Ballet injuries: going behind the scenes

New York City Ballet is the ballet company I have worked for over the past 7 years. They are one of the top ballet company's in world. In 2013, AOL created a short web series following New York City Ballet and highlighting important aspects of this top ballet company. The series is called city.ballet and you can find me in the opening of some of the episodes.

Building on from last week's post on dancer's emotional battle with injuries, I wanted to include this episode about ballet injuries. The episode does an excellent job of showing what kinds of injuries ballet dancers get and what it's like when they are unable to do their jobs.

After watching the video on YouTube I read the comments underneath. Most comments are people relating with what injuries they have had. I find that to be really nice because just as Claire says in the video, when you are injured it can feel like you're the only one. Talking with others who are going through the same thing or have in the past can be very comforting. 

Other comments are those who realize how strenuous ballet can be. It's shocking to me that people still don't realize how hard ballet is on the body. I come face-to-face with that fact everyday but, to others who never see the ballet dancers in pain they don't believe they are. One of the comments comes from a man who says he knows nothing about ballet but is very familiar with American football and after watching this video he is rethinking whether football is really the most competitive sport/activity.

I think seeing the dancers in this video explain and show what it's like to be injured is really helpful in understanding how ballet injuries affect dancers. If you are interested in more videos like these watch the whole web series, it is worth it. There are 2 seasons and each episode has an important topic. They can be found on YouTube or AOLgo.com 

There are also two great documentaries about famous ballerinas careers and overcoming their injuries. The first is 'A Ballerina's Tale' which is about Misty Copland who dances with American Ballet Theatre. A portion of the fascinating film is dedicated to her recovery from potentially career-ending fractures in her left tibia.

The second is 'Restless Creature' which is about Wendy Whelan who danced with the New York City Ballet. It is a brilliant film about a 46 year old principal dancer who is struggling to recover from a very serious hip injury while also coming to terms with retiring after 30 years of dancing with the company.

Both films bring the audience in on the passion that each of these dancers have and their lowest moments when trying to recover from injury. They both show what it takes to get back to dancing at a professional level. Both films can be found on Netflix.

Depression is anger turned inwards

In addition to the physical toll injury takes on the body, for dancers the emotional toll can sometimes be even greater. I used this image taken by Henry Leutwyler, of a dancer's feet as a metaphorical representation.What may look fine on the outside (the foot on the right) is no indication of what is going on in the inside (the foot on the left).

When dancers get injured the first thing that happens is an immediate isolation. One minute they are working on a schedule with many people and the next minute they are home alone and only seeing doctors and physical therapists.  It can be lonely, feeling like you are the only one not dancing. The only thing that surrounds you is the injury. Why did it happen? How long will I be unable to dance? What is the extent of the injury? When can I get back to dancing? These are all questions that plague the dancer at first. Thinking about the injury constantly can lead to similar phases of grieving.

First is denial. You can't believe this happened especially at this point in your career. (Because there is never a good time to be injured, it always feels like the worst timing ever!) If only you didn't get injured you'd been able to do that role you always wanted to do or get that gig you've been rehearsing for all season. Then comes anger. You get angry at yourself and start blaming yourself. I wasn't strong enough. Why didn't I speak up and say it was bothering me beforehand.  A lot of emotions come from feeling like a failure or defeated. Dancers are so passionate about their art and their bodies are their main tools. When something happens to their most important tool it feels like a failure. This stage becomes intertwined with depression. The depression and anger rolled together usually tend to be the darkest period, since you also feel lonesome.

Finally you reach acceptance. There is a moment when you realize your love for dance is still strong and you are not willing to give up on it just yet. If you focus and not wallow, you could come back better then ever. At this point, the dancer has a diagnosis and is working towards goals one day at a time. It's slow progress but it's progress. They feel grateful for the small things they have achieved and move forward knowing they have gained new perspective and knowledge about the body.

It's certainly a journey but it pushes dancers to grow in ways that they may never have imagined. Getting injured makes dancers more aware of their bodies and how they work with them. It also makes them realize why they began dancing in the first place, a renewed sense of passion. I think it is an important part of becoming a professional artist. It's like they say sometimes, you have to hit rock bottom to know which way is up.

