Introduction
This case study forms part of the practical assessment and rehabilitation of the dancer program.
Assessment
Ms. E is a 20-year-old dancer. She has been dancing for 17 years, performing ballets in modern and contemporary dance and musical theater.
She scored 7/9 on the Beighton scale[1], which indicates she is super mobile. [2] Her Beighton score is as follows:
Motor test scores left and right 1. Passive dorsiflexion and hyperextension of fifth MCP joint over 90° 112. Passive apposition of thumb to forearm flexor surface 003. Elbow passive hyperextension over 10° 114. Knee passive hyperextension over 10 ° 115. Positive Knees fully extended and torso bent forward so palms are flat on floor 1 7 / 9 total
Ms. E’s main complaint was pain at the top of her feet when doing rolls and rolls.
Pre-Pointe Assessment
1. Airplane Test[3]
Dancers must be in the correct starting position and given appropriate cues to complete the test. A detailed description of this test is available here. Always remember to test and compare left and right sides. When performing this test, it is important to observe: Pelvic control Knee Alignment Coordinated control of movement and ability to keep hips level. It is recommended to take a video of this test. This enables the evaluators to analyze the movements in detail and provide feedback to the dancers.
Ms. E completed the test on the left and right sides. On her left side, she demonstrates a slight lift of her hip on her raised limb. However, she does display good alignment control and balance. She has better alignment and control on her right side than on her left.
2. Single Leg Heel Raise Test[3]
When Ms. E completed the single-leg heel raise test on her left side, she rolled between her toes as she moved up and down and exhibited a slight sickle in her foot. When testing the right side, Ms E’s foot was not aligned correctly and her big toe was fully raised. she has claws too her toes. As discussed here, for ballet dancers, the most important role of the intrinsic muscles of the foot is to counteract the claw effect of the long flexors of the toes. [4] When the test was repeated, Ms E’s calf moved away from her other leg. This compensation is an attempt to gain control and stability. Also, Ms. E is rolling over and can’t stay centered/aligned like she can on her left leg.
3. Topple Test[5]
The tip over test assesses a dancer’s ability to perform a clean spin. [6] As with aircraft testing, it is important to capture video of this test because the action happens very quickly. So it’s hard to check all the points you need for a passing score with a naked Eye. The video also enables evaluators to provide feedback to the dancers.
When Ms. E completed this test, her placement and landing were slightly off and needed to be more centered. She rolled her toes and couldn’t maintain alignment when on pointe.
4. Single Leg Sauté Test[7]
When conducting an assessment, it is best to avoid consecutive single-leg heel raises and sauté tests, as both tests assess calf endurance. Therefore, if the tests are performed one after the other, the results will not be accurate as the dancers may be affected 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 forward. When she did more reps, she couldn’t lift her toes that high. On her right, Ms. E can’t jump as high, and her landing is more erratic; she can’t land in one spot. when she is tired To compensate, her upper body began to sway.
5. Pencil Test[8]
The pencil test assesses the overall range of plantarflexion of the ankle-foot complex. [9] Because of Ms. E’s hypermobility (as evidenced by her Beighton score), one would expect her to have good plantarflexion range. In the pencil test, the pencil is placed flat on Ms. E’s foot.
Each of these five tests is discussed in more detail on the Pre Pointe assessment page.
Quick Point Shoe Assessment
Pointe shoes are discussed in detail here.
Lady E dances in Grishkho pointe shoes. As mentioned above, Ms. E has limited mobility. Therefore, the ideal pointe shoe for Ms E will provide more strength support and structure. However, when evaluating her shoes, the uppers of both pairs are very flexible.
Based on the subjective assessment, Ms. E disclosed that her shoes were worn out from normal walking as well as from her usual ballet and ballet lessons.
