Category: Injury Prevention

9/10/2018 0 Comments

Am I ready for pointe work?

A dancer’s progression to pointe work is a much anticipated moment. It is completely normal to be excited about this milestone, but it is extremely important not to rush into pointe work. There are a variety of factors that need to be considered to ensure that a dancer is ready to sufficiently meet the demands of pointe work.

Criteria for pointe readiness based on expert recommendation:

Appropriate age (at least 11 years old)
Minimum of 3 to 4 years of ballet training
Full plantar flexion range at the ankle (>90 degrees)
Adequate balance control
Good core stability and strength of the lower quarter (Richardson 2017)

It is important to note that core strength and proximal hip control are better indicators of ankle stability than isolated foot/ankle strength. If a dancer has poor turnout control from the hip and inadequate core stability, the ankle is less stable en pointe, thus placing the dancer at increased risk for injury (Bullock-Saxton 1994). According to research, the tests most predictive of readiness for pointe* are the airplane test, topple test, and saute test (Richardson 2010). These tests are an indication of the dancer’s neuromuscular control and skill set, which are more significant factors than isolated muscle strength (Richardson 2017).

What are the risks if I start too early? If the dancer begins pointe work without adequate range of motion and/or neuromuscular control, they can hinder proper technique development, foster bad habits, and potentially increase the amount of stress on the developing bones as well as the surrounding musculature. There is rapid bone growth and remodeling between the ages of 9-15 years old. During this time, growth plates are weaker than the surrounding bone, making them less resistant to different forces and more susceptible to injury. In addition, there are neuromuscular changes that occur as the dancer accommodates to rapid growth. The dancer takes time to adapt to changes in strength, flexibility, and proprioception, which ultimately influences motor control and performance en pointe. Therefore, chronological age cannot be a sole marker for pointe readiness (Richardson 2017, Shah 2009).
It is important to communicate with your ballet teacher regarding the progress of your technique and whether you meet the criteria to initiate pointe work. Health care professionals (MD, PTs) with a background in dance can assist in conducting pointe readiness screens.

*Description of pointe readiness tests:

Airplane test: the body is pitched forward into a flat back arabesque with the leg at 90 degrees and the pelvis square to the ground. The dancer must bring the fingertips to the ground while performing a plie with the supporting leg. The dancer returns to the starting position and performs five plies total. The knee must track over the center of the foot, the pelvis must remain in neutral, the head/trunk remains stable, the foot does not pronate, and the dancer does not lose balance for four out of five attempts.
Topple test: pirouette en dehors from fourth position. Look for full releve, full passe height, straight supporting leg, vertical alignment, and controlled landing. The dancer must complete one successful turn out of two attempts.
Saute test: 16 single leg saute jumps without support. The dancer must keep the pelvis in neutral, keep the trunk upright, fully straighten the supporting leg, roll through the foot on the landing, and point the foot in the air for eight out of 16 repetitions (Richardson 2010).

References:
1) Richardson, M. Principles of Dance Medicine, Functional Tests to Assess Pointe Readiness. A webinar through the Harkness Center for Dance Injuries. Accessed Feb 23, 2017.
2)Bullock-Saxton, J. E., Janda, V., & Bullock, M. I. (1994). The influence of ankle sprain injury on muscle activation during hip extension. International journal of sports medicine, 15(06), 330-334.
3) Richardson, M., Liederbach, M., & Sandow, E. (2010). Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science, 14(3), 82-88.
4) Shah, S. (2009). Determining a young dancer's readiness for dancing on pointe. Current sports medicine reports, 8(6), 295-299.

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7/8/2018 0 Comments

Preparing for Summer Intensives: Tips for Going In Healthy and Leaving Stronger

Summer intensives typically involve long training days. A dancer may train 6-7 hours a day for 5-6 days a week. It is important that a dancer is physically prepared to sustain these long hours to avoid overuse injuries and burnout.

