Evidence Based Guideline for the Conservative Treatment of the Posterior Ankle Impingement Syndrome in Professional Ballet Dancers. Professional Assignment Thesis, 2010

Professional Assignment Thesis, 2010 (Module III.1 and III.2)

Evidence Based Guideline for the Conservative

Treatment of the Posterior Ankle Impingement

Syndrome in Professional Ballet Dancers

European School of Physiotherapy, Hogeschool van Amsterdam (HvA), Tafelbergweg 51, Amsterdam, The Netherlands.

February 2011

The Authors of the Guideline

T. Soler, R. Jezerskyte Banfi, L. Katsman

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Preface

This guideline is a part of the professional assignment thesis created for the curriculum of the European

School of Physiotherapy.

The authors of the guideline are: Tamara Soler, Ruta Jezerskyte-Banfi and Leon Katsman.

This guideline is intended to assist physiotherapists in creating the treatment plan for the posterior ankle

impingement syndrome (PAIS) in professional ballet dancers.

At the end of the guideline the reader will find a summary of the scientific literature regarding the conservative

treatment modalities, as well as authors‟ recommendations for the use of each modality.

It is the authors‟ hope, that the reader will be able to use this guideline in clinical practice and that further

research will be instigated in order to create the specific evidence based protocol for the conservative

treatment of the PAIS in professional ballet dancers.

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Contents

Preface ............................................................................................................................................................... 2

Contents ............................................................................................................................................................. 3

A. Introduction ..................................................................................................................................................... 4

A.1 Target group ............................................................................................................................................. 4

A.2 Problem definition ..................................................................................................................................... 4

A.3 What is PAIS?........................................................................................................................................... 4

A.4 The role of the physiotherapist ................................................................................................................. 5

A.5 General Treatment ................................................................................................................................... 5

B. Diagnostic Process......................................................................................................................................... 6

B.1 Introduction ............................................................................................................................................... 6

B.2 Screening .................................................................................................................................................. 6

B.3 History-taking ............................................................................................................................................ 7

B.4 Examination .............................................................................................................................................. 7

B.5 Differential diagnosis ................................................................................................................................ 7

B.6 Assessment tools...................................................................................................................................... 8

B.7 Analysis .................................................................................................................................................... 9

B.8 Conclusion ................................................................................................................................................ 9

B.9 Treatment plan.......................................................................................................................................... 9

C. Therapeutic Process ...................................................................................................................................... 9

C.1 Therapeutic methods .............................................................................................................................. 10

C.2 Evaluation ............................................................................................................................................... 18

C.3 Preventing the PAIS ............................................................................................................................... 19

Acknowledgements........................................................................................................................................... 19

References ....................................................................................................................................................... 20

Supplements ..................................................................................................................................................... 22

Supplement 1. Conclusions and recommendations .................................................................................... 22

Supplement 2. Assessment tools .................................................................................................................. 27

A. In

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A. Introduction

This guideline has been developed according to the request of the Health team members working at Het

Nationale Ballet (HNB) in the Netherlands, and is a consecutive product following the literature review and

expert consensus produced by the authors of this guideline. The main objective of the guideline for the

physiotherapists was to enhance the health, training, well-being and performance of professional ballet

dancers suffering from the Posterior Ankle Impingement Syndrome (PAIS). Particular need for an evidence-

based guideline was noted by the authors while reviewing the literature and interviewing experts in the dance

field. The absence of an adequate research, as well as the lack of unanimous agreement between

physiotherapists regarding the conservative treatment plan for PAIS, inspired the authors to engage in the

process of a guideline creation. Furthermore, the significance of such guideline lies in the necessity for

dancers, physiotherapists, ballet and insurance companies to acquire a transparent way of working while

creating and evaluating the conservative treatment plan for PAIS.

The advice and recommendations discussed in this guideline create an evidence based outline of the most

common modalities used by physiotherapists for the conservative treatment of PAIS, in order to assist the

reduction of symptoms and to achieve prior activity level of a professional ballet dancer.

A.1 Target group

This guideline is intended for physiotherapists with different specializations (manual therapists, sports

physiotherapists, etc.) that treat professional ballet dancers with PAIS after an acute or chronic episode. In

addition to the specific background knowledge about dancers‟ activity and injury pathomechanics, mastered

by physiotherapists working in the field, the guideline is designed to be used as a complementary tool when

creating an effective treatment plan for professional dancers suffering from PAIS.

A.2 Problem definition

The scientific literature and physiotherapy experts working with dancers indicate that professional ballet

dancers are often predisposed to the PAIS, due to the specific ballet technique demands. Nevertheless, the

treatment of this pathology is lacking a comprehensive and complete guideline.

A.3 What is PAIS?

PAIS is defined as a clinical disorder in which the posterior ankle pain occurs during forced plantar flexion

position. In professional ballet dancers it is typically a chronic problem of insidious onset. In addition, onset of

symptoms can be secondary to a precipitating injury to other anatomical structures around the ankle

(Maquirriai 2005, Robinson 2007).

Pathological entities involved in PAIS are generally categorized as osseous or soft tissue. Osseous

impingement involves displaced os trigonum, hypertrophic posterior talar process, loose body and/or a

prominent superior calcaneal tuberosity (van Dijk, 2006, Peace et al. 2004). Soft tissue impingement involves

thickening or calcification of the posterior tibiotalar capsule and postraumatic scar tissue. Secondary

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involvement of the Flexor Hallucis Longus (FHL) tendonitis (“Dancer‟s tendinitis”), Achilles tendinitis, and

tarsal tunnel syndrome or osteochondral lesion can often mimic PAIS (Bureau et al. 2000).

A.3.1 Epidemiological data

No precise epidemiology records of PAIS exist for neither the general nor professional ballet dancers

population. “A great amount of weight-bearing plantar flexion of the ankle especially in the „demi-pointe‟

and in „pointe‟ positions is a crucial component of classical ballet technique, therefore it is considered to

be one of the major factors evoking and exacerbating PAIS (Russell et al. 2010).

A.3.2 Diagnosis

Diagnosis of PAIS is based on clinical history and physical examination. In professional ballet dancers it

is typically a chronic problem of insidious onset. In addition, onset of symptoms can be secondary to a

precipitating injury to other anatomical structures around the ankle (Robinson, 2007). The most

commonly seen features of PAIS in professional ballet dancers include pain during activity in the

posterolateral or posteromedial aspect of the ankle (especially during „relevé‟ movement), swelling,

grinding sensation (during forced plantarflexion), reduced joint mobility and impaired physical activity as

well as participation.

Differential diagnosis is usually performed with additional laboratory examination tools such as

radiography, CT scan, MRI or an arthroscopy. The physicians and physiotherapists may consider

radiographic examinations to confirm the diagnosis, therefore optimizing the therapy.

A.4 The role of the physiotherapist

Physiotherapy can play an important role in different stages of the rehabilitation process in professional

dancers with PAIS. Primarily, guiding the dancer through the course of pain alleviation and teaching how to

cope with the actual situation. During the rehabilitation process, assistance and special competencies of sport

physiotherapists, physiotherapists or manual therapists working in the dance field are necessary.

Physiotherapy cannot always have a good prognosis, especially, when osseous structures are involved (e.g.

Os Trigonum). Nevertheless, the consequences of the disorder, such as decrease of muscle strength, lack of

ankle stability, core muscle weakness and postural or functional alignment can be avoided and/or improved by

physiotherapy.

Furthermore, an efficient communication is essential between the Health team members, dancers,

choreographers, teachers and company directors in order to recognize limitations and to provide the best

treatment possible.

A.5 General Treatment

No specifically structured conservative treatment for PAIS is as yet known. In everyday practice, the treatment

plan often involves the use of several modalities simultaneously. A combination of exercise therapy, manual

therapy, technique re-education, ankle and core stability training is performed. A more detailed description of

the various modalities and timeline used, are provided in the evidence based review developed by the authors

of the guideline.

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B. Diagnostic Process

B.1 Introduction

Assessing the severity and nature of the dancer‟s complaint and the possibility to modify it by applying

physiotherapy is the main objective of the diagnostic process. The PAIS diagnosis is based on clinical history

and physical examination. The initial assessment must first concentrate on impairments of body functions and

body structure, after which the focus will shift to limitations of activities and restrictions of participation, and

finally to the influence of environmental and personal factors. A very important aspect of the initial assessment

is the detection of red and yellow flags. Such screening process has to be performed by the physiotherapist,

and in case a red or yellow flag is found, a dancer has to be referred to an appropriate specialist.

