Dance Medicine – PediaCast 581

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Description

Drs Megan Liberty and Aimee Heslop visit the studio as we explore Dance Medicine. From injury prevention to proper footwear and pointe readiness, discover how to keep young dancers safe, strong, and thriving. We hope you can join us!

Topics

Dance Medicine
Proper Dance Footwear
Pointe Readiness
Preventing Dance Injuries

Guests

Dr Megan Liberty
Sports Medicine
Nationwide Children’s Hospital

Dr Aimee Heslop
Physical Therapy – Sports and Orthopedic
Nationwide Children’s Hospital

Guest Host

Eric Leighton
Sports Medicine
Nationwide Children’s Hospital

Links

Performing Arts Medicine at Nationwide Children’s Hospital
Sports Medicine at Nationwide Children’s Hospital
Physical Therapy – Sports and Orthopedic at Nationwide Children’s Hospital

Journal of Dance Medicine and Science
Determining Pointe Readiness in Young Adolescent Female Dancers: A Systematic Review
Communication Between Medical Practitioners and Dancers

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast is brought to you by Sports Medicine at Nationwide Children's Hospital. Hello everyone and welcome once again to PediaCast. We are a pediatric podcast for moms and dads.

This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 581.

We're calling this one Dance Medicine. I want to welcome all of you to the program. So, dance medicine, it's a thing and it bridges the gap between athletic training and artistic performance.

And this week we're going to share expert insights on injury prevention, readiness for point, flexibility, footwear, and the importance of a supportive dance environment. So, whether your child or teenager dances for fun or has big stage dreams, this episode is packed with tips for keeping them safe, strong, smiling, and dancing. Of course, in our usual PediaCast fashion, we have some terrific guests joining us.

Dr. Megan Liberty is a sports medicine physician at Nationwide Children's Hospital. Also, a trained dancer and with a professional experience. Dr. Aimee Heslop is also a dancer with professional experience and training, but also a physical therapist in sports and orthopedic medicine at Nationwide Children's. So, they have a lot of expertise, yes, but also practical experience with dancing from a very young age. And so, they're going to be great experts and resources for us as we learn about the field of dance medicine. We also have Eric Leighton with us.

He is an athletic trainer and functional rehab leader for sports medicine at Nationwide Children's, and he returns as a guest host to facilitate our conversation. They'll all be with us shortly, but first I want to remind you that the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

If you're concerned about your child's health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. So, let's take a quick break. We'll get our dance experts settled into the studio, and then we will be back to talk about dance medicine. It's coming up right after this. 

Dr. Megan Liberty is a sports medicine physician at Nationwide Children's Hospital and an assistant professor of pediatrics at the Ohio State University College of Medicine. She completed a Bachelor of Science degree in ballet and biology at Indiana University, followed by her medical degree at Kansas City University. Dr. Aimee Heslop is an advanced physical therapist with sports and orthopedic physical therapy at Nationwide Children's. She completed a Bachelor of Fine Arts degree in dance at Ohio State and a doctorate in physical therapy from Rosalind Franklin University of Medicine and Science.

Both have extensive experience in professional dance and in the practice of dance medicine, meaning they have insight, knowledge, and passion for supporting young dancers and their families. That is our topic today, dance medicine. But before we dive into that, let's offer a warm PediaCast welcome to our guests, Dr. Megan Liberty and Dr. Aimee Heslop. Thank you both so much for being here today.

[Dr Megan Liberty]
Yeah, thank you so much for having us on.

[Dr Aimee Heslop]
We're really excited to be here, feel really passionate about treating this population, and I can't wait.

[Dr Mike Patrick]
Yeah, we are really excited to talk about dance medicine as well. We also have a guest host driving the conversation today. Eric Leighton is an athletic trainer and the functional rehab leader for sports medicine at Nationwide Children's and a frequent guest host when we cover sports medicine topics such as the one today.

So, a warm welcome to you, Eric, and please take it away.

[Eric Leighton]
All right. Good morning. Thank you, Dr. Mike and Dr. Mike and the entire PediaCast crew. Thanks again for having us in the studio. And yeah, this is definitely a topic that we're all three of us are very passionate about. So besides being the lead for functional rehab, I've also been working around performing arts myself for the past 25 years.

Multiple family members who were semi-professional, pre-professional dancers, worked in the local professional ballet company, et cetera, been on stage myself for about 30 years. So, it is definitely a passion mark for me as well. We definitely want to talk to you today about dance and dance medicine.

Dancers as athletes, and we'll definitely cover that point here, I'm sure a few times later on, dancers are athletes. I would dare most other traditional athletes that we may think of to do what a dancer does on a daily basis. And so, there are some very unique things about dance, about its athleticism, about its art form.

And that's what we want to what we want to cover today. So, let's just start right off with we're going to go straight to Megan here. Megan, what is dance medicine?

[Dr Megan Liberty]
All right, cool. So, I kind of think of dance medicine as a niche under the larger sports medicine umbrella that focuses on the prevention, diagnosis, and treatment of injuries related to dance. As many of us know, dance is an activity that requires similar attributes from a physicality standpoint that many of our other sports athletes possess, including from a strength, endurance, energy utilization.

But many dancers actually don't view themselves as athletes primarily. It's an art form, and dancers take just as much pride and if not, more time developing their artistry, you know, as they do their physical technique. It's also important to note that not all dance forms are the same.

I feel like when a lot of people think of dance medicine, you know, their mind probably goes more directly to ballet. But if you think of the skill set that, say, a ballet dancer requires comparing them to, say, a triple threat musical theater artist, now it's almost like comparing baseball to soccer, you know, from a from a skill set standpoint. Here at Nationwide, within our dance medicine program, we work in a team-based approach where our dancers and athletes are seen by an athletic trainer and physician.

