Injury Prevention and Management for Dancers E-Book

Nick Allen

• Herausgeber: Crowood
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Veröffentlichungsjahr: 2019

Beschreibung

Dancers represent a unique athletic population. They can often be required to perform a variety of shows of differing intensity and styles: professional ballet dancers may perform up to 150 shows a year, across eighteen different productions. The dynamic and demanding nature of dance can however lead to injury, making injury prevention and management a vital part of dance training. Drawing on research and knowledge from both sports and dance medicine, this book will provide dance and healthcare professionals with a fundamental understanding of dance terminology, physiology and movement requirements, and how these relate to specific injuries commonly sustained in dance. Proposed models and structures of pathology-specific rehabilitation and usable examples are illustrated with step-by-step photographs and anatomical diagrams, as well as case studies for common injuries. Training programmes, conditioning exercises and advice are supported by findings from contemporary medical literature to ensure an informed, conclusive and evidence-based approach to the healthcare of dancers. Chapters will cover a range of issues including the unique challenges seen in dance and how they differ from other athletic populations; physical preparation and conditioning for dance; injury prevention, tracking and management models and an exploration of the regional anatomical injuries commonly seen in dance. Structured rehabilitation and detailed exercise programmes are covered and dance criteria for musculoskeletal injuries, concussion and post-surgery are discussed.

Leseprobe

Injury PreventionAND MANAGEMENT FOR DANCERS

Injury PreventionAND MANAGEMENT FOR DANCERS

Nick Allen

First published in 2019 byThe Crowood Press LtdRamsbury, MarlboroughWiltshire SN8 2HR

[email protected]

www.crowood.com

This e-book first published in 2019

© Nick Allen 2019

All rights reserved. This e-book is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the publishers, as allowed under the terms and conditions under which it was purchased or as strictly permitted by applicable copyright law. Any unauthorised distribution or use of this text may be a direct infringement of the author’s and publisher’s rights, and those responsible may be liable in law accordingly.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library.

ISBN 978 1 78500 658 6

All dancer and exercise photographs by photographer Ty Singleton unless otherwise indicated.

All anatomical diagrams courtesy of Openstax unless otherwise indicated.

CONTENTS

Introduction

1. Background to Dance Medicine

2. Challenges in Dance

3. Injury Audit in Dance

4. Physical Preparation in Dance

5. Injury Prevention, Management and Rehabilitation

6. Head and Neck Injuries

7. Injuries to the Thoracic Region, Shoulder, Arm and Hand

8. Lumbar, Pelvic, Hip and Groin Injuries

9. Upper Leg and Knee Injuries

10. Lower Leg, Ankle and Foot Injuries

Conclusion

Bibliography

Index

INTRODUCTION

This book was commissioned to provide a resource for healthcare staff working in dance or with an interest in dance medicine. While dance medicine sits firmly under the umbrella of sports and exercise medicine, there are certain specificities relating to dance that may influence the outcomes with dance patients. This book is designed to give healthcare practitioners a basic understanding of dance terminology, physiology and movement requirements, and how these may relate to specific injuries sustained in dance. It will draw on experiences in both sports and dance medicine to propose models and structures of pathology-specific rehabilitation programmes, and will give usable examples based on dance patients.

When considering the rehabilitation of surgical patients, it is important to discuss proposed protocols with the surgeon involved, to ensure they complement the surgical procedure undertaken and comply with any post-surgical restrictions. While the examples given in this book have been used with actual patients, it is important to clarify any rehabilitation programme with surgical colleagues in each case.

Furthermore, it is well understood that prevention is better than cure. This book will explore areas for general conditioning that may serve to enhance performance as well as reduce the risk of injury. The importance of the role of understanding the extent and nature of injury is also discussed. The need to create evidence within the healthcare practitioner’s own environment is emphasized. Current thoughts on the structure and content of in-house injury audit programmes is also provided, to give healthcare practitioners the tools to support their own advances in the care of dance patients. Evidence-based information is a key driver within all areas of medicine and dance medicine is no different. This book draws upon the extensive research that has been published in the field (referenced in the Bibliography).

DANCE TERMINOLOGY

The assessment and successful management of dancers must reflect the specificity of their needs. This requires an understanding of the nature of movement and of the terminology used to describe movements that are specific to dance. The list of terms described below is by no means exhaustive. Much of the terminology is derived from the five standard positions used in ballet that relate to the position of the arms or legs.

