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Stretching the Point: Part 2

Posted By Gabrielle Davidson and Maggie Lorraine on behalf of the IADMS Education Committee, Wednesday, August 24, 2016

In Part 1 of “Stretching the Pointe” we discussed some issues that may arise as a result of incorrect use of the foot and faulty foot alignment in training.

 

Anatomical information about the foot is available in previous blog posts here.

 

In discussing the foot and the dancer, there are a few specific injuries and conditions that need to be taken into account to further strengthen the argument for ensuring correct alignment and muscle activation when teaching young dancers how to pointe their feet.

    


One of the most common of these injuries is posterior impingement of the ankle. This is when tissues at the back of the ankle are inflamed and prevent full ankle range into plantarflexion (pointing, demi pointe or pointe). This can either be due to compression of the soft tissues between the posterior edge of the tibia, the talus bone and the superior calcaneus [1] or irritation of the tendon sheath of the FHL (flexor hallucis longus- the muscle that controls the big toe into plantar flexion- full pointe)[4]. Posterior impingement and FHL tenosynovitis can go hand in hand and are often caused by the repetitive nature of dancers rising to demi pointe and pointe, and also pointing their feet [5]. It is thought that poor coordination of the lower leg and intrinsic foot muscles can exacerbate this condition. The condition can also arise after a sprained ankle and forced plantar flexion injuries, and in some cases has also been attributed to the presence of an os trigonum, a small bone that sometimes develops behind the ankle bone (talus bone). The os trigonum is a normal part of the ankle anatomy but sometimes fails to fuse with the talus therefore creating a small ‘extra’ bone in the ankle, and this can sometimes increase the effect of posterior impingement [1,3].

 

FHL tenosynovitis is frequently seen in female ballet dancers. It has been called “dancer’s tendinitis” but research has found that the condition is rarely a pathology of the tendon itself but of the sheath surrounding the tendon [1,2,3]. As mentioned above it can be part of the posterior impingement syndrome. The flexor hallucis longus muscle originates from the back of the fibula (outer lower leg bone/ lateral lower leg bone), then travels down along the inside of the lower leg and ankle where it inserts into the base of the big toe via the tendon. Its primary role is to flex the big toe assisting to pointe the foot (into plantar flexion), stabilise the foot and ankle as the dancer rises to demi pointe, and assist the foot to rise to full pointe [4].

 

The repetitive change in foot position from full plantar flexion (on pointe position) to full dorsiflexion (plié position) can cause this FHL tendon sheath to become inflamed [5], especially if it is not being supported by the other ankle and intrinsic foot muscles.


  


The repetitive loading of bones, especially in the feet, in activities such as fouettés (repetitive plantar flexion action of one foot on and off pointe) or landing from a series of repetitive jumps may cause bony stress. This is when loading of the bone outweighs its ability to recover and remodel, therefore leading to weakening of the bone structure itself and the resulting stress reactions or fractures [6,9].

 

Dancers are susceptible to a unique fracture at the base of the second metatarsal called the “dancer’s fracture” that is rare in other athletes and possibly as a result of the demi pointe and pointe work they carry out whilst dancing [5,7]. Controlling the amount of load a dancer is undertaking and controlling the rate at which this is increased, as well as making sure they have sufficient muscle support in both their feet and ankles will always help to reduce the risk of these overuse injuries.

 

Injuries to the mid foot in dancers while rare, can be debilitating [5]. The mid foot comprises the navicular, cuboid and three cuneiform bones. It stabilises the arch and transfers the forces generated by the calf, to the front of the foot during the stance phase of gait, so in dance terms this is whenever the dancer moves through their feet either rising or jumping. Acute cuboid subluxation may occur with ankle sprains, overuse of the peroneal muscles during repetitive movements such as rising up and down from pointe and excessive pronation of the foot, although the precise mechanism has not been proven [8]. Stress fractures and fractures of the navicular bone can be a career ending injury for a dancer.

 

  


Lisfranc injuries are injuries that occur to any part of the articulations of the 5 long metatarsal bones with the tarsal bones. These bones are connected by thick plantar ligaments (found on the underside of the bones) and strengthened by the tendons of tibialis posterior, peroneal tendons as they wrap under the foot and tibialis anterior tendon over the top of the arch. The Lisfranc ligament is the only ligament that binds the first and second metatarsal bones [8]. The mechanism of injury to this area in dancers may result from trauma to the foot of the female dancer when performing advanced pas de deux choreography where the edge of the pointe shoe sticks against an irregular floor surface when being slid along the foot by her partner. It can also occur from missed jump landings, during pirouettes/spins or during take-off for a jump [5].

 

Of course there are many more injuries that can occur in the course of a young dancer’s life but these are just a few of the main ones seen in the feet and ankles, some of which can be reduced with particular technique training and attention given to the development of specific muscle activity in the calves and intrinsic muscles of the feet, as mentioned in the previous blog post from the Education Committee.

 

The biggest message for young dancers, is to not allow pain to continue for too long. Seek treatment earlier rather than later to prevent too much time out of the studio and take heed of exercises and advice given by health professionals as their aim will always be to get you back dancing as soon as possible and for as long as possible.

 

Gabrielle Davidson and Maggie Lorraine

B.PHTY(HONS)              Leading teacher at the Victorian College of the Arts Secondary School

 

 

 

 

References:

[1] Russell J.A., Kruse D.W., Koutedakis Y., McEwan I.M., Wyon M. Pathoanatomy of posterior ankle impingement in ballet dancers. Clin Anat. 2010;23:613–621.

 

[2] Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers. J Bone Joint Surg Am 1996; 78 (10): 1491-1500.

 

[3] Peace,KA., Hillier, JC., Hulme,A., Healy, JC. MRI features of Posterior Ankle Impingement Syndrome in Ballet Dancers: A Review of 25 Cases. Clinical Radiol 2004: 59:1024-1033

 

[4] Kirane,YM., Michelson,JD., Sharkey, NA. Contribution of the Flexor Hallucis Longus to Loading of the First Metatarsal and  First Metatarsaophalangeal joint. Foot Ankle Int 2008; 29(4):367-377

 

[5] Kadel,N MD. Foot and Ankle Problems in Dancers.Phys Med Rehabil Clin N Am 2014; 25: 829-844

 

[6] Davidson, G., Pizzari,T., & Mayes, S. The Influence of Second Toe and Metatarsal Length on Stress Fractures at the Base of the Second Metatarsal in Classical Dancers. Foot and Ankle International  2007;28: 1082-1086

 

[7] Micheli, L. J., Sohn, R. S., & Solomon, R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am, 1985; 67(9), 1372-1375.

 

[8] emdedicine.medscape.com. Lisfranc Fracture Dislocation

Trevino, SG., Early, JS., Wade, AM., Vallurupalli, S., Flood, DL

 

[9] Mayer, SW MD., Joyner, PW MD., Almekinders, LC MD., Parekh, SG MD MBA. Stress Fractures of the Foot and Ankle in Athletes. Sports Health 2015: 6(6), 481-557.  

 

Kadel, N. J. Foot and ankle injuries in dance. Physical medicine and rehabilitation clinics of North America 2006; 17(4), 813-826.

 

O'Malley, M. J., Hamilton, W. G., Munyak, J., & DeFranco, M. J. Stress fractures at the base of the second metatarsal in ballet dancers. Foot & ankle international 1996; 17(2), 89-94.

