Caring for Muscles During the Performance Season

            "Take care of your body.  It's the only place you have to live." - Jim Rohn

          With the Nutcracker performance season upon us, dancers will be spending extra hours in rehearsals, numerous hours in theaters, and will be expending tons of energy entertaining countless audience members.  While performing is the ultimate goal of dance training, it still takes a toll on the body.  My last post addressed the risk of injuries that result from overused and fatigued muscles.  Over the long term, cross-training and periodic training can help prepare dancers for the stress of performance, but it is also important for dancers to know how to care for their muscles during the performance season.

            It is extremely important for dancers to warm-up before all rehearsals and performances.  Warming-up increases blood flow to the muscles, which ensures the delivery of oxygen and fuel, and raises the internal temperature of the muscles, which leads to the increased flexibility necessary to perform beautiful grand jetés and développés.  Most companies will hold a formal warm-up class before rehearsals and performances, but if there is not one available, it is each dancer’s responsibility to take the time to sufficiently warm-up his or her body to reduce the risk of injury.

            After the warm-up is complete and while the dancers are waiting for their turns on stage, is the perfect time to don all those fashionable sweaters and leg warmers that dancers always carry around in their bags.  Many dancers mistakenly wear these clothes at the beginning of class and peel them off as the body grows warm.  Their intended purpose is to keep already warmed-up muscles from growing cold while waiting.

 

            Drinking water is also a necessity to keep muscles working well.  Hydration is extremely important when trying to avoid muscle cramps.  Muscles are 70% water, which is why the fibers can move freely against each other.  When muscles are dehydrated, the lubrication decreases and movement becomes painful.

            Muscles should definitely be stretched once a performance and/or rehearsal are completed.  Static stretching in the wings before an entrance will not help a performance.  Instead it may hinder it!  My post on different types of stretching will help you understand why static stretching before a performing may actually decrease a muscle’s ability to contract efficiently.  When static stretching follows a performance, however, it is a valuable part of the cool-down that keeps dancers flexible and allows time for the internal temperature of the muscles to gradually decrease.  Stretching and cooling down reduce the chance that muscles will cramp or go into spasm when leaving the studio or theater.  Being sure to wear warm clothes over dance clothes  will also help keep muscles from cramping when dancers leave a warm studio or theater and move out into colder air.   

 

            Finally, a snack that is high in protein will help repair any minor muscle damage that might have occurred while dancing and help ensure that the muscles will be ready for another several hours of rehearsing and/or performing the following day.

            

Dancers, Fatigue & Injuries

           "Fatigue makes fools of us all. It robs you of your skills and your judgment, and it blinds you to creative solutions. It's the best-conditioned athlete, not the most talented, who generally wins when the going gets tough." - Harvey Mackay


Participation in any type of physical activity bears the risk of injury.  Injuries occur in all types of sports programs and across all forms of dance.  With the increased availability of educational information about cross-training and caring for the body, Sports Medicine and Dance Medicine professionals are hoping to decrease the incidence rates, but it is interesting to look at when injuries are more apt to occur and why.

            Studies within the dance community have indicated injury rates as high as 95% in professional ballet dancers and 82% in professional contemporary dancers.  Injury rates in dance are comparable to those in other professional sports.

            Research has shown that 67% of dance injuries occur late in the day and that 75% of all injuries occur during preparation for performances when bodies are tired and/or overworked.   The lack of time and resources for tissue repair, additional hours of rehearsal, and constant repetitive movements when rehearsing specific phrases from dance pieces have all been cited as causes. 

            Dancers are known for diets that are low in nutritional value.  They are constantly going to extremes to avoid foods that may cause them to gain weight or diminish the aimed for aesthetic in the dance community.  Performance and rehearsal schedules allow little time for careful meal planning and food consumption, and it is difficult for dancers to consume enough calories to equal the amount of calories burned during an intensive performance season.

             Additionally, a large percentage of female professional dancers are amenorrheic, or do not have regular menstrual cycles.  The absence of a monthly period results in abnormal estrogen levels which reduce the amount of calcium that the body can absorb and use for repair. 

            Although most athletes’ bodies are able to use protein to recover quickly from minor muscle tears, this is not the case for dancers.  Without a proper diet filled with additional calories for tissue repair, the body is placed under stress during normal situations.  Once the intense performance season begins, the body is unable to care for itself efficiently.

            When this nutrition deficit is combined with a rehearsal/performance schedule that allows little time for rest and recovery, dancers are placed at a high risk for injuries.  While a minor breakdown in body tissue can be sufficiently repaired during an interval of rest, in dancers, who do not have sufficient rest time, the breakdown of tissue becomes greater than the body’s ability to repair, or remodel. 

