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Bodywise Dance health professionals

Each year dancetrain asks a leading group of performing arts healthcare professionals to talk about their expertise and experiences plus any new technological developments in the management & treatment of injuries.

This years Bodywise articles cover remedial coaching, dance screening, injectables, happy hips and much more, bookmark this page to refer back to it when you have a niggle or question thats needing some attention, the page is live for 1 year or until we take a look at whats new for next years guide.

One thing we took away this year was how important it is to see a healthcare professional that has experience and understands the psychology of a performing artist, the pressure to keep performing and pushing yourself, even with injury, has a unique set of parameters that must be navigated and understood by the healthcare professional.

The Benefits of Private Coaching
by Natalie Orola
thebalanceddancer.com | [email protected] | 0415 715 080

The importance of a regular dance class builds socialisation skills, develops ‘team spirit’, allows for easier pathways to group performances and concerts, and provides students with clear, real-time benchmarks at their level within the class environment. So, where does private coaching fit in?  At The Balanced Dancer, private coaching provides a wide range of supplemental benefits or “enhancers” to regular dance class, which do not trump, but allow dancers to excel and make the most of their regular dance class. The benefits of private coaching are wide-ranging and no two private coaching students will have the same experience. Unlike the generally standardised method of teaching in a regular dance class, private coaching provides customised learning – strengths and weaknesses can be identified in the very early stages of the relationship and tailored coaching plans can be developed to harness a dancer’s strengths and rectify and overcome any limitations.  Private coaching also offers a personalised experience – the relationship between coach and student is unique, fluid and really “one of a kind”. Private coaches are not just teachers who instruct a particular method – they often take the role of “mentor” or “big sister” and allow students to walk away from each coaching session with a deeper understanding about not only their syllabus, but the student’s broader aspirations and visions.  

A good way to think about the relationship between private coaching and regular dance classes is to compare it to the relationship between personal fitness training and group fitness classes. Whilst regular dance classes are an effective way for dancers to learn method and routine, the most effective way for a dancer to harness their strengths, appreciate their abilities and develop their dance goals in a holistic way in a personal dedicated setting is through private coaching. A healthy mix between formal dance school training and private coaching is vital for any dancer who wants to not only excel in dance but also personally gain and grow from all that dance has to offer.

“tailored coaching plans can be developed to harness a dancer’s strengths and rectify and overcome any limitations.”

Natalie Orola is the Founder of The Balanced Dancer. Natalie is an Associate of the Australasian Dance Association (ADA) (formerly the Federal Association of Teachers of Dancing), an Affiliate Member with The Commonwealth Society of Teachers of Dancing (CSTD) and trained in the Royal Academy of Dance (ballet) syllabus, holding over 10 years of dance teaching experience at various dance schools throughout Sydney, Gold Coast and Brisbane, Australia.

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Dance screening & injuries on the rise
by Holly McPaul
baimed.com.au | 02 4227 1990 | [email protected]

What is a Dance Screen?
A dance screen is comparable to the appointments you make with your dentist or optometrist, except for the dancers body. We look at movement patterns, technique and dance movement control. Sometimes it is a simple thing that throws off the rest of the body or movement pattern and is easily corrected with exercises (that we call correctives). Your dance screen will be part of your dancer profile, allowing us to compare previous screens, and we can track changes to make sure that students continue to perform at their very best.
 The screen is also very beneficial for the students parents and teachers and supports the teaching of safe and correct technique ensuring the activities done in youth do not hurt the adults body later in life.
How often should you be screened?
Ideally 3 times per year. We must consider that the body is always growing and changing and physical work load and demand are usually increasing as well. 

Why have a dance screen?
The screen helps to determine any areas of a dancers’ body that could be prone to injury and highlights any areas, like their strength or flexibility, that can be improved on, from an aesthetic or performance perspective. Exercises are often simple but highly effective. Seeing a dance physiotherapist like myself, once every three to six months, decreases the likelihood of load related injuries. Every dancer is a changing athlete that needs reassessing and managing to assure that their physical capacity and their physical demand remain equal.

We are able to direct dancers to the the BaiMed Performance Centre to work under our highly skilled sports science team. Here they receive further objective testing and strength programming specific to the needs of the dancer identified in the screen. 
The biggest goal is to keep people injury free so that they’re in the studio doing what they love doing. That’s my number one goal.
Are you seeing an increase in any types of dance injuries?
I am seeing more load related injuries, such as stress fractures and tendonopathies (chronic inflammation of tendons). These occur for a number of different reasons. Sometimes it is when training or performing volume increases rapidly and there’s not enough recovery time between classes or performances. Sometimes they occur when difficult skills or movements are performed incorrectly. A lot of the time they can occur because of a strength or range of motion deficit that’s causing a particular body part to become overloaded beyond its physical capacity.  
There is a lot of focus in the world of elite sports around capacity versus load and the idea is that to minimise injury, we have to ensure that workload doesn’t exceed physical capacity. It’s the same with dancers who are essentially training as elite athletes. When load (the amount and types of dancing you are doing) and capacity (how strong and flexible you are) are out of balance we see load related injury starting to occur.
With the aid of Social Media there is a lot of pressure on young girls and boys to be able to do skills that are perhaps above and beyond their skill level. Some students are also not being taught by professional or skilled or experienced dance teachers. Seeing a dance specialist physiotherapist will help those parents without an extensive knowledge of dance understand how incorrect technique can cause injury.

