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Not “IF” but “WHEN”: Rehearsing for medical emergencies in dance

Posted By Carina M. Nasrallah, MSAT, ATC, CISSN, Thursday, April 13, 2017

He was only 18 years old - healthy, strong and a beautiful performer. It was just a typical day of class and rehearsals. Everything seemed normal.  No one knew that he had a congenital heart condition that would cause his heart to stop unexpectedly in the middle of rehearsal.  He simply collapsed.

 

 

Catastrophic injuries and life-threatening medical emergencies are not common in the dance studio or theater.  Ankle sprains, bruised toenails and sore backs are more the “bread and butter” of dancers’ woes, and as a result it is easy to develop a false sense of security - the mentality that “it would never happen to us”.  But it is critical to remember that dancers are elite athletes and not immune to catastrophic injury.  Therefore, having a plan for handling emergency situations is not a recommendation - it is necessity.

 

What is an emergency action plan (EAP)?

An emergency action plan (EAP) is a written document that outlines how medical emergencies will be managed within a dance institution or performance venue.  The plan should be clear, comprehensive, and adaptable to a variety of scenarios.  Many facilities may already have a barebones EAP - a paragraph or two discussing what to do in the case of fire, flood, medical emergency, etc.  But a detailed and comprehensive EAP should read more like the choreography notes for a Balanchine ballet.  The reader should be able to visualize how the scene would unfold, which characters will emerge from the wings, the sequence of steps, and the location of props.

 

 

 

Who should be involved?

In the case of an emergency roles need to be delegated and the parties should know their responsibilities in advance. Instructors, staff, administrators, any on-site or off-site medical personnel (i.e. athletic trainers, physical therapists, attending physicians), and the local EMS team should be familiar with the venue-specific EAP.  The plan should answer the following: Who will call EMS? Perform the initial evaluation? Retrieve the emergency contact card? Fetch emergency equipment? Escort EMS into the facility? Keep in mind qualifications, location, and availability. When working with minors a staff member needs to be designated to accompany the child to the emergency department and/or make treatment decisions if a guardian is not present.  A list of key administrative and medical personnel along with contact information should be included in the EAP. Clear lines of communication should be established along with any special instructions (i.e. dialing “9” first from a landline, information to given to EMS, name/address of the receiving emergency facility, etc).

 

 

Plan, prepare, and plot it out

Often a qualified medical professional may not be available to perform the initial evaluation in a medical emergency.  Therefore the EAP should outline scenarios in which EMS needs to be activated and when it is unsafe to move an injured dancer depending on level of consciousness, type and location of injury, etc. A healthcare professional trained in emergency care services should assist with developing these guidelines using easily understood language and terminology.  Additionally all instructors and staff should be trained in automatic external defibrillation (AED) use, cardiopulmonary resuscitation (CPR), and first aid. Emergency contact cards for each dancer should always include a “consent to treat” signed by the dancer or parent/guardian (if a minor).

  

 

Locating and setting up emergency equipment can cost precious minutes in situations when seconds can mean the difference of life or death.  Automated external defibrillators are a life-saving investment that all companies and studios should consider making.  They can be easily mounted on a wall in a studio or carried on tour without even requiring a “per diem”! The EAP should include a detailed description of the location of automated external defibrillators (AEDs) and first aid kits. Someone not familiar with the facility’s layout should be able to locate any emergency equipment by following the EAP.  Similarly, the plan should establish an entry and route for emergency care personnel to approach the venue and access the injured person quickly. Floor plans or diagrams may be beneficial for clearly designating routes and locations of emergency equipment. These should be specific to each venue.

 

The performance should never be a rehearsal

As any dance patron knows, seeing a show that has never been rehearsed is not worth paying for.  Similarly, implementing the action plan in an emergency situation should never be the first time it is rehearsed.  This only invites disaster. An EAP should be reviewed and revised as needed at least once a year with staff, administrators, and medical personnel.  Practicing scenarios to drill the EAP is the best way to reinforce the action steps. Then when the unthinkable happens and the adrenaline kicks in chaos does not ensue. A well-designed and rehearsed EAP will reduce time-costly errors and ensures that communication and order are maintained in an emergency situation.  Being unprepared could cost everything.

 

So returning to the young dancer above - what was the end of his story?
That is for you to determine. What is your plan?

