KEEPING DANCERS DANCING
by Jan Dunn, MS
This month’s topic in our ongoing Dance Wellness series is “Causes of Dance Injuries” (also called “risk factors” in the dance medicine world). We all know that dance is a risky business – injuries do happen. But learning what causes them can go a long way in helping to reduce that risk, and keep you “Dancing Longer / Dancing Stronger” (actually the title of an excellent dance medicine books for dancers!). All of the information in this article is supported by dance medicine research over the last thirty years.
The risk factors discussed below are NOT listed in any order of importance! In many dance injury situations, more often it is a combination of “causes” that may result in injury (I will explain what I mean by at the end !). We’ll cover five today, and five tomorrow:
1) Poor alignment and faulty technique:
While it is true that many injuries result from a combination of factors, this one is usually agreed to be one of the most important. Dr. Justin Howse, longtime physician to The Royal Ballet in England (now retired) and one of the early pioneers in Dance Medicine, went so far as to say that all injuries were the result of faulty technique. Most current experts would agree that while faulty technique is a major component of injuries, they would not necessarily concur that it is the only factor.
By “Alignment problems” we mean such postural patterns as:
-forward head (the head not in good alignment with the spine and torso)
-forward shoulders (rounded shoulders)
-lumbar lordosis (“swayback”)
-thoracic hyperextension (protruding ribcage)
-hyperextended knees (knees straightened beyond 180)
– foot pronation or supination (rolling in or out)
A dancer who has good alignment is more likely to have “efficient movement” (using only the muscles and amount of energy necessary to accomplish the movement), and is less likely to be putting strain and tension on soft tissue (ligaments / tendons / muscles) around the joint, thus resulting in less possibility of injury.
A young dancer complains of knee pain. The dance medicine physical therapist or physician gives a diagnosis of patellofemoral syndrome, which frequently involves the patella (kneecap) not tracking properly in the patellar femoral groove (the groove in the femur through which the patella glides, on knee flexion and extension). Looking at the dancer’s plie in first, the medical specialist and the dance trainer note that the dancer’s feet are turned out to 65 degrees, and the knees are not aligning over the toes, but falling instead in front of the great toe. Foot pronation (rolling in) and lumbar lordosis (“swayback”) is also noted. The dancer’s external rotation (turn-out) in the hip joint is then tested lying prone (on the stomach), and is found to be 48 degrees – so she is “forcing her turn-out”, which can cause knee pain (and possibly other problems). Recommendations are given for medical treatment for the knee pain, and she is also given cueing for proper plie technique, using her natural turn-out of 48 degrees, and not forcing at the knee and ankle.
The crucial point here is that ALL injuries in dance need to be evaluated for technique concerns, to see if this may have played a causative part. If the dancer rehabs the injury without knowing if faulty technique is involved, the injury is more likely to re-occur when returning to full dance activity.
2). Anatomical limitations:
Every dancer’s body is different, with different capabilities. Some dancers are very flexible (sometimes TOO flexible – more on that in a moment), and do not have as much strength as would be desirable. Others are very strong, but lack the flexibility of their neighbor’s high extensions. Knowing your own body, and its particular strengths and limitations, is key to avoiding injury.
A good example is the above mentioned dancer with actual 48 degrees turn-out, who was trying to go beyond what her body is capable of. Here are a few more examples:
-many people are naturally uneven in their hip turn-out capacity: one side may have 55 degrees, and the other only 48 degrees. If the dancer consistently forces the lesser turned-out hip to match the one with more turn-out, problems may result around the hip joint of the lesser one, and possibly also further up or down the kinetic chain (for example, the knee / foot, or in the low back).
-many dancers have tibial torsion. This is a slight bowing out of the tibia (the shin bone), often with the kneecaps pointing slightly inward. Frequently both they and their teachers are unaware of this anatomical structure. Tibial torsion is fairly common (in a recent screening of college dancers, it appeared in over half the students) and is usually genetic. It does not stop you from being a dancer (and many dancers have it, as mentioned in the college screening above). However, it IS important that the dancer (and teacher) be aware of it, as it affects foot and knee alignment patterns. The common plié cue of “knee over 2nd toe”, does not usually work well for a tibial torsion leg. If the dancer does the plie with that cueing, they may supinate (roll out) their feet, and may develop unexplained knee pain. Once they are aware of their leg structure, and align their feet / knees accordingly, the pain frequently resolves and the possibility of chance of eventual injury is decreased.
I mentioned above that some dancers can be TOO flexible. At the 2009 IADMS conference (International Association for Dance Medicine and Science), a keynote session was devoted to recent research in this area. British researcher Dr. Rodney Grahame, MD, internationally known for his work in Joint Hypermobility Syndrome (JHS), was the featured speaker. JHS causes the extreme flexibility seen in many dancers, and is a genetic condition which can predispose a dancer for injury. Dancers with this condition are often unable to control the end range of movement (ROM) in a joint, and their bodies have increased difficulty understanding “core control” and stability. Accurately diagnosing this condition, and taking it into consideration in the dancer’s training, will help them to avoid injury and achieve their full potential.
