When Should My Child See A Doctor for Dance Injuries?

Most injuries in dance don’t happen suddenly. Instead, students often suffer from chronic overuse injuries. Some minor impairments can be treated without visiting a physician. Too often, though, smaller injuries become more severe because proper care is not administered early or because dancers continue self-care despite warning signs that more specialized care may be necessary.

Parents and teachers of children and teens want to know, “What are the warning signs that a dance student should see a doctor?”

1.  Here is what you need to know…

Pain = Cause for Concern

Pain is our body’s way of telling us something is wrong. Even the youngest children (3 or 4 years of age) can tell us where and when something hurts. Unfortunately, sometimes dancers learn very early to overlook or ignore pain. Teachers and parents can create an environment in which students develop a mindset to recognize and respect their body’s warning signals. There is no gain in ignoring pain.

2.  Here is the answer to the question…

If the pain, discomfort, or problem persists beyond 2-4 days, your child should see a doctor.

Acute Injuries

These are usually obvious because they come about as a result of an incident. Landing wrong from a jump. Falling from a lift. Slipping while crossing the stage. Severe injuries like broken bones obviously need immediate attention and a visit to the doctor. For most common ailments…

1. First aid suggests the R.I.C.E method (rest, ice, compression, and elevation) for strains, sprains, swelling, etc.
2. In addition, staying hydrated and eating well promotes healing.
3. See #2 above

More about treating common dance injuries

Overuse/Chronic injuries

Overuse or chronic injuries are sometimes triggered by an event that is allowed to persist without proper rest or rehabilitation. However, often they are caused or aggravated by other circumstances (this is a great list, adapted from this one about kids in sports):

• growth spurts
• imbalance between strength and flexibility
• inadequate warm-up
• excessive activity (for example, increased intensity, duration, or frequency of training)
• improper technique
• unsuitable floors

Signals of Chronic Pain

Deborah Vogel (thebodyseries.com) offers these four signals of chronic pain, as well as an excellent explanation of  how dance injuries start in small ways, in an article about a hamstring/sciatic injury. I highly recommend you read her words for yourself.

1. Pain that gets progressively worse during working out.
2. Pain that comes after you work out and the next day comes back after less working.
3. Pain that is accompanied by a certain movement (e.g. arabesque).
4. No real sense of “pain” but a definite restriction of movement.

It is normal to have temporary muscle soreness after a challenging class or when working in a new way. Anything that persists, particularly in the ways mentioned above, should be discussed with a physician or dance/athelete specialist. This should be done sooner, rather than later (see #2 above).

A Note on Anti-Inflammatory Drugs

These are often overused in the dance community. Sometimes a doctor will recommend them and they can help bring down swelling. However, they are misused when taken to “get through a class” or otherwise mask pain (see #1 at the top of this post).

Reinjury

Dancers often re-injure themselves when they return too quickly to activity. Temporary muscle soreness can sometimes improve with a return to class. However, if moving makes it feel worse, the body may need more rehabilitation time and/or medical attention.

After and injury, always ease back into activity. It is better to be safe than sorry. Dancers don’t like to hear this when they are eager to get back or feel pressure to return to class but, remind them that temporary setbacks are just that – temporary, and not worth permanently injuring oneself.

“An ounce of prevention is worth a pound of cure.”

Prevention

Of course, preventing injury in the first place is ideal. Although sometimes this is not entirely possible there is a lot a parents can do to keep their dance students injury-free.

Find a studio that is committed to safety

• What is your studio’s philosophy?
• Is there proper flooring (i.e. – something sprung or with some “give”)?

Find a studio that is committed to quality instruction

• Do the students spend a reasonable portion of their class warming-up (not stretching but individual body-part and full-body exercises that encourage blood flow)?
• Are students encouraged to master foundational basics before moving on?
• Do students receive individual attention and feedback from their teachers?
• Etc… (see this series for more on quality instruction)

Encourage dancers to stay hydrated

• How much water is really necessary is debated, however, there are many active dancers that probably do not drink enough water. Here are some suggestions to improve water intake.

Encourage healthy, balanced nutrition

• I know this can be a tough one for families and kids on the go but it is so important! Here are some good pointers on healthy eating from kidshealth.org. Another great resource: nourishinteractive.com

Some other things you can do

• Encourage rest and proper sleep habits
• Encourage a positive outlook
• Remove the stress and pressure to “work through” or “push on” through injury
• Try cross-training with other activities (not to load extra onto already tired kids but to promote balance in the body; you might even speak to your child’s teacher or studio owner about alternatives within the studio)

Check Out These Related Articles!!