THE FIVE POSITIONS

First Position

In first position, the arms are held in a ‘circle position’ to the front. The position will just engage the subacromial space, requiring the dancer to have good scapula stabilization, to allow for posterior tipping of the scapula, which will prevent subacromial impingement syndromes. The lower legs and the feet are held with heels together and turned out. This must be achieved from the hips rather than the lower leg, which would cause torsion through the knees and tibia. Moreover, it is important that it can be held without rolling in or pronation through the foot. Rolling or pronation of the foot may predispose the dancer to bone stress injuries of the navicular or tendon injuries to the tibialis posterior among others.

Photo 1  Dancer in first position with arms bras bas.

Second Position

The arms are held in a rounded position with less than 90 degrees of abduction and in the transverse plane. Again, scapula stability is important, to reduce the risk of shoulder impingement. The legs are abducted to slightly greater than shoulder width apart and held in the turn-out position. Increased control from the hips is necessary to maintain the alignment of the knee over the (second) toe, to prevent pronation through the foot.

Photo 2  Dancer in second position with arms held in second.

Third Position

In third position, the arm is held in first position while the other is held in second position. The leg corresponding to the first position arm is adducted so the foot crosses half in front of the other foot. This creates a smaller base of support. The dancer is still in a turned-out position, so control of pronation through good hip and gluteal activation is needed.

Photo 3  Dancer in attitude derrière éffacé en pointe with arms in fourth position.

Fourth Position

From third position, the arm in first position is elevated while the front foot is moved forwards. Scapula stabilization is required through the range while the arm is elevated, ensuring good scapulathoracic patterning.

Photo 4  Dancer in fifth position at the barre with arms in fifth.

Fifth Position

Both arms are elevated in this position, further increasing the need for good scapula stabilization. The front foot is adducted and fully crossed over the rear foot. This decreases the base of support and demands good gluteal activation in a tensioned and externally rotated position of the front leg.

FUNDAMENTAL MOVEMENTS

There are a number of fundamental movements that dancers will perform in class and choreography, which need to be understood.

Plié

The plié is a fundamental movement performed to various ranges. Demi-plié can resemble a small knee bend or squat but starts with the dancer’s legs in first position and heels kept close together and in contact with the floor. Failure to control this position from the hips results in rolling-in or pronation through the foot. The navicular drop has been associated with torsion through the knee, medial tibial stress syndrome, stressing of the navicular and increased pressure on the first metatarsal joint (made worse in the presence of a hallux valgus).

Photo 5  Dancer doing a plié in fifth with arms in first.

A grand plié can be performed from either second or third position of the legs and requires the dancer to go further into knee flexion. From second position the heels remain on the floor while in third position the heels rise from the floor, to accommodate the additional movement.

Photo 6  Dancer relevéd up to demi-pointe in fifth position.

Relevé

The term relevé derives from the French relever, which means to rise. The dancer performs heel rises, which may be from any of the starting positions to en demi-pointe (onto the metatarsolphalangeal joints (MTPJs)) or, in the case of the female dancers, to en pointe (weight-bearing through the tips of the toes). Most athletic pursuits recognize the need for good calf capacity, with the gastrocnemius and soleus being utilized to support the athlete. Good calf capacity is essential in dancers, so this must be properly assessed as part of performance evaluation or return to dance criteria, to ensure preservation of the forefoot joints. It is also important in the prevention of overuse injuries in areas such as the Achilles and tibialis posterior tendons.

Photo 7  Dancer performing tendu à la seconde.

Battements

Battements are dynamic, beating movements of the legs at various angles. They may be tendus, with a small movement, or glissés, which encompasses a quicker movement, or grand battement, which is a quick movement from tendu and glissé to a higher position. In order to develop leg speed, it is important that dancers have good core control to prevent overloading of the lumbar region during higher movements. Failure to control the deceleration at the end of the movement can result in damage, either acutely or over time.

Photo 8  Dancer performing tendu devant.