B. 2 Screening

During the screening process an indication for physiotherapy is examined. The physiotherapist assesses the

dancer‟s pattern of complaints and symptoms and the possible presence of yellow and red flags. Yellow flags

are indications of psychosocial and behavioral risk factors for the persistence and/or deterioration of the

dancer‟s health problems. Red flags are patterns of signs or symptoms (alarm signals) that may indicate

serious pathology (e.g. fracture), necessitating further medical diagnostics. It is of great importance for the

physiotherapist to be able to recognize the typical pattern of complaints of the PAIS and the ankle in general,

in order to decide whether there are specific red flags that do not fit with this pattern. In case a red flag is

detected, the dancer must be informed and advised to contact the appropriate specialist. (See figure 1)

Figure 1. Interrelations and differentiation of PAIS pathologies

Acute PAIS →

Chronic PAIS →

Source-based: Van der Wees et al. 2006

Contact phisician Plantarflexion

Injury

(+inversion or eversion)

Suspected fracture

Distal syndesmosis

rupture

Osteochondral

lesion

Posttraumatic

Overuse

Functional instability

and/or mucle

weakness

Instability during activity

Structural limitation

With new

tissue damage

Treatment

as acute

Treatment

for

instability

Manual therapy

Physiotherapy

Osteochondral lesions

Osteophytes

Contact

physician

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B.3 History-taking

History-taking considers questions related to the causative factors involved (e.g. an old inversion trauma or

pain and swelling after an acute plantar hyperflexion event), development of the complaint over time and the

status presence according to the International Classification of Functioning, Disability and Health (ICF) model

propose by the World Health Organization (2001). (See Table 1)

B.4 Examination

Dancer‟s functional performance is assessed during the physical examination in regard to the mobility and

movement. Dancers‟ main complaint is pain during activity in the posterolateral or posteromedial aspect of the

ankle, particularly performing “relevé” movement. Pain and sometimes a grinding sensation experienced

during forced plantar flexion test and pain in the posterior aspect of the talus with palpation denotes positive

PAIS (van Dijk, 2006). Furthermore, evaluation of the joints (ankle, knee, hip and SI) and functional testing is

performed involving muscle strength, mobility, balance, and coordination tests.

B.5 Differential diagnosis

Differential diagnosis is usually performed with the help of radiographs, CT scan, MRI or an arthroscopy.

Table 1. ICF-form.

* Red flags are not included in the table

Disease/Disorder

Posterior ankle impingement syndrome

Body functions/ Structures

Sensation of pain

Structural alignment

Mobility of the foot and ankle

joints

Stability of lower extremity joints

Muscle power, tone and

endurance in the lower leg

Static and dynamic alignment of

the lower leg

Proprioception ,coordination and

balance

Activities

demi-pointe‟,„en pointe‟ (in some

cases „demi-plié‟ and „plié‟)

positions during ballet classes,

rehearsals and performances

walking, running, jumping (push-

off)

Participating (social context)

remunerative employment

professional background

(previous employment)

professional rank (level of

participation within the

company)

dance community life

recreation, leisure, and other

activities outside the

professional/company life

Environmental factors

family, friends and social environment

employer, ballet staff and colleagues

professional rank within the company

stage and rehearsal facilities

(e.g. floor, ventilation)

working conditions (e.g. health and safety rules,

touring, scheduling, replacement casts, emergency

performances, difficult choreography)

access to the health services, systems, and policies

Personal factor

age, sex, ethnicity, social background

past and present professional experiences

comorbidity (e.g. other articular disorders, heart and

lung disorders, diabetes mellitus, nutritional

disorders)

psychological issues (e.g. performance anxiety,

tension, fear of unemployment)

injury/pain perception, coping, self-efficacy and

motivation

lifestyle (e.g. inadequate diet, fatigue, smoking)

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B.6 Assessment tools

See some of the models for the questionnaires, below in the Supplement 2 (Appendix section).

● Forced plantar flexion test

The passive forced plantarflexion test should be performed with repetitive quick passive hyperplantarflexion

movements in a patient sitting with the knee flexed at 90˚. The test can be repeated in slight external rotation

or slight internal rotation of the foot on the tibia. The investigator can apply a rotational movement on the point

of maximal plantarflexion, thereby „„grinding‟‟ the posterior talar process/os trigonum between tibia and

calcaneus. A negative test rules out a posterior impingement syndrome. A positive test, in combination with

pain on posterolateral palpation, should be followed by a diagnostic infiltration. (van Dijk 2006, expert

opinions, 2010)

● The Pain Questionnaire (SEFIP) for Dancers

The SEFIP form is intended primarily for professional dancers but can also be used for dance students on

various courses, dance teachers and others who dance regularly and with relatively high intensity. Certain

words might have to be adjusted, e.g. “production” may be replaced with another suitable term better

reflecting the activity concerned. (Ramel 1999)

● The Foot & Ankle Disability Index (FADI) Sport Score

The Foot and Ankle Disability Index (FADI) Sport is a self-report instrument which was designed to assess the

functional limitations related to foot and ankle conditions while assessing tasks that are essential for sport.

FADI Sport has a total point value of 32 points. It is scored as percentages, with 100% representing no

dysfunction. (Martin et al 2009)

● Visual-Analogue-Scale Foot and Ankle (VAS FA)

Visual-Analogue-Scale Foot and Ankle has the following features: a questionnaire based on 20 questions

requiring purely subjective answers; three different question categories (pain, n = 4; function, n = 11; other

complaints n = 5); Visual-Analogue-Scale (VAS) based rating; computerized evaluation. (Richter et al. 2006)

● Patient Specific Complaints (PSC)

With the help of this instrument the dancer is asked to select three activities that he/she consider to be the

most important. The difficulties caused by performing these activities are scored on three separate 100 mm

Visual Analogue Scales (VAS) ( Source-based: Keun et al. 2004)

● Functional Evaluative Tests For Dance

The Functional Evaluative Tests for Dance instrument was developed by Liederbach (1994) in the Harkness

Center for Dance Injuries. It provides the basis for functional evaluation of static dance postures. Each

position has specific criteria to assess in determining the ability of the dancer to achieve and maintain static

postures. The Evaluation Criteria are to be use as guidelines for observing the dancer with respect to key

elements of each Position/Action. Dynamic evaluation is usually carried out after the clinician is satisfied with

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the dancer‟s ability to maintain static postures. The physiotherapists may go directly to dynamic evaluation if

they are familiar with the dancer‟s performance, rehearsal, training, and injury history ( Brinson and Dick

1996).

● The Healthier Dancer questionnaire

Using the Healthier Dancer questionnaire different aspects of dancers‟ health, well-being and injury can be

assessed (Brinson and Dick 1996).

B.7 Analysis

Information collected during the phases of diagnostic process defines dancer‟s complains in terms of

impairments of body functions and structures, limitations in activities and participation, as well as

environmental and personal factors. Establishing a physiotherapy diagnosis and assessing the indication for

physiotherapy are the main objectives.

B.8 Conclusion

After answering the below mentioned questions, the physiotherapist and the dancer should discuss the

individual treatment goals and create a treatment plan.

Questions to be answered:

● What is the physiotherapy diagnosis?

● Is physiotherapy indicated?

● Can the dancer be treated according to the guideline?

B.9 Treatment plan

The treatment plan is made according to prioritized physiotherapy goals. The physiotherapist must discuss the

treatment plan with the dancer in order to agree on the future goals. The overall objective of the treatment

must be connected with the specific help seeking question of a dancer. Since rest is a very important factor in

the healing process, going back to activity should be regulated and gradual in order to prevent „over-loading‟.

C. Therapeutic Process

The objectives for the therapeutic process are set to optimize dancer‟s functions, activities, and participation.

On the basis of the physiotherapy diagnosis, the treatment plan is formulated, discussed with the dancer and

adjusted accordingly. The physiotherapist and the dancer should discuss the level of expected outcome and

make necessary adjustments regarding dancers‟ specific requirements. The treatment plan should contain

treatment goals (SMART), timeline, modalities and preferably evidence based practice. The treatment process

should be re-evaluated and adjusted regularly. The importance of preventing injury recurrence must be

emphasized.

