STATEMENT BY AUTHOR - arizona.openrepository.comarizona.openrepository.com/arizona/bitstream/10150/192307/1/azu... · incidence and variety of injuries. ... The ankle joint (talocrural

INJURY PREVENTION FOR DANCERS: EVALUATINGTHE IMPORTANCE OF EDUCATION ON

BIOMECHANICS FOR DANCERS IN TRAINING

Item Type text; Electronic Thesis

Authors Correia, Danielle Coimbra

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.

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Link to Item http://hdl.handle.net/10150/192307

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STATEMENT BY AUTHOR

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ACKNOWLEDGEMENTS

This interdisciplinary project could not have been completed without the generous help of

many individuals. First and foremost, I must thank my best friend and mom, Marcia Wong, whose unconditional love and support throughout the past 22 years has not only made this thesis possible, but also has shaped my character in every way. Huge thanks go out to my dad, Ken Wong, as well, whose love and humor has always challenged and inspired me to achieve more than I ever anticipated. This project could not have been completed without the dedicated guidance and support of Dr. Cindy Rankin. I thank you immensely for helping brainstorm, issue surveys, tabulate surveys, and edit countless drafts; but more importantly, thank you for your wisdom in all matters of academia and life. My gratitude also extends to Amy Ernst for insightful dance consults and Jon Davison for sharing his dynamic knowledge of excellence in physical therapy. A special thanks also goes out to Deborah Kenner and Tucson Regional Ballet as well as Cheryl Carnes and Basis Charter School for opening up your doors and minds to this project.

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Table of Contents

I. ABSTRACT…………………………………………………………………………..6 II. INTRODUCTION……………………………………………………...……………7

III. BACKGROUND

a. Skeleto-Articular System Overview………………………………………………9 b. Female Dance-Specific Health Considerations………………………………….13 c. Common Dance Foot and Ankle Injuries

i. Inversion Ankle Sprain…………………………………………………..15 ii. Fifth Metatarsal Stress Fracture…………………………………………20

iii. Plantar Fasciitis…………………………………………………………..23 iv. Achilles Tendonitis………………………………………………………26

IV. METHODS

a. Populations……………………………………………………………………….28 b. Surveys

i. Pre-Survey………………………………………………………………..29 ii. Post-Survey………………………………………………………………31

c. Analysis of Survey Response.……………………………………………………31 d. Statistical Analysis……………………………………………………………….31 e. Instruction………………………………………………………………………..32

i. Lesson I: Warm-up and Stretching………………………………………33 ii. Lesson II: Core Strength, Turnout, and Alignment……………………...35

iii. Lesson III: Common Dance Injuries and their Prevention………………39

V. RESULTS a. Tucson Regional Ballet Dancers

i. Attitudes……………………………………………………………….…44 ii. Knowledge…………………………………………………….…………47

b. Basis Charter School Students (Control Group 1 ) i. Attitudes……………………………………………………….…………51

ii. Knowledge…………………………………………………….…………52 c. University of Arizona Dancers

i. Attitudes……………………………………………………………….…55 ii. Knowledge…………………………………………………………….…59

d. University of Arizona PSIO 380 Students (Control Group 2) i. Attitudes……………………………………………………………….…64

ii. Knowledge…………………………………………………….…………68

VI. DISCUSSION a. Tucson Regional Ballet Dancers…………………………………………………70 b. Basis Charter School Students vs. TRB Pre-Instruction Dancers………………..74 c. University of Arizona Dancers…………………………………………………..76 d. University of Arizona PSIO 380 Students……………………………………….79

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VII. LIMITATIONS……………………………………….……………………….……80 VIII. FINAL THOUGHTS…………………………………………….…………………81

IX. REFERENCES AND FIGURE CREDITS…………………….………………….82

X. APPENDICES

I. Ballet Terminology Index…………………………………………………..86

II. Exercise Protocols…………………………………………………………..88 a. Resisted Dorsiflexion, Plantar Flexion, Inversion, and Eversion b. Foot pick-up exercises

c. Towel Scrunches d. Single-Leg Balance e. Gastrocnemius and Soleus Stretches

III. Biomechanics Course Syllabus…………………………………………….90

IV. Pre- and Post-Surveys a. TRB Dancers…………………………………………………………95 b. Basis Students………………………………………………………..99

V. Pre- and Post-Surveys

a. UA Dancers…………………………………………………………101 b. UA Students…………...……………………………………………105

VI. Teaching Tools

a. Flashcards………………………………………………..................109 b. Selected Illustrations………………………………………………..116

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I. ABSTRACT

Despite the effortless grace of ballet dancers in movement, this population sustains high

rates of injury. It is hypothesized that the prevalence of injury could be attenuated by providing

relevant injury prevention education to pre-professional dancers in training. This project

evaluates the importance of teaching biomechanics and exercise physiology, with emphasis on

orthopedic injury prevention. Three educational modules were taught to 28 female dancers, ages

11-17, who dance ≥4 days/week. Pre- and Post-instruction surveys analyzed changes in attitude

and understanding about anatomy and injury prevention. A second population, University of

Arizona dance majors, was also surveyed before and after a UofA course in Dance

Biomechanics.

Survey data revealed both the dancers’ strong interest in the lessons and their improved

ability to articulate prevention mechanisms post-instruction. For example, dancers’ answers

improved in accuracy by 90% regarding the impact of wearing unsupportive footwear.

Furthermore, 96% of dancers indicated that they believe this knowledge can be directly

incorporated into their own dance technique. Altogether, this study suggests that given the

demanding nature of dance, instructors should provide education about both technique and

relevant biomechanics to minimize the potential for injury for dancers in training of all ages.

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II. INTRODUCTION Classical ballet, while maintaining its defining characteristics of upper body lift, the

turnout, and the creation of seamless lines with the body that stem from historical tradition, is

taught using methodologies which have reflected the modernization of the art. Rather than being

seen purely as entertainment, the athletic nature of dance has grown to merit innovative

approaches, combining its timeless beauty with meticulous scientific investigation.

Figure 1: Lorena Feijoo - San Francisco Ballet

The rise in popularity of dance today has unfortunately set the stage for an increased

incidence and variety of injuries. While elite professional dancers are subject to constant

rigorous strain on their bodies, it is important to realize the vulnerability of younger pre-

professional dancers as well. Unfortunately, many of the smaller studios are unable to hire fully

qualified instructors, i.e., those who are wary of potential injuries and knowledgeable about their

prevention. In order to address some of these troublesome current trends, a shift in pedagogy

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must be made in which the ballet instructor is aware of and willing to implement injury

prevention strategies to prolong the potential dance career of his or her students.

In ballet classes, it is common that each dancer receive individual feedback on his/ her

execution of movement. For example, an instructor may caution the student to keep the knees

aligned with the toes in plié*; however, the importance of this from an injury prevention

perspective is never directly addressed (note: all italicized ballet terms are defined in Appendix I:

the Ballet Terminology Index). The majority of dance students, therefore, fail to realize that the

importance of pulling up and using the ‘center’ serves as a method by which to engage the

abdominal muscles to support the lower back. Using the bend of the plié to land from jumps is

more than a way to prevent an audible thud; it minimizes the impact on joints and their

associated tissues.

A key method to shift the thinking of dancers and their instructors is through education

about the anatomy and physiology of injury prevention technique. A very effective way to

approach the anatomical and biomechanical background information is by setting it in a context

that interests the audience, namely, the dancers in training who are interested in dance science to

improve their technique. Presented in this way, the dancer is empowered not only to understand

on an intellectual level the reasoning behind certain techniques, but also is given the tools to take

better care of his or her body in the dance studio and beyond.

This project aims to evaluate the importance of teaching biomechanics and exercise

physiology, with a focus on orthopedic articular injury prevention for dancers in training. A

series of 3 educational modules will be taught, and Pre- and Post-instruction surveys will assess

changes in attitude and understanding. Lesson I of the instruction will introduce the basic

anatomy and physiology of the musculoskeletal system, including histological and gross

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structure, mechanisms of function, and relationship to other tissues and systems. Dance class

format will be explored looking particularly at the reasons behind a progressive warm-up and the

benefits thereof. Mechanisms of efficient stretching will also be a crucial component of this

section. Lesson II will focus on the characteristic ballet turnout and proper lower extremity

alignment. The contributors to and benefits of core strength will also be examined in detail. The

third and final Lesson III will cover musculo-skeletal injuries of the lower extremity, including

the ankle inversion sprain, dancer’s (5th metatarsal) fracture, dancer’s heel (plantar fasciitis), and

Achilles tendonitis. In closing, injury prevention via injury-specific exercises and stretches will

be taught.

III. BACKGROUND

a. Skeleto-Articular System Overview

Among their numerous individual functions, the skeletal and muscular systems and

associated connective tissue collectively serve to facilitate the extreme mobility and rigorous

stabilization required by dancers. Long bones (see Figure 2) consist of epiphyses, or the knobby

ends filled with spongy bone, metaphyses (where an epiphyseal plate in growing bones is

located), and a central diaphysis, or shaft comprised primarily of compact bone surrounded by

the periosteum. Articular (hyaline) cartilage covers the epiphyses to decrease friction at the joint,

where bone articulates with another bone (Tortora 2006). Bone attributes its hardness to

calcification following the deposition of mineral salts, while its tensile strength and flexibility are

due to its matrix of collagen fibers. Bone lengthening occurs at the epiphyseal plate until the

approximate age of 18 and 21 for females and males, respectively. However, bone retains the

ability to remodel throughout the lifetime (Tortora 2006). Although multiple bone components

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are supplied by both sensory and sympathetic neural input, the periosteum is the most densely

innervated and provides much of the sensory or pain perception (Mach 2002).

Figure 2: Long bone anatomy

In order to perform exquisite dance movements, a variety of joints must work in concert.

There exist three main types of joints: synovial joints, fibrous joints (united by fibrous tissue),

and cartilaginous joint (united by hyaline cartilage or fibrocartilage). For the purposes of this

review, primary emphasis will be on synovial joints (Figure 3), the most common and mobile

type of joint in the human body. They are characterized by a joint cavity surrounded by a

relatively loose joint capsule (e.g. the knee joint), which allows for a wide degree of range of

motion and requires accessory ligaments to provide stability (Moore and Dalley 1999). The

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capsule also contains synovial fluid to assist in lubrication of the articulation surfaces. Synovial

joints are functionally classified according to the nature of the articulating surfaces and the

degree of movement allowed (see Appendix VI: Teaching Tools). For example, the ball and

socket joint of the hip (acetabulum of the hip bone articulated with the head of the femur) allows

for flexion, extention, ab- and adduction, which combine to enable circumduction of the hip, as

in a rond de jambe.

Figure 3. The Most Ubiquitous Human Joint

As stated above, connective tissue is required for stabilization of the synovial joint.

Ligaments are parallel bundles of dense regular connective tissue (mostly collagen and elastin)

that connect bone to bone (Tortora 2006) (Figure 4). Dancers strive to achieve a certain degree

of hyperlaxity of their ligaments for overall flexibility, which can be achieved through stretching

due to the elastic nature of the tissue. At the same time, however, this malleability can lead to

pathological hyperlaxity, which can lead to recurring injury (e.g. chronic dislocations, sprains,

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etc.) (Moore and Dalley 1999). Surrounding intrinsic and extrinsic muscles and their associated

tendons also play a large role in joint stabilization.

Figure 4: Histology of a ligament: dense, regularly arranged connective tissue

The ankle joint (talocrural articulation) (Figure 5) will examined in detail in order to

more thoroughly understand the functional anatomy of a synovial joint and its associated

structures. The ankle joint is formed by the distal ends of the tibia and fibula, which create a

mortise, or a deep socket, into which the trochlea (the superior portion) of the talus articulates

(Moore and Dalley 1999). It is a hinge-type synovial joint, which allows for much greater range

of motion in flexion and extension versus other motions. In fact, the joint is more stable in

dorsiflexion due to the tensile strength of the grip of the malleoli on the trochlea as the wider part

of the trochlea slides posteriorly. This causes a slight spreading of the tibia and fibula, which are

held together tightly by the interosseous, transverse, anterior, and posterior talofibular ligaments

(Moore and Dalley 1999) (Figure 6a/b). In contrast, ankle instability in plantar flexion will be

discussed in “Common Dance Foot and Ankle Injuries.”

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Figure 5: Slightly oblique frontal x-ray of the ankle joint

Figure 6a: Anterior view of ankle ligaments

Figure 6b: Posterior view of ankle ligaments

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b. Female Dance-Specific Health Considerations

With the growing popularity of hip-hop, jazz and modern, dance is becoming

increasingly more popular among males; however, it remains a predominantly female activity

(i.e. in any given high-school age dance class of 25 students, there may be 1-2 men). Thus, due

to the number of female participants and the highly athletic nature of dance, a myriad of female

dancers sustain injuries, which will be the predominant focus of this research. It is important to

realize that one factor that explains the prevalence of injuries in dancers in training is the Female

Athlete Triad. The three components of this disorder are: disordered eating, amenorrhea, and

premature osteoporosis (Hobart and Smucker 2000).

Traditionally, dance (ballet especially) has always emphasized the importance of

achieving and maintaining an ideal slender and toned physique. Dancers often aim to achieve

this body type too rapidly and without the guidance of a medical professional. Extreme means

are often employed, leading to anorexia nervosa, bulimia nervosa, or other eating disorders.

While many individuals who experience the Female Athlete Triad do not meet the strict criteria

for any of these specific disorders, they still have inappropriate eating habits and are labeled with

the more general term of having disordered eating. Amenorrhea is defined as a complete lack of

menstrual bleeding by the age of 14-16, or at least a 6-month absence of a period which had

otherwise been regular (once monthly). Lastly, osteoporosis is the loss of bone mineral density,

which is often irreplaceable. The resulting fragile bones are more susceptible to injury,

including, but not limited to, stress fractures, a prevalent injury in the dance population (see

“Common Dance Foot and Ankle Injuries: Fifth Metatarsal Stress Fracture” below).