Preparing for Long Training Days:

Refine your technique: Ensure that you are taking daily technique classes to prepare. Focus on alignment and stability to avoid misuse injury. Avoid mistakes such as excessive turnout from the knees/ankles, overpronation, clawing the toes, winging/sickling en pointe, and sinking into hyperextension.
Increase your endurance: Technique classes alone don’t always prepare you for dancing for extended periods. It is important to supplement dance classes with cardiovascular exercise and strength training to prepare for choreography and long training days. Most injuries occur when a dancer is fatigued and therefore it is important to improve aerobic capacity to delay fatigue. About 20 minutes of moderate to vigorous cardiovascular exercise such as swimming or cycling can bring about aerobic fitness increases and improve stamina (Koutedakis 2004).
Increase your strength: Dancers need adequate strength to sustain intense training. Cross-training to build strength could include Pilates, yoga, or weight training. Diversifying physical activity helps prevent muscle imbalances and can improve endurance and strength without redundancy.
Address areas of weakness: Core strength and proximal hip control are better indicators of ankle stability than isolated foot/ankle strength. If a dancer has poor turnout control from the hip and inadequate core stability, the ankle is less stable en pointe, thus placing the dancer at increased risk for injury. Focus on developing core stability and proximal hip strength to prevent injury (Bullock-Saxton 1994).
Address areas of tightness: Stretching exercises can be performed daily. Common areas of restriction include the hip flexors, the long toe flexor (flexor hallucis longus), external rotators of the hip, and the piriformis. Dynamic stretches (holds of <30 seconds) are appropriate for warming up the muscles. Prolonged stretches (>30 seconds) should be performed after class has ended. Make sure to avoid over-splits to prevent joint damage and ligament laxity.

Come Back Stronger
Avoid working through through fatigue, illness, or injury. Always seek help from a medical practitioner if an injury occurs. Ensure that you are getting adequate rest in between training days to prevent tissue damage. The muscle requires 12-24 hours of rest following intense levels of physical activity in order to heal and repair damaged tissue prior to additional workouts (Koutedakis 2000). Set a mandatory rest period after summer intensives and avoid jumping into another intensive. It is recommended that a dancer takes a rest period of 2-5 weeks after an intensive or performance season to improve/maintain strength, flexibility, and aerobic capacity. Cross-training can be performed during rest periods (Koutedakis 2004). A rest period is critical for adequate recovery and time to reflect what you have learned.

1) Koutedakis, Y., & Jamurtas, A. (2004). The dancer as a performing athlete. Sports Medicine, 34(10), 651-661.
2)Bullock-Saxton, J. E., Janda, V., & Bullock, M. I. (1994). The influence of ankle sprain injury on muscle activation during hip extension. International journal of sports medicine, 15(06), 330-334.
3)Koutedakis, Y. (2000). " Burnout” in Dance: the physiological viewpoint.

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6/4/2018 0 Comments

Adjusting Food Intake for the Off-Season

Rest is essential for recovery and healing. It is a recommended to take a couple weeks off after a summer intensive. Adjustments in food intake should be made during these rest periods. Typically, one week is not enough time for your metabolic rate to decrease or for lean mass to dissipate significantly. However, durations longer than one week can result in loss of muscle mass and fat gain if you're not supplementing with resistance training and/or adjusting calorie intake. Plan to make small, simple changes to account for the reduced calorie expenditure when you're not dancing. Be careful not to overcompensate with extreme calorie restriction.This is counterproductive and can cause muscle loss, illness, and injury when you begin training again.

What adjustments should be made to diet during the off-season?