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Moreover, understanding the pathomechanics of injury through background knowledge in anatomy and

biomechanics is critical in defining a rehabilitation program. The simultaneous clinical and movement training

is required when creating a rehabilitation program for a professional ballet dancer. Specific skills must be

achieved prior to starting the studio work; nevertheless, most likely the overlap between clinical and

professional goals will occur. The following scheme (see Table 2), created according to Liederbach (1994),

and is suggested as a guideline for the rehabilitation process.

Table 2. Rehabilitation stages for a dancer.

C.1 Therapeutic methods

The therapeutic modalities presented below are discussed as general statements due to the fact that specific

evidence for the modalities used treating PAIS in professional ballet dancers do not exist. Therefore, the

recommendations are intended to be applied by practitioners according to their specific knowledge concerning

individual cases. (See Table 3)

Stages/ Goals

Clinical goals

Studio goals

Stage 1:

Restricted Stage

(up to 1 week)

Reduce swelling and pain

Active rest

Evaluate kinetic chain for the

dysfunction

Maintain aerobic conditioning

Restrict pain aggravating

activities

Restrict tissue loading

Perform somatic and mental practice

Integrate anti gravity exercises (floor bar, Pilates,

etc.)

Stage 2:

Restoration stage

(from 72 hours up

to 3 weeks)

Restore ROM and strength

Progress aerobic conditioning

Begin functional weight

bearing and basic skills

Begin proprioception and

neuromuscular training

Restrict pain aggravating

activities

Permit limited movement with restricted tissue

loading

Concentrate on alignment, ankle and core stability

Take bar exercises in the dance class (exclude

painful movements)

Stage 3:

Reacquisition

stage

(from 3 to 6

weeks)

Increase load and loadability

Progress with stability,

balance, proprioception and

coordination training

Incorporate explosive training

Progress to full class/day, as tolerated

Limit number of jumps and rehearsals

Stage 4:

Refinement stage

(from 6 to 12

weeks)

Build up self confidence and

control

Train complex skills

Progress cardiovascular

exercises

Increase speed and loads

Progress dynamic balance

Increase muscle strength

Unrestricted dance movement

Implementation of injury management and

prevention techniques learned during the

rehabilitation process

Source-based: (Liederbach, 1994)

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● Manual therapy

Physiotherapists frequently use passive mobilizations of the ankle joints for the treatment of ballet dancers or

athletes with PAIS (expert opinions, 2010). The current research does not provide enough information about

the manual therapy interventions specifically for acute or chronic PAIS, nevertheless, there is evidence for the

efficacy of this treatment, when combined with multimodal or exercise therapy, in cases of acute ankle injuries

(Brantingham et al. 2009, Bleakley et al. 2008, van der Wees et al. 2006, van der Wees et al. 2006).

The authors recommend passive mobilizations of the ankle joints for the treatment of professional ballet

dancers with PAIS in order to reduce pain and regain mobility before starting active exercise therapy (expert

opinions, 2010). Furthermore, manually guided active ROM exercises (extrinsic feedback) are recommended

when treating PAIS in order to stimulate intrinsic feedback encouraging the correct movement patterns (expert

opinions, 2010). Additionally, active manipulations using McKenzie Belt technique are suggested.

Ankle stability exercises

Research shows that lack of stability in the ankle can be improved with Whole body vibration training (WBVT)

which is a new rehabilitation method that has been linked with improving balance and muscle function. WBVT

improved static balance and Star Excursion Balance Test (SEBT) scores amongst dancers exhibiting ankle

instability (Cloak 2010). Likewise, elastic resistance exercises are shown to improve balance in subjects with

or without history of lateral ankle sprains (Hak 2009). Evidence shows that daily ankle disk training assists in

preventing ankle sprains (Arnold 2004). Balance training protocols have consistently been shown to improve

postural stability in subjects with chronic ankle instability (CAI) (Holmes 2009).

The authors of the guideline strongly recommend ankle stability exercises for the conservative treatment of

PAIS in professional ballet dancers when acute or CAI is present.

Stretching exercises for the ankle

According to the research both, jogging and static stretching exercises appear to be beneficial to individuals

participating in sports activities. It is of importance to note, that for the decrease of muscle stiffness, dynamic

stretching series while running were more effective than static stretching at the ankle joint (McNair 1996).

Looking at stretching more deeply, research shows greater increase in active ROM compared to passive

ROM when micro stretching is performed (Wyon and Matthew, 2009). Furthermore, it is important to note that

young dancers with a tendency to have very lax joint structures should be identified early and advised against

overstretching (Reid 1988).

The authors recommend active resistance and dynamic stretching exercises for the conservative treatment of

PAIS in professional ballet dancers who present no chronic or structural ankle instability.

Proprioception/ Neuromuscular training

Proprioception is not commonly assessed in dancers (Batson 2009). Nevertheless, it is important to examine

it, as a minimal proprioceptive deficit can compromise finely tuned motor control, increasing the risk of injury.

Batson (2009) suggest that a proprioceptive deficit undetected, can lead to adaptations in alignment, localized

weakness, and altered central motor programming. Therefore, “if proprioception is insufficiently recovered

after injury the dancer may lack confidence to move fully and safely” (Batson 2009).

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The studies mention below suggested that retraining proprioception after injury must address different levels.

According to Batson (2009), proprioception should be trained at the level of central nervous system, reflex

spinal level, brain stem level, and cortical level to guarantee a good recovery. Therefore, a combination of

proprioceptive exercises like wobble boards, Pilates reformer training, plyometric training and mini-trampoline

exercises with additional challenges of body positioning, range of motion (ROM), and cognitive- and manual

interference would be recommended (Batson 2009, Willardson 2007). Other factors (positive feedback

concerning the performance, increase of the dancers‟ autonomy, and encouraging an external focus) and

techniques (Alexander Technique, Feldenkrais Awareness through Movement, and Body-Mind Centering)

should also be considered to refine visual and proprioceptive feedback. Batson (2009) describes that

increased muscular efficiency and higher retention of rehabilitation benefits are shown when somatic practices

are combined with manual therapies.

van der Wees et al. (2006) suggest that proprioception should be trained across the full ROM, in order to

activate the mechanoreceptors under specific angles as well; this is particularly relevant to the ROM after

mobilizations.

According to Zech et al. (2010) balance training should be emphasized, as it is shown to be effective for

postural and neuromuscular control of the ankle.

The Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie-

KNGF) guideline for acute ankle sprain describes that wobble board exercises alone are insufficient to train all

aspects of proprioception. Therefore, they recommend the use of functional Daily Life Activities (ADL) or sport

specific types of exercises.

Further high-quality clinical trials are needed to enhance the evidence base and to help physical therapists to

select effective and more specific strategies for dancers, during neuromuscular training.

The authors strongly recommend proprioception training in which the combination of functional and activity

related exercises are considered.

Endurance training

Dance is a very demanding form of physical activity. Especially, since dance has a high degree of physical

exertion, the concept of aerobic capacity becomes very important factor over a significant period of time

(Brinson and Dick, 1996). A dancer is required to have strong aerobic foundations in order to meet the

required workload (Twitchett et al. 2009). Efficient aerobic capacity is necessary to guarantee an improved

performance, reduce the risk of injury and therefore prolong dancers‟ careers.

The authors recommend emphasizing endurance training for the conservative treatment of PAIS in

professional ballet dancers. Furthermore, endurance training must be incorporated in the rehabilitation

process in the first stages, in order to prevent the decrease of dancers‟ aerobic capacity and therefore to

maintain the loadability

Strength training

The recent review by Koutedakis et al. (2009) noted that there is no scientific evidence available

recommending the use of different strength training regimens for different dance styles. However, amongst

other causes, reduced muscular strength accounts for injuries that are of greater severity in dancers

(Koutedakis et al. 2009, Brinson and Dick 1996). Van der Wees et al. (2006) indicates that strength training

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promotes the recovery in cases of functional instability of the ankle. According to expert opinions, strength

training for the ankle is frequently used in practice when treating PAIS in professional ballet dancers.

Plyometric training is proved to enhance ankle functional stability (Ismail et al. 2010).

Therefore, the authors are of the opinion that strengthening exercises for the ankle and foot (in combination

with the strengthening exercises for the kinetic chain) are recommended when treating PAIS in professional

ballet dancers. Furthermore, the authors recommend additional implementation of plyometric training in order

to improve ankle functional stability.

● Core stability exercises

Scientific literature recognizes the fact that strength and stability exercises for core muscles are the key

components in training programs for athletes (Bliss et al. 2005, Behm et al. 2010). It also emphasizes the

relationship between the core stability and incidence in the lower extremity injuries (Bliss et al. 2005, Willson

et al. 2005). Nevertheless, despite the popularity of core training, there is a lack of scientific studies conducted

to validate its benefits for athletes (Willardson, 2007).

