Avoid Jumping into Injury
In some recent interviews with dancers Dr. Davenport MD and Dr. Kat PT realized that dancers have been limiting and modifying their movement much more than we expected. Whether it was due to space, floor surface or just some extra time off dancers have decreased their jumping, and big movement across the floor. This is something that many dance medicine professionals were concerned about when we realized the length of time dancers would be out of the studios due to the COVID-19 pandemic. As dancers begin to transition back into the studios whether it’s a professional dancer returning for rehearsals, a collegiate level dancer returning for the fall semester, or a studio dancer ramping up their training for the year; there is a high risk for stress injuries. Dr Davenport and I discuss two stress related injuries that we are concerned about seeing, how they develop, and how to progress back in a safe manner to avoid them.
When we entered the pandemic most of us expected dancers to be at home and working in a small space for a few months. When we look back at information that we initially put out we expected a baseline level to be maintained, but now with the extended time away there are new concerns as dancers begin to progress back into full class and rehearsals.
Two major areas of stress injures in dancers are:
Stress Fractures/Stress reaction
Metatarsals for ballet dancers
can happen in any bone that is not used to the stress
Tendonitis
Primarily around the ankle
Peroneals
Achilles
FHL/ Tib post
Stress Injury to Bone:
Many people think about bone like a stick -
you can pick up a stick off the ground and break it in half.
Either it’s a full stick or a broken stick.
But this is not actually how bone works.
Bone is more like a tree.
Like a tree may lose some branches and grow new branches, a bone constantly is remodeling.
It breaks down old bone and lays down new bone.
At some point the tree may lose branches before it has the time to grow new ones, this can cause the tree to become unhealthy and can even die.
This same thing happens with bone
If the normal process of breaking down bone outpaces the ability to lay down new bone, then the bone becomes unhealthy. This can result in stress fractures or stress reactions
This unhealthy bone starts with a stress reaction, which is an earlier sign that the bone breakdown is outpacing the bone build up.
If we catch the problem at that stage then often we can prevent the next stage.
The next stage is a stress fracture where the bone breaks and this will take longer to heal compared to a stress reaction.
How to stress injuries occur
This balance of breaking down bone and laying down new bone can get out of balance for two main reasons.
The first reason is too much stress on the bone too quickly.
Breakdown may be accelerated, and the build up is not happening as quickly
In dancers, we commonly see this during a rapid increase in activity, most commonly coming back in the fall from less activity over the summer, increasing rehearsals for a show, like Nutcracker, increasing dancing such as competition season, or doing more or new activities such as a summer intensive.
This is the primary concern we have with dancers decreasing their dancing and jumping due to COVID and being excited to get back to the studio. There is a risk of trying to make up for lost time and getting back to activities too quickly. We don’t want our dancers to be out again due to an injury!
The second main reason for the normal break down and build up of bone to get out of balance is not having the nutrients to build bone.
If a dancer’s nutrition is not keeping up with activity level, then the bone will not have the right amount of nutrients to build up new bone and a stress injury can occur.
If a dancer’s activity level has decreased over COVID, then it is possible a change in nutrition may also be important to monitor with getting back to dancing.
if you are someone who has any kind of chronic inflammation the build up of bone can be slower
Processed food and sugar can cause chronic inflammation in some individuals. Do you best to get nutrients from whole foods.
Stress reactions in the Foot
Remember not all bones are created equal
Some bones have excellent blood supply, others do not
Some bones are in locations that naturally take more stress
Metatarsals have good blood supply but take extra stress, which is why it is a common area of stress fractures
Signs and Symptoms of Stress Reactions
Achy Pain
Night pain
pain that continues after ending activity for the day
foot cramping that is more than normal
What to expect if you do develop a stress reaction or stress fracture
Rest- these injuries require time off and for the bone to heal
a untreated stress reaction can turn into a stress fracture
Boot for a stress fracture
if a stress reaction is caught early enough sometimes we can use a steel shank/hard soled shoe instead of a boot
Stress reaction can be as little as 3 weeks of time off
a dancer must be 100% pain free with walking prior to return to dance progression
Stress fractures can be complicated and require more time in a boot
usual time frame is 6 week in a boot
dancer must be pain free out of the boot with walking prior to return to dance
can take up to 6 weeks to build back up to a normal work load after coming out of the boot
Can continue to complete cross training in the boot to keep the body as strong as possible
Imaging
inital imaging at the doctors office is an x-ray
not all stress reactions/fractures will show up on an x-ray
MRI- more specific test for stress reactions/fractures
will show a darker gray area or a black line depending on how advanced the injury is
Bone Loading
want to progressively load the bone structures, tendons and muscles that attach onto or near the bone
Building up for pointe work and jumping
Strengthen at the hip
glut max and glut mid should be working to absorb shock
lunges, hip hinges
Strengthen at the feet
toe yoga
Make sure to roll out your feet- tight muscles can cause just as much harm
4 layers of muscle on the bottom of the foot
Walk around your house in your pointe shoes
Think of how many years it took you to build up to dancing a lot of hours on pointe
Pay attention to what is normal pain for you vs. pain that is not normal, pain that does not go away.
if you are fatiguing quicker than normal maybe back down your training just a little to allow your body more time to recover
remember stress injuries happen because breakdown happens faster than repair.