Continue to practice healthy nutrition habits as recommended during training.
Slightly reduce portions of meals and snack sizes. Approximately 250 fewer calories per day are needed if your goal is to maintain your weight during your break. A larger reduction in calorie intake can lead to loss of muscle mass and should be avoided.
Be aware of hidden and unhealthy fat in foods like salami, biscuits, pastries, sausage, and other processed meats. Some of these convenience foods that you might eat while training for hours a day become a serious problem when you are sedentary.
Increase the proportion of vegetables in your meal and slightly reduce the starch or protein portions. Do NOT cut out entire food groups.
Consume at least 2 cups of fruits and 2½ cups of vegetables a day.
Don't skip meals and avoid fad diets (e.g., Paleo, detoxes, juicing).
Drink at least 6 to 8 glasses of water each day. Have no more than 2 to 3 cups of caffeinated drinks a day. Be aware of calories from alcoholic beverages.

Cross-Training During Off-Season
Rather than restricting calories during vacation or off-season, consider cross-training with cardio and resistance training. Low-impact, moderate-intensity cardio such as swimming or fast walking are excellent options to allow for extra calorie burning and promote muscle retention. Walking at ~3.8 to 4 miles per hour (3 to 4 miles/day) or swimming for 30 minutes at a moderate intensity are good options. Add light resistance training with weights, Pilates, or yoga while on a break from dance in order to maintain flexibility and promote muscle gain.
Enjoy your summer and remember that you deserve a break!

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5/9/2018 0 Comments

Dancing Through Burnout

Burnout or overtraining can be characterized by:

Long-standing fatigue
Reduced performance without a specific cause
Behavioral/emotional changes (Koutedakis 2000)

Risks for burnout and injury:

Inadequate rest: Muscle requires 12-24 hours of rest following intense levels of physical activity in order to heal and repair damaged tissue prior to additional workouts (Koutedakis 2000).
Fatigue: Dancing > 5 hours per day can lead to fatigue and increases risk for injury (Koutedakis 2000).
High frequency of classes: Dancing >20 hours per week can increase likelihood of burnout.
Poor diet: Most dancers consume less than 70-80% of their recommended caloric intake. Inadequate intake can contribute to deterioration of lean body mass, which can negatively impact physical performance.
Lack of cross-training: Diversifying physical activity helps prevent muscle imbalances and can improve endurance and strength without redundancy.
Reduced endurance: Aerobic capacity levels are lower in dancers compared to other athletes.
Decreased strength: Dancers have less lean muscle mass and strength compared to other athletes. In addition, they load their muscles suboptimally, which can result in further strength decreases (Koutedakis 2004).

Signs/symptoms of burnout:

Frequent injuries
Constant fatigue
Frequent respiratory tract infections
Behavioral/emotional changes such as reduced appetite, loss of excitement for dance, irritability, anxiety, and depression
Weight loss
Alteration in sleep patterns
Changes in technique
Inability to recover sufficiently after training
Menstrual changes
Weakening of the bone
Increased resting heart rate and blood pressure
Reduced heart rate recovery after normal levels of dancing

Decreased ability for the body to utilize oxygen during maximal exercise
Reduced muscle strength
Increased time to heal
Increased susceptibility to infection (Koutedakis 2000)

Solutions and setting realistic expectations:
1) Allow for full rest days in between heavy training days. This will provide adequate time for tissue healing and recovery and prevent further tissue damage.
2) Set mandatory rest periods after performance seasons and summer intensives. It is recommended that a dancer takes a rest period of 3-5 weeks off from dance. Research shows that rest periods improve/maintain strength, flexibility, and aerobic capacity. Cross training can be performed during rest periods (Koutedakis 2004).
3) Get adequate sleep. Dancers may need up to 9 to 10 hours of sleep per night during intense training periods. Set an early bedtime for yourself and try to avoid screen time distractions before bed.
4) Eat a balanced diet. It is important to have adequate nutrition to boost your immune system and optimize your performance.
5) Don’t work through fatigue, illness, or injury.
6) When returning to dance, slowly ramp up activity load. Consider starting with a modified dance schedule when returning from rest periods.
7) Increase endurance. Most injuries occur when a dancer is fatigued and therefore it is important to improve aerobic capacity to delay fatigue. About 20 minutes of moderate to vigorous cardiovascular exercise such as swimming or cycling can bring about aerobic fitness increases. Swimming is a preferable choice for improving endurance over activities such as running or cycling, which place much more demand on the lower extremities (Koutedakis 2004).
8) Increase muscle strength. Body conditioning, weight lifting, and pilates are excellent for increasing lean muscle mass.
9) Address the signs of burnout early to avoid prolonged symptoms.
10) Consider reducing your schedule intensity if you are dancing > 5 hours a day or > 20 hours per week.

