The Dancer's Injury

     Technically, by definition, we recognize Art as the quality, production, expression, or realm, according to aesthetic principles, of what is beautiful, appealing, or of more than ordinary significance¹ , and Sport as an athletic activity requiring skill or physical prowess and often of a competitive nature¹.  Artists and athletes are viewed as being from two distinct subspecies.  Today Dancers perform and compete quite regularly so that boundary between artist and athlete has distinctly blurred.  Professional dancers get hurt just as often and suffer just as serious injuries as athletes in contact sports.  The practices, so often segregate, as performing arts medicine or sports medicine must coalesce when considering a dancer’s care.    For the last twenty years a special group of dedicated clinicians have worked targeting the special needs of the performing artist (See PAMA - Performing Arts Medical Association).

 What is it really that makes the dancer prone to injury?  Their bodies are conditioned so perfectly to their craft.  Their endurance is profound.    In part it is the need for repetition, the essential mandatory rehearsal of a set of moves performed until the sequence flows from their bodies without requiring thought.  Simultaneously they concentrate on sequence as well as form and music not to mention expression though this is more a feeling than a thought but still, it is part of the dancer’s awareness as they move.  Each element contributes to the motion they produce, to the energy being transferred through the trunk and limb and this is what a dancer must master.  It is so common to hear them say “it was silly really, how I hurt myself” and one will almost always be able to trace a dancer’s injury to a moment of distraction.  The moves themselves are obvious.  The injuries themselves fairly predictable. 

     The statistics do not seem to change over time.  A dancer sprains ligaments and strains muscles. Partners will see disc injuries and more traumatic ligament and muscular damage.   Degenerative changes will plague older dancers, with joint diseases affecting the spine, ankles, knees, hips, feet and shoulders.  In approximately this order one sees clicking hips, hallux valgus (bunion), patella disorders,  stress fractures, scoliosis, coxarthrosis, and spondylolysis as the usual leaders. Competent clinicians know how to treat these.  The trick is realizing that successful treatment of a dancer requires acknowledging more than just the injury as part of the problem to be overcome.  The successful treatment of a dancer involves artful negotiation between the clinician and patient, compromise that will allow adequate healing as well as continuation of their performance.

1.       Dictionary.Com

Workout Basics

     The potential variations are endless, but here are the underlying principles.

Aerobic exercise increases metabolic rate, burns fat and improves cardiac function.

Anaerobic exercise pushes beyond pure aerobics increasing metabolic rate, building endurance, enhancing power and further improving cardiac health (in those who are healthy enough to tolerate this).

    When one performs aerobic exercise for up to about 30 minutes, one taps into purely aerobic mechanisms (as a generalization).  Beyond the 30 minutes one starts tapping into anaerobic metabolism which is a more efficient calorie burner.

Weight training: as a topic can be overwhelming. In an oversimplified summary:

 Lower weight/more repetition:  builds some muscle, builds endurance, burns calories to a lesser degree, increases muscle metabolism.

 Higher weight/few repetition: builds muscle, builds strength, builds power, ultimately enhances the long term metabolic rate.

          Aerobic sessions should be at least 30 minutes long, but 45 – 60 minutes will allow one to accomplish more.

          Weight training sessions should include enough work to fatigue at least 4 major muscle groups.

          You can combine aerobics and weight training through calisthenics…. Call these mixed sessions.  I call them boot camp exercises.

          Abdominal strengthening should be viewed as its own category and should (my opinion) done at every workout.

Aerobic workouts should be vigorous enough to get the heartrate up to at least 130 and no more than 160 for 25 minutes or longer.  You get more cardiac and metabolic benefit from an aerobic workout if the intensity is varied throughout the session (It also makes them less boring). Straining for a few minutes at a higher intensity makes a lower level exertion seem easier.  In this way a medium intensity that seemed hard, done after a few minutes of a really hard exertion, now seems easier…. You end up tolerating a higher average intensity by the end of the session.  Not a bad way to progress your workouts. 

Aerobics:  At least three sessions a week, though 4 – 5 are the ultimate goal.

Walking: Walk for 30 minutes at a medium pace (2.5 miles/hour).

          When this gets too easy, add two to five minute intervals of walking as fast as you can.  Once you can do 3 five minute intervals at a speed pace in a 30 minute walk, increase the length of the walk.  You can also use three levels of intensity, in the same way ( for example: 3 minutes warm up, slow pace, 5 minutes medium pace, 2  minutes fast pace, 3 minutes medium pace, 2 minutes slow pace, 5 minutes fast pace 3 minutes medium pace, 2 minutes slow pace).

