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The Importance of Vitamin D for Dancers

Posted By Derrick D. Brown on behalf of the IADMS Dance Educators’ Committee, Wednesday, April 26, 2017

Vitamin D has received a great deal of attention in the last 5 years both in popular media and in dance medicine and science research, and with good reason. While much emphasis is placed on its role in bone health, a key question revealed from the research is whether it also can provide other benefits for pre- and professional dancers.  The purpose of the post is to highlight some of the research done on dancers and discuss why it might be important to keep an eye on your Vitamin D levels.

 

 We could say, that ‘if vitamins had a prima ballerina assoluta , Vitamin D (Vit-D) would almost certainly receive that rare and prestigious honour. Such a unique status usually reveals a high level of complexity, which fully describes this vitamin, as D appears to be one of the few organic substances that the human body processes both via our food and from the sun. Two major forms you might have heard of, are vitamin D2 and vitamin D3.  Both D2 and D3 are found in dietary supplements and fortified foods. While there are differences, they do not greatly influence metabolism or activation in the body. You might have seen many confusing letters/ numbers combinations that describe Vit-D. The table below offers an overview of the many ways in which Vit-D is characterized in popular and health-based media.

 


 

Vit-D exerts considerable influence on the metabolism of micronutrients calcium and phosphorus, as well as key bodily organs: intestine, bone, and kidney.  The image below provides a schematic of Vit-D metabolism as it occurs naturally due to sun exposure. Oral forms of  Vit-D follow similar metabolic pathways through organs.

 


Fig.1 Metabolism processes of Vitamin D

© Designua | Dreamstime.com

 

 As mentioned above, thanks to the photochemical processes from ultraviolet B (UVB) light, our bodies can produce significant levels of Vit-D from the sun. As with most rules there is an exception. The amount of D3 that your body can convert from UVB depends on your skin pigment. So naturally dark-skinned individuals may block UV light and prevent D3 synthesis. Geography also plays a role; more Northern countries, including, Scandinavia, the Netherlands, the UK and Germany, receive less sunlight than, say, Mexico. Sunscreen, once considered a ‘must’ is now cautioned for some; and should be used after sufficient time in the sun to allow for Vit-D synthesis, but not at the risk of sunburn (see practical recommendations below).

 


© Hanna Monika Cybulko, Dreamstime.com

 

 Vitamin D and Dancing

Wolman et al (2013) studied a group of 19 UK based elite classical ballet dancers over a six month period for vitamin D levels.  During the winter, all 19 dancers were either insufficient or deficient, and even in the summer months only three dancers had normal levels of the vitamin.  Similarly, Dulcher and colleagues (2011) found similar results and whilst such small cohorts are not generalisable, they do provide a glimpse of the challenges that young dancers may face. Notable in both studies are the similar findings made across genders and, importantly, in different geographic locations. A possible reason for Vitamin D deficiency in young dancers, is that while studying at pre-professional academies most dancers spend considerable time in the dance studio, upwards of 5-6 hours a day, and so receive little exposure to sunlight, particularly in the northern latitudes during winter months.

 

 Vitamin D and diet.

Even with the complexity of skin type, geography and adequate healthy exposure to the sun (see practical recommendations below), we can also receive some of our D from the diet. Those who opt for an omnivore diet that is well balanced should have no trouble with additional Vitamin D sources from some dairy products, fatty fish and egg yolks, as well as fortified foods. However, vegans and vegetarians might need to work a bit harder to find significant dietary Vit-D. Larsson and Johansson, (2002) in a comparative study which assessed the dietary intake and nutritional status of young Swedish vegans and omnivores. All youths had dietary intakes lower than average of Vit-D with female vegans particular low even with Vit-D production via skin exposed to ultraviolet B (UVB) light. Similar results have been seen in Danish (Kristensen, 2015) and Finnish vegans. Together with the aforementioned studies on vegetarians and vegans from Nordic countries, it is reasonable to presume that some vegan dancers may also have low levels of this nutrient.  Vegetarians and vegans can find many products fortified with Vit-D. Many alternatives to milk (oat, almond, rice) are now fortified with Vit-D.  Even certain mushrooms (Portabella and Cremini) are exposed to large doses of UVB during growth increasing Vit-D levels dramatically, although due to the complex process mentioned above don’t expect to receive adequate amounts of usable (bioavailable) D by eating multiple servings of mushroom ragout!