Ports de Bras

Port de bras translates from the French as ‘carriage of the arms’. Involving movement through the trunk into flexed and extended positions, it requires flexibility through the trunk and hamstrings. It is also necessary for the dancer to have good control of the core muscles of the trunk, to prevent excessive compressive forces through the lower spine, particularly with movements into extension. When dealing with patients with extension-related back pain, the practitioner needs to understand the technical capacity of the dancer’s port de bras as a potential cause. Quality of lower lumbar movement may be compromised, with a stiff lower lumbar section seen and an excessive higher lumbar ‘give’ into extension as a focal point or hinge for movement, creating overloading.

Developpé and Arabesque

These are generally slow positions where the leg is ‘unfolded’ from the hip. The movement can be made to the front with hip flexion (devant), to the side into hip abduction (à la seconde), or back into hip extension (derrière), with either a bent leg (attitude) or straight leg (arabesque). The dancer must maintain good alignment of the lumbar region and also needs to have the strength to hold the positions. Failure to control the neutral position of the lower lumbar region, due to less than optimal core control, can result in over-activity of the iliopsoas group as stabilizers, creating pressure on the lumbar region (and restricting the range of the hip). Movement through second position may create femoral acetabulum impingement potentials with cam or pincer morphologies. Failure to control movements may also result in excessive loading through the hip labrum, resulting in tears.

Photo 9  Dancer performing developpe devant en croisé.

Photo 10  Dancer performing developpé à la seconde en face.

Arabesque movements range from small, with limited extension from the hip, to an extreme extension at the hip combined with some trunk flexion and extenuation through lumbar spine extension. Loading through the hip and lumbar spine needs to be controlled well to prevent injuries. In younger dancers, over-loading may manifest in stress response or stress fractures to the pars region.

Photo 11  Dancer in first arabesque.

Pointe Work

In pointe work, dancers (typically female) adopt an extreme position of the foot, weight-bearing through the tips of their toes while wearing a pointe shoe. Weight-bearing typically is through the first and second toes. The shoe has a block and some arch reinforcements to assist in supporting the foot. Getting onto pointe may be a gradual process from a neutral/flat position from the floor via a relevé, it may involve a quick jump or sauté, or the dancer may step onto pointe via a piqué. Whatever the process, optimal whole-body biomechanics are critical in preventing injuries when performing pointe work.

Sickling through the foot can result in excessive forces through the medial longitudinal arch. The presence of a Morton’s toe or hallux valgus can alter forces through the foot and leg, resulting in injuries if not well controlled. The flexor hallucis longus and tibialis posterior play a pivotal role in achieving and stabilizing this position. As such, they are at risk of injury if they are insufficient for the loading required. The alignment of the knee, hip and trunk all impact on the transmission of forces. Over-extending when en pointe (further into plantar flexion) can result in posterior impingement of the ankle. The presence of an os trigonum may exacerbate this.

Photo 12  Dancer in fifth position en pointe.

Photo 13  Dancer in retiré en pointe.

Turning/Pirouettes

When setting up to turn, whether performing fouettés or pirouettes, many dancers will start in a turned-out position of the hip. This leads to stressing of the medial foot, with increased pressure seen through the deltoid ligament complex and tibialis posterior. When turning en demi-pointe, the tibialis posterior is then required to stabilize the midfoot in a loaded position. Good ankle stability in a plantar flexed position is important. Turning requires dancers to have good trunk control and good scapula stability. To reduce the impact of motion sickness, dancers will ‘spot’; this involves focusing on a particular spot and maintaining the head position until the spot disappears, then rapidly spinning the head round to find the spot again. Excessive forces through the neck are a consideration in this case.

Jeté

Dancing involves various types of jumping, using various starting positions. Jumps can be performed off both legs or one leg. A sissonné is a popular jump where dancers jump from two feet and split their legs like scissors.

Photo 14  Dancer performing sissonné with arms in fourth position.

Jumping can be largely broken down into small (petits jetés), middle (jetés) and large (grands jetés). Smaller jumps see dancers using their lower leg muscles more, while larger jumps demand greater use of the upper legs and gluteal muscles. Strength, control and landing mechanics play a key role in injury prevention with larger jumps. Landing positions can be directed through choreography, so a dancer may be required to land in a turned-out position, increasing rotational torque pressure through the knee. This may increase the risk of anterior cruciate ligament (ACL) injury. Ankle sprains may also result from a failure to land correctly. More commonly in contemporary dance, some variations of jumps and landings (not always on the feet) can also increase the risk of other traumatic injuries.