Holly McPaul from BaiMed is a Physiotherapist and Exercise Physiologist with a Bachelor of Exercise Science and Rehabilitation UOW, Master of Physiotherapy USYD. Holly has danced since she was 3 as well as taught dance for many years. Holly is an advocate for specific programs for dancers – including a Dance Specific Screen, designed to highlight strengths and weaknesses in order to structure programs to suit the individual. 

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HSC Dance – how does it support a dance career?
by Katelyn Boshell
thedancetank.com.au | 0415 839 030

Maintaining a dancing body at peak performance level can be a struggle for dance students rehearsing for an eisteddfod, exams or even for their final NSW Higher School Certificate (H.S.C) practical examinations.

“Students often hear that they need to prepare their bodies both mentally and physically, but what does this really mean?”

Students undertaking the NSW 2 Unit H.S.C Dance Course through their secondary school/college or externally study the essential components required for body maintenance. The course teaches the core principals of the Safe Dance Practice pedagogy to ensure bodies are prepared for examination at peak fitness level, as well as safeguard against injury.

Students develop their physical dance technique through a series of contemporary dance exercises that concentrate on correct alignment to dance efficiently without the threat of injury.

Exercises begin on the floor focusing on Graham Technique through static stretching and spinal alignment curves and extensions. Moving to the barre, exercises such as tondues and balances assist the student to find their core stability. Centre-work follows, such as adage/shape exercises allowing a better understanding of engaging the required muscles to ensure correct quality of line. Lastly, a range of travelling/locomotor sequences explore kinaesthetic awareness as well as improve stamina and endurance for performance examination pieces.

Mental preparation for these final examinations is as crucial as training the physical body. The H.S.C Dance Course provides students with the knowledge of beneficial body maintenance tools consisting of healthy nutrition and hydration, good sleeping patterns and alternative lifestyle physical activities such as walking, swimming, Pilates, Yoga etc. to maintain a healthy and fit body. A healthy body provides a dancer with the ability to maintain a positive and confident attitude which will enhance their performance quality and portrayal of their work.

Undertaking the H.S.C. Dance Course is an excellent foundation for an individual’s future career in dance. Obtaining knowledge and understanding of the anatomical mechanics of the body; injury prevention practices; and mental preparation skills; are integral elements for establishing a well-rounded dancer and increasing the longevity of their professional dancing career.

Katelyn Boshell has over 20 years of experience in the field of Dance. Experience includes but not limited to; NSW Department of Education trained Primary and Secondary teacher (B. Arts/B. Education Honours UNSW) specialising in Dance and Schools Spectacular choreographer for the past 6 years.

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Are Injuries Preventable
by Louisa McGinness
easternsuburbssportsmed.com.au | [email protected] | 02 9389 2766

“Up to 75% of dance injuries are preventable – so how can I reduce the risk of getting injured?”

Research has estimated that up to 75% of all dancers’ injuries are due to overuse1, regardless of the age, gender or training level of the dancer2.

Overuse injuries develop over time and are a result of repetitive pulling, twisting or compression. A key to avoiding injury as a dancer can be as simple as avoiding significant changes in overall dance training – a concept referred to as ‘load management’ in sports medicine. The long hours involved in dance training do not cause injury – it’s how you build up to long training periods that is important3 in injury prevention.

Situations which commonly involve significant change in training load for dancers include: commencing fulltime training, starting a new contract after a period of time off, returning to dance training after holidays, starting new choreography, or an increase in classes or rehearsals prior to exams or performances.

It is important to anticipate upcoming changes in load, and to plan ahead. Preventing injuries can be as simple as maintaining some level of training or physical activity during holidays, or slowly increasing your training in anticipation of an increase in your load after commencing fulltime training.

A common tool used by elite athletes to monitor training load change is called the ‘acute: chronic workload ratio’. An example for dance students may involve calculating the average of the hours spent in classes or rehearsals over 4 weeks. If a dancer increases their hours of training by more than 1.5 times the average of the previous 4 weeks, they may be 2–4 times more likely to sustain an injury in the subsequent 7 days3.

The longer you are involved in fulltime training, the less likely you are to be injured4. Overload injuries may also be more common in periods of rapid growth – it may be worth tracking your growth on the wall during your teenage years.

‘Acute’ and ‘Overuse’ injuries – how do I manage them?

An acute injury is a sudden onset of pain associated with a particular movement or incident, such as a sprained ankle, strained muscle or an injury due to direct impact. Rest, ice, compression and elevation are the essential first steps to reduce the tissue damage that occurs from swelling and bruising.

Ice can also be effective in the short-term management of overuse-type injuries, providing relief from swelling and inflammation, which can often accompany pain.

With both acute and overuse injuries, it is important to have the injury promptly diagnosed and managed by a health professional who understands the demands of dance training. Health professionals with experience working with dancers are able to help you resume your training in a modified capacity as soon as possible, minimising loss of fitness and strength associated with injury. Acute and overuse injuries can worsen if dancers delay seeking appropriate advice and treatment. Prompt injury diagnosis and correct management, as early as possible, can significantly reduce the recovery time associated with injury.

If you are suffering an overuse-type injury following an increase in training, see your physiotherapist or doctor as soon as possible to facilitate a speedy recovery.

Louisa McGinness is a Sports Physiotherapist at Eastern Suburbs Sports Medicine Centre. She was the full-time physiotherapist for Matilda the Musical through their Sydney and Melbourne seasons and the physiotherapist for the Top 20 of So you Think You Can Dance Australia in 2014. Verity Wright, Sports Podiatrist, is also able to provide treatment and advice tailored to dancers.  Louisa and Verity have extensive dance training and are available for consultation at Eastern Suburbs Sports Medicine Centre. 

