THE JOINT BY JOINT APPROACH
The joint by joint approach was popularized by Physical Therapist and FMS pioneer Gray Cook. The idea behind this approach is that certain joints need mobility, and others need stability in order to have a functioning body, both for health and athletic performances.
This post and subsequent posts within this series will delve more deeply into the joints and how this approach rings true for dancers and aesthetic based performers.
“We talked about some of the things in dance.. We gotta make it look good. But maybe our training should try to prevent some of the damage we might be doing in our end stage activity.”
–Charlie Weingroff, Training = Rehab Rehab = Training
The Ankle Joint
I believe it is important to begin with one of the more important aspects of the dancers’ joints – the ankle joint. When you think of the ankle, you think of that bony part sticking out, and that is about it. In reality we have several aspects of the ankle that are comprised of 3 articulations: the talocrural joint, the subtalar joint, and the distal tibiofibular syndesmosis. The 3 major contributors to stability of the ankle joints are: 1. the congruity of the articular surfaces when the joints are loaded, 2. the static ligamentous restraints, and 3. the musculotendinous units, which allow for dynamic stabilization of the joints. (4)
Starting off with one of the more relatively difficult joints to discuss, there are several things to address in dancers:
- Landings and jumps into and out of full plantarflexion
- En Pointe and its transfer of force on the toes
- Figure skaters and subsequently ice hockey players
In regards to the joint by joint theory, it is said that the ankle joint needs more mobility within a given anatomical model. However, if there is excessive ankle mobility (aka hypermobility of the joint), would chasing more ankle mobility be the go-to method for furthering a dancers’ career? And if not, what would the strategies be for such individuals with joint laxity? We will discuss the variables within this blog post further below.
When dancers present with hypermobility, often times [hypermobility] will present in much more than the ankle joint and present itself in nearly all joints leading up the kinetic chain (namely the hip, lumbar region, and shoulder complex). When dealing with more than adequate mobility in the ankle region, at times dancers have often “rolled” their ankles, largely due to a lack of hip external rotator strength along with peroneal stress from landing in en pointe as well. In the cases of hypermobility of the ankle joint, an equally or more amount of strength in surrounding structures (peroneals, gastroc, and higher up the kinetic chain) is necessary to overcome the excessive mobility within a particular joints’ mobility, due to the passive structures (connective tissue and ligaments) not providing the stability necessary for proper force absorption and force production.
Sahrmann has noted that if there is a stretch for prolonged durations (such as when there is an elongation of the ankle plantarflexors through extended tension found in active or passive stretching), that there may present weakness within the joint or muscle when asked to perform basic movements if not properly addressed within a rehab or exercise program. (1)
In regards to the popular position of en pointe, landing into and jumping out of this specific position can prove tricky for those who present hypermobility within the ankle joint. Due to the small base of support within this pose, it is often commonplace to roll or sprain the ankle when training and practicing.
“What causes this instability of the ankle?” you ask. Well, here we go!
Functional Instability vs. Mechanical Instability
When ankle sprains or inversions are discussed, we must look at functional instability along with mechanical instability of the ankle joint.
Tropp et al (2) discussed the notion of mechanical instability as a cause of CAI due to pathologic laxity after ankle-ligament injury… A more recent definition of functional instability is the occurrence of recurrent ankle instability and the sensation of joint instability due to the contributions of proprioceptive and neuromuscular deficits. (3)(4)
Whether this is due to mechanical or functional instability, in reality it could be due to both forms that could lead to this dysfunction. Further, an increased stretch on the dorsiflexors could increase the amount of time for an appropriate load to be placed on the ankle musculature for a proper stretch reflex to occur, and thus reactive timing of the stabilizers could play a role into the dysfunction of the ankle as well. Further research is needed on this behalf however. (5)
Q-Angle and how it translates down the kinetic chain
Although the Q-Angle refers to how the hip and knee are inter-related, especially within a female population, I feel it would be trite to gloss over its implications on the ankle joint. For the uninitiated, the Q-Angle represents the angle of the ASIS over the center of the patella, with the second line drawn from the center of the patella to the tibial tubercle. View the accompanying drawing to avoid having your mind blown.