Partnering/Pas de Deux

The nature of the dance style and the choreography may determine the nature of partnering. In ballroom, for example, it is typical for the male dancer to provide the lead. In ballet, the male lead supports the female lead to perform challenging positions or movements during a pas de deux, and is usually required to lift his partner. Lifting presents a number of challenges, with both partners needing to work with each other’s movement and momentum in order to achieve the lift. A lift may extend to a full press above the head with one arm, which demands the appropriate strength combined with good technique.

The partner doing the lifting will be at risk of injury to shoulders and the spine, but lifting is not a passive process for the partner being lifted. Typically, but not exclusively, this will be a female dancer. While being lifted, a dancer needs to take care to maintain a good core and trunk position.

From a contemporary perspective, more movement-based descriptions may be encountered. While many movements have their origins in ballet, they have evolved and may no longer be easily described using the same terminology. For example, contemporary dance may involve more ‘floor work’, with dancers utilizing contact with the floor far more frequently than in ballet, and with ‘crashing’ to the floor not uncommon. This aspect of contemporary work can increase the prevalence of upper limb and even concussion injuries. Partnering in contemporary dance may also differ. Rather than executing some of the cleaner lines exhibited in ballet, contemporary dancers are known to engage in momentum-based lifts using rotation and angles. This enables them to create lifts where a smaller partner can execute a lift with a larger partner. While this may support artistic ambition, if it is not executed well, it will introduce a disproportionate load and an increased risk of injury.

Photo 15  Rosie Kay Dance Company: 5 Soldiers. BRIAN SLATER

CHAPTER 1

BACKGROUND TO DANCE MEDICINE

Dance has played a vital role for thousands of years, as entertainment and as a means of expression in societies throughout the world. Records show various forms in India dating back as far as 6000 BCE, and, relatively more recent, there is evidence of dance being important in ancient Egypt and Classical Greece. ‘Dance’ is a generic term that covers a multitude of styles or genres. Classical ballet and contemporary or modern dance are the two dominant Western genres, but there are many other styles practised and performed in the UK today, including African, Ballroom, Bellydancing, Bharatha Natyam, Bodypopping, Breakdancing, Contact Improvization, Flamenco, Historical/Period, Irish, Kalari, Kathak, Jazz, Jive, Latin American, Line Dancing, National and Folk, Raqs Sharqi, Salsa, Square Dancing, Street Dance, Tango and Tap!

Dance is an aesthetic pursuit, with the cornerstone of many of the movements performed being derived from ballet technique. According to dancer, teacher and choreographer Anna Paskevska, ‘Ballet is ultimately a logical technique; it favours the shortest, most efficient route from one position into another. This factor gives an aesthetic clarity to all motions.’ But is dance a sport? ‘Sport’ can be defined as an activity that involves physical exertion and skill. Many definitions of sport go on to include the concept that the activity is governed by various sets of rules and can be competitive, involving a contest or game between two or more opponents. Given these definitions, dance may not be defined as a sport, but it is undoubtedly an athletic pursuit. Numerous studies into the physiological demands of dance attest to its demands for physical exertion and particular skills.

The benefits of exercise-related activities are numerous, wide-ranging and well publicized. They are physiological, enhancing health and preventing disease, and psychological, improving mood, selfesteem, psychomotor development, memory and calmness. The health benefits of dance as a physical activity have also been recognized. A dance-based programme may improve aerobic power, muscle endurance of the lower extremities, muscle strength of the lower extremities, flexibilities of the lower extremities, static balance, dynamic balance and agility, gait speed. It may also increase bone-mineral content in the lower body and the muscle power of the lower extremities, as well as reducing falls rate and risks to cardiovascular health. As such, the role of exercise, including dance, was the focus of a government initiative to improve the health of the UK through the Department of Health’s ‘Be Healthy, Be Active’ programme in 2009.

