Miss. A. was referred for assessment from another physical therapist. She was initially assessed on May 12, 2017.
Miss A. is a 16 year old competitive dancer with a goal of dancing professionally. She dances in multiple disciplines up to 25 hours per week, but ballet is reportedly her strongest discipline and that which she is most passionate about. Her primary reported complaint at the time of assessment was continued left foot pain after suffering an avulsion fracture of her navicular on December 6, 2016. After the injury, she was stabilized in an aircast for 7.5 weeks and then commenced physiotherapy treatments 1-3 times per week. As she would improve in her range of motion and strength she would return to dancing, and on multiple occasions would have to subsequently stop due to secondary foot/ankle “injuries”. She spent the dance season resting, then returning to full dance, then being forced to stop due to reinjury or pain. She reported being frustrated about this as she would return to dancing in the numbers she would be choreographed in, and then have an injury (rolling her ankle, for example), then be told she could not compete for that number. After several attempts she was “pulled” out of all numbers by her teachers as changing the choreography to bring Miss A in or out of the numbers was reportedly a challenge. This information is included in the story as Miss. A emphasized several times that this was incredibly frustrating as she believed she had the capability to perform and compete. X-ray imaging had shown the fracture to be healed and Miss. A stated she felt she should be able to dance given her injury had healed.
With further questioning Miss A shared that prior to the fracture she had had chronic pain in her left lateral knee and hip, left hamstring, and that she was being treated for chronic ITB syndrome as well. She reported being seen weekly before her fracture by a physiotherapist and the treatment focused on releasing her left ITB and hamstring. She also had mild neck pain and stiffness that she attributed to dancing and posture. This was reportedly never assessed or treated. When asked whether she had prior challenges with her dance technique, or if she had any corrections that were being continually made by her teachers, she did not have any insight. Her mother did say however, that Miss A would wear through her pointe shoes at a rate that seemed much higher than other dancers (one pair for every 30 minutes on pointe) and that she always found this odd.
Other pertinent history included a left ulnar fracture in 2008 and physical urticaria and dermatographism suggesting a heightened immunological response to food and environmental allergens. This limits treatment techniques as she has had allergic reactions to any proprioceptive tape she has tried.
Prior to starting dance at age 11 Miss A had trained as a gymnast. She reported having multiple small injuries but nothing that “stood out”. She did however report having a significant fall on the high beam at age 9/10 where she injured her tailbone and had to stop training for a “week or so” while it healed. It was never x-rayed and there was no post injury rehabilitation.
When she was initially assessed on May 12th she had a goal of completing her grade 8 ballet exams May 30th, having several weeks off dance in the spring, then returning to summer intensives and full dance by mid summer.
Miss A complained of pain “over her left navicular bone” with any dance, and occasional pain “over her cuboid” with more prolonged dance (greater than 2 hours) or pointe work (over 10 minutes). She described the pain as sharp with dancing and achy afterwards. She reported occasional achy pain with walking as well. On questioning Miss A reported that she was weaker on her left ankle, but the pain was her primary complaint.
Miss. A reported that she believed the majority of her symptoms were caused by the fracture in December 2016, but that she knew there was a connection to her other symptoms and that there “must be something else going on or it would be better by now”. She was tearful during the subjective assessment and she reported being fearful that she wouldn’t be able to dance again. She also reported a belief that she needed to complete her ballet exam as if she didn’t it would prevent her from moving forward with her class and would impact her long term success as a dancer. She also reported that it had been very difficult to refrain from dancing “full out” upon her trialed returns to dance as it was competition season and thus there was a strong focus on performance. She reportedly did not see a prolonged departure from dance as an option as she had already taken time off as the fracture healed.
For Miss A. the meaningful task was a full return to full time dance training (>25 hours per week) and performance.
Based on Miss A’s expressed goals and challenges, the meaningful tasks identified at the time of the assessment included the following.
1) Standing postural screen
2) Relevé – in first position
3) Demi-plié – in first position
For both tasks the upper extremities were left in neutral first position. These 2 tasks were chosen as they are the basis for any jump or turn in ballet and would allow us to assess the alignment, biomechanics and control of the left foot while doing a bilateral standing task.
