Welcome back to the dance blog! Ok so we’ve spent several weeks now discussing common
injuries in dance. Specifically we’ve been looking at injuries of the “lower chain.” The lower chain, to recap, is the pelvis to the hips to the knees, the ankles and the feet. Arguably the most important area of consideration when discussing dance. The lower chain is not only where the majority of dance injuries occur but additionally, is what most contributes to making dancers as a patient population such an exceptionally unique population.
Over the past several weeks we’ve been looking at anatomy, pathomechanics and treatment
options for various injuries including; ankle sprains, ACL tears, meniscus tears and acetabular labrum tears. As I mentioned during last week's blog post, and as you may have noticed as we’ve progressed through the various injuries, there are a lot of commonalities in how a dancer injures a given joint in the lower chain. Essentially, sudden or unexpected pivoting or rotational movements are the culprit when it comes to the injuries we’ve discussed so far. At least when it comes to other athletic populations, sudden or traumatic events cause these injuries the vast majority of the time.
When looking at dance however, these pathomechanics don’t seem to be responsible for this
collection of injuries. Instead we’ve discussed how the very nature of dance training should, in theory, actually safeguard dancers against these injuries. The choreographic nature of dance combined with the repetitive drilling of technical movements should all but eliminate the risk of sudden and unexpected pivoting or rotational movements. And yet, with the exception of the ACL tear, the injuries discussed thus far are common amongst dancers. So how does that make sense?
How can it be possible that an athletic population that regularly rehearses pivoting and rotational movements and that, generally speaking, choreographs its movement so as to eliminate unpredictability still commonly suffer from injuries caused by sudden pivoting and rotational movement? Well the answer is simple… it isn’t.
Does that sound confusing? Well, let me explain. When it comes to the larger athletic population it is true that ankle sprains, meniscus tears and acetabular labrum tears are most commonly caused by sudden pivoting or rotational movements. These are normally traumatic and sudden events. This is the soccer player running into and colliding with another soccer player. It’s the footballer getting tackled at the knee from the side, bending the knee medially. But these occurrences are incredibly rare in dance. Rare is it that a dancer collides with another dancer on stage. And I am yet to see a dancer tackle anyone during a performance.
So what’s the deal? Well, as I discussed briefly last week, the way we train dance goes a long way in eliminating unpredictability in dance movements. That’s good as it lowers our chance of suffering these kinds of injuries. However, there are aspects of dance culture that favor certain aesthetics which result in a method of training that specifically increases our chances of these injuries. Specifically I’m talking about the long valued 180 degree turnout and hyperflexibility.
Dance as an industry has a long running trend of favoring dancers who are either hyperflexible, possess 180 degree turn out (appear to anyways) or have both. The problem is this, the vast majority of dancers don't possess an anatomical turnout at 180 degrees. And no dancer should be pursuing hyperflexibility period! The result of this industry favoritism is that many dancers train specifically to attain these traits so as to better their odds of making a successful career of dancing. This is where the biomechanics come into play.
When we try to make our turnout appear to be 180 degrees, i.e. force our turnout, what we are most oftenly doing is increasing the external rotation by twisting the tibia on the femur. This increases the amount of force expressed across the knee. Specifically, it increases the amount of force expressed along the medial meniscus. Visually, this is the dance with “180 degree” turnout whose knees drift medially during plié. This medial drift focuses all the forces in the knee through the medial meniscus. Over time, repetitive loading and unloading of the knee joint results in derangement of the medial meniscus. This increases the probability of a medial meniscus tear, the most common meniscus tear in the dance populations.
Similarly, in regards to hyperflexibility, many dancers engage in static stretching with the goal of increasing their flexibility as much as possible. Often, this is done without as much of a focus on muscle strengthening exercises, generally due to the fear of strength training limiting flexibility. This leads to an imbalance between flexibility and strength that favors flexibility and as a result destabilizes the various joints in the lower chain. This destabilization results in uneven and fluctuating amounts of force being expressed across the various joints.
This is compounded if the dancer engages in unhealthy stretches such as oversplits which, as we’ve discussed before, permanently deranges the hip capsule DRAMATICALLY altering how forces are expressed through the joints of the lower chain. In fact, hip derangement the likes of what is caused by oversplits directly increased the probability of experiencing an acetabular labrum tear.
Looking at a dancer who engages in both forced turnout and hyperflexibility and we can see that such a dancer is, in many ways, directly training to experience one of these injuries. And this is where the big difference in how these injuries occur in dancers versus other athletic populations is highlighted. While most athletic populations suffer one of these injuries following a sudden, traumatic event, in the dancer population these injuries are actually a result of repetitive derangement over time. I like to call this injury type the “one bridge too far” injury.
