's it. Yup. So again here, she's collapsing in over there. What we're looking for is we're looking for getting a little bit more complete alignment there, so, is that hard to keep? Yeah, that's hard for her to keep. Her more comfortable place is a wing and a sickle, over here on this foot. Just turn this way and show them on the other side quick. All right. I'll scoot out the way. Again, this one is a little bit better. That's where we would like it to be. But this one's definitely better on the left than she is on the right, in terms of pointing over here.
All right. And come back down. Just do a plié for me in first. So this is just a normal plié, and as you can see, here, she's slightly rolling in on her feet, go back up out of your plié. So this is her turnout already here we're getting more of a collapse. That's where we should be. Do a plié, keeping that alignment. And that is way hard for her. You can see how hard she is working over here to try and keep that positioning. Can you go into a full on grande plié for me? You watch. Again. Now, if we go into right to the end, you want to look, are her heels the same height and it doesn't look like your heels are the same height. Yeah, this one looks slightly higher than the other one. And then go back up. And falling out of your grand plié, as well. That's an alignment issue. So we definitely want to be looking at intrinsic foot muscles. Are they grabbing on the floor? Which we saw when she was doing her her pre-pointe assessment tests, we saw gripping of those toes and alignment issues in pointe. So we're going to have a good check of her alignment and see how that is, and then check her intrinsics and give her some rehab exercises to do.
Objective Assessment and Findings[edit | edit source]
Showed roll over
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.
Checked alignment of foot (pts problem that needed to be corrected) in pre pointe and in roll over)
Drew alignment markers – helped pt A LOT to correct alignment
Intervention and Outcome[edit | edit source]
Foot and ankle exercises shown (Doming, big toe ext, digits up, piano, big toe abd)
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.
All right. So doming is definitely one of the ones we want a give to her. 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. 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.
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.
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.
Outcome – no pain in roll over provided she does her exercises, taken off pointe until can get properly fitted with correct shoes
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.
References[edit | edit source]
- ↑ Alter M. Science of Flexibility. Sheridan books 2004 (third edition); page 89