Standing Postural Screen
Even though Miss A’s meaningful task was ballet dancing it was important to assess her standing posture to determine existing postural alignment and control within and between regions while weight bearing through her feet, especially given that she also experienced some mild pain with walking. The standing postural screen also allowed for assessment of the starting positions for both the relevé and demi-plié tasks.
Optimal alignment in standing includes a neutral pelvic girdle with no rotations or torsions, and both SIJs controlled, femoral heads centred in the acetabulum with the knees in neutral and the talus centred in the mortice, with weight bearing through the four corners of the foot, and the foot in neutral. It also includes a neutral head and neck on a stacked thorax, with no rotations within the thorax or cervical spine and no torsions within the cranium.
In standing there were no reported symptoms.
Kristine’s original presentation of her findings:
On assessment of Miss A’s standing posture there was an intracranial torsion to the left and the sphenoid was rotated to the left. The mandible was deviated right and compressed on the left. There were multiple Cspine shifts including C2,3 and 7 to the right and C1,4,5,6 to the left. She had a mild intra shoulder girdle torsion to the right and her left sternoclavicular joint was compressed. The upper thorax was compressed but there was no overall thoracic or pelvic rotations. The hips were both centred equally, the left ankle was compressed at the distal tib-fib joint and the hind foot was in slight inversion.
Because of ballet being her meaningful task a standing postural screen was also completed in ballet first position. In this position with the hips externally rotated the head, neck thorax and foot/ankle remained in the same relative position. The pelvis posture did change however and there was now a transverse plane rotation to the right, with the sacrum counternutated on the left. There was compression at the sacrococcygeal joint and a compressed left proximal tib fib joint.
Assessing Relevé in first position is an opportunity to see how weight is transferred and how motor control is maintained while rising onto the forefoot bilaterally. For a dancer this is an essential movement as it forms the basis of many postures and actions in dance. Optimal strategy for a first position relevé includes maintaining the body in neutral alignment as described in the standing postural screen while flexing at the talocrural joint and mid foot while extending through the MTPs. The foot intrinsics should maintain foot control with no over activation of the tibialis posterior and flexor hallucis longus musculature.
Kristine’s Original Presentation of Findings for Relevé
During Miss A’s relevé the left ICT increased very early in the movement and the right TPR of the pelvis increased early as well. The left SIJ remained unlocked.
She lost intrinsic foot control (as observed by her foot sickling in) at the same time as the ICT increased. All other sites of impairment remained the same during this task.
Correcting the left ICT made the right TPR of the pelvis worse.
Correcting the sacrococcygeal joint improved the cranium, pelvis, and also improved the foot control as she was able to complete a relevé while maintaining her foot position
At the end of the range of motion of the relevé she did lose foot control and went into excessive mid foot flexion and MT1 and 2 rotation. This was not seen with the other assessed corrections as she was not able to perform the full relevé task due to the early loss of control through the foot.
Assessing demi-plié in first position provides an opportunity to assess how the foot responds to a squatting task with the hips in a turnout position, as used in ballet. Optimal strategy for a first position plié is similar to that of a squat, in that there should be no increase in rotations or torsions within the pelvis, the femoral head position should be maintained centred in the acetabulum, the knee should not change in compression and should stay aligned along the second metatarsal.
Kristine’s Original Presentation of Findings for the Demi-Plie Task
During Miss. A’s demi-plié she had a very early increase in left lateral translation at C1 followed by her left foot shifting (observed shift included shift in COM laterally, increased activation of tibialis posterior and flexor hallucis longus, and increased MT 1 external rotation)
She also had altered mechanics at the knee whereby at terminal extension on return to standing there was a reduced palpable external rotation of the tibia relative to the femur. This movement pattern increased with increased repetitions of the task.
With correction of CI the pelvis control improved fully, knee control and mobility partially improved, and foot control improved partially. With correcting the left foot position and manually correcting C1 there was the best correction of the entire task.
Using Functional Units – demi-plié in first position
Functional Unit #1
Pelvis: maintained the same starting position as first position standing (RTPR/LSIJ unlocked) – no change in task
Hips: no mention of any aberrant findings
Thorax: no mention of any change from starting position
Driver FU#1: only one site of impairment therefore at this time the pelvis is considered the driver for this unit
Functional Unit #2
Cranium: no change in LICT
Neck: early left lateral translation C1, no mention of any change in any other cervical segments or upper thorax (TR 1 or 2)
Driver FU#2: Co-driver of both cranium and C1 – only a partial correction occurred with correction of either. A co-correction was not tested on the task of relevé
Functional Unit #3
Left foot: loss of center
Left knee: you note that there was a loss of external rotation of the tibia when coming out of the demi-plie – this finding is more relevant to releve than demi-plie. I would want to know if the tibia internally rotated at the initiation of the demi-plie – that would be more relevant to this task.