 

An interesting videowhich highlights the horror for a dancer of a career threatening injury:

Portrait of a Dancer: Lauren Cuthbertson

 

 

Tags:  dancers  foot  injury  teachers 

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Stretching the Point

Posted By Maggie Lorraine on behalf of the IADMS Education Committee, Monday, August 15, 2016

Learning how to bend the knees and point the feet may be the first movements that dance students learn. It is sobering to consider that both of these movements are potentially harmful if not executed correctly and practiced in perfect alignment.  Experienced teachers of children and young people often notice that by encouraging students to “stretch” their feet rather than “point”, they are less likely to crunch their toes. Crunching results in a “shortened” line of the foot. On the other hand, “stretching” encourages the students to lengthen the leg through to the ankle and arch of the foot.  Anatomically speaking we are talking here about plantarflexion of the ankle of course, although this actual term is seldom used in a teaching context.


 

The pointed or stretched foot is the image that we so closely identify with classical ballet and arguably the control of the stretched foot whilst dancing is one of the skills that may take the longest to master.  It requires repetition throughout the dancers’ training to ensure sound alignment.  When teaching young children to dance it is important to consider the bone development of the body, which is called ossification. The completion of growth in a tubular (long) bone is indicated by the fusion or closure of the epiphyses (growth plates), located at each end of the long bone.  The long bones of the feet are the metatarsals – full anatomical information about the foot is available in previous blog posts hereThe final epiphysis to close does so at an average age of 16 years in boys and 14 years in girls (1). Of course, dancing can place added stress on growing bones and negligent dance training may also affect the development of the bony structures - repetitive trauma in training and increased impact due to poor biomechanical alignment can cause the epiphyseal plate to widen, rather than close (2).

 

It is acknowledged that foot and ankle injuries are the most prevalent injuries in classical ballet in both the student and professional population (3). The extreme position of the foot and ankle when dancing on demi pointe, (see illustration b) where the ankle is in full plantarflexion, the body weight is distributed on the ball of the foot, or en pointe, where the dancer is on the tips of her toes (see illustration c), the weight of the body is carried through the ankle joint, and the longitudinal axis of the foot may put the dancer at risk of injury.  Poor training, alignment, and faulty technique are all contributing factors to injury. Dancers, like athletes, are prone to common overuse injuries but they are also vulnerable to unique injuries, due to the extreme demands of ballet.

 

 

Teaching students how to align their feet and ankles, avoiding the urge to sickle (invert) or fish or wing (evert) when stretching their feet, and also ensuring that they do not crunch their toes (in an attempt to achieve the illusion of a high arch) will hopefully assist the student in avoiding serious foot problems. These issues will be exacerbated when the dancer rises on demi or full pointe. The control of the ankle when rising in an aligned position is a strengthening action.  However, when the ankle and foot is not aligned the action of weight bearing is potentially injurious.

 

 

Frequently students crunch their toes in an attempt to point their feet harder and consequently this action contracts the muscles of the foot causing the joints of the foot and ankle to compress.  Unfortunately, due to the students wearing shoes, the teacher does not always notice this problem, and the repetitive action possibly results in weakness in the intrinsic foot muscles and overuse of the extrinsic foot muscles, though this reasoning needs to be investigated scientifically. The issue sets up a pattern in the use of the foot that results in the toes crunching both when rising on demi pointe.  Strengthening the intrinsic foot muscles could potentially enable the middle joint of the toes to remain lengthened while stretching the foot. Research groups around the world are currently investigating just such possibilities and continually present their progress at annual IADMS conferences.


As teachers, we know that the habits that are developed in early training always affect the student in later years when greater complexity of training is introduced. Setting up the pattern amongst our students that they should strive to hold their feet evenly on the floor and keep their toes stretched out along the surface of the floor will help. While the feet are bearing the body’s weight they should be holding the ground at three points - one behind the back of the heel, and two in front of the heads of the first and fifth metatarsals. This triangle forms a base from which the muscles and soles of the feet can work to support the arch and align the feet. Potentially this will assist in the recruitment of the intrinsic foot muscles.

           

The intrinsic muscles are like the “core” muscles of the foot.  Because they are deep and don’t cross over too many joints, they can work well in stabilizing and protecting the arch and structures within the foot.  If the foot intrinsic muscles are weak, the foot structures are more prone to increased stress and injury.  Strengthening the intrinsic muscles of the foot is good for people with foot injuries and for those looking to prevent injury”(4).

 

Supporting the arches whilst standing all helps in ensuring strong, adaptable feet for dancing.

 

 

The extreme positions created when dancing on pointe are particularly hazardous if the body and foot are not physically ready to deal with the weight of the body on pointe. IADMS has produced a really useful guide to point readiness available here.

 

In conclusion movement habits practiced in early training can have a profound effect on the young dancer’s development and their potential for injury.  By laying the foundation of sound alignment the teacher will empower the student to achieve their goals with reduced potential for injury.  Celia Sparger describes it well: 

           

"It cannot be too strongly stressed that pointe work is the end result of slow and gradual training of the whole body, back, hips, thighs, legs, feet, co-ordination of movement and the 'placing' of the body, so that the weight is lifted upwards off the feet, with straight knees, perfect balance, with a perfect demi-pointe, and without any tendency on the part of the feet to sickle either in or out or the toes to curl or crunch. “

 

The IADMS Education Committee will post a follow up article describing possible foot and ankle conditions and injuries that may impact on the dancer written by Gabrielle Davidson who is the Physiotherapist of the Dance Department at the Victorian College of the Arts Secondary School.

 

Maggie Lorraine

Leading Teacher in Ballet at the Victorian College of the Arts Secondary School. Australia.

Member of the IADMS Education Committee

 

References

(1) Weiss, D., Rist, R. and Grossman, G. Guidelines for initiating pointe training.  IADMS Resource Paper, 2009.  Available here.

 

(2) Laor T, Wall EJ, Vu LP. Physeal widening in the knee due to stress injury in child athletes. AJR Am J Roentgenol. 2006; 186(5): 1260–1264.

 

(3) Foot and Ankle Injuries in Dance.  Physical Medicine and Rehabilitation Clinics of North America December 2006.  

 

(4) Amy McDowell, P.T From ARC Physical Therapy Blog

 

Further resources

Common Foot and Ankle Ballet Injuries

Dancing Child: Foot Development and Proper Technique

 

Micheli, L. J., Sohn, R. S., & Solomon, R. (1985). Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am, 67(9), 1372-1375.

 

O'Malley, M. J., Hamilton, W. G., Munyak, J., & DeFranco, M. J. (1996). Stress fractures at the base of the second metatarsal in ballet dancers. Foot & ankle international, 17(2), 89-94.

 

Wiesler, E. R., Hunter, D. M., Martin, D. F., Curl, W. W., & Hoen, H. (1996). Ankle flexibility and injury patterns in dancers. The American journal of sports medicine, 24(6), 754-757.

 

Kadel, N. J. (2006). Foot and ankle injuries in dance. Physical medicine and rehabilitation clinics of North America, 17(4), 813-826.

 

O'Malley, M. J., Hamilton, W. G., Munyak, J., & DeFranco, M. J. (1996). Stress fractures at the base of the second metatarsal in ballet dancers. Foot & ankle international, 17(2), 89-94.

Tags:  dancers  foot  teachers  toes 

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Foot Injuries in Dancers. Are they preventable?

