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By Ronda Wimmer, PhD, MS, LAc, ATC, CSCS, CSMS, SPS
Understanding the culture of performing arts, specifically related to dance, is as important as the treatment and prevention of many dance injuries. Dancers in genres from hip hop to ballet commonly develop overuse injuries.
It is important to understand not only the mechanisms of injury, but also the intensity that performing arts demands upon the dancers. Such demand include hours of training, working on basic skills and keeping current new techniques; not to mention the back-to-basic skills needed to keep a dancer's skills honed.
From a preventative standpoint, Chinese Medicine can play a huge role. This is an area that needs to be addressed, as well as the physical perspective of strength, alignment and biomechanical considerations.
Common Injury Patterns
Many professional dancers are prone to overuse injuries because of the young age start. Dance requires strength, flexibility and endurance, all of which are movements needed to perfect the neural patterns that provide the grace and execution of the complex, repetitive movements.
These overuse injuries depend upon the type of dance being performed, the intensity and frequency of rehearsals, classes, and performances, as well as the training durations. Environmental factors also play a role, such as cement floors versus wood, as well as cold studios. A dancer's strength, body alignment, biomechanical compensation patterns when fatigued, nutritional deficiencies, proper recovery, sleep and any history of prior injuries also contribute to their overall condition.
Western medicine addresses the anatomical model. Chinese medicine addresses the constitutional model. Chinese medicine can provide not only exercises for cross-training to allow dancers to rest and recover from their grueling training demands, but also treatments that can balance the totality of their system to prevent injury, aiding in career longevity.
Keeping dancers on their feet ready for auditions and getting them through shows injury-free depends upon preventive measures and addressing compensation patterns immediately. These signs and symptoms typically identify themselves as restrictive movements (tight), pain and/or discomfort. Dancers tend to dance through pain because dancers are extremely passionate about what they do and constantly want to improve their skills in order to be better performers (perfectionists). Some younger less experienced dancers try to take class after class not allowing themselves enough time to recover.
It is important to educate dancers on how to take care of themselves and not let the industry take advantage of them. In any professional sport, athletes are expendable – there is always another athlete in line to take their place. This is also true for dancers. Once a dancer's career takes off, it is auditions for the next gig, teaching dance classes between, modeling and dancing for movies, music tours, videos, and commercials. Depending on the "gig" and the money allotted, many times there is only either a nurse or EMT available. In other cases, massage therapists are brought in, and sometimes physical therapists and/or chiropractors. But my experience is that many are not used to working with dancers!
As a result, an understanding of dancers' mentality is completely absent, along with the specific treatments necessary for the dancers. Most are first taken to the hospital and then released with medications as the standard protocol for studio liability. The injury pattern(s) and/or compensations are not really addressed or rebalanced before the next performance.
However, now that dance medicine is gaining more acceptance, dance companies are implementing certified athletic trainers, physical therapists, chiropractors and massage therapists for the performers. This has been important in lowering the cost of worker's compensation. It provides a "win-win" situation for both the dancer and the dance company. However, for smaller, short-term performances, this is not the case and dancers are often left on their own.
Some of the common injuries treated include neck (whipping motion), shoulder (rotator cuff),elbow, wrist, hip (TFL), knee, ankle (lateral, anterior/posterior tibialis, shin splints, Achilles tendon), back, and the feet (plantar fasciitis, Morton's neuroma, jammed MTPs).
Providing the dancer with information on how to prevent injuries in order to stay healthy is critical in order for the dancer to take responsibility for their own health. Career longevity is based upon keeping the body in balance from multiple perspectives.
Recently, one of my dancers I have been working with for a number of years came in with neck issues from dance rehearsals for a music tour she landed. This is a pretty common injury with dancers, so I will address this specifically from a Western and Chinese medicine treatment standpoint.
Western medicine addresses structural, functional and biomechanical aspects. Some areas to consider: neck alignment, core strength, and hot versus cold treatments.
Neck alignment for dancers and non-dancers alike is important. However, for dancers, head position and execution of expression are paramount. Dancers' necks tend to follow a common pattern: the neck extensors (splenius capitis, semispinalis capitis/cervicis, longissimus capitis /cervicis and multifidus muscles, scalenus anterior/medius and levator scapulae) are usually tight; while the neck flexors (SCM, longus capitis, longus colli) are typically weak.
When these muscles are tight on the posterior neck, this causes contractions which will pull the neck back, causing the chin to go up. Many dancers are told by their choreographers to lower their chin due to this compensation pattern. This compensation pattern creates an imbalance that is seen in a dancer's performance and also causes pain.
The idea is to balance the compensation patterns in order to prevent cervical hyperextension. Back injuries travel in 45-degree patterns for muscular compensation up the spine. With that said, the cervical flexors need to be strengthened, while the extensors need to be lengthened (stretched).