The existing studies agree that the phase of training and the specific health status of an athlete should be

considered when recommending core stability exercises (Willardson, 2007). Furthermore, as mentioned in the

review by Behm et al. (2010), training programs preparing the athletes for a variety of alternating postures and

external forces, must incorporate the destabilizing component into the exercise regiment. It has been

suggested that the foundation for core stability exercises in elite athletes should be formed by round-based

free-weight exercises with moderate levels of instability (Behm et al. 2010).

Guidelines for initiating point training in ballet students (Weiss et al. 2009) recommend delaying point work in

cases where the student has weak trunk or pelvic (core) musculature. According to the expert opinions

(2010), core stability exercises are often used in practice when treating professional ballet dancers with PAIS.

The authors suggest core stability training as a part of an exercise program for the conservative treatment of

PAIS in professional ballet dancers. Core stability training should be considered in a specific phase of the

rehabilitation process in order to reduce the load and to enhance the control in the lower extremities. Pilates

and Yoga exercises can be used as supplementary components of core stability training (Omkar et al. 2009,

Emery et al. 2010).

Kinetic chain exercises

Identification of the kinetic chain dysfunctions, which are responsible for the functional biomechanical

deficiencies, is an important factor when establishing treatment plan for PAIS in professional dancers (expert

opinions, 2010). Kinetic chain deficits which can be detected during functional testing and must be treated in

order to prevent the risk of failed rehabilitation or predispose a dancer to further injury (Macintyre 2000).

According to Geraci et al. (2005), a long-term successful outcome and prevention of re-injury are more likely

to occur if the focus of rehabilitation is on the restoration of the functional kinetic chain, rather than on a

specific injured tissue. The review by Seto and Brewster (1994) recommended the use of open and closed

kinetic chain exercises in order to improve proprioception and function after foot or ankle injuries. Closed

kinetic chain exercises are considered to be an integral part of accelerated knee/leg rehabilitation programs

due to their effect on increasing effectiveness of rehabilitation protocols (Kibler 2000, Lutz 1993).

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The authors recommend early identification of deficiencies in the kinetic chain and implementation of closed

kinetic chain exercises in the early phases of the conservative treatment of PAIS in professional ballet

dancers.

Ice therapy

Research showed to have no clear answers about the use of ice therapy for pain and swelling reduction after

an acute ankle sprain. Icepacks are not an effective method to reduce swelling and pain (van der Wees 2006),

even though the KNGF Guidelines recommend the use of icepacks and compression, combined with rest and

elevation (RICE) during the acute phase, to enhance patient sense of well-being. Bleakley et al. (2004) found

no evidence of optimal treatment results of ice for closed soft- tissue injuries.

Further control trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue

injuries.

The authors suggest that more research must be conducted regarding the effects of cryotherapy for the

conservative treatment of PAIS in professional ballet dancers. Nevertheless, the authors recommend the use

of protection measures, icepacks and compression, combined with rest and elevation (PRICE) during the

acute phase, in order to enhance patient sense of well-being.

Taping

The use of taping techniques or braces has been shown to reduce and prevent the risk of reoccurrence of the

ankle sprain in high-risk sports. Expert opinions and literature point out the positive effect of taping on

proprioception and muscle activity stimulation on stabilization of the ankle in ballet dancers with overuse

syndrome. Geyer et al. (1993) showed that applying tape leads to significant changes in muscle activity as

well as height and antagonist reflex patterns. These changes were particularly obvious in dancers with

unstable ankle and metatarsal joints. KNGF guidelines for the acute ankle sprain suggest that as a treatment

modality, taping technique have a negative effect on functional stability in the long run.

Therefore, the authors recommend the use of taping only in specific situations: preventing injury re-

occurrence, the first phases while returning to activity or under high performance demands. Taping must be

used as a preventive tool and not as a substitute for other treatment modalities such as ankle stabilization

exercises or self awareness.

Orthotics

In practice, the use of insoles is occasionally considered during the conservative treatment of PAIS in dancers

(expert opinions, 2010). Healthcare professionals prescribe foot orthoses (FOs) for treatment and prevention

of lower limb injuries. Tourné et al. (2010) showed that plantar orthotics is considered during conservative

treatment for CAI to treat any static disorders such as hindfoot varus or a flat foot valgus. These disorders can

contribute to future ankle traumatic inversion injuries and alter the proprioceptive control. According to

Douglas (2007) athletes with CAI showed a consistent loss of balance or postural control. The research

revealed positive effects of foot orthoses on postural control.

The authors do not recommend the direct use of orthotics for the conservative treatment of PAIS in

professional ballet dancers, although it is occasionally used in everyday practice for the general population.

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Nevertheless, the authors recommend the use of the orthotics in case there is a static disorder present,

limiting the function, activity or participation of the dancer (such as hindfoot varus or flat foot valgus).

Massage

Massage therapy is used as a stress reduction technique and to enhance recovery of ballet dancers in daily

practice more than a preventive or as a modality to restore injury (Nadia et al. 2010). Massage is also

contraindicated during the acute phase of an injury, as it can increase swelling and bleeding in the tissue,

prolonging the recovery time. Scientific literature is insufficient to conclude whether massage facilitates

recovery from a fatiguing effort. Both, tissue healing and a psychological effect of massage are areas that may

prove to be promising with further research (Moraska 2005).

The authors remark the need for further research for sports massage, especially well-designed studies,

involving therapists specifically trained to administer this type of therapy.

Furthermore, the authors recommend the use of specific massage techniques for the conservative treatment

of PAIS in professional ballet dancers only when there is a need to release muscle tension or to enhance

patient sense of well-being.

● Electrotherapy

There is no conclusive evidence to support the use of electrotherapy while treating professional ballet dancers

with PAIS. The evidence for the use of electrotherapy in sports related ankle injuries is only marginal as well

(Clijsen et al. 2007, van der Wees et al. 2006).

Therefore, the authors do not recommend the use of this therapeutic modality for the conservative treatment

of PAIS in professional ballet dancers, due to no additional value to the healing process.

Ultrasound

There is little and no high quality evidence available to support the use of ultrasound therapy for

musculoskeletal conditions of the lower limb (Shanks et al. 2010, Robertson and Baker, 2001), nevertheless,

this therapy continues to be widely used as an adjunct modality by physiotherapists (Wong et al. 2007). The

authors neither encourage nor discourage the use of ultrasound therapy for the conservative treatment of

PAIS in professional ballet dancers.

Acupuncture

Although acupuncture is not performed by physiotherapists, it was chosen by the authors of the guideline as

an additional modality, due to the suggestion from one of the interviewed experts. The effect of acupuncture

on pain and the use of this therapy for dancers remain controversial. According to the study carried by Vested

et al. (2009) no significant analgesic effect of acupuncture was found. Furthermore, the research suggested

that regarding the relation between acupuncture and pain, the psychological impact of the treatment remains

unclear. Kelly (2009) presents the benefit of acupuncture for patients with specific disorders such as: low back

pain, neck pain, chronic idiopathic, headache, migraine and knee osteoarthritis, although suggestions for

other conditions are still recommended.

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The use of acupuncture for pain reduction remains unclear according to the scientific literature. Despite no

evidence found concerning acupuncture specifically for PAIS, to the authors‟ knowledge this modality is

frequently used in the rehabilitation process of dancers for pain reduction.

Therefore, the authors neither encourage nor discourage the use of acupuncture for the conservative

treatment of PAIS in professional ballet dancers.

Ballet technique re-education

The strong connection between specific ballet dance related injuries and faulty technique or poor

biomechanics, in combination with other risk factors, is a common fact in professional dance practice

(Solomon et al. 2000, expert opinions, 2010). The dance research emphasizes neuromuscular re-education in

order to minimize the re-occurrence of injury and to accelerate the return to full ballet activity. Furthermore,

imagery and kinesthetic awareness are reported to have an effect on the relationship and alignment of

skeletal parts, by changing habitual neuromuscular patterns (Krasnow 2001).

The authors recommend emphasizing ballet technique re-education for the conservative treatment of PAIS in

professional ballet dancers in order to prevent the risk of reinjury and to enhance the full return to ballet

activity.