 

 Supplementing Vitamin D

Given much that was mentioned, one might conclude that the easy route would simply be to take a supplement. But before you run out, buy up and start popping Vit-D, it is important to caution that for athletes (dancers being a type of athlete) there may be complications. Multiple studies suggest that taking more than 5,000 IU (125mcg)/day could actually negatively impact your performance. And then quality of supplements is equally important so that no undue toxins from inferior supplements are ingested. If extremely low levels are suspected, seek the advice of a suitable medical professional/ clinical dietician who can assess serum (blood) Vitamin D levels and discuss if supplementation is right for your individual needs. A more comprehensive overview of the process and interactions can be found in the newly published book Dancer Wellness or via the nutrition resource paper, both under the auspices of IADMS.

 


 

Further Resources

 

 Brown DD, Challis J.  Optimal  Nutrition for Dancers. In: Wilmerding V, Krasnow D, eds. Dancer Wellness. 1st ed.; 2017:163-191.

 

 Challis J, Stevens A, Wilson MA. IADMS Nutrition Resource Paper 2016. 2016:1-36.

 

 Ducher G, Kukuljan S, Hill B, et al. Vitamin D status and musculoskeletal health in adolescent male ballet dancers a pilot study. J Dance Med Sci. 2011;15(3):99-107.

 

 Kristensen NB, Madsen ML, Hansen TH, et al. Intake of macro- and micronutrients in Danish vegans. Nutrition Journal. 2015;14(1):1-10.

 

 Larsson CL, Johansson GK. Dietary intake and nutritional status of young vegans and omnivores in Sweden. Am J Clin Nutr. 2002;76(1):100-106.

 

 Wolman R, Wyon MA, Koutedakis Y, Nevill AM, Eastell R, Allen N. Vitamin D status in professional ballet dancers: winter vs. summer. J Sci Med Sport. 2013;16(5):388-391.         

 

 

 Derrick D. Brown is Programme Manager and Lecturer at Bern University Masters of Advance Studies in Dance Science, Bern Switzerland. Associate researcher/ lecturer at the ArtEZ Institute of the Arts , Arnhem, The Netherlands. He is also a Doctoral candidate in neurocognition and motor control at Donders Institute for Brain Cognition and Behaviour; Radboud University, Nijmegen, the Netherlands. 

 

 

 

Tags:  dancers  health  nutrition  sun  teachers 

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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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Are You Warm Enough to Start Dancing?

Posted By Brenton Surgenor and Andrea Kozai on behalf of the IADMS Dance Educators’ Committee, Monday, April 3, 2017

 

Warming up is essential before taking part in any type of dance activity, but it’s not always clear how to warm up effectively.  This blog post sets out the what, why and some of the how-to’s of an effective dance-specific warm-up.  This prefaces our new, upcoming Resource Paper on effective warm-up for dancers, which has much more information and advice on how to prepare the body for dancing.

 

Firstly, an effective warm-up will prepare you (or your dancers) mentally and physically to meet the challenges and physical requirements of a class, rehearsal, or performance.  As the name suggests, a warm-up should increase your core body temperature, which prepares your muscles and joints to function effectively during dancing as well as reduces injury risk.

 

During the warm-up there is an increase in the amount of energy required by your working muscles.  This means your body needs to consume more oxygen and fuel (glucose) to generate energy to power your muscles.  A byproduct of all this extra energy production is the increase in body temperature that gives the warm-up its name, so the cardiovascular section of a warm up is vital in ensuring your body is ready to go.  Therefore, sitting in the sun enjoying a hot coffee will not have the same benefits as a physical warm-up, as a warm-up ensures that your cardiovascular system, breathing rate, and energy-producing systems gradually increase to meet the higher demand for energy when you begin dancing.