So while it may appear that these injuries happen to dancers following landing from a jump or changing directions quickly, the reality is that these injuries are being trained for due to a pursuit of unhealthy dance ideals such as the perfect turnout or hyperflexibility.
And to further support this claim, let’s return to the ACL tear. As I mentioned in my blog post on ACL Tears, the rate of occurrence within the wider athletic population is as high as 8%. In the dancer population however, it’s closer to 0.4%. That’s a HUGE difference. And it totally makes sense. Recall that while sudden pivoting and rotational movements do contribute to ACL tears, there is an additional requirement of anterior translation of the Tibia on the Femur. This is an important difference as there is no benefit to engage in any stretching that increases flexibility of the Tibia on the Femur in the anterior direction.
Rather the bigger emphasis is on medial flexibility secondary to that forced turnout. As a result, we aren’t training the biomechanics needed for an ACL tear the same way that we are a medial meniscus tear. This is why the dancer population experiences ACL tears at a rate so much lower than the rest of the athletic population. When it comes to ACL tears, the benefits of the choreographic nature of dance isn’t being undermined by unhealthy training practices.
It’s worth noting here that in the wider athletic population ACL tears are often more common than meniscus tears. Adversely, in the dancer population meniscus tears are much more common than ACL tears and it’s because of unhealthy training practices like pursuing hyperflexibility and forced turnout.
Don’t get me wrong, I’m not arguing that dance should stop performing leg movements above 90 degrees or that all dance should be performed in parallel. I AM however, calling out the industry and dancers within it to reconsider whether or not these increased risks of injuries, injuries that we should be protected against, are worth it for that extra few degrees of unstable turnout.
Often in the dance world there is a fear that if you don’t possess these traits that you will
somehow not be valued or that it will be harder to get a job. This is a part of the dance culture that needs to be challenged and ultimately changed! And understand that some of our industries greatest dancers didn’t actually fall into many of the “norms” that we think of when we think about dance. Mikhail Baryshnikov, began his life as a gymnast. He was all of 5’6” and in a world where the average male ballet dancers was no less than 5’10” and more often around 6’, Baryshnikov not only excelled in the dance industry, he is still considered today to be one of the greatest male ballet dancers in dance history. So maybe, just maybe, we can still create world shaping artists even if they don’t possess 180 degree turnout or hyperflexibility!
Alright, that’s a wrap on our discussion on common injuries of the lower chain. We’ll no doubt
return to this area of discussion and include more injuries and even expand to the upper chain but for now we're gonna change it up. Join us next week as we begin to talk about something that I honestly have never heard someone talk about in regards to dance and dance training. Next week we’re gonna look at the menstrual cycle in bio-sex females and talk about how hormone fluctuations through the cycle should be paired with different methods of training. We’ll talk about when in your cycle you should ease up on training intensity due to an increased risk of injury and when you should double down and take advantage of energy surges created by your hormone levels.
In the meantime, this week’s dancer shout out is Michela Semenza. Michela began her dance training at the Myers Ballet School performing in productions with the Northeast Ballet Company. She attended Hudson Valley Community College where she earned her Associate’s degree in science, majoring in Fine Arts. Michela continued her college education at the prestigious collegiate ballet program with Butler University, where she received a Bachelor of Arts in Dance Pedagogy in May of 2020. Michela has trained with the Central Pennsylvania Youth Ballet and has performed across Eastern Europe with the Butler Ballet ensemble. Besides ballet, Michela has trained extensively in both jazz and modern dance training in techniques such as Siminson, Cunningham and Graham. Michela is currently an apprentice with the New York State Ballet Company. Make sure to check her out during their upcoming production of the Nutcracker!
If you've been reading these blogs then you know that the New York State Ballet is a good friend of ours here at Pinnacle Hill Chiropractic. And as we all know, COVID-19 has left many sectors of the American economy struggling to survive. Among these are the arts. It’s never been more important to support local businesses and art communities. With that said, I’d like to draw some attention to the New York State Ballet’s upcoming production of The Nutcracker. Performances will be held on December 23rd, 26th and 27th. Now due to social distancing and other safe health practices ticket availability is limited. The good news is, the show will be entirely streamable so there's no reason not to watch! Nutcracker is a Christmas staple if you’re a fan of dance and even if you’ve never seen a show it's a great tradition to start with the kids and grandkids. So help support local businesses and help to support the arts by visiting the New York State Ballet website and purchasing a ticket on December 12th when the box office opens.
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