Unfortunately, the Female Athlete Triad is often undiagnosed due to lack of knowledge on the

issue, lack of communication, or both (Hobart and Smucker 2000). Physicians, parents, and

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dance teachers should raise the awareness of the Triad to promote healthy eating habits and

overall lifestyles for active children.

c. Common Dance Foot and Ankle Injuries

i. Inversion Ankle Sprain

One of the most commonly seen injuries in sports medicine, particularly in dancers, is the

acute ankle inversion sprain (Figure 7). The prevalence of this type of ‘rolling-in’ sprain can be

explained by the fact that unstable loading onto the foot (such as landing a jump, or a jété) leads

to inversion twisting due to the lateral ligament’s instability and weakness relative to the medial

ligament (Moore and Dalley 1999). Following this motion, the anterior talofibular ligament,

which runs anteromedially from the lateral malleolus to the neck of the talus, frequently

experiences the majority of the tear, which can happen to either a limited number of fibers within

or across the entire ligament (Moore and Dalley 1999) (Figure 8). The calcaneofibular ligament

and the lateral malleolus of the fibula are also involved in severe ankle sprains because of the

ligamentous attachment that runs posteroinferiorly from the tip of the lateral malleolus to the

lateral surface of the calcaneus. This anatomical arrangement can also yield a fracture of the

lateral malleolus of the fibula (Moore and Dalley 1999).

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Figure 7: Inversion ankle sprain

Figure 8: Lateral view of ankle

Sprains are classified as grade I, II, or III, depending on the severity of the injury. For

example, a grade I sprain would present with minimal pain and swelling, and no ecchymosis (or

visible bruising) would be seen, being as the connective tissue involved had likely experienced

little to no tearing. On the other hand, a complete tear of the ligament resulting in severe pain,

swelling, and visible bruising is characteristic of a grade III ankle sprain (Wexler 1998).

Treatment, particularly for grade I and II sprains, incorporates many elements, including

rest, ice, compression, and elevation (RICE) (Davison 2009). Often nonsteroidal anti-

inflammatory drugs (NSAIDs) are recommended to help alleviate pain and swelling as well.

Before returning to normal activity, some degree of immobilization (as well as non-weight

bearing) of the joint is likely to be recommended, particularly following a grade II sprain. This

care should continue until the patient experiences no pain on walking (Wexler 1998). Grade III

sprains, on the other hand, may require either plaster immobilization and/or surgical repair (Ryan

and Stephens 1987). Two surgical options include, but are not limited to, arthroscopy (to

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visually detect damage to the ligament, bone, and cartilage) and reconstruction (to repair the

ruptured connective tissue with sutures and/or other healthy ligaments or tendons from

surrounding areas) (Bernstein, 2003). If the connective tissue has not completely healed

following injury or surgery, the individual is likely to experience chronic, or frequently

recurring, ankle sprains.

While important for all populations, rehabilitation is particularly critical for dancers due

to the subsequent increased potential for reinjury. The patient is much more likely to sprain the

ankle again as a result of an increase in joint laxity and a subsequent decrease in strength

following the initial injury (Wexler 1998). Any ankle sprain is characterized by microtearing of

the collagen fibers of the ligament (Figure 4), the most severe of which (Grade III) involves a

complete rupture of the ligament (Bernstein, 2003). Because one of the main properties of

collagen is tensile strength, any damage to this tissue results in instability of the ligament itself.

Furthermore, significant muscle atrophy should be expected to occur post-injury because the leg

must be non-weightbearing for a given period of time. Although certain exercises are permitted,

as determined by the doctor or physical therapist, they tend to be isometric in nature.

Although a common injury in all sports, the ankle inversion sprain presents a number of

unique problems for dancers. For example, Morrison and Kaminski concluded that one risk

factor for both acute and chronic inversion ankle injury is if the individual has an unusually large

range of motion of the metatarsophalangeal joint, a characteristic expected of dancers (see

Figures 9 and 10) (Morrison and Kamisky 2007). It is highly desirable both aesthetically and

functionally to have flexibility in this joint because it allows for a higher demi-pointe (or plantar

flexed position), putting the dancer population at higher risk for inversion ankle injuries. This

weightbearing demi-pointe position allows for greater “play” in the joint because the narrowest,

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posterior portion of the talus forms the ankle articulation, leading to reduced stability (see Figure

5). In addition, the anterior talofibular ligament is in a position of greatest tension in plantar

flexion, which makes it more likely to sustain injury (Wexler 1998).

Figure 9: X-ray highlighting Metatarsophalangeal Joints

Figure 10: Demonstrating passive motion at the metatarsophalangeal joint (ankle in plantar flexion)

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No matter the grade of the injury, treatment should be tailored for dancers taking into

account their specific needs. For example, a professional (or even pre-professional) dancer has

an extremely demanding schedule, which often requires that he or she dance at least 5-6 days per

week (Mellion et al. 1997). It is important that the physician or physical therapist treating the

dancer realize the importance of a rapid recovery for the job of the dancer. At the same time,

however, it is critical that the dancer understand that a full recovery needs to be made in order to

prevent reinjury, as discussed above. This is particularly limiting in dance because protective

support that is frequently used for other forms of athletics (such as ankle taping or lace-up

braces) often limit the range of motion of the dancer so they are unable to perform movement

correctly, if at all (see Figure 11 below).

Figure 11: A traditional lace-up brace, which maintains the foot in dorsiflexion

Taking these difficulties into account, the dancer should focus first and foremost on

preventing inversion ankle sprains. To this end, exercises should focus on stabilization of the

ankle joint (see Appendix II: Exercise Protocols). This would include resisted plantar flexion,

dorsiflexion, inversion and eversion using Therabands (or other exercise elastic resistance bands)

and towel scrunches (see Appendix I for illustrated exercises). Other stability work should

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incorporate balance exercises, such as single-leg weightbearing exercises on various surfaces (ie.

wobble board, Airex, Dyna Disc, etc.) (Howse 2000). Improving strength of muscles and

collagenous structure of connective tissue, in conjunction with the enhancement of neural control

of protective reflexes (trained through these and other similar exercises) ultimately prevent initial

or further (post-injury) damage of the lateral ligaments of the ankle in unstable situations (IAOM

2008).

ii. Fifth Metatarsal Stress Fracture

Stress fractures of the foot and ankle have been found to be prevalent in dance, especially

the ballet community (Marski 2009). The 5th metatarsal stress fracture is commonly referred to

as the “dancer’s fracture” (see Figures 12 and 13). Stress fractures in general are due to repeated

localized forces that gradually degrade the bone to the point of forming small fissures (Howse

2000). When the dancer loses balance while bearing his or her full weight on the ball of the foot,

the laterally directed (inversion) force applies a great deal of stress on the metatarsal in plantar

flexion (demi-pointe) (Mellion et al. 1997). An inflammatory and subsequent regeneration

response is triggered to repair the cracks; however, if the bone continues to be subject to repeated

forces, multiple stress fractures or even a complete fracture can result (see Figure 14) (Strayer et

al. 1999).

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Figure 12: Location of the 5th metatarsal and types of fractures

Figure 13: Stress Fracture of the 5th Metatarsal (Jones Fracture)

Figure 14: Complete Fracture of the 5th Metatarsal (Mid-Shaft Fracture)

Dancers with untreated stress fractures will often feel pain while dancing as well as in

ambulation if the fracture is severe (Howse 2000). While it is known that the periosteum is very

well innervated, there is more recent evidence that small neurons in compact bone also relay pain

associated with these micro-fissures. Research suggests that the primary cause of skeletal pain is

the mechanical distortion of the periosteum and bone tissue following fracture (Mach 2002).

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Diagnosis and treatment for the 5th metatarsal stress fracture varies widely depending on

the severity of the trauma. In all cases, stress fractures often present with localized pain, area of

warmth, ecchymosis, and edema (Howse 2000). Fractures are described within the Torg’s

Classification System, which ranks the injury between type I (least severe) through type III (a

complete, wide fracture line) (Strayer et al. 1999). Type I fractures are generally treated with

non-weightbearing immobilization for 6-8 weeks, while type II fractures may be corrected

surgically, depending on the patient’s desire (Davidson 2009). Type III stress fractures of the

metatarsal require surgical fixation. Surgical intervention, however, is highly contested among

orthopedic surgeons due to the fact that more conservative measures, such as non-weightbearing

immobilization, are equally successful (Morski 2009). In consideration of the dance and other

elite athlete populations, however, acute surgery will be more common due to a smaller post-

operative recover time (full return to activity roughly 3 weeks following surgery versus 8-12

weeks of non-weightbearing immobilization) (Morski, 2009). In all cases, a period of rest from

activity usually results in muscle wasting; however, specific exercise programs that do not strain

the stress fracture site can be designed for dancers by a supervising physical therapist (Howse

2000).

As above, proper training of the surrounding musculature is key for prevention (see

“Inversion Ankle Sprain”). However, once the injury occurs, early diagnosis is the most crucial

component of a swift recovery from a stress fracture. As discussed in Elias et al. (2008), a

problem among many professional athletes and dancers alike may be that they tend to

underreport initial symptoms “in order to avoid being placed on inactive status” (Elias et al.

2008). Delayed treatment may also be due to the misconception in the dance profession that pain

is expected and “dancing through it” is the best course of action (Arnheim 1991). This, in turn,

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often results in acute injury becoming chronic, as is the case with the “dancer’s fracture.”

Dancers should recognize that highly conditioned bodies tend to heal more rapidly than those of

their sedentary counterparts and that upon suspicion of injury, immediate care should be taken

for efficient and effective recovery.

iii. Plantar Fasciitis

Plantar fasciitis, or “dancer’s heel,” is one of the primary causes of heel pain (Singh et al.

1997). The plantar fascia itself (see Figure 15) is comprised of three bands of ligamentous

connective tissue on the sole of the foot, which together run from the medial tubercle of the

calcaneus, anteriorly along the arch of the foot, and terminate at the proximal phalanx of each toe

(Donatelli 1996). Microtears of the fascia occur after repeated trauma (similar to that of a stress

fracture), which yields a chronic inflammatory response accompanied by a great deal of pain,

especially following long periods of inactivity (ie. sleeping or prolonged sitting). Tightness in

the Achilles tendon can predispose an individual to plantar fasciitis because it keeps the foot in a

plantar flexed position, preventing the stretch of the fascia tissue (Figure 16) (Davidson 2009). In

fact, 78% of patients diagnosed with plantar fasciitis also exhibit notable Achilles tightness

(Singh et al. 1997). Due to the acute pain experienced on weightbearing, movement tends to be

symptom-limited.

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Figure 15: Plantar Fascia and Associated Structures

Figure 16: Close Relationship between Achilles tendon and Plantar Flexion

Dancers present numerable risk factors associated with plantar fasciitis that should be

considered. For example, wearing shoes with inadequate arch support has been shown to

predispose individuals for plantar fasciitis (Davidson 2009). Ballet shoes, both flat (leather or

fabric) and pointe (Figures 17a/b), are completely lacking in cushioning and arch support.

Furthermore, many young dancers, especially in the desert climate, enjoy wearing flip-flops,

most of which have completely flat rubber soles. Another aggravating factor is frequent walking

barefoot on hard floors, a problem especially for modern dancers. Lastly, any occupation

involving prolonged weight bearing has been shown to be associated with plantar fasciitis, which

is without a doubt a characteristic of professional dance (Singh et al. 1997).

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Figure 17a : Completely flat insole of pointe shoe, belonging to renowned ballerina Margot Fonteyn

Figure 17b: Flat sole of pointe shoe

Prevention and treatment regimens are similar and should be consistently employed for

dancers. Because of its close association with tightness in the Achilles, stretching of both the

Achilles tendon and the plantar fascia should be implemented (see Appendix II: Exercise

Protocols) (Davidson 2009). Strengthening of the fascia and surrounding areas include

stabilization exercises similar to those of the inversion ankle sprain (see above), but focus more

on the plantar surface of the foot (ie. towel scrunches and marble pick-ups). Treatment strategies

could also include change in footwear, night splints that hold the foot in dorsiflexion (such as a

Strasburg sock), ultrasound, and heat therapy (Singh et al. 1997). Ultrasound therapy uses high-

frequency sound waves that penetrate the affected tissue to promote healing through warmth.

Proposed benefits include increased circulation, breaking down of scar tissue, reduction of

inflammation, reduction of nerve irritation, all of which can alleviate pain. Heat therapy works

by similar mechanisms, although it is not able to penetrate the tissue as effectively because it is

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applied superficially. Although other diagnoses, such as Sever’s disease, bursitis, tarsal tunnel

syndrome, and Paget’s disease often present similarly, it is important to diagnose plantar fasciitis

as soon as possible to begin appropriate treatment (Davison, 2009).

iv. Achilles Tendonitis

Inflammation of the Achilles tendon is rather prevalent in ballet dancers, totaling roughly

9% of ballet injuries (Hellier et al. 2004) (Figure 17). Tendonitis, much like stress fractures and

plantar fasciitis, is considered an overuse injury, but can also be triggered by incorrect placement

and anatomic anomalies. Furthermore, tendonitis can present rather suddenly, especially when

an individual begins a new rigorous activity (Davidson 2009). In its pathology, the sheath of the

aggravated tendon thickens, adding resistance to movement and making it much more painful

(Ryan and Stephens 1987). A torn Achilles requires surgical intervention (see Figure 18 below).

Figure 18: Achilles Tendonitis

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Because the child’s body is constantly undergoing rapid regeneration and growth of

tissues, true tendonitis is not expected to appear before age 18-20 with rigorous activity, and it is

believed that the terminology is currently used to incorrectly describe other less severe injuries

(Davidson 2009). Dancers at any age, however, can experience a failure to adapt to high

physical demands of the activity on the level of the connective tissue and supporting

musculature, which can lead to tendonitis at a younger age than is seen in inactive or moderately

active children (Morski, 2009).

As was discussed previously, it is important that the dancer realize that the protocol

following a diagnosis of tendonitis will include at least two weeks of rest, during which time the

tendon can heal (Ryan and Stephens 1987). Following this period, moderate dance activity can

be initiated as long as he or she remains asymptomatic until return to full participation. A

common treatment can include injection of steroids or local anesthesia; however, the dancer

should not confuse this symptomatic approach of pain relief with that of true treatment to

facilitate healing. In fact, if tendonitis goes completely untreated, it may lead to a full rupturing

of the involved tendon, which will then require surgical repair (Ryan and Stephens 1987).