Driver FU#3: only one site of impairment for demi-plie – left foot
Relationship between drivers of the functional units:
Pelvic correction (sacro-coccygeal joint): the relationship of this driver was not tested on the others
Cranial region co-correction of cranium and C1 restored pelvic control – no mention if the alignment of the pelvis improved, partially improved the control of the left foot
Left foot correction: inconsistent partial correction of C1
A co-correction of the left foot and C1 resulted in best performance of the task but the pelvis was not tested.
Conclusion: Co-driver cranial region and left foot BUT the pelvis is not known in this task.
Screening task summary
Findings from the above assessment helped guide further assessment and treatment. In ISM, a driver is that area or areas of the body which, when corrected, results in the best total body response and best performance of the screening task. If one sole correction does not create a full change in the alignment, biomechanics and control of the task, there may be a secondary, tertiary, or co-drivers whereby more than one area of the body needs to be corrected in order to have the best perceived experience in the body and create the opportunity for best alignment, biomechanics and control.
To summarize the findings for Miss A’s postural screen and meaningful task assessment:
1) standing postural screen: multiple areas of impairment, worsening when the feet are in a ballet first turned out position
2) releve: pelvis primary driver with a secondary left foot driver at end range of the task
3) demi-plie: Cranial primary driver with secondary left foot driver
Drivers & Motor Control
In all three screening tasks there was non optimal alignment, biomechanics and control of the left mid foot.
With performing a relevé there was still loss of end range motor control even with the primary driver (the left coccyx/pelvis region) corrected. With correction of the primary driver and the secondary foot driver she was able to perform the task but she did not have the motor control to perform this task independently without correction and constant verbal cueing.
With performing a plié there was loss of motor control of the foot in both directions that improved with correction of CI and the foot.
Assessment of the motor control of the foot was completed after the vector analysis.
As her function improves through the course of treatment, higher loads, increased repetitions and more challenging screening tasks will be used to further assess the biomechanics, alignment and control of the left foot mechanics.
Once a body region has been determined as a potential driver we utilize further tests to determine which system, or systems (articular, neural, visceral, myofascial) is/are impairing function of that driver.
A listening approach was used during tests of active mobility, and passive mobility to determine which system(s) impairments were causing the sub-optimal alignment, biomechanics and control in the different drivers. Listening involves correcting the driver to the point of first resistance (R1). Once the ground forces have been neutralized (by having the patient lift each foot off the ground) and the body has been allowed to process the correction, the correction is released and the clinician passively listens (feels through the hands) the direction, depth, length and quality of “stop”) of the first vector that pulls the driver back to its non optimal position or alignment.
Primary Driver – pelvis (coccyx) for releve
In the sacrococcygeal region the initial listening during a passive correction exposed a neural vector. The left sacrococcygeal joint was found to be compressed. When the coccyx was corrected, and the correction released, passive listening revealed a vector that was initially short in an inferolateral direction from the coccyx suggesting increased tension in the sacrotuberous ligament, then a second tension in the sacrospinous ligament.
As is possible in clients with longstanding motor control issues, when a dominant vector is released other vectors may be exposed. With Miss A’s initial assessment, once these short vectors were released using a neural manipulation technique (Barral Institute), over activation was then noted in the left obturator internus and left bicep femoris (especially where the sciatic nerve branches into the tibial and common perineal nerves) muscles.
Primary Driver – Cranial region (C1) for demi-plie
In the standing screen C1 was non-optimally translated (Diane – we don’t use the word shift anymore remember…) to the left and this worsened with the demi-plié. When Miss A was put in a supine position the C1 and cranium alignment were consistent with her standing posture. Vector analysis after release of the correction again showed a neural system impairment with overactivity in Rectus capitus posterior minor (RCPM).
Once RCPM was released using a release with awareness technique a very long dural vector was noted into the spinal dura.
