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 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 was 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]
The dancer must be in the correct starting position and be given the appropriate cues to complete the test. Detailed instructions for this test is available here. Always remember to test and compare both sides. When conducting this test try to observe: pelvic control, knee alignment, coordination control of movements and the ability to maintain square, level hips. It is advisable to record this test, for an easier analysis and to provide feedback to the dancer.
Ms E completed the test on both the left and the right sides. On her left side, she demonstrated a slight lift of her hip on the raised limb. She did, however, present with good alignment, control and balance. On her right side, her alignment and control were better than on the left side.
When Ms E completed the single leg heel raise test on her left side, she rolled between her toes going up and down and demonstrated slight sickling of her foot. When testing the right side, the alignment of Ms E's foot was incorrect and she lifted her big toe up completely. There was also clawing of her toes. On repeating the test, Ms E's bottom leg moves away from her other leg. This compensation is an attempt to gain control and stability. The clawing of her toes indicates that her intrinsic muscles are gripping the floor. Moreover, she is rolling over and cannot stay as centered / aligned as she did on her left leg.
The topple test assesses a dancer’s ability to perform a single clean pirouette.[5] 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 with the naked eye. A video also helps the assessor to give feedback to the dancer.
When Ms E completed this test, her placement and landing were slightly off and needed to be more centered. She rolled over her toes and was not able to maintain her alignment when on pointe.
4. Single Leg Saute[6]
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.
5. Pencil Test[7]
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.
Quick Point Shoe Assessment[edit | edit source]
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.
On subjective assessment she revealed the shoes had been broken in by normal walking, normal ballet class and barre class.
On initial assessment, she has an incorrect pointe shoe fitting.
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.
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 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.
2. Point
On conducting a point assessment, Ms E over-collapses into a wing or a sickle on the right. The left is slightly better aligned.
3. Plie
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.
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.
Objective Assessment and Findings[edit | edit source]
1. Observe Pain Provocating Movement - The Roll Over
On observation of Ms E's roll over, her foot is collapsing out and losing alignment.
When correcting this, Alignment Markers can be drawn and she can be asked to do this in front of a mirror to offer visual input until she has the strength and proprioception to complete the task without the assistance. Added to that, teaching Ms E where the correct alignment is will help significantly with rollovers.
2. Drawing Alignment Markers and checking alignment of foot [8][9]
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 and not sickling or over-winging. The dancer can also place her feet together in parallel and rise onto demi-pointe and the marker should create a vertical line.
Intervention and Outcome[edit | edit source]
This patient was given five simple exercises to help strengthen the muscles, and improve foot control and awareness.
1. Doming
Doming is a good exercise for this dancer 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 outcome should be flat, straight toes while lifting up the metatarsal head.
2. Big Toe Up
This exercise requires the four small toes to be kept comfortable on the ground while lifting the big toe up. This exercise will target the Extensor Hallucis Longus.
3. Big Toe Down
This exercise requires the four small toes to be lifted up while keeping the big toe comfortable on the ground. This exercise will target 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 the opposite order, beginning with placing the big toe down first and ending with the small toe.
If there is any sign of gripping or clawing with the toes, as Ms E demonstrates, this exercise needs to be practiced until the toes are comfortable and 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 and the big toes are lifted up, moved towards each other and away the the other toes on the foot and placed down on the floor. The movement is then reversed by lifting the big toe up and returning it to the toes on that foot.
Outcome[edit | edit source]
Ms E has been asked no not practice pointe work until the has done her exercises and has no pain on the forefoot in 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 to correct strengthening.
- Plantarflexion strengthens the Gastrocs and Soleus. It is important to hinge at the ankle, keeping the toes stay dead straight, following through with pointing the toes, with no clawing.
- Dorsiflexion strengthens the Tibialis Anterior
- Inversion with flat foot and pointed foot
- Eversion with flat foot and pointed foot
References[edit | edit source]
- ↑ Alter M. Science of Flexibility. Sheridan books 2004 (third edition); page 89
- ↑ 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.
- ↑ 3.0 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.
- ↑ 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.
- ↑ 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.
- ↑ Lynn Batalden PT. Pointe-Readiness Screening and Exercise for the Young Studio Dancer. Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.
- ↑ Bonham K. The Prevalence and Efficacy of Cross-training in a Professional Ballet Environment: A Literature Review. (2021). Senior Theses. 397
- ↑ 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.
- ↑ 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.