The prevention of Achilles tendonitis is multi-faceted, but has many long-term benefits.

Before taking part in a rigorous new activity, such as dance, it is important that the individual

begin their work gradually, with a great deal of focus on acquiring the appropriate stretch and

strength to be able to safely perform at the level of his/her peers (Davidson 2009). All dance

classes are heterogeneous in the skill and experience level of its individual students, especially

being as they tend to be formed based roughly on age groups. It would be ideal for both children

and adults interested in starting classical dance to participate in an introductory pre-dance class

aimed at preparing them to take class with more seasoned dancers. Ideally, this would not only

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include work on physical stamina and strength, but also education about injury prevention

mechanisms as they engage in the thrill of classical dance.

IV. METHODS

a. POPULATIONS

The population of interest for educational outreach included ballet dancers of the Tucson

community who dance at a serious level (at least 4 days/week) in middle or high school (11-17

years of age). Twenty-eight female dancers from the Tucson Regional Ballet’s Academy of

Dance who fit these criteria were selected to participate (21 of whom completed both Pre- and

Post-Surveys). Unfortunately, there were no male students in the class; however, all were

members of the studio’s Junior or Senior Company, indicating their significant level of

commitment to dance as well as their ballet experience. All TRB dance students under 18 years

of age whose data is included in this research project provided parental consent and oral minor

assent to participate. All adult participants signed consent forms as well. The control group was

comprised of 28 6th grade (11-13 year-old) female students from Basis Charter School in Tucson.

Figure 19: Tucson Regional Ballet Junior Company Student Athena with the skeletal leg model

29

The second population of interest was University of Arizona undergraduate and master’s

level dance students (ages 18-24+) enrolled in a one-semester course entitled “Biomechanics for

Dancers” (University of Arizona course DNC 455). Forty-seven students fit this category, 40 of

whom completed both Pre- and Post-Surveys. Of the participants, 75% were female (n=30) and

25% were male (n=10). The course, taught by dance faculty member Amy Ernst, focused on

“the evolution of human body form; systematically study skeletal, muscle, connective tissue, and

joint anatomy; review principles of mechanics and fundamental Cartesian system for analysis of

movement; study basic patterns of movement; assess anatomical illustration styles and uses and

become familiar with stress and injury potentials and their prevention” (course syllabus: see

Appendix III). The control group for this population was comprised of undergraduate (non-

physiology major) students enrolled in a one-semester course entitled “Fundamentals of Human

Physiology” (University of Arizona course PSIO 380) and taught by Dr. Cindy Rankin. Forty-

five 18-23 year-old and two 24+ year-old students participated. Of the participants, 81% were

female (n=38) and 19% were male (n=9).

b. SURVEYS

i. PRE-SURVEY

In order to best gauge the TRB dancers’ understanding of the material presented in the

lessons as well as to evaluate the impact of this knowledge on their execution of movement, a

pair of surveys was issued pre- and post-instruction. The survey featured 3 parts (see Appendix

IVa for full survey): the first incorporated epidemiological questions for statistics on the

population (age range and gender). Part two gauged the dancers’ attitude about and interest in

learning more about their anatomy and physiology in the context of dance and their enjoyment of

dance itself. For this part they were instructed to rank their answers from 1-5 based on the

30

strength of their belief for a given question (ie. 1=strongly disagree through 5= strongly agree).

The third component of the survey was a series of ten True/False questions about anatomy,

biomechanics, and health-related behavior. In addition to selecting True or False, the dancers

were instructed to provide an explanation for their answer if possible.

The control group of non-dancers was given the same general survey and similar

instruction. Their surveys did differ from those of the dancers’ in that dance terminology was

replaced with general athletic vocabulary (e.g. ‘plié’ was changed to ‘squat’ for question 6; see

full Control Pre-Survey in Appendix IVb). This control group from Basis Charter School

completed only the Pre-Survey and received no subsequent instruction.

University of Arizona dancers and non-dancers were given a slightly more sophisticated

survey (see Appendix Va and Vb for complete surveys). The first part of the questionnaire was

similar; however, these more mature students were asked about their perspective on the

importance of education in the prevention of and recovery from injury. The majority of the

questions tested the same concepts using more advanced vocabulary and wording. The only two

questions that differed significantly between the age groups was a nutrition question (which

replaced the lactic acid question) and a difficult anatomy question regarding the abdominals

(which replaced a question regarding ankle pronation), as these topics were deemed more

relevant for the material being covered in the university dancers’ biomechanics course. Both

groups of university students (biomechanics course DNC 455 and in human physiology PSIO

380) completed Pre- and Post-Surveys, although neither group received dance-specific

instruction beyond what was covered in their respective classes.

31

ii. POST-SURVEY

The Post-Surveys were largely identical to the Pre-Surveys (see Appendix IVa and Va for

complete surveys). The wording in part two, gauging attitude and interest, was changed to

reflect how they felt about the instruction in terms of the amount they learned as well as how

they felt about its applicability to their execution of movement. Two open-ended questions were

also added to ask for any additional comments they have as well as to find out what the most

interesting concept they learned was. Otherwise, questions were identical. The Post-Survey was

issued to the dancers at TRB 1.5 weeks following Lesson III and one week prior to the end of the

semester for University of Arizona students. It is important to note that UA Dancers’ Post-

Survey responses were only graded for attitude questions, as biomechanics lecture material did

not directly address knowledge-based questions. For consistency in analysis, the same attitude

Post-Survey questions were tabulated for UA PSIO 380 students.

c. ANALYSIS OF SURVEY RESPONSE

To maintain objectivity for the grading of surveys, specific criteria were outlined based

on an answer key. In addition to marking the True/False questions as correct or incorrect, the

written justification or explanation was graded on a scale of 0-3. A zero represented a blank or

incorrect answer; a 1 was given for a vague answer that followed the correct train of thought; a 2

signified that the explanation was good but was missing key idea(s); a 3 represented an excellent,

detailed, and complete answer.

d. STATISTICAL ANALYSIS

Comparisons between baseline (pre-survey) and final (post-survey) mean explanations

were made using a student’s paired two-sample t-test on SPSS 17 (currently known as PASW

{Predictive Analytics SoftWare}). Group means were compared, as no individual identifiers,

32

coded or otherwise, were used in order to maintain complete subject anonymity. It is important

to note that 7 participants who had completed the pre-survey were absent on the day of the post-

survey; therefore, the mean score for each question from the 21 completed surveys was used to

substitute for the missing 7. This was done because the statistical analysis required equal sample

sizes, and it was impossible to determine which pre-surveys to exclude, as no identifiers were

utilized; however, it is possible that this could have led to a type I error (Gravetter et. al. 2006).

Data with a level of p<0.05 was deemed significant (denoted by an *).

e. INSTRUCTION

As previously stated, all lessons were given to dancers of the Junior and Senior Company

of the Tucson Regional Ballet’s Academy of Dance. The three-part series took place over the

course of three consecutive weeks (Tuesdays for the Junior Company and Saturdays for the

Senior Company), each lesson lasting 20-25 minutes based on the level of audience participation.

All lessons were designed as multimedia experiences to enable all types of learners to grasp the

material.

Figure 20: Introducing the project to the Senior Company Students

33

i. LESSON I: WARM-UP AND STRETCHING

The first day of instruction was designed as not only an introduction to the project, but

also as an overview of warming up and stretching, as applied to dance. The lecture was taught

interactively primarily through questions to the dancers, and participation was awarded through

the receipt of an index card with the correct answer, which they were told could be claimed for

something special at the end of the presentation (Figure 21). The index cards, in addition to

identifying the engaged students, also provided a visual reference for the student to see her

correct answer in both graphic and written form.

In discussing warming up, the lesson focused on the effects on the cardiovascular system

(including, but not limited to, increased heart rate and stroke volume as well as vasodilation),

muscular system (including increased heat production from additional blood flow, metabolic

activity, and oxygen delivery), and the skeletal system (primarily the increased production of

Figure 21: Awarding a participation flashcard to Cassie

34

synovial fluid in the joints). Color photos of the human heart and the shoulder joint were used to

illustrate these points (see Appendix VI).

Following the overview of warming up, basic musculo-skeletal anatomy was discussed

through an illustrated figure and human cadaver photographs of the Achilles tendon and

gastrocnemius muscle (see Appendix VI). Each dancer was asked to think of this inside view in

comparison to the surface anatomy of their own posterior lower leg. The purpose of this

integrated thinking was to encourage the dancers to begin to incorporate their knowledge of

anatomy and physiology with the exterior view of the image in the studios’ mirrors.

Stretching was then discussed, using elastic Therabands of various tensions to illustrate

the elastic properties of the musculo-tendinous complex. To integrate stretching with the

conversation of warming-up, the class was then asked about why a dance class is structured as it

is (from slow, fluid movements at the barre, to stretching, and finishing with fully self-supported

movements of increasing speed and intensity at center). This allowed the dancers to review the

importance of warming up before stretching, and the importance of stretching before jumping

and performing high extensions.

Lastly, the lesson ended with a fact or fiction discussion regarding lactic acid. It was

asked of the dancers whether lactic acid is the cause of long-term soreness, a subject of common

misconception. After some short debate, it was shown that lactic acid, a byproduct of anaerobic

respiration, is flushed out of the system within 30 minutes of its production. The current theory

on muscle soreness was explained to be small tears within the muscle itself. The dancers were

happy to discover that they could redeem their index cards of participation for a piece of

chocolate candy, which they were free to eat after their ballet class.

35

ii. LESSON II: CORE STRENGTH, TURNOUT, AND ALIGNMENT

The second lesson was aimed at instructing dancers on the importance of core muscles,

turnout, and correct alignment for dance. To begin the lesson, illustrations were shown to

explain the layering of the abdominal muscles (from deep to superficial), as well as the

complexity of the erector muscles of the back (see Figures 22/ 23 and Appendix VI). An

interactive discussion arose regarding why the core plays a central role in movement, including,

but not limited to, preventing back injuries, providing correct postural alignment and aesthetic

quality. Flashcards were again awarded for participation.

Figure 22: Explaining an illustration of abdominal muscles

36

Following the discussion about the core, the mechanisms and rationale of turnout were

investigated. It was explained that although turnout is largely continued today due to deep-

rooted traditions of the ballet, it provides a tremendous functional advantage in movement. It was

taught that the rotation in the hip joint allows for a greater safe range of motion of the lower

extremity. This was illustrated to the students by a demonstration of a grand battement à la

seconde in parallel and turned out.

Following this, the misalignment of ankle, knee, and hip was addressed. The topic was

introduced by a brief introduction of the skeletal system, for which two chicken bones were used:

one dry to emphasize the hard, brittle nature of dead bones and one that had been soaked in

vinegar for 1.5 weeks, which had made it extremely malleable (see Figure 24). This

phenomenon occurs because the acidity of the vinegar strips the bone of its crystallized inorganic

mineral salts which provide its characteristic hardness (Tortora 2006). It was emphasized that

Figure 23: Discussing the corset-like layers of the abdominal wall (TRB ballet instructor Deborah Kenner pictured on left)

37

although their bones are not flexible to this degree, they are not quite as brittle and dry as the first

bone. The main point was to illustrate that their living bones are a conglomerate of the two: they

have immense strength due to the mineral makeup of the skeletal system, but they are still prone

to adaptation and change for younger dancers still in the process of growing and developing. It

is therefore extremely important that educational instruction be given to this subset of the dance

population.

To tie together core strength, the turnout, and the skeletal system, a practical application

of alignment was used: a demi-plié in first position. A volunteer from the class was chosen to

perform a demi-plié, with most of the class observing in a lateral view. The biomechanics of this

motion were illustrated with a skeletal model of the right leg, which was bent in the same manner

as that of the dancer (see Figure 25 on following page). The surfaces of the knee were examined

closely, and students were allowed to see the structures that are most affected by ‘rolling in’ at

the knee or ankle, as well as how this contributes to long-term injury. The dancers were very

enthusiastic to try flexion and extension of the model.

Figure 24: Senior Company Dancer Alyssa examines the properties of the de-mineralized chicken bone

38

To extend the discussion of alignment to the distal portions of the lower extremity, it was

emphasized that correct pelvic and knee alignment should prevent the occurrence of pronation of

the foot (or ‘dropping of the arches/ rolling in,’ as its more commonly referred to in dance).

Rolling in, especially in pointe shoes, was said to often lead to bunions, which are not only

painful but also unsightly. To finish with a concrete example and self-test that the dancers can

continue to perform in the future, the students were instructed to examine the soles of their ballet

slippers for accumulation of dirt. These places are indicative of their weight distribution. If the

shoe appears to be dirtier in the medial part of the sole, it may suggest that the dancer is placing

too much weight in their arch and should be aware of their pronation. Similar to the first lesson,

dancers who participated by being volunteer models, working with the skeletal leg model, or

receiving an index card were offered sugar in the form of Smarties candy.

Figure 25: Demonstrating proper plié biomechanics with Senior Company Member Hallie

39

iii. LESSON III: COMMON DANCE INJURIES AND THEIR

PREVENTION

This final lesson was intended to conclude the previously discussed material by applying

the information to better understand common foot and ankle dance injuries as well as ways in

which to prevent them. For each injury and exercise discussed, a student model was used to

engage the dancers.

The first injury covered was the ankle inversion sprain. The dancers were taught about

the ligaments involved (anterior talofibular and calcaneofibular ligaments, most often) using the

skeletal leg model, which had colored rubber bands attached to tangibly demonstrate their

locations (Figures 27 and 28). It was shown why it is that the demi- and full-pointe positions

yield greater instability and makes the dancer more susceptible to sprains. Care and maintenance

was discussed, including RICE treatment, immobilization, anti-inflammatory drugs, and surgery

to repair severe sprains. Lastly, it was discussed that it is important for dancers to prevent

Figure 26: Selecting student volunteers as injury prevention models

40

sprains because unlike most other athletes, they are unable to maintain the required range of

motion using braces, taping, and other immobilization devices during recovery.