            When the same muscle groups are used repeatedly during long hours of rehearsal and performance, they grow tired and use up their energy reserves.  When the central nervous system (CNS) receives the message that a muscle is fatiguing and having difficulty holding a contraction, it either tries to get the muscle to work harder, or activates surrounding muscles (synergists) to help.

            Muscular fatigue is only one piece of the puzzle.  Long work hours also stress the central nervous system.  The CNS uses sensory input to determine where the body is in space.  Messages communicated through visual clues and proprioceptive clues help the CNS determine which muscles need to contract and to determine the force that must be used to keep the body moving safely.  Although the body is engineered so that the CNS will protect the tired muscles by directing adjustments in the body, when the CNS is stressed, its ability to direct these adaptations slows down.  The delayed response affects motor control and coordination.  Landings from jumps and the body’s ability to slow down after leaps or turns are affected.  As a result, the way the body normally distributes the stress over the bones and joints is also compromised.

            The change in stress distribution and the lag time in reorganizing the muscular response set the body up for injuries.  All of these factors explain why most dance injuries occur late in the day or during an intense performance season.  Since dancers have a very high pain tolerance, when they get injured, they often do not realize it immediately.  Moreover, injured dancers tend to “dance through” the pain so they do not lose roles or jobs.

            In an ideal world, major rehearsals could be scheduled early in the day before the body is fatigued, and schedules could be designed to accommodate rest periods for dancers to allow for ample recovery time.  Unfortunately, rehearsal space is not always available at ideal times, and dancers need to be able to accommodate the schedules of theater personnel, musicians, and stage, sound, and lighting crews.  Additionally, audiences are only available after the traditional workday ends – in the evening.

            Educating dancers to listen to their bodies, eat properly, cross-train, and using periodization training can be helpful.  Rather than “dancing through” pain, dancers should be encouraged to care for injuries before they become chronic or more serious.  While eating properly has always been a challenge for dancers, a bit of knowledge about healthy foods and the convenience of food today make it easier.  Cross-training will strengthen all of the muscles in the body so that when some muscles fatigue, the synergistic, or helper muscles, will be prepared to start working, and periodization training can help prepare the dancer for performance season and alleviate some of the stress on the body.

            We are given one body to last our entire life.  It is up to us to learn as much as we can about how to dance in a way that preserves its health to the best of our ability.

---------------------------------------------------------------------

       Liederbach, M. Schanfein, L. & Kremenic, I. What is known about the effect of fatigue on injury occurrence among dancers? Journal of Dance Medicine and Science. 2013;17(3):101-8.

       Murgia, C. Overuse, tissue fatigue, and injuries. Journal of Dance Medicine and Science. 2013;17(3):92-100.

      Shah, S., Weiss, D. & Burchette, R.  Injuries in professional modern dancers: incidence, risk factors and management.  Journal of Dance Medicine and Science. 2012;16(1):17-25.

      Tajet-Foxell, B. & Rose, F. D. Pain and pain tolerance in professional ballet dancers.  British Journal of Sports Medicine. 1995:29:31-4.

Labral Tears of the Hip

            "To keep the body in good health is a duty... " - Buddha

               The joints in our bodies are protected by two types of cartilage.  Hyaline cartilage covers the surface of the bones and protects them from the friction damage that would occur if the bony surfaces rubbed against each other.  White fibrous cartilage can be found in joints that are subjected to frequent stress.  This type of cartilage helps keep joints intact and acts as a shock absorber.

            Movements that are repeated over and over again will gradually start to wear away cartilage just as a stream will erode the surface of a rock over time.  When joints are placed in unnatural positions, such as a turned out position, the body’s weight cannot be distributed normally over the joint, and undue stress is placed upon it.  Unnatural joint positions also occur when the dancer's body is misaligned or the dancer has a muscular imbalance.  When this stress is combined with repetitive movements, tiny tears begin to occur in the cartilage.  After a while these tears increase and result in bigger tears.  Additionally, jumps, leaps, pivots, and turns create enough force to cause cartilage damage on their own.  It is not surprising then that those who participate in ice hockey, soccer, football, golf, and ballet are at a greater risk for developing tears in the cartilage of the hip joint.

From arthroscopichipsurgeon.com

           
The labrum is a ring of white fibrous cartilage that can be found along the edge of the acetabulum, or the socket in the pelvis where the femur sits.  Its job is to hold the femoral head in place by increasing the depth of the hip socket. 