 

 

 

Additional Resources

1. Andersen J, Courson RW, Kleiner DM, McLoda TA. National Athletic Trainers' Association Position Statement: Emergency Planning in Athletics. J Athl Train. 2002 Mar;37(1):99-104. PubMed PMID: 12937447; PubMed Central PMCID: PMC164314.

 

2. Emergency action plan (template). National Institute for Occupational Safety & Health. October 2003.

 

3. Casa DJ, Guskiewicz KM, Anderson SA, Courson RW, Heck JF, Jimenez CC, McDermott BP,
Miller MG, Stearns RL, Swartz EE, Walsh KM. National Athletic Trainers' Association Position Statement:
Preventing Sudden Death in Sports.
 J Athl Train 2012Jan-Feb 47(1):96-118.

 

4. Gates R. Be Prepared for Disaster. Occupational Health & Safety. May 

Tags:  dancers  emergency  injury  teachers 

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Snapping Hip Syndrome

Posted By Janine Bryant on behalf of the IADMS Education Committee, Wednesday, October 5, 2016

Do your dancers ever say, ‘My hip snaps or pops when I do grand battement or developpe´ devant or a´ la seconde’?

 

The snap sometimes presents with pain but sometimes not, and happens either on the up phase or down phase of the movement. Dancers might also notice decreased range of motion through multiple planes of movement. .

Snapping or clicking hip is common in dancers and athletes who regularly move through range of motion extremes, experience some degree of tendinitis, and repeat abduction of the legs above waist level.  With proper diagnosis and care, the condition can be addressed in a timely way so that the dancer does not lose too much rehearsal and class time.

 

Usually painless and harmless, a snapping hip can happen as a result of a tendon or muscle passing over a bony structure. It can occur frequently in dancers in three ways:

 

·         Lateral Snapping Hip (Iliotibial band syndrome), which is more common, involves movement of the iliotibial (IT) band moving over the greater trochanter (large bony structure on the head of the thigh bone) and is also referred to as external snapping hip syndrome. A clue to diagnosis of this condition may be the inability to adduct past anatomic neutral, an anatomical position where the two bones that form a joint are parallel to one another, - with the bones parallel and joint space uniform, this creates ‘anatomical neutral’. A more likely indicator, however, is the location of the pain along with palpable tenderness.  Pain to the lateral (outside) side of the knee as well as pain at the lateral hip can occur simultaneously and could be symptomatic of lateral snapping hip. Initially, there may be a sensation of stinging or needle-like pricks that are often ignored. This can gradually progress to pain every time the heel strikes the ground and finally can become disabling with pain when walking or when climbing up or down steps. (1,2,3)

 

 

      

 

 

·         Anterior Snapping Hip presents as a kind of clicking or snapping, as the iliopsoas tendon passes over the iliopectineal eminence on the front of the pelvis or pelvic brim. This can be caused by inflammation of the bursa that lies between the front of the hip joint and the iliopsoas muscle. A cartilage tear or bits of broken cartilage or bone in the joint space can cause snapping, or a loose piece of cartilage can cause the hip to ‘lock up’. (2)

 

 

·         Intra-Articular Snapping Hip (intra-articular meaning inside the joint) results from capsular instability caused by muscular imbalance, skeletal inconsistencies, such as a leg length discrepancy or bony deformity, or previous injury to the hip joint or from a labral tear. Dancers with this condition may experience decreased range of motion in the hip and a painful click directly inside the joint caused by bony instability resulting from hip dysplasia or excessive congruency resulting from Femoral Acetabular Impingement (FAI). (2)

 

Treatment:   Dancers could benefit from physical therapy to strengthen the surrounding musculature, improve flexibility, restore function, and prevent re-injury.  Movement reeducation and progressive resistance training might also prove effective. (6) Dancers may need to temporarily reduce rehearsal/class regimen as part of recovery/management of the syndrome.

 

Please refer to the examples below.

 

 

 

 

Resources for further reading:

1.       Keene S, Coxa saltans: iliopsoas snapping and tendinitis. Hip Arthroscopy and Hip Joint Preservation Surgery.2014; 64(1):1-16.

