THIRD EDITION

Dance Technique &

Injury Prevention
Routledge Justin Howse

Routledge
T a y lo r & F ra n cis C r o u p
N e w York Londor
 First published in North America in 2000 by
Routledge
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2 Park Square, M ilton Park, Abingdon, Oxon OX14 4RN
www.routledge-ny.com
By arrangement with A&C Black

Routledge is an imprint o f the Taylor & Francis Group, an informa business

Third edition originally published in 2000 by

A & C Black (Publishers) Limited
35 Bedford Row, London WC1R 4JH

Second edition 1992

First published 1988

ISBN 0-87830-104-6

Third edition © 2000 Justin Howse and Moira McCormack

First and second editions © 1992, 1988Justin Howse and Shirley Hancock

Cataloguing-in-Publication data is available from the Library of Congress.

All rights reserved. No part of this publication may be reproduced in any form
or by any means — graphic, electronic or mechanical, including photocopying,
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written permission of Routledge.

Cover photograph by Catherine Ashmore

Typeset in Baskerville
 Contents
Foreword by Dame Ninette de Valois vii
Preface ix
Acknowledgements xi

Section O n e • Anatomy and Physiology

Physiology 1

1.1 The Skeleton 1 The Autonomic Nervous System 35

The Axial Skeleton 1 The Sensory System 35
The Appendicular Skeleton 4 Skin Sensation 36
The Upper Limbs 4 Aural Sensation 36
The Lower Limbs 5 Visual Sensation 36

1.2 The Joints 6 1.5 The Skin 37

Types of Joint 6
Joint Movements 7 1.6 The Cardio-vascular System 38
The Upper Limbs 9 Constitution of the Blood 38
The Lower Limbs 9 Circulation of the Blood 39
The Lymphatic System 42
1.3 The Muscles 15
Striated or Skeletal Muscle 15 1.7 The Alimentary Canal and Digestion 43
Unstriated or Involuntary Muscle 16 The Alimentary Canal 43
Cardiac Muscle 17 Digestion 44
Action of Muscles 17 Functions of the Liver 45
Muscles and Levers 17
Muscle Contraction 19 1.8 The Respiratory System 46
Neuro-muscular Co-ordination and Engrams 19 Anatomy of the Respiratory System 46
Red and White Muscle Fibres 20 Respiration: External, Internal or Tissue 47
Individual Muscles 20 Transport of Oxygen or Carbon Dioxide 47
Trunk Muscles 20 Control of Respiration 47
Upper Limb Muscles 23
Lower Limb Muscles 23 1.9 The Excretory System 48
Muscles which move Individual Portions
of the Body 29 1.10 The Endocrine System 50
Head and Trunk 29 Actions of the Endocrine Glands 51
The Rib Cage 29
The Shoulder Joint 29 1.11 Anatomical Points relevant to Ballet 52
The Elbow 30 Stance and Muscle Groupings 52
The Hip 30 Turn-out 54
The Knee 31 Plié 55
The Ankle, Foot and Toes 32 Tendu 57
Rise 58
1.4 The Nervous System 33 Pointe 59
The Voluntary or Somatic Nervous System 34 Age to start Pointe Work 59
iv Contents

Section Two • Injuries: PhysiologyCauses,

Pathology, Physiology Physiology
Treatment, Physiology 61
Prevention, Physiology
Nutrition