Posted By Maggie Lorraine on behalf of the IADMS Education Committee, Wednesday, July 6, 2016

Perfecting the art of dance requires long hours of intensive training over many years with constant repetitions of exercises to refine and perfect the execution of sequences and movements. Dance places high demands on the body and for this reason professional dance training institutions often include physique testing, conducted by the resident physiotherapist as part of the audition process. Subsequently even the physiques that are deemed “ideal” for training at a pre professional level are at risk of injury as a result of faulty alignment and technique.  In recent years the quest for greater virtuosity in performance has added an extra layer of risk to the aspiring young dancer who is hoping to achieve a career in dance. Issues such as more intrusive stretching techniques to achieve higher extensions of the leg, bigger and higher jumps with added complexity, more virtuosic turns and particularly greater engagement of the spine in movement. These trends have all added to the necessity for dance teachers to have a comprehensive knowledge of human anatomy, physiology and kinesiology. This knowledge will give teachers the information to guide their students to reach their full potential and to avoid sustaining injuries.

 

No dancer is immune to the possibility of injury, however the young dancer who is experiencing a growth spurt is at the greatest risk. Whilst growing, a child’s bones are more susceptible to issues, since as the bones lengthen the growth places stress on the muscle tendon unit and consequently the young dancer at a higher risk for stress fractures and fractures.

 

Building from our previous posts on the foot’s skeletal and muscular structure, this article focuses on the foot and issues that arise from faulty biomechanics, technique and resulting from over pronation of the feet.



Incorrect turn out of the legs and feet often results in over pronation or “rolling “of the foot and ankle. To make up for inadequate mobility at the hip, dancers often rely on the rotation of the knee, and ankle to achieve the desired 180-degree turn out of the feet. This problematic mode of movement compromises the control of the rotation of the leg in the hip socket and the efficient recruitment of the deep rotator (turn out) muscles which assist in the stabilizing muscles of the legs and pelvis.  Maintaining alignment, stability, strength and control is difficult to achieve whilst dancing with torsion of the knee, and pronated foot. When the foot is pronated the weight of the body falls through the unaligned joints of the knee and ankle creating an increased torque of the medial (inner) arch and ankle and poor intrinsic foot muscle control  (see photograph above).


When there is poor intrinsic muscle strength in the arch of the foot, foot pain may occur. The intrinsic foot muscles are the tiny muscles, which contribute to control a ballet dancer's arch. If the muscles are not working effectively, larger muscles known as the extrinsic foot muscles, which originate on the leg and cross over the ankle joint, become overused.


Over-pronation of the feet can lead to a number of problematic conditions, which contribute to foot pain and may cause conditions such as bunions, hallux rigidus, plantar fasciitis, and sesamoiditis.

 


Unfortunately bunions can be common in dancers. They begin to develop in young dancers who do not have the muscle recruitment in place to support the growing bones. Both male and female dancers are at risk from the increased stress on the medial column of the foot as a dancer attempts to achieve greater turnout from the knee and ankle. Some bunions (or hallux valgus) are hereditary, however dancers may develop them as a result of forcing turn out with little to no intrinsic muscle control. Tight fitting shoes and pointe shoes may also contribute to bunions as the shoes narrow to the pointe and the foot is broadest across the metatarsals. Squeezing the toes into narrow pointe shoes put pressure onto the big toe joint which is exacerbated by carrying the weight of the body on the tiny surface of the shoe en pointe.

 

Repeated strain on the big toe joint may result in hallux rigidus or stiffness of the big toe. Dancers with bunions are more prone to hallux limitus. The shock and forces from dancing can lead to inflammation of the big toe joint, and over time cause stiffness and a lack of range of motion. Because of the pain and stiffness, dancers will shift their weight to the outside of the foot during demi-pointe. 

  

Metatarsalgia is an overuse injury and the term describes pain in the ball of the foot, which usually develops over months. High impact activities such as jumping without sound foot control and abnormal weight distribution on the foot can result in this injury. Although this injury is not solely a result of hyperpronation, the reduced foot control resulting from poor intrinsic strength will be a contributing factor.

 

Sesamoiditis is another condition where pain is often felt in the ball of the foot and is a result of excessive pressure on the forefoot. The sesamiod bones are two tiny bones within the flexor hallucis longus (FHL) that run to the big toe and when a person has sesamoiditis the tendon become inflamed. Dancers, who alternate between extreme plantar flexion and dorsiflexion rely on the flexor hallucis longus (FHL) for dynamic stability of the foot during these movements and they may be particularly susceptible to this condition. Other causes can be an increase in activity, having a foot with a high arch or a bony foot (with insufficient fat to protect the tiny bones) and also stress fractures. Most frequently dancers with sesamoiditis have an imbalance of FHL vs. gastrocnemius/soleus {calf muscles} and FHL vs. intrinsics.

 

The plantar fascia is a dense band of fibrous tissue that originates at the heel and connects to the base of the toes. It stretches each time the foot is used, and is prone to overloading especially if the arch is not supported by proper footwear. Dancers experience pain and swelling at the inside base of the heel and arch area and it is known as plantar fascilitis.

This article has focused on foot injuries, which may result from faulty biomechanics of the foot in dancers.

Forcing turn out from the foot and ankle instead of at the top of the leg at the hip joint results in faulty alignment and poor muscle recruitment. Dancers require strong intrinsic muscles of the feet, which are imperative for aligned foot control against the ground in repetitive movements of the foot, pointe work and jumping.  Without this control of the foot the dancer is at risk of injury.

The next article in this series will examine issues resulting from incorrect stretching of the foot and faulty

biomechanics of rising to demi pointe and pointe.

 

Maggie Lorraine

 

The following IADMS link provides an excellent training program for dancers:

 

         Turnout for Dancers: Supplemental Training

         Feet: Skeletal and Muscular Structure

         Resource Paper: The challenge of the Adolescent Dancer

Follow these links for more information:

YouTube - 1

YouTube - 2

 

 

Further reading:


Grossman G, Krasnow D and Welsh TM. Effective use of turnout: biomechanical, neuromuscular, and behavioral considerations. Journal of Dance Education 2005; 5(1): 15-27.

 

Jeffrey A. Russell, PhD, ATC. Breaking pointe: Foot and ankle injuries in dance.

 

 

Maggie Lorraine is the Leading Teacher in Ballet at the Victorian College of the Arts Secondary School and is a member of the IADMS Education Committee.

Tags:  dancers  feet  foot  injury  prevention  teachers 

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Caring for bony injury demystified!

Posted By Meredith Butulis, DPT, ACSM HFS, Monday, June 27, 2016

Welcome to Part Three of our three part series on muscle, ligament, and bone injuries. We will explore some common myths and how you can use current evidence to efficiently return to optimal performance. This month we will explore bony injuries.

 

“It’s just a stress fracture; I can keep going.”

 “I only take the boot/orthopedic shoe off to dance, other than that I wear it all the time. Is that OK?”

“I can prevent shin splints by stretching my calves more.”

 

As dancers, teachers, or allied health professionals, we’ve likely experienced situations like these.

 

What are some essential pearls that dancers, teachers, and allied health providers need to know when it comes to preventing and caring for bony injuries?

 

What are the most common bony injuries in dancers?

At this time, research does not clearly differentiate dancers versus other athletes with regard to bony injury; however, common bony injury sites for athletic youth and adults including dancers will be discussed here.

 

Common sites for bony injury, particularly stress fractures, include metatarsals, tibia, fibula, navicular, talus, calcaneus, and pars interarticularis.1,2,3,4 Teens and youth are also susceptible to injuries involving epiphyseal (growth) plates. See Fig 1. for an illustration of these common locations.



