Patellar Femoral Syndrome Part 2

          My last post discussed the chronic condition known as patellar femoral syndrome, the related symptoms, and possible treatments.  Since it is always better to bypass injuries than figure out how to recover from them, this post will address some causes of this condition and how to avoid them.

      This condition occurs when the patella, or knee cap, is misaligned. When it is misaligned, it cannot slide along the groove in the femur when it moves. The patella can move out of this position as a result of an acute injury from a fall or a sudden movement, but one of the main causes is a misalignment that develops over a period of time.  This misalignment occurs when the muscles that are meant to stabilize this joint and hold the knee cap in position begin pulling on the knee joint unevenly.  

          Muscle groups work in pairs. The pairs work opposite each other - one group extending while the other flexes, or bends the joint. In order to create stability, both groups need to pull on the joint evenly, creating equal tension in all directions. When one muscle group is tighter than its partner group, the tension is unequal and the patella is pulled out of position.   
                   

        This condition can be the result of tight quadriceps, which are the four muscles along the front of the thigh, or tight hamstrings, which are the muscles that run along the back of the thigh. These muscular imbalances can be avoided by making sure that all of the muscles are worked and stretched evenly. 
        
        Dancers tend to use certain muscle groups more than others and need to be aware of what muscles may not be worked as often. Cross training in other activities like yoga, Pilates, biking, swimming or walking can help ensure that all muscles are worked evenly.  Dancers also need to be aware of the iliotibial band, also called the IT band for short - this tendon connects the gluteus maximus muscle and the tensor fascial lata muscle to the skeleton.  Dancers use the gluteus maximus a lot since it is responsible for returning the leg to its original position after it has been lifted to the front, lifting the leg in arabesque, and is one of the main muscles involved in turning the leg out.  

            The tensor fascia lata is constantly relied upon by dancers as it is responsible for lifting the leg to the front and the side and rotating it inward. 

        The constant use of these two muscles causes the IT band to grow tight. Dancers need to stretch out the IT band often so it does not pull the knee joint out of position.

        By simply being aware of which muscles might need some extra work and being sure to stretch every muscle equally, most chronic conditions relating to poor skeletal alignment can be avoided.  It is extremely important for dancers to learn about muscular imbalances, to know their own bodies and to cross train to be healthy, strong dancers.

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.

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       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.

When Dance Training Gets in the Way of Being Healthy

            Dancing should look easy; like an optical illusion.  It should seem effortless.  – Bruce Marks

         A dancer’s job is to create a grand illusion for the audience.  The most difficult steps must look easy, and no one must ever guess that pointe shoes contain feet that are home to bunions, blisters and bleeding toes.  Like athletes, dancers need to perform with sore, and sometimes injured or overworked muscles, but unlike athletes, dancers must never show any sign of weakness.  Dancers must always be ready to push themselves to the next level to secure a role or a job, and there is no option for taking the easy way out.

 

            While all of these qualities are necessary in a field where performance is the ultimate goal, it is these same qualities that can be harmful to dancers when they begin cross-training or conditioning classes.

            Pilates and yoga instructors and personal trainers usually offer several variations of an exercise, ranging from beginner to advanced levels.  Most dancers, in spite of being new to this type of training, will choose the most advanced version simply because that is what they have been trained to do.  Although dance teachers might make statements like, “You may do a double turn if you want,” or “You may add beats to this exercise if you’d like,” dancers know that if they want to be noticed, an option does not truly exist.  They are expected to challenge themselves.  Unfortunately, since dancers’ muscles are specifically trained for dance exercises, the advanced version may be too difficult at first and strain the dancer’s body.

            As the conditioning class or session progresses and the trainer looks to the client to determine if he or she can handle a heavier weight, more repetitions or a more difficult exercise, the dancer will not portray an accurate picture.  If a dancer finds an exercise taxing or difficult, no one will ever know it.  Dancers are always performing, and they are trained to make the most difficult look the easiest.

