Posts Tagged ‘injuries’

Going beyond the abs for true inner strength

By Suzanne Martin, PT, DPT

“Core? What is that?” I received this query from a French editor when she was translating my Better Back book into French. Today we have so much biomechanical research to answer that question.

It’s true that most dance injuries occur in the ankle and foot; however, overuse injuries are the hallmark of dance training, which is repetitive by nature. The biomechanical chain from the core downward is of crucial importance in helping dancers continue to dance. The top of this chain is, of course, the core.

Most people think the core consists of the abdominal muscles. But that’s only part of the story. The core is not only cylindrical (the abs) but also has a top and bottom. Think of this inner unit as Computer Central.

Training dancers in the concept and mechanics of the inner unit as Computer Central is the next wave in comprehensive career preparation. Core control separates the beginners from the advanced in terms of coordination and technical finesse; without it, limbs literally flail in partnering.

Parts of the inner unit
The inner unit has four elements. Located in the front are the deep abdominals (the transverse abs), which run from side to side, creating an abdominal “corset.”

Underneath a flat soft-tissue layer are the multifidi, each of which connects several vertebrae. These thin muscles, of varying lengths, stabilize the spine. These muscles work underneath the long, strappy muscles (the erectors) that run vertically down the back. The erectors stabilize the back in large orientation motions of the spine, such as the arch of arabesque.

At the top of the inner unit is the respiratory diaphragm, a circular muscle that moves up and down like a piston.

At the bottom is the pelvic floor, also called the pelvic diaphragm. It moves in a small, parachute-like motion, rounding up into the body to support the internal organs above.

Why inner-unit control matters
These four aspects of the inner unit must coordinate to protect and stabilize the low back and act as an anchor, or ballast, for the motions of the upper body. For my clients with scoliosis and especially for flexible women, teaching them to internally “hold” the center of gravity by coordinating the inner unit essentially gives them an insurance policy against severe low back injuries.

Boys and men have other reasons to pay attention to the precision of inner-unit use. They tend to have greater strength in general, laying on more muscle mass after the adolescent growth spurt. But this absolute strength can mask any deficits in the postural muscles. Also, boys who start dance late or progress into partnering before they’ve gained enough torso strength risk back problems.

Another key reason for control is that the inner unit must be stabilized in order for the psoas to properly work for leg elevation, e.g., développés. You just can’t get around it—the inner unit provides low-back protection, an anchor for upper-body and arm use, and a stable base from which the legs lift. Plus, it guides the knees and feet into optimal contact with the ground. The core does everything except cook your dinner.

Just like Joseph Pilates said in Return to Life, anything worth doing takes time to develop, so be patient in your pursuit of the consciously working core.

I have faith in you.

Visualize and Exercise

Finding the components of the inner unit in dance motion is the subject of much interest in dance medicine and physical therapy circles. Here are some tips to help you find them most effectively.

Visualize: Your center of gravity
Place one hand on your navel, then go 3 inches down and imagine going 3 inches inward. Place your other hand on your low back opposite the front hand. Your center of gravity is in this area. Feel your hands sandwiching this area. Bring your head weight over this area. Notice how the back relaxes when the center of gravity and head are aligned.

Exercise 1: Finding the inner unit
Transverse abdominals
Kneel on all fours in a tabletop position. Make a flat back, extending your head and tailbone in opposite directions. Keeping your back flat, lift your abdominals up toward the spine. To access the deepest abdominal muscle layer, visualize your abdominals as ‘smiling’ from hipbone to hipbone. Try pulling the muscles in and pushing them out without your breath initiating the action. Then pull them in and hold them while thinking of the diaphragm moving up toward your head and then down toward the tailbone four times.

Multifidi
Sit tall on the edge of a chair with a firm surface. Place your hands on your low back at the waist. Shift your ribs forward and feel the big, strappy erectors pop out. Then feel for the trough between the erectors and the spiky dinosaur bumps of the spine.

Now sit tall with your head and ribs in a vertical line over your pelvis (so you’re no longer shifted forward). Without changing the orientation of the back (no flexing or arching), feel like you’re pushing back against the muscles in the trough to tighten them. These are the multifidi. 

Pelvic floor
Think of the pelvic floor as diamond shaped, with the four points being the pubic bone in front, the tailbone in back, and the two sitz bones (ischial tuberosities) at the bottom. The diamond can be divided into two triangles, front and back.