 

2.       Lewis CL. Extra articular snapping hip: A literature review. Sports Health.2010; 2(3):186-90.

 

3.       Grumet RC, Frank R, Slabaugh M, Verkus W, Bush-Joseph C, Nho S. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010;2(3):191–196.

 

4.       Battaglia M, Guaraldi F, Monti C, Vanel D, Vaninni F. An unusual cause of external snapping hip. J Radiol Case Rep, 2011; 5(10)1–6.

 

5.       Reiman, M P, Thorborg K. Clinical examination and physical assessment of hip jointrelated pain in athletes. International J Sports Phys Ther.2014; 9(6): 737–755.

 

6.       Laible C, Swanson D, Garofolo G, Rose DJ. Iliopsoas syndrome in dancers. Ortho J Sports Med.2013; 1-3.

 

7.       Weber A E.The hyperflexible hip: Managing hip pain in the dancer and gymnast. Sports Health 2015:7(4); 346–358.

 

8.       Frank RM, Slaubaugh M, Grumet RC, Verkus W, Bush-Joseph C, Nho S. Posterior hip pain in an athletic population: Differential diagnosis and treatment options, Sports Health.2010; 2(3): 237–246.

 

9.       Lee S, Kim I, Lee SM, Lee J. “Ischiofemoral impingement syndrome.Ann Rehabil Med. 2013; 37(1): 143–146.

 

10.    Sobrino, F J, Crótida C,  Guillén P.Overuse injuries in professional ballet: Injury-based differences among ballet disciplines.Orthopaedic J Sports Med, 2015; 3(6).

 

11.    Smith PJ, Gerrie BJ, Varner KE, McCulloch PC, Linter DM, Harris JD. Incidence and prevalence of musculoskeletal injury in ballet: A systematic review.Orthop J Sports Medicine, 2015; 3(7).

 

12.    Domb BG, Shindle MK, McArthur B, Voos JE, Magennis EM, Kelly BT. Iliopsoas impingement: A newly identified cause of labral pathology in the hip. HSS J.2011; 7(2): 145–150.

 

13.    Pun  S, Kumar D, Lane NE. Femoroacetabular impingement,  Arthritis Rheumatol, 2015; 67(1): 17–27.

 

14.    Sajko S, Stuber K. Psoas major: A case report and review of its anatomy, biomechanics, and clinical implications. The J Canadian Chiro Assoc. 2009; 53(4): 311–318.

 

 

Janine Bryant, BFA, PhD (ABD) is Senior Lecturer at the School of Arts at The University of Wolverhampton in the UK.  She is also a Registered Safe in Dance International Certificate Provider and member of the IADMS Education Committee.

 

Tags:  dancers  hips  injury  pain  teachers 

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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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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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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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Injury Prevention Research: Investigating patellar tendon development in adolescent dancers

Posted By Aliza Rudavsky on behalf of the IADMS Education Committee, Thursday, July 30, 2015

Our final injury prevention installment comes from Aliza, reporting early findings of a piece of research which has investigated patellar tendon development amongst adolescent dancers. 

Jumper's knee is a condition where there is pain just below the knee cap associated with jumping.  The medical term for this condition is "patellar tendinopathy" and it is a fairly common condition in elite dancers, especially those who are strong jumpers and tend to jump a lot.  Jumper's knee is an overuse condition.  The main risk factor for developing symptoms is having pathology within the patellar tendon (pictured below).  It is not clearly understood when pathology can develop in the tendon or when the tendon matures.  

 

A group of researchers from Melbourne are investigating how this tendon changes during adolescence in young ballet students.  The goal of this study is to identify normal and abnormal tendon development.  In order to observe changes in the tendon, this study involves using a 3-D ultrasound device called a UTC (Ultrasound Tissue Characterization) to image the patellar tendons of young ballet students at the Australian Ballet School and the Victorian College of Arts Secondary School throughout puberty.   

This research group will be following the same cohort of students over a two year period to monitor subtle changes in their tendons as they grow and progress through skeletal maturity.  Dancing and other exercise volume is also being closely monitored as well as participation in classes and any injuries.  