Clinically, I also find that many dancers think that they have a chronic muscle strain as opposed to a bony injury, especially when fractures are located in the back, pelvis, hip, shins, or feet (Fig 2). For example, dancers often enter the clinic with a self-diagnosis of “hamstring strain,” “hip flexor strain,” “back strain,” “plantar fasciitis,” or “ shin splints.” Once medically evaluated, many of these are found to be fractures. 



Now that we’ve taken a look at common sites of bony injury, let’s get into some common myths and alternative views surrounding these bony injuries! We will delve into management tips, and foundations for designing your own injury prevention programs.

 

Myth # 1: It is OK to dance on a stress fracture.

 

Fact: Dancing on any fracture is not recommended. A stress fracture indicates excessive loading to the involved bone, typically over a period of time; this is different than an acute fracture, which occurs in a single episode.3 Continuing to dance on any fracture can lead to a non-union where the bone terminates its healing process; this is an undesirable outcome as it can lead to needing to permanently modify activity choices. High-risk locations are much more susceptible to delayed or non-union injuries.3,5,6

 


Myth #2: All ankle and foot injuries should be treated with PRICE (protect, rest, ice, compress, elevate) for 2-3 days followed by gradual return to activity as long as they don’t show excessive swelling and bruising at first.

 

Fact: Many bony ankle injuries actually do not swell and bruise extensively immediately. Many can also take more than two weeks to show on an X-ray image.3,7 There are a few indicators that should lead a dancer to see a medical provider initially, as opposed to trying self-treatment for a few days. These indicators are known as the Ottawa ankle rules, and further medical evaluation should be performed. If there is bony tenderness to the distal 6 cm of the medial or lateral malleolus, posterior edge or tip of either malleolus, talar neck, navicular, or base of the 5th metatarsal, medical evaluation is indicated (Fig 4).8 Additionally, if there is inability to weight bear to walk at least four steps either at the time of injury or subsequent time, medical evaluation is indicated. 8  



Myth #3: Once a fracture has healed, the dancer can return to his/her previous level of dance immediately.

 

Fact: Return to activity is guided by the high versus low risk classification of the fracture, the extent of the injury, and the typical training or competitive schedule for the individual.9 Generally, stress fractures take 6-8 weeks to heal with proper rest and rehabilitation; 7 the high risk sites can take quite a bit longer to heal.2,3 Low back fractures typically have a minimal healing time of 3 months.6

 

Proper management of a stress fracture goes beyond bone healing. Ligamentous laxity, leg length differences, areas of joint hyper or hypomobility, and neuromuscular imbalances can all play a role in minimizing improper loading forces through the body.3 Rehabilitation professionals also often use functional test batteries to determine the neuromuscular control of the involved body part prior to returning a dancer to activity.

 

Additionally, comprehensive management of a stress fracture is not limited to physical rehabilitation. Training schedules, adequate recovery strategies, fatigue management, nutrition, medications, menstrual cycle patterns, and footwear should also be evaluated.3

 

 

Myth #4: Stretching the calves regularly will prevent shin, ankle, and foot bony injury.

 

Fact: Injury prevention requires a comprehensive approach in managing multiple risk factors. Risk factors are commonly divided into intrinsic (a property of the individual human body), and extrinsic (the environment surrounding the individual).  Intrinsic risk factors include bone density, skeletal alignment, flexibility, muscular endurance, bone turnover rate, hormonal balance, and nutrition.10  Extrinsic factors include dance surfaces, footwear, training schedules, and load.10 All of these factors need to be considered with regard to the individual performer (Fig 5). 

 


Concluding thoughts:

Now that we’ve explored bony injury myths, and samples of current recommendations in prevention & treatment, how will you utilize this information in your practice?  

 

References:

 

1. Brunker PD, et al. Stress fractures: a review of 180 cases. Clin J Sports Med. 1996; 6(2): 85-9.

 

2. Bennell KL, Brunker PD. Epidemiology and site specificity of stress fractures. Clin Sports Med. 1997. 16(2): 179-96.

 

3. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress Fractures of the Foot and Ankle in Athletes. Sports Health. 2014;6(6):481-491.

 

4. Smith PJ, Gerrie BJ, Varner KE, McCulloch PC, Lintner DM, Harris JD. Incidence and Prevalence of Musculoskeletal Injury in Ballet: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2015;3(7)

 

5. Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress Fractures of the Pelvis and Legs in Athletes: A Review. Sports Health. 2013;5(2):165-174.

 

6. Standaert CJ, Herring SA (2007). Expert Opinion and Controversies in Sports and Musculoskeletal Medicine: The Diagnosis and Treatment of Spondylolysis in Adolescent Athletes. Archives of Physical Medicine and Rehabilitation. 88(4): 537-40.

7. Verma RB, Sherman O. Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment. Am J Orthop. 2001; 30(11): 798-806.

8. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417.

9. Deihl JJ, Best TM, Kaeding CC. Classification and return-to-play considerations for stress fractures. Clin Sports Med. 2006 Jan;25(1):17-28, vii.

10. Bennell K, et al. Risk factors for stress fractures. Sports Med. 1999 Aug;28(2):91-122.

 

Further Reading:

1. Robson B, Chertoff A. Bone health and female dancers: Physical and Nutritional Guidelines

Resource Paper. International Association of Dance Medicine and Science. 2010. Available at: http://c.ymcdn.com/sites/www.iadms.org/resource/resmgr/resource_papers/bone_health_female_dancers.pdf

 

About the Author: Meredith Butulis, DPT, MSPT, OCS, CIMT, ACSM HFS, NASM CPT, CES, PES, BB Pilates is a dance-specialized Physical Therapist, Personal Trainer, Pilates Instructor, and dance performer. With over 15 years of experience, she is based in Minneapolis, MN at Twin Cities Orthopedics and the Minnesota Dance Medicine Foundation.

Tags:  bone  dancers  injury  teachers 

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Maybe you should stop dancing… a little

Posted By Luke Hopper and Peta Blevins, Wednesday, June 15, 2016

We all know how super hard dancers work. Dance is a passion, a lifestyle and an identity for millions of people around the world. And you only get to the top with hard work and grit right? But can you have too much of a good thing?


Most dancers know the stories of dance legends like Nureyev and Cunxin dancing through adversity night and day, spending more time in the studio than any other dancer on their way to greatness. And we have all heard stories of dancers pushing their bodies through performance because the show must go on. These are inspirational stories of motivation and determination, but the fact is while dancers are super humans they certainly aren’t superhuman, and injury caused by over working in dance is a worldwide problem. A dancer who has not experienced some form of injury that has forced them to stop or modify their training is a rarity. This is really no surprise because dancers love what they do. They want to be the best they can be and put a huge number of hours into the studio pursuing their dreams. But all this training can come at a cost. No-one can work as hard as dancers do without running the risk of experiencing injury or illness that is going to stop them dancing in some way. So, could dancers actually train less, reducing the risk of injury or illness, and still progress in their training, perhaps even faster?


 


The majority of dance injuries are referred to as overuse injuries. The term overuse means just what it says - injury occurring as a result of the body being overused. The tissues in the body become fatigued and susceptible to injury when a dancer is overusing them. This is the risk dancers take in dedicating so much time training. Nobody wants to get injured and one of the hardest parts about injury for a dancer is having to take the time out of dance to recover and rehab the injury. But let’s step back and look at the injury from a different perspective. Maybe the injury is a way in which your body is showing that you are working too hard and the injury has actually just forced you into a period of recovery time? Think all of the days or weeks in the past years that you may have spent not dancing as a result of injury or illness. This is time that your body has spent recovering from training. Wouldn’t it be a better option to dedicate time for recovery as part of your regular practice so that you don’t become too injured or ill to dance in the first place?