 

A warm-up will have a number of other beneficial effects. These include: increasing the flow of synovial fluid (the lubricant in the joints), which allow your bones to slide more freely; improving the elasticity of your muscles, joints and ligaments for increased range of movement; and increasing the speed that signals travel through your nerves, which improves your overall balance, coordination and proprioception (your body’s ability to understand its orientation). For more information about proprioception see IADMS Resource Paper “Proprioception”. 

 

 

Whilst it’s good to include some stretching as part of your warm-up, not all types of stretching are beneficial before dancing.  The role of stretching during a warm-up is to mobilize muscles and prepare them safely to carry out the range of motion required of dance activities, not to increase flexibility. Stretching should happen after the activation of the cardiovascular system and when core body temperature is raised.  Dynamic stretching (taking the joint through a full range of motion in a slow and controlled way) is the best form of stretching in a warm-up.  This is because research suggests static stretching (stretches held in one position for longer than 15 seconds) can have a negative effect on balance, proprioception (knowing where your body is in space) and the muscles’ ability to produce powerful quick movements like jumps (Morrin and Redding, 2013). While static stretching can be an important part of flexibility training it is not an appropriate method of warming up; on the contrary, the purpose of dynamic stretching is to ready the body for full range, dynamic motion (Quin, Rafferty and Tomlinson, 2015).  For more about stretching, see IADMS Resource Paper “Stretching for Dancers”.

 

 

Warming up your mind is just as important as warming up your body.  A good warm-up will give you an opportunity to check how you are feeling, to notice your posture and any unnecessary physical tension or pain.  It can also help you concentrate and focus, which should contribute to technically better dancing and reduced risk of injury (Laws, 2005; Malliou et al., 2007).

 

Although a thorough and effective warm-up should take about 20 minutes, the time required is dependent on a number of factors including, but not limited to: whether the dancer has participated in any physical activity that day (is it the first class of the day or has the dancer recently completed another class); how warm or cold the environment is; and how much space and time is available for the warm-up. This should include a general physiological warm-up that prepares the core body temperature for physical activity.  Importantly too, the warm-up should include specific activities that relate to the style of the dance to follow (Quin, Rafferty and Tomlinson, 2015).

 

A warm-up generally consists of three or four sections: a gentle pulse-raising section, a joint mobilizing section, a muscle lengthening section, and sometimes a second pulse-raising section (Quin, Rafferty and Tomlinson, 2015). The pulse-raising sections aim to increase cardiorespiratory and metabolic rates; these are the prerequisite to all further activity. The joint mobilizing section consists of gently moving the various joints through their ranges of motion, and the purpose of the muscle lengthening section is to prepare the muscles for the demands to come through the use of dynamic stretching (Wilmerding and Krasnow, 2017). It is also appropriate to include remedial exercises for injury prevention purposes at the end of the warm-up (Volianitis et al, 2001), and mental skills and preparation can be included at any stage.

 

Remember the benefits of a warm-up will be reduced or even lost once the body returns to its resting states of heart rate, respiration, and body temperature, so try to keep the time between the end of the warm-up and the dancing a minimum. Warm clothing and continued movement (but not static stretching) will help keep the body’s core temperature elevated. However, this is dependent on what happens after the warm-up (does the dancer keep moving or do they sit down and rest) and environmental elements such the ambient temperature. Cooler temperatures and the lack of movement may cause the effects of the warm-up to dissipate more rapidly.

 

Unfortunately, there is no magic recipe for warming up and the most important thing to remember is that the warm-up should be specific to the type of dance activity to follow (in other words a ballet warm-up will be different from a jazz warm-up). However, with an understanding of a few basic principles, it should be safe and easy for you to design a warm-up that works for you. 

 

 

Here are some suggestions to help you design your perfect dance warm-up.

1.      Involve your mind and take a moment to center yourself.  Check in with how you are feeling; notice any areas where you need to give special attention. 