REFERENCES:
1) Koutedakis, Y. (2000). " Burnout” in Dance: the physiological viewpoint.
2) Koutedakis, Y., & Jamurtas, A. (2004). The dancer as a performing athlete. Sports Medicine, 34(10), 651-661.

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3/5/2018 0 Comments

Injury Incidence and Prevention Tips

Dance is highly demanding and requires exceptional flexibility, balance, power, agility, coordination, and endurance. To properly execute movements, a dancer assumes positions that place excess stress on bones, muscles, tendons, and ligaments, thus leading to high injury rates. The injury incidence is reported to be as high as 5.6 per 1,000 dancing hours for pre-professional dancers, and 4.44 per 1,000 hours in a company of professional dancers (Allen et al, 2012). In comparison, the injury rate for elite gymnasts is 2.86 per 1,000 hours and 0.69 for novice gymnasts (Saluan et al, 2015). Gymnasts have a higher percentage of traumatic injuries, whereas 75% of the injuries sustained in dance are related to overuse. Overuse injuries are caused by repetitive movements/stress which can lead to micro-injury of the tissue that is being loaded. If the injury rate exceeds the rate of healing/repair, the tissue can become damaged (Sephton, 1998).

The majority of dancers are fatigued at the time an injury occurs. This is because fatigue compromises muscle performance, coordination, joint stability, and neural feedback (Liederbach 2012). Overuse injuries tend to be more severe in nature and result in more dance time lost. Lower leg injuries are reported to be between 66 and 78% of the injuries, whereas foot/ankle injury comprises 14 to 57% of all injuries among dancers. Injuries sustained during class and performances are more severe than injuries that occur during rehearsals (Allen 2012).

Common risk factors for injury include:

Delay of recognition
Prior history of injury
Premature return to dance before full recovery
Lack of proper training
High number of dance hours
Insufficient warm-up prior to dancing
Lack of shock absorption from improper shoe wear and hard flooring
Nutritional deficiencies
Biomechanical imbalances such as inadequate turnout, lack of core control, or weak lower body strength (Russell, 2013)

General principles for avoiding injury include:

Increase aerobic capacity
Plan for adequate warm-up and avoid over-stretching
Improve technique
Cross-train to help with muscle imbalance
Know the signs of a potential injury and don’t resume dance until the injury is resolved
Wear protective and adequate fitting shoe wear
Establish rest periods
Hydrate and eat a balanced diet (Allen, 2014)

The injury rate has been significantly reduced with medical management. Therefore it is essential to seek a healthcare professional with experience in dance if pain persists. Dr. Chris Koutures (http://www.dockoutures.com) provides very useful insight on signs that an injury may be developing in "Dance Discomfort: Deciding to Dial Up a Dance Medicine Specialist" (http://www.activekidmd.com/dancersdiscomfort/). Koutures has extensive experience in treating dancers and is an excellent resource for all dance-related injuries.