We do have a clinic assistant that helps with scheduling any additional imaging studies or referrals. Many of our dancers are seen by Aimee in physical therapy, you know, or Eric in the functional rehab setting. And we work really, really closely with the dancer and their family on getting them back to their activity back on stage as quickly and safely as possible.

We're also able to utilize many of the subspecialists that we have here through Nationwide Children's from sports nutrition, orthopedic surgery, psychology, adolescent medicine, you know, and we work really, really hard to provide exceptional care that meets the needs of all of our athletes and our dancers.

[Eric Leighton]
So, you mentioned, I mean, like you said, it's definitely a team approach and it's a very unique population. So, to kind of go with more of that, why does having a dance specific provider matter so much versus another provider, for instance?

[Dr Megan Liberty]
Well, we are all former dancers, so we speak the language. So, I think that is very helpful from the dancer standpoint, you know, to come in and tell us exactly what it is that they were doing. And, you know, we have a really good understanding and personal experience, you know, understanding the demands that our dancers are faced with.

I would like to think that we do a great job of taking care of athletes from all sports, you know, and it isn't always necessary to have a care team that may have personal experience, you know, whether it's in dance or, you know, football or in baseball season right now. But I do think it's helpful, you know, to have that kind of thorough understanding of what it is our dancers are going through.

[Eric Leighton]
Yeah, it definitely helps a lot. Definitely speaking the language. It's it is, for lack of a better way to put it, can be not so much an insular community, but they didn't always have the attention that other traditional athletics had or as athletes.

So, yeah, knowing what you're talking about, being able to speak the language definitely goes a long way. I found when I'm working with the kids and the families. So, I think this next part here, I'm going to kind of kick this this one over to you, Aimee, is and I know what it looks like.

We're very similar with what you and I both do. You as a physical therapist, myself as an athletic trainer. But from your point of view and how you approach it, what does dance physical therapy look like?

[Dr Aimee Heslop]
So, my job as a performing arts physical therapist is helping that dancer and their family members identify common technical errors, maybe some biomechanical faults in their dance technique. And then I also take into consideration that specialized return to sport, return to sport progression back to their specific genres of dance. I help them get out of pain while also improving their technique and helping them optimize their performance and getting them back to what they do as efficiently but safely as possible.

And my favorite part is really helping our dancers prolong the longevity of what they love to do, whether that be dancing professionally or being able to run and play and have a great movement vocabulary as an athlete and as a human. And helping them to advocate for themselves in the future as they become adults and then go into their whatever they choose as their future profession. That's my favorite part of what I do is helping them to kind of learn how to self-advocate and take care of themselves in the long term as well.

[Eric Leighton]
Yeah, I definitely know from kids we've all seen, kids we've seen together, things like that. I think, yeah, one of my favorite parts is definitely getting them back in the studio, back on stage. And if they if they can learn how to take care of this in the future, if they never have to see us again, that's always a huge success.

I know one huge question that a lot of parents consider or think about, you know, their kids interested in dance. Their son, their daughter is interested in dancing and particularly certain kinds of dance. But that question, what is a good age to start dance and kind of go beyond that?

So, what's a good age to start? But other specific genres or to use the more basic term, the forms of dance, the styles, that's different to start at different ages.

[Dr Aimee Heslop]
Yeah, great question, Eric. So, we get this question all the time. I know that dancers can start at any age.

So, I started when I was two or three years old and then really specialized in that from there on out. One genre that is a bit different is we do not want dancers starting point until the age of 12. So that is one that is a little bit different.

But the benefits of starting so young are that socialization component, learning that movement vocabulary from a young age, music appreciation, discipline. And then having that sense of community are some great benefits of just being in dance from, you know, such a young age. And I think a lot of the dancers that I treat start that early, and they may be dancing up to 30 to 40 hours a week.

So, something to keep in mind and educate parents on with is that research really shows that sports specialization can lead to increased risk of injury, burnout and even dropping out of sport long term. So, we really need to be mindful of these dancers and how they're growing and those high volumes of training. How can we keep them safe in what they're doing?

Multi-sport athletes are actually able to reach higher elite levels of sport in the research. So, I think that dance is something that is different than that. We really are dancing and specializing at a young age, even though that may not be ideal.

So how can we help them be safe in that and educate them on ways they can prevent injury and lower those risks if they are starting so young?

[Eric Leighton]
Yeah, that's actually a topic our chief here in sports medicine, Nationwide Children's has made, has had the talk many times about early specialization versus differentiation. And dance is one of those activities, one of those art forms that it requires that in order to progress, you know, along the line that most people want to. It requires that that dedication specialization early on.

And it can be done. It can be done safely. It can be done well, but it's you know, there are things to consider.

And again, that's why you come to these two amazing people right here that we're talking to, because they're going to help you through that and give you the give the advice you need. Megan, we just talked about how specialization, you know, and it requires a lot of hours to master most art forms, most things that require this level of specialization and performance require a lot of hours to master. So, what are some guidelines from your view for our limits based on age?

[Dr Megan Liberty]
Well, from the International Association for Dance, Medicine and Science, and this is going to be like for ballet in specific, particularly if that dancer has some pre-professional aspirations, you know, typically a nine- or 10-year-old, you know, may be dancing at least three 90-minute ballet technique classes per week. You know, plus they may have an additional one to two classes and in another dance form and may have intermittent rehearsals, you know, sprinkled throughout the week, depending on, you know, where they are at in their performance seasons. A top level pre-professional program.

So, we're thinking more high school age students, you know, they may be in the studio 20, 30 hours per week. And then you talk about our second company trainee program dancers, you know, who may be later high school, you know, late teenage or early 20s, and they're looking at 30 plus hours. You know, it's definitely a full-time job by that point.