          A 30 minute speed walk with no slow intervals is a good “medium to hard” aerobic workout when you don’t have a lot of time.  This would be a session where you do not vary the intensity, but keep it high the whole time, but for a shorter workout time.  This is a good thing to do at least once a week.  When 30 minutes at your highest intensity gets too easy, you’ll need to find something to do that is harder than walking ( ie run, bike, swim or join a gym to have access to other aerobic equipment)

For any other type of aerobic workout, the same system of varying intensity can be applied.

Add calisthenics to a walk:  Add 30 second to 2 minute intervals of lunging steps, or broad jumps or skips.  Walk backwards for segments, jog, or sprint.

An excellent way to build functional power and endurance is to interrupt an aerobic walk with 2-3 minutes of abdominal crunches, pushups, or other stationary calisthenics.

Just Breath

Take a deep breath.  Are you sure you did the best you could?  You should be standing or sitting with good posture while you do it.  So, back straight, head on top of your body, shoulders back, pelvis in neutral, stomach in, knees soft and fingers and toes relaxed.  Now for some of you this is a delicious position of release and for other, TORTURE.  The latter group should read on. 

      The body prefers a neutral posture like the one I just described.  And when you start any breath or movement from that position you will find it so much easier.  But for now the goal is just to breath. 

      First, tackle the back.  Make yourself as tall or long as you can be, reaching up toward the ceiling and down toward the floor at the same time with the opposite ends of your spine.   Once you are convinced you cannot stretch any taller or longer release the tension without losing any of the length.  In doing this you probably bent your head forward so please replace it back on top of the shoulders.  And the shoulders, notice that with the head now neatly on top of the neck, you can easily see both of them in your peripheral vision?  Well this is wrong.  You see them because they are in front of you, and their place is at the side almost aligned with each ear (almost but not quite that far back).  You will want to “roll” the shoulders slightly (we call this direction outward, and when I say we I mean the <cough> experts - doctors, therapist, trainers, dancers, movement specialists etc).

If you are having trouble rolling the shoulders, here is a tip: first straighten both arms in front of you as if you were about to imitate a zombie walk, then bend them both at the elbows (your elbows should be touching your sides).  Turn the forearms so that the palms are turned up without moving the elbow.  Now again, without moving the elbows, move the hands, right to the right, left to the left, to the sides of your body in a horizontal motion.  Voila, this rotated the shoulders.

     Top done, here comes the trickier parts.   Without formal dance training, many people have issues with the concept of pelvic neutral.  Forget everything else for a minute and focus just on your hips.    Standing is probably preferred here but you can do this seated.  To find your neutral pelvic position, arch your back as hard as you can pushing your hips backwards (do not move your head or your feet) and then relax.  Next, curl your hips under you, pushing them forwards as far as you can, again without moving your head or your feet and then relax.  Do this a few times.  That place that the hips comes to rest every time?  That is your “pelvic neutral” position.  Tadah!  With a little practice you learn what that position feels like and you just know when you are in it.  It becomes easy to assume “the position”. 

        Stomachs prove another trouble area for many, compromising so many simple motions unnecessarily.   Dancers brace and this is a worthwhile trick everyone should learn.  To brace you pull the stomach in as you inhale (nice deep breath).    As you exhale, let the air out but keep the stomach in (keep the muscles contracted, the stomach flat).  I know, yet another thing that will require some practice but well worth it.  Practice moving around after bracing and eventually you will find it quite simple.

The term “knees soft” refers to knees held in a position slightly bent so that there is no tension in the legs at all.  If you try standing on fully straight knees and then bend then just slightly you will see the difference.    When isolated a straight knee does no work, but in conjunction with a braced abdomen, a neutral pelvis, a straight back etc, etc more work is needed to keep the legs completely straight, and so a correct posture requires soft knees.

      Finally. We must not forget, after all this work, that our endpoints, the fingers and toes should not be gripping at those last bits of tension we subconsciously cling to, so always take a second to remember to relax the fingers and toes.

