​What is Joint Hypermobility?                                                                                                                                  
Joint hypermobility refers to greater than normal range of motion in a given joint. Excessive range of motion can be attributed to factors such as bone shape, hormonal influences, impaired proprioception, reduced muscular strength, and decreased collagen strength (Knight 2012). Collagen is a structural protein within connective tissue. Fascia, ligaments, joint capsule, tendons, skin, blood vessel walls, gastrointestinal lining, and respiratory tracts contain connective tissue. Defects in connective tissue proteins contribute to joint laxity and can result in widespread symptoms (Hakim 2015).

What are hypermobility disorders?
Hypermobility disorders refer to a group of conditions involving symptomatic joint hypermobility. Some hypermobility disorders such as Ehlers-Danlos syndrome are caused by abnormal structure and function of collagen and connective tissue proteins. Hallmark features of connective tissue disorders include stretchy skin, loose joints, and fragile tissues (Simmonds 2007).

What are common signs/symptoms of Hypermobility disorders?   

• Frequent joint dislocations
• High injury rate
• Fatigue
• Difficulty sleeping
• Chronic pain
• Frequent headaches/migraines
• Dizziness
• Orthostatic hypotension
• Gastrointestinal pain
• Anxiety
• Delayed healing
• Decreased proprioception and strength

Joint hypermobility is common among dancers and rhythmic gymnasts because of the flexibility demands in both disciplines. 

How do we screen for Hypermobility?
The 5-point hypermobility questionnaire, Beighton scale, and Brighton criteria are useful screening tools for hypermobility. Two positive responses on the 5-point questionnaire provides a sensitivity of 84% and a specificity of 85% for detecting joint hypermobility (Kumar 2017).

How is Hypermobility diagnosed?
Joint hypermobility is identified through a comprehensive patient history as well as a variety of clinical tests.

How can Physical Therapy help?
Physical therapy can play a vital role in providing treatment strategies for individuals with joint hypermobility to improve joint stability, reduce pain, and improve function. Treatments may include:

• Muscle Strengthening: Increasing muscle strength is vital for improving joint stability to counteract underlying joint laxity. 
• Education on safe flexibility: Understanding how to improve tissue mobility safely helps to prevent injury and protect the integrity of the connective tissue. 
• Endurance: Increasing cardiovascular and muscular endurance is important for reducing fatigue which is a common symptom in hypermobile individuals.
• Balance and Proprioceptive Activities: Increasing proprioception and improving postural control is key for increasing stability to reduce further pain or injury. Taping or bracing may be utilized to improve joint awareness and aid in further stability. 
• Manual Therapy: Hands on treatment such as soft tissue mobilization may be used to reduce myofascial pain and calm down the nervous system. 

 
References: 

1. Isobel Knight MSc, Moira McCormack MSc, 7 Howard Bird MA MD FRCP .Managing Joint Hypermobility – A guide for Dance Teachers. March 2012. https://www.onedanceuk.org/wp-content/uploads/2018/05/Managing-Hypermobility-for-the-Dance-Teacher-FINAL.pdf Accessed May 20, 2021. 
2. Hakim, Alan. What are Hypermobility Syndromes? May 2015. https://www.hypermobility.org/what-are-hypermobility-syndromes accessed May 23,2021.
3. Simmonds, J. V., & Keer, R. J. (2007). Hypermobility and the hypermobility syndrome. Manual therapy, 12(4), 298-309.
4. Kumar, B., & Lenert, P. (2017). Joint hypermobility syndrome: recognizing a commonly overlooked cause of chronic pain. The American journal of medicine, 130(6), 640-647.