The bottom line as far as this second risk factor is concerned: It is important that dancers and teachers understand the individual student’s anatomical structure, and work within that person’s physical capabilities.
3) Environmental factors:
Dance injuries can sometimes happen due to factors in the environment that are often beyond the dancers’ control. Being aware of these, and taking appropriate action, can lesson the possibility of injury. These factors include:
-Temperature: Too hot or too cold a studio / theatre. Too cold means that the dancer will not be able to properly warm-up, or be able to keep the body warm while dancing. Too hot may lead to loss of water and electrolytes (excessive sweating), causing muscle cramps / spasms, as well as more serious problems such as heat stroke.
-Floor: Most teachers and dancers are aware that a concrete floor or poorly sprung wood floor (laid over concrete) is detrimental for the body. Professional dance companies routinely carry specially constructed portable floors on tour, to absorb the force of gravity as the dancer moves. Research shows a marked decrease in the rate of “shin splint” pain (in the front of the tibia, the shin bone) when properly sprung wood floors are installed. Another causative factor involving floors is the overuse of rosin, which can result in a hazardous build-up of uneven and irregular patches on the floor surface.
There are a number of ways to describe fatigue-related injuries in dance:
-The two periods in which injuries are more likely to happen are at the beginning and at the end of a dance season (or school year, with student dancers). At the beginning, this is because often the dancer is returning to a heavy schedule after being off, and at the end because they are frequently tired from months of rehearsal, classes, performances, and not in peak physical condition. On a daily basis, most dance injuries happen between 4:00 and 6:00 PM, again because the dancer is more tired than earlier in the day.
-Overuse syndrome: Professional dancers average 45 hours a week of rehearsals, performance, and class, which together with extreme occupational demands and technique problems (see #1 above) can cause injury. Young dancers in summer camps are at special risk for overuse injuries, when they are going from their usual school-year schedule, of 3-5 classes per week, to a summer program with 3-5 classes per day. It is advised that student dancers who are enrolling in intensive summer programs do a pre-camp conditioning program, to help avoid injury.
-Even if the dancer is in good physical condition, and the situation is not one of the several described above, fatigue-related injury can occur if a class focuses a particular movement (jumps, for example), and repeats them over and over.
5) Muscular imbalance:
To avoid injury, the muscles surrounding a given joint should be relatively equal in strength and flexibility (“balanced”), so that one side of the joint is not being stressed more than the other. Different dance forms affect the body differently in this respect, depending on how it is being used. In ballet, for example, there are three common muscles imbalances:
-Quadriceps (front of the thigh) vs. hamstrings (back of the thigh): the hamstrings are usually weaker, and are one of the most frequently injured muscle groups in dance. One reason for this imbalance is often the emphasis on forward motion through space, which is powered by the quadriceps. One way to address this particular concern, besides actual hamstring strengthening exercises, is to create class sequences which move into the back space — for example running backwards in combination with a turn into a forward leap, then turning again into the backwards run.
-Gastroc-soleus (calf muscles) vs. anterior tibialis (front of the shin): In ballet, because of the constant pointing of the foot, the calf muscles are usually the stronger of this muscle pair. This imbalance can be one of the possible causes of “shinsplint” pain. Using motions / exercises which flex the ankle often in dance training can help to address this imbalance, as well as specific strengthening exercises for these muscles.
-External hip rotators (turn-out muscles) vs. internal hip rotators (turn-in muscles): This imbalance frequently exists because of the excessive amount of turn-out used in ballet, as opposed to parallel or turn-in movements. The muscles which control internal rotation are usually weaker and more frequently injured because of that imbalance. Creating parallel and internal rotation movements to add to the ballet barre is one way to address this situation, as well as strengthening exercises for the weaker muscle groups.
Many research studies have proven the importance of outside (of class) conditioning for dancers. By addressing their imbalances with a specific conditioning program, such as Pilates / Gyrotonics / Franklin Method / cross training, they are able to more fully prepare for the demands of dance, and to decrease their injury risk.
Tune in tomorrow as we cover the next five!
BIO: Jan Dunn is a dance medicine / Pilates / Franklin Method specialist based in Denver / Boulder, CO, and Los Angeles, CA. She is Co-Director of Denver Dance Medicine Associates, and Adjunct Professor, University of Colorado – Boulder, Dept. of Theatre and Dance. She has been active in Dance Medicine since 1984. Previously she was Coordinator of The Dance Wellness Lab, Dept. of Theater & Dance, Loyola Marymount University, Los Angeles, CA , and has held dance faculty positions at Connecticut College, Florida State University, Hartford Ballet, Washington Ballet, and Colorado Ballet. She has been active with the International Association of Dance Medicine and Science (IADMS) for 22 years, serving as Board member, President, and Executive Director. Jan was Associate Dean / Workshop Coordinator at the American Dance Festival 1983 – 1991, originated The Dance Medicine/Science Resource Guide; and was co-founder of the Journal of Dance Medicine & Science. She has taught dance medicine, Pilates, and Franklin workshops worldwide, has published numerous articles, and presented at many US / international conferences.