Podiatry for Dancers – Verity Wright
Our feet are the foundation of our dance.
Barefoot and shod dancing can both elicit abnormal stresses on our feet and toes.
Excessive pain and discomfort in the feet and toes tolerated over a period of time can lead to chronic and degenerative concerns.
Having your feet assessed by a Podiatrist will allow your foot health to be assessed and management options explored.  Treatment can include; mobilisation to the joints, taping techniques to offload inflammation, special toe devices to unload pressure, special dancing inserts to redistribute pressure areas.

Additionally our skin and nail health can be severely disrupted by our dance practice. Skin and nail issues can be best treated by your Podiatrist.

1. Smith, P. J., Gerrie, B. J., Varner, K. E., McCulloch, P. C., Lintner, D. M., & Harris, J. D. (2015). Incidence and prevalence of musculoskeletal injury in ballet: a systematic review. Orthopaedic journal of sports medicine, 3(7), 2325967115592621.
2. Yau, R. K., Golightly, Y. M., Richardson, D. B., Runfola, C. D., Waller, A. E., & Marshall, S. W. (2017). Potential Predictors of Injury Among Pre-Professional Ballet and Contemporary Dancers. Journal of Dance Medicine & Science, 21(2), 53-63. 
3. Hulin BT, Gabbett TJ, Blanch P, et al. Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Br J Sports Med 2014;48:708–12 
4. Caine, D., Bergeron, G., Goodwin, B. J., Thomas, J., Caine, C. G., Steinfeld, S., ... & André, S. (2016). A survey of injuries affecting pre-professional ballet dancers. Journal of Dance Medicine & Science, 20(3), 115-126.

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Dentist or Dance Physiotherapist? BOTH!
By Susie Bond
evolutionpilates.com.au | [email protected] | 02 9518 5009

Would just two visits a year to a specialist dance physiotherapist make a significant impact to injury prevention?
Dance physiotherapists love to assist dancers achieve their top goals in dance. Everyone visits the dentist regularly to prevent dental problems. Regular visits to a specialist dance physio should be made, in the case for dancers going through rapid growth spurts. Simple core stability, joint strengthening and leg alignment exercises can make all the difference for injury prevention.

“When I give a specific strengthening exercise to a dancer, I often say “this is like a ‘cleaning the teeth’ exercise”, that is something you would do every day.”

Research shows that dancers are more prone to injury (e.g. Knee), as a teenager, when number of hours of dance load increase per week. It is good to a see a specialist dance physiotherapist to manage an injury and do a Pre pointe assessment. It is also important to check out physical niggles and limb and trunk alignment issues, before a big problem arises. A regular visit to the dance physiotherapist at least 1-2 times each year, will help guide the dancer, their parents and teachers through the many changes during the adolescent growth time.

Susie Bond is the Director of Evolution Pilates and MG Pilates, she is a Physiotherapist, Pilates Instructor, Dancer Physiotherapist and commenced dance training when she was 5. Susie runs regular lectures to Pilates teachers, dance schools and post Dance degree courses in Australia and UK. She is a founding committee member of the special Dance Network, in the Sports Australia group of the Australian Physiotherapy Association, which organised lectures to teach physios how best to treat dancers. She is a member of the Australian Pilates Method Association and of the International Assoc. for Dance Medicine and Science. Her passion is for dance, performance enhancement, healing physio treatment and injury prevention.

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Weight Watching & Your Identity
by Jocelyn Penna
performancepsychology.com.au | [email protected]

People drawn to dance possess many amazing traits, beliefs and values that enable them to excel such as determination, emotional connection and focus. Yet, these same characteristics can place dancers at risk of suffering from stress and high pressure. Developing awareness of your strengths and vulnerabilities can help you keep a healthy, productive and enjoyable balance.

When Weight Watching is turning into something harmful.
Dancers bodies are their instrument, and not only are they required to keep it in good working order, but they can also feel the pressure to keep it looking a certain way. Being externally judged means that dancers often watch and scrutinise their own bodies more closely than other people may. This scrutiny can become problematic.

Weight watching may be turning into something harmful if you are significantly restricting food intake, feeling overly tired, thinking or talking about appearance often, comparing what you eat to other people, fear gaining weight, making excuses about what you are eating or are eating in private.

All people benefit from a healthy diet. We all need differing amounts of nutrients and energy for our body to perform optimally. Unhealthy weight management habits can quickly result in you being unable to perform, hinder your future in dance, and lead to permanent detrimental changes in body and brain functioning. More information about disordered eating can be found on the Butterfly Foundation website- thebutterflyfoundation.org.au.

You cannot perform your best if you are not physically and mentally healthy. If you’re not sure if your nutrition is meeting your needs, consult a sport dietitian who works with dancers. If your mind is stuck on thoughts about body image, or you don’t feel good about yourself for any reason, then talk to someone you know who cares about you, or consult a sport psychologist familiar with the demands of dance.

Dancers often become passionate about their craft at a young age. They can identify strongly with dance and become personally and emotional involved in their roles. Identifying strongly with something is great, it means you are passionate, committed and have great potential to be an expressive and animated performer.

“Dancing is what you do and what you love, but you are much more.”

You could be a loyal friend, caring daughter or son, committed activist, passionate thinker, strong leader, and many other things.

Performances face external judgement, which despite being subjective, can be taken personally. So those with a narrow identity may struggle when faced with the challenges of being a performer. If your worth is being pushed around by nerves, performance results, body image or injury, it’s valuable to explore why. When you appreciate seeing yourself as you really are, you allow your performance and enjoyment to grow enormously.