As dancers return to the studio, it is important to gradually introduce jumps to prevent lower leg injuries. Foot and ankle injuries are often incurred during dynamic movements like jumping, and improper flooring, poor technique, and fatigue can increase the risk of injury.
Here are some important tips to lessen the likelihood of sustaining injury during jumps:

1. Dance on appropriate flooring (i.e., sprung floor with adequate shock absorption) 
2. Utilize proper technique while jumping
3. Wear supportive shoes that are in good condition
4. Apply periodization principles 
5. Train endurance: Dance-related injuries most commonly occur when the dancer is fatigued. Therefore, it is imperative to increase cardiovascular fitness to reduce injury. Examples include short bouts of jumping rope, jogging in place, fast walking, cycling, and/or swimming. 
6. Asses and train the specific elements of the jump:

• Improve plie depth: Address any muscular or joint restriction that could be affecting your plie depth. Seek a healthcare professional if you are having any pain on the top of the ankle with plie.
• Articulation of foot with take-off: Improve strength of foot intrinsics and calf complex. Jumping on the pilates jumpboard can be useful when working on articulating through the foot with jump take-off and landing. 
• Achieving full pointe range and knee extension in the air: Address any muscular or joint restriction that could be limiting full ankle plantarflexion or knee extension range of motion. Seek a healthcare professional if you have pain in the back of the ankle with pointing the foot. 
• Dynamic core/pelvic stability: Avoid sinking in the hip on the standing leg or collapsing forward in the trunk on the take-off/landing. Strengthen the core dynamically with exercises like squat jumps, skater jumps, and spring lunges to improve trunk alignment and pelvic control during jumping. This will ultimately reduce load on the foot/ankle. 
• Eccentric gluteal and soleus control on the landing : Strengthen the gluteals and soleus eccentrically to avoid collapsing in the hips or foot/ankle on the landing. This can be improved with working on squats and soleus rises with a slow and controlled descent to strengthen the muscle eccentrically. 
• Improving muscle power to achieve adequate height: Incorporate plyometrics into your cross-training and work on dynamic movements such as skater jumps, squat jumps, and spring lunges. Vary the speed of the exercise to improve muscle power. 
• Leg alignment/Hip control in fondu: Work on achieving adequate turnout from the hips and avoid collapsing of the knee inward during fondu. Practice plie in second position with correct alignment of the hip and knee. 

If you are experiencing pain that doesn't subside with rest, there are experts who can help.  Learn more about chronic pain and the importance of proper testing for treatment,
References:
Russell J. A. (2013). Preventing dance injuries: current perspectives. Open access journal of sports medicine, 4, 199–210. https://doi.org/10.2147/OAJSM.S36529

What is a bunion?

• A bunion is localized, painful swelling at the base of the big toe due to bony overgrowth (Sheil, W).

What are the common signs/symptoms?

• Angulation of the big toe towards the second toe. 
• Inflammation of the big toe joint (pain, redness, swelling, and/or warmth at the base of the big toe joint).
• Reduced range of motion in the big toe evident with pain/limitation on demi-pointe.

What are the risk factors?

• Family history of bunions
• Individual anatomy (joint laxity, pes planus, limited mobility in the foot/ankle joints) 
• Reduced core/pelvic stability
• Impaired lower quarter strength 
• Poor technique
  • Excessive winging of the foot/ankle
  • Increased pronation (arch collapse) often due to lack of turnout from the hip
  • Leaning on the big toe en tendu, walking in turnout)
• Poor fitting flat shoes or pointe shoes 
• Starting pointe work too soon 

Can I prevent bunions from getting worse?

• Yes!

​What can I do to improve my bunions?

• Correct the big toe alignment. Taping the foot can help improve the alignment. Try to avoid using toe spacers between the first and second toes as it can weaken the muscles between the toes. 
• Ensure that your flat shoes and pointe shoes are properly fitted. Avoid toe boxes that are too narrow.
• Wear protective shoes outside of dance class. Avoid walking barefoot or wearing non-supportive sandals. 
• Focus on refining your technique. Avoid excessive winging of the foot, ensure adequate turnout from the hips, and avoid collapsing in the arch.
• Strengthen! Improve the strength of the muscles that control the big toe as well as the foot intrinsics, deep external rotators of the hip, and core musculature. 
• Improve the range of motion in the metatarsals, midfoot, and ankle with joint mobilizations and dynamic stretching. 
• If the big toe is inflamed, consider doing a flat barre and flat center.  Don’t dance through the pain! 
• Avoid starting pointe work too soon. 