Practice pulling up the muscles of the pelvic floor. Don’t grip them; instead imagine that an elevator is lifting them into your pelvis. Go easy.

Now squat in a wide second position, bracing your hands against your thighs. Practice lifting the muscles of the pelvic floor even though you are widening the bones of the pelvis into the squat. Stay there and breathe four times, working on keeping the pelvic floor muscles engaged in this wide position.

Respiratory diaphragm
Since the diaphragm is circular, let’s find it in several places. Place your hands on the front of the ribs. Now sniff briskly. The movement you feel in front is the action of the diaphragm. Now place your hands on the sides of the ribs. Inhale and see the sides of the rib cage expand; as you exhale, gently squeeze the rib cage.

Next, get a Thera-Band® and place it horizontally around your back below armpit level, making it tight enough to feel the tension (but not too tight). Breathe in and feel the rib cage expand and press against the band to the back. To fully fill the lungs when you inhale, think of filling two cones, one on either side of the body, from the base of the cone up to the tip, which reaches above the level of the collarbone.

Exercise 2: Straw exercise
(Imagine being sucked up through a straw. This is also a good one to do in a car while waiting in traffic.)

Sit on a surface that’s high enough to let your feet dangle above the floor. (In a car, simply keep your feet on the floor.) Slump down like a deflated accordion. Inhale, and as you exhale, gently pull your sitz bones together. Then press down on the sitz bones and feel an imaginary hand lift the skin of the low back so that you roll slightly forward. Elevate through the pelvic floor. Keep lifting the spine through the waist and lift the rib cage off the waist. Continue stretching up through the middle and upper back, thinking of going up through the rib cage. Then stretch the neck up like a giraffe’s neck.

Stay tall and inhale. Exhale and get taller; inhale and stay tall. Repeat. Exhale and get taller, then relax.

Visualize: Pelvic placement using the inner unit
Stand with your feet a few inches apart, toes facing forward in parallel. First feel the external muscles. Using the abdominals, tuck your pelvis, shortening the distance between the breastbone and the pubic bone. Then try tucking the pelvis by tightening the glutes (pulling the back of the pelvis down toward the thighs). Then arch the back by tightening the erectors, the big, strappy muscles of the back.

Now find a neutral pelvis with the hipbones lifted and the tailbone pointing down toward the floor. Experiment by moving the pelvis into a tuck and then into an arch only by changing the tightening of the pelvic floor. First tighten the front and notice the slight tuck. Then tighten the back and feel the slight arch. Train yourself to find a neutral pelvis and support the low back through the use of the deep muscles of the pelvic floor.

Exercise 3: Coordinating the inner unit
Take a tabletop position on your hands and knees with the knees 3 to 4 inches apart in parallel. Find a flat back. Reach behind you with the sitz bones so that the pelvis is neutral, without a tuck.

Feel the abdominals lift against the spine and an imaginary hand holding the low back flat, creating a sandwiching effect. Feel the width between the sitz bones as you lift the pelvic floor up toward the head without disturbing the orientation of the pelvis or back. Tuck the toes under. Inhale and exhale, then lift the knees about 2 inches off the floor. Stay there and breathe for four breath cycles, then lower the knees. Repeat.

Cross-training, body awareness, and old-fashioned common sense mean fewer injuries among students

By Darrah Carr

“Break a leg!” The theatrical well wish for actors and dancers has an irony that often escapes young performers. Indeed, for most young, healthy dancers, the possibility of injury feels remote and doesn’t factor greatly into their daily routine. For their older, more experienced teachers, however, the reality of injury and the desire to prevent it create a serious responsibility.

Sarita Zuniga of Sarita’s Dance Studio leads students in a prerehearsal yoga session, in which she encourages the integration of mind and movement. (Photo by Marina Zuniga-Johnson)

Fortunately, for as many potential problems that dancers can face, there exists an equal number of precautions that teachers can take. To begin with, teachers must establish a healthy working environment within the studio, taking into consideration the need for safe physical facilities as well as for strong emotional support.