The 4 cardinal rules to follow when injured

So you fell in rehearsal and tweaked your ankle. Your knee has been hurting more and more recently after doing a new exercise class. You were doing weights at the gym and feel a twinge in your shoulder. The first thing you should do is remember RICE!!!

1. REST—Stop doing what hurts and rest as much as you can
2. ICE—Use an ice pack to ice up to 20 mins or you can ice massage for no longer than 5 mins
3. COMPRESS—Wrap the injury or use a compression sleeve
4. ELEVATE—Raise the injury anywhere above the heart to encourage blood flow to leave the injury

These steps are very important during the first 24 hours of an injury. Usually when something has been injured it swells with blood because the body is trying to heal itself. However, most of the time the body's reaction is excessive and RICE is used to help reduce the inflammation. The excessive swelling can do more harm, if left untreated. Prolonged swelling can lead to chronic or long term swelling making tissues more rigid, which make them more susceptible to injury. After doing all four steps over the course of 24 hours, see a doctor or physical therapist. 

5 tips to prevent injury

In my last post I talked about some statistics on ballet injuries and I wanted to include this week's post with some helpful tips on how to prevent injures from happening.

• Eat well—Having a balanced diet that includes the proper amount of nutrients to sustain an active lifestyle is important. If your body is not receiving the energy it needs, it will be weak and tired.
• Stay hydrated—Drinking a lot of water helps your muscles stay energized allowing them to activate more easily. It also speeds up the recovery time. If your muscles are dehydrated they will stay sore longer and won't get rid of the toxin build up as easily. 
• Get enough rest—Overtraining will definitely cause injury because your body will not have had time to recover and ultimately won't support you. This can be one of the most difficult things to accomplish as a professional dancer because of the rigorous schedule. But please get enough sleep and rest during the little time you may have. It's important!
• Do cross-training—Since overuse is one of the top ways dancers get injured, cross-training helps build other muscles that don't get used often. It gives the muscles that do work a lot a rest. This way you get a more balanced exertion of muscle.
• Warm up and cool down—Warming up before class or rehearsal is essential. Cold muscles are a sure way to get injured. Cooling down is most often forgotten but just as important. After exercise you should always stretch and roll out. Stopping abruptly after exercise slows your heart rate down, and the blood pools in your legs and feet which can make you feel dizzy. You should continue exercising slowly and gradually stop moving. 

These tips are all important to stay healthy and limit the risk of injury. However, dancers do a lot of repetitive movement for several hours a day and as the study in my previous post has shown it can lead to increased stress on the body. On top of the intensive training, there is very little down time between performance seasons and rehearsals. Therefore, follow these tips and you are on your way to being a healthier, stronger you!

Some ballet injury statistics

While doing some research on ballet injuries I found a study from Orthopedic Journal of Sports Medicine. I found the statistics to be very interesting and wanted to share them.

TYPES OF BALLET INJURIES

• 75% to 91% of all ballet injuries affect the lower extremity
• 39% to 53% of occur in the foot and ankle, specifically
• 29% of dancers have patellofemoral pain syndrome, according to another study
• 91% of dancers report a snapping hip, according to one study. 58% of those dancers have pain from it

INJURY RATES

• Amateur dancers have 0.97 injuries per 1000 dance hours. Professional dancers have a higher incidence of injuries—1.24 injuries per 1000 dance hours. Combined, amateur and professional dancers suffer 1.09 injuries for 1000 dance hours
• Male dancers have a higher injury rate than the females—1.29 injuries per 1000 dance hours compared to 1.03

OVERUSE BALLET INJURIES

• Overuse injuries comprise 75% of all injuries to amateur dancers
• 57% of injuries in professional ballet dancers are overuse injuries

I wanted to show in numbers how injuries affect ballet dancers and how important it is to understanding the demands on their bodies.  Once there is a complete understanding it becomes easier to create a plan to decrease injuries. Here is the link to the full study: https://doi.org/10.1177/2325967115592621.  This is a concise compilation of facts but there are a lot more interesting facts if you were to look at the full study.

