Please fill in the required information below, before you see your physiotherapist. Date Personal information: Name Date of birth Dance School Number of hours of ballet per week Number of hours of dancing total per week Number of years of classical ballet training Have you ever seen a physiotherapist/doctor for a previous injury? Yes No If yes, please detail: Do you have any medical conditions/take any regular medications? If yes, please detail. Please list 3 areas of technique you would like to improve in your ballet www.alphingtonsportsmed.com.au @AlphSportsMed Page 1
The following questions will be discussed with your physiotherapist, please leave blank. Subjective assessment: Past injury history: Current injury history: Past/current niggle history: Foot cramping? Night pain? Morning stiffness? Previous investigations? Additional information: www.alphingtonsportsmed.com.au @AlphSportsMed Page 2
Physical Assessment Part one General observations Note any areas of swelling specific to foot/ankle Right Left PALPATION Right Left Posterior-medial ankle Posterior-lateral ankle Achilles tendon Base of 2nd metatarsal Anterior shin Medial shin Other PASSIVE RANGE OF MOVEMENT Right Left Big toe dorsiflexion Midfoot pronation Posterior impingement test * Hip external rotation in neutral ACTIVE RANGE OF MOVEMENT Right Left Ankle plantar flexion (point toes) Medial gastrocnemius activation * STRENGTH TESTING - through range Right Left Flexor hallucis longus (big toe) * Tibialis posterior (sickle) Peroneals (fishing) Other comments: www.alphingtonsportsmed.com.au @AlphSportsMed Page 3
Physical assessment - Part 2 (standing) General observations Note: - Foot type - Big toe alignment Right Pronated/neutral/supinated Neutral / valgus Left Pronated/neutral/supinated Neutral / valgus - Muscle bulk/symmetry Toe spacer recommended? Yes No Yes No Plie range of movement (Knee to wall test) Single leg calf rise endurance Must complete >25 pain free to pass* Note quality of rises Doming Unable / Difficult / Easy Unable / Difficult / Easy Plie to releve single leg Must complete x8 each foot to pass * Note gastrocnemius activation Poor / fair / good / very good Poor / fair / good / very good Aeroplane test x6 Poor / fair / good / very good Poor / fair / good / very good Hops parallel Must complete x16 each leg to pass* Jumps 5th changement x8 Single leg balance full demipointe Must complete x10 sec to pass* www.alphingtonsportsmed.com.au @AlphSportsMed Page 4
Summary of findings: To pass this assessment and therefore be deemed safe to commence pointe training, has the dancer demonstrated: Currently injury/niggle free Pain free on flexor hallucis longus testing Pain free on posterior impingement testing Single leg calf rise endurance >25 with good alignment/technique Able to consistently activate gastrocnemius on demipointe position Single leg demipointe balance testing >10 seconds each leg 8x good quality single leg releve each leg 16x good quality single leg parallel hops each leg Please note the following key findings of this assessment: As a result, the physiotherapist recommends this dancer: Is ready to commence pointe work. Is not yet ready to commence pointe work, however will be able to once her strength and technique has improved. Is not suitable for pointe training. Date Signed Physiotherapist s name www.alphingtonsportsmed.com.au @AlphSportsMed Page 5