            Lastly, since dancers are used to working with sore or tired muscles and have extremely high levels of pain tolerance, they may not always listen and respond to their bodies the way others do.  A pulling or burning sensation in the muscle may be ignored and classified as a slight twinge that must be worked through, and dancers may continue the exercise, assuming that they are feeling “good pain” when in fact they are feeling an injury occurring.  Dancers may not even realize they are injured until swelling or extreme pain occurs.

            When in a cross-training or conditioning program, dancers need to remember that starting to train at the beginner level is not a bad thing, it is okay to acknowledge tired muscles and to listen to their bodies in a different way, and trainers need to remember that dancers will push themselves to the absolute limit.  Cross training in dance is necessary and effective, but both dancers and trainers need to be aware of the psychological ramifications of dance training in order to keep the dancer healthy.

The Barre: Why It Might Be Time To Step Away...

“Without tradition, art is a flock of sheep without a shepherd.  Without innovation, it is a corpse.” – Winston Churchill

            There are few absolutes in the world, but every dancer who enters a ballet class knows that he or she should claim a space at the barre because barre work is the first part of class.  It is at the barre that muscles warm-up, stretching begins, new movements are introduced, dancers acclimate to the space and neurological pathways, that will be called upon in the center, are established or reinforced.

            Therefore, barre work is an excellent way to prepare the dancer’s body for work that will be done in the center, isn’t it?  Not entirely, say research studies that have measured muscle activation in dancers performing exercises both with and without the barre.

         In a 2001 study published in the Journal of Dance Medicine and Science, researchers found, that although there was no significant difference in muscle activation of the working leg during a développé devant, the muscles of the standing leg were activated significantly more when the développé was performed without the barre. (3)

            When Torres-Zavala, Henriksson and Henriksson studied professional ballet dancers in 2005, they found that the central balance point differed when dancers performed développé à la seconde with and without a barre. (2)

            In 2007, during a presentation given at the International Association of Dance Medicine and Science Annual Meeting, researchers spoke of a difference in muscles that were used with and without the barre when dancers executed rises to pointe from second position and pique retirés. (1)

            All of these findings seem to indicate that exercises performed at the barre may not be preparing the muscles and body for the work that is done in the center.  Dance physicist, Ken Laws, writes about dancers depending on the barre and using it to shift the torso farther forward in the arabesque position than can be realistically performed in the center.

            The barre should definitely be used in the warm-up, but dance educators need to be aware of the fact that it may not be as effective a place for preparing the body as has always been thought.  The barre is an important tool for focusing on the working leg, but teachers need to understand that stabilizing muscles are not being activated and that weight shifts at the barre are different from weight shifts in the center.

            Depending upon the focus of the class, perhaps, classes should not always warm-up at the barre.  Class can occasionally begin with traditional pliés, tendu and développé combinations in the center to help the dancer engage stabilizing muscles right away.  At other times the teacher may choose to design combinations that are performed partially at the barre and partially without holding onto the barre.  Additionally, cross training in other forms such as Pilates will help the dancers develop stabilizing muscles that might not otherwise be trained as often as gesturing muscles.

            The research that the field of dance science is providing can be invaluable in helping dance educators produce stronger dancers, but they need to be willing to use it.  It may mean departing from tradition at times, but sometimes change can be a good thing.

(1) Kadel N. & Couillandre A. (2007). Kinematic, kinetic, and electromyographic (EMG) analysis comparing unsupported versus supported movements in the ‘en pointe’ position. Journal of Dance Medicine and Science. 11(1), 23.

(2)  Torres-Zavala C, Henriksson J, & Henriksson M. "The influence of the barre on movement pattern during performance of développ." Proceedings of the 15th Annual Meeting of the International Association for Dance Medicine and Science. 2005, Stockholm, Sweden. Ed. Solomon R. &  Solomon J.  

(3) Wilmerding M. et al. (2001). Electromyographic comparison of the développé devant at barre and centre. Journal of Dance Medicine and Science.  5(3), 69–74.