References:
Shiel,W.Bunions(HalluxValgus). https://www.medicinenet.com/script/main/art.asp?articlekey=2552. Accessed April 4, 2020. 
Howell,L.Does Pointe Work Cause Bunions? https://www.theballetblog.com/portfolio/does-pointe-work-cause-bunions/Updated August 31, 2010. Accessed April 4, 2020. 

SET GOALS:

• What goals are you looking to achieve during this break (e.g., improving core control, extensions, jumps, turnout)?
• What motivates you to reach these goals? 
• What barriers stand in the way of reaching these goals?
• What daily steps can I make to reach these goals? 

TIPS FOR SETTING GOALS

• Make attainable goals
• Create a daily schedule 
• Focus on the foundations (e.g., increasing core control and hip control to improve developpe and turns)
• Realize that it takes time to achieve goals - it takes 6 to 8 weeks to build muscle strength!

 
USE THIS TIME TO CATCH UP ON REST:

• Ensure you are getting at least 8 hours of sleep a night. Healing and repair requires rest!
• Set aside at least 1 day a week for physical rest. This is a great time to allow dance-related injuries to FULLY heal!

 
MAINTAIN ADEQUATE NUTRITION:

• Eat a balanced diet to reduce stress, improve cognitive function, increase recovery, and improve performance
• Incorporate a lean protein source with each meal to aid in muscle repair/recovery

 
IMPROVE OVERALL FITNESS LEVEL

• Increase strength (conditioning, resistance training)
• Restore muscle imbalance (cross-training)
• Gain flexibility (by improving strength!)
• Increase endurance (brisk walk, hike, stationary bike, rower for 20-30 min 3x/week)
• Improve balance control
• Refine basic dance technique/alignment
• Take advantage of online resources 

Use this time to re-set, re-focus, recover, and refine your technique! 

Online resources:
*Health en Pointe individual nutrition and physical wellness sessions (by appointment)
*Lisa Howell ballet blog training at home series: https://www.theballetblog.com/blog/training-at-home/; 
*Dance prehab digital for videos to improve dance foundations as well as individual wellness/dance-specific training sessions: https://danceprehab.com/login/)

Inflammation is the body’s normal response to promote healing when the body is fighting infection related to injury, wounds, allergens, toxins, or infection. Typical signs of inflammation include swelling, pain, and redness. In contrast, signs of inflammation may not be apparent with chronic inflammation. Chronic inflammation is typically caused by excess body fat or immune dysfunction. While acute inflammation promotes healing, chronic inflammation can result in DNA damage and increase cancer risk.

Despite the numerous “anti-inflammatory diets” promoted online, research is barely emerging in regards to diet and inflammation. So far, scientific studies indicate that consuming a variety of nutritious foods may help reduce inflammation and keep chronic inflammation at bay. Foods that enhance immune function are also important in fighting inflammation. Here is what we know thus far about foods and inflammation:

• Fruits and vegetables provide phytonutrients with potential anti-inflammatory properties.
• Healthy omega-3 fatty acids and monounsaturated fats promote anti-inflammatory pathways.
• A diet high in saturated fat may increase inflammation; trans fats may also be inflammatory.
• Animal studies indicate that dark chocolate, green tea, red wine, turmeric and ginger may reduce inflammation.

However, these findings have not been observed in humans and it is unknown how much and how often these foods must be eaten to provide benefits. 

​Tips for reducing inflammation:

• Include fruits and vegetables with every meal.
• Consider eating a variety of protein sources, including fish, tofu, legumes, and low-fat dairy.
• Choose monounsaturated fats including olive, canola, safflower, sunflower, peanut and avocado oils. Eat omega-3 rich foods like salmon, walnuts, flaxseed and chia seeds. Avoid partially hydrogenated oils and high amounts of saturated fat.
• Choose whole grains such as quinoa, brown rice, millet, and bulgur.

In addition to a healthy diet, inflammation can be reduced by getting adequate sleep, remaining physically active most days of the week, and maintaining a healthy weight.