The evidence so far has demonstrated that people with pathology in their tendons are at a much higher risk of developing jumper’s knee symptoms.  Researchers have discovered already that after approximately 17 years old, tendons are mature and do not generally turn over new tissue; therefore, if people have pathology within their tendons by this age, it will likely remain within their tendons for life.  This doesn’t mean they will definitely get jumper’s knee symptoms, however they are at a much higher risk than someone with completely healthy tendons.  In younger dancers and athletes (pre-pubertal), the incidence of pathology on their patellar tendons is much more rare and it is thought that perhaps during these pubertal years where adolescents are surpassing their peak height velocity (peak height growth spurt) pathology can develop.  Once we have a better understanding of how tendons mature normally during this time period, we may be able to gain some insight into abnormal tendon maturity.  Throughout this study and in future studies, we hope to gain further understanding of the impact of loading this tendon before it has fully developed and clarify how much jumping is ideal for optimal tendon formation in order to reduce jumper’s knee in dancers and other jumping athletes.  

 

Aliza Rudavsky

Doctorate of Physical Therapy

PhD Student, University of Copenhagen 

 

Tags:  dancers  injury  teachers  tendon 

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Dancing Longer: Safe and effective dance practice to optimize performance, and minimize injury risk

Posted By Edel Quin on behalf of the IADMS Education Committee, Monday, July 27, 2015

This is the third installment on the topic of dance injury on the IADMS blog. Elsa began by introducing us to injuries and injury management in dance, highlighting some great examples of specialized and tailored injury care for dancers in the UK (National Institute of Dance Medicine and Science) and the USA (Harkness Center for Dance Injury). This was followed up by Stephanie’s post on multi-disciplinary screening programmes as a means of highlighting “any concerns with regards to health, injury risk or mental and physical capabilities” and also the potential role of screening as an educational tool in contributing towards injury prevention. As the next contributor in this series, I focus on minimizing injury risk from the perspective of safe and effective dance principles as applied to dance teaching and dance making.


 

Photographer: Chris Nash, 2015.
Trinity Laban Conservatoire of Music and Dance
Dance Science Testing with Wayne McGregor | Random Dance
Dancer: Jessica Wright

Firstly, it is important to dispel the impression that safe dance practice is about ‘wrapping dancers in cotton wool’ to the point that there is no risk, no creativity, no progression. I do not dare to think what dance - a wonderful, expressive, art form - would become if this were the way we engaged with dance teaching and dance making! No – safe dance practice is the complete opposite, it is a means by which dance can continue to challenge physical (and mental) capabilities, through the application of knowledge and understanding of research-informed practice. It is often noted that choreographic practices of today are increasingly demanding of dancers physicality, and at times reach extremes of athleticism. This can be what makes dance exciting! But, how can we continue to push these artistic boundaries, without increasing an already high injury rate1… enter safe and effective practice.

The principles

Safe practice does not solely aim to reduce injury risk, optimizing dancer potential is just as, if not more, important! The combination of these two aims results in the ultimate intention of prolonging participation in dance through healthful practice. The principles are borne out of dance science research, and engage with key overlapping areas of physical, psychological and environmental knowledge (see figure 1 below). Once understood these principles can be applied and adapted to any dance style, any age group, and any dance setting. 


Ask yourself…

As dance leaders (i.e. teacher, choreographer, artistic director, etc.) some of the key safe practice questions we should ask ourselves are:

1. Do I understand and apply physiological principles of warming-up and cooling down to my dance classes/rehearsals? [look out for the upcoming IADMS Resource Paper on Warm-up and Cool-down!]

2. Am I aware of different ways to stretch and when is it best to the different types? [see here]   

3. Do I understand basic anatomical principles and have an awareness of the possible implications of any alignment variations, such as hypermobility or a forward pelvic tilt, within my dancers?  [check out ‘Teaching the Hypermobile Dancer’ by Moira McCormack or ‘Improving Pelvic Alignment’ by Jennifer Deckert]

4. Do I consider the physiological training needs of my dancers (not just the technical or artistic needs)? [see IADMS Resource Paper]  

5. Do I appropriately balance amounts of activity with rest within in dance class/rehearsal3?

6. Do I understand and encourage effective fuelling (nutrition and hydration) in my dancers? [see IADMS Education Committee Resource Paper]

7. Do I know how to manage an injury, if one occurs during my dance session, or how to engage an injured in the dance class? [check out First Aid for Dancers or Technique Class Participation Options for Injured Dancers]