Colleagues who work in sports are often amazed when they hear how much time dancers actually train. It is way above the training time of elite or professional athletes. This is partly because of two fundamental principles of physical training used in sport, progressive overload and recovery. Progressive overload refers to the concept that training should stress, fatigue and challenge the body beyond a comfortable limit. As a result, after the training, the body responds by adapting with strength or fitness gains, or whatever physical capacity the training challenged. But it is only after training that the body adapts; it is only when the body is recovering that we improve. Making sure you get enough sleep is just as important as working really hard in the studio. We do some of our best work at night when we are asleep in bed.


These principles go beyond the physical and apply just as strongly to psychological factors. There is a huge amount of psychological pressure that goes hand in hand with being a dancer. Dancers may feel pressure to look a certain way, they may be worried about gaining employment, and more and more there is increasing demand for dancers to have versatility in their performance skills. It’s not always possible to leave our worries at the studio door and often we find they creep into the studio behind us and start affecting our performance. Often the first reaction we have when we notice performance dropping off is to increase our training efforts, but maybe training smarter is a better option than just training harder.


A first step in becoming a smarter dancer is looking at yourself as a whole person, not just a dancing body but also a dancing mind. It’s important to acknowledge that pressures from within and outside the dance world, as well as a combination of physical and psychological factors, can have an impact on your performance. Finding a balance between pushing hard and backing off training when you need to recover is a bit like walking a tightrope; it’s very easy to lose your balance and only you can feel where your center of gravity is. There can be a bit of a stigma attached to taking it easy; no one wants to be seen a quitter or a ‘lazy dancer’. But it’s so important to be aware of your own recovery needs and to know when you can push your training and when you need to spend more time focusing on recovering from the hard work you’ve put in.


 


So let’s think about recovery in the context of injury or illness again. You push a little hard through training, ignoring the niggle in your foot or tickle in your throat and all too soon you are too sick to get out of bed or you’re watching class from the side waiting for your foot to recover. Can you frame this series of events as your body forcing you to recover after you have been forcing your body to train? If you can accept that recovery in dance is inevitable (and indeed, essential), then you have the choice of taking the recovery pill the easy way or the hard way. There is nothing like coming home from a hard day’s training, feeling you have accomplished something and are on your way to being a brilliant dancer. So reward yourself, take some downtime, even half a day coupled with an easy afternoon’s training. You are much better spending the day recovering and doing some light training than pushing your body with another hard session risking injury or a week in bed.


So how much training is enough and how much rest is too much? Ultimately, this is your choice, nobody knows your body’s limits better than you. A good place to start is to plan your training over the next few months. In sports this is called periodization and IADMS President Prof Matt Wyon’s articles are a great guide to get you on the way here. By scheduling rest periods it means that you may be able to train differently on your work days and Glenna Batson’s article on distributed practice in dance can help you through that. You will also need to think about your existing schedule, when do you have high intensity classes, days or weeks and how can you schedule your recovery time around these periods.


Finally, recovery does not mean being a couch potato. Elite athletes don’t spend nearly as much time in physical training as dancers but they certainly train full time. This means that when athletes aren’t training in the gym or on the field they will often be reviewing games, looking at game strategy or doing mental skills training. This is referred to as active recovery. So why not schedule half a day a week or so to study dance history or even better catch up on your journal of dance medicine and science articles or IADMS blogs! There are heaps of activities you can do that aren’t dancing that will let your mind and body rest and recover and make you a better dancer.

  

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Luke Hopper (Post-doctoral Research Fellow) and Peta Blevins (PhD Candidate) are based at the Western Australian Academy of Performing Arts. Peta Blevins’ PhD advisory team include Luke Hopper, Associate Professor Gene Moyle (Queensland University of Technology) and Dr Shona Erskine (Western Australian Academy of Performing Arts). Peta will present her research investigating recovery in dance at the IADMS conference this year at the Hong Kong Academy for Performing Arts.

Tags:  dancers  teachers 

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Caring for ligament sprains demystified!

Posted By Meredith Butulis, DPT, ACSM HFS, Wednesday, May 25, 2016

Welcome to Part Two of our three part series on muscle, ligament, and bone injuries. We will explore some common myths and how you can use current evidence to efficiently return to optimal performance. This month we will explore ligamentous injuries.

 

“It’s just an ankle sprain; can I perform this weekend?”

 “My hip flexors are always tight, so my friend taught me the frog stretch; is this a good stretch?”

 

As dancers, teachers, or allied health professionals, we’ve likely experienced questions like these.

 

What are some essential pearls that dancers, teachers, and allied health providers need to know when it comes to preventing and caring for ligamentous injuries?

 

What is a ligament and what does it do?

A ligament is a connective tissue in the body that connects a bone to another bone.  Ligaments serve to create stability in the joint structure. Injury to a ligament is called a sprain, which is different than a muscle or tendon injury.

 

Myth # 1: After resting a new sprain for a few days, the dancer will be ready to return to the stage.

 

Fact: Ligament healing depends on the grade of the sprain, location, and overall health of the dancer.


 


However, the most common sprain, that involving the ATFL (anterior talofibular ligament) in the ankle, notably takes 6 weeks to 3 months to achieve mechanical stability4, with 30% of these sprains continuing into a state of chronic instability.5

 


Dancers may wonder if they should see a medical provider if they suspect a sprain. A correct diagnosis will help lead to the most efficient route of correct treatment. There are a few indicators that should lead a dancer to see a medical provider initially, as opposed to trying self-treatment for a few days. These indicators are known as the Ottawa and/or clinical prediction rules, and further medical evaluation should be performed. Since these findings indicate possible fracture, we will discuss them in next month’s blog post on bony injury.

 

Myth #2: New ligament injuries should be treated with PRICE (protect, rest, ice, compress, elevate) for 2-3 days followed by gradual return to activity.

 

Fact: Rehabilitation strategies depend on the type of injury and its phase of healing. Current evidence supports matching rehabilitation strategies to healing phases.

 


Within this decade, sports medicine has also revealed that ligament sprains are more than a localized injury; they affect the entire kinetic chain and sensorimotor system of the body. 7, 8 Therefore, rehabilitation needs to include these elements. Details on proprioceptive training can be found in the International Association of Dance Medicine & Science’s resource paper, Proprioception.9 Details on progressions of functional training can be found in General Considerations for Guiding Dance Injury Rehabilitation in The Journal of Dance Medicine and Science. 10

 

Myth #3: Stretching is the best strategy to prevent sprains.

 

Fact: Stretching can be part of an injury prevention program, as it can help to improve joint alignment and neuromuscular efficiency; however, stretching by itself has not been proven to prevent injury. 11 Currently, there is not a consensus on best prevention, as injury prevention involves addressing the individual within the context of his/her abilities, movement tasks, and environment. 7, 8, 10

 


Generally, stretches should be reserved for muscles, not ligaments. One should not attempt to stretch his or her ligaments, as they may excessively elongate and fail to stabilize the joints that they protect. 12

 

Here is an example of a popular dance “frog” stretch targeted at the ligaments and capsule in the front of the hip. Since the stretch targets ligaments and the joint capsule, it is not recommended.