2.1 Patho-physiology of Injury: 2.5 Specific Treatments of Injuries 79

Inflammation and Healing 61 First Aid Measures 79
Inflammation 61 Physiotherapy Treatments 81
Tissue Changes in Inflammation 62 Cold Therapy 81
Sequelae of Inflammation 65 Heat Therapy: Methods and Effects 82
Healing of Injuries 66 Interferential Therapy 85
Healing by First Intention 66 Faradism 86
Healing by Second Intention 66 Transcutaneous Nerve Stimulation (T.N.S.) 86
Factors affecting Healing 67 Acupuncture 86
Acupressure 86
2.2 Types of Injury 67 Traction 87
Joint Injuries 67 Massage 87
Bone Injuries 69 Mobilisations 87
Acute Fractures 69 Manipulations 87
Stress Fractures 70 Stretching 88
Tendon Injuries 70 Exercises: their Value and Aims 89
Tendonitis 71 Exercises: Passive and Active 89-90
Tendon Rupture 71 Exercise Training 90
Tenosynovitis and Peritendonitis 72 Fatigue 91
Tendon Insertion Injuries 72 Medical and Surgical Treatments 92
Muscle Injuries 72 Drugs 92
Muscle Tears 72 Operations 93
Muscle Stiffness 73 Alternative Therapies 94
Acupuncture and Acupressure 94
2.3 Causes and Complications of Dance Osteopathy 94
Injuries 73 Chiropractic 94
Causes of Dance Injuries 74
Injuries caused by Faulty Technique 74 2.6 The Prevention of Injury 95
Environmental Causes of Injury 75 Development of Good Technique 95
General Complications of Injury 76 Development of Muscle Strength and Joint
Effects on the Whole Body 76 Mobility 95
Local Effects 77 Preservation of Cardiorespiratory Fitness 96
Good Nutrition 96
2.4 The Treatment of Injuries: General Preventative Orthopaedic Assessment 96
Principles 78
The Primary Aim of Treatment 78 2.7 Nutrition 99
Rest of the Injured Part 78 Nutritional Requirements 100
Maintenance of Adequate Circulation 78 The Daily Diet 101
Adequate Nutrition 79 Pre-performance Intake 102
The Secondary Aim of Treatment 79
 Contents
Section Three • Specific Injuries:
3.1 Sprain of the Lateral Ligament of the
Ankle 104
3.2 Rupture of the Lateral Ligament of the
Ankle 108
3.3 Sprain of the Medial Ligament of the
Ankle 109
3.4 Chronic Sprains of the Lateral and
Medial Ligaments of the Ankle 109
3.5 Anterior Capsular Sprain of the
Ankle 109
3.6 Fracture of the Lateral Malleolus 109
3.7 Fracture of the Medial Malleolus 110
3.8 Osteochondral Fracture of the Dome of
the Talus 111
3.9 Achilles Tendonitis 112
3.10 Rupture of the Achilles Tendon 113
3.11 Achilles Tendon Bursitis 113
3.12 Os Trigonum and Large Posterior
Tubercle of Talus 114
3.13 Tibialis Posterior Tendonitis and
Tenosynovitis 115
3.14 Flexor Hallucis Longus Tendonitis and
Tenosynovitis 115
3.15 Extensor Hallucis Longus Tendonitis 116
3.16 Stress Fractures of the Metatarsals 116
3.17 Osteochondritis of the Head of the 2nd
or 3rd Metatarsal 118
3.18 Plantar Fascial Strain 119
3.19 Capsular Strains of 1st Metatarso-
phalangeal Joint 119
V
their Cause and Treatment
Physiology Physiology104
3.20 Sesamoiditis 120
3.21 Hallux Valgus and Bunions 121
3.22 Hallux Rigidus 123
3.23 Ingrowing Toenail 124
3.24 Corns and Callosities 125
3.25 Sundry Spurs, Areas of Calcification,
etc. 125
3.26 Stress Fractures of the Fibula 125
3.27 Stress Fractures of the Tibia 126
3.28 Anterior Compartment Syndrome 128
3.29 Calf Muscle Tears 129
3.30 Anterior Knee Pain 129
3.31 Capsular Strains of the Knee 132
3.32 Injury of the Medial Ligament of the
Knee 132
3.33 Injury of the Lateral Ligament of the
Knee 133
3.34 Injuries of the Cruciate Ligaments of
the Knee 133
3.35 Damage to the Medial Meniscus of the
Knee 133
3.36 Damage to the Lateral Meniscus of the
Knee 134
3.37 Ruptures of the Quadriceps Tendon or
the Patellar Tendon or Fracture of the
Patella 135
3.38 Quadriceps Muscle Strains and Tears 136
3.39 Adductor Muscle Strains and Tears 136
vi Contents