Load and loadability

The overtraining syndrome (OTS) is a common feature in elite athletes as well as in professional ballet

dancers. Because of the complexity, a combination of excessive training demands and other biologic,

psychological, and social stressors, OTS is difficult to measure (Purvis et al., 2010). Scientific dance research

shows that the risk of injuries increases due to the fatigue and overload (Brinson and Dick, 1996). The

prevention of overtraining and fatigue in a professional ballet setting can be avoided by introducing the

periodization model which is being widely used in sports (Wyon, 2010). Moreover, the use of the

multidimensional load/carriability model developed by The Nederlands Paramedisch Instituut (Hagenaars et

al. 2002) can help the physiotherapists to monitor the balance between dancers work load and his/her

loadability. The Healthy Dancer Diary (HDD), developed by Jacques van Rossum and Hanno van der Loo

bureau Adphys for the Amsterdam School of the Arts (The Netherlands) is a tool for dancers to get a better

understanding about the relationship between the physical and mental conditions (the loadability), and the

rehearsals or performances (the load). Healthcare practitioners could benefit from implementation of such a

tool, because it would allow them to design suitable prevention programs as well as diagnose and treat

injuries more effectively.

Therefore, the authors recommend graduated workloads, periodization and well scheduled rest/activity

periods in order to avoid fatigue and OTS.

The use of a multidimensional load/carriability model is suggested in order to monitor the balance between a

dancers work load and his/her loadability.

Additionally, the authors suggest implementation of a web-based training diary for dancers (HDD),

● Communication, information and advice

According to Lai et al. (2008) and expert opinions (2010), medical practitioners rarely communicate with each

other concerning a dancer. Furthermore, the lack of communication, concerning injured dancers, between

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dance teachers, choreographers, and company directors may also have negative a effect on the recovery

process. Therefore, developing appropriate and effective systems of communication, interaction, and mutual

understanding will assist the dancer in regaining and maintaining health (Solomon et al. 2000).

Numerous research studies emphasize the importance of information provided to the dancers, teachers and

choreographers about the anatomy, physiology, psychology, nutrition and dance bio-mechanics as it can

provide a valuable tool for assessing fitness level, controlling overtraining (“burnout”), improving ballet

technique and therefore preventing injuries (Koutedakis et al. 2008). In the Netherlands, significant efforts

were made by the physiotherapists (e.g. Willemsen T. book “Anatomy and Injuries” (2007) to inform dancers

about their own bodies and their susceptibility to injury.

Additionally, scientific research studies (Kromhout and Butzin, 1993, Kulik 1994) have shown that the use of

instructional software for physical education purposes improves learning time and, in addition, promotes

greater motivation and enjoyment of the students (Mohnsen 2001).

The authors recommend incorporating information and advice concerning the PAIS in the conservative

treatment plan for PAIS in professional ballet dancers, therefore improving the communication between the

Health team members, ballet staff and dancers.

In the authors opinion information and advice should consider the following arguments:

the specific pathology of PAIS;

the consequences of the pathology for the dancer in terms of functions, activities and participation;

the relation between the load and the dancers loadability given a specific situation (information about the

activity restriction and/or dosage);

the dancers injury perception and coping style;

the work place environment and professional demands;

implementing the multimedia instructional programs in order to make the provided information or advice

more appealing for the dancers.

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Table 3. Summary of rehabilitation goals and treatment modalities used

C.2 Evaluation

The physiotherapist assesses the dancers‟ capability to bear the higher load by means of the Patient-specific

Complaints (PSC) instrument (van der Wees et al. 2006) and by evaluating dancers‟ functional impairments

(e.g. Functional Evaluative Tests for Dance). Sudden overloading indicates presence of pain and/or swelling

and/or restricted ROM and/or decreased participation in the activities (ballet classes, rehearsals and

performances). The treatment process should be re-evaluated and adjusted after three, six and twelve weeks.

Increased baseline values should be detected by the measurement tools used in previous evaluations. Pain,

stiffness and patient-specific complaints present the parts of the subjective treatment progress. The ROM

during plantarfextion, ankle strength, coordination, endurance and load-bearing capacity present the objective

parts of the therapeutic progress. Positive treatment results should be apparent after each evaluation. In case

there are no improvements found, the treatment plan should be re-evaluated and/or the dancer should be

referred to the specialist.

Rehabilitation Goals Treatment modalities

Control swelling PRICE

Decrease pain PRICE/ Manual therapy

Increase sense of well being PRICE/ Soft tissue massage techniques

Restore ROM in foot and ankle joints Manual therapy

Reestablish neuromuscular control Proprioception exercises/ plyometric exercises/

different feedback techniques/ balance and

coordination training

Maintain cardiorespiratory condition Aerobic activity (e.g. stationary bike)

Restore muscular strength Eccentric, isometric, concentric contractions/

/Resistance exercises (e.g. theraband exercises)/

Open and closed kinetic chain exercises/ PNF

exercises

Restore local endurance Increase activity and functional loading

Restore muscle power Plyometric exercises (e.g. speed and resistance

variations)

Restore postural control Static postural and dynamic functional re-education

Improve stability Core stability exercises/ Ankle stability exercises/

Plyometric exercises/ balance and coordination

training

Decrease muscle tone Stretching exercises (e.g. passive, active, PNF

techniques)/ Soft tissue massage techniques

Reduce kinetic chain dysfunctions Technique re-education, closed chain exercises

Increase functional level Increase tolerance of activity performance to the

required participation level/ Train fine and complex

skills

Acknow

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C.3 Preventing the PAIS

The physiotherapist should inform and give advice to the dancer about the specific measures (preferably

evidence-based) necessary to avoid the reoccurrence of symptoms. The dancer should be advised to monitor

the balance between load and personal loadability, to use the supportive devices (tape or bandage) only

during high level activities (performances) and wear the footwear after work that permits ultimate comfort for

the ankle (Willemsen 2007). Instruction to continue varied exercise training in addition to the dancers usual

activities after the therapy process is accomplished should be given as well.

Acknowledgements

The authors want to express their gratitude to the following:

the client, Aina Bilkins and Ronald Klassen (HNB), for their continuous encouragement and assistance;

the coach, RMT. RPT. Rolf Hoogland for his guidance provided during the review writing process;

John ten Kulve, Ted Willemsen, Anita Radier, Marleen Grol, Rob Oskam, Jan Simons and MD, PhD. C.Niek

van Dijk for their indispensible collaboration during the project.

Special thanks go to the external advisors: Ana Aguilar, Aurelija Galvelyte, Juncal Roman and Vasiliki Folia.

Refe

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20

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Supplements

Supplement 1. Conclusions and recommendations

Explanation of evidence levels

The levels of evidence used on the conclusions of the guideline have been defined in Dutch national

agreements (EBRO/CBO) and used as well by KNGF- guidelines.

Four levels of evidence are distinguished depending on the quality of the studies on which they are based:

Level 1: a study of A1 quality, or at least two independent studies of A2 quality

Level 2: one study of A2 quality or at least two independent studies of B quality

Level 3: one study of B or C quality

Level 4: expert opinion

Quality categories

A1 Systematic review including at least two independent studies of A2 quality

A2 Randomized double-blind comparative clinical trial of sound quality and sufficient size

B Comparative studies not meeting all the quality criteria mentioned under A2 (including case-control studies

and cohort studies)

C Non-comparative studies

D Opinions of experts, e.g. physical therapist interviewed by the authors of this guideline.

Conservative treatment plan of PAIS for professional ballet dancers

Manual Therapy

The authors of the guideline recommend passive mobilizations of the ankle joints for the treatment of professional

ballet dancers with PAIS in order to improve pain and regain mobility before starting active exercise therapy

(expert opinions). Furthermore, manually guided active ROM exercises (extrinsic feedback) are recommended

when treating PAIS in order to stimulate intrinsic feedback encouraging the correct movement patterns (expert

opinions). Additionally, active manipulations using McKenzie Belt technique are suggested. (level 1), (level 4)

Quality of evidence A1: (Brantingham et al. 2009, Bleakley et al. 2008, van der Wees et al. 2006, van der Wees et al.

2006)

Quality of evidence D: expert opinions, 2010

Stability exercise of the ankle

The authors of the guideline strongly recommend ankle stability exercises for the conservative treatment of PAIS

in professional ballet dancers when acute or chronic ankle instability is diagnosed.(level 1)

Quality of evidence A1: (McKeon et al., 2008)

Quality of evidence C: (Cloak et al, 2010, Hank et al., 2009, Arnold et al 2006, Holmes et al., 2009)

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Stretching exercises of the ankle

The authors of the guideline recommend active resistance and dynamic stretching exercises for the conservative

treatment of PAIS in professional ballet dancers who present no chronic or structural ankle instability.