 


Instead, alternatives like stretching the hip adductors or hip flexors would provide safer and more muscularly targeted stretches. 

 


Clinically, I have found that when dancers are instructed in how to stretch muscles instead of ligaments and joint capsules, their pain often decreases; their functional pain free range of motion often improves within a couple of weeks.

 

Concluding thoughts:

Now that we’ve explored ligament sprains, myths, and samples of current recommendations in prevention & treatment, how will you utilize this information in your practice?  

 

 

 

References:

1. Manske RC. Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder. Philadelphia, PA: Mosby. 2006.

 

2. Axe MJ, Snyder-Mackler L. In: Current Concepts of Orthopedic Physical Therapy, Independent study course 21.2.11, 3rd Ed.  Manal TJ, Hoffman SA, Sturgill L. American Physical Therapy Association. 2005.

 

3. Haddad SL. Sprained ankle. OrthoInfo. American Academy of Orthopedic Surgeons. 2016. Available here.

 

4. Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. J Athl Train. 2008; 43(5): 523-529.

 

5. Wilkstrom EA, Hubbard-Turner T, McKeon PO. Understanding and treating lateral ankle sprains and their consequences: a constraints-based approach. Sports Med. 2013; 43(6): 385-93.

 

6.  Phuc L. Human Anatomy System: Skeletal System (Free App for iPhone)

 

7. Petersen W, Rembitzki IV, Koppenburg AG, et al. Treatment of acute ankle ligament injuries: a systematic review. Archives of Orthopaedic and Trauma Surgery. 2013;133(8):1129-1141.

 

8. Fulton J, Wright K, Kelly M, et al. Injury risk is altered by previous injury: a systematic review of the literature and presentation of causative neuromuscular factors. International Journal of Sports Physical Therapy. 2014;9(5):583-595.

 

9. Batson G. Proprioception. International Association of Dance Medicine and Science. Resource paper. 2008. Available here.

 

10. Liederbach MJ. General considerations for guiding dance injury rehabilitation. JDMS. 2000; 4(2): 54-64.

 

11. Clark MA, Lucett SC, Sutton BG, Eds. NASM Essentials of Personal Fitness Training, 4th Ed. Baltimore, MD: Wolters Kluwer; 2012

 

12. Norkin CC, Levangie PK. Joint Structure & Function, 2nd Ed. Philadelphia, PA: FA Davis; 1992.

 

Further Reading:

1. Critchfield B. Stretching for dancers. Resource Paper. International Association of Dance Medicine and Science. 2011. Available here.

 

2. Sefcovic N. First aid for dancers. Resource paper. International Association of Dance Medicine and Science. 2010. Available here.

 

 

About the Author: Meredith Butulis, DPT, MSPT, CIMT, ACSM HFS, NASM CPT, CES, PES, BB Pilates is a dance-specialized Physical Therapist, Personal Trainer, Pilates Instructor, and dance performer. With over 15 years of experience, she is based in Minneapolis, MN at Twin Cities Orthopedics and the Minnesota Dance Medicine Foundation.


Tags:  dancers  injury  ligament  sprain  teachers 

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Caring for muscle strains demystified!

Posted By Meredith Butulis, DPT, ACSM HFS, Tuesday, April 26, 2016

Welcome to our three part series on muscle, ligament, and bone injuries. We will explore some common myths, and how you can use current evidence to efficiently return to performance. This month, we will begin with muscular injuries.

 

“I strained my hamstring three months ago!”

“Why does it take so long to heal?”

“I’ve done everything from stretching to massage and I keep losing flexibility!”

 

As dancers, teachers, or allied health professionals, we’ve likely experienced or witnessed these self-diagnosed and self-treated muscle strains.

 

What are some essential pearls that the dancer, teacher, and allied health provider need to know when it comes to caring for muscular injuries?

 

Myth # 1: A muscle strain is the cause of the motion loss.

 

Fact: Muscle strains are quite prevalent in dance and sport injury. 1,2 In addition to muscle spasm and tension that can follow a strain, structures that can limit range of motion include the joint capsule, ligamentous or myofascial adhesion, joint swelling, bone structure, neural tension, and dysfunction in how segments of the body work together. 3,4 It is common to have multiple structures limiting range of motion, even if there was a specific incident that seemed to cause the limitation. 1,3 Resolving the range of motion loss depends on a correct assessment of the entire kinetic chain.1,4,5,6, 7

 

Example: A dancer presents to an allied health provider; over the past month, she notes pain at the top of her left hamstring and progressive motion loss with stretching into left leg forward splits. She has received several sessions of hamstring soft tissue work without improvement. She has been working on back walkovers and back bends, but you find that she does not have the thoracic and shoulder motion for proper alignment of the shoulders over the wrists. You find that this has led to segmental dysfunction of the entire thoracolumbar spine. The solution to restoring this dancer’s left splits lies in restoring proper mobility of the spine and proper alignment of the shoulders over wrists in performing her bridge and back walkover skills.

 

This case illustrates the importance of assessing the performer’s skill specific alignment throughout the kinetic chain when formulating a treatment plan. It also illustrates that range of motion loss may present as muscular pain, but the cause may not be a muscular strain.


 




Myth #2: Muscle strains should typically be treated by self-prescribed stretches and fascia release.

 

Fact: All tissues progress through healing phases. Current evidence supports matching rehabilitation strategies to healing phases. 1,5,6


 




Myth #3: After a muscle strain, a dancer should be back to full performance ability within 1-2 weeks.

 

Fact: There are different types of muscle strains. Correct identification and proper early treatment can help manage time frame expectations. 


 

 

Dancers, however, often do not rest or seek medical care.6 They also often take up to 32-50 weeks to return to premorbid dance levels after hamstring muscle strains.6 This prolonged recovery period is possibly due to lack of early proper treatment and premature return to activity.6  Additionally, re-injury rates can be quite high; the hamstring re-injury rate within one year is 34%1

 

As we can see, seeking medical evaluation (even for a minor strain) could help dancers develop a proper plan of care to help with efficient return to performance.

 

Concluding thoughts:

Now that we’ve explored muscle strains, myths, and current recommendations in treatment, what will your actions be next time you suspect a muscle strain?

 

References:

1. Foglia A, Bitocchi M, Gervasi M, Secchiari G, Cacchio A. Conservative Treatment of Muscle Injuries: From Scientific Evidence to Clinical Practice. In: Bisciotti GN (Eds) Muscle Injuries in Sport Medicine, InTech, 2013. Available here.

 

2. Roberts KJ, Nelson NG, McKenzie L. Dance-related injuries in children and adolescents treated in US emergency departments in 1991-2007. J Phys Act Health. 2013; 10(2): 143–150.

 

3. Konin JG, Harrelson GL, Leaver-Dunn D. Range of motion and flexibility. In: Andrews, Harrison, Wilk (Eds) Physical Rehabilitation of the Injured Athlete, 3rd Ed, Philadelphia, PA: Saunders, 2004, pp. 129-156.

 

4. Lee D, Lee LJ. The role of the pelvis in hamstring injuries and posterior thigh pain. In Touch. 2009; 127.

 

5. Page P. Pathophysiology of acute exercise-induced muscular injury: clinical implications. Journal of Athletic Training. 1995; 30(1): 29-34

 

6. Deleget A. Overview of thigh injuries in dance. Journal of Dance Medicine & Science. 2010; 14(3): 97-102.

 

7. Tiidus PM, Ed. Skeletal muscle damage and repair. Champaign, IL: Human Kinetics. 2010.

 

 

 

About the Author: Meredith Butulis, DPT, MSPT, CIMT, ACSM HFS, NASM CPT, CES, PES, BB Pilates is a dance-specialized Physical Therapist, Personal Trainer, Pilates Instructor, and dance performer. With over 15 years of experience, she is based in Minneapolis, MN at Twin Cities Orthopedics and the Minnesota Dance Medicine Foundation.