Jocelyn Penna from Focus Performance has 15 years experience working with professional and developing performing artists.  She enjoyed background in dance and now studies the psychological challenges and rewards of being involved in the field.  

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Happy Hips?
by Deborah Chen
inspiredphysio.com.au | [email protected]

As dancers continue to push their body right to the extent of their flexibility I’m seeing an increase in hip pain complaints – particularly a pinching in the front of their hip when doing front kicks or developping leg to devant. Sometimes the pinch is only there with those particular activities and other times the pinch turns into a deep, dull ache that can last for a few hours and can eventually become constant.

This pain could be caused by a couple of different things – it could be something as simple as adjusting technique because of an overactive hip flexor muscle and as complex as torn hip cartilage (also known as a labral tear). Having been someone who has ‘faked’ her turnout for most of my dancing life, experienced labral tears in both my hips and had two hip arthroscopy surgeries to repair them I am a big advocate for learning about your true turnout muscles or deep hip rotators and stabilisers.

There are six muscles that work to exclusively rotate your thigh bone or femur outwards – they are your piriformis, quadratus femoris, obturator internus, obturator externus, superior gemilli and inferior gemilli. These muscles work to give you standing leg turnout as well as active turnout for things like demi plie or maintaining turnout when your leg is en lair in a developpe. If you’re looking for whether you’re working the turnout muscles correctly you should feel them contract around your lower bottom around the bottom of your leotard. Try this by standing with your feet together in parallel and rotate your thigh bones outwards – you may notice your knee caps now face directly forwards and feel your lower bottom muscles contracting.

Activating your turnout muscles should take some pressure of the hip flexors doing all the work but you also need to stabilize your thigh bone in its socket. To do this we need to activate the illiacus. The illiacus is a bit of a secret muscle – it sits inside the front of your pelvis and combines with the psoas to become the iliopsoas. The hip joint is a ball and socket joint and the illiacus is there to help hold the ball centrally in the socket. If you’ve loosened up your hip flexors and are still getting a pinch or blocked feeling in the front of your hip you could be experiencing anterior hip instability as a result of an underactive illiacus. This could potentially be reducing the height of your kicks and developpes in devant.

“Many dancers are also told that they are ‘hypermobile’ or ‘lax’ in their ligaments – which is fun when you want to be flexy but less fun if you’re experiencing pain due to lack of muscle/ligament control.”

Something as simple as learning to activate your illiacus muscle may help to reduce laxity pain you experience in your hips and may even reduce clicking of the hips.

I can’t stress enough, the importance of acting on pain or restriction as soon as you notice them. It doesn’t always mean you’ll need to stop dancing – it may mean an adjustment in your technique and learning to activate the correct muscles to rehab and prevent further injury. Don’t be scared to speak up and let your teachers know if you’re struggling – it could very well be what prevents long term injuries in the future.

Deborah Chen Registered Physiotherapist B.App.Sc. (MRS-RT), Master of Physiotherapy from Inspired Physiotherapy
Deborah studied dance as a child completing her Major 3 level in Ballet (Australian Dance Assessment Program). She has also taught ballet and lyrical in the Hills area of Sydney.

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Turnout – what is it?
by Samantha Jakelic
kineticaphysiotherapy.com.au | [email protected] | 02 9948 6188

Dance teachers and students are constantly talking about and working on making the most of turnout. It is what makes Ballet fundamentally unique. Turnout is the ability to outwardly rotate the leg so that the knees and toes turn away from the midline. The “perfect” 180o turnout is often desired amongst dancers and choreographers because of its aesthetic appeal. However, did you know that turnout has also been shown to allow more efficient weight transfer, better control of extensions and reduce the risk of injury?1

What does turnout really mean?
The vast majority of turnout is achieved by external rotation of the hips within their sockets and is often referred to as pure turnout. This pure rotation from the hip joints when combined with a small amount of outward rotation of the knees and ankles this is called your functional turnout. Pure hip rotation is the key area for working your turnout – it should contribute 80-90% to the standing in 1st position functional turnout. Using too little from the hip and too much from the knee, shin and foot can increase the risk of injury. Turnout can be influenced by the strength and flexibility of the surrounding muscles, bony architecture of the joints and laxity of the ligaments. As a result, we think about turnout in two different ways – how much can the hip joint give you (in the joint, ligaments and tissues) and how much strength do you have in your turnout muscles (actively).

Passive turnout (Your turnout potential!):
Passive turnout is the maximal possible amount of movement at the joints. It is achieved without the use of any muscles and is largely dependent upon the orientation and shape of the bones, laxity of the ligaments and joint capsules. Subtle differences in pelvis and hip joint development influence the passive hip turnout potential. The depth of the hip socket, the direction of the hip socket and many other factors all affect the potential turnout. When we measure turnout, we examine the relaxed amount in the hip joint with the leg in neutral – this represents what we traditionally consider our hip turnout – the passive amount in 1st position. Passive turnout is achieved when a therapist or teacher turns a dancer’s legs into turnout while the dancer is lying relaxed on a bed. However there are other places where turnout is important and limited by the bones and joint structure. We also need to consider:
turnout capacity elevated at the front (attitude and arabesque)
turnout capacity while elevating into 2nd
turnout capacity while elevating behind you

Active turnout (Your strength):
Active turnout is achieved when a dancer moves into turnout on their own such as when standing in 1st position. It relies on the activation of the muscles that move the leg into turnout and the relaxation of the muscles that oppose this movement.