The American Academy of Pediatrics does have some recommendations in regard to organized physical activity for young athletes. They do suggest that young athletes, again, not specific to dance, who participate in more hours of sport each week than their age in years and those that spend twice as much time in organized sports than they do, I call it being a kid or free playing, are at an increased risk of developing overuse injuries. We also see that, as Aimee had mentioned, that kids who concentrate earlier in life or specialize earlier on and focus on one type of activity are actually at an increased risk of actually dropping out of that activity completely and may be less physically active later in adulthood.

So, when I counsel families on this or when they're asking me about choosing a studio that would be appropriate for their child, I know I try to harp on the point that it's really important to focus on quality over quantity. A single minute, a single 90-minute ballet technique class is much better for the development of their technical foundation than, say, spending those 90 minutes, but 30 minutes is maybe ballet, 30 minutes tap, 30 minutes in acrobatics or contemporary dance. And we see a ton of that coming into our clinics here.

[Eric Leighton]
And then one of the other things you mentioned, and Aimee had mentioned before, too, and it's the classic style of dance, the classic shoe we think of in ballet that most people think of as being on point. And you talked about as far as the best age to start doing that, if that's their goal. What's that what's that age that you said is the time to start point to be point ready?

[Dr Aimee Heslop]
Twelve years old is what we suggest for that. And that's factoring in growth, development. And then there's also some more factors that we'll look out at in a future question here regarding if they're physically ready with their functional status.

Are they strong enough? Do they have good range of motion? Is their technique looking appropriate and safe for them to be on point?

So those are things we look at with that specific genre of dance that are really important to stress. So, we're not setting them up for failure. Right.

[Eric Leighton]
Yeah, exactly. A point being on point for a lot of young dancers, young women. Obviously, that's sometimes the ultimate goal in ballet.

But, you know, dancing on point, as beautiful as it is, is tough to do and tough to do right. It can be done. Obviously, you just you do the training.

But like Aimee just said, there are certain there are certain marks we have to hit first. We want to make sure that we can do it and do it right. Actually, we're going to come back to you again, Megan.

We're talking about flexibility. I mean, you know, I think everybody knows or assumes that most dancers are flexible. It seems to be, you know, you think dancers, gymnasts, they're flexible.

Right. But with growing kids, times that can kind of come and go. So, we know the flexibility.

It is a must have for dancers and they need it. They need it all. But where should they focus and what's OK to push and what shouldn't be pushed when it comes to flexibility?

[Dr Megan Liberty]
So, again, it depends on the goal of the dancer, you know, and of course, the genre of dance that they're participating in. Of course, there is some large degree of flexibility that is needed to be successful in ballet but may not be as critical in some other dance forms like, you know, maybe a tap dancer or hip-hop dancer. I mean, being flexible, it's nice, but if the strength isn't there and the flexibility isn't functional, then it really isn't helpful.

So, yes, we do commonly get asked, how can I improve my flexibility? There are some anatomical factors and, you know, some genetic factors that we have to kind of work within your own body and what your own physical limitations are. But controlling what you control, advocating for a really good, proper warm up, that does not mean sitting in the splits to chatting with friends for, you know, 10 minutes before starting class.

You know, a warmup that really prepares your body, prepares your mind for your upcoming class or your rehearsal, you know, getting your heart rate up, getting your blood pumping, getting your muscles moving. So then when you go to start your technique class, you know, you're stretching a muscle that's already kind of been woken up and activated. A good, slower ballet bar is a really, really good starting point for developing, again, not just the flexibility, but the technical skill set and the strength to support that flexibility.

And then making sure that you're cooling down properly at the end of your day, too. Personally, I'm a big fan of foam rolling. I think it's a great way to help ease sore muscles and improve your mobility without overexerting your joints, you know, that you've spent, you know, whether a class period or rehearsal peering, taxing.

But remember, you know, any line can be beautiful. I would much rather see a beautifully extended, safe à la Saccone at a 90-degree angle than messy legs, you know, with, you know, trying to get knees up to ears. And it's not safe or physically, you know, aesthetically pleasing to look at.

[Eric Leighton]
Yeah. Yeah. You had mentioned, you talked about, you know, the flexibility versus strength and, you know, with all of our athletes, dancers and traditional athletes.

So, again, that's something we always preach. We work on and function we have. And I know in physical therapy as well.

Yes, the flexibility is great to have, but if you can't control it because you don't have the strength to stabilize it, that just turns into becomes worse. And yet we've had over the years studios I've worked with in the past who didn't have a proper warmup sequence. It was sitting around and talking, you know, with their friend in the splits, not really stretching, instituting that, making sure that we had a program.

We reduced our overall overuse and some of the more niggling, smaller injuries by 60 to 75 percent. So, we definitely saw the difference there. All right.

Another one again, when dancers, they're always looking for this. And again, more so in ballet than maybe other genres like tap or hip hop or something like that. Turnout.

Dancers want turnout, right? They want to all have that perfect 180-degree rear toes are facing opposite directions. Thing that always blows the kids mind is that I can still do that.

Some of them can't. But, Aimee, what is it about turnout? What, you know, what are they looking for?

What do they want? What do we have to be careful of?

[Dr Aimee Heslop]
Great question. I get this from so many parents and dancers that are coming in. They say, my teacher and I are working on my rotation, my turnout.

I just can't seem to get it. And they come in for an injury. And I like to go off of what Megan had said of everybody is different.

And I want them to find their superpower in their body. It's their hip. It is not Dance Magazine's hip is what I tell them all the time.

Our hips, as Megan mentioned earlier, we have our capsule, our bones, our ligaments. Our muscles, there's many things that anatomically, can we change them? I can change some things.