8. Am I aware of how I could create a positive and healthful learning climate in the dance studio?  [check out ‘Standing on the Shoulders of a Young Giant How Dance Teachers Can Benefit From Learning About Positive Psychology’ by Sanna Nordin and Ashley McGill]

9. Do I know how to adapt my safe practice knowledge to my specific dancers and dance style? [see chapter 10 in Quin, Rafferty & Tomlinson (2015)]

If the answer to any of the above is ‘No’ or ‘I’m not sure’, then let today be the day that you take the first step to exploring that specific area of your practice a little more. Dance has evolved, our understanding of the dancing body and mind has evolved, our teaching practices should also continue to evolve.  Keeping up to date with the developments in dance medicine and science research are certainly integral to my own safe and effective dance practice, and that of the dancers that I teach.

While not every dancer or dance teacher has access to the wonderful work of organizations such as the Harkness Center for Dance Injuries in New York or the National Institute of Dance Medicine and Science in the UK, fortunately every dancer, dance teacher, dance leader has access to the growing number of widely available resources, a mere sample of which have been included in this post!  IADMS obviously provides a wide range of easy-to-read research-informed educational resources such as the Resource Papers, the Bulletin for Dancers and Teachers, as well as Posters to adorn dance studio walls. There is also an expanding number of dance-specific texts that are applying the research into practice. There is even an organization dedicated to supporting, developing, encouraging and endorsing safe and healthy dance practice world-wide; Safe in Dance International (SiDI), go here for more.

So, as we strive to advance our art form, let’s do so with the aim of minimizing injury risk, optimizing potential and prolonging participation, by educating ourselves on dance science informed principles. As dance medicine and science research continues to develop, so should our knowledge and application of safe and effective dance practice. Just imagine the possibilities….!

  

Photographer: Kyle Stevenson, 2010.
Trinity Laban Conservatoire of Music and Dance
MSc Dance Science Students Investigating the Dance-specific High Intensity Fitness Test
Dancers: Helen Reeve and Casey McEldowney


For further reading, have a look at these resources:

1. Shah, S., Weiss, D.S., & Burchette, R.J. (2012). Injuries in professional modern dancers: Incidence, risk factors, and management. Journal of Dance Medicine and Science, 16(1), 17-25.

2. Quin, E., Rafferty, S., & Tomlinson, C. (2015). Safe Dance Practice. An applied dance science perspective. Champaign, Ill, USA: Human Kinetics.

3. Batson, G,. & Schwartz, R.A. (2007). Revisiting the Value of Somatic Education in Dance Training Through an Inquiry into Practice Schedules. Journal of Dance Education. 7(2):47-56

 

 

Edel Quin MSc FHEA

Dance Educator and Researcher, Programme Leader MSc Dance Science at Trinity Laban Conservatoire of Music and Dance

Tags:  dancers  injury  teachers 

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Injury Prevention: Screening as a tool for education

Posted By Posted by Stephanie De’Ath on behalf of the IADMS Education Committee, Tuesday, July 7, 2015

What is screening?

Screening is often used for pre-entry to a school or company to highlight any concerns with regards to health, injury risk or mental and physical capabilities. Although research suggests that protocols should, where possible, be carried out by a physiotherapist or dance science professional there are some protocols that can be adopted by schools or companies with limited resources to at least complete some of the tests for educative purposes.  Although not widely used as an educative tool, screening provides a great opportunity for dancers to learn more about their bodies, optimise performance and identify injury risk1. By addressing the weaknesses or concerns which arise as a result of the screen, a programme of activity can be developed to compliment training and reduce the likelihood of injury. As a member of Trinity Laban's screening team for the past four years, in this post I will explore how screening can contribute to injury prevention from an educational perspective.

 

What is involved in screening?

As highlighted by Liederbach et al2, screening often involves collating information on many components including medical history, skeletal structure, alignment, range of motion, strength, cardio-respiratory response, motor skills, stability and mobility, self esteem, motivation and nutrition amongst others.  From personal experience, the benefits for using screening as an educative tool, rather than pre-entry or for research, is that the methods can be adaptive to reflect the student needs, the current staff's knowledge/experience and developments in research. This can however make it somewhat difficult to use the data for research, which is why changes in protocols should be considered carefully

 

In the UK National Institute of Dance Medicine and Science (NIDMS) screening program, we explore a number of different areas which include: health and injury history, current training exposure, anthropometrics, hypermobility/flexibility, strength, a functional musculoskeletal screen and an aerobic fitness test. Once the assessments have been completed, individuals are invited for feedback to go through each test result: looking at comparable means and discussing how their results can impact their training.