            The labrum often tears away from the acetabulum due to overuse and small injuries that may occur during twisting or pivoting movements and accumulate over time.  Dancers who experience a labral tear may complain of pain in the front of the hip, feel a “catch” in the joint when moving, experience stiffness in the hip, and/or have a limited range of motion at the joint.  These feelings may get worse after a long walk, or after staying in one position for a long time.  As the tear grows, the pain may radiate down the leg, to the side of the hip, or toward the lower back, and may become constant enough and severe enough to cause the dancer to avoid certain exercises and/or lessen the amount of time spent in class or rehearsals.

            If left untreated, a torn labrum can cause a shift in the way the femoral head sits in the acetabulum and increase the stress on the joint, predisposing the dancer to arthritis.

From arthroscopichipsurgeon.com

            Labral tears are diagnosed through an MRI scan of the hip.  More and more frequently, medical professionals are trying to avoid surgery and work instead with physical therapists to help dancers with this injury.  Anti-inflammatories will help with pain management, and physical therapists can work with dancers to eliminate any muscular imbalances they may have and to strengthen the muscles of the hip.  If the pain continues, cortisone shots can also help.  Because the inner side of the labral cartilage has no blood vessels, it has no way to repair and/or heal itself as do other soft tissues like muscles and tendons.

            If physical therapy does not work, or if the tear is too severe, surgery may be required.  During the surgery, any pieces of cartilage that have completely torn off can be removed, and the surgeon will trim the torn edge of the labrum and re-attach it to the edge of the acetabulum.  The recovery time for this type of surgery is a long one – 4-6 months with physical therapy for rehabilitation.

            The good news is that, although labral tears have been very common among ballet dancers, dance medicine specialists believe that education can play a key role in decreasing the risk.  Providing both dance educators and dancers with information about proper anatomical training, the dangers of muscular imbalances, the dangers of fatigue and overuse of the body, and the benefits of cross-training can help produce healthier dancers who can dance longer, stronger and happier without this type of injury.

Injuries of the Hip

            “There are three steps you have to complete to become a professional dancer: learn to dance, learn to perform, and learn how to cope with injuries.” - D. Gere

 The most common hip injuries among dancers are muscle strains, tendonitis, and bursitis.

            Dancers tend to have muscular imbalances because they repeat the same exercises and use the same muscles in the same ways over and over again.  These imbalances lead to tightness in certain muscle groups.  Tight muscles are susceptible to injury since they have a limited range of motion.  As a result, dancers often strain their hamstrings. 

            The hamstrings run along the back of the thigh and are responsible for extending the hip joint and flexing the knee.  As with all injuries, the dancer should rest the leg and use ice and anti-inflammatories to reduce pain and swelling.  Once healing begins, gentle stretching and rolling the injured area with a tennis ball or foam roller will help with scar tissue tightness and rehabilitation.

From physioanswers.com

            Tendonitis refers to the irritation and inflammation of any of the tendons that connect the muscles at the hip joint.  Tendonitis manifests itself as pain around the joint and develops gradually.  At the onset, the pain will lessen, or even disappear,  when the dancer is moving but will increase afterward.  Eventually, the pain will become constant and radiate to the knee and/or lower back.  The dancer will feel stiff and tight in the morning or after dancing and moving, and stretching will be uncomfortable.  Rest, ice, and anti-inflammatories will lessen the swelling and irritation and help to alleviate the discomfort.  Being sure to warm up the area completely before dancing will help as well. 

            Tendonitis is usually caused by muscular imbalances and/or alignment issues that place stress on certain areas of the hip.  When exercises are repeated over and over again while the body is misaligned and not working correctly, the tendons become irritated and inflamed.  A physical therapist who knows about dance can help determine the cause and help to correct alignment issues and/or suggest cross-training exercises to help with imbalances so the tendonitis does not keep recurring.

            Another condition that can be caused by muscular imbalances and/or misalignment in the body is bursitis.  Bursae are tiny fluid-filled sacs that help prevent and reduce friction at joints where body parts are constantly moving against each other.  The most common type of bursitis is trochanteric bursitis, which occurs on the outside of the hip. 

stretch for IT band

gluteal stretch

            Dancers with this condition complain of pain on the outside of the hip when lying down or when pressure is applied to the area.  This pain increases during activity and is felt especially when walking up stairs.  Stretching the iliotibialband or a stretch of the gluteal muscles, which tend to be tight in dancers, may help relieve pressure on the bursa. 

            Bursitis can also be caused by trauma to the hip.  A fall in which the hip collides with the floor can irritate the bursa sac and cause a painful inflammation.  Ice and anti-inflammatories will help with the pain and irritation.  If the attack of bursitis cannot be traced to a specific trauma, then a physical therapist should be consulted to determine the cause of the condition and help correct it.