Figure 27: Rachel demonstrates the mechanism of an ankle inversion sprain

Figure 28: Explaining the ligaments involved in an inversion sprain using the skeletal model and surface anatomy

41

Next, the group was taught about the dancer’s fracture of the fifth metatarsal. The

student model was used to demonstrate supination of the ankle (or sickling) on demi-pointe

(Figure 29), and the effect of weightbearing on the lateral portion of the foot. After the basic

anatomy and symptoms of a stress fracture were explained, an x-ray of a fifth metatarsal stress

fracture was shown (see Figure 30 and Appendix VI). It was then discussed that if untreated, a

stress fracture can lead to a full fracture, which was illustrated by another x-ray of the same

bone. The dancers were instructed that if they feel localized pain in their foot that persists for a

week or more, they should check in with their dance teacher, parent, and/or a doctor for

evaluation.

Figure 29: Illustration of sickling of the ankle on demi-pointe

Figure 30: TRB company dancer Paetia learns to identify the metatarsals

42

A discussion of dancer’s heel, or plantar fasciitis, was conducted next. Students were

asked to flex their feet and feel along the arch the location of the plantar fascia, which was

indicated on a large copy of Figure 7 and on the muscle leg model. Common symptoms were

discussed, and its relation to tightness of the Achilles was illustrated. Dancer-specific issues

were covered, including walking/dancing barefoot as well as the seasonal change in footwear to

non-supportive flip-flops. An Old Navy flip-flop was brought in to demonstrate the problems of

wearing such flat soles.

d

Figure 31: Exploring the functional relationship between the plantar fascia and the Achilles tendon

Figure 32: Junior Company Dancer Sarah compares her leg with the muscle leg model

43

Achilles tendonitis was the last of the overuse injuries discussed. Dancers were taught

that tendonitis involves a gradual thickening of the fascia, which limits flexibility because of the

irregular pattern of scar tissue accumulation. Severe cases can ultimately require surgery on the

tendon. The discussion of tendonitis was related back to the importance of warming up and

easing gradually back into high levels of dance after extended periods of inactivity (i.e. summer,

etc.).

To conclude the last lesson, the dancers learned five basic exercises/ stretches that can be

done to help prevent the occurrence of these and other lower extremity injuries. The first was a

series of plantar flexion/ dorsiflexion, inversion/eversion of the foot using Therabands to add

resistance to the motion (Figure 33). Next, another student model was used to demonstrate towel

scrunches and subsequently marble pick-ups (Figure 34). The fourth exercise taught was the

single leg balance, including variations such as standing on a pillow, closing the eyes, or passing

a ball with a friend. Lastly, the dancers were encouraged to stretch their gastrocnemius and

soleus daily using a small lunge with the back leg straight and then bent. Another stretch to

benefit the plantar fascia, which everyone participated in to close the lesson was simply sitting

upright on the heels, with the toes curled under (in a demi-pointe position) (Figure 35). The

dancers’ special treat of the last day were gummi candies which were themed “Operation,” to

remind them to continue maintaining their bodies and preventing the need for surgery.

44

Figure 33: A TRB dancer learns towel scrunches

Figure 34: Senior company student Paetia practices proper technique for Theraband strengthening exercises

Figure 35: TRB dancers perform a plantar fascia stretch together

45

V. RESULTS

a. TUCSON REGIONAL BALLET DANCERS

i. ATTITUDES

On the Pre-Survey, it is interesting to note the high level of interest of the participating

TRB dancers, as evidenced by their responses to the three initial questions (Appendix IVa). The

first question (see Graph 1 below), regarding the dancers’ desire to know more about their basic

anatomy and physiology, yielded a strong majority who agreed (60%), many of whom strongly

agreed (29%), and very few (n=3, or 11% of the total 28) who had no opinion. No one disagreed

on any level. The second question (see Graph 2), which gauged the dancers’ incentive for

knowledge acquisition (i.e. to become a better dancer) yielded a large majority who either

strongly agreed or agreed (total = 85%), 3 who had no opinion, and 1 who did not agree with the

statement. In terms of their passion for dance, as one would hope, 96% of the dancers said they

strongly agreed with the statement “I love to dance!” with only 1 individual selecting “agree”

(Graph 3).

Graph 1. TRB Pre-Survey response: Attitude Question 1

I would like to know more about how my body works

No Opinion11%

Agree60%

Strongly Agree29%

Strongly Disagree0%

Disagree0%

Strongly DisagreeDisagreeNo OpinionAgreeStrongly Agree

n=28

46

Graph 2: TRB Pre-Survey Response: Attitude Question 2

I wish I knew more about stretching and strengthening so I could be a better dancer

No Opinion11%

Agree21%

Strongly Agree64%

Disagree4%

Strongly Disagree0%


n=28

Graph 3: TRB Pre-Survey Response: Attitude Question 3

I Love to Dance!

Strongly Agree96%

Disagree0%

Strongly Disagree0%

No Opinion0%

Agree4%


n=28

The post-survey revealed very favorable outcomes of the instruction. For example, 100%

of dancers claimed to feel that they learned more about how their bodies work (71%= strongly

agree and 29%= agree, n=21) (Graph 4 below). Additionally, 76% strongly agreed that this

knowledge could help them improve in dance, with the remaining 24% agreeing as well (Graph 5

below). Lastly, two open-ended questions provided qualitative data regarding the dancers’

favorite topic covered as well as any other comments they wanted to express.

47

Graph 4: TRB Post-Survey Response: Attitude Question 1

I have learned more about how my body works

Agree29%

Strongly Agree71%

Strongly Disagree0%

Disagree0%

No Opinion0% Strongly Disagree

DisagreeNo OpinionAgreeStrongly Agree

n=21

Graph 5: TRB Post-Survey Response: Attitude Question 2

I have learned more about stretching and stregthening, and I feel it could help me become a better dancer

Agree24%

No Opinion0%

Disagree0%

Strongly Disagree0%

Strongly Agree76%


n=21

ii. KNOWLEDGE

TRB Pre- and Post-Survey answers (Graphs 6 and 7) reveal a general increase in

accuracy. Although the majority of Pre-Survey answers tended to be correct, it is notable that

there were fewer omitted answers in the Post-Survey, as noted by the yellow bar below. In fact,

the only 2 questions left blank in this survey was #6 (n=1) and #9 (n=3). Overall, Post-Survey

questions tended to be answered more correctly following instruction, noted particularly through

questions that were 100% correct, including #1, 3, and 4.

48

Graph 6: TRB Summary of Pre-Survey Results

TRB Pre-Survey Results

05

101520253035

1. Warm

up

2. La

ctic a

cid

3. Fli

p-flop

s

4. Ab

s

5. Ev

ersion

6. Ali

gnmen

t

7. Hy

dratio

n

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Freq

uenc Omitted

IncorrectCorrect

n=28

Graph 7: TRB Summary of Post-Survey Results

TRB Post-Survey Results

05

10152025

1. Warm

up

2. La

ctic ac

id

3. Flip

-flops

4. Ab

s

5. Ev

ersion

6. Ali

gnmen

t

7. Hyd

ration

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Freq

uenc Omitted

IncorrectCorrect

n=21

Accompanying the increased correctness of answers, it was found that explanations to the

questions also tended to improve, both in terms of accuracy and precision. Questions were

grouped into two main categories: Warm-up/ Stretch (Graph 8) and Injury Prevention (Graph 9).

Out of the three warm-up/ stretch questions (#1, 2, and 8), only question 8 (regarding stretching)

did not rise significantly. Question 1 mean improved from 1.0357 ± 0.081 to 1.4375* ± 0.100,

n=28

49

while question 2 mean increased from 0.2500 ± 0.098 to 0.8578* ± 0.165 (* indicates

statistically significant improvement at p<0.05 level of significance).

Graph 8: TRB Warm-up/ Stretch Pre-/ Post- Instruction Comparison of Explanations

TRB Warm-Up/ Stretch Survey Explanations

0

0.5

1

1.5

2

2.5

1.Warm Up 2. Lactic Acid 8. Stretch

Question

Mea

n Pre-SurveyPost-Survey

n=28

Within the injury prevention questions (#3, 4, 5 and 6), all answers were statistically

improved. The question 3 mean rose sharply from 0.9286 ± 0.162 to 1.7614* ± 0.125 (an 89.7%

increase), while question 4 baseline was 0.8929 ± 0.119 with a final score of 1.2868* ± 0.075.

Question 5 was improved from 0.12500 ± 0.13239 to 1.6193* ± 0.096, and question 6 started at

1.3929 ± 0.107 and ended at 1.8579* ± 0.118 following instruction. Again, the increases in

mean indicate a rise not only in correctness, but also of thoroughness of answers, with a 0 being

completely incorrect or omitted through a 3, a highly detailed, thorough answer.

50

Graph 9: TRB Injury Prevention Pre-/Post- Instruction Comparison of Explanations

TRB Injury Prevention Survey Explanations

0

0.5

1

1.5

2

2.5

3. Flip Flops 4. Abs 5. Pronation 6. Alignment

Question

Mea


n=28

Additionally, questions 7, 9, and 10 serve as control questions, as their content was not

discussed in the lessons. Question 7, which addressed hydration and the thirst mechanism

improved significantly from 1.000 ± 0.126 to 1.2868* ± 0.127 (Graph 10 below). Question 9

regarded the spring-like action of muscle and titin did not improve at all, being as the mean for

both Pre- and Post-Survey results was 0.000. Lastly, the final question asked participants to

think broadly about injury prevention and health, and the mean increased from 0.8929 ± 0.107 to

0.9518 ± 0.096, which was not statistically significant.

Graph 10: TRB Explanations to Other/ Control Questions

TRB Control Questions Survey Explanations

0

0.5

1

1.5

2

2.5

7. Hydration 9. Titin 10. Prevention

Question

Mean Pre-Survey Post-Survey

n=28

51

b. BASIS STUDENTS (CONTROL GROUP)

i. ATTITUDES

The Basis group of 28 female students was generally slightly less enthusiastic about

learning more about their anatomy and physiology than the TRB dancers. As seen in Graph 11,

while the majority of students were interested in gaining more insight into their bodies (75%

total agreed or strongly agreed), the other fourth either had no opinion or actually disagreed with

this statement. When asked about the application of this knowledge and improving in athletics,

72% (n=20) agreed or strongly agreed with the correlation between the two. Twenty-one percent

remained indifferent, while 7% (n=2) disagreed (Graph 12). Lastly, it is important to note that

this group was partially selected by the fact that they were females who enjoyed participating in

athletics, just as all of the TRB dancers had indicated (see Graphs 13 and 3).

Graph 11: Basis Survey Attitude Question 1

Basis Students: "I wish I knew more about how my body works"

No Opinion21%

Agree43%

Strongly Agree32%

Strongly Disagree0%

Disagree4%


n=28

52

Graph 12: Basis Survey Response: Attitude Question 2

Basis Students: "I wish I knew more about good posture and strengthening so I can be a better athlete"

No Opinion21%

Agree43%

Strongly Agree29%

Disagree7%

Strongly Disagree0%


n=28

Graph 13: Basis Survey Response: Attitude Question 3

Basis Students: "I love to play sports!"

Agree53%

Strongly Agree47%

Strongly Disagree0%

Disagree0%

No Opinion0%


n=28

ii. KNOWLEDGE

Overall trends in the survey data from the Basis Charter School students tended to be

similar to those of the TRB dancers’ Pre-Survey. Graph 14 on the following page is a summary

of survey answers in terms of accuracy. As seen below, the majority of question answers, as

with TRB dancers, tended to be correct, with the exceptions of numbers 2, 6, and 7.

53

Graph 14: Summary of Basis Survey Results

Basis Survey Results

05

101520253035

1. Warm

up

2. La

ctic a

cid

3. Fli

p-flop

s

4. Ab

s

5. Ev

ersion

6. Ali

gnmen

t

7. Hy

dratio

n

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Freq

uenc Omitted

IncorrectCorrect

n=28

Graphs 15-17 compare the TRB Pre-Survey data directly with that of the Basis students,

as these both represent baseline measures. In the first category, Warm-up/ Stretch Questions, the

level of detail expressed between the groups was very similar (mean difference ≤0.2), with the

biggest difference being the lactic acid question 2, with means of 0.25 ± 0.098 and 0.536 ± 0.120

for TRB and Basis students, respectively. More variability between the groups was seen in the

Injury Prevention questions, in which the dancers tended to score higher than the Basis students.

The most dramatic example of this discrepancy was that of question 5 (pronation of the ankles/

“rolling in”), in which the difference between the student groups was 0.786, representative of a

significant disparity between the two. Question 6 about knee/ ankle alignment also posed some

degree of difficulty for Basis students, whose mean was 0.536 points lower than that of TRB

dancers. See “Discussion” for proposed reasons for these significant differences.

54

Graph 15: Comparison between baseline TRB and Basis survey explanations for Warm-up/ Stretch Questions

TRB Pre-Survey vs. Basis Warm-up/ Stretch Explanations

0

0.5

1

1.5

2

1.Warm Up 2. Lactic Acid 8. Stretch

Question

Mea

n TRB Pre-SurveyBasis Survey

Graph 16: Comparison between baseline TRB and Basis survey explanations for Injury Prevention Questions

TRB Pre-Survey vs. Basis Injury Prevention Explanations

0

0.5

1

1.5

2

3. Flip Flops 4. Abs 5. Pronation 6. Alignment

Question

Mea


Graph 17: Comparison between baseline TRB and Basis survey explanations of Miscellaneous/

Control Questions

TRB Pre-Survey vs. Basis Control Question Explanations

0

0.5

1

1.5

2

7. Hydration 9. Titin 10. Prevention

Question

Mea


55

c. UNIVERSITY OF ARIZONA DANCERS

i. ATTITUDES

Similarly to TRB high school and middle school dancers, University of Arizona School

of Dance majors and minors (and selected graduate students) enrolled in a mandatory

Biomechanics course for dancers demonstrated high levels of interest in anatomy and

physiology, as evidenced by Graph 18 below. It that 96% of students (n=46) wanted to learn

more about their bodies. Similarly, 96% of the dancers indicated that they believe this

knowledge can be helpful in improving their dance technique, and in fact, the vast majority

strongly agreed with this statement (76% of total) (Graph 19). Furthermore, as seen on Graph 20,

98% of the participating UA dancers believe to some degree that education is a critical

component of injury prevention as well as throughout the healing process. Lastly, with the

exception of one person, Graph 21 reveals that all participants in this category strongly

acknowledged that they not only have an active lifestyle, but also enjoy dance. It is interesting to

note that throughout the four attitude questions, a consistent 2% strongly disagreed with all of the

statements. This 2% came from one specific individual’s survey, who may have read the scale

incorrectly, as every student in the course participates in 2-4 dance classes daily in addition to

weekend and evening rehearsals, therefore suggesting that they do indeed have quite an active

lifestyle.