As Richard d’Alton, director of International Ballet of Houston, notes, “the artistic director is responsible for having good flooring. Dancing on concrete or wood with no marley is an archaic thing of the past. Thank goodness our standards have come a long way since then!” Having a well-stocked first-aid cabinet with plenty of ice on hand is another must for studio owners, as are operating hours that reflect a balanced, realistic schedule. “Overwork, multiple private lessons, and late night rehearsals are not necessary,” d’Alton says. “Dancers must be considered as human beings. And, as human beings, we all shut down at some point during the day. There is no need to go until 10 p.m. I believe in quality rather than quantity of instruction.”

Balancing the studio schedule by offering a wide variety of classes can also reduce injuries related to overuse. Sarita Zuniga, owner of Sarita’s Dance Studio in San Antonio, TX, explains, “We aim to have a well-rounded, balanced program and encourage the students to try different disciplines of dance. On Mondays we offer ballet and jazz; on Tuesdays it is folklorico; on Wednesday nights we have flamenco, and so on. If the students can do different movements every day, then they are not constantly relying on the same muscle groups and they don’t run as high a risk of injury from overuse.”

Studios with a more singular focus can also promote balanced musculature by encouraging their students to cross train. Zola Dishong, who runs Contra Costa Ballet in Walnut Creek, CA, along with her partner, Richard Cammack, advocates Pilates for her population of serious classical ballet students. “Bringing Pilates into the studio has been great because the philosophy of the class is all about injury prevention,” Dishong says. “You can strengthen any weaknesses and even work through an injury with Pilates.”

D’Alton encourages his ballet dancers to seek additional Pilates training outside of the studio and to spend time lifting weights as well. “Boys especially need weight training,” he says. “I don’t want them to be the size of champion prize fighters, of course. But they must be strong enough to partner the girls correctly. It is another means of injury prevention.”

Zuniga enhances her dancers’ training with yoga. “We always do 30 to 40 minutes of yoga before beginning rehearsal. We play soothing music, lower the lights, and meditate a bit so that the dancers can start listening to their bodies. I try to inspire them to integrate their whole mind into the movement,” she explains. “I’ve seen a big change in the dancers. Yoga strengthens their core and balances their muscles. In dance, many problems stem from overuse injuries. If dancers are straining their quads, for example, then yoga can balance that by lengthening their hamstrings.”

A studio owner’s efforts to create a healthy working environment must be maintained by the entire teaching staff. Diane Pippen, who co-owns Diamond Dance Center in Forrest Hill, MD, along with her sister, Barbara Peterson, believes that faculty education is of primary importance for injury prevention. “If you have a big faculty, you must sit down with them and review teaching expectations in terms of the physical developmental stages that children go through and the anatomical principles that apply. Teachers have to be on the lookout for things like pronation and hyperextension, and they must know what the proper anatomy is,” Pippen says. “Teachers also have to be aware of growth-spurt injuries such as problems with ligaments and tendons. As girls hit puberty and their hips widen, for example, we start to see problems with pronation, especially in the knees. Teachers can’t force a perfect fifth position on those kids.”

 ‘Bringing Pilates into the studio has been great because the philosophy of the class is all about injury prevention. You can strengthen any weaknesses and even work through an injury with Pilates.’ —Zola Dishong

Pippen cites a number of anatomical variances among students that can lead to injury if not properly monitored, including tibial torsion, hyperextended knees, shin splints, hip popping, pelvic tipping, and ankle issues involving the peroneal and posterior tibialis tendons. She believes that students must be made aware of the unique, individual structures of their own bodies. “Children need to be educated about their own bodies and made to understand that ‘My body does this, but not this,’ ” Pippen explains. “The culture at the studio needs to be supportive enough that students feel comfortable speaking up [about physical concerns] and modifying certain movements if need be.”

Whatever the style of dance, certain movements tend to lead to injury more than others. Teachers must be aware of potential pitfalls within the given vocabulary and take precautions to demonstrate those steps safely. Dishong recommends introducing new petit allegro jumps at the barre so that students become familiar with the intricacies of the steps before moving to the center. D’Alton suggests that teachers set a goal for the day and then build the structure of the class accordingly. “You can’t do big jumps before small jumps. You can’t make dancers go up on pointe or do anything in the center until they are properly warmed up,” he notes. “We don’t do grand pliés until the middle of the barre. They are bad for you in the very beginning of class. And, I never encourage grand plié in fourth. It is a position we don’t use very often in ballet anyway, and it causes unnecessary strain.”