Stress Injury to the tendon
Tendonitis, tenosynovitis
What is tendonitis
Literally means inflammation of the tendon
I always say that tendons are like plants - they like to be watered appropriately.
Too little water and plants cannot grow but too much water will drown them.
Similarly, tendons like to have the right amount of stress. Too little stress and they cannot get stronger but too much stress may cause inflammation and damage to the tendon.
recently the tendons have been in a little bit of a drought where they have not been stressed to the same extent that they were 6 months ago
For dancers coming back to a studio after a change of activity, we worry about too much stress on the tendon too quickly. The tendon may not be strong enough to hold up and cause inflammation and then lead to a partial tear and then to a full thickness tear if not treated.
Inflammation→ remodeling → tendonosis → small tears → can progress to a full tendon tear
Cause of Tendonitis
Too much load too soon
Sudden increase in work or load into the tendon
if you have been at home and not jumping
if you have not been working with big movement traveling across the floor
suddenly jumping on a hard floor without some of the other larger muscles working to absorb some of the load
See tendonitis happen in dancers who are coming off of a lay off
can see in a dancer coming back from another injury and tries to progress too quickly
Signs and symptoms
Pain along a tendon
PT testing often have pain with Manual Muscle Testing, Muscle Length Test and palpation right over that tendon
Sometimes you will see a little pocket of fluid or direct swelling over the affected tendon
Many times this is pain that you notice early in your day, or early during activity
In early cases the pain will decrease as you get warmer
Have seen this too often in dancers who push back too quickly from injury or from a lay off
Imaging
not necessary for many initial tendon injuries
treatment will remain the same whether we have the image or not
offload the tendon to calm it down
progressively load the tendon back up
Goal of treatment is to
Our key goal in tendinopathy rehab is improving the capacity of the tendon and muscle to manage load
tendon connects the muscle to the bone
treatment programs can help offload the tendon by increasing the strength of the muscle
PT needs to understand how to properly dose exercise for endurance, strength, power along with what muscles may be weak causing increased work by the irritated tendon/muscle complex
Usually want to load the tendon
Isometrics (load the muscle/tendon without moving the joint)
I look to do these throughout the ROM
Eccentrically load the tendon throughout the range
Lengthening contractions- tendon is assisting in controlling the lowering phase of a motion
eccentrics help with deceleration
How to properly stress tendons
clinicians should advise that complete rest is not indicated and that they should continue with their recreational activity within their pain tolerance while participating in rehabilitation.
Build strength and endurance, increase function, increase power, develop the stretch shortening cycle through plyometrics, and then full return to dance
Right now I would encourage dancers to focus on eccentric loading of the tendons
Backwards walking/jogging
If your feet are strong you can do releves off the edge of a step
Strength programs like the calf strength challenge is a progression to build strength and endurance in the calves.
Really looking at a minimum of 25 single leg releves before returning to jumps or beginning a plyometric program
Plyometric program for dancers on the webpage helps build that quick stretch shorten cycle needed for repetitive jumps
Return to the studio guidelines-
Baseline layoff level for a professional level dancer who may be expected to return to rehearsal for up to 6 hours is usually 2-3 hours of activity a day
If you are currently not doing anything slowly build back up, start with one hour a day, and add ½ hour to a full hour of work per week until you reach the baseline of 2-3 hours a day/ 5 days per week. Approximately 10% per week.
This should include pointe work if appropriate and jumps. Overhead lifting for anyone who will be doing partnering lifts
as you build back up you can add time or intensity
30 minutes of barre is not the same as 30 minutes of jumps
Want to maintain baseline activity for 2-3 weeks pain free, let your body adapt to this stress
Over the next 2-3 weeks focus on building up to a full 4-6 hours of work focusing on increasing grade allegro, overhead lifting, and pointe work
For a professional level dancer your body should tolerate 4 hours of class and conditioning pain free prior to returning to the studios.
Time should be mixed between dance specific and cross condition
Take away message-
Our key goal to avoid these kinds of injuries by progressively increasing the load to the bone, tendon or muscle.
If you are worried that you may be developing a stress injury, please see someone earlier rather than later as the quicker we can treat these the sooner we can get you back to dancing. The longer you wait the longer the treatment takes