56

Graph 18: UA Dancers Pre-Survey Attitude Question 1

UA Dancers: "I would like to know more about how my body works"

36%

60%

2%2%

0%

Str. Dis.DisagreeNo OpinionAgreeStr. Agree

Disagree n=46


UA Dancers: " I would like to more about stretching and strengthening so I could improve my dancing"

20%

76%

2%2%

0%


disagreen=46

57


UA Dancers: "Education is a crucial component of injury prevention and recovery"

2%22%

76%0%

0%


No Opinion

Disagree n=46


UA Dancers: "I have an active lifestyle and enjoy dance"

2% 7%

91%0%

0%


No Opinion

Disagree n=46

In the Post-Survey, 40 UA dancers indicated that the biomechanics course they had

nearly completed had given them knowledge that is applicable and boosts their confidence.

Graph 22 shows that a total of 92% of dancers felt that they learned more about their own

anatomy and physiology. Question 2 answers (Graph 23) reveal that while the majority (84%) of

dancers felt this knowledge can be directly applied to improve their dance technique, answers

varied between strongly disagree- strongly agree. Another question of applicability, 95% of

58

dancers admitted to feeling more confident communicating their physical maladies with medical

professionals (Graph 24). The last attitude question 4 (Graph 25) confirmed that the vast

majority (95%) of the dancers in biomechanics agree or strongly agree that this background

knowledge builds their confidence because they understand the scientific root cause of their

technique limitations.

Graph 22: UA Dancers Post-Survey Attitude Question 1

UA Dancers Post-Survey: " I have learned more about how my body works"

Strongly Agree77%

Agree15%

Disagree0%

No Opinion0%

Strongly Disagree8%


n=40


UA Dancers Post-Survey: "I have learned more about stretching and strengthening and I feel it could help improve

my dancing"

Agree37%

Strongly Agree47%

No Opinion8%

Disagree3%

Strongly Disagree5%


n=40

59


UA Dancers Post-Survey: "I feel more confident communicating my injuries with doctors/ physical therapists"

Agree33%

Strongly Agree62%

Strongly Disagree5%

No Opinion0%

Disagree0%


n=40


UA Dancers Post-Survey: "I feel more confident as a dancer knowing the biomechanical explanations behind some of my

technique limitations"

Agree25%

Strongly Agree70%

Strongly Disagree5%

Disagree0%

No Opinion0%


n=40

ii. KNOWLEDGE

Graphs 26 and 27 below represent the UA dancers’ performance on the knowledge-based

survey questions (Appendix Vb). As evidenced on Graph 26, the dancers tended to answer the

majority of the questions correctly, with the only exceptions being #5 (regarding the layering of

the abdominal muscles), #7 (regarding hydration and the thirst mechanism) and #9 (regarding

titin and muscle spring). Questions 1, 4, and 10 were answered 100% correctly. In comparing

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the Pre-and Post-Survey data for UA dancers, it appears that there was no change in the accuracy

of answers, for the students answered question 4 100% correctly once again, and the profile of

various alignment answers is nearly identical. In fact, the dancers did slightly worse in the Post-

versus the Pre-Survey, with 63% and 61% correct with each respective attempt.

Graph 26: UA Dance Pre-Survey Answers

UA Dancers Pre-Survey Results

0102030405060

1. Warm

up

2. Br

eakfa

st

3. Fli

p-flop

s

4. Ab

s

5. Mus

cles

6. Ali

gnmen

t

7. Hy

dratio

n

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Freq

uenc OmittedIncorrectCorrect

n=46

Graph 27: UA Dance Post-Survey Selected Injury Prevention Answers

UA Dancers Post-Survey Selected Injury Prevention Results

0

10

20

30

40

50

60

4. Abs 6. Alignment

Question

Freq

uenc Omitted

IncorrectCorrect

n=41

61

Graph 28 indicates the level to which the dancers were able to justify their answers. The

majority of the questions (incl. 1, 3, 4, 5, 6, and 7) were answered with a moderately high level

of detail ~1.5 ±0.25 (scale: 0-3). The question with the highest mean of 1.890 ± 0.143 was #6,

which asked about knee and foot alignment in plié. Titin question 9 was left blank in all cases

(and therefore had a mean of 0.000).

Graph 28: UA Dance Pre-Survey Answer Explanation Means

UA Dancers Pre-Survey Explanations

00.5

1

1.52

2.5

1. Warm

up

2. Br

eakfa

st

3. Fli

p-flop

s

4. Ab

s

5. Mus

cles

6. Ali

gnmen

t

7. Hy

dratio

n

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Mea

n

n=46

While it is evident that the dancers are somewhat aware of the rationale behind warming

up and stretching, it is important to note that the vast majority only understand this topic

superficially. This is evidenced in Graph 29 below. For example, 76% of UA dancers received a

1 on their explanation of question one. Question 8, regarding stretching, had 89% of dancers

either receiving a 0 or a 1 for their answer.

62

Graph 29: UA Dance Pre-Survey Explanations of Warming-up/ Stretching questions

UA Dancers Pre-Survey Explanations: Warm-up/ Stretch

05

10152025303540

1. Warm up 8. Stretch

Question

Freq

uenc

0123

n=46

In terms of nutrition-based questions, it appeared the dancers had a somewhat more

comprehensive knowledge (Graph 30). For example, question 2 yielded only 6.5% of dancers

(n=3) answering nothing or completely incorrectly (0). While roughly half of dancers did not

answer question 7, those who did were able to explain the thirst mechanism to some degree.

Graph 30: UA Dance Pre-Survey Explanations of Nutrition Questions

UA Dancers Pre-Survey Explanations: Nutrition

05

10152025

3035

2. Breakfast 7. Hydration

Question

Freq

uenc

0123

n=46

63

Perhaps the most interesting category though, Anatomy and Injury Prevention gave

mixed results (Graph 31). For example, very few dancers were able to justify their answer about

the order of the layering of the abdominal wall (89% earned a 0 for their answers); however, this

question yielded the highest number of excellent explanations (3 dancers earned a 3 for their

answers). While 18 dancers did not answer the alignment question, it had the highest mean of all,

1.890 ± 0.143.

Graph 31: UA Dance Pre-Survey Explanations of Anatomy and Injury Prevention Questions

UA Dancers Pre-Survey Explanation: Anatomy and Injury Prevention

0

10

20

30

40

50

3. Flip-flops 4. Abs 5. Muscles 6. Alignment

Question

Freq

uenc

0123

n=46

Graph 32 illustrates the apparent decline in the level of detail of explanation for two

selected injury prevention questions. The mean answer for question 4 about abdominal core

strength importance, changed from 1.290 ± 0.460 to 0.707 ± 0.117. The most drastic reduction

in precision was for question 6 regarding knee and ankle alignment, which was 1.892 ± 0.730 at

baseline and fell to 0.756 ± 0.143.

64

Graph 32: UA Dance Pre-/Post-Survey Comparisons in Injury Prevention Question Justifications

UA Dancers Pre- and Post-Survey Selected Injury Prevention Explanations

00.5

11.5

2

2.53

4. Abs 6. Alignment

Question

Mea


d. UNIVERSITY OF ARIZONA PSIO 380 STUDENTS (CONTROL GROUP)

i. ATTITUDES

Overall, the control group of University of Arizona PSIO 380 students appeared to be

equally interested in learning about their own anatomy and physiology as the dance students,

independent of the group’s general level of activity. Graph 33 indicates that a total of 96% of the

47 participants strongly agreed or agreed with the question of being interested to learn more

about their bodies. When asked if their desire to obtain this knowledge was to promote an active

lifestyle, 86% indicated “strongly agree” or “agree” (Graph 34). The fourth attitude question

revealed that there was a mix of reported activity levels; however, the majority of students

strongly agreed or agreed with having an active lifestyle (total= 86% of 47 participants: see

Graph 36).

65

Graph 33: UA Students Pre-Survey Attitude Question 1

UA Students: "I would like to know more about how my body works"

Agree37%

Strongly Agree59%

No Opinion2%

Strongly Disagree2%


n=47


UA Students: "I would like to more about stretching and strengthening so I could lead an active lifestyle"

Strongly Disagree7%

Strongly Agree47%

Agree39%

No Opinion7%

Disagree0%


n=47

The control group also revealed a strong belief that education is a crucial component of

injury prevention and recovery (question 3, Graph 35). In fact 47% strongly agreed with this

statement, and 47% agreed, with the remaining 6% strongly disagreeing or having no opinion.

66


UA Students: "Education is a crucial component of injury prevention and recovery"

Agree47%

Strongly Agree47%

No Opinion4%

Strongly Disagree2%

Disagree0%


n=47


UA Students: "I have an active lifestyle"

Agree60%

No Opinion6%

Disagree6%

Strongly Agree26%

Strongly Disagree2%


n=47

Post-survey data revealed that the students in Dr. Rankin’s PSIO 380 course gained

knowledge of their own anatomy and physiology (Graph 37), and they feel this awareness has

given them confidence in various ways (Graphs 39/ 40). All 60/60 students who participated in

the Post-Survey expressed their certainty that they learned about their bodies in this course (see

following page for corresponding Graph 37); however, over half of this group (54%) either did

not have an opinion or disagreed with the idea that knowledge of stretching and strengthening

67

gained in the course can directly help improve their athleticism (Graph 38). One very favorable

response is that 77% of students felt more confident using medical terminology to communicate

with doctors or physical therapists after having taken this course (Graph 39). While others did

not have a strong opinion either way, only 3% disagreed. Lastly, 95% students strongly agreed

or agreed to having gained confidence by understanding scientific justifications of their physical

limitations (Graph 40).

Graph 37: UA Students Post-Survey Attitude Question 1

UA Students: "I have learned more about how my body works "

Agree21%

Strongly Agree79%

No Opinion0%

Disagree0%

Strongly Disagree

0%


n= 60


UA Students: "I have learned more about stretching and strengthening and I feel it

could improve my athleticism"

No Opinion36%

Agree42%

Disagree18%

Strongly Agree4%

Strongly Disagree

0%


n=60

68


UA Students: "I feel more confident in communicating my physical injuries with doctors and/ or physical

therapists"

Agree57%

No Opinion20%

Strongly Agree20%

Strongly Disagree0%

Disagree3%


n=60


UA Students: " I feel more confident as a knowing the biomechanical explanations behind some of my physical

limitations"

No Opinion5%

Agree54%

Strongly Agree41%Disagree

0%

Strongly Disagree

0%


n=60

ii. KNOWLEDGE

University of Arizona students of various majors enrolled in PSIO 380 demonstrated a

moderately high level of baseline knowledge in the Pre-Survey. As shown in Graph 41, they

69

tended to answer questions accurately, with the exception of questions 5, 7, and 9. In comparing

and contrasting Graphs 42 and 43, question 6, which asked about knee and ankle alignment,

worsened to a significant degree. In fact, more students got it incorrect than correct in the Post-

Survey (n= 29 and 30, respectively). Because UA Dancers’ Post-Survey explanations were not

graded due to time constraints of the surveying process (with the exception of 2 questions), PSIO

380 students also did not receive grades on their Post-Survey explanations.

Graph 41: UA Students Pre-Survey Answers

UA Dancers Pre-Survey Results

0102030405060

1. Warm

up

2. Br

eakfa

st

3. Fli

p-flop

s

4. Ab

s

5. Mus

cles

6. Ali

gnmen

t

7. Hy

dratio

n

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Freq

uenc

y

OmittedIncorrectCorrect

n=46

Graph 42: UA Students Post-Survey Answers

UA Students Post-Survey Results

010203040506070

1. Warm

up

2. Br

eakfa

st

3. Fli

p-flop

s

4. Ab

s

5. Mus

cles

6. Ali

gnmen

t

7. Hy

dratio

n

8. Str

etch

9. Tit

in

10. P

reven

tion

Question

Freq

uenc

y

OmittedIncorrectCorrect

n=60

VI. DISCUSSION

70

a. TUCSON REGIONAL BALLET DANCERS

Young pre-professional female dancers from the Tucson community appear not only to

demonstrate interest in learning about their functional anatomy as it is related to dance, but also

are able to enunciate the material which they have learned in the hopes of applying it in the

context of their movement technique. Pre-instructional outlook questions revealed that the

majority of Tucson Regional Ballet junior and company dancers, ages 11-17+, all of whom were

enthusiastic about dancer were interested in learning more about the anatomy and physiology of

their own bodies (29% strongly agree + 60% agree). Furthermore, they were interested in

gaining knowledge of stretching and strengthening to improve their dance technique (64%

strongly agree+ 21% agree). This desire and enthusiasm to incorporate knowledge of functional

anatomy and physiology with traditional dance instruction highlight the importance of integrated

dance teaching not only for the sake of injury prevention, but also for the student’s own

intellectual curiosity. Post- survey data illustrates not only that all students learned more about

their bodies’ physiology (71% strongly agree + 29% agree), but also that they feel this

knowledge can help them become better dancers (76% strongly agree + 24% agree).

One of the primary topics addressed in the intervention was the mechanisms of and

rationale behind warming up and stretching, in which most of the dancers appeared to be

interested and were able to grasp. For example, in both cases (pre- and post-instruction), all

participants answered question 1 correctly that a warm-up is important before dancing; however,

they were not able to articulate why, as evidenced by a mean of 1.0357 ± 0.081. Post-survey

data revealed that they understood the rationale more thoroughly, as the mean increased to

1.4375* ± 0.100 after the lessons were complete.