 

How can screening contribute to injury reduction?

There are many benefits and outcomes of screening, however the following are the five testing protocols that I typically find to be most helpful in educating dancers on injury reduction. These protocols can easily be adopted by individuals, especially those with limited resources.

 

1.  Health and injury history

As we already know, results from injury history, menstrual status and nutritional status can be combined to “red flag” symptoms of Female Athlete Triad3. A red flag for each area would be:

- Frequent bone related injuries (more than 2) in the last 12 months e.g. Fractures, bone bruising, etc and/or already diagnosed osteoporosis and/or a known low bone mineral density.

              - Amenorrhea, or no menstrual cycle, for more than three months.

              - And disclosure of, or indicators of, an eating disorder or disordered eating.

There are of course many other areas which may arise as a concern from completing the health and injury questionnaire. For example a low BMI or sleep disturbances, however what is important in this instance is that any red flags for Female Athlete Triad or any other issues are dealt with appropriately. Therefore, if you do not have the provision in your school/ company to provide nutritional advice, have a reliable contact who you can refer your dancers to.

2.  Single jump height

Single jump height measures how high an individual can jump. This result is important information for dancers, however what I find more interesting as an observer of the test is the biomechanics of an individual's jump technique. By looking out for the following we can use the screen itself to optimise the performance of the jump and reduce injury:

             - Are they rolling in or out of the ankles during take-off/landing?

             - Turning in/out of the feet, looking to see if one is more turned out than the other.

             - Are they able to maintain the 90 degree angle at the knees during take-off and
             landing, as specified in the test protocol.

             - If/when fatigued, are they able to maintain technique e.g. feet pointed during
             jump, land in parallel, maintain height, maintain speed, etc

By breaking the jump down and giving this feedback to the dancers I find this to be more helpful than informing them how high/powerful their jump is (of course they will still be interested in this!) as you may point something out to them that hasn’t been identified before.


3. Turnout/turn in

There are a number of different ways to test turnout/ turn in, however I find active standing turnout to be one of the most useful for educative screening, as it is most representational of the dancer in the studio. The dancer will stand on two rotational discs (therefore removing the friction from the floor) and starting in parallel they will turnout or in. The distance of each measurement will be recorded in degrees and repeated three times for accuracy, as they can be rather wobbly if you haven't used them before! In literature it is suggested that dancers should be achieving 70 degrees of turnout4, which may be true for ballet dancers, however for other dance genres this requirement may not be as necessary. What I find that we are actually looking for here is bilateral balance between the right and left side, with no more than 10 degrees difference between the right and left score. An inability to achieve bilateral balance may be an indicator of muscle weakness or tightness in the internal or external rotators or simply a lack of proprioception. I particularly like this test because the dancers are unable to "cheat" due to there being no resistance from the floor - but make sure their knees stay over the toes to ensure no cheating!

                      USEFUL VIDEO HERE.

4. Plank

Like all of the other tests, the plank is more than just achieving a number, it can be indicative of a number of different physical aspects. However from past experiences we usually see dancers achieving roughly around the 2-3min mark.

Whilst the dancer is completing the plank (feet hip width apart and resting on forearm) you can also look out for the following:

              - Feet: are they rolling in/ out or can they maintain a true parallel?

              - Hips: are they even? Or does one side dip more than the other?

              - Alignment: can they ensure that the head, hips and feet sit in one straight line.

              - Shoulder blades: do they "wing" off the back?

5. Dance Aerobic Fitness Test (DAFT)

Over the past 10 years schools and companies have been able to use Dance Specific Fitness Tests (DSFT)5,6,7. One of the most frequently used DSFT by schools and companies is the contemporary Dance Aerobic Fitness Test (DAFT). This fitness test has a number of advantages beyond the data produced i.e. heart rate and rate of perceived exertion (RPE). Observers can also make notes on the individual’s technique over the five stages, each of which is four minutes and progressively increases in intensity. An observer might look out for: arm placement, landing from the jumps, extension of movements, focus, musicality, coordination, etc. The DAFT stage three is representative of the effort levels required for a technique class and stage five is representative of performance intensity. Therefore, the individual can track the changes in their heart rate and RPE over a time period, to see if their training is providing any positive adaptation in their aerobic fitness levels and resistance to fatigue, which allow them to perform set movement at a lower relative intensity. There is currently no published data available on the norms or averages for each stage of the DAFT, however Redding et al will be presenting this information for the first time at the 25th Annual meeting in Pittsburgh…so watch this space!