Quality of evidence A1: (Wyon et al., 2009)

Quality of evidence A2: (Nair et al, 1996)

Quality of evidence C: (Reid, 1988)

Proprioception/ neuro muscular training

The authors of the guideline strongly recommend proprioception training in which the combination of functional

and activity related exercises are considered. Further high-quality clinical trials are needed to enhance the

evidence base and to help physical therapists to select effective and more specific strategies for dancers during

neuromuscular training.

Quality of articles A1: ( Willardson 2007, Zech et al. 2010, van der Wees et al. 2006)

Quality of articles C: (Batson 2009)

Endurance training

The authors of the guideline recommend emphasizing endurance training for the conservative treatment of PAIS

in professional ballet dancers. Furthermore, endurance training must be incorporated in the rehabilitation process

from the first stages, in order to prevent the decrease of the dancers‟ aerobic capacity and therefore to maintain

the loadability. (level 1), (level 3)

Quality of evidence C: (Brinson and Dick, 1996)

Quality of evidence A1: (Twitchett, 2009)

Strength training

The authors of the guideline are of the opinion that strengthening exercises for the ankle and foot (in combination

with the strengthening exercises for the kinetic chain) should be recommended while treating PAIS in

professional ballet dancers. Furthermore, the authors of the guideline recommend additional implementation of

plyometric training in order to improve ankle functional stability. (level 1), (level 3), (level 4)

Quality of evidence A1: (van der Wees et al. 2006, Koutedakis et al. 2009)

Quality of evidence B: ( Ismail et al. 2010)

Quality of evidence C: (Brinson and Dick 1996)

Quality of evidence D: expert opinions, 2010

Core stability exercises

The authors of the guideline suggest core stability training as part of an exercise program for the conservative

treatment of PAIS in professional ballet dancers. Core stability training should be considered in a specific phase

of the rehabilitation process in order to reduce the load and to enhance the control in the lower extremities.

Specific Pilates or Yoga exercises can be used as supplementary components of core stability training. (level 1),

(level3)

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Quality of evidence A1: (Willardson et al. 2007)

Quality of evidence B: (Emery et al. 2010)

Quality of evidence C: (Bliss et al. 2005, Behm et al. 2010, Willson et al. 2005, Weiss et al. 2009, Omkar et al. 2009)

Kinetic chain exercises

The authors of the guideline recommend early identification of deficiencies in the kinetic chain and

implementation of closed kinetic chain exercises in the early phases of the conservative treatment of PAIS in

professional ballet dancers. (level 1), (level 3), (level 4)

Quality of evidence A1: (Macintyre 2000, Geraci et al.2005, Seto and Brewster 1994, Kibler 2000)

Quality of evidence C: (Lutz, 1993)

Quality of evidence D: expert opinions, 2010

Ice therapy

The authors of the guideline suggest that more research must be conducted regarding the effects of cryotherapy

for the conservative treatment of PAIS in professional ballet dancers. Nevertheless, the guideline recommends

the use of protection measures, icepacks and compression, combined with rest and elevation (PRICE) during the

acute phase, in order to enhance patient sense of well-being. (level 1)

Quality of articles A1: (van der Wees et al. 2006, Bleakley et al. 2004)

Taping

● The authors recommend the use of taping in specific situations: preventing injury re-occurrence, the first phases

while returning to activity or under a high performance demands. (level 3)

Quality of articles C: (Geyer et al., 1993)

● Taping must be used as a preventive tool and not as a substitute for other treatment modalities such as ankle

stabilization exercises or self awareness. (level 1)

Quality of articles A1: (van der Wees et al. 2006)

Orthotics

● The authors do not recommend the direct use of orthotics for the conservative treatment of PAIS in professional

ballet dancers, although it is occasionally used in everyday practice for the general population. Nevertheless, the

authors recommend the use of the orthotics in case there is a static disorder present, limiting the function, activity

or participation of the dancer (such as if hindfoot varus or a flat foot valgus is present). (level 1),(level 3),(level 4)

Quality of articles A1: (Douglas 2007)

Quality of articles C: (Tourné et al. 2010)

Quality of articles D: expert opinions, 2010

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Massage

The authors of this guideline remark the need for further research into sports massage, especially well-designed

studies utilizing therapists specifically trained to administer this type of therapy. Furthermore, the authors

recommend the use of specific massage techniques for the conservative treatment of PAIS in professional ballet

dancers only when there is a need to release muscle tension or to enhance patient sense of well-being. (level 1),

(level 3)

Quality of evidence A1: (Moraska 2005)

Quality of evidence C: (Nadia et al, 2010)

Electrotherapy

The authors of the guideline do not recommend the use of this therapeutic modality for the conservative

treatment of PAIS in professional ballet dancers, due to no additional value to the healing process. (level 1)

Quality of evidence A1: (Clijsen et al. 2007, van der Wees et al. 2006)

Ultrasound

The authors neither encourage nor discourage the use of ultrasound therapy for the conservative treatment of

PAIS in professional ballet dancers. (level 1), (level 3)

Quality of evidence A1 :(Robertson and Baker 2001, Shanks et al. 2010)

Quality of evidence C: (Wong et al. 2007)

Acupuncture

● The authors neither encourage nor discourage the use of acupuncture for the conservative treatment of PAIS in

professional ballet dancers, as the use of acupuncture for pain reduction remains unclear according to the

scientific literature. Despite no evidence found concerning acupuncture specifically for PAIS, to the authors‟

knowledge this modality is frequently used in the rehabilitation process of dancers for pain management. (level 1)

(level 4).

Quality of articles A1: (Kelly 2009, Vested et al. 2009)

Quality of evidence D: expert opinions, 2010

Technique re-education

The authors of the guideline recommend emphasizing ballet technique re-education for the conservative

treatment of PAIS in professional ballet dancers in order to prevent the risk of reinjury and to enhance the full

return to ballet activity. (level 3), (level 4)

Quality of evidence C: (Solomon et al. 2000)

Quality of evidence D: expert opinions, 2010

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Load and loadability

The authors of the guideline recommend graduated workloads, the periodization and well scheduled rest/activity

periods in order to avoid fatigue and OTS. (level 1), (level 3)

Quality of evidence A1: (Purvis et al. 2010)

Quality of evidence C: (Brinson and Dick 1996)

Quality of evidence A1: (Wyon 2010)

The use of a multidimensional load/carriability model is suggested in order to monitor the balance between

dancers work load and his/her loadability. (Hagenaars et al. 2002)

The authors of the guideline suggest implementation of a web-based training diary for dancers (HDD).(Laws

2009)

Communication, information and advice

The authors of the guideline recommend incorporating information and advice concerning the PAIS in the

conservative treatment plan for PAIS in professional ballet dancers, therefore improving the communication

between the Health team members, ballet staff and dancers. (level 3)

Quality of evidence C: (Solomon et al. 2000, Koutedakis et al. 2008, Willemsen, 2007)

Additionally, the authors of the guideline encourage the use of instructional software for physical education purposes in

order to promote greater motivation and enjoyment for dancers while learning about the PAIS (Kromhout and Butzin 1993,

Kulik 1994, Mohnsen, 2001).

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Supplement 2. Assessment tools

The Pain Questionnaire (SEFIP) for Dancers

http://www.prevent.se/Documents/prevent.se/arbetsmiljoarbete/systematiskt%20arbetmiljoarbete/hjalpdokument/hjalpdokument_scen_eng_dancers_self-

estimated.pdf

The Foot & Ankle Disability Index (FADI) Sport

Score

http://www.orthopaedicscore.com/scorepages/foot_and_ankle_disability_index_fadi.html

Visual-Analogue-Scale Foot and Ankle (VAS FA)

http://www.foot-trauma.org/uk/vase.htm

Patient Specific Complaints (PSC)

http://www.fysionet.nl

Functional Evaluative Tests For Dance http://www.med.nyu.edu/hjd/harkness/assets/functional_evaluative_tests_revised.pdf

The Healthier Dancer questionnaire http://www.gulbenkian.org.uk/pdffiles/Fit-to-dance.pdf

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Foot and Ankle Visual Analogue Scale (VAS FA).

Name Sex

m / f

Date VAS

Internal nr.