I can get them more joint mobility. If their joint is stiff, we can work on their mobility of their muscles a little bit. But what's important to me is that they're using their, their hip range of motion.

So, 180-degree turnout is what I think people picture in their mind of what first position should look like, which is that classic heels are together, kissing, toes are out to the side. Our hip naturally, the normal hip range of motion into that range is 40 to 60 degrees. So, if we take that on both hips, at the end of that spectrum, 120 would be like a phenomenal range of that spectrum, which is much less than 180 degrees.

So, I like to show people that what their natural hip range of motion is in the clinic, using a tool, I have a goniometer and then showing them that we can find more strength in that end range of motion for them to be able to maybe get a few more degrees. But the important part is being able to functionally use their rotation. So, if you're taking a plie, which is just a squat in a specific dance position, basically, if we're going into that plie and we're forcing our turnout, it's going to have a lot of effects, not only on our hips, but our knees, our feet, our toes.

It's going to create a chain reaction that is not safe for our bodies. And a lot of times it's that connection that we need to make in the clinic to help the dancer and even the dance educator understand how to use our rotation so they can carry that over into the studio because they may be using this new rotation with me that is safer and from their hip, but when they go to rehearsal, they're being asked to crank their turnout more. So, I think that education component of why it's important, why it's safe to work from what they have themselves.

And then that light bulb that goes off for them is truly amazing when they find out, wow, I can actually do more pirouettes when I'm using my hip because I have the stability, I'm able to support myself rather than pranking from something that I don't have physically. And I think that's one of my favorite parts of my job is not only getting them out of the pain but then seeing them progress functionally when they realize how to use their body to their advantage. Yeah.

[Eric Leighton]
And I think you two made, you both made a terrific point. And again, it's something that we educate the parents and stuff on, but, you know, hopefully through this, through this broadcast here, others can hear it too. Just remembering that not everybody has that quote unquote perfect magazine look, you know, it's just like many other things, those shots, those things we see in the magazines, that is the idealized perfect thing.

And some of that's edited. Let's be honest, we got to remember not everybody can do what everybody else does working within what you have safely and correctly. So again, you know, if you're, if you've got a question or, you know, obviously, especially an injury, you, you come talk to these, these people right here, they'll help with that.

All right. So, this one, uh, kind of to both of you, again, we've, we've gone back and forth a couple of times on, on point, but maybe to get a little deeper into the details of on point. So again, the dream of many young dancers, many young ladies who get into ballet, some of their dream is to get up on point in those point shoes.

So, we've, we've mentioned a couple of times around age 12 is the appropriate time, but what are some of the more details? So, the appropriate time to consider training on point, what are the things they need to do to be ready?

[Dr Megan Liberty]
I mean, I typically start that conversation by just asking the dancer what their goals are, you know, if their goal is, you know, a dance on point, because it's, it's something that they've, you know, had, had, you know, something that they have set as a goal for themselves and something that they would like to try and do versus is this a dancer that, you know, wants to pursue dance, you know, professionally, you know, or is this a dancer who's, you know, coming from a studio who may be the focus isn't ballet, but their friends are all going on point and they just feel like that it's time for them to go up on point too. So that, that's typically kind of where I, where I start the conversation.

I typically only recommend starting point, you know, if the dancer is getting good, dedicated ballet technique class, at least two to three days per week, and that they have been in ballet, getting that good, dedicated ballet technique class for at least the last three to four years. So, a little bit different than say, you know, a dancer that comes in and tells me, well, I've been dancing since I was three years old. I do all of the dance forms, but I may only be taking like a 45-minute ballet class per week.

You know, that may not be a situation where I would say, hey, I don't think that you have the technical skill set and foundation to, to progress on to a point. I know we've said generally around age 12 are the recommendations, again, from the International Association from, from dance medicine and science. And the dancers need to have sufficient plantar flexion, or when they point their foot, they have to have a sufficient range of motion to be able to get themselves over the platform or over the box of the shoe.

And then once you get yourself over the platform on the box of the shoe, you need to be able to support yourself. So then having sufficient strength to be able to do that are really, in my opinion, the most important components when it comes to progressing to training up on point.

[Eric Leighton]
Yeah. And a lot of that, like talking about the time or the, you talk about the time and training, I think, you know, correct me if I'm wrong, but if I remember correctly from the Harkness and I Adams, a lot of times the age, you know, that, that 12 year old range, we tend to find that because by the time they've started dancing, by the time they've gotten into those dedicated focus classes, like you mentioned, minimum about four, four years of a, of a base and a background, that's usually about the age they're going to be. One question I've had multiple times; we don't x-ray their feet.

We're not using x-rays to determine if they're ready to go up. Is that correct?

[Dr Megan Liberty]
A hundred percent. Correct. That, yeah, a skeletal, you know, the decision isn't made based on just the skeletal maturity or from a bone age standpoint, the age of 12, that recommendation really did come out because by 12, as you'd had said, you know, these, these dancers have been in, you know, I would hope, you know, would be in.

Dance studio where they're, they've had the amount of time to kind of focus on their, their ballet technique.

[Eric Leighton]
Yeah. Yeah. Then, you know, once, once we do know they're ready, once they've been in, usually when young ladies come to me for this, I know Aimee does it as well.

So, we'll, we'll talk about this, but when they're ready to see if they're ready to go on point, we do a point readiness screening. And usually, they've been in pre-point classes for a while or pre-point training, so they've been getting those fundamentals, and the instructor looks at them and goes, okay, I think you're about ready now. Let's have you have you check.

So, Aimee, that's, you know, again, point readiness screening. That's something I know I do. I know you've done it too.