Based on an initial assessment, her pointe shoes appear to be inappropriate:
1. Rise
The patient starts parallel so it is easier to compare left and right sides. She moves from flat on the floor to tiptoe. This is a quick test to check alignment, and it assesses the level of effort required to move to your toes. When making this assessment, if The patient moves through the hemifoot pads to the toes and back. [4]
When Ms. E performs this test, her left knee is hyperextended. Her transition to pointe is jerky and consists of two movements rather than one fluid movement. At the end of the movement, she collapsed on her toes instead of standing up to control the movement.
When she stands on pointe, Ms. E will bend her knees or fall forward on pointe. She went too far into the box and couldn’t control/raise her feet. Her feet have yielded or collapsed. This can overstretch the ligaments and tendons in the front.
2. Pointe
During the pointe assessment, Ms E had excessive collapse into a wing or sickle on her right side. Her left side is slightly aligned.
3. Plié
When Ms. E performed the plié, her feet rolled inwards slightly, causing her turnout to drop. When the therapist provided corrections, Ms E found the movement more difficult, but the posture could be maintained.
Ms E was then asked to do a thigh, and it was clear that her heels were not the same height. She deviates slightly from a straight line when she leaves her thighs, which may indicate weak inner muscles.
Objective Assessment and Findings
1. Observe the movement that causes pain – turn over
When Ms. E was observed rolling over, her feet collapsed and lost alignment.
To help correct this alignment mark, you can draw. Dancers can also be asked to repeat movements in front of a mirror. This provides visual input until the dancer has the strength and proprioception to perform the task without assistance. Teaching proper alignment can also Help roll over. [4]
2. Draw alignment marks and check foot alignment [10][11]
Place a mark at the point between the outer and inner malleolus and draw a straight line down to the second toe. This line should be straight when the dancer points to her toes. She shouldn’t have scythes or overwings. The dancer can also bring her feet together and in half pointe and The marker should create a vertical line. [4]
Intervention and Outcome
Ms. E performed five simple exercises to help strengthen her muscles and improve foot control and awareness:[4]
1. Doming
Push-ups were a good exercise for Ms. E because she gripped and gripped the floor with her toes, indicating intrinsic muscle weakness. This exercise encourages lifting of the metatarsal heads and transverse arch. Toes should be flat/straight as you lift the metatarsal heads.
2. Big Toe Up
While the big toe is lifted, the four little toes remain comfortably on the ground. This exercise targets the extensor hallucis longus.
3. Big Toe Down
The four little toes are lifted while the big toe remains comfortably on the ground. This exercise targets the extensor digitorum longus.
4. Piano-ing
With this exercise, all ten toes are lifted. The goal is to drop each toe in sequence, starting with the little toe and ending with the big toe. Then start with the big toe and end with the little toe in reverse order.
If there is any sign of toe grabbing or grasping as Ms. E demonstrated, this exercise needs to be practiced until the toes are comfortable and remain relaxed/straightened.
5. Big Toe Abduction
The final exercise recommended for Ms. E is big toe abduction. Place your feet parallel on the floor. The big toe is lifted away from the other toes on the foot (i.e. abducted) and rests on the floor. Then by lifting the big toe and returning it to the Starting position (i.e. adduction).
Outcome
Ms. E was asked not to practice pointe movement until: she had completed her exercises; was free of pain in her forefoot when she rolled over; and had been evaluated with a professional fitter for a pointe shoe fit.
Treatment Recommendations
1. Ball rolling
2. Intrinsic stretching and massage
3. Theraband Exercises – Alignment and control are critical in all of these exercises:
- Plantar flexion strengthens the gastrocnemius and soleus muscles. It is important to hinge at the ankle, keep the toes fully straight, then point the toes and avoid scratching
- dorsiflexion strengthens tibialis anterior
- Flat-footed and pointed-footed handstands
- Eversion with flat foot and pointed foot
References
- ↑ 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.
- ↑ Jump up to: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.
- ↑ Jump up to:4.0 4.1 4.2 4.3 4.4 Green-Smerdon M. Biomechanics of the Dancer’s Ankle and Foot Course. Plus , 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.
- ↑ Jump up to: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.