 

So…what do we do with all this information?

Well, as you can see from the above information, the outcomes are primarily indicators of an area of weakness. To allow this information to contribute to injury reduction we need to ensure that we apply these findings back into training. Therefore, I would recommend that your feedback time is highlighted as one of the most important features of your educative screening session. These indicators cannot be actioned if dancers do not understand the importance and relevance of the results, and furthermore, how to implement this into their training. Ensure you are confident with the official protocols for each test and most importantly, develop a network of dance specialist professionals who you trust for onward referral.

 

References/ recommended resources

1.       Wilson, M., & Deckert, J. L. (2009). A screening program for dancers administered by dancers. Journal of Dance Medicine & Science, 13(3), 67-72.

2.       Liederbach, M., Hagins, M., Gamboa, J. M., & Welsh, T. M. (2012). Assessing and reporting dancer capacities, risk factors, and injuries: recommendations from the IADMS standard measures consensus initiative. Journal of Dance Medicine & Science, 16(4).

3.       Torstveit, M. K., & Sundgot-Borgen, J. (2005). The female athlete triad: are elite athletes at increased risk?. Medicine & Science in Sports & Exercise, 37(2), 184-193.

4.       Howse, J., & McCormack, M. (2009). Anatomy, Dance Technique and Injury Prevention. A&C Black.

5.       Wyon, M., Redding, E., Abt, G., Head, A., & Sharp, N. C. C. (2003). Development, reliability, and validity of a multistage dance specific aerobic fitness test (DAFT). Journal of Dance Medicine & Science, 7(3), 80-84.

6.       Redding, E., Weller, P., Ehrenberg, S., Irvine, S., Quin, E., Rafferty, S., Wyon, M. & Cox, C. (2009). The development of a high intensity dance performance fitness test. Journal of Dance Medicine & Science, 13(1), 3-9.

7.       Twitchett, E., Nevill, A., Angioi, M., Koutedakis, Y., & Wyon, M. (2011). Development, validity, and reliability of a ballet-specific aerobic fitness test. Journal of Dance Medicine & Science, 15(3), 123-127.

 

Stephanie De’Ath, MSc, SRMT, is a Lecturer in Dance Science at UK Higher Education Institutions and is a Sports and Remedial Massage Therapist at London Contemporary Dance School and Central School of Ballet.

Email: stephaniedeath1@gmail.com

 

Tags:  dancers  injury  screening  teachers 

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An Introduction to Dance Injury

Posted By Elsa Urmston on behalf of the IADMS Education Committee, Thursday, June 4, 2015

 

Well, it’s the moment that all dancers and their teachers dread.  Sustaining an injury in dance can be at best, a ‘momentary’ interruption to dance training and performance, at worst a career-ending catastrophe.  Thankfully, dance medicine and science colleagues have produced a vast range of conditioning and injury prevention strategies to enable dancers to be stronger and ever more versatile, as well as take ownership over injury if, as and when it might occur.  Yet of course, by just looking at the repertoire of our modern dance and ballet companies, we can see that choreographers and audiences have increased their expectations of what the human body can achieve.  Injury remains a very real possibility. 

Improving awareness of dance injury, in terms of how and when it might occur, and ensuring dancers know about injury care, can play a large part in the successful rehabilitation and timely return to dancing.  This blog post is one in a series which introduces dance injury.  Subsequent posts will focus on how we might be able to prevent dance injury in the first place, through screening for dancer health and wellness, and by ensuring dance educators’ practice is safe and effective for all involved.