3.40 Groin Strains 137 3.48 Interspinous Ligament Damage 140

3.41 Hamstring Strains and Tears 138 3.49 Facet Joint Strains 141

3.42 Clicking H i p 139 3.50 Lumbar Disc Prolapse 141

3.43 Gluteal Bursitis 139 3.51 Stress Fractures of the Lumbar

Vertebrae 141
3.44 Buttock Pain 139
3.52 Dorsal and Upper Spinal Pain 143
3.45 Sacroiliac Strains and Displacements 139
3.53 Acute Torticollis 144
3.46 Pain in the Sacro-iliac Area 140
3.54 Shoulder and Arm Problems 144
3.47 Strain of the Muscles inserted into the
Iliac Crest 140

Section Four • StrengtheningPhysiology

Exercises
Physiology 145

Section Four contains a series of exercises, illustrated by 160 specially-modelled photographs.

Section Five • Technical Faults and Anatomical Variations:

Physiology their Causes, Consequences and Treatment 178

5.1 Discrepancy in Shoulder Level 179 5.11 Quadriceps Insufficiency 193

5.2 Tension around the Neck and Shoulders 5.12 Tightness of the Hamstrings 194
180
5.13 Swayback Knees 195
5.3 Discrepancy in the Length of the
Clavicles 181 5.14 Tight Achilles Tendons 196

5.4 Scoliosis 182 5.15 Tibial Bow 197

5.5 Kyphosis 183 5.16 Posterior Block of the Ankle Joint 198

5.6 Lordosis 184 5.17 Rolling 200

Fourteen Causes 185
5.18 Weak Intrinsic Muscles of the Feet 201
5.7 Over Turning 187
Associated Injuries 189 5.19 Variations in the Length of the Toes and
of the Metatarsals 202
5.8 Restriction of Turn-out at the Hips 190
5.20 Incorrect Weight Placement 205
5.9 Tightness at the Front of the Hips 192

5.10 Weakness of Adductors 193

Index 207
 Foreword
Dame Ninette de Valois

This book gives us the opportunity to indulge

in some serious reflection. It is full of highly
technical observations on movement as related
to the world of ballet and is accompanied by
helpful illustrations. A great deal of it should
be rewarding to students, dancers, teachers,
repetiteurs and ballet staff in general. I dare to
add that, in my opinion, it is also food for
thought for choreographers. Today it is not
customary for choreographers to give either
scientific or practical thought to their
choreographic demands. Let us recall that a
composer has to remember to keep within the
range of a singer's voice. It therefore seems
right for a choreographer to study more
carefully not only the limitation of dancers'
limbs but also the limitation of their general
stamina.
This page intentionally left blank
 Preface
We have written this book in response to
various requests from many different quarters.
The content and layout of the book reflect the
whole variety of interests and requirements of
these different people. We have tried as much
as possible to cover the various aspects of
knowledge which have been requested. We
realise, therefore, that one or more sections of
the book may be of no interest at all to some
readers but of the utmost importance to
others. We originally considered publishing it
in more than one volume but found the
financial saving would have been negligible
and indeed, if someone wished to purchase the
entire work it would have been considerably
more expensive. The reader must therefore
pick and choose those sections which are of
interest.
When deciding on the content of the book
we found that there was nothing available on
the market to fill the needs of dancers,
teachers or those treating dancers' injuries.
Even in anatomy and physiology the available
text books were either far too simple or too
complicated. In particular there was nothing
at all covering the consequences of technical
faults in dance or the problems that can be
associated with particular injuries in a dancer.
Hence the final decision to try to incorporate
all these various aspects of anatomy,
technique and injury into one volume.
Section 1 has a twofold aim. Primarily it is
directed at student teachers who are required
to learn anatomy and physiology and have to
take an examination in the subject as part of
their teaching diploma. This section should
cover everything that they will be required to
know. Its secondary purpose is to provide a
reference section for those who wish to check
up on anatomical names used in the later
sections.
Section 2 should be of some interest to the
medical practitioner and physiotherapist but is
particularly aimed at dancers and teachers in
order to give them an insight into what
actually happens as a result of an injury, the
general cause of injuries and also some idea of
the value or otherwise of the treatment which
may be offered. There is such an abundance
of advice available now for those who are
suffering from any type of sports injury, which
must include dance injuries, that it is difficult
for the average person to evaluate the
usefulness or otherwise of treatment that is
proffered. Unfortunately, many aspects of
treatment which are widely advertised and
discussed are completely useless. We would
particularly urge dancers to read and think
carefully about the sub-section on nutrition
and fluid intake.
Sections 3 and 5 are the most important of
all. Section 3 is aimed at helping the injured
dancer to recover as rapidly as possible from
an injury and then take steps to prevent a
recurrence. Section 5 is directed at the
prevention of injury by discussing the
important consequences of various technical
faults in the hope that more effort and
attention will be paid to the elimination of the
faults once their consequences are understood.
Section 4 is included to aid those who wish
to devise their own muscle strengthening
programme, although text and photographs
can never be an adequate substitute for a visit
to an exercises orientated physiotherapist or a
good body control teacher.
The illustrations, whether diagrams or
photographs, have been intentionally
somewhat exaggerated where it is necessary to
emphasise or clarify a point. Particularly when
looking at a dancer for a technical fault or
anatomical problem the variations from the
normal may be very slight, so a good eye and
a great deal of practice may be required to
sort out the true cause of a dancer's injury. So
often the apparent reason for the injury is
X Preface