Literature2 has shown that passive turnout range in the hip joint unfortunately does not improve across childhood or adolescence. Gains in turnout range is to do with strengthening our hip rotators and stretching the opposition muscles. So in order to improve our turnout we should be focused on exercising the muscles that help us move into turnout. It is important to work safely within your joint capacity! Strengthen but work safely and smartly with your physiotherapist and teacher to maximise your strength.

Does dancing help or hinder my turnout?
By repetitively practising the precise movements that are specific to the artistry of ballet will actually help you improve your turnout. Research3 has shown that strength in the muscles of the hip improved with training and continues to build through the first year of a full time program to a greater extent in dancers than in non-dancers. So it is more likely that dancing will help rather than hinder your turnout.

What can I do to improve my turnout?
1. Strengthen the deep hip external rotators: The deep muscles that sit closest to the hip joint (quadratus femoris being the main one) are responsible for actively moving our hip into external rotation. These are the muscles we want to target to improve our active turnout range.
2. Improve core activation to ensure neutral lumbo-pelvic-hip alignment: A neutral line through low back, pelvis and hip will ensure efficient activation of our deep hip rotators and help to optimise movement.
3. Ensure adequate flexibility of the hip internal rotators: A lack of flexibility of the hip internal rotators (adductors, tensor fascia latae, iliopsoas and pectineus) will restrict active hip outward rotation. Releasing these muscles will help to maximise turnout range.

We strongly advise arranging a consultation with your friendly dance physiotherapist for an assessment to determine the specific exercises that will help you improve your turnout.

Does not having “perfect” 180o turnout mean I will never become a professional dancer?
The “perfect” turnout is measured in first position and is described as 180o of leg external rotation. Experts agree that this is rarely attainable due to the structure of our hip bones. Overcompensating and attempting to maintain rotation beyond the strength and joint capacity can place the dancer at risk of pelvic and hip pain, shin splint and knee injury. Ideally, we want almost all of our turnout to come from hip external rotation rather than forcing it from our knees and ankles. This means that for most people 180o of turnout is not physically possible.

Many professional dancers with successful careers do not have the “perfect” turnout with the most recent research showing company level classical dancers averaged 60o of passive external rotation (from each hip), 35o of active hip external rotation and 133o of functional turnout when standing in first position. At the enthusiast level, dance physiotherapists see normal range at 45o of passive rotation potential but this number varies enormously.

“Dance encompasses a whole lot more than just perfect turnout – artistry, grace and musicality. Maximising your strength and learning to use it by keeping knees in alignment with toes, there is every possibility that less than perfect turnout will still permit you to have a successful dance career.”

1 Pata, D., Welsh, T., Bailey, J., & Range, V. (2014). Improving turnout in university dancers. Journal of Dance Medicine & Science, 18(4), 169-177.
2 Steinberg, N., Hershkovitz, I., Peleg, S., Dar, G., Masharawi, Y., Heim, M., & Siev-Ner, I. (2006). Range of joint movement in female dancers and nondancers aged 8 to 16 years. The American journal of sports medicine, 34(5), 814-823.
3 Bennell, K. L., Khan, K. M., Matthews, B. L., & Singleton, C. (2001). Changes in hip and ankle range of motion and hip muscle strength in 8–11 year old novice female ballet dancers and controls: a 12 month follow up study. British journal of sports medicine, 35(1), 54-59.
4 Washington, I., Mayes, S., Ganderton, C., & Pizzari, T. (2016). Differentials in Turnout Among Professional Classical Ballet Dancers. Medical problems of performing artists, 31(3), 160.

 Samantha Jakelic Physiotherapist APAM. Samantha was a former dance student herself, she understands the importance of preventing injuries, chronic injury management and fixing those niggles fast. Sam understands that providing alternative activities to maintain fitness, strength, and flexibility when an injury occurs is the cornerstone to a dancer’s recovery through every part of their lifespan.

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Remedial Coaching
by Suzanne Way
professionalballetcoaching.com | [email protected] | 0407 010 286

What is something dancers really struggle with when they get injured?
In my experience I have found dancers struggle with the time frame of their injury. How long will I be out of class and rehearsal? What opportunities will be missed? These questions immediately set up a stress reaction in the body and must be dealt with carefully.

Why should dancers continue to do class whilst recovering from an injury?
The prime function of remedial coaching is to work with the injured dancer privately at their own pace to restore strength and integrity to the area and most importantly to correct the posture and technical weakness which created the injury in the first place. To join class is to work at the pace of the other dancers and would not be recommended until I felt confident the dancer could cope with the demands of class without compromising the results already achieved. By all accounts the first experience rejoining class must be positive, essential to restoring confidence and self esteem.

What advice do you offer dancers during this very trying time?
Mentoring is paramount, psychologically the expectation of pain either continuing or returning is always present. Will the injury hold up under normal class/rehearsal conditions?

Questions the dancers ask themselves, Will my injury support multiple pirouettes? Will my injury sustain working en pointe? Will my injury support my body through allegro work without cause of re injury?

Strengthening the mind, trust, encouraging the belief system to remove the mental blocks associated with the healing process can not only benefit but encourage a very positive recovery with a stronger disposition and less risk of self sabotaging in the future.

What should dancer and parent do?
As an experienced remedial coach I feel both the dancer and the parents must trust and be invested in the structured plan suggested and the time involved for recovery. To date this has been highly successful with outstanding results, the dancer is proactive armed with the knowledge and resources to prevent and overcome further injuries. Students do return from overseas to be coached privately, they trust me implicitly and know they have my best interests and confidentiality at heart.