This picture alone represents the difference between males and females. If some inferences can be assumed, the larger the Q-Angle within a female dancer, the more assumed lateral knee instability, possibilities of an MCL tear shoot up, and lateral ankle instability is also increased if left unchecked. Further, if the dancers’ q-angle is largely ignored, we must check “above and below” the joint to see where motion has either been limited or is excessively added. If the knee is unstable, the hip and ankle will be affected. If the ankle is unstable, the knee will be affected (and thus the hip as well). And so on the kinetic chain is affected due to individual anatomical properties…
Utilizing this philosophy, if we were to examine an athlete such as a hockey player or figure skater, more often than not their footwear has a large affect on their ability to not only transfer force but also the kinematic relationship through the knee and hip joints as well. Limited positioning, such as ankle dorsiflexion, within a skating shoe can create a deficit not only within the ankle’s mobility in an ice-related environment, but also create a possible reduction in strength and reaction time. This can be seen through a lowered proprioception of the peroneals along with reduced muscular strength due to muscular positioning. More research is needed to elucidate whether or not an athlete’s given ankle instability is driven by their shoe wear, functional or mechanical instability, or if a previous ankle injury (on-ice or off) increases this finding. (5)
So what are some steps we can take in order to proactively counteract either limited or excessive ankle mobility? From a strength coach’s scope of practice and a dancer’s perspective, I can recommend a few things:
Utilize non-cushion or minimal footwear
- This idea may be counterintuitive, as if someone has excessive mobility of the foot, wouldn’t you want to encourage more stability through the shoewear? In fact, it is the opposite. If a dancer or even general population folk present to a strength training session in running shoes, the first thing to do is take those bubble shoes off – they are not helping your ankles to “feel” the ground.
- On the opposite end, the argument can be made that if we aren’t wearing any shoes, we are encouraging the dancer to possibly roll their ankle into further supination due to missteps or lack of overall stability. This is where my job as a coach comes into play, as coaching and constant cuing should encourage the opposite and wanted behavior of an active “tripod” foot position within strength training exercises.
Assessing Ankle Mobility
- One point to take away before doing manual muscle testing on ankle mobility is to realize that, for fear of sounding like a broken record, range of motion is stolen from either above or below the affected joint. If an ankle presents to have limited ROM, and an athlete or dancer’s predisposition is to walk with an out-toe 24/7, then perhaps the problem is not actually at the ankle level, but rather at the hip level.
- Ankle plantar flexion (movement downward) 0-50
- Ankle dorsiflexion (movement upward) 0-20
Perform Self-Myofascial Release
- This will help proprioception of the peroneal stabilizers along with helping to prevent excessive supination of the foot and ankle region.
Encourage mobility if necessary
- For the athlete or dancer that presents limited range of motion after assessing for ankle mobility
Increase hip external rotator strength
- By simply strengthening your hip external rotators, and overall reducing the amounts of shear force that the tibia is experiencing on both ends of the patella and ankle joint (or “stacking” your joints), you can avoid ankle and knee instability issues as well.
Encourage stability during strength training
- Single leg exercises such as stiff leg deadlifts, lunges, and more advanced progressions towards plyos such as lateral/medial hurdle hops and landings
Understand that at times we must reign in visual aesthetics for overall health [of a joint]
This point will be difficult to swallow because dancers and performers are often “chasing” that next level of flexibility or specific position in order to advance within their professional career. It can be likened to an athlete performing a particular behavior to achieve success by any means necessary, whether it is performance enhancing drugs, or excessively stretching. On one end it is largely ignorance that may limit the success of a given athlete (limited by knowledge that a certain behavior will elicit further success – such as strength training, eating properly, etc.), and on the other end it is the opposite, as the athlete or dancer knows full well what they are doing in the face of unnecessary pressures to succeed, which could in turn elicit irrational behaviors to achieve said success by any means necessary.
The take home message I’d like for you to leave with is that a dancers’ (and athlete) feet is largely their lifeline to continuing professionally. If proper care is not taken to perform requisite exercises due to environmental or individual factors, then the responsibility will largely lie on you when you do inevitably happen to roll an ankle! So take care of your feet.
Stay tuned for more awesome articles within this series of the Joint by Joint Approach and its applications to dancing!
(1) Sahrmann, Shirley. “Chapter Two: Concepts and Principles of Movement.” Diagnosis and Treatment of Movement Impairment Syndromes. N.p.: Mosby, 2002. 19. Print.
(2) Tropp H, Odenrick P, Gillquist J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med. 1985;6:180–182.
(3) Hertel J. Functional instability following lateral ankle sprain. Sports Med. 2000;29:361–371.
(4) – http://www.ncbi.nlm.nih.gov/pmc/articles/pmc164367/
(5) – http://www.udel.edu/sigma-xi/thesis-award/2007/neeld/thesis.pdf