71

Question 2, regarding lactic acid and muscle soreness, posed a source of confusion both

prior to and following the three lessons. The pre-survey revealed a medley of omitted, incorrect,

and correct answers, with the mean of the answer rationale a 0.2500 ± 0.098. In contrast, the

vast majority of participants answered the question incorrectly post-instruction (86% incorrect

vs. 14% correct); however, the mean accuracy of the explanation rose to 0.8578* ± 0.165. This

is likely to have arisen due to confusion regarding the wording of the question, which did not

differentiate between short-term/ immediate soreness (which can be caused by lactic acid) and

long-term soreness (caused by microtears in the muscle). Many of the written explanations

illustrated this discrepancy, which would be clarified in future education.

The last question under the category of Warm-up/ Stretching was number 8, which asked

if and why it is important to hold a stretch for at least 30 seconds. One pre-survey answer from a

14-16 year-old ballerina stated: “I am not sure why but that’s what I have been told.” This quote

clearly demonstrates that it is unfortunately too common for dancers to receive instruction

without justification. For this question the pre-instruction mean of 0.7857 ± 0.094 did not rise

enough post-instruction (0.8096 ± 0.083) to be considered statistically significant. Furthermore,

one person incorrectly marked “False” in the post-survey whereas 100% were correct originally.

These results can be explained in numerous ways. It is possible that because this topic was

covered solely in the first lesson, the dancers did not remember the anatomical details as well as

more recent material. It is also likely that this topic was covered from a scientific point of view

which used too much jargon and advanced terminology that was less interesting to the young

dancers. Figures and Therabands were used for this lecture; however, it may have been more

helpful to utilize other, more dance-specific metaphors as vehicles to teach the musculo-

tendinous stretch mechanism.

72

Overall, the warm-up/ stretching topics covered in this instruction were intended to

highlight dance-specific issues for whole-body injury prevention. More specifically, it was

emphasized that warming up and stretching aid in maintaining flexibility of the soft tissues and

muscles. It would be interesting in future work to investigate the understanding of these soft

tissue as well as whole-body (and mind) subjects more in depth. These were, in effect, a

secondary focus of this project, which was centered primarily around the prevention and

maintenance of orthopedic articular injury.

Pre- and post-instruction comparison data from the questions emphasizing injury

prevention revealed that the dancers learned about and were able to better articulate ways in

which they can protect their skeletal and connective tissue structures. Question 4, for example,

tested their knowledge of the importance of strong abdominal muscles. In addition to 100%

correctness for this question in the post-survey, improvement in the explanation was noted:

0.8929 ± 0.119 at baseline and 1.2868 ± 0.075 for a final score. Dancers were able to better

explain the functional anatomy beyond the ambiguous topic of controlling the ‘center,’ as the

core is frequently termed in dance classes. This is an extremely important concept for injury

prevention to improve posture, balance, and movement of the extremities.

Moving distally from the core, questions 5 and 6 addressed alignment and pronation at

the knee and ankle joints. Pre-survey data clearly indicated that the dancers had a moderate

basal level of knowledge on these topics (i.e Q.5pre mean = 1.25 ± 0.132; Q.6pre mean= 1.3929 ±

0.107). This alone suggests that their dance teacher, Deborah Kenner, has been discussing

alignment with her young dancers. One 14-16 year-old dancer’s pre-survey response to question

5 (regarding the importance of preventing pronation of the foot) wrote: “I am not sure, but I

know that I get that correction a lot.” Despite starting with an awareness of the topic, the mean

73

for both questions increased significantly (Q.5post mean= 1.6193* ± 0.096; Q.6post mean=

1.8579* ± 0.118 after instruction). Part of the dancers’ success in these two questions likely is

associated with the fact that in order to teach this concept, audience participants were used to plié

in comparison to the skeletal leg model. This tool was particularly useful for the younger junior

company (middle school) dancers, as they had less exposure to anatomy in school and were

enthusiastic about more active participation as well as about the model itself. In fact, one of the

comments written on the post-survey by an 11-13 year-old ballerina was “I loved the legs,”

referring to this and the muscle leg model. It is important that proper lower extremity alignment

be emphasized in the studio due to the potential for damage to multiple areas of the knee and

foot/ ankle (including, but not limited to bunions and tendonitis).

The last question in the category of injury prevention, regarding the usage of flip-flops,

saw the largest improvement in terms of precision and accuracy of explanations. Originally, 5

dancers had either omitted this question or marked the incorrect answer, whereas in the post-

survey, all participating dancers responded correctly. Furthermore, as a collective unit, the

dancers were much more capable of explaining why flip-flops can be detrimental to the feet

(Q3pre mean: 0.9286 ± 0.126; Q3post mean: 1.7614 ± 0.125). It was encouraging to see that

certain dancers even remembered the cause-and-effect relationship between the unsupportive

shoes and plantar fasciitis.

It is noteworthy to also discuss the changes between the pre- and post-surveys for the

idealized control question about the muscle protein titin. Titin was not discussed in any

intervention lessons, and it was not expected that any participating dancers in either dancer or

non-dancer groups would have had exposure to this material, as it is generally taught in upper

division undergraduate biochemistry or cell physiology courses. The pre-survey data presented

74

exactly as expected, with the majority (54%) of the 28 dancers omitting this question, 18%

guessing incorrectly, and the remaining 28% guessing correctly (see Graph 6). In contrast,

however, 81% of the 21 post-survey participants guessed the same question correctly, with the

remaining 19% omitting it. One potential explanation of why the percentage of correct answers

increased so drastically is that the dancers could have mistakenly recalled the discussion in

lesson 1 about the viscoelasticity of the musculo-tendinous complex and have assumed that it

was related to titin. It also, could have been, quite simply, that because both the question above

and below it were “True,” they guessed the same answer for the sake of convenience. What

justifies the use of this question as a control is the fact that for both the pre- and post-surveys, no

dancers were able to explain their answers, which supports the hypothesis that answers would be

derived entirely from guessing.

b. BASIS CHARTER SCHOOL STUDENTS VS. TRB PRE-INSTRUCTION

DANCERS

As stated previously, the baseline (Pre-Survey) TRB data was very similar to that of

Basis Charter School sixth grade female students, with a few exceptions, most notably in the area

of injury prevention. The questions grouped under Warm-up/ Stretch and Miscellaneous/

Control showed no statistical significance between control (Basis) and experimental (TRB)

groups. That being said, it is interesting to note that both groups tended to have low baseline

Warm-up/ Stretch values, representing answers that lacked detail and clarity. For example, one

Basis student justified her answer for question 8 (regarding the length of time needed to stretch a

muscle) as “It sounds about right.” This suggests that perhaps all athletic young people, dancers

or not, should be taught more specifically about the critical importance of both warming up and

stretching before intense physical activity.

75

The second category, Injury Prevention, had not only the largest percentages of incorrect

responses, but also explanations that tended to be vague and underdeveloped. Although there

were a few exceptions (such as one Basis student who, in response to question 3 wrote, that

when wearing flip-flops “you might pronate and that will give you knee and ankle problems”),

the precision of answers was generally much smaller for this group relative to TRB dancers. One

hypothesis is for this discrepancy is that despite the changes in terminology from dance-specific

in the TRB Pre-Survey to more general in this Basis Control Survey, some of the concepts were

based on common dance concerns (such as question 5 regarding the dropping of the arches/

rolling in), which the students may not have been directly addressed in other sports. This is an

important consideration because the majority of these students drew from their own experiences

to answer questions (e.g. “I learned the hard way-sprained ankle!!!” in response to question 1:

the importance of warming-up or “My feet don’t hurt when I wear flip-flops…,” another

student’s response to question 3). It is also possible that dancers are more aware of injury

prevention techniques than their active non-dancer peers.

It is also noteworthy to point out that many Basis surveys presented more thoughtful

scientific detail than their dance peers. For example, in responding to the question of hydration

and the thirst mechanism (#7), one student wrote that in addition to water, you may need protein.

Another student explained her correct answer to question 5 by saying, “It’s bad because when

you pronate (drop your arches) it gives you serious knee and ankle problems and you might have

to get them replaced.” This degree of specificity, not only in terminology, but also in

rationalization of cause-and-effect was very impressive, especially considering that she is merely

in sixth grade. Considering that many of the TRB dancers were attending high school, it is

evident that the Basis school students performed exceptionally well. It is also possible, however,

76

that the Basis students felt pressured to add detail to their surveys because they were in an

academic environment (with their biology teacher present, Cheryl Carnes) versus the more social

environment of the dance studio where all TRB surveys were completed.

c. UNIVERSITY OF ARIZONA DANCERS

University of Arizona undergraduate and graduate students appear to be very interested in

learning about the biomechanics of dance, and present with a moderate level of baseline

knowledge of nutrition, warming-up/ stretching, and injury prevention. A course such as

Biomechanics for Dance seems to be the ideal vehicle through which to deliver this material.

For example, 96% of dancers revealed in the Pre-Survey that they wanted to learn more about

their own bodies, an 95% of Post-Survey participants felt like this class helped them achieve this.

This demonstrates that this active population wants to gain additional awareness of their

functional anatomy beyond what is presented in traditional dance classes, which they have been

participating in for many years. Over 95% in both cases, before and after completing the course,

strongly agreed or agreed that this information can be beneficial to improving in dance. This is

an important consideration for any young person who is strongly interested in pursuing dance as

a career and who would like to explore alternative ways through which to become better

performers.

Dancers pursuing bachelors or masters in fine arts at the University of Arizona

demonstrated in the Pre-Survey their moderately high level of baseline knowledge (see Graph

19), with the majority of explanation means around 1.5 ± 0.25. It is interesting to note that the

question in which they demonstrated the most thorough knowledge was about injury prevention

through alignment of the knees and feet in plié (Question 6, mean 1.890 ± 0.143). This may be

due to numerous factors, including their having sustained a related injury. Additionally, faculty

77

at the UA School of Dance all have completed at least a bachelor’s degree, which could indicate

that more of them are using their educational background in their dance classes. It was

surprising to find that this question did not yield an increase in percent correctness (it decreased

from 63% to 61%), and that explanations to this question were much more vague (mean= 0.756

± 0.143). This is hypothesized to be due to the fact that the dancers were given much less time to

complete the Post-Surveys relative to the Pre-Surveys. Qualitatively, the vocabulary of a select

number of surveys included exact scientific references not seen in Pre-Surveys, such as one 18-

20 year-old dancer, who referred to preventing injury to the meniscus and ACL (Anterior

Cruciate Ligament) specifically. This finding confirms the dancers’ self-reported increase in

confidence in communicating with medical professionals using correct terminology, taught to

them through Amy Ernst’s biomechanics course.

The dancers’ awareness of injury prevention was also reflected in question 3, which

alluded to the potentially harmful consequences of frequent wearing of unsupportive flip-flops.

Many of them recognized that flat-soled shoes are commonly contributing factors to ankle

pronation and ‘fallen arches.’ In fact one 21-23 year-old dancer said they knew about fallen

arches and flip-flops “from my own experience.” Because preventative care was not emphasized

in Biomechanics DNC 455, grading of the responses to the knowledge-based questions would

have been largely irrelevant. Future investigation of the impact of this type of education on UA

dancers could be done with Amy Ernst’s course “Injury Prevention for Dancers,” offered in the

spring semester 2010, and every other spring thereafter (alternating with biomechanics).

In terms of injury prevention and recovery, Pre- and Post-Survey data reveal the

importance of a strong working knowledge of functional anatomy. Pre-Survey Question 3

demonstrates that 96% of UA dancers believe that education is a crucial piece of injury

78

prevention as well as recovery. This perspective is shared by many physical therapists, who

spend the first appointment with a patient not only evaluating their physical concerns, but also

explaining to them the nature behind their pathology.

In building a relationship between health provider and patient, it is also imperative that

adequate communication be established. One such barrier to communication is a

misinterpretation of symptoms due to the patient’s inability to articulate them with enough

precision. This can yield severe repercussions of misdiagnosis. Thus, it is important for a

population prone to injury, such as serious dancers in training to be able to obtain accurate

diagnoses for the most efficient medical care. Education outreach appears to be a key

component of this, as evidenced through UA dancers’ Post-Survey response to question 3 (see

graph 16). From the 40 participating dancers, a total of 95% of dancers agreed or strongly

agreed to feeling more confident articulating their symptoms with medical professionals.

Psychological factors in dance, although not deeply explored in this research, are of

considerable significance. For example, as discussed in I. Background (section b), weight

consciousness in dance can yield eating disorders anorexia and bulimia nervosa. This disordered

eating downstream can cause other grave pathologies characteristic of the Female Athlete Triad.

On the other hand, boosting the confidence of young dancers can serve to counteract some of

these negative psychological factors. For example, Post-Survey results showed that 95% total of

UA dancers strongly agreed with or agreed with feeling more confident as a dancer after having

taken the course and knowing the explanations behind some of their limitations in technique.

Dance is extremely competitive in nature, and it is important to realize that an individual’s

anatomy may limit them in certain respects (e.g. perfect turnout, extreme flexibility, high demi-

79

point position, etc.). This knowledge, in turn, can enable dancers to strive for their personal best,

rather than judge themselves relative to other dancers around them.

d. UNIVERSITY OF ARIZONA PSIO 380 STUDENTS

It was interesting to note the positive impact of PSIO 380 on this student population. For

example, 96% of students at the beginning of the semester had expressed interest in learning

more about their bodies’ inner workings, and by the end of the course, 100% of the class felt that

they have gained insight into their bodies. Because this group of students represented a variety

of students and their level of activity was not controlled for, only 46% of participants agreed

with having both learned more about stretching and strengthening as well as its applicability to

their athleticism. The main problem with a question worded in this way is that in order for the

subject to agree to such a statement, he/she must agree with both components, i.e., it is possible

that students view this genre of knowledge as useful for improving athletic performance but they

did not feel these topics were addressed in this class and vice versa.

Overall, subject attitude responses clearly revealed that the application of the information

covered in the PSIO 380 course extended well beyond the realm of the classroom. For example,

Post-Survey attitude questions indicated that students gained confidence in their own ability to

communicate accurately with medical professionals (77% total agreed or strongly agreed). Their

personal confidence was also enhanced through the understanding of the underlying

physiological mechanisms that dictate selected physical limitations (a total of 95% strongly

agreed or agreed).

