Ouch! Five common dance injuries & how to treat them.

DOCTORS, PHYSICAL THERAPISTS AND DANCERS SHARE THEIR HEALING TIPS.

WITH OVER 600 MUSCLES, 206 bones and countless nerves, ligaments, and tendons in the body, it's almost impossible for dancers to escape getting injured. Acute injuries, such as a sudden sprain or muscle pull, seem to happen out of the blue. One minute you're dancing, the next minute you've hit the floor. Chronic problems, like tendonitis, develop from repetitive stress over time. The dance community is paying mare attention, with companies like New York City Ballet and Pittsburgh Ballet Theatre providing cross-training, pre-season screenings, and educational seminars to reduce injuries. In today's fast-paced, competitive world of dance, the new catch phrase is injury prevention. Though there are many types of injuries, some are more common among dancers than others. DANCE MAGAZINE interviewed health care specialists and performers about five of the most prevalent injuries.

ANKLE SPRAINS

Few dancers manage to perform without ever spraining an ankle. According to Dr. William Hamilton, orthopedic consultant to the New York City Ballet, American Ballet Theatre, and the School of American Ballet (and my husband), ankle sprains are the most common acute injury in dance. Less well-known is that they also tend to happen more than once. Megan LeCrone, a promising young corps dancer, has had three sprains since joining New York City Ballet three years ago. Her most recent ankle injury occurred in a late afternoon rehearsal of The Nutcracker when she says she felt a "pop after slipping in a pile of snow."

Fatigue may have been a factor. LeCrone recalls feeling tired before she slipped, due to back-to-back rehearsals. It was impossible to tell if the injury was serious because her "ankle looked like a balloon!" Luckily the swelling went down after she began the standard treatment for all acute injuries: RICE, an acronym for rest, ice, compression, and elevation.

The next step in rehabilitating a dance injury is to grade the severity. According to Marika Molnar, director of Westside Dance Physical Therapy in Manhattan, a Grade 1 ankle sprain could be a microtear or excessive stretching of the ligament with no looseness, while a Grade 2 involves a more severe tear, at times with a noticeable pop, and some instability. Grade 3 is a complete tear of the ligament with significant instability. LeCrone remembers, "My first sprain was so bad my foot was just hanging off the end of my leg." This time it wasn't that serious, most likely because she had kept her ankle strong with daily physical therapy exercises. If the ankle is still weak, painful, or swollen in spite of time and rehab, you may need surgery. Dr. Hamilton believes that operating on torn ligaments in professionals with Grade 3 sprains can allow for a faster and more solid recovery.

KNEE INJURIES

The knee is vulnerable to injuries that range from mild to severe, including meniscal or cartilage tears. Apart from the usual wearing out of cartilage from loading the joint, Dr. Douglas Padgett, who practices at the Hip and Knee Center at the Hospital for Special Surgery in New York, believes that some of these knee problems may occur in dancers with limited hip rotation. Twisting your knees to improve turnout may place you at risk for meniscal damage.

Choreography that involves deep squats or sudden grand plies can also damage knee cartilage. "It's like pinching your finger in a door hinge," says Katy Keller, clinical director of physical therapy service at the Juilliard School. Johary Ramos, a former dancer in the Fosse national tour, remembers performing a somewhat brutal number where he had to jump from a ladder backstage onto a trampoline and land in a squatting position on the stage. In one performance, Ramos says, "I felt a weakness but didn't know anything was structurally wrong. I did nine more performances until my bad knee was so swollen that I couldn't walk."

At first, it may be difficult to tell if an injury is mild, moderate, or severe, especially if you're like most dancers, who rarely give in to pain. So, unless your physical evaluation indicates that you need surgery because your knee is locked, you follow the same procedure for ankle sprains: RICE and rehab, including hands-on therapy and exercises. You may also try other modalities like electric stimulation to speed up the healing process. If your knee continues to catch or cause swelling and pain, your doctor may order an MRI for a more accurate diagnosis. Dancers who require surgery usually have it performed with an arthroscope, which is an instrument about the size of a drinking straw that can remove bone fragments and trim the meniscus.