Talk us through that. What is, what are we looking for in a point readiness screen to see if a young lady is ready to put on point shoes and start her official on point work?

[Dr Aimee Heslop]
Yeah. When I have a dancer coming in and they're telling me my whole class is going on point this year. Like, am I ready?

I always like to take it back to the functional objective measurements to help them understand why I may be saying not right now, but in the future. Because I think it helps them kind of come back and see, okay, these are things I can still work on to put myself there in the next few months if I'm not there today. We look at some evidence-based functional testing.

This has all been published. And then we've been really referencing the International Association of Dance Medicine and Science. So, references there for these tests.

If you guys are interested in looking in the future after listening to the podcast, we look at a functional airplane test, which is a posse balance going into an arabesque and doing some plies or squats to touch the floor. And I'm looking at how that whole kinetic chain works together. We look at range of motion, as Megan said.

So, pointing your foot, there's a thing called a pencil test where we will literally put a pencil or this measuring tool goniometer on the top of the ankle to make sure they have full range to achieve getting up on their box. We also look at a single pirouette, topple test, and then a hop test that's called a sauté test, where we're looking for 16 hops in a row. And I'm checking the mechanics of that entire lower extremity and how everything's working together to make sure that the alignment is correct and we're not having pain.

And we're meeting these functional criteria that have been researched to show we are ready. And it's going to be a safe choice for us to tell that dancer, yes, you're okay, because I don't want them ending back in the clinic in a month when they weren't ready, just because I want to make them happy and say, you are. We want to keep them safe.

That's our number one priority.

[Eric Leighton]
Yeah. Yeah, exactly. I mean, we do, we do all those tests and, you know, I always tell them too.

I said, listen, we gotta, I gotta see how many you can get. Right. Said, you know, it doesn't necessarily have to be every single one because now once you qualify, you're going to go back to the studio and at bar and at center away from the bar, you're going to do hundreds of these and yeah.

And build it up, but we need to see that they have that, that fundamental, that, that the body's ready to take on that level, Megan. So, you know, obviously with, with, with this, with this art form, with any kind of athletics, you know, there's always the chance for injury, you know, for anybody that can happen no matter what you, no matter what you do. So, but obviously each sport, each activity can be different.

So, what are the common injuries we see in dancers and what should we be aware of? What should we keep our eyes open for?

[Dr Megan Liberty]
Yes. And unfortunately, uh, injuries are quite common in dance. Again, the most common ones generally of the overuse variety, foot and ankle, probably the most common that I see in my clinic, but again, depends on the, the dance form that, you know, the patient tends to specialize in if they focus on one particular dance form, you know, again, or if they're involved in, in multiple.

I'll typically start my assessment of course, by asking them what forms of dance that they are currently, are currently in, you know, about their, their general, you know, week to week class schedule, any kind of current rehearsal schedule, what upcoming performances, competitions, auditions do they have? And then were there any recent changes? So, did they recently change a level?

Did they change a studio? Are we in summer intensive season? You know, where overuse injuries, you know, were very, very common in that time, time period.

Some of our dancers do participate in other sports, which I am definitely a proponent of. So, what other sports or activities are they doing outside of the studio? Have they had a growth, growth spurt recently?

And then when was the last time that they had their shoes fitted, you know, or, you know, are the shoes that they're wearing particularly worn out? But yes, many of the injuries that we see are more of the overuse variety. And this includes things like, like stress fractures, apophysitis in our younger dancers, tendonitis, you know, muscle strains.

We see a lot of low back injuries, particularly spondylolysis, you know, especially in our, our competition dancers where they're doing a lot of acrobatic type skills, you know, and then our male dancers who may be doing a lot of partnering, you know, anything upper body is, is, is also fair game.

[Eric Leighton]
Yeah. There tends to be a lot depending sometimes depending on the season when you have competition versus show based studios, quite often, one of the, one of the studios I work with on the regular weekly, we have certain, certain times of the year, of course. So if they're preparing for a big show, usually, you know, early on in the rehearsal season, it's not too bad, but as we get closer to tech and to dress rehearsals, there's an uptick, you know, there's a lot more hours spent on stage and in the studio getting ready at that point, obviously we've been at it for a while, so things can be a bit more tired.

So that taking care of yourself matters a lot. So, going along that same vein there, Aimee, what are some of the best ways then to prevent injury? What can they do?

What can the kids be doing? What can the parents be advocating for to, to try to, to try to prevent these things as much as possible?

[Dr Aimee Heslop]
Yeah, this is a very loaded question. I would say I could go on this for hours. My key components that I tell people are listen to your body and speak up when something feels wrong.

Speak up to your teachers, your family, your fellow dancers. I think addressing the problem early on and getting that intervention from us earlier is way better than a wait and see approach because then we're getting additional injuries on top of it. It becomes a chronic thing.

Our body is going through a lot as we talked about, like with tech and all it's a year-round season is what we have going on in the dance world. So, I think getting ahead of it is key. Strength training.

I cannot stress enough. I think that dancers are often terrified of lifting weights or doing things that don't look like dance. And in reality, it is exactly what they need.

So that comes with a caveat is I don't want to tell our dancers to do more and more and more, but it really is going to come to it being built into the repertory for the year, and I think it comes down to our artistic directors and our dance educators to not overload their bodies and be able to incorporate that into their normal dance repertory for the year, rather than asking them to do more outside of the studio itself.

The strength training, getting to physical therapy, not overloading their bodies, and then other things like nutrition, sleep, hydration, managing stress, like huge for recovery timelines. And being able to keep themselves healthy. And I really just can't stress enough, like looking at our calendar year as a whole, I mean, dance is really based on tradition instead of science.