Because knowledge-based questions were only graded on the basis of correctness, it is

somewhat difficult to deduce the changes in understanding of the survey questions. It is

important to note that none of the topics on the survey were directly addressed in either PSIO

80

380 or DNC 455. Physiology students had, however, explored properties of soft tissue regarding

collagen and elastin, which led many of the students to answer control question 9 about titin

incorrectly. Because certain participants were able to articulate the molecular structure with the

correct rationale, a grade higher than a zero would have been issued independent of the fact that

it was not precisely the answer that was being sought.

VII. LIMITATIONS

Although many of the findings in this research are widely applicable, it is important to

realize that there are numerous limitations. For example, instructional intervention and

subsequent data collection was sampled only from a small group (n=28 pre- and n=21 post-

instruction) from one Tucson ballet studio, which is not expected to be representative of all ballet

studios. Furthermore, both groups from this population were primarily instructed by one ballet

teacher, Deborah Kenner, whose teaching style may not be representative of that of other

teachers. Furthermore, because instruction and pre-/post- testing occurred at one Northeast

studio, it is possible that the majority of the students attended the same nearby schools, and data

is in no way expected to be representative of the education received there.

Some degree of study bias inevitably was also likely to have played a role. For example,

the primary researcher designed, delivered, and graded the surveys and lesson plans. In order to

decrease this bias, however, before the surveys were issued to the experimental and control

groups, test surveys were issued to a small pre-control group to ensure clarity of questions, and

all three project advisors approved the surveys. Although no lessons were taught in accordance

with specific survey questions, it is possible that they may have indirectly affected instructional

content. This could have been avoided had another individual taught the lessons, for example;

however, this was logistically impossible in the timeframe of this project. Furthermore, bias at

81

the participants’ end was unavoidable as they appeared to enjoy the lessons and subsequently

may have wanted to aid the researcher. This seemed to have been reflected in the fact that post-

survey had hardly any omitted answers (including for the titin control question that was not

discussed) and that responses tended to be more detailed. Another example of this phenomenon

was the more thorough answers on question 7, regarding hydration and the thirst mechanism,

neither of which was covered in the three lessons.

VIII. FINAL THOUGHTS

Dancers in serious training of all ages appear to be greatly interested in their functional

anatomy and physiology as it relates to dance. It is apparent that there exists a deficiency in their

awareness of their bodies in movement, which can be easily remedied by an infusion of more

scientific explanations behind corrections in body placement, alignment, stretching, etc.

Addressing dancers’ concerns specifically from this perspective could facilitate more effective

injury prevention and maintenance and encourage overall health for these active young people.

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References Anandacoomarasamy, A. and Barnsley, L. “Long term outcomes of inversion ankle

injuries.” Br J Sports Med 2005;39:14-18. Arnheim, Daniel D. Dance Injuries: Their Prevention and Care. 3rd ed. Princeton, NJ:

Princeton Book Company, 1991. Bennell, K. L. et al. “Changes in hip and ankle range of motion and hip muscle strength

in 8-11 year old novice female ballet dancers and controls: a 12 month follow up study.” Br J Sports Med 2001;35:54-59.

Bernstein J (ed): Musculoskeletal Medicine, Rosemont, IL; American Academy of

Orthopaedic Surgeons, 2003, p.242 < http://nemsi.uchc.edu/clinical_services/ orthopaedic/footankle/ankle_sprain.html>.

Davison, Jon. Personal Interview. 16 Mar. 2009. Differential Diagnosis and Manual Therapy of the Foot and Ankle. IAOM-US 2008 Donatelli, Robert A. The Biomechanics of the Foot and Ankle. 2nd ed. Philadelphia: F. A.

Davis Company 1996. Elias, Ilan et al. “Bone stress injury of the ankle in professional ballet dancers seen on

MRI.” BCM Musculoskeletal Disorders 2008; 9:39-45. Gravetter, Frederick J. et al. Measurement and Statistics: Introduction for Social and

Behavioral Sciences. Mason, OH: Cengage Learning, 2006. Grieg, Valerie. Inside Ballet Technique: Separating Anatomical Fact From Fiction in the

Ballet Class. Hightstown, NJ: Princeton Book Company, 1994. Hillier, J. C. et al. “MRI features of foot and ankle injuries in ballet dancers.” The British

Journal of Radiology. 2004;77:532-537. Hobart, Julie A. and Smucker, Douglas R. “The Female Athlete Triad.” American Family Physician. 2000; 61:3357-64,3367. Howse, Justin. Dance Technique and Injury Prevention. 3rd ed. London: A&C Black,

2000. Lindstedt, S. L., LaStayo, P. C., and Reich, T.E. “When active muscles lengthen:

properties and consequences of eccentric contractions.” News Physiol. Sci. 2001;16:256-262.

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Mach, D.B. et al. “Origins of skeletal pain: sensory and sympathetic innervation of the mouse femur.” Neuroscience. Vol. 113, No. 1, pp. 155-166, 2002.

Marski, Lynn Marie. “Musculoskeletal Concerns in the Dancer” Lecture. Sports

Medicine Conference: Orthopedic Surgery Conference. University Medical Center, University of Arizona, Tucson, AZ. 13 April 2009.

Mellion et al. Team Physician’s Handbook. 2nd ed. Philadelphia: Hanley and Belfus Inc.,

1997. Moore, Keith L. and Dalley, Arthur F. Clinically Oriented Anatomy. 4th Ed. Philadelphia:

Lippincott Williams & Wilkins, 1999. Morrison, Katherine E. and Kaminski, Thomas W. “Foot characteristics in association

with inversion ankle injury.” Journal of Athletic Training 2007:42(1):135-142. Ryan, Allan J. and Stephens, Robert E., eds. Dance Medicine: A Comprehensive Guide.

Chicago: Pluribus Press, 1987. Singh, Dishan, Angel, John, Bentley, George, and Trevino, Saul. “Plantar fasciitis:

Clinical Review.” British Medical Journal. 19 July 1997: 315: 172-175. Strayer, Scott M., Reece, Steven G., and Petrizzi, Michael J. “Fractures of the proximal

fifth metatarsal.” Am Fam Physician 1999;59(9):2516-22. Tortora, Gerard and Derrickson, Bryan. Principles of Anatomy and Physiology. 11th Ed.

Hoboken, NJ: John Wiley & Sons, 2006. Wexler, R. K. “The injured ankle.” Am Fam Physician 1998;57(3):474-80.

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Figure Credits Cover: X-ray: <http://www.chanhongoh.com/images/diamond_xray.jpg> Pointe shoe: <http://artelier.org.uk/atelier/images/dance-1416.jpg> Figure 1: Basic Medical Anatomy. Alexander Spence. 1990. <http://homepage.mac.com/myers/misc/bonefiles/bonestruct.html> Figure 2: <http://www.web-books.com/eLibrary/Medicine/Physiology/Skeletal/Joint.htm> Figure 3: Moore and Dalley, Anatomy, 24. Figure 4: “Histology Atlas” Pearson Education 2003. <http://cwx.prenhall.com/bookbind/pubbooks/martini10/chapter3/medialib/Fig03015.html.> Figure 5: Moore and Dalley, Anatomy, 634. Figures 6a/b: “Syndesmosis ankle sprains” Massage Today. <http://www.massagetoday.com/mpacms/mt/article.php?id=13163.> Figure 7: <http://media.photobucket.com/image/ankle%20ligaments/Timewalker/anklesprain.jpg> Figure 8: Ankle Sprains. CitiSport Physiotherapy and Sports Injury Clinic. 16 March 2009 < http://www.citisport.co.uk/city_in_paint/pages/newsletter3/news_a.html>. Figure 9: <http://z.about.com/d/foothealth/1/0/k/0/-/-/mtpjlabelxray.jpg> Figure 10 : < http://www.jfootankleres.com/content/2/1/2/figure/F2> Figure 11 : <http://dsp.imageg.net/graphics/product_images/p1001843p275w.jpg> Figure 12 : <http://www.med.umich.edu/1libr/sma/sma_meta5tar_art.htm> Figure 13 : Strayer et al. “Fractures,” 2518. Figure 14 : “Essential Insights on Treating 5th Metatarsal Fractures.” 1 April 2006. Podiatry Today. 20 March 2009. < http://www.podiatrytoday.com/article/5382>. Figure 15: Singh et al. “Plantar Fasciitis,” 173. Figure 16: University of Wisconsin. “Health Information: Plantar Fasciitis.” 2009. <http://apps.uwhealth.org/health/hie/2/19568.htm>. Figures 17a/b: <http://www.ballerinagallery.com/margot-shoes.htm> Figure 18 : <http://footcarexpress.com/foot-orthotics/achilles-tendonitis/> Figure 19 : <http://danceadvantage.net/2008/06/24/sickling-and-rolling-in/> Figure 29 : <http://danceadvantage.net/2008/06/24/sickling-and-rolling-in/>

85

Appendices

I. Ballet Terminology Index II. Exercise Protocols

a. Resisted dorsiflexion, plantar flexion, eversion, and inversion b. Pickup exercises c. Toe curling/ Towel scrunches d. One-Foot balance e. Soleus/ Gastroc. Stretches

III. Biomechanics Course Syllabus IV. Surveys

a. Tucson Regional Ballet: Pre- and Post-Surveys b. Basis Charter School Survey

V. Surveys a. University of Arizona Dancers: Pre- and Post-Surveys b. University of Arizona Students: Pre- and Post-Surveys

VI. Teaching Tools a. Flashcards, Color Photos, etc.

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APPENDIX I:

Ballet Terminology Index (Courtesy of American Ballet Theater’s Online Ballet Dictionary)

À la seconde: To the second. A term to imply that the foot is to be placed in the second position, or that a movement is to be made to the second position en l'air. Barre: The horizontal wooden bar fastened to the walls of the ballet classroom or rehearsal hall which the dancer holds for support. Every ballet class begins with exercises at the bar, which are performed by the dancer while clasping the bar with one hand. Bar exercises are the foundation of classical ballet. Center: Implies unsupported exercises done in the center of the room following barre work. Demi-plié: Half-bending of the knees. Demi-Pointe: On the half-point. Indicates that the dancer is to stand high on the balls of the feet and under part of the toes. First Position: Position in which the heels touch and the toes face opposite directions, ideally making a 180 degree angle between the feet. Grand battement : An exercise in which the working leg is raised from the hip into the air and brought down again, the accent being on the downward movement, both knees straight. Jeté: Throwing step. A jump from one foot to the other in which the working leg is brushed into the air and appears to have been thrown. There is a wide variety of pas jetés (usually called merely jetés) and they may be performed in all directions. Parallel: Alignment in which the legs are turned in from the hip sockets, with the knees and feet pointed forward. Plié: Bent, bending. A bending of the knee or knees. This is an exercise to render the joints and muscles soft and pliable and the tendons flexible and elastic, and to develop a sense of balance. There are two principal pliés: grand plié, or full bending of the knees, (the knees should be bent until the thighs are horizontal) and demi-plié. Pointe: On the point (of the toes). Today the toes of pointe shoes are reinforced with a box constructed of several layers of strong glue in between layers of material. Rond de jambe: Round of the leg, that is, a circular movement of the leg, done clockwise (en dehors) and counterclockwise (en dedans). Second Position: An extension of first position, in which the feet are spread apart by about 2 feet’s distance.

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Sickling: This term is used for a fault in which the dancer turns his or her foot in from the ankle, thereby breaking the straight line of the leg. Supporting Leg: A term used by dancers and teachers for the leg which supports the body so that the working leg is free to execute a given movement. Tutu: Short classical ballet skirt made of many layers of tarlatan or net. The romantic tutu is the long skirt reaching below the calf. Turnout: This is the ability of the dancer to turn his or her feet and legs out from the hip joints to a 90-degree position. This turn-out, or en dehors, is one of the essential principles of the classical dance, giving the dancer freedom of movement in every direction. Working Leg: A term used by dancers and teachers to denote the leg that is executing a given movement while the weight of the body is on the supporting leg

Turned out supporting

leg

Classical tutu

Turned out working leg

Dancing in the center

On pointe

88

APPENDIX II: EXERCISE PROTOCOLS

89

90

APPENDIX III Biomechanics Syllabus

DNC 455/455H/555/591-003 Biomechanics for Dance (3 credits) Spring 2009 Class Meetings Wednesday and Friday - 2:00-3:20pm Optical Sciences Room 408 & Gittings Studio 124 Instructor Amy Ernst, MFA; Associate Professor 121E Gittings Building; 621-2923; [email protected] Office Hours: By appointment Teaching Assistant Brooke Melton - [email protected] Graduate Preceptor Kristin Chew - [email protected] Course Description and Objectives

Dance is an art form whose purpose is to communicate ideas and feelings; but because it is a type of body movement, that movement can be studied in the same way as any body movement, using the principles and techniques of Biomechanics. This biomechanical analysis is often misunderstood by some who think that it somehow reduces the art of dancing to a mechanical act. This is not so. The biomechanical analysis looks at only one aspect of dance, in the same way that an X ray of a broken leg gives information only about the bones and not about the leg as a whole. As we all know, there is far more to dance than just the physical movement.

In this course we also concentrate a good deal on Kinesiology, or the study of movement.

However, this definition is too general to be of much use. Kinesiology brings together the fields of anatomy, physiology, physics, and geometry, and relates them to human movement. Thus, Kinesiology utilizes principles of mechanics, musculoskeletal anatomy, and neuromuscular physiology. The term Biomechanics is frequently used interchangeably with Kinesiology. The differences between the two terms are based on research focus.

The human body, in many respects, can be referred to as a living machine. It is important, when

learning about how the body moves (Kinesiology), to also learn about the forces that are placed on the body causing movement. Mechanics is the branch of physics dealing with the study of forces and the motion produced by their actions. Biomechanics involves taking the principles and methods of mechanics and applying them to the structure and function of the human body.

My goal for you is to increase your knowledge and sophisticated information about the human

body so that you will continue to grow as intelligent dancers, ensuring that you will move even more efficiently, powerfully, and expressively than you do now. Principles of dance injury prevention will also

91

be incorporated into the course material, to further safeguard your artistry and longevity as a dancer. I expect each of you to work hard in this class to learn and apply this material. If you do, your dancing skill and body knowledge will improve, and your incidence of injury will hopefully decrease!