Examiner

Date of birth

Time: 1 preoperatively/ 2 postoperatively, before implant removal / 3 at the time of implant removal/ 4 after implant

removal

Instructions for filling out the questionnaire Period:

Describe only the period before the accident or the surgery

Describe only the period between the accident / surgery and the implant removal (IR)

Describe only the period since implant removal (IR)

(To be marked by the examiner)

On the reverse page is a questionnaire with questions relating to “foot problems“ (e.g. pain of foot). For the answer of the

questions a scale is available in form of a line. Please mark the appropriate point on the line with a cross, which

describes best your personal situation at the above mentioned period. At the very left side of the line is the most negative

value, at the very right the most positive. Please use only marks, do not write text.

This is an example for an answer of the question “How are you today? as shown:

Very bad ├───────────────────────────────8──────────────┤ Excellent, very well

The answer at the cross on the line means in this example that you feel today “well “, however not “very well“.

Please answer the questions only negatively when the foot problems are really responsible for your limitation relating to a

certain activity. Example: You would answer the question about foot problems when running with „running not possible “

because you do not have the necessary stamina for running. What we mean is that you could run in principle without foot

problems or, whether your foot problems - like pain - make running impossible.

You do not have to answer each question! Answer only the questions which you would like and which you have

understood! Please use the field “additions/characteristics/remarks“ for suggestions for improvement and/or criticism.

Explanation of some terms:

Physical rest: This means that you do not do arduous things, i.e. you are reading a paper, lying on the sofa or in bed,

watching television etc..

Physical stress: This means that you perform physical activities, i.e. arduous garden work, occupational work, sport etc.

Housework: Everyday activities like cleaning windows, ironing, dusting, washing up, cooking etc..

Activities of daily life: Personal activities such as getting out of bed, eating, washing yourself, getting dressed, tying

your shoes etc.. The answer to this question should not refer to activities which are already mentioned in another place of

the questionnaire (e.g. standing, bending forward, stretching etc.).

Additions / characteristics / remarks:

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How much do foot problems affect your gait?

Strong

limping ┤──────────────────────────────────────────────├No changes, normal gait

How often do you have foot pain in physical rest?

Constantly,

always ┤──────────────────────────────────────────────├Never, very rarely

How intense is this foot pain in physical rest?

Extreme

pain ┤──────────────────────────────────────────────├No pain

How often do you have foot pain during physical activity?

Constantly,

always ┤──────────────────────────────────────────────├Never, very rarely

How strong is this foot pain during physical activity?

Extreme

pain ┤──────────────────────────────────────────────├No pain

Do you have the impression that one leg is weaker than the other?

The weakness restricts

me substantially ┤──────────────────────────────────────────────├Same strength as in the

healthy leg

Do you have callous at the foot / feet?

Widespread,

painful callus ┤──────────────────────────────────────────────├No callus

Do you have a limitation of ankle or foot range of motion?

My foot/ankle joint is

constantly rigid ┤──────────────────────────────────────────────├No limitation of range of

motion at any time

Do you have problems when climbing stairs?

Climbing stairs

impossible ┤──────────────────────────────────────────────├Climbing stairs without limitation

possible

How much do foot problems affect your occupation?

Occupation cannot be

practiced any more ┤──────────────────────────────────────────────├No limitation

How much do foot problems hinder you driving a car (operating clutch, accelerator, brake pedals)?

Driving a car not

possible ┤──────────────────────────────────────────────├Driving a car without limitation

possible

How long can you stand without foot problems?

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Only briefly, and with

crutches/stick ┤──────────────────────────────────────────────├For hours, without limitation

How much do foot problems affect your ability to stand on one leg?

Standing on one leg

impossible ┤──────────────────────────────────────────────├No limitation

How long can you walk without foot problems?

Impossible, or briefly

with crutches/stick ┤──────────────────────────────────────────────├For hours, without

limitation

Do foot problems stop you from running (e.g jogging / on soft or uneven ground)?

Even short jogging is

impossible ┤──────────────────────────────────────────────├Jogging for extended

periods possible

How much do foot problems affect your daily activities (e.g. getting dressed, eating, washing etc)?

Impossible on my own,

need constant help ┤──────────────────────────────────────────────├No limitation

How much do foot problems restrict traveling (traveling with trains, busses, aircrafts etc.)?

Traveling impossible ├──────────────────────────────────────────────┤ No limitation

Do you have problems finding good footwear?

Can only wear

orthopaedic shoes ┤──────────────────────────────────────────────├Can wear any type of

shoe

How much do foot problems restrict walking on uneven ground?

On uneven ground

walking is impossible┤──────────────────────────────────────────────├No limitations on

uneven ground

How much is your sensation in your foot / feet reduced?

No sensation ├──────────────────────────────────────────────┤ Normal sensation

Source-based: (Richter et al 2006)

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● The Pain Questionnaire (SEFIP) for Dancers

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The Foot & Ankle Disability Index (FADI) Sport Score

The Foot & Ankle Disability Index (FADI) Score - Sports Module

Clinician's name (or ref) Patient's name (or ref

Please answer every question with one response that most closely describes your condition within the past

week. If the activity in question is limited by something other than your foot or ankle, mark N/A

No

difficulty at

all

Slight

difficulty

Moderate

difficulty

Extreme

difficulty

Unable to

do

1. Running

2. Jumping

3. Landing

4. Squatting and stopping quickly

5. Cutting, lateral movements

6. Low-impact activities

7. Ability to perform activity with your

normal technique

8. Ability to participate in your desired sport

as long as you would like

Thank you very much for completing all the questions in this questionnaire.

Available from: http ://www.orthopaedicscore.com/scorepages/foot_and_ankle_disability_index_fadi.html

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● Functional Evaluative Tests For Dance

Static (Postural) Functional Evaluation:

This table provides the basis for functional evaluation of static dance postures. Each position has specific criteria to

assess in determining the ability of the dancer to achieve and maintain static postures. The Evaluation Criteria are to use

as guidelines for observing the dancer with respect to key elements of each Position/Action.

Dancer

Position/Action Clinician Observation

Evaluation Criteria

1. Parallel 1st position

stance

Sagittal View

COG to BOS relationship

Are any of the following compensatory strategies present:

• fixed equines, midtarsal/first ray plantarflexion,

longitudinal arch height

• genu recurvatum

• pelvic tilt

• hyper or hypolordosis

• T-L to L-S junctions

• Cervical/head posture/control

Coronal (posterior) view

Symmetry of:

• general LE weight bearing

• calcaneal-crural alignment („assumed‟ & STJ neutral

stances)

• fore- to rear-foot relationship

• navicular tuberosity to floor

• popliteal and gluteal folds

• PSIS, iliac crests, etc.

• scapular angles, acromion processes

2. Parallel foot plant

while executing

repetitive, transverse

plane rhythmic pelvic

rotations

Anterior

Are any of the following present:

• pelvis on femur rotation relationship

• pelvic response, primary spinal adaptation to rotation:

level

• transverse plane ROM symmetry

• primary LE adaptation to rotation: at subtalar, midtarsal,

tibial,

• integrity of whole LE

• inv/ev. rocking with LE rotation

Sagittal

Is there:

• COP symmetry

• Supernal compensations

3. Straight leg,

forward flexion of the

spine

Posterior

• Axial segment ROMs and sequencing

• Is Scoliosis present

• Any soft tissue atrophy/hypertrophy

Sagittal

• COP distribution

• location of COG over BOS

• change in genu recurvatum, fixed equinus

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Dynamic (Technical) Functional Evaluation:

This is a continuation of the Static table using dynamic ballet-based techniques in place of static positioning. Dynamic

evaluation is usually carried out after the clinician is satisfied with the dancer‟s ability to maintain static postures. The

clinician may go directly to dynamic evaluation if they are familiar with the dancer‟s performance, rehearsal, training, and

injury history.