Heightened body awareness and a thorough education can extend to the waiting room, where pamphlets and articles on injury prevention can be made available to students and their parents. The International Association of Dance Medicine, the American Council on Exercise, and Deborah Vogel’s “The Body Series” are just a few invaluable resources for teachers to draw upon.

“Many times parents don’t know how to help a child who is complaining of pain,” Zuniga notes. “We educate both dancers and their parents on the RICE method (rest, ice, compress, and elevate), and we encourage Epsom salt soaks for minor aches and pains. We also explain that if the body is tired and not getting proper nutrition, then the chances of injury increase. Rest, nutrition, and injury prevention are all connected. Many parents don’t understand this.”

When addressing both parents and students, d’Alton stresses the importance of allowing time to warm up even before class begins. “It is not OK for a student to sit in the car for 40 minutes, or even 15 minutes, and then run into class,” he says. “Students shouldn’t arrive 2 minutes before class time, or, even worse, 5 minutes after class begins.”

Many teachers also advise families about the risk of injury from non-dance–related activities. Dishong notes, “Nine times out of ten, when a dancer comes to me with an injury it is from gym class, running track, or some other kind of sports activity.”

Zuniga too recognizes the prevalence of sports injuries. “Coaches tend to be more abusive to the body than instructors in the fields of dance or fitness,” she says. “They can have a mentality of ‘No pain, no gain,’ which really is the philosophy of the past.”

Even when students get injured outside of the studio, dance teachers are often sought out for advice. “Parents tend to think that you know everything about the body, so they’ll call and ask your opinion even if the child got injured in school,” Zuniga says. “I’ll say, ‘Call a doctor; I’m not qualified.’ Then I’ll always refer them to a medical professional.”

Often dance teachers act as important facilitators among an injured dancer, a concerned parent, and a doctor. “I’m not qualified to diagnose a dancer. No teacher should attempt to do that,” d’Alton states. “It is my job to ensure that an ache or pain doesn’t turn into something more serious. I have to make sure that if something is hurting, dancers are being honest with themselves and are also letting us know. Dancers are very motivated people. We know that they always want to be in the studio. But if they are in pain, then the first thing they need to do is to take a few days off.” If the pain is severe or persistent, d’Alton insists that the dancer see a doctor in order to determine whether an X-ray or MRI is needed. He’ll also serve as the dancer’s advocate. “If I don’t agree with the doctor’s diagnosis, then I’ll encourage them to seek a second or even third opinion,” he says.

Many studios develop relationships with local medical professionals who specialize in dance medicine, sports medicine, or physical therapy. These specialists are often more helpful in treating an injured dancer than pediatricians or other general practitioners. Pippen, whose own background as a nurse comes in handy when addressing her students’ injuries, says, “We do have to counsel our parents to see a sports medicine doctor or one who has a dance background. We find that ‘regular’ doctors frequently do not understand the needs of dancers; their first inclination is to put them on crutches, in huge braces, or completely off dance when ‘relative rest’ and other treatments are warranted. We also find that some doctors do not always explain the diagnosis to the parent or the child, which I do not agree with at all. I want them to understand what is going on and how to fix it.”

An injury often leads to a greater understanding of the body and can have a lasting impact on a dancer. “I’ve seen very positive results when girls return after an injury,” Dishong says. “They are forced to be more intelligent about their work, to work more slowly, and to make better choices. They are often better off for it.”

While guiding dancers along the road to recovery, d’Alton requires them to watch classes and rehearsals. “The dancers usually want to watch anyway. They always hate being away from the studio. They can learn so much by watching their teacher teach and by watching both the good and bad examples of their fellow students,” he says.

Easing into classes after an injury is important in preventing reinjury. D’Alton does not believe in putting recovering dancers back into their regular class schedule right away. For one, the other dancers in the class need to continue to be challenged and shouldn’t be held up by a recovering dancer’s slower pace. “Working with a recovering dancer requires a good deal of one-on-one time. I don’t mind going in early or staying late to help a dancer with specific exercises until they can be incorporated back into their regular class,” d’Alton says. “It is a slow process. As their teacher, you have to put all expectations aside. Let them know that they don’t need to prove anything; they just need to get better.”

The recovery process requires patience from the dancers, of course, but also from their parents. “Often parents are very driven for their child to succeed in dance,” d’Alton says. “But you can’t get a quick fix in this business. And there is nothing more important than the long-term health and safety of the dancer.”