Required Texts and Readings

Inside Ballet Technique Separating anatomical fact from fiction in the ballet class By Valerie Grieg Anatomy of Movement (Revised Edition) By Blandine Calais-Germain Handouts provided by instructor.

Course Requirements General:

1. Note: this course is open to dance majors and minors only. Students taking this course are enrolled under one of the following categories, depending on their status and qualifications (*Preceptorships have already been determined and are not available for enrollment).

DNC 455: Undergraduate dance majors and minors

DNC 455H: Honors dance majors and minors DNC 555: Graduate students DNC 491: Undergraduate Preceptorship DNC 591-002/-003: Graduate Preceptorship

2. This course is not available for audit.

3. Grades in each of the categories above are awarded according to the number of points earned. The maximum number of points possible to earn if you are registered under DNC 455 is 1000 points. The maximum number of points possible to earn under DNC 455H and DNC 555 is 1400 points.

Earned points-to-grades for DNC 455 are as follows:

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900 – 1000 points = A 800 – 899 points = B 700 – 799 points = C 600 – 699 points = D

599 points & below = E Earned points-to-grades for DNC 455H and DNC 555 are as follows: 1300 – 1400 points = A 1200 – 1299 points = B 1100 – 1199 points = C 1000 – 1099 points = D 999 points & below = E DNC 455 Requirements Students are required to attend all lecture and studio lab days and complete all Quizzes and Exams for a maximum of 600 points toward the final grade. Including these requirements, you have a choice among the following three options for your remaining 400 points: a Poster Presentation (handled in pairs or trios), a Research Paper (handled alone), or the Final Exam. You may choose only one of the three options. Opportunities to earn points are as follows: Attendance = 150 points (5 points per class) 2 Quizzes @ 50 points each = 100 points 2 Exams: Exam I @ 150 points = 350 points Exam II @ 200 points Poster Presentation = 400 points or Research Paper = 400 points or Final Exam = 400 points Total Maximum Points = 1,000 points DNC 455H, 555 Requirements Students are required to attend all lecture and studio lab days and complete all Quizzes and Exams for a maximum of 600 points toward the final grade. Including these requirements, for your remaining 800 points you will be completing the Research Paper. You will also complete either the Poster Presentation (handled in pairs or trios) or the Final Exam. Opportunities to earn points are as follows: Attendance = 150 points (5 points per class) 2 Quizzes @ 50 points each = 100 points 2 Exams: Exam I @ 150 points = 350 points Exam II @ 200 points Research Paper = 400 points Poster Presentation OR Final Exam = 400 points Total Maximum Points = 1400 points

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Classroom Behavior The aim of education is the intellectual, personal, social, and ethical development of the individual. The educational process is ideally conducted in an environment that encourages reasoned discourse, intellectual honesty, openness to constructive change and respect for the rights of all individuals. Self-discipline and a respect for the rights of others in the university community are necessary for the fulfillment of such goals. The Student Code of Conduct Integrity is expected of every student in all academic work. The guiding principle of academic integrity is that a student’s submitted work must be the student’s own. This principle is furthered by the student Code of Conduct and disciplinary procedures established by ABOR Policies 5-308 - 5-403, all provisions of which apply to all University of Arizona students.

Code of Academic Integrity Introduction to the Poster Presentations and Research Papers It is recognized that individuals will have particular or specialized interests related to Biomechanics and Kinesiology. If you and a partner(s) decide to conduct a Poster Presentation, the research and oral presentation must be handled equally between you. The Research Papers will be handled alone. The Poster Presentations will be presented in Studios 124 and 130 at the end of the semester (days and times TBA), and your Research Papers will be due to my office on or before Friday, May 15, 3PM. If you are completing either a Presentation or a Paper, you will need to consult with me within the first few weeks of the semester regarding your chosen topic. I am always available to work on your research projects with you. Above all, these special research projects should focus on applications and implications for dancers. For either the Poster Presentation or the Research Paper, a list of possible topics/ideas is listed below: -In-depth analysis of a particular joint in the body -Investigation of an injury potential or syndrome -Analysis of a movement pattern used in technique class -Analysis of a somatic system or body therapy -Development of a focused conditioning program -Research into a particular musculoskeletal disorder -Case Study of a dancer here in our department

-A Biomechanics/Kinesiology course syllabus with rationale and lecture outline, practical assignments, grading methods, etc.

-An analysis of anatomical and biomechanical illustration styles There are many, many more research topics from which to choose! Please note that both the Poster Presentation and the Research Paper are to be analyses, not just reiterations of existing syllabi, systems, methods, injury facts, etc.

94

The Poster Presentations will last 10 minutes and will be both a visual (via a large, triple-folded cardboard poster) and oral representation of your project. You may use handouts and any additional tools to help illustrate your analysis. The oral presentation, as well as the written component, must be shared 50% x 50% between the team. The written component will include a summarized analysis of your topic, plus an extensive bibliography (minimum of 10 sources). For this type of course, the Research Paper must be 10-15 pages with illustrations (if critical to your topic), have appropriate appendices attached, and include an even more extensive bibliography (15-20 sources). Again, I am available for assistance.

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APPENDIX IVa: Pre- Survey Dancers from TRB

My age: 5-7 8-10 11-13 14-16 17+ Gender: Male Female Please mark how you feel about these

statements: (circle one)

Strongly Disagree

Disagree No Opinion

Agree Strongly Agree

I would like to more about how my body works……………………………

1 2 3 4 5

I wish I knew more about stretching and strengthening so I can become a better dancer…………………………………….

1 2 3 4 5

I love to dance! ...........................................

1 2 3 4 5

Please read each statement carefully and circle True or False. Please explain your answer.

1 It is important to warm-up before dancing

True False Why or why not?

2 The reason I get sore is because of lactic acid buildup in my

muscles


3 Wearing flip-flops could hurt my feet


4 It’s important to have strong abdominal muscles for dance


5 The main reason I don’t want to drop my arches and roll in when I stand is because it looks bad

True

False

Why or

why not?

96

6 The main reason for keeping my knees in line with my toes when I plié is so I can jump higher from that position


7 It’s enough to drink water when I’m thirsty, since my body knows how much it needs


8 In order to get a good stretch, I need to hold it for at least 30-60 seconds


9 Titin is the primary molecule responsible for the spring-like action of the muscle


10 Those who train well, eat right, and drink plenty of water can prevent lots of injuries


97

APPENDIX IVa: Post- Survey Dancers from TRB

My age: 5-7 8-10 11-13 14-16 17+ Gender: Male Female Please mark how you feel about these


Strongly Disagree

Disagree No Opinion


I have learned more about how my body works……………………………

1 2 3 4 5

I have learned more about stretching and strengthening, and I feel it could help me become a better dancer…………………………………….

1 2 3 4 5

Other comments?


1 It is important to warm-up before dancing


2 The reason I get sore is because of lactic acid buildup in my

muscles




4 It’s important to have strong abdominal muscles for dance



True

False

Why or

why not?

98

6 The main reason for keeping my knees in line with my toes when I plié is so I can jump higher from that position










11. The most interesting thing I learned was:

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APPENDIX IVb: Pre- Survey Basis Students

My age: 5-7 8-10 11-13 14-16

17+

Gender: M F

Please mark how you feel about these statements: (circle one)

Strongly Disagree

Disagree No Opinion


I wish I knew more about how my body works………………………..……

1 2 3 4 5

I wish I knew more about good posture and strengthening so I can become a better athlete…………

1 2 3 4 5

I love to play sports!................................

1 2 3 4 5


1 It is important to warm-up before playing sports


2 The reason I get sore is because of lactic acid buildup in

my muscles




4 It’s important to have strong abdominal muscles for sports


100


True

False Why or why not?

6 The reason for keeping my knees in line with my toes when I squat is so I can jump higher from that position










101

APPENDIX Vb: Pre- Survey University Dancers

My age (circle one): Under 18 18-20 21-23 Over

24

Gender (circle one): Male Female Please mark how you feel about these statements: (circle one)

Strongly Disagree

Disagree No Opinion


I would like to know more about how my body works ……………………

1 2 3 4 5

I would like to more about stretching and strengthening so I could improve my dancing…………

1 2 3 4 5

Education is a crucial component of injury prevention and recovery………

1 2 3 4 5

I have an active lifestyle and enjoy dance...................................................

1 2 3 4 5


A warm-up is important before participating in dance


Eating a balanced breakfast is important


Wearing flip-flops frequently could have detrimental effects on the feet


It’s important to have strong abdominal core muscles for dance


102

From superficial to deep, the primary abdominal muscles are: the rectus abdominis, external obliques, the transverse abdominis, and the internal obliques (deepest).

True


The reason for keeping my knees in line with my toes when in plié is to have greater force output and height


Thirst is an adequate indicator of the body’s water requirements


In order to get a good stretch, it should be held static for at least 30-60 seconds


Titin is the primary molecule responsible for the spring-like action of the muscle


Training well, eating right, and drinking plenty of water can prevent many major injuries


103

APPENDIX Va: Post- Survey University Dancers

My age (circle one): Under

18 18-20 21-23 Over

24

Gender (circle one): Male Female Please mark how you feel about these


Strongly Disagre

e

Disagree

No Opinio

n

Agree

Strongly Agree

1 I have learned more about how my body works ………………………………

1 2 3 4 5

2 I have learned more about stretching and strengthening and I feel it could improve my dancing…………

1 2 3 4 5

3 I feel more confident in communicating my injuries with doctors and/ or physical therapists……………………

1 2 3 4 5

4 I feel more confident as a dancer knowing the biomechanical explanations behind some of my technique limitations……….......................................

1 2 3 4 5


1 A warm-up is important before participating in dance


2 Eating a balanced breakfast is important


3 Wearing flip-flops frequently could have detrimental effects on the feet


104

4 It’s important to have strong abdominal core muscles for dance


5 From superficial to deep, the primary abdominal muscles are: the rectus abdominis, external obliques, the transverse abdominis, and the internal obliques (deepest).

True


6 The reason for keeping my knees in line with my toes when in plié is to have greater force output and height


7 Thirst is an adequate indicator of the body’s water requirements


8 In order to get a good stretch, it should be held static for at least 30-60 seconds




10



11

It is important to fight the natural anterior tilt of my pelvis as I dance


105

APPENDIX Vb: Pre- Survey University Students

My age (circle one): Under 18 18-20 21-23 Over

24

Gender (circle one): Male Female Please mark how you feel about these statements: (circle one)

Strongly Disagree

Disagree No Opinion


I would like to know more about how my body works ……………………

1 2 3 4 5

I would like to more about stretching and strengthening so I could lead an active lifestyle……………………………

1 2 3 4 5

Education is a crucial component of injury prevention and recovery………

1 2 3 4 5

I have an active lifestyle........................ 1 2 3 4 5


A warm-up is important before participating in athletics


Eating a balanced breakfast is important


Wearing flip-flops frequently could have detrimental effects on the feet


It’s important to have strong abdominal core muscles for athletics


106

From superficial to deep, the primary abdominal muscles are: the rectus abdominis, external obliques, the transverse abdominis, and the internal obliques (deepest).

True


The reason for keeping my knees in line with my toes when squatting is to have greater force output and height


Thirst is an adequate indicator of the body’s water requirements


In order to get a good stretch, it should be held static for at least 30-60 seconds


Titin is the primary molecule responsible for the spring-like action of the muscle




107

APPENDIX Vb: Post- Survey University Students

My age (circle one): Under

18 18-20 21-23 Over

24

Gender (circle one): Male Female Please mark how you feel about these


Strongly Disagree

Disagree No Opinion


1 I have learned more about how my body works……………………………………

1 2 3 4 5

2 I have learned more about stretching and strengthening and I feel it could improve my athleticism..………………………...

1 2 3 4 5

3 I feel more confident in communicating my physical injuries with doctors and/ or physical therapists……………………….

1 2 3 4 5

4 I feel more confident as a knowing the biomechanical explanations behind some of my physical limitations........................

1 2 3 4 5


1 A warm-up is important before participating in athletics


2 Eating a balanced breakfast is important


3 Wearing flip-flops frequently could have detrimental effects on the feet


4 It’s important to have strong abdominal core muscles for athletics


108

5 From superficial to deep, the primary abdominal muscles are: the rectus abdominis, external obliques, the transverse abdominis, and the internal obliques (deepest).

True


6 The reason for keeping my knees in line with my toes when squatting is to have greater force output and height


7 Thirst is an adequate indicator of the body’s water requirements


8 In order to get a good stretch, it should be held static for at least 30-60 seconds




10 Training well, eating right, and drinking plenty of water can prevent many major injuries


109

APPENDIX VI: TEACHING TOOLS

A. Flashcards

Cardiovascular System!(Heart rate, stroke

volume, and vasodilation)

Muscular System! (Heat and increased

metabolism/02 delivery)

110

Skeletal System! (Synovial fluid in joints)

When to stretch? After Warming up!

111

How long to stretch? Static: 30-60 sec.

Why do I hold the stretch?Change elastic

properties of musculo-tendinous and collagen

complex!

112

Order of dance class? Barre, stretch, center

(adagio to grand allegro)

Why this order? Warm up your body

before stretching! Stretch body before

jumping!

113

Lactic acid and soreness:Fiction!

Lactic acid is flushed out within 30 mins!

Soreness is from small tears in your muscles!

Strong core muscles: Support your whole

body!

Abdominal and back muscles:

Prevent injury and support movement/

posture

114

Turnout origins: tradition and greater

range of motion

Alignment: Hip, Knee, and Ankle for Injury Prevention

and power output!

115

Pronating/ Rolling In/

Dropping Arches

Bunions: Painful and Unsightly!

116

B. Selected Illustrations: Layering of the abdominal muscles

Source: Tortora, Gerard and Derrickson, Bryan. Principles of Anatomy and Physiology. 11th Ed.

Hoboken, NJ: John Wiley & Sons, 2006.

117

Muscles of the back

Source: Tortora, Gerard and Derrickson, Bryan. Principles of Anatomy and Physiology. 11th Ed.

Hoboken, NJ: John Wiley & Sons, 2006.

118

Assorted Synovial Joints of the Body

Source: Moore, Keith L. and Dalley, Arthur F. Clinically Oriented Anatomy. 4th Ed.

Philadelphia: Lippincott Williams & Wilkins, 1999.

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