Secondary Driver – left foot for demi-plie
In the left foot, passive listening was used during correction of the subtalar, talocrural and midfoot joints and again a long, deep neural vector suggestive of the tibial nerve was noted. Correcting the cranium/C1 (cranial region) facilitated correction of the foot suggesting that the twists in the musculoskeletal system were taking up all the potential of the nervous system to permit elongation.
Once the tibial nerve was released using a neural manipulation technique (Barral Institute) the second vector was from over-activation of the tibialus posterior muscle (neural system impairment, the muscle was not tight but rather excessively activated at rest). This was released using a release with awareness technique and followed by a dry needling technique. Once these longer vectors were released a more detailed articular assessment was possible and there was joint stiffness at the calcaneocubiod and cubonavicular joints.
It is hypothesized that Miss A’s story began when she was 9/10 years old and sustained in the fall where she “injured her tailbone”. As she never had any rehabilitation after this injury she developed compensatory strategies for this injury which led to an increase in dural tension. With her quick transition at age 11 to competitive dance and pointe work (and with her already pre-existing neural tension) she developed strategies for ballet technique that were non optimal, leading to the avulsion injury of her left navicular in December 2016.
Because her initial post-fracture rehabilitation focused solely on the foot range of motion and strength, and did not pick up the neural impairments and non optimal motor control strategies that were pre-existing, she continued to utilize the same non-optimal strategies she had pre-fracture and thus failed to progress in her rehabilitation.
On assessment, Miss A also did not have the proper alignment, biomechanics, and both craniovertebral and intrinsic foot control to do one (never mind multiple) repetition of a left unilateral releve, and was instead compensating for this by over activation of her flexor hallucis longus and tibialus posterior muscles, thereby adding to the local stress on the recently healed navicular bone.
In addition to this, because she was returning to a high level of dance in both number of hours and challenge of task, she was now showing signs and symptoms of pure overuse, and her unwillingness to stop dancing posed a serious challenge to her rehabilitation potential.
Based on the principles of the Integrated Systems Model (ISM), the treatment plan was developed to first release and align the different drivers for the different screening tasks, then teach a new strategy to control, and then incorporate this into movements as identified by the patient’s meaningful tasks and goals. The initial treatment plan was as follows:
R: Primary drivers:
- Coccyx for relevé: sacrotuberous and sacrospinous ligaments, sciatic nerve at junction to tibial nerve
- C1 for demi-plié: release RCPM, spinal dura at C1,
- Foot for demi-plié: tibial nerve, tibialis posterior, flexor hallucis longus, joint mobilization of calcaneocuboid and cubonavicular joints
A: Align CO-C1 – best cue was “imagine there is a fishhook between your head and your neck and someone is gently pulling on a line towards the sky”, while aligning the foot with “imagine the four corners of your foot connected to the ground, keeping your calf relaxed. For the tailbone the best cue was “imagine you have a fish weight attached to your tailbone and it is being pulled gently down towards the floor, making sure it is untucked from between your legs; and if it was a tail – that it would have the freedom to wag just a little bit”
C: The connect cue that was used in the foot to help engage the intrinsic muscles as opposed to over-activating tibialus posterior and flexor hallucis longus was “Engage the muscles in your foot as if you were wearing a slipper that was slightly too small, but do not let your calf get ‘grippy-grippy’”.
M: Incorporate the above align and connect cues into the following exercises:
- Commence with demi-plié descending only as far as can control, doing 10 repetitions 5 times daily. Plié depth to be increased as control improves
- Commence with bilateral relevé in first position at the bar, 10 repetitions x10 daily, progressing to different ballet positions as control improves
Miss A progressed quickly through these exercises and we were able to initially progress her exercises to more challenging tasks as her foot control increased, taking her through all ballet positions and adding on more challenging arm and neck positions as well.
Miss A continued to dance full time throughout her treatment despite recommendations to stop or at least decrease her hours of training, which greatly complicated treatment.
Synopsis of Video Case Study:
This synopsis is for the following videos which are not the same person as the report.
Miss A. is a 13 year old competitive dancer. She reported having tightness in her right hamstring that developed after a jumping turn. There was initially back pain which had resolved with local treatment of her lumbar spine. She reported the tightness was worst with “full stretch” of her right leg and that it felt like there was a knot that just wouldn’t let her stretch any further.. Her history was otherwise clear for any injuries or medical concerns.