Thoracic extension is another goal for dancers to work on. This can involve positioning the thoracic spine on a bolster with the neck in neutral position while doing this exercise. Keeping the lower back stable and breathing in as they do the exercise will assist in addressing neck hyperextension.
Another exercise that can be used to strengthen neck flexors is to sit or lie down and do isolated neck flexors by pulling the chin to the chest, contracting the muscles and holding it for a couple of seconds before releasing it. Tell the patient to build to three sets of 10-12 reps a day.
Postural integration and core strengthening involve the awareness of posture and neck position in normal daily activities that the patient is involved in throughout the day. Many dancers do not have enough core strength to facilitate coordination between upper/lower body isolation, which is helpful in transferring effort to the spine. Pilates pelvic tilts can open up the exterior of the hip and help balance the hip joint, keeping it powerful and flexible. This will help prevent compensation patterns with leaps and jumps, keeping the neck relaxed, and the hips relaxed and open.
Heat vs. Cold: When using heat and cold treatments, it is important to know when to implement each. Heat is used in the belly of the muscles to help relieve muscle tension. It will also take care of inflammation problems associated with tendonitis. Cold is used at the insertion point of the muscle if inflammation is present. DO NOT put ice over the entire joint, as many athletes do; it will lock up the joint.
Typically, RICE (Rest, Ice, Compression and Elevation) is used for strains or muscle tears to keep inflammation down. Rule of thumb: if you take a hot shower and it feels better, use heat; if it feels worse, use ice.
Dietary recommendations include eating foods that are high in fish oils, glucose, and omega-3 fatty acids to prevent inflammation. Calcium is also important for muscle contractions and bone density. Taking multivitamins and mineral supplements will be important to replace what the dancer is expending. Juicing with whole and organic foods is an ideal way to get these nutrients overall; however, taking them in pill form is the next-best thing when traveling.
The Eastern perspective addresses a dancer's individual constitution that identifies the relationship between pathogenic invasion, organ system function, and local pathology of joints and muscles; and explains the relationship of the internal/external system the channel system affecting other areas of the body.
In TCM, qi and Blood stagnation is the root of all pain and presents with pain and stiffness. A number of factors can contribute: scarring, HT/LG qi deficiency creating poor blood flow, yin deficiency or internal excess heat (increased blood viscosity), yang deficiency, etc. Bottom line: qi and Blood are not moving to varying degrees.
To put this into perspective, if the condition is at the superficial level, then Wind, Cold, Damp, Heat Bi syndrome will be associated. If deficiency is present, then the superficial condition can progress to the next level, considered the deep layer, which is associated with Wind Damp and/or Cold Damp that can generate local heat.
This can progress further into systemic heat or Damp Heat, which can progress into more severe chronic inflammation conditions. The deepest level includes Phlegm, Blood Stasis and LV/K deficiency, which progresses to degenerative joint conditions.
With many dancers, there are deficiencies and excess conditions, and each needs to be addressed on an individual basis. The dancer will have stagnation of blood and qi with underlying deficiency of the Zang/Fu organs that may be generating the stasis. In chronic cases, qi and Blood fail to reach the area due to Zang/Fu organ deficiency or obstruction.
Specific association with Zang/Fu organs relates to the LV/GB as the channel passes through the sub-occipital area. LV qi stagnation is a primary culprit for neck pain; LV Blood is associated because of its function to lubricate and nourish the sinews. LV Blood Deficiency presents with stiffness, crackling joints, dryness and loss of elasticity. K/UB are also associated with the entire spine and thus bone degeneration.
The pattern of qi/Blood deficiency is associated with the normal wear and tear of muscles; however, dancers go beyond normal wear and tear, decreasing the body's ability to move blood and qi that support all the Zang/Fu organs. This allows for invasion of the six external pathogens and is also a precursor to degeneration. This can progress to Phlegm, which typically can be seen with numbness, rather than pain occurring in conjunction with Blood stasis.
Specific to neck pain, Ashi point with pressure can be used, associated with the semispinalis capitis/cervicis, splenius capitus/cervicis, longissimus capitus/cervicis, levator scapula, trapezius upper/middle, and down into the rhomboids minor/major.
Common pattern of differentiation involving dancers include qi and Blood Deficiency associated with stiff, weak, dull, intermittent pain that is better with rest and worse with activity. Blood stasis involves chronic, stabbing pain. Qi and yin deficiency are associated with crackling joints, improvement with rest, worsening after massage, and joints that are easily irritated. LV/K deficiency involves the lower back and knees.
Yang deficiency is related with cold extremities, yin/yang deficiency is accompanied by fatigue, exhaustion tinnitus, some dizziness. Wind Damp invasion causes stiffness and heaviness of achy joints. Sometime when on tour, dancers will be affected by humid weather. Of course, the assumption is that if the dancer is under the care of an acupuncturist, tongue and pulse diagnosis will be addressed.
Local Points to Consider
GB20: great point for wind invasion, the upper neck and the entire head.
GB21: great for Qi Stagnation, stiff and tight neck
UB10 works with the deeper neck muscles as well as Wind invasion.
Distal points to consider: Lateral neck pain/stiffness - GB39 + SJ5, posterior neck pain/stiffness SI3, as well as UB60. UB60 is also good for relaxing muscles and sinews. Rotational neck movement Luozhen more for acute pain. For really good results needle while dancer is performing neck rotation right/left.
Points for Blood Stasis - UB17, SP6, SP10, LI4
Phlegm points - ST40, SP5, UB20
Qi/Blood Deficiency - ST36, SP6, R12, UN20, UB21
Qi/Yin Deficiency - R3, R4, UN20, UB23, LG7 + K6
Yang Deficiency - R6, K3, SI3, D4 (can moxa all)
Ear points - Shen Men, liver, sympathetic
The above are just examples of points; obviously each patient will need to be individually diagnosed according to TCM to identify pattern combinations present. Many combinations can be used.
Here are some herbal formulas that can be used. Again, there are a number of formulas that can be implemented or made specifically for your patient. I combine formulas already made:
Qi and Blood deficiency - San Bi Tang
Qi/yin deficiency - Sheng Mai San + Huang Qi Gui Zhi Wu Wu Tang
LV/K Yin deficiency - Liu Wei Di Huang Wan + Si Wu Tang
K yang deficiency - Jin Gui Shen Qi Wan Fu Zi Tang
K yin/yang deficiency - Du Huo Ji Sheng Tang
A key factor I would like to point out is that stress and emotional factors cause muscle spasms and increase compression within the affected vertebrae. This decreases qi and Blood flow, and can allow external pathological invasion of the six external pathogens. The ability to get the dancer to calm the mind and rest is of key importance not just to promote injury prevention, but also in terms of the artistic expression of the individual dancer.
Dance expression has a lot to do with the body's ability to be able to relax and contract continuously, with feeling that translates into expression of the art form. A choreographer has an idea that the dancer provides that ability to express as part of the performance. The ability to perform this expression clearly and easily with the dancer's body is reliant upon the balance of the body free of compensation patterns – relaxed and full of expression. Physical injury can affect this, as well as one's mental state (anxious, lacking confidence, stressed, maybe shy). Due to the competitive nature of dancers, they tend to be extremely susceptible to high stress physically, emotionally and mentally from continual training, as well as auditions.
It is important to cross-train with other types of activities to relax the muscles and allow for movement recovery. This also includes the psychological aspect, as dancers tend to be under lots of stress making them anxious. I recommend Tai Qi, Qi Gong and Yoga as examples.
Yoga can be even more specifically implemented using the chakras. However, when dancers are traveling usually this will be implemented on one's own, or sometimes the tour will hire a yoga instructor to travel with the dancers. Other times one of the dancers is already trained as a yoga instructor and that dancer implements the yoga while on tour! This is a critical aspect of keeping the dancer well-rounded and in a more relaxed state in performances and training. This is crucial for recovery and meditative at the same time.
Preventing injury and extending the longevity a dancer's career involves numerous factors. The biomechanical, emotional and mental considerations all translate into a dancer's expression and execution of the choreographer's expectation and vision within a performance. Dancers are prone to overuse injuries just by the "nature of the beast" in their profession. There are long hours, intense training sessions, and numerous classes to stay current on the newest moves and performance schedules.
Since dancers are so passionate about their profession and tend to be perfectionists, many will dance through pain. Therefore, it is paramount to provide information from multiple perspectives to give these dancers treatment options to help them remain injury free. In order for dancers to stay healthy, they need to take responsibility for their own health.
Chinese medicine is an important element in the treatment program for dancers in order to maintain a balanced system. The use of Tai Qi, Qi Gong and/or yoga is an important variable for cross-training dancers to a more relaxed state, as well as improved recovery. Acupuncture and herbal formulas can be used for performance enhancement and maintenance, helping prevent injury.
Remember, dancers are perfectionists with lots of physical, mental and emotional stressors; all of these play a factor the artistic expression of their performance. Chinese medicine can provide not only exercises for cross-training to allow dancers to rest and recover from their grueling training demands, but also treatments that can balance the totality of their system to prevent injury, providing career longevity.
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Maciocoa G. Foundations of Chinese Medicine, 2nd Edition. Elsevier / Churchill Livingstone, China, 2005.
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MacClean W, Lyttleton J. Clinical Handbook of Chinese Medicine, Volume 2: Spleen and Stomach. University of Western Sidney, 2002.
MacClean W, Lyttleton J. Clinical Handbook of Chinese Medicine, Volume 3: Blood, Fluid, Channels. University of Western Sidney, 2009.
Madden C, Putukian M, McCarthy E, Young C. Netter's Sports Medicine, 1st Edition. Elsevier, Mosby, Sanders, 2010.
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