 

Tags:  dancers  myths  teachers  tips 

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5 Questions With Andrea Alvarez and Siobhan Mitchell

Posted By IADMS Student Committee, Thursday, March 10, 2016

Our next featured members in the “5 Questions With…” column are Student Committee Members, Andrea Alvarez and Siobhan Mitchell. Andrea is a third year graduate student at Case Western Reserve University in Cleveland, OH, USA. Siobhan is a PhD student at the University of Bath, UK.

 

-How did you first get interested in dance science/medicine?

 

Siobhan - When I started training full-time we had an assignment to design a cross-training programme – I really got into the science of it and thinking about injury prevention and nutrition and ways to optimize my dance training and performance. A few years later when I was doing my undergraduate degree, we had a dance science module and this really inspired me to take my interest forward and apply for the Dance Science MSc at Laban – the rest is history!

 

Andrea - When I started taking classes about dancer wellness and health. While I was an undergraduate student, Texas A&M University was in the process of creating the dance science track kinesiology major. Since I was very active in the program, I decided to change my major once it was approved. It did not take long before I realized that was the right choice. I quickly started to find connections between all my science courses and how they could relate to dance and dancers. I remember sitting in my Athletic Injuries class thinking “I want to be an athletic trainer for dancers!” I was told there was no such thing, and I replied “well, I guess I am creating a new career.” Luckily, there are many of them now.

 

-Are you currently participating in research? Can you give us your elevator pitch or brief summary of your research area?

 

Siobhan - I am currently working on my PhD research exploring the implications of maturation timing upon psychological well-being in elite dancers. Current research suggests that maturation timing (whether an individual biologically matures in advance of their peers, later than their peers or at an average time) may be an important factor in how individuals cope with different learning experiences and social contexts and can therefore play a role in subsequent psychological wellbeing. My PhD research aims to explore this within the context of elite dance training and to investigate how we might use this knowledge within dance teaching contexts to promote and to optimise psychological wellbeing in adolescent dancers. I’m also working on a body composition research project with fellow IADMS member Jasmine Challis - we are trying to establish norms for a novel form of body composition assessment – we presented some of our findings at the IADMS conference in Pittsburgh!

 

Andrea - I am just starting my research this semester. I am working parallel to another institution, looking into how participation levels affect recovery among college dance students. Hopefully, I will have more details soon.

 

-What is the best thing about being a student member of IADMS?

 

Siobhan - The annual meetings and having the opportunity to network with and meet the people whose papers you’ve been reading all year! It’s great to feel a part of a community who share your interests and passion.

 

Andrea - Having the opportunity to meet and network with many professionals in our field of study/interest, and connecting with other students and young professionals from around the world who may be going through similar experiences. Also, having access to the Journal of Dance Medicine & Science, as well as many other resources like the Educational Opportunities Document, forums and blog, social media, etc.

 

-What has been your favorite IADMS experience?

 

Siobhan - Getting the opportunity to do poster presentations at the Annual Meetings in Seattle (2013) and Pittsburgh (2015) and of course being part of the student committee – it’s been a great experience so far!

 

Andrea - Oh there are too many. I would say the 24th Annual Meeting in Basel, Switzerland because it was my first time traveling overseas, and I was less shy about approaching professionals and talking to them and asking questions.  But also, the 21st Annual Meeting in Washington, D.C. holds a special place in my heart because it was my first time attending, and I was the only student traveling with my professors.

 

-What would you say to a student thinking of joining IADMS?

 

Siobhan - It’s a brilliant opportunity to create a network of friends and connections who share your passion for dance science – it’s like a big family and it’s a wonderful thing to be a part of.

 

Andrea – Do it!! It is a great opportunity with amazing experiences!



If you are interested in the Student Committee and its initiatives, contact us at student@iadms.org.

 

Special thanks to the “5 Questions With...” sub-committee, Andrea Alvarez and Siobhan Mitchell.

Tags:  5 Questions With  dancers 

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Stretching: Some thoughts on current practice

Posted By Maggie Lorraine and Elsa Urmston on behalf of the IADMS Education Committee, Wednesday, February 10, 2016

Dancers are often passionate about developing their flexibility, reaching ever-greater ranges of motion (ROM), as choreographers require ever-more spectacular contortions of the body.  For example, it’s been observed that the height of the développé in Les Sylphides Nocturne section has increased from 60° to nearly 180°, and of course, different dance styles require different ROM at different joints; Spanish dancers need increased ROM in the shoulders compared to a non-dancing population whereas classical ballet dancers need extensive ROM in the hips.  We see a wide range of images and videos online nowadays which see young dancers especially, pushing their body into incredibly contorted positions, often compromising safety and alignment, and possibly leading to increased likelihood of injury as they pursue increased ROM.  It’s not as simple as pushing dancers into various positions, as it has been reported that up to 17 factors can affect flexibility, including age, body morphology, genetics, gender, bones, nerves, muscle, ligaments, and connective tissue, so it becomes vital as dance educators that we educate our dancers to look after their body, practise safe stretching activities and understand that achieving optimal flexibility is a complex process.


 

How does stretching work?

The physiology of stretching is complex, and in fact the causal links between stretching and increased flexibility are not wholly understood.  As a result, research on optimal stretching approaches changes often, and it’s because of this that it is so important for teachers, dancers and choreographers to revisit their knowledge of stretching for dancers, and update their practice regularly.  Having an understanding of the muscular-skeletal system and its interaction with the nervous system helps, as does knowing that the main physical structure whose length can be altered is the muscle fibre.  The resistance to lengthening that is offered by a muscle fibre is dependent upon its connective tissues; when the muscle elongates, the surrounding connective tissues become more taut.  And so trying to find the balance between flexibility, muscular release, alignment and strength is vital.  For more in-depth discussion of the physiology of stretching, look at Matt Wyon’s article for IADMS Bulletin for Dancers and Teachers here.

Every body is different

Every dancer’s body is different. Some dancers are inherently less flexible or mobile. Dancers with ‘tight’ bodies are built for stability and have dense connective tissues. Their muscles are less extensible. Conversely, some dancers are innately more flexible; however, the hypermobile physique has an increased risk of injury. These dancers tend to have a larger joint ROM, but are also more vulnerable to serious ligament sprains. It is important to avoid comparing the flexibility of one dancer with that of other dancers and therefore it is imperative to work on the individual needs of each dancer.

It is worth noting that:

o   some joints are not meant to be flexible.

o   bony structures can limit movement of a joint.

When working with younger dancers, there are added complications.  The skeletal growth spurt in adolescence often results in a loss of flexibility so that muscle tissues become shorter relative to bone length until muscle growth catches up to bone growth. Dance teachers need to recognize that young dancers will go through a phase of apparent loss of flexibility. During this time there is also an increased chance of injury to muscles.  It is so vital to work gently with the body at this time, not only to avoid injury but support the dancer’s psychological wellbeing – the apparent loss of control, strength and flexibility at this time can be debilitating.

Stretching tips

·         It is important to perform stretching after dancing or another activity when muscles and connective tissues are warm. Never stretch cold muscles.