And that is why we are so, I feel behind in how we are approaching our calendar year for dancers, which we'll get into later, but being mindful of those things and just coming in earlier than later and just listening to how you're feeling. You know, your body better than anybody else does.

[Eric Leighton]
Yeah. I, yeah, you made the exact point about, you know, dancers and lifting weights, you know, something that either they were told not to do, or they think they shouldn't do, but yeah, that is, it's important. They need that strength.

They need that power to go along with all this. What, you know, dancing is dancing is tough. It's a lot harder than most people think.

And then that, and the workout, you know, I always tell all my athletes of all different walks of life, all different genres, I said, listen, the workout is 24 seven, it's not just how you work out or just the time when you're in the studio. It's how you got ready for that day. It's how you recovered from it.

It's nutrition. It's the sleep. It's the stretching.

I said, yeah, you may not be physically working out, but if you got to think about the whole day, even that eight, nine hours you're sleeping, that's part of it. So, making sure you get that proper rest. And one example, one phrase I like to use on my kids and parents, because it usually gets them kind of to, uh, to sit up and listen.

When they talk about going nonstop, I'm going to say, listen, you're human. You need rest. I said, let's talk about Broadway.

And I always ask him what happens every Monday on Broadway. And they look at me for a second. I'm like, nothing.

Broadway goes dark. And these are grown adults who don't have growth plates. So, they're not growing.

They take a day off. You can't dance every day and be successful like that. So, you need that.

You need that recovery. You need that rest so that you can be your best. So that's one of the things I like to, I like to kind of throw at them there.

All right. Well, again, we get back to shoes, Megan, and you know, proper shoes. Well-fitting whether using, you know, the right shoes at the right time, dance sneakers or blocks is one of those things.

And you mentioned at one point getting them refit every so often. So, what is it about the shoes? Why, why are the shoes so important?

[Dr Megan Liberty]
I mean, again, that your shoes are an extension of your artistry of your, your technical skills. So, if you have poorly fitted shoes or shoes that are too worn out, you know, you're not going to be able to perform as effectively. And it may be setting yourself up for, for an injury, unfortunately.

So, I do recommend that my, you know, dancers who are on point. So, my, my ballet dancers, especially who are on point, you know, multiple days per week, that they are actually refitted for their point shoes at least once per year. The reason for that is, is that your feet do change over time.

You know, hopefully as you get older and your feet and your ankles become stronger, a shoe that you may have been fitted for when you first went on point when you were 12 years old, you know, may not be the best shoe or the best, you know, brand, you know, model, et cetera. When you're a 16, 17-year-old, you know, pre-professional student. Plus, your choreographic demands, you know, of course change as you get older and, and your skillset improves.

As far as how often should I get new point shoes? Again, this is something that is completely individual. Um, there are a lot of factors that go into that.

And it totally depends on the dancer and, you know, where they're at and they're with their current class and rehearsal demands. Again, for my dancers who are on point multiple days per week, you know, if they're able to, I suggest being at least three pairs of point shoes in their bag. You have a softer pair that might be better for rehearsals that require a lot of jumping, Goldilocks pair that are kind of your work horseshoe for the time being, and then a newer pair that, you know, may be more supportive and better for like a point class situation.

But it's something that is very, very individualized. I also commonly get asked about wearing different shoe types in different dance forms. And, you know, one thing that kind of comes up pretty frequently here is, you know, can I wear my sneakers to ballet class?

And I'm generally like, well, you know, a dance sneaker, especially if you're rehabbing a foot or an ankle injury that provides just a little bit more additional support than like a ballet slipper would. Yeah, sure. Why, if your teachers are cool with it, why, why, why not?

So again, just kind of having that bridge where, okay, we might be able to get you back into the studio a little bit sooner, but just kind of modifying your footwear, you know, in the, in the meantime.

[Eric Leighton]
Yeah, quite often, you know, I see it all the time in the, in the dance world with a lot of the, you know, the teachers I work with who've been dancing professionally themselves, they don't always dance in their character shoe in there, you know, their show shoe all the time. Be hard to, to dance in that, you know, all the time. Sometimes they work out in those blocks or dance sneakers, but, you know, work back into that.

And yeah, like you said too, I mean, you, you got to, you got to change them every once in a while, but you got to update them while a young lady may, you know, obviously her foot's done growing at 15, 16, wherever she's at, she may not be getting her foot, may not be getting any longer. But yeah, there's the shoe still needs updated. Think of like, you know, if you were a young baseball player, you're not going to be able to play with the baseball mitt you started with in eighth grade when you're a senior in high school, it's just not going to fit.

It's not going to work well. So yeah, making sure you keep up with that and have, have the right equipment so that you're not borrowing those injuries.

[Dr Megan Liberty]
And, and wear good supportive street shoes when you're outside of the studio too. I mean, I can't even count how many times a day I have dancers come into clinic for a foot or ankle problem and they're rolling in and flip-flops or slide things that are very popular right now. And I'm like, well, these slides are doing nothing to help your ankle sprain.

[Eric Leighton]
I've had many young dancers, young athletes who, who, you know, give me dirty looks because I tell them they can't wear their Uggs or their Chuck Taylors, you know, for the time being while they're recovering from an injury. Cause there's no support. Well, speaking of injuries, Aimee, coming back, coming back from injury, returning.

So, getting back in the studio, getting back on stage, obviously there's, there's some levels to that. What, uh, what are the, what are the main things we need to look for or consider to be able to come back?

[Dr Aimee Heslop]
Yeah, I have three things I look at when we are returning from an injury. How is our communication? We've touched on that a ton.

So, we really want to bridge the gap between what we're seeing here in the clinic and then what's happening in the studio and then providing that open communication to artistic directors and dance educators is going to help get their support and then truly understand where we're at in the process, why it's important to not just throw us back on stage when we're not ready. I think the communication component is so important and overlooked oftentimes because they might look good for us. And then modifying classes and rehearsals.