PHYSIOLOGICAL DEMANDS AND THE IMPACT OF INJURY

The physiological demands and athletic loading in dance reinforce the need for sports medicine practitioners to be aware of the potential risks, and support these remarkable athletes. Additionally, the role of sports medicine is to protect and improve public health and fitness. While participation figures in dance may fall short of those of some of the popular sporting pursuits, it is a growing area of physical activity. This is most notable in young females, where there has been a concerning drop-off in levels of participation in sports. Providing appropriate support for dancers is, therefore, aligned with public health agenda. However, it is recognized that participation in sport or dance can introduce a risk injury. It has been estimated that the cost of athletic injury worldwide is around $1 billion, with around 29 million injuries (new and recurrent) each year in the UK. These injuries can result in time away from exercise and, therefore, less exposure to its associated health and psychological benefits. For non-professional athletes or dancers, the impact may extend to the workplace, with decreased productivity occurring through diminished capacity or complete absence as a result of injuries incurred. The financial impact will extend to costs to the National Health Service and any post-injury care needed for more serious injuries. Family and social life may also be disrupted by injuries, due to the limitations placed on injured participants.

Photo 16a  The physiological demands of dance are significant. 2FACED DANCE COMPANY

Photo 16b  Rosie Kay Dance Company. BRIAN SLATER

The negative impacts of injury to elite, professional athletes and dancers can be significant. The financial ramifications of injury range from the costs of medical care to loss of personal income through withdrawal from competition or performance. The time away from training and competition can lead to a performance deficit, which could result in withdrawal from funded programmes and impact on the team or dance company’s performance. Future contracts may also be adversely affected by injury history and status. The potential of a longer-term sequelae of injury also needs to be considered. In one study, eighty per cent of retired footballers indicated joint pain during at least one activity of daily living, and 32 to 49 per cent reported being diagnosed with osteoarthritis – a higher percentage than expected for their age equivalents in the general population.

Similar concerns over long-term effects have been raised in dance. Evidence of a higher prevalence of osteoarthritis in dancers compared with age-equivalent non-dancers was found in a study that measured radiographic findings of osteoarthrosis, including sclerosis, joint space narrowing, osteophytes, and subchondral cysts as part of the diagnostic criteria for osteoarthritis. It is noteworthy that the level of evidence of these studies is lower with some results from the reporting responses via questionnaires, and this may be limited due to a number of confounding variables and biases, including a bias in respondents who have experienced some of the musculoskeletal problems being questioned as well as other methodological challenges to high-level evidence. However, in the absence of stronger evidence to the contrary, it is reasonable to make a strong recommendation to pay more attention to the long-term sequelae of injury. Furthermore, reducing the injury burden on individuals, sports and dance organizations, as well as society, through an increased focus on the incidence and aetiology of injury and potential strategies for its prevention is surely to be advocated.

DEFINING INJURY RISK FACTORS

Injury management and prevention are a key responsibility of healthcare practitioners. Sporting risk factors have been defined by many authors. Hershman states that ‘risk factors for a particular sport are derived by combining the epidemiology of injuries for a particular sport and the predisposing conditions that may lead to injury.’ Although this provides a global view towards injury risk identification, there is a need to provide greater specificity to the predisposing conditions. Fuller and Drawer indicate where risk factors can be further delineated to allow a greater degree of specificity to the athlete and their needs; they define an injury risk factor as ‘a condition, object or situation that may be a potential source of harm to people’ and risk as ‘the probability or likelihood that a risk factor will have an impact on these people’.

Risk factors can be categorized as intrinsic or extrinsic. Intrinsic factors are considered to be those specific to an individual participant, and can include age, strength and joint stability. Extrinsic factors arise from external sources, and may include surfaces, protective equipment and the laws of the game. Risk factors can also be divided into modifiable and non-modifiable. Modifiable risk factors, such as strength and flexibility, can be altered through training, whereas non-modifiable aspects, such as gender and age, may not be altered. Although the non-modifiable factors may not be altered, they can still be used to predict potential risk and mediate further injury.

One risk factor in dance that could be considered non-modifiable is the presence of benign hypermobility joint syndrome. It has been demonstrated that this disorder, which is often hereditary, is more prevalent in vocational ballet dancers and the lower ranks of professional ballet companies compared with a matched non-dancing population with an odds ratio of 11.0. Whilst there is no cure for this musculoskeletal disorder, which is associated with increased elasticity, an awareness of its presence allows measures to be taken to control factors that, in combination with the increased collagen elasticity, may predispose to injury.

THE AETIOLOGY OF INJURY