      

Now, you have your posture and can take a breath.  Inhale through the nose.  Take a nice forceful breath of air that fills your lungs.  Your chest should move and should lift your arms a bit.  Your spine will feel as if it gets a little longer. When you cannot comfortably take in any more air, pause for a second and then with an even flow of air, exhale through your mouth.   Do not be afraid to purse your lips slightly.  Feel your shoulders slope downwards as you exhale.  Your arms lower and your hips sink slightly.  If you have done this all correctly you may even feel your body sway slightly.   That makes sense.  If you fill something with air, it gets lighter, right?

      

         Good Luck!

      

The Neck Pain Saga –Part 1 – The Trapezius

    The trapezius muscle originates at the base of the skull as well as from a thick ligament (ligamentum nuchae) that arises from the neck vertebrae and from the spinous processes of thoracic vertebrae.  It is a large muscle that is theoretically divided into three parts because its fibers lie in three directions and move differently.  The upper portion’s fibers insert on the lateral (outer) third of the clavicle.  The middle portion’s fibers insert on the acromion process (outer top portion) of the scapula.  The lower portion’s fibers insert on the spine of the scapula.  The upper trapezius (traps) works to elevate the scapula (shrug the shoulders upwards).  The middle fibers of the traps retract the shoulder blades (pull the shoulder blades back and together).  The lower fibers of the traps depress the scapula.   These actions set the shoulders in their proper position. In their proper position, the shoulder blades (the scapulae) form a support like a cup to cradle the head on top of the body.  So it is the trapezius muscle that forms this support meant to hold the head in an erect posture.  When we thrust our head forward we render the trapezius fairly useless of this major duty.   With our head forward, we use the muscles of the neck to support the head instead, dangling it in front of our shoulders.  These neck muscles are not meant to work this way.  Their fibers are aligned in other directions so that their optimal forces pull down toward our shoulders and chest not to push upwards toward our head.  When we use the muscles improperly, they fatigue, and even become damaged and this is the source of so much neck muscle pain and pathology commonly seen.  To correct, or better, avoid developing unhealthy posture and neck pain, one should maintain a healthy trapezius muscle.  Attention must be devoted to all three portions of the muscle.  Shoulder shrugs are a common exercise, well known to most that will exercise the upper traps.  Reverse flys are an example of an exercise that strengthen the middle trapezius though care must be taken to elevate the arms in a “Y” pattern and not simply extend them behind them horizontally because this will emphasize working the rhomboid muscle.  It is harder to find examples of exercises to strengthen the lower traps.   There is an excellent example pictured on the website :(http://www.staceyjaffmd.com/trunkwork.html) Standing with knees bent, slightly flexed at the waist with a straight back, keeping both arms straight, you hold a single weight in both hands and then raise and lower the weight for 12- 16 repetitions.  In the exercise pictured a simultaneous squat is performed to maximize the work accomplished.  There are other trapezius exercises as well, these are just examples. 

      With a strong, healthy trapezius you set yourself straight, literally, correcting, at least, one plane of your posture. 

Getting in shape for a new activity.

     Blog number one.  I wonder how often they start this way?  I have not read many.    It took quite a while to set up the site so my creative drive to write has ebbed.  But this was to be a short topic. 
     I bought new boots this weekend, Labor Day sales adding to their irresitable appeal.  Taupe, suede, to the knee with five inch platform heels.  Now those readers who might be doubting that a board certified physician, especially one specializing in Physiatry might ever purchase such high heels please remember I am human first, and female.  These two aspects of me will win over the medical degree almost always when there are boots at stake, at sale price, that fit well.    I was practical for about 10 minutes in the store, making sure they fit and that I could walk normally.  Then I strut around for another 10 minutes squealing inside (subconsciously making sure my toes did not turn gangrenous).  When I got home I started my new exercise program.  If I am to wear these new boots I am going to have to get my ankles in shape for them.  Ah, here is where my geek shows.  The shoes fit, do not misunderstand me.  But my ankles are not used to holding my weight in the position of such extreme equinus (that means my foot in an extreme pointed position like a ballerina pointing her toe).  I need to improve the range of motion across my ankle, specifically, plantarflexion (or pointing my foot).  I found a photo of the position I like best for stretching the front of the ankle and lower leg:

You gently lean back onto the left leg in this position, using your arms to hold your weight so that you do not over stretch.  You should not feel any pain.  Try holding the position for 30 seconds, fo this 3-5 times each day.  Then switch legs.

    I also wear the boots around the house for short times (30-60 minutes) for conditioning purposes.  The only problem there is that I need help getting them off.  The guys down at the front desk have been very kind about helping with that. 
       See, I do take my own advice.  I do get in shape for "extreme" new activities.