1. Demi-plié, parallel

Posterior

Changes in:

• navicular tuberosity position • calcaneal-crural

alignment

• iliac crest and above symmetry

Sagittal

• symmetrical dorsiflexion: primarily ankle or midtarsal

• COP location

• trunk alignment stable

4. Port-de-bras:

a. en bas to 5th

(i.e.

flexion)

b. en bas to 2nd

(i.e.

abduction)

Posterior

Is there:

• scapulo-thoracic balance (upper-lower trap/serratus)

• scapulo-thoracic symmetry

• shoulder impingement, full abduction ROM

• scapular stabilization

• Cervical-thoracic spine dysfunction

Sagittal

Is there:

• scapular protraction

• full flexion ROM

• thoracic extension

5. Static 1st position

parallel relevé

(Observe bi- and

unilaterally)

Posterior

Is there:

• equal calcaneal height

• COP distribution, strategic stabilization - where

• forefoot- to rearfoot relationship

• ROM at ankle, midtarsal, MTPs

• spinal adaptations

• weight shift asymmetry R vs. L

• fatigue - R vs. L (calf; hip and/or ankle control)

Sagittal • Postural adaptations to lower BOS

6. Undirected

arabesque, each side Posterior and sagittal

• ROM taken up at hip before spine

• L-S dysfunction

• level of max spinal hyperextension, spondylo. step-off

• hip hike

• symmetry of and locus of rotation

• stance limb COP; COG over BOS; maintenance of

turnout

• C-, T- spine; scapular/UE relationship, head alignment

7. Gait Sagittal and Coronal • observation for planar dominances and asymmetries

• comparisons/contrasts with „normative‟ kinematics

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2. Grand-plié, turned-

out Sagittal and Anterior

• pre-movement: re-assessment for turned-out stance

• motion: symmetrical flexion at MTPs, ankles, knees,

hips

• lateral rotation maintained and aligned over 1st/2nd

metatarsal

• spine and pelvis neutral and stable

• muscular control eccentric and concentric

• ROM taken up at demi- before grand-plié action

• COP distribution and foot/ankle alignment throughout

3. Plie to releve

(observe bi- and

unilaterally)

Sagittal and Posterior

• postural integrity with weight shift

• initiation of movement, control of movement

4. Plié to relevé with

port-de-bras to 5th

Sagittal and Posterior

• neutral postural stability

• COP distribution

• COG over BOS location

5. 2nd position plié,

weight shift into

passé retire

Sagittal

Is there:

• flexion at hip or lumbar spine

• spine and pelvis neutral

• posterior pelvic tilt, lumbar flexion

• COG over BOS

• COP distribution

• sufficient hip abduction strength

Posterior

• femoral glide symmetrical

• lateral shift of neutral pelvis

• hip hike or hip sink

• appropriate adaptation at ankle/foot

6. Plié, fifth position

to tendu fourth

position, close fifth.

Reverse to back.

Reverse to other

side.

Sagittal

• pelvis and spine neutral

• postural stability and weight shift on stance leg

• foot/ankle adaptation of stance foot

• full surface area of gesturing foot on floor

• full weight shift to front leg

• pelvic/spine adaptation (i.e. functional unilat. hip

extension)

• movement controlled

• abdominal activation

• maintenance of lateral thigh rotation, square pelvis

• symmetry and location of distal lower extremity

rotation

7. Sissonne Sagittal and Anterior

• check locus of landing force

• appropriate muscular control of landing forces

through kinetic chain

• proper overall alignment maintained

8. Unilateral hops

with opposite foot in

coup-de-pied

position

Sagittal and Anterior

• depth and control of plié and subsequent height of

jump (i.e. maintenance of lateral rotation without

anterior pelvic tilt; hip sink; excessive or late pronation)

• postural control

• surface area of feet and COP distribution on take off

and landing. Zero, single or double heel strike on

landing

• Pronatory and supinatory control on take off and

landing

• control of lateral thigh rotation, compensations at

distal LE

• time to onset of fatigue (i.e. recruitment of trunk

musculature)

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The Healthier Dancer Questionnaire

CONFIDENTIAL

Please try to answer all questions; tick the answer or write where appropriate (capitals please). If you do not want to

answer any of the questions, please put a cross.

1. What is your gender?

a.

Male

Female

b. your age group:

16-19

20-24

25-29

30-34

35-39

40-44

2. a. Your height ______m _____cm

b. Your weight ______kg _____g

3. Are you currently?

a. A student

b. A professional dancer

4. Where did you train/are you training now?

name of school or college ________________________

and when? dates ____________

5. How many years have you been dancing regularly

(including school)? ______

6. Is your present dance form

a. Classical Ballet

b. Contemporary Dance

c. Jazz

d. Tap

e. South Asian

f. Afro/Caribbean

g. Other (please say) ____________

7. How many classes do you do a week?

____________

8. Do you warm up.......... ? Tick as many as

appropriate. Yes/ No

a. Before class

b. Before rehearsal . If yes, for how long?

c. Before performance . Number of minutes ____

9. Do you warm down.......... ? Tick as many boxes as

appropriate

10. Have you had any of the following injuries in

training, rehearsal and/or performance in the last 12

months? Tick as many as appropriate

a. Muscular

b. Skeleton/bones

c. Joints

d. Other

e. None

11. If you did have injuries, where were the sites of

injury? Tick as many as appropriate

a. Arms/hands

b. Shoulders

c. Neck

d. Upper back

e. Lower back

f. Ribs

g. Pelvis

h. Thighs

i. Lower legs

j. Feet

k.Elbows

l. Knees

m. Ankle

12. How many days have you been unable to work

because of injury?

in the last 12 months?

a. 1-3 days

b. 4-6 days

c. 7-14 days

d. 15-21 days

e. More than 21 days

f. None

13. What type of professional help did you have for

the injuries? Tick as many as appropriate

a. Physiotherapist

b. General practitioner

c. Specialist/consultant

d. Masseur

e. Acupuncturist

f. Osteopath

g. Chiropractor

h. Counseling

i. Other (please specify) ________________________

14. Who paid for the treatment on the last occasion?

a. Myself

b. Insurance Company

c. Employer/school

d. Shared by employer/school and myself

e. Free on NHS

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15. Can you give the rough cost to you of all

treatments over the last 12 months? _______ €

16. What do you think was the cause of these

injuries? Please answer for all your injuries and tick

as many responses as are applicable

a. Fatigue/overwork

b. Unsuitable floor

c. Cold environment

d. Insufficient warm up

e. Difficult choreography

f. Different choreographers

g. Repetitive movements in rehearsal

h. Partnering work

i. Inadequate diet

j. Psychological (e.g. depression)

k.Ignoring early warning signs

l. Other (please explain briefly)

17. How do you react to warning signs of an injury?

a. Tell someone else e.g. teacher/director

b. Take own preventative steps

c. Seek professional treatment

d. Soldier on

18. How do you tend to phase your recovery after

injury?

a. Take it slowly/follow professional advice

b. Return as quickly as possible

c. Follow my own instinct

19. Do you take regular medication?

a. No

b. Yes

(If yes, please state briefly what it is for and brand

name)

20. How many years have you smoked/did you

smoke? (Include all smoking periods in between if

you have given up more than once)

Number of years _____

21. How many cigarettes or ounces of tobacco do

you smoke a day?

a. None

b. 1-5

c. 6-10

d. 11-20

e. More than 20

22. How much alcohol do you drink a week?

in glasses of wine, measures of spirits or half-pints

of beer

a. None

b. 1-14

c. 15-21

d. 22-28

e. More than 28

23. If you are currently on a diet, please state briefly

what it is:

24. Have you ever taken advice on diet from:

a. GP/nurse

b. Dietician

c. Magazine

d. TV program

e. Other (please state) __________

25. What nutritional supplements do you take?

a. None

b. Vitamins

c. Iron

d. Calcium

e. Other (please state) __________

26. Have you experienced any of these in the last 12

months? Tick as many as are applicable

a. General anxiety

b. Tension with people

c. Performance anxiety

d. Depression

e. Stress due to external factors (e.g. bereavement,

moving house)

f. Eating problems

g. Over-use of alcohol/drugs

h. General low self-confidence

i. Sudden drop in self-confidence

j. Consistent difficulty in concentrating in class/rehearsal

27. How have you started to plan for your retirement

from performing?

a. Consulting Dancers Resettlement Trust

b. Talking to a counselors

c. Following course of study

d. Developing other practical skills

e. Planning to have a family

f. Other (please specify)

28. Have you ever made use of a professional

counselor to talk through personal or professional

difficulties? Yes/no

a. As a student

b. As a professional dancer

29. If yes, how many sessions did you have?

a. 1-5 b. More than 5

30. Do you have ready access to a counselor now if

you want one?

a. Yes b. No

31. If no, would you like to have a counselor readily

available?

a. Yes b. No

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32. Do you feel that your vocational training

prepared/is preparing?

you adequately for your life as a dancer?

a. Yes b. No c. More or less

33. If not, how could it be/have been better?

34. In what ways do you think a free or reduced-cost

health and injury service for dancers could best

contribute to solving physical and psychological

problems?