2.      Make your warm-up dance (and type of dance) specific.

3.      Introduce an activity to gradually increase your heart rate.

4.      Keep the movement simple to begin then progress to more complex and challenging movement patterns.

5.      Mobilize all the joints in your body and don’t forget about your spine and upper body, especially if your dance style includes upper-body weight bearing or/and partnering work.

6.      Give yourself a goal or try some positive self-talk.

7.      Use dynamic stretching and take your body carefully through full ranges of motion saving the static stretching for the cool-down or the end of the day.

8.      Wake up your nervous system by incorporating quick changes in direction and stopping to balance on one leg – this will engage your proprioceptors. 

9.      Once you are feeling warm and just a little bit sweaty, introduce some power movements like small jumps followed by some bigger ones.

10.  Towards the end of the warm-up, pick the pace and progress your movement to speeds nearer the pace of the following dance activity.

 

Whatever you choose to include, by the end of the warm-up you should feel ready to meet the mental and physical challenges of dancing. For more detailed information, check out the new IADMS resource paper on warming up for dancers.

 

 

For more information about warming up see the following resources.

1.      Harris J, Elbourn J. Warming up and cooling down. Champaign, IL: Human Kinetics, 2002.

2.      Laws, H., & Apps, J. (2005). Fit to Dance 2: Report of the second national Inquiry into dancers' health and injury in the UK. Dance UK.

3.      Malliou, P., Rokka, S., Beneka, A., Mavridis, G., & Godolias, G. (2007). Reducing risk of injury due to warm up and cool down in dance aerobic instructors. Journal of Back and Musculoskeletal Rehabilitation, 20(1), 29-35.

4.      Morrin, N., & Redding, E. (2013). Acute effects of warm-up stretch protocols on balance, vertical jump height, and range of motion in dancers. Journal of Dance Medicine & Science, 17(1), 34-40.

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

6.      Volianitis S, Koutedakis Y, Carson R. Warm Up: A Brief Review. Journal of Dance Medicine and Science 2001; 5(3): 75-79.

7.      Wilmerding MV, Krasnow DH (eds). Dancer Wellness. Champaign, IL: Human Kinetics, 2017.

 

 

Written by Brenton Surgenor (BPhEd, MA, MSc), Hong Kong Academy for Performing Arts and Andrea Kozai (MSc, CSCS), Virtuoso Fitness

Tags:  dancers  teachers  warmup  warm-up  wellness 

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Developing a Personal Dancer Wellness Plan

Posted By Donna Krasnow and Ginny Wilmerding on behalf of the IADMS Education Committee, Monday, January 30, 2017

Our focus for this blog post is on a new IADMS and Human Kinetics publication, edited by renowned dance educators and IADMS members, Ginny Wilmerding and Donna Krasnow.  Dancer Wellness is a useful, one-stop resource for all dance teachers interested in embedding dance medicine and science principles into their practice and ensuring the long-term health and wellbeing of the dancers with whom they work.  Here, Ginny and Donna give us a taste of how to design a personal dancer wellness plan as a foundation for long and effective dance practice.

 

Photo by Jake Pett, image reproduced with permission by Human Kinetics:
http://www.humankinetics.com/products/all-products/Dancer-Wellness-With-Web-Resource

 

As a dancer, you will face many challenges to your health and wellness. Every aspect of your training, from the environment and what you eat to your technical work and possible injuries affect your health. You can design your own personal dancer wellness plan and continue to develop it for many years. You can seek the assistance of teachers, health care professionals, and others in your support network to help you create your personalized plan.

 

Let’s start with the basic foundations of the dancer’s life. You can learn about your dance studio floors and other environmental aspects such as temperature, ventilation, lighting and sound, and make sure that you are working in a studio that meets certain requirements. You can speak to the school director and your teachers if you find problems in these areas. You may feel more confident if you have others such as parents or other dancers join you in these discussions. Next, you can study anatomy and physics. You can make sure that you are dancing in the best possible alignment, and that you understand scientific principles of movement. You can pair up with a friend from class and do partner assessments. You can also examine your learning strategies so that you have multiple ways to learn new technical skills in class. Finally, think about ways to supplement your class work with outside conditioning, and consider what areas of conditioning need the most focus, whether that is muscular strength, flexibility, or cardio-respiratory endurance. Conditioning can decrease fatigue and improve your confidence.