So, we're not just going to not run at all and then go run a marathon, right? If we think about a runner or a sprinter, I kind of formulate that with our dancers. If we are feeling better, oftentimes I'll have a dancer go back in there and said, I was feeling really good.

So, I went, and I did everything and now I'm not feeling good again. Like they're anxious to get back to it. So, I think using objective measurements, looking at their strengths, showing them why what I'm seeing is not correlating with we are ready for full function and then helping be there, I like to say I'm like a guide, right?

They're doing all the work but helping guide them with what to do in class. Are they okay to just do bar right now? There is a time and a place obviously for sitting out like a stress injury or something that we're worried about.

Safety's key, but it is rare that I will tell a dancer they can't do anything. Very rare. Like there's always going to be something being mindful of safety, but getting them back to bar, maybe they can do tendu, center and adagio, but we're not going to do petite or grand allegro yet.

So, I think that gradual progression back is something that is really important to have a dance medicine provider working with you because we're able to understand the ins and outs of each genre and then working to help transition their biomechanics and technique into the classroom is another key component of return from injury. If they graduate here and then they go back to their old ways, they're going to end up back in here in a few months. So, I think premature graduation from therapy is not good.

I think you should really go through your entire program with us and make sure that you're ready to be done. Prematurely graduating is something that scares me at our dance population because they might end up back in here for something else. So, following through with the program as well.

[Eric Leighton]
And, you know. Definitely, and that, and that, like you said, that modifying, you know, modifying classes, rehearsals, as you get back to work, you know, when you just start to feel better, uh, that doesn't mean everything is solved, right?

[Dr Aimee Heslop]
Exactly.

[Eric Leighton]
The symptoms are gone. Maybe not the cause is completely gone. One of the phrases, again, I have a lot of, a lot of goofy phrases, metaphors I use to help, you know, explain it to the parents.

I always tell them, I said, listen, at first, my first couple times back, my first couple of workouts, my first couple of rehearsals, I would rather leave the studio going, yeah, I probably could have done a couple more rather than, oh God, what did I just do? Right. I don't want to walk out of there dragging my foot behind me realizing I went too far.

So, I would rather be, huh, I could have gone a little farther today. And then carefully adding that, but listen, listen to your physician, listen to your therapist. You know, we're not, we're not doing this just because we think it's funny.

They know exactly how you're supposed to, uh, to get back to make sure, as I tell them, I like to do it right. And I like to do it once. I don't want to have to, you know, I'm trying to get rid of you.

My job is to get you out of my clinic. So as much as I like you then going, you know, going forward from that. So, you know, once people are back to dance, you know, other things that will help us help them to, to not be injured, to be in better shape, to be able to handle it.

And I think, you know, a question for both of you, let's call it, you know, the technical term is periodization. So, periodization and cross-training. Megan, you mentioned at one point, a couple of questions back about, you know, athletes are dancers who play other sports and do other activities.

And it's a great, you know, a great combination of things that rounds out the body. So that periodization and cross-training, what is it? Number one, and why is it important?

[Dr Aimee Heslop]
So, I'm so passionate about this right now, about periodization and cross-training. So, if we think about every other sport or most sports, there is an off season, there's tapering. Dance, we are rehearsing for practice instead of performance.

Everybody is wondering when they get on stage, why am I getting injured after a performance? It is because we run dances into the ground to prepare for something. If we think about, my husband was a college swimmer.

If we think about before his meets, he would have rest and recovery so he could peak performance, optimal performance when he was swimming, right, at the meet. For dance, we are running a number over and over and over again. We're fatiguing ourselves.

So then when we get on stage, it is not our optimal performance. And we don't think about periodization in our season. So there really isn't that off season.

That is going to be a problem that takes years to solve. I think it's going to start with the adolescents and the youth kind of growing up and realizing these things and helping to implement that into dance programs. So, I think as dance providers, we need to keep that in the back of our minds and help to educate not only our students, but the dance artistic directors on how we can work with our dancers.

Maybe if they have a repertory or choreography coming in that is a ton, a ton of jumping, maybe in technique class that week, we are not jumping, right? We're working on our strength. We're working on stability instead.

So that's my talk on periodization. And then cross training, I think dancers, I'm debunking myths all the time on they're scared to lift weights, right? So, I'd sort them in here.

We're going to find power. We're going to be stronger and it's going to help you in what your technique. I think cross training does not need to look like more dancing.

That's something I tell them all the time. Conditioning and dance should not look like things that look like dance. It should look different.

[Eric Leighton]
Yeah. When I do warmups in here, for instance, I'll, I'll, with a young dancer, I'll have them doing warmups and I'll have them doing some dynamic warmups that look more like track and field and they look at me kind of sideways, like, what does this have to do with dance? I mean, it's all part of how your body works.

And so, I'm just starting with more of a basic movement, even not as specific as dance helps, but yeah, that all the time, just making sure that they have that chance to recover, as you mentioned, you know, that, that the progression of the dance, we mentioned it earlier. I said, as we get closer to a show, as we get closer to a competition, the hours in the studio go up as we, as we get closer to show time, we're not just doing a piece here, a piece there, we're running the entire show. Right back in my days in theater, we would run the entire show twice a day, back-to-back the entire two hour show that was dress rehearsals.

So yeah, you're exhausted and yeah, you know, you get that nervous energy when the curtain goes up on opening night, but your body is not in that a hundred percent right place. All right. Megan, you got any thoughts on, on as far as cross-training of what's, what's good to do and, and way other ways to prevent injuries or what they can, what can they look to do to make themselves better?

