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On site physical therapy.

With this series of articles I hope to share with you some of the more common problems that professional ballet dancers face daily and how we approach treating them. In our space at the theater, we have to think on our feet and be prepared for anything. Our most valuable commodities are our brains, hearts and hands! We schedule one person every fifteen minutes, which often turns into 2 or 3 depending on emergencies. Our job at the theater is to prevent any serious injuries by evaluating a dancers' complaint while it is still a minor annoyance.

Both male and female dancers commonly complain that they cannot plie fully, that they feel "stuck" in the ankle joint. Not surprising since they spend so much more time in the releve position! What seems to happen is that the talus gets stuck in the position of plantar flexion and just does not glide back under the mortice space made by the tibia and fibula (top of the ankle joint). They then continue dancing in this position and experience sharp pain in the anterior ankle when they land or plie, so they avoid the plie even more. The posterior calf muscles get tighter from overuse and the supporting musculature gets tighter probably as a protection mechanism. Often the posterior joint capsule of the ankle adaptively shortens and you may find that the talus is in a more pronated position.

In treating this problem it is essential to first release the tight muscles and fascia that maintain this extreme plantar flexed position of the ankle. I usually start at the posterior ankle joint and work on the posterior aspects of the tibia and fibula with the goal of separating the two bones a bit to make space for the talus. I spend a few minutes with soft tissue techniques to release the tight structures, usually the medial soleus and the flexor hallicus longus muscle belly, which is more on the posterior lateral side of the calf. Then I release the anterior calf, especially the peronius tertius (the winging muscle) in the anterior lateral aspect of the calf and the plantar surface gets a few strokes going toward the heel.

Following the soft tissue release work I mobilize the ankle. First, I place the talus in the position of subtalar neutral, where it can easily glide posteriorly. This is usually in a more supinated position than where the foot is being held.

Second, I place one hand on the calcaneus and traction it posteriorly as I glide the talus back into place. Often this becomes a high velocity thrust technique.

Third, I ask the dancer to dorsiflex the ankle several times as I move the talus with her so that we have an active and passive movement of dorsiflexion.

Finally, as the dancer continues this motion I begin to give slight resistance to dorsiflexion for motor reeducation. After about 10 repetitions, I maintain the position to allow the posterior calf and ankle to lengthen and stretch for several minutes.

The dancer then stands and performs a parallel plie making sure to keep weight through the heel. I suggest they imagine that the heel continues to move posteriorly as they plie. They usually feel an improvement. I review with them the maintenance strategies of stretching and strengthening: lying on their back with their feet up on the wall (about 80 degrees of hip flexion), knees slightly bent. I ask them to actively flex their ankle until they can get the bottom of their feet to be parallel to the ceiling and then very slowly, they straighten their knees. This accomplishes both aspects of muscle coordination: contraction of the anterior musculature and lengthening of the posterior musculature. They repeat several slow ankle dorsiflexion movements. They can see if their foot is out of alignment and can control it better in this position. I advise them to keep the line of the leg centered between the ankle bones and through the second toe while they do this exercise. This also allows the dancer to decompress the lumbar spine and to work on better foot and ankle alignment.

Believe it or not, that takes about 15 minutes and I am on to the next person!

Marika Molnar, PT
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Title Annotation:On Site Dance Medicine
Author:Molnar, Marika
Publication:Journal of Dance Medicine & Science
Geographic Code:1USA
Date:Apr 1, 2007
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