merely a culmination of far less obvious
underlying causes which will each have to be
dealt with or removed if recovery is going to
be permanent.
In order to avoid the clumsiness of he/she
we have referred throughout the text to 'he'
but the statements made usually refer to both
sexes, apart from the few occasions when a
remark very obviously refers to one or other
sex alone. Most of the photographs are of
male dancers because it is usually easier to see
their muscle outlines.
 Acknowledgements
The authors wish to acknowledge their very
great debt to all the people who have given so
much assistance in enabling them to produce
this book. It is impossible to mention
everybody but they would particularly like to
thank the following: first and foremost all the
dancers and dance teachers and professional
students without whose willing assistance they
would have been unable to work out the
various causes of the different problems and
devise the most effective forms of treatment.
Frequently, the injured dancer has allowed
some new form of treatment or different
approach to be tried thus enabling us to
expand our knowledge.
Our grateful thanks for the actual
production of the book must go to Joy Ball
and Maureen Spencer for all the typing, word
processing and alterations; to Irene Prentice
for most of the line drawings and for some
additional drawings to Sarah Howse; to Mike
Ethrington for his tremendous help and advice
with the photographs; to Machael de Souter
for acting as a model for all the photographs
of the exercises in Section 4; to Judith Roose
for posing in the correct and incorrect
postures; to Phil Harris for the proof reading,
correction and help with the layout of the
book; to Anne Watts of Messrs A. & C. Black
for all her help, advice and particularly her
patience; and, finally and most importantly, to
Sherley, Tim and our children for all their
forbearance and toleration when we were
having to spend time on the book which
should really have been spent with the
family.
 SKULL