 

Next, let’s look at the mental components of dancer wellness. In terms of your mental training, you can consider how reliant you are on the mirror, and shift your emphasis to physical sensation and developing your kinesthetic sense of movement. You can use your teachers’ images and create your own images to enhance your dancing, especially in areas where you need improvement. Dance psychology can provide important tools for motivation, and help you deal with a wide range of views about yourself, including self-concept, self-awareness, self-esteem, self-confidence, and self-compassion. Rest and recovery are crucial for your health, and may be the most overlooked aspects of wellness. Consider your sleep habits, and also look at ways to cope with stress and anxiety, especially near performances. Finally, you can find alternate ways to rest, such as mentally practicing choreography.

 

Last, let’s consider the physical components of the dancer’s health. Make sure you are getting all the nutrients you need, such as carbohydrates, protein, fats, vitamins and minerals, and water. See if there are ways to eat fewer foods that have little nutrition, and add foods such as fruits and vegetables. If you smoke, design a plan to stop, and make sure you are physically active during periods of time that you are not dancing. For bone health, it is important to include weight-bearing exercise in your activities. Through your conditioning work, make sure you understand how methods of gaining strength, flexibility, and core support can give you knowledge you need to prevent injuries and sustain long hours of dancing and rehearsing. If you add a new technique to your training, you may need to add different conditioning exercises that prepare for those demands.

 

By developing your personal dancer wellness plan, you can improve your health and have many years of rewarding dancing. Good health contributes to dance injury prevention, less fatigue, better nutrition to fuel your energy needs, and enhanced self-esteem. You can find out much more about the principles discussed here in the new Dancer Wellness book.  You can purchase a copy with accompanying e-resources here. Happy reading!

Tags:  Dancer Wellness  dancers  teachers  wellness 

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Book Review: Dancer Wellness Textbook

Posted By K. Michael Rowley on behalf of IADMS Promotion Committee, Wednesday, January 11, 2017

This phenomenal Dancer Wellness textbook is like a who’s who of the dance medicine and science world. A quick scan of the Table of Contents will toss up well-known names in the community like Luke Hopper of Australia, Emma Redding of the UK, Derrick Brown of the Netherlands, and Margaret Wilson of the US among many many more. This textbook embodies what I personally have wanted from IADMS for the entire time I’ve been aware of the organization – a reference textbook combining the best of the best in contributors, scientifically and clinically rigorous information, and accessibility to multiple audiences.

 

 

Editors M. Virginia Wilmerding and Donna H. Krasnow have done a superb job compiling everything a dancer, dance teacher, or dance practitioner needs to know about dancer health and wellness. These two have even included chapters on Psychological Wellness (authored by Lynda Mainwaring of Toronto, Canada, and Imogen Aujla of the UK) and Optimal Nutrition for Dancers (authored by Derrick Brown of the Netherlands and Jasmine Challis of the UK). These two topics are frequently cited as overlooked or under-acknowledged. Well, not for these two star editors who clearly made every effort to give readers this important information.

 

A highlight of the textbook design is the Application Activity found at the end of each chapter. This takes information from the chapter and helps readers incorporate the main points into their practice or their wellness plan. In addition, the supplemental resources found on Human Kinetics webpage would be quite useful for students and teachers. Here, readers can find sample syllabi, slides, tests and quizzes, as well as learning activities for inside and outside the classroom.

 

I’ll end this short review by highly recommending this textbook. Whether you’re already plugged in to IADMS and the dance medicine and science community or not, this textbook is a great up-to-date summary of where the field stands. It delivers only the best to students, teachers, and practitioners who take advantage of it. You can order the textbook at Human Kinetics, here.