·         Stretch muscles and their connective tissue (fascia) and not structures such as ligaments, tendons and joint capsules.

·         Holding a static stretch for 30 seconds is enough to maintain joint range of motion and current flexibility but if increasing flexibility is the goal, then deformation of the connective tissue is necessary to produce permanent muscle length change. This will require gradual increase of duration and frequency of stretch.

·         A dynamic stretch moves a muscle group fluidly through an entire range of motion and some studies suggest a dynamic stretch is just as effective, and sometimes better, especially before a workout.


·         Never ever stretch to pain.


·         Stretch in aligned positions.


·         It is important to balance a stretching program with strengthening exercises. The reason for this is that flexibility training on a regular basis causes connective tissues to stretch which in turn causes them to loosen and elongate. When the connective tissue of a muscle is weak, it is more likely to become damaged due to overstretching. Strengthening the muscles, which are bound by the connective tissue, can prevent the likelihood of such injury. In the words of Julie Alter, "strengthen what you stretch, and stretch after you strengthen!”

Matt Wyon again explains the various approaches to stretching that exist here, discussing the benefits of static stretching, PNF techniques and fast stretching amongst others, and when to best undertake these approaches for best results.  New research by Morrin and Redding also suggests that "...a cardiovascular warm-up, followed by 30 seconds static stretches, followed by 30 seconds dynamic stretches, provides the optimum performance of vertical jump, balance, and hamstring range of motion."  Their research was reviewed on the IADMS blog back in 2015, you can read it here.

 

Overflexibility

Images on the web of teachers pushing their students’ limbs into positions, contorting the angle of the pelvis for example, or crunching the vertebrae of the lower back are prevalent.  It’s vital to remember that it is possible for the muscles of a joint to become too flexible. As muscles become more flexible, less support is given to the joint by its surrounding muscles because those muscles become more lax. Excessive flexibility can be just as bad as not enough because both increase the risk of injury.

 

Once a muscle has reached its absolute maximum length, attempting to stretch the muscle further only serves to stretch the ligaments and put undue stress upon the tendons. Ligaments will tear when stretched to more than 6% of their normal length. Even when stretched ligaments and tendons do not tear, loose joints and/or a decrease in the joint's stability can occur and there is a greater potential for injury either in that specific joint, or indeed in other parts of the body. 

 

Yet our young dancers do aspire to achieve these positions – let’s work harder to educate them in the safe practice of stretching and balancing that with strength development.  IADMS have a wealth of resources to help teachers, dancers and parents to guide towards safer stretches, not only Matt Wyon’s paper that we have already referred to but the IADMS Resource paper on stretching also has some great guidance for safe practice.  Quin, Rafferty and Tomlinson’s excellent new book Safe Dance Practice has extensive references on the topic throughout, updating us with all recent research so we are as current in our practices as possible.


 

Further resources

 

Critchfield, B.  (2011). Stretching for Dancers Resource Paper.  Available here

 

Deighan M. Flexibility in dance. J Dance Med Sci. 2005;9(1):13-17.

 

Morrin N, Redding E. Acute effects of warm-up stretch protocols on balance, vertical jump height, and range of motion in dancers. J Dance Med Sci. 2013;17(1):34-40.

 

Quin, E., Rafferty, S. and Tomlinson, C.  Safe Dance Practice.  Champaign, IL: Human Kinetics, 2015.

 

Wyon, M. Stretching for Dance.  IADMS Bulletin for Dancers and Teachers.  2010;2(1):9-12.  Available here

 

Great little animation ‘Do you really need to stretch’ here too.

 

 

 

Maggie Lorraine is the Leading Teacher in Ballet at the Victorian College of the Arts Secondary School, Australia and is a member of the IADMS Education Committee.

 

Elsa Urmston is the DanceEast Centre for Advanced Training Manager in Ipswich, UK and is also a member of the IADMS Education Committee.

Tags:  dancers  stretching  teachers 

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Nurturing passion in dance

Posted By Imogen Aujla, PhD, on behalf of the IADMS Education Committee, Monday, December 21, 2015

Passion for dance is important: as teachers we want our students to be passionate, love what they do, and get involved at every opportunity. But is it really good for dancers to eat, sleep and breathe dance? What happens when passion turns into an obsession?


 

Research in mainstream psychology suggests that we are passionate about an activity when we love it, value it highly, and spend a lot of time on it. However, we can be more harmoniously or more obsessively passionate about an activity that we love. Harmonious passion (HP) means that we choose to engage in dance freely because we love it, but we don’t have any contingencies attached to it, and we can stop dancing at any time if we no longer enjoy it. Obsessive passion (OP) is a more rigid type of persistence, where dance takes up a large proportion of our identities and we find it difficult to stop. Often, people high in OP attach certain contingencies like self-esteem or social acceptance to the activity, so if they stop dancing they may feel that they have lost their identity and their sense of self-worth. Importantly, we have levels of both HP and OP about dance, but the two types of passion can have quite different outcomes. Research has shown that higher levels of HP result in greater enjoyment, satisfaction, well-being, and long-term involvement in dance. In contrast, higher levels of OP are associated with more negative feelings, anxiety, burnout and injury. So it’s easy to see which type of passion would be preferable among student dancers, but is there anything we can do as teachers to affect this? We may not be able to influence whether or not our students are passionate about dance in general, but we may be able to help prevent passion from becoming an obsession.

 

A growing body of research in dance and music suggests teachers can help to facilitate the development of HP by adopting autonomy-supportive behaviours. Autonomy essentially means that students feel they have a choice and a voice in class. You can help your students to feel more autonomous by giving them choices in class, such as the focus of an exercise, groups to work with, musical accompaniment or incorporating improvisation into technique exercises. You can also explain the rationale behind exercises. Helping students understand what an exercise is for or about will encourage them to set their own goals based on this insight which they can monitor and update. As a result, when students’ autonomy is supported, they are more likely to feel that they are engaging in dance for autonomous and harmonious reasons. On the other hand, very controlling behaviours from teachers may facilitate the development of OP by reducing students’ feelings of autonomy, choice and control. It’s also worth encouraging dancers who seem somewhat obsessive to pursue other interests and friendships outside of dance so that their identities are formed from many activities and relationships. Dance may be their favourite activity, but it isn’t the be-all and end-all!

 

Recommended reading

·         Aujla IJ, Nordin-Bates SM, Redding E. Multidisciplinary predictors of adherence to dance. J Sports Sci. 2015;33(15):1564-1573.

·         Mageau GA, Vallerand RJ, Charest J, Salvy SJ, Lacaille N, Bouffard, T, Koestne, R. On the development of harmonious and obsessive passion: the role of autonomy support, activity specialisation and identification with the activity. J Pers. 2009;77(3):601-646.

·         Padham M, Aujla IJ. The relationship between passion and the psychological well-being of professional dancers. J Dance Med Sci. 2014;18(1):37-44.

·         Rip B, Fortin S, Vallerand RJ. The relationship between passion and injury in dance students. J Dance Med Sci. 2006;10(1-2):14-20.

·         Vallerand RJ. On passion for life activities: The dualistic model of passion. Adv Exp Soc Psychol. 2010;42:97-193.

 

 

Dr Imogen Aujla completed her PhD at Trinity Laban Conservatoire of Music and Dance, and is now based at the University of Bedfordshire as Course Coordinator of the MSc Dance Science programme. 

Tags:  dancers  psychology  teachers 

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