The Myo-Care EMS

Part of my treatment plan for the osteoarthritis in my knee is to make sure my thigh, butt and hips are strong. Those are all the major muscle groups needed to keep the knee stable and alleviate stress on the knee joint. Using a portable electric muscle stimulator machine is a helpful way to get strong muscles. It is used to help activate a specific muscle that has a hard time engaging due to injury.

My physical therapist instructed me to get a doctor's prescription for a portable NMES machine to use on my quadricep muscles. Then he gave me the website Medi-Stim.com to order Myo-Care EMS. The Medi-Stim company will require the doctor to fax them the prescription or for you to mail them the original. My physical therapist recommended this model because it is the simplest one to use and it comes with 4 self-adhesive electrodes that you apply yourself. Some models come with pre-set electrodes to apply to the quad in the same area for everyone. However, with electrodes that you apply yourself you can make the stimulation more specific to your body and target the muscles you would like. My favorite thing about the Myo-Care machine is that it only take about 10 to 20 mins of exercise to feel the specific muscle you are trying to work. I use it everyday and I can really feel my muscles fatigue from use.

The best thing about the Myo-Care EMS is that it is simple and easy to use. Some other electric stimulation machines are too high tech and have too many buttons. There are only 3 buttons with two knobs to increase the stimulation intensity with the Myo-Care EMS. It has last setting recall, so when you use the machine to do your exercises it remembers your settings, that way you don't have to set them again. The back of the machine has a clip so you can attach it to your clothing and not hold it during use. It also comes in a carrying case that holds the machine with the electrodes, and it is small enough and light enough to carry anywhere. It is perfect when you are going on vacation or just commuting from work to the gym.

Similar to all electrotherapy equipment it is best to have a physical therapist assist you in your first try. This way they can tell you what exercises to do with the machine and where best to place your electrodes. After that, you will be off to stronger muscles in no time.

Athlete or artist?

When it comes to ballet dancers there is often a debate about whether they are artists or should they be considered athletes. Recently, ballet dancers have been appearing more frequently in main stream media like television and film. They have been abundantly used in advertising as well. Dance is everywhere. With the emergence of athleisure more and more people no longer see dance and ballet as an elite art form reserved for the wealthy and refined. Ballet has become more relatable and accessible. Part of this accessibility, I think, is having people understand the work behind becoming a ballerina. I think what makes ballet dancers unique is that they are both artists and athletes.

In order to be a successful ballet dancer both artistry and athleticism are needed. The physical work is hard, repetitive, and all of it is done in very unnatural positions.  Ballet dancers always work with turn out (where your toes, knees and hips all face outward instead of straight forward) and the women always work in pointe shoes, dancing on their toes. Ballet requires high jumps, low bends, and fast moving while always maintaining grace. This all requires a fit body, therefore making them athletes. Ballet is also an art form. No two dancers, dance the same because their personality comes through the dancing and that is the artistic side of ballet. The artistic side ties in with the performance factor. Since ballet is a live performance and not a competition, there are no scores or ratings, there is only expression and individuality. I think it is a beautiful thing to see both aspects, athletics and artistry, of ballet come together.

Knowledge is power

I want to go through some of the major injuries I've had over the past couple years and together we can learn a lot about the body. Let's start with the most recent. High ankle sprains are more rare than your typical sprain. The high ankle sprain is located, as the name suggests, anywhere above the ankle joint. The two major bones above the ankle joint are the tibia and the fibula. When you have a high ankle sprain you partially tear the ligaments that hold those two bones together. There are varying degrees of tearing, which an MRI can show how severe the sprain is.  Ligaments do not heal back together. Scar tissue will form over time and bridge the gap. The build up of scar tissue and how weight falls to the area above the ankle joint  are why high ankle sprains take longer to heal than low ankle sprains.