 

Editors M. Virginia Wilmerding (left) and Donna H. Krasnow (right)

Tags:  dancers  review  teachers  wellness 

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Introducing the knee: Anatomy and biomechanics

Posted By Elsa Urmston and Jonathan George on behalf of the IADMS Education Committee, Monday, November 28, 2016

As dancers, educators and clinicians, we know that knees cope with a lot!  Over the last decade or so, the demands placed on the dancer’s body has increased exponentially and ever more complexly.  Acrobatic movement is becoming evident and the effect to the joints of the limbs can often mean greater incidence of injury.  As Liane Simmel points out “pirouettes on the knees, knee drops, and even a plié in fourth position require particular leg stability and optimal mobility in the knee.”1  In reviewing the literature, Russell2 identifies the lower extremity to repeatedly be the most commonly injured region of the body amongst dancers.

 

 

The knee joint is hugely complex and as Teitz (in Solomon et al, 2005)3 explain there is no bony stability in its structure.  A modified hinge joint, the knee comprises articulations between the femur and tibia, and the patella and femur, held together by a fibrous capsule and connected via a network of ligaments.  It’s this lack of potential stability which makes the knee prone to injury, often through misalignment and poor mechanics, although as well through sudden trauma or overuse.  Over the next couple of weeks we have a series of posts which focus on the knee; today we zone in on the structure, anatomy and mechanics of the knee itself.  Part 2 provides an overview of common knee injuries amongst dancing populations, and in Part 3 we focus on two case studies of young men who have experienced knee issues during their training and have been successfully rehabilitated to class and performance via a joined-up clinical and educative rehab programme.

 

 

The tibio-femoral joint is a hinge joint, capable of flexion (bending) and extension (straightening).  The screw-home mechanism allows the knee to slightly internally and externally rotate too.  During the last 30° of knee extension, the tibia (open-chain movement such as rond de jambe en l’air) or femur (closed-chain movements such as ascending from a demi-plié) must externally or internally rotate respectively by about 10°.  This determines the knee as a modified hinge joint.  You can see Rosalie O’Connor from American Ballet Theater demonstrating the screw-home mechanism in a rond de jambe action here!

 

The patellar-femoral joint serves to heighten stability in the joint.  The patella (knee cap) is a sesamoid bone which sits in the quadriceps muscle, and during flexion and extension undergoes complex gliding movements. The fairly unanimous consensus as to the function of the patella is to effectively increase the movement arm of the patella tendon about the tibio-femoral joint, thereby magnifying the movement and force of the quadriceps muscle group about the knee.4

 

 

The stability offered by the joint capsule is complemented by numerous, strong ligaments and more than any other joint in the body, these ligaments are vital in guiding the aligned movements of the bones as they come together to form the joint.  Yet, they are arranged in such a way that the stability is not always constant; some remain taut to ensure stability when the knee is extended and others slacken to ensure mobility when the knee is flexed5.

 

The medial and lateral collateral ligaments

The collateral ligaments are located on either side of the knee joint (collateral means side by side).  The medial collateral ligament – the one on the inside of the knee – is taut in knee extension and external rotation.  It controls the knee if the knee rotates inwards and in fact when the knee bends in a demi-plie, it controls approximately 80% of the medial stress on the knee (Besier et al, 2001)6.  The lateral collateral ligament – located on the outside of the knee – becomes taut with knee extension and provides lateral stability to the knee.  It controls approximately 70% of the lateral stress of the knee for example when the knees bow out on flexion and cause the feet to roll outwards (Besier et al).

 

The cruciate ligaments

The cruciate ligaments join the tibia and femur to one another within the internal structure of the knee.  The cruciate ligaments prevent any forward/ backward motion of the femur and tibia in relation to one another.  The anterior cruciate ligament also has another role in aiding rotation of the knee and controlling hyperextension in the joint.  It also plays a role when deceleration from jumping, floor work and quick changes of direction are required. It is now also widely accepted that the anterior cruciate ligament provides up to 40% of medial knee stability7.