Suzanne Way A.R.A.D. director of Professional Ballet Coaching Australia is now specialising in remedial coaching. A life member of the Royal Academy of Dance she trained at both The Australian Ballet School and The Royal Ballet School in London. She has an extensive career in classical ballet including The Royal Ballet and The Australian Ballet. Suzanne has created successful curriculum for full time students in both the U.S.A and Australia and now due to success devoting her time to remedial coaching.

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The Importance of a Dance-Specific Musculoskeletal Assessment
by Shannon Trotter
ssphysio.com.au | [email protected] | 02 9527 4099

A dance assessment carried out by a physiotherapist who specialises in treating dancers can be used to identify a dancers’ strengths and weaknesses which in turn may decrease their risk of injury. It is also used to assess readiness for pointe work and for general improvement in technique and performance. Often, dancers will present to our clinic with injuries that could have been avoided with prior assessment and appropriate management programs. The long term benefits are immense with reduced risk of injury, less time off dancing and improved performance.

A study posted in the Journal of Athletic Training shows that 42% of dancers before the age of 8 had previously sustained an injury. The physical demands of repetitive practice puts a large amount of strain on a young dancers growing body. Growth spurts usually occur from ages 8-12 (girls) and 10-14 (boys). During this time, extra stress placed on the body through dance can cause stress fractures, tendinopathies, torn ligaments and various other injuries.

A typical dance assessment may include;

  • A thorough dance history and injury history
  • Postural assessment
  • Assessment of range of motion of joints – particularly those in the lower limbs and feet
  • Assessment of turnout range of motion as well as strength of deep hip rotators
  • Pelvis and trunk stability – this is the ability to activate the deep core muscles dynamically to control movement and protect the spine
  • Intrinsic foot muscle strength as well as ankle and foot stability
  • A range of dance specific skills
  • Growth – physical and mental development and readiness

Other than biomechanical risk factors assessed by the physiotherapist, another key to preventing dance injuries is being aware of young dancers growing bodies and educating dance teachers, adjudicators and parents on the dangers of pushing young dancers beyond their physical limits. Dancers have an amazing sense of body awareness; however often struggle to understand the difference between muscle fatigue from exercise and “bad” pain from an injury.

Tips for safe dance practice;

  • Don’t keep dancing on an old injury. If you have had an injury for more than a few weeks and are hoping it will “just go away by itself” – chances are it won’t, and you are more likely to make it worse with more dancing. As a rough guide, any pain that lasts more than 3 days should be assessed.
  • Full rehabilitation of an injury is essential. The absence of pain does not necessarily mean your injury has recovered. It is imperative that you recover full range of motion, strength and dance specific skills so that you are able to dance to your full potential without becoming injured again.
  • Know the difference between “good” and “bad” pain. Listen to your body. Dancers will often push through pain with the fear that they won’t be able to dance at all.
  • If you’re injured, you can’t keep doing the same thing.” If you don’t change what you’re doing- then expect the same results”. If you have an injury and keep aggravating it, it will never improve. It is important to listen to your physiotherapists instructions on what you can and can’t do. It is highly unlikely that your physio will ever prescribe total rest for an injury. It is likely they will send you back to dancing as soon as possible with a modified dance program.
  • See a physiotherapist who specialises in dance. We all know dancers are not your average humans. They are expected to be able to achieve so much more in regards to flexibility and strength. Physiotherapists with dance experience will have the knowledge of what you are likely to do in each class and therefore can more easily fine tune a modified dance program for you. Their knowledge is also essential in the end stage of rehabilitation where dance specific training and exercises are necessary for an injury-free return to full dancing.

Whether you have an injury or you just would like to improve your technique, undergoing a dance-specific musculoskeletal assessment will put you in a strong position to enjoy injury-free dancing and enhance your performance.

Shannon is a Physiotherapist at Southside Physiotherapy & Sports Injury Centre. Her love of dance began when she started ballet at 3 years old. Shannon is able to bring together the knowledge and skills she has as both a dance teacher and physiotherapist to successfully treat dancers in her clinic.

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Starting Pointe Work
by Louise Drysdale
pondera.com.au | [email protected] | 07 3846 1488

Do growth plates in the foot affect the ability for the dancer to commence pointe work and can commencing pointe work too early create long term negative side effects?
These are difficult questions to answer because there is a lack of research explicitly investigating this. Growth plates are a bit like elastic in pregnancy pants – in young dancers, they are not yet comprised of fully calcified bone, in fact they are cartilaginous and ready to expand and grow as a dancer gets taller. Growth plates (around the ankle) generally fuse at age 14 for girls and age 16 for boys. Most girls I see progress to pointe are 11.5- 16 years of age. The International Association of Dance Medicine and Science recommends age 12 as an appropriate age to start or start preparing for pointe work.

Commonly, the injuries we see that are usually aggravated or occur during pointe work include ankle sprains, foot bone stress reactions, posterior ankle impingement and tendon pain, most of which can be resolved with good movement analysis, treatment and management. A comprehensive pre -pointe assessment allows the opportunity to educate dancers about their bodies to minimise the risk of these occurring.

Perhaps the real question (which we also don’t know the answer to) is – what would happen if a dancer were to start pointe at 15 years instead of 10 years? Would their chances as a professional dancer be hindered? Would they be stronger and have had more time to work on developing technical proficiency?

There are many factors to the dancer being ready for pointe work but what are you looking at in the foot for pointe shoe readiness?
To align yourself en pointe, you need to be able to achieve 180 degrees (a straight line) through your shin, ankle joint and metatarsals. Sometimes, even with exercises and physiotherapy help, a dancer cannot achieve 180 degrees. It is then that the student, teacher and physiotherapist should consider the safety of the dancer in making the decision to go ahead with pointe work.