Your tibia and fibula separate slightly when you put weight on your foot and separate further when you increase dorsiflexion, which is flexing of the foot. Some doctors may recommend surgery where they insert a nail connecting the two bones making certain that the tibia and fibula are stable while the ligament heals (limiting the separation of the tibia and fibula). They remove the nail once the ligaments are stable enough. However, with ballet dancers this surgery is not recommended because it makes the ankle joint too stiff. Ballet dancers need to have more loose ankle joints than the average person because we do much of our dancing on our toes. Therefore, the recommended treatment for a dancer is to put the foot in a boot and use crutches since weight-bearing puts too much pressure on the ligaments if they aren't healthy enough. Crutches and a boot are necessary for about 6-8 weeks. I was on crutches for 3 months (which is longer than usual) because as I was about to get off crutches I slipped in my shower and re-sprained the ligaments and had to start the healing process all over again. That was a low moment for sure.

Now the other injury I'm dealing with is osteoarthritis in the knee.  This is a very common joint disease that most often affects people in their middle age or elderly years. Osteoarthritis is known as "wear-and-tear" where the joint experiences eroded cartilage (shock absorbers) and bone spurs. Even though it is commonly seen in older people it is also very common in most athletes including ballet dancers. I am certain most professional ballet dancers have some degree of osteoarthritis but depending on how severe it is, determines the treatment plan. Most athletes can handle a significant amount of osteoarthritis because of how fit they are. If the muscles surrounding the joint are strong, then the muscles can absorb the force rather then the force solely falling on the joint.

Osteoarthritis is treated with pain management. No matter how much cartilage has deteriorated each person's pain level is different. I for example have a significant loss of cartilage and bone spurs that cause my knee to lock and click. During certain movements the loss of cartilage causes grinding bone on bone. However, I don't feel a tremendous amount of pain and can dance without much limitation. My doctors have informed me that another patient may have the same degree of the disease and be in so much pain they can't walk up a flight of stairs. There are many things that can be done to improve the pain. Non-surgical options include acupuncture, massage, physical therapy, hyaluronic acid injections (help lubricate the knee), or PRP injections (help generate healing). If one wanted to have surgery it would most likely be some form of cartilage transplant.  I chose the hyaluronic acid injection called Monovisc which is a single injection said to last up to 6 months. I received the injection for the first time this Friday 6/7/19. It was not painful and it happened in under 10 minutes. I was able to walk out of the office with minimal soreness.

I hope all of this was informative, when dealing with injuries it is of utmost priority to get as much knowledge about your injury as possible. Seeing multiple doctors and exploring all your options of treatment is very important. Once you have all your information then you can decide, which doctor you feel comfortable with and trust. Ask many questions and do your own research. Talking to others who have had similar injuries also is very helpful. Especially with dancers it is important to see doctors who are familiar with a dancer's body and the requirements of the job.

Every setback is a setup for a come back...

Welcome to my blog, Tougher in a Tutu! Many people don't realize how strenuous and difficult ballet can be. Especially, since much of the point of dancing ballet is to make it seem easy. It is an art form that takes years to master and typically begins at a young age. The years of precise training can lead to very serious and detrimental injuries. The truth is that the wear and tear on the body results in a short career. Injuries are just part of the ballet world and very few avoid them.

Throughout my 20 years of dancing, I have had multiple injuries ranging from bruised bones to serious knee cartilage surgery. I am currently recovering from a high ankle sprain on my left ankle and partially related severe right knee arthritis. The way in which we work our bodies is unique and requires a full range of motion (beyond what is expected in a normal person's body). That is why when ballet dancers injure themselves it is important that we see the right doctors, physical therapists and trainers who fully understand the expectations of our craft. Similar to top athletes we push our bodies to the limit everyday and we need to be strong to handle that.

This blog is a resource for anyone coming back from an injury but will be focused on ballet in particular. It will include tips, advice, exercises, meal ideas, and an overall look into my personal recovery. The title of this post is a quote that has always inspired me to get back up when I fall. Injuries are no fun but they make you stronger and wiser. I hope you will join me on my road to recovery and in turn become stronger and wiser as well.