 

The menisci

The medial and lateral meniscus are two cartilaginous discs which sit on the tibia and deepen the articular surface of the knee joint – they provide a kind of collar in which the bony ends of the femur sit, thereby improving the congruency and stability of the knee joint.  They assist with shock absorption and help to friction thus aiding smooth knee movement. The menisci are critical in the production of synovial fluid-‘the oil’- around the knee joint.

 

Bursae

The knee has the most extensive distribution of bursae in the body. More than 20 bursae are thought to be within the knee joint, with the primary role of reducing friction amongst the structures of the knee joint.  Many are located around the patella to aid its gliding function within the muscle and over the top of the joint itself.

 

Iliotibial Band

The iliotibial band is an adaptation of erect posture and provides key lateral support to the knee and hip; it runs down the side of the upper leg from the rim of the pelvis, to the outer edge of the femur and tibia.

 

This super video really provides a great introduction to the anatomy and ligament structure of the knee joint – take a look!

 

 

The musculature

As with the skeletal anatomy of the knee, the muscles which act on the knee are complex!  Because the muscles of the thigh also act on the hips, they often have a dual purpose –hip movement is included in brackets for ease of understanding here!  We have provided a simple table of the main muscles which act on the knee to produce movement.

 

Muscle

Action

Anterior/ front of the thigh

Rectus femoris

Knee extension (hip flexion)

Vastus medialis

Knee extension

Vastus intermedius

Knee extension

Vastus lateralis

Knee extension

Sartorius

Knee flexion (hip flexion, hip abduction and hip external rotation)

Posterior/ back of the thigh

Biceps femoris

Knee flexion and external rotation (hip extension and hip external rotation)

Semitendinosus

Knee flexion and internal rotation (hip extension and hip internal rotation)

Semimembranosus

Knee flexion and internal rotation (hip extension and hip internal rotation)

Popliteus

External rotation of femur when foot fixed; internal rotation of tibia when foot free

Medial surface of thigh

Gracilis

Knee flexion (hip adduction and hip flexion)

Posterior/ back of calf

Gastrocnemius

Knee flexion (ankle plantarflexion (pointing))

 

 

As you can see muscles often have more than one role in creating the movement of the limbs – we separate them out to learn about them, but of course they should be seen in their entirety to understand the complexity of the muscular system.  This video really helps us to see the wholeness of this system but understand each individual muscle’s location in relation to each other – take a look.

 

 

 

 

1.    Simmel, L.Alignment of the leg and its impact on the dancer's knee: Clips from the 2014 Annual Meeting
2.    Russell, J. Preventing dance injuries: Current perspectives, Journal of Sports Medicine, 4, 199-210.
3.    Solomon, R., Solomon, J. & Cerny Minton, S. Preventing Dance Injuries.  Champaign, IL: Human Kinetics, 2005.

4.      DeFrate LE, Nha KW, Papannagari R, Moses JM, Gill TJ, et al. The biomechanical function of the patellar tendon during in-vivo weight-bearing flexion. Journal of Biomechanics 40:1716–1722, 2007.

5.      Clippinger, K. Dance anatomy and kinesiology.  Champaign, IL: Human Kinetics, 2016.

6.      Besier, TF., Lloyd, DG.,  Cochrane, JL. and Ackland. TR. External loading of the knee joint during running and cutting maneuvers. Medicine and science in sports and exercise33, no. 7:1168-1175, 2001.

7.      Quatman CE, Kiapour AM, Demetropoulos CK, et al. Preferential loading of the ACL compared with the MCL during landing: a novel in sim approach yields the multiplanar mechanism of dynamic valgus during ACL injuries. American Journal of Sports Medicine, 42:177–186, 2014.

 

More information about the knee’s structure can be found in a variety of dance specific dance anatomy, kinesiology and safe practice books.

 

Elsa Urmston is the Centre for Advanced Training Manager at DanceEast, Ipswich, UK as well as Chair of the IADMS Education Committee and a member of the One Dance UK Expert Panel for Children and Young People.  Jonathan George is a Chartered Physiotherapist at the DanceEast Centre for Advanced Training.

Tags:  anatomy  biomechanics  dancers  knee  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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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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