A hypermobile (flexible) foot can be problematic. Dancers who have no trouble achieving 180 degrees (and more) often find it difficult not to sink into the pointe shoe or balance on one leg on a flat foot in a pointe shoe because their muscles aren’t strong enough to control the ankle or small joints through the midfoot. I always test simple toe co-ordination foot lumbrical muscle exercises and make this part of an everyday routine.

“If you are a dance teacher and have students preparing for pointe, ask them to take barre in bare feet occasionally – it will reveal many secrets hidden beneath the canvas flat!”

Sickling and over fishing are equally undesirable habits, so care should be taken to correct these in everyday rises, tendus, jumps etc.

What are some of the more common issue that prevent dancers going on pointe that can be assisted with physio and Pilates exercises?
1. Old or current injuries! This is a familiar scenario- a dancer will present for a pre-pointe assessment, although with questioning they reveal back, knee or hip pain that currently affects their dancing and hasn’t been addressed. It’s very hard to develop competency en pointe when you are already compensating for pain somewhere else.
2. Optimal use of turn out from the hip. It is absolutely possible to dance professionally without having “flat” turn out. However, activation of the deep external rotators of the hip during basic ballet movements is often lacking.
3. I will ask a dancer to do “as many calf rises as they can” on a single leg in parallel, with good foot (controlling sickling and fishing), knee, hip and trunk alignment. Depending on the age and experience level of the dancer, 25-35+ calf rises is a good target.
4. Whole body trunk and pelvic co- ordination in ballet and non- ballet context. The “Airplane Test” is (according to research) viewed by therapists and dance teachers alike as a good indicator of pointe readiness. There is a handy YouTube video of this test in cyberspace.

When starting pointe work, you should be making a commitment to yourself to really look after your body and dedicate time and energy to ballet and conditioning exercises beyond that of “just a hobby”. Chronological age and skeletal maturity are only part of the puzzle. All clients who visit for a pre-pointe assessment leave with homework, even if the answer is “yes” to pointe shoes. Such is the life of a dancer!

Louise is a physiotherapist at Pondera Physiotherapy and Pilates in Brisbane. She has a keen interest in dance injury management and prevention- from budding students to seasoned professionals. She is currently Assistant Physiotherapist to Queensland Ballet and Queensland Ballet Academy. 

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by Andrew Cobb
sports-spinal.com.au | [email protected] | 03 9878 8088

Osteoarthritis (OA) of the knee is quite common as you age but can develop much earlier when someone has suffered a significant knee injury. A classic example of this is when an athlete ruptures their anterior cruciate ligament (ACL), regardless of the treatment sought you can expect to see OA changes in the knee within 20 years. Quite often these athletes are still young and having major surgery like a partial knee replacement is best to be avoided for as long as possible. In these circumstances, there is a growing demand for injectables to delay the need for surgery. For all of these injections you need to discuss the appropriateness of them with your GP, sports physician or orthopaedic surgeon.

Corticosteroid (Cortisone) injections have been used in OA joints for years to help settle down pain and swelling. They give relatively quick relief and they aren’t cost prohibitive like some of the newer injectables. One of the bigger issues with corticosteroid injections is they can cause cartilage break down which would eventually make the OA worse. These injections should be used sparingly, they appear to be a quick fix but can’t be used long term.

Platelet Rich Plasma (PRP) injections have become more common in the last 5 years for management of OA knees. PRP is usually derived from a blood sample from the patient that is spun in a centrifuge to separate the blood into different layers. Once spun the Platelet layer is collected and used for the injection. The reported benefits of a PRP injection are reduced pain, stiffness and potentially slowing down cartilage degeneration. In theory, this delays the need for surgery however it doesn’t work for everyone. Given the promising early results more research is being done about the make-up of the PRP injection and which conditions and patients respond well.

Hyaluronic Acid (HA) Injections are an option as the knee becomes more painful and normal anti- inflammatory drugs aren’t helping control the pain or swelling. HA is normally found inside the synovial fluid that lubricates the knee joint however in a joint that is suffering from OA the HA starts to break down making the synovial fluid less effective and the joint painful and stiff. You normally would have 3-5 injections spaced 1-2 weeks apart. There is now limited evidence that shows that some people get relief from HA injections and it can help people delay more invasive operations. It takes some months before the benefit of an HA injection is seen.

Mesenchymal Stem Cell injections are getting a lot of media attention at the moment, but despite the excitement and huge cost there is currently no substantial evidence that supports the use of these injections in a OA knee. The Australian College of Sports Physicians recent position statement was updated saying they have “specific concerns about patient safety” and that further “rigorous clinical research” needs to be done.

Andrew Cobb is an APA Sports Physiotherapist and Director of Bellbird Sports & Spinal. He has over 15 years clinical experience and treats a large number of dancers and gymnasts. Andrew is also a qualified Clinical Pilates instructor and draws on his 15 years as a ballet dancer when treating and rehabilitating performers.

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Tips To Help Your Body During Exam & Comp Time
by Charissa Fermelis
charissafermelis.com | [email protected] | 0438 020 167

The winter dance competition season has come and gone, and fast approaching is the spring exam timetable and soon enough, we will be in the midst of concert preparation. The yearly dance calendar can be quite a confronting routine, punctuated with extra rehearsals and private lessons; there are few opportunities for ‘down time’ or an ‘off season’ where rest and recuperation are allowed.

Add to a dance student’s busy diary their high intrinsic expectation and perceived external pressure from teachers and parents – the result can be a physically exhausted and emotionally drained young person.

I remember this all too well. In amongst all this dancing, I somehow needed to find time to stay abreast of school study, engage with my non-dancing peers and also just chill out!