Learning How to Gauge Injuries Can Prevent You From Being Sidelined

This is an excellent article from Dance Spirit magazine. It offers easy guidelines about when to sit out and when to see a doctor.

Talking to Your Doctor About Injuries

Another one from Dance Spirit, this article lays out exactly what doctor’s need to know from dancers. A dancer’s “normal” may be different than a non-dancer due to the type of training dancers receive. Physicians need to know what you were capable of before your injury. This article has a lot of great information and stresses that dancers should not minimize their pain, as is their tendency.

Breaking Tiny Foot Bones

Stress fracture signs and treatment on Ballet Shoes and Pointe Shoes Blog.

Everything You Ever Wanted to Know About Turnout – Part I

What You’ll Find In Part I

1. How Important Is Turnout, Really?
   
2. Explaining The Mechanics Of Turnout
3. Recognizing Proper/Improper Turnout
4. Nature vs. Nurture

If you want to learn some techniques for improving your turnout, you can jump straight to Part II. But I highly recommend you read this first because it provides crucial information that will help you make better use of the information in Part II.

If you study classical ballet, you are well aware that the outward rotation of the hips (or turnout) is essential to the training and traditions of this form. Even if you are not trained in ballet, as a dancer you probably use turnout at least some of the time. Concert or theatrical dance forms (like modern or jazz dance) in particular utilize turnout within their movement vocabulary. Ask most dancers, and you’ll discover that turnout is high on their list of things to improve and increase.

But is having extreme turnout really ideal?

The human body is designed primarily for forward motion. We walk, run, sit, and stand in the sagittal plane. In dance, the use of turned out legs is primarily utilized for ease of motion on the proscenium stage, a venue in which the performers present movement to an audience which sits entirely on one side of the stage (as opposed to all around or on three sides).

A little history: When dance (ballet) moved to this forum from the royal courts, dancers spent more time moving side to side, necessitating a degree of turnout.  Since then, this rotation of the legs has been exaggerated, accepted as the ideal, and adopted as the aesthetic in ballet.

With developments in dance medicine, there is evidence that 180-degree turnout is not possible, necessary, or even healthy for all ballet dancers – even the pros (although how much this has changed about ballet training traditions is debatable).

Sideways locomotion certainly does not require rotation to such a degree. Turnout does allow the greater trochanter to avoid the ilium as the leg is lifted above the waist,  however 180 degrees of turnout is not required for this clearance. In fact, Gayanne Grossman, associate professor of anatomy and kinesiology at Temple University suggests that “most dancers have a maximum rotation of 55 degrees in their hips.” [see this 2008 article from Dance Magazine] This means that many who appear to have 180º turnout  are making up the difference in the lower leg. 

I suspect that dancers who have danced for years without injury probably discovered early that it is not how much turnout you have that is important, it is how you use what you have. Therefore, it is imperative to know how to use it!

What you need to know to make the most of your turnout:

• How the hip functions
• What is improvable and what is not
• How to increase turnout safely and without injury
• What you can do to maintain optimum turnout for your body

Understanding How Turnout Is Achieved

In anatomical terms, turnout is the outward (sometimes called lateral, or external) rotation of the hip joint.

The hip joint is the joining of the head/top of the femur (thigh bone) to the acetabulum, or hip socket (seen in the diagram below).

This joint is a ball and socket joint, which allows for a wide range of motion on all three planes (sagittal, lateral, and transverse).  The hip joint can produce flexion (forward of the body), extension (as in standing, not the unfortunately labeled lifting of the leg which is actually flexion in anatomical terms), abduction (away from the midline of the body), adduction (toward the midine of the body), inward rotation (turning-in), and outward rotation (turning-out).  Most dance movements are a combination of these actions.

Muscle Action

The hip joint is very complex and most of the muscles surrounding the socket are responsible for more than one action of the hip joint.  These muscles both initiate and restrict movements of the hip. The outward rotators are pictured in the diagram on the right. 

The muscles that pass posterior (behind) the hip joint contract to initiate turnout while the anterior muscles lengthen, and those anterior (in front of) the joint contract to initiate inward rotation while the posterior muscles lengthen.