Miss A’s meaningful complaint was tightness in the back of her right thigh that increased when she had her leg in full stretch. She reported it was worst with her leg straight and her trunk folded over her leg.
Miss A believed that she had a knot in her right hamstring but was concerned as it wasn’t working out with the foam rolling and stretching she typically does as self care.
The meaningful task chosen to assess the hamstring “tightness” was a standing forward fold with the legs in neutral as this reproduced the feeling of tightness when she was assessed in the clinic
The screening tasks chosen for Miss A were a standing postural screen and a standing forward fold.
Standing Postural screen:
- Functional Unit #1 (3rd thoracic ring to hips)
generally compressed mid thorax with multiple translations and rotations:
R 6 (especially), 4 – translated right/rotated left
R 5, 3 translated left/rotated right
pelvis – TPR and IPT right
Hips – right femoral head slightly anterior
Driver: No driver found as this was a screening task
- Functional Unit #2: (2nd thoracic ring to cranium)
small ICT Left
sphenoid left rotated
mandible compressed on left
C1 translated right
Driver: No driver found as this was a screening task
- Functional Unit #3 (Knee-ankle-foot)
knee – compression right proximal tib fib joint
foot – Right talus adducted and medially rotated
Driver: No driver found as this was a screening task
- Functional Unit #1: (3rd thoracic ring to hips)
thoracic rings – no change
pelvis – no change
hip – no change -seats well
NO drivers found in FU #1 for this task
- Functional Unit #2: (2nd thoracic ring to cranium)
*** NOT SHOWN ON VIDEO (as there was no change in the pre-video screen my mind forgot to demonstrate this on the video)
in the pre-video assessment there was no change in the cranium or upper thoracic rings during the standing forward fold screen
NO drivers found in FU #2 for this task
- Functional Unit #3 (Knee-ankle-foot)
knee – increased compression and non optimal position
foot – increased adduction and medial rotation of talus
2 potential drivers found in FU #3 – knee and foot
Screening Task/ Driver Summary
FU #1: no drivers identified
FU #2: no drivers identified
Correcting the foot worsened the alignment and compression of the knee, partially corrected the cranium/C1 and fully corrected the pelvis and thorax, somewhat improved the client’s experience of the meaningful task
Correcting the knee gave a partial correction of the cranium/C1, gave a full correction of the pelvis and thorax ( this was not well shown on the video), and increased the compression of the knee, and somewhat improved the client’s experience of the meaningful task
Correcting the foot and knee together gave a full correction of the pelvis, thorax and cranium/C1 and significantly changed the experience in the client’s body for the meaningful complaint
Correcting the cranium/C1 could have been assessed next to see what impact that correction had on the knee and foot together for the postural screen and the forward fold task. Because there was no change in the cranium/C1 with the forward fold, it was not identified as a potential driver for this task…..however I would still be interested to see the connection for other tasks and for the standing postural screen
For the meaningful task of forward fold the knee and foot are co-drivers.
Further Assessment of the Knee and Foot including Vector Analysis of Both
Vector Analysis of the foot – the distal tib fib was not able to fold (dorsiflex) over the talus. The first vector limiting this motion was from tibialis posterior. Once this was released the second vector was from flexor hallucis longus. Both were released using release with awareness techniques. This was a neural system impairment
Vector Analysis of the knee exposed a trigger point and over activation of the popliteus muscle. Again this was released using a release with awareness technique.
On the video it is apparent once Miss A is standing after the vector released the knee and foot that there is still more vectors to be assessed and released in the foot, but this was not captured in this session or in this video.
It is hypothesized that when Miss A completed the jump she had a technical error in the landing that caused loss of motor control of her knee and foot that then caused the increased activation of tibialis posterior, flexor hallucis longus and popliteus. This was now causing altered biomechanics at the right knee that, with a forward fold, did not allow for the eccentric lengthening of biceps femoris muscle and caused the tight feeling that was Miss A’s meaningful complaint.
Follow up treatment sessions
In follow up treatment sessions (and in the continuation of this session) the right foot and knee mechanics would be re-assessed and more vector analysis would be done. The motor control of the right foot and knee would be assessed further to determine the potential cause for the increased activation of the knee and foot muscles, and specific exercises would be prescribed to assist with increasing the capacity of the intrinsic muscles of the foot.
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