Outlined below are some methods to assist with physical recovery during those heavy dance periods, to reduce muscle soreness, begin the tissue repair process and restore function in order to maximise performance potential and help minimise the risk of injury.

  • Stretch following activity – long indulgent stretches, working through all the major muscle groups, holding the stretch for 30 seconds but repeating each 3 to 5 times
  • Ice pack – utilise an ice pack at home (or a bag of trusty frozen peas!) on any acute injuries to help reduce pain, swelling, bruising and inflammation
  • Soak feet in cold water – to soothe tired feet, especially helpful after dancing en pointe
  • Injury management – have any new niggles assessed by a dance physiotherapist to establish a treatment plan, or implement your self-management regime at home to stabilise ongoing or chronic issues
  • Massage – either by making an appointment with a myotherapist or massage therapist, or by self-massaging on a foam roller or spikey massage ball at home
  • Compression garments – wearing compression leggings or compression socks on long car trips home after dancing will help prevent swelling pooling in the feet and assist with blood circulation
  • Postural drainage – resting with the feet elevated up the wall or on the edge of the couch helps with venous return
  • Adequate sleep – the National Sleep Foundation recommends a teenager aim for between 8 and 11 hours of sleep per night
  • Optimal nutrition – replenish glycogen and protein, water rehydration

“Add to a dance student’s busy diary their high intrinsic expectation and perceived external pressure from teachers and parents – the result can be a physically exhausted and emotionally drained young person.”

Charissa Fermelis is a physiotherapist and Pilates practitioner with a Bachelor of Physiotherapy degree and Pilates teaching qualification through the Australian Pilates Method Association. Charissa has a passion for dance injury rehabilitation and technique integration in the adolescent dancer, intertwining scientific-based clinical medicine with a holistic and grounded approach to wellbeing. Charissa has worked alongside renowned physiotherapists of the Victorian College of the Arts and dance community to develop highly regarded dance physiotherapy assessment procedures. She currently consults in Melbourne and the Gold Coast, and at regional dance schools around Victoria.

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The Importance of the Intrinsic Muscles in the Feet
by Gabrielle Davidson & Joanne Maskrey
insyncphysiopilates.com.au | [email protected] | 03 9813 2188

The humble foot is a highly mobile collection of joints, ligament and muscles that allow for flexibility of the ankle in demi-plies, the beautiful arc of the pointed foot, the explosive push off, and the light, quiet landing of allegro. Dancers are able to execute these movements precisely with the activation and control of highly trained intrinsic muscles of their feet.
The intrinsic foot muscles are a vital part of the technique for every dancer, male and female. The strength of these relatively small but essential muscles govern how far the foot can arch, which creates the aesthetically pleasing line all dancers desire. Long toes when jumping are the springs at the end of your feet, as the longer levers of lengthened toes give your jump more power.
When the concept of pointing the foot is first introduced to little ballet dancers they will naturally curl their toes. This is because the intrinsic muscles don’t switch on automatically. Watching how the foot works without shoes lets dancers see what their toes are doing.
As young dancers get older they become more able to select the muscles they use to execute movements. Students can then spend time learning how to activate and work their intrinsic foot muscles.
Class work becomes harder and more complex with the introduction of larger jumps, pirouettes, balancing on demi-pointe and full pointe. This puts much greater stress on the bones of the feet.
The intrinsic muscles of the feet, by their attachment to the bones, offer columns of muscular support to maintain the health of the bones and joints. Common dance injuries such as posterior ankle impingement and stress fractures of the metatarsals can often be traced back to weakness of these little muscles.
The Australian Ballet’s medical team is at the forefront of dance medicine research. It has discovered that intrinsic muscles help prevent posterior ankle impingement by acting as a counterbalance to the strong pull of the calf muscles that can compress the back of the ankle joint as the dancer pointes their feet.
Another role of these important little muscles is to support the arches of the feet. Rolling the feet (when the arches drop and are no longer visible when standing in first position) sends twisting forces through the knees and subsequently makes turnout more difficult at the hips. This can then affect the back and limit the biomechanical efficiency of the dancer’s entire lower limb.
There are many exercises available to help dancers activate and strengthen their feet. A dance physiotherapist or experienced dance teacher can provide individual assessments and targeted strength programs to suit specific needs.
Ultimately, the dancer must be able to integrate the new technique into their everyday dance classes. This can take a little while, because the dancer might need to change how they point their feet and habitual motor patterns take time to change, such as the way the dancer points their feet, so it is important to keep working with focus and concentration.
The tendu is the best way to engage and strengthen the foot intrinsic muscles in class. Done at the beginning of the class, dancers can warm up their feet and achieve greater articulation to prepare for more complex choreography.
Rising to demi pointe is also an important way to keep working and strengthening intrinsics. Toes should be able to remain lengthened and not shorten or curl. This will give the foot the long lever in the take off for a jump or to keep rising to pointe.
It is just as important to release the intrinsic muscles after class. Using a spikey ball and self-massaging can help keep your feet supple.
Remember, as tempting as it is to use passive joint stretches to increase the arch, these only add strain and stress to the ligaments and joints without creating muscular support. So put in time to develop good use of your muscles around the foot and ankle, particularly your intrinsic muscles. It will stand you in good stead for stronger and healthier feet, and a better pointe. Happy doming!

Gabrielle Davidson ( B.PHTY (HONS) and Joanne Maskrey (B.PHTY)  are both Dance Physiotherapists at InSync Physiotherapy & Pilates with an extensive knowledge and history of treating dancers.

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