References:
1.Allen, N. Nevill, A. Ballet Injuries: Injury Incidence and Severity over 1 Year. Journal of Orthopaedic and Sports Physical Therapy. Vol 42, number 9, September 2012. 781-790.
2.Saluan, Paul et al. “Injury Types and Incidence Rates in Precollegiate Female Gymnasts: A 21-Year Experience at a Single Training Facility.” Orthopaedic Journal of Sports Medicine 3.4 (2015): 2325967115577596. PMC. Web. 4 Feb. 2018.
3.Sephton, Sharlene. "Foot Injuries in Dancers." ADVANCE for Physical Therapy and Rehab Medicine (1998) Web. 4 Feb. 2018.
4.Liederbach, Marijeanne. "Epidemiology of Injuries in Dance: Biopsychosocial Considerations." Principles of Dance Medicine: Clinical Management of the Dancer Patient. July 12, 2012, New York University Langone Medical Center. 2012. Print.
5. Russell, J. A. (2013). Preventing dance injuries: current perspectives. Open access journal of sports medicine, 4, 199.
6. Allen, N., Ribbans, W. J., Nevill, A. M., & Wyon, M. A. (2014). Musculoskeletal injuries in dance: a systematic review. Int J Phys Med Rehabil, 3(252), 2

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1/23/2018 0 Comments

Welcome to Health en Pointe!

Our goal is to empower the dance community by providing helpful tips and resources to optimize health, improve function, and ultimately extend one’s career. Pursuing a successful dance profession should not inflict chronic pain, perpetual stress, or diet confusion. The competition and politics of the dance world can be discouraging, but with realistic and intelligent strategies to address your challenges, you can thrive as a dancer! Health en Pointe provides evidence-based information on injury prevention, nutrition, and wellness for current and former dancers.

We are a qualified team of health professionals that understand the life of a dancer. Here is some information about the founders of Health en Pointe, Moira the Physical Therapist, and Nasira, the Registered Dietitian:

Moira is a former competitive gymnast and dancer. She trained at various summer intensives such as Kaatsbaan Ballet and Houston Ballet. She graduated Summa Cum Laude from the University of Arizona with a B.F.A in dance. She danced and performed pieces in jazz, modern, and ballet. In 2015, Moira graduated from California State University Long Beach with a Doctorate in Physical Therapy. She has also completed training in vestibular rehabilitation from the prestigious Rehabilitation Institute of Chicago. Currently, she is working at Progressive Physical Therapy in Costa Mesa. She is also serving as the PT resource for the ABT Gillespe School in Orange County. Her extensive dance background in various movement styles engendered a unique understanding of complex movement patterns and translated into a knowledgeable approach to treating movement dysfunction. In addition, her first-hand experience with dance affords her unique understanding on preventing and treating the various disorders associated with dancers of all ages. In her free time, she teaches Pilates and lectures on prevention and management of dance related injuries. She is working on completing her Pilates apparatus accreditation with Body Arts And Science International (BASI) and is actively incorporating her learned skills in daily treatment sessions.
Nasira is a registered dietitian, fitness expert, and professor of nutrition. She was drawn to public health and nutrition as a result of her diverse background in science, fine arts, and fitness. Nasira is currently an adjunct faculty member at Chapman University, a private practice registered dietitian, and post-doctoral researcher. She also guest-teaches ballet throughout Orange County. She has been a classical ballet dancer for over 18 years and trained with Pacific Northwest Ballet in Seattle, WA and the University of Arizona School of Dance and attended summer intensives at the National Ballet of Canada and American Ballet Theater NY. The BFA program at the U of A prepared her for a career as a professional dancer, choreographer, and dance instructor, however, her passion for science led her to pursue an alternative path. Upon graduating Summa Cumma Laude from the University of Arizona, Nasira continued her studies in pursuit of a career as a nutrition professional and obtained a Masters in Public Health from UCLA and a Doctorate in Nutritional Sciences from Loma Linda University. Nasira has been a certified personal trainer since 2008, and is a certified yoga instructor. Her experience in the fitness industry has deepened her knowledge of biomechanics and kinesiology, which has improved her dance technique and understanding of injury prevention.

We hope you find Health en Pointe to be an integral resource and become a better dancer because of it. We encourage your active participation in this blog and welcome comments, questions, and sharing. Please visit us often!

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Am I ready for pointe work?

Preparing for Summer Intensives: Tips for Going In Healthy and Leaving Stronger

Adjusting Food Intake for the Off-Season

Dancing Through Burnout

Injury Incidence and Prevention Tips

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