If this is confusing, picture the spine of a book -

When the book is opened the outside edge of the binding contracts while the other edge lengthens and visa versa.  This inverse relationship is true for all muscle actions and is the key to analyzing movement.

False Turnout

Turnout does not occur from anywhere other than the hip. A false turnout can be achieved by pronating the tarsus (rolling in) to create the illusion of a wider turnout than is being achieved by the hips alone.  This causes a twisting in the knee, a joint which is only designed to extend and flex in the sagittal plane, and this usually leads to misalignment of the pelvis, which actually reduces outward rotation.  False turnout also creates the potential for a myriad of injuries, as we’ll discuss in Part II.

Turnout Is A Verb

Although we sometime use the word turnout as a noun or a position (i.e. “Your turnout could be better.”), it is more appropriately thought of as an action, a verb.

Because outward rotation is not the body’s natural state, the work does not stop once the position or desired degree of rotation has been attained. Instead, outward rotation of the hips requires continual action within the body, even when the rotation is held in a position (like ballet 5th).

How To Recognize Proper/Improper Turnout

There are some simple visual cues that indicate turnout is being forcefully executed.

As mentioned above, dance instructors looking for indication of false turnout will expect to see the feet roll in, the pelvis tilt, and the knees and toes pointing a different direction than the center of the hip joint indicates.

When a dancer is forcing turnout beyond their physical capabilities, tension will appear in the buttocks and probably other areas of the body such as the shoulders or neck.

When you hear teachers say “knees over toes,” they are asking you to properly align the turnout of your legs and avoid pronation both in standing and in plié.

Students, try this: Bend your knees slightly, turn out as much as you can, and then gently lengthen the legs. You are forcing your turnout. What does it feel like? Do you feel a tension or twisting in the knees? Are your feet rolling toward the big toe (pronating) to maintain this position? Do you feel balanced or secure in this position?

When the legs are opened without force and turnout is supported with the deep rotators, iliopsoas, and abdominals, one should be able to trace a line directly from the hip, through the center of the knee, and to a point between the second and third toe of the foot.  A neutral or properly aligned pelvis (with the sitz bones pointing downward) is a good indicator as well because when the turnout is forced, generally the pelvis will tilt, creating a swayed back.

A dancer who consistently performs with false or forced rotation in the hips will eventually complain of sciatic, knee, foot, and/or back pain. Therefore, if a dancer is having any of these problems it is always a good idea to pay special attention to their turnout and alignment while dancing.

Nature vs. Nurture

Almost everyone “afflicted” with what he/she considers a limited degree of turnout has at one time found solace in the idea that, for some, the degree of turnout is limited by the unchangeable structure of the body and not for lack of trying.

It is true that some have a narrow sacrum which allows for more efficient locomotion overall. Men have a narrower sacrum than women, giving them the potential for more impressive jumping skills. Of course the width of this area varies among women as well. But, before you begin to think that having a narrow pelvis is ideal, some have observed that this narrow pelvis often is paired with a forward facing acetabulum. This facing results in, you guessed it, a lesser degree in outward rotation than those with a side-facing hip socket. The depth of the acetabulum can also affect turnout.  A shallow hip socket allows for higher degrees of both outward and inward rotation in the hip than does a deeper hip socket.

Aside from these natural limitations, turnout is only hindered by problems in how we have nurtured (or not nurtured) the muscles and tissues surrounding the hip, and perhaps our mental state or expectations. There are three ways in which a dancer can nurture their ability to turnout and to actively maintain that turnout during movement:  Awareness, Release, and Strengthen Without Tension.  And we will learn more about these in Part II!

Dance Advantage recommends further investigation:

Deborah Vogel’s Tune Up Your Turnout is a handy resource. Easy to read with the essentials of what you need to know as a teacher or student. Deb answers your most pressing questions about turnout, provides stretches for the appropriate muscle groups, and offers quality advice on how to test and improve your range of motion safely.

Also check out the FUNctional Anatomy curriculum for your classroom (by Deb Vogel and Anneleise Burns Wilson) and Deb’s new multimedia course, Essential Anatomy that comes with video, outlines, and study guides.

You can get all of the above at The Body Series. I have been following Deb’s work online for years and have such faith in her as an information source for dancers, that I don’t mind at all telling you that that link is an affiliate link.