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]
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 each side. 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 make a video recording 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 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.
2. Single Leg Heel Raise[3]
When Ms E completed the single leg heel raise test on her left side, she rolled between her toes while 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. When repeating the test, Ms E's bottom leg moved away from her other leg. This compensation is an attempt to gain control and stability. 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] Moreover, in this test, Ms E was rolling over and could not stay as centered / aligned as she did 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 with the naked eye. A video also enables 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 Sauté[7]
When conducting a pre-pointe / dancer assessment, it is beneficial to avoid performing the single leg heel raise and the sauté sequentially back-to-back because 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 began to flex her hips and lean forwards. She was unable to get as high up onto her pointe as she completed more repetitions. On her right side, Ms E could not jump as high and her landings were significantly more erratic - she was unable to land in one spot. As she tired, her upper body began 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 lay 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 had very flexible shanks.
On subjective assessment, Ms E revealed that her shoes had been broken in by normal walking, normal ballet class and barre class.
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 rights. She moves from flat on the floor up into pointe. This is a quick test to check alignment and 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 a pointe, and then reverses the movement.[4]
When Ms E performed this test, her left knee was locked into hyperextension. Her transition onto pointe was jerky and comprised of two movements rather than one fluid movement. At the end of the movement, she collapsed onto pointe instead of rising up and controlling the movement.
When she was up on pointe, she knuckled over or fell forward onto pointe. She overshot getting onto the box, and was not able to control / hold her foot up. There was 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-collapsed into a wing or a sickle on her right side. Her left side was slightly better aligned.
3. Plié
When Ms E performed a plié, she slightly rolled in on her feet, creating a collapse in her turnout. When the therapist offered a correction, Ms E found the movement was more difficult, but could maintain the position.
Ms E was then asked to perform a grande plié, and it was apparent that her heels were not at the same height. As she moved out of her grande plié, she fell 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 collapsed out and lost 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 offers visual input until the dancer has the strength and proprioception to complete the task without the 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 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]
This patient was given five simple exercises to help strengthen her 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 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 will 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 down 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 towards each other and away the 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 was asked not to practise pointe work until: she had done her exercises; had no pain in her forefoot during in the rollover; and had 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 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]
- ↑ 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.
- ↑ 4.0 4.1 4.2 4.3 Green-Smerdon M. Biomechanics of the Dancer’s Ankle and Foot Course. Physioplus, 2022.
- ↑ 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.
- ↑ 6.0 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.
- ↑ Batalden L. 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
- ↑ Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.
- ↑ 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.