MANDIBLE

CLAVICLE

SCAPULA

STERNUM -
HUMERUS
RIB

VERTEBRA
•RADIUS

' INNOMINATE BONE - ULNA

PELVIS
SACRUM

COCCYX CARPAL BONES

METACARPALS

SYMPHYSIS
PHALANGES
PUBIS

FEMUR

PATELLA

TIBIA

FIBULA
v
c

t
J

TARSAL BONES
METATARSA

PHALANGES

1.1 The Skeleton.

 SECTION ONE
Anatomy and Physiology
1.1 The Skeleton
T h e skeleton forms the scaffold u p o n w h i c h the
other tissues are b u i l t a n d it forms the basis o f the
shape o f the h u m a n body. M a n y lower animals
have no skeleton at a l l ; good examples o f these are
the jellyfish a n d worms. A s c e n d i n g the a n i m a l scale
the skeleton can be i n two forms - there is the
exo-skeleton or a skeleton that forms outside, as one
sees i n the lobster a n d other shellfish a n d insects
where the h a r d covering o f the b o d y forms the
scaffold a n d a l l the muscles a n d soft tissues are
l y i n g w i t h i n this h o l l o w scaffolding. H i g h e r u p the
a n i m a l scale the endo-skeleton, or inside skeleton,
has been developed a n d this is seen i n fishes, birds
a n d m a m m a l s . T h i s endo-skeleton once again m a y
be i n two forms - cartilaginous as i n most fishes or
b o n y as i n birds a n d m a m m a l s .
I n h u m a n beings the skeleton is made up o f two
m a i n tissues, namely cartilage and bone. Bone itself
is very h a r d a n d c a n only sustain a relatively s m a l l
a m o u n t o f b e n d i n g before it breaks. I n c h i l d r e n the
a m o u n t o f bend that can take place before
fracturing is far greater than i n a mature adult a n d
this greater flexibility c a n result i n p a r t i a l or
greenstick fractures i n the c h i l d . C a r t i l a g e is less
h a r d than bone and w i l l permit a significant
a m o u n t o f b e n d i n g and this allows some movement
to take place. T h i s is seen, for example, i n the
costal cartilages at the ends o f ribs where these j o i n
onto the sternum, or breast bone. W h e r e one bone
meets another bone, a j o i n t is formed. T h e r e are
various types of j o i n t a n d these are dealt w i t h i n
Section 1.2.
T h e d i a g r a m ( F i g . 1.1) shows the h u m a n
skeleton a n d names the more i m p o r t a n t bones. T h e
skull, w h i c h contains a n d protects the b r a i n , is
supported o n the vertebral c o l u m n ; the vertebral
c o l u m n also contains a n d protects the spinal c o r d .
Part w a y d o w n the vertebral c o l u m n lies the
thoracic cage, w i t h i n w h i c h are the heart a n d
lungs. A t the lower end o f the vertebral c o l u m n is
the sacrum, a collection o f bones w h i c h , as a result
of evolution, have become fused or j o i n e d together
to form one bone. A t the tip o f the sacrum there is
the coccyx a n d this is usually movable, a l t h o u g h
only passively, a n d it represents a r u d i m e n t a r y tail.
T h e s a c r u m forms part o f the pelvis, the sides o f
the pelvis being made u p o f two large bones c a l l e d
the i n n o m i n a t e bones. These j o i n at the back to the
sacrum at the sacroiliac joints a n d at the front they
form the symphysis pubis. B o t h o f these joints a l l o w
a very s m a l l a m o u n t o f movement. A t the sides o f
the pelvis are the h i p joints from w h i c h the legs
extend d o w n w a r d s . A s far as the upper l i m b s are
concerned, the attachment o f the shoulder girdle to
the rest o f the skeleton is far less secure a n d
definite. A t the i n n e r end o f the clavicles, or c o l l a r
bones, there is a j o i n t w i t h the breast bone, but
apart from this the sole connection w i t h the rest o f
the b o d y is by the various groups o f muscles a r o u n d
the shoulder girdle.
T h e m a i n functions o f the skeleton are as
follows.
a) T o act as a scaffold a n d p r o v i d e a support for
all soft parts o f the body, thus g i v i n g the b o d y
its shape.
b) T h e muscles are attached to the bones a n d it is
the c o n t r a c t i o n o f the muscles, c o m b i n e d w i t h
the rigidity o f the bones o f the skeleton, w h i c h
allows accurate a n d precise movements o f the
various parts o f the b o d y to take place.
c) It has a protective role where it encases the
b r a i n , spinal cord a n d the heart a n d lungs.
H o w e v e r , the chest or thoracic cage has a
secondary function w h i c h w i l l be mentioned
later i n connection w i t h respiration.
d) W i t h i n certain bones there is red m a r r o w
w h i c h constitutes p a r t of the b l o o d - f o r m i n g
tissues o f the body.
T h e P a r t s o f the Skeleton
T h e skeleton c a n be considered i n two parts:
a) the A x i a l Skeleton w h i c h is composed o f the
skull, vertebral c o