Research suggests that the most commonly perceived causes of injury were cited as ‘fatigue’ and ‘overwork’, along with repetitive movements amongst dancers and managers alike.  Organisations such as IADMS, Dance UK and Harkness Center for Dance Injury amongst many other dancer wellness initiatives, all advocate for optimising dancers’ training and performance through supporting dancer fitness and conditioning, ensuring sound biomechanical function in dancing and promoting an autonomy supportive environment for dancers to flourish.  New research from ArtEZ Institute for the Arts in Arnhem, Holland has sought to reconceptualise how the undergraduate dance curriculum is shaped to maximise performance through the principles of periodisation.  The programme year is designed as a series of macro- and micro-cycles in which the training intensity alternately increases and decreases, ensuring that the dancer develops and recovers without causing staleness or overtraining.  The approach has seen a significant reduction in injuries and less course dropout since the instigation of this system.  Take a look at this easy-read overview of the project at ArtEZ here.

 

So what actually happens when I sprain my ankle or strain a muscle?   

Essentially, if cells become damaged, the body releases a number of chemicals that create an inflammatory response, usually resulting in swelling, redness, heat, pain and loss of function.  Inflammation is the body’s natural response in promoting new cell growth, and is a necessary stage of the healing process.  The injury process can be conceptualised like this:


How can we help our dancers manage injury in the short-term?

Try and help your dancers remember the acronym PRICED – it’s an invaluable first aid guide to immediate treatment which can be self-administered, and when used in the first minutes and hours after injury can help in controlling pain and inflammation and assist in the safe return to dancing.

  • PROTECTION: Remove additional danger or risk from injured area.
  • REST: Stop dancing and stop moving the injured area.
  • ICE: Apply ice to the injured area for 20 minutes every two hours.
  • COMPRESSION: Apply an elastic compression bandage to the injured area.
  • ELEVATION: Raise the injured area above the heart.
  • DIAGNOSIS: Acute injuries should be evaluated by a health-care professional.

And in the first few days after injury, help them to avoid HARM too.

 

  • HEAT: Any kind of heat will speed up the circulation, resulting in more swelling and a longer recovery.
  • ALCOHOL: Alcohol can increase swelling, causing a longer recovery.
  • RUNNING OR OTHER EXCESSIVE EXERCISE: Exercising too early can cause further damage to the injured part. Exercise also increases the blood-flow, resulting in more swelling.
  • MASSAGE: Massage increases swelling and bleeding into the tissue, prolonging recovery time.

 

And what about managing injury more long-term?

Drawing on some of the most recent research findings about injury, such as the periodisation work at ArtEZ, the growing body of research-informed practice around screening dancers and the importance of safe dance practice, we should be seeking ways to embed these examples of best practice in our work to minimise the likelihood of injury first and foremost.  But in managing injury more long-term, we should aim to reduce swelling, restore proprioception (awareness of where the body is in space without relying on the visual system), maintain cardiovascular health and ensure a healthy, balanced and varied diet to facilitate healing.  IADMS have a very accessible resource paper full of practical ideas about First Aid for Dancers here.

 

Local provision

In the UK the establishment of the National Institute of Dance Medicine and Science means that through shared expertise and a network of multidisciplinary partners, better and more affordable, high quality, evidence-based, dance specific health care and dance science support services are being offered to dancers across the sector.  Please check out their website.

In the USA the Harkness Center for Dance Injury is dedicated to providing the dance community with the highest quality injury care and preventative resources. Harkness offers many subsidized and free services including orthopaedic and sports medicine clinics, physical therapy and athletic training services, and injury prevention lectures and workshops.  Please check out their website.

If there are other support services in your locality not listed here, please do add them in the comments box below.

 

For information about dance injury and treatment have a look at the following recommendations:

Laws, Helen. Fit to Dance 2-Report of the second national inquiry into dancers’ health and injury in the UK, 2005.

Solomon, Ruth L., John Solomon, and Sandra Cerny Minton, eds. Preventing dance injuries. Elsevier, 2005.

 

For more information about optimising dancers’ fitness have a look at these texts too:

Welsh, Tom. Conditioning for dancers. University Press of Florida, 2009.

Krasnow, Donna and Jordana Deveau.  Conditioning with imagery for dancers.  Thompson Educational Publishing, 2010.  Additionally there are some useful introductory videos on Krasnow and Deveau’s approach here.

 

Don’t forget to watch out for our forthcoming posts continuing this series about preventing dance injury.

 

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

Email: elsa.urmston@danceeast.co.uk

Tags:  dancers  injury 

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