[Dr Megan Liberty]
Yeah, I think that this is something that is slowly changing over time. You know, I, I reflect back to my time as a dancer and I remember being told that, oh my gosh, if I went for a run that I would, you know, injure my knees, you know, or if I tried working on squats in the gym, you know, that I would create too much bulk in my, in my leg muscles, you know, meanwhile, if you look at what a plie is, it's, it's a, it's a squat. So again, trying to encourage dancers that yes, you are as much of an athlete as, you know, any other ball sports, you know, or, uh, you know, somebody that's participating and, and, you know, maybe something that's not quite as, you know, artistic driven and that they need to, you know, take care of their body like any other, we would expect that from any other athlete.

I think that it's something that the perception is, is slowly changing. And I think, you know, some of the more prominent dancers who are on social media that, you know, kind of show their workouts and some of the things that they do outside of the studio that keeps them in shape and, you know, keeps them, you know, on the top of their game, trickles down to, to our patient population, you know, which is, you know, you know, in the younger age ranges.

[Eric Leighton]
Yeah. As, as Aimee had mentioned before, you know, the dance and dance world, it's, it's based in tradition, less so in science originally. And yeah, I mean, you know, you look at ballet and some of the things, and you know, these, we're talking hundreds and hundreds of years old, and that was just the way it was done and it's very rooted in those deep traditions.

So yeah, the, you know, those, those thoughts, those approaches can be definitely slow to change, but, uh, we're definitely seeing more and more. I work with a lot of Irish dancers specifically, and it has definitely swung to becoming a much more athletic and athletic looking. The muscle build is not shunned.

They kind of, they kind of love it and live in it. They, they, they, they plan to look like that, but yeah, we're seeing it change. It can be slow, but, uh, but again, that, uh, taking care of your body and that cross training can really be important and can help in the long run.

So, all right, we covered a lot of stuff today about dance and dancers and what goes into it. And it is, it is a, it's a beautiful art form. I mean, obviously all three of us absolutely love dance.

Ballet is one of my absolute favorite things. I love going to watch a ballet but also knowing what goes into it. There's, there's a lot there.

There's a lot that goes into it that needs to be prepared for and taken care of correctly. But to their point, it's also, it's amazing. It's amazing development and skills and, and just the developing a well-rounded young human being.

So, it's a terrific place to be in a terrific place to start. So, Megan Liberty, thank you so much for, for all of that. And Dr. Mike, I think we've covered pretty much everything we can think of when it comes to dance right now.

[Dr Mike Patrick]
Yeah, this has been just such an interesting conversation. I just sat back and like, just, you know, absorbed at all of it and take it in. And the dancers that you guys take care of are really lucky to have you as a team.

You know, folks who are experienced in dance, you know, know what the challenges are, know what the common injuries are, know what rehabilitation looks like to get back and all of those things. So, kudos to you. And we are going to have some links in the show notes for everyone.

Of course, to sports medicine and also sports and orthopedic physical therapy at Nationwide Children's Hospital. But we also have a landing site for performing arts medicine at Nationwide Children's Hospital, and we'll put a link to that in the show notes as well. And then for the providers out there, I know that this is a parent podcast, but we do have a lot of pediatricians, family practice docs, nurse practitioners who listen to this podcast.

We are going to have a couple of articles from the Journal of Dance Medicine and Science for you in the show notes. One, determining point readiness in young adolescent female dancers, a systematic review, and another one, communication between medical practitioners and dancers. And we'll put those in the show notes as well.

That is at PediaCast.org. And this is episode 581. So once again, Dr. Megan Liberty, Dr. Aimee Heslop, thank you both so much for being here today.

[Dr Aimee Heslop]
Thank you so much for having us. Thank you so much. I love dance being put on a platform that can be seen by so many.

So, thank you so much, guys.

[Dr Mike Patrick]
Yeah, absolutely. And also thank you to Eric Leighton, sports medicine and often co-host when we do these sports medicine topics. Thanks so much, Eric.

[Eric Leighton]
Well, thank you, Dr. Mike. We always appreciate the chance, the invitation to come to the studio and be with you and also to Dr. Liberty and Dr. Heslop. Thank you so much for your expertise today.

[Dr Mike Patrick]
We are back with just enough time to say thanks once again, to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Megan Liberty and Dr. Aimee Heslop, both with sports medicine at Nationwide Children's Hospital. And Eric Leighton, our guest host also with sports medicine. Don't forget, you can find us wherever podcasts are found. We are in the Apple podcast app, Spotify, iHeartRadio, YouTube, and Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android.

Our landing site is pediacast.org. You'll find our entire archive of programs there, including show notes for each of the episodes, our terms of use agreement, and that handy contact page, if you would like to suggest a future topic for the program. Reviews are also helpful wherever you get your podcasts.

We always appreciate when you share your thoughts about the show, and we love connecting with you on social media. You'll find us on Facebook, Instagram threads, LinkedIn X, and BlueSky. Simply search for PediaCast.

Don't forget, we have a sibling podcast called PediaCast CME. That stands for continuing medical education. It's similar to this program.

We do turn the science up a couple of notches and offer free continuing medical education credit for those who listen. And that includes physicians. Yes, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.

And it's because Nationwide Children's is jointly accredited by all of those professional organizations, that it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements. Shows and details are available at the landing site for that program, PediacastCME.org. You can also listen wherever podcasts are found.

Simply search for PediaCast CME. And then one additional podcast that I host called FAMEcast, and it is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine. So, if you are a teacher in academic medicine or a faculty member in any of the health sciences, then this is a podcast for you.

You can find FAMEcast at FameCast.org and wherever podcasts are found by searching for FAMEcast. Thanks again for stopping by. And until next time, this is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids. So long, everybody.