HAMSTRING INJURIES

Muscle pulls are rarely serious, unless they occur in a vulnerable area, such as the hamstring. According to Dr. Hamilton, this muscle spans two joints (the knee and hip), with "a large blood supply that causes inflammation and scar tissue when it's torn." Dancers use the hamstring in almost every movement of the lower body, making it easy to overload. Tightness is the main cause of these injuries, although Keller believes that other factors include structural asymmetries, like a crooked pelvis, and muscle strength imbalances. Many young dancers experience these imbalances during growth spurts, when they temporarily lose flexibility, strength, and balance. What to do? Like most good dancers, they work harder.

This scenario happened to Sylvie Rood, a student at the School of American Ballet who began to lose her technique as her bones lengthened, leaving her muscles and tendons lagging behind. Rood said she was determined to "get my passe level with my hip, and it started to hurt. I thought stretching would help but it only made things worse." She now realizes that, until her growth stabilizes, she needs to back off, rather than work harder. As for her pulled hamstring, rest followed by a progressive stretching and strengthening program has helped her recover. Dancing yourself back into shape with this muscle pull is not recommended.

HIP INJURIES

Some dancers are born with perfect turnout--the envy of every ballet dancer. But in some instances, says Dr. Padgett, this large degree of rotation may be due to shallow hip sockets (acetabular dysplasia), which the body attempts to stabilize with a very large acetabular labrum--the supporting rim of hip cartilage. "It's terrific when you're 16, terrific when you're 23, not so good when you're 35," says Dr. Padgett. Why? Because in some cases symptomatic labral tears may represent the first step toward degenerative arthritis and, perhaps, even a hip replacement. So much for great turnout!

Most doctors diagnosed hip pain as tendonitis until 10 years ago, when new MRIs revealed meniscal-like tears in the labrum. This tear, according to Dr. Padgett, is similar to tears in the knee with "catching or intermittent locking after a violent maneuver, like a Broadway performer doing a big fan kick." A more common symptom is a gradual increase in groin pain, causing the dancer to avoid certain movements, like developpe a la second.

Stephanie Walz, a principal dancer with the contemporary Maximum Dance Company in Miami who was initially blessed with excellent turnout, remembers the feeling. "It was like a growing, nagging pain, like when you've overdone things but it doesn't go away." Still, labral tears that heal or become asymptomatic within three months require monitoring rather than surgery. American Ballet Theatre physical therapist Peter Marshall usually advises relative rest along with strengthening exercises. He also recommends avoiding turnout and staying away from anti-inflammatory medication that could mask the pain.

BACK INJURIES

Chiropractor Dr. Lawrence DeMann Jr. in New York says, "The most common problem is when the dancer says 'My back is out!' from joint fixation." Simply put, the back freezes up, causing a localized aching pain over a specific joint that limits movement (rather than nerve pain that radiates down an arm or a leg from a ruptured or degenerative disc.) While it's hard to pinpoint the reason, possible causes for back problems include fatigue, hypermobility (where you can wrap your legs around your head), scoliosis, leg length inequalities, and emotional stress. The most severe cases involve intense spasms in which the muscles contract to protect the joint.

Dr. DeMann treats spasms by freeing up the joint. Marika Molnar recommends physical therapy to reduce inflammation, using alternating heat and cold, which speeds up the exchange of fluids and brings a fresh blood supply to the area. She also gives exercises for the deep abdominal muscles to stabilize the back and pelvic girdle. She counsels against crunches and sit-ups during the acute phase.

Movin' Out's leading dancer John Selya has had only a couple of back injuries during his varied career in ballet and on Broadway. One time his back went out after he landed from a jump and was suddenly, he recalls, "completely crooked. I couldn't straighten up for two days." While performing a variety of dance styles over the last two years in the show, Selya doesn't believe that any particular movement pushed his back over the edge. Instead, he says, "There's probably a huge emotional component to nay back going out. Personal things were happening that I'm sure contributed to the tension and my back problem." Hormones that flood the body in times of stress cause the muscles to tighten in an effort to form a protective body armor. Under these circumstances, stress reduction strategies, from massage to counseling, can help.

While dance injuries are a fact of life, there is a lot you can do to reduce their severity. These treatments include decreasing fatigue, backing off during growth spurts, getting a correct diagnosis, and rehabilitating residual problems to prevent re-injury. Your body will thank you!

Linda Hamilton, Ph. D., a senior advising editor of DM, is a clinical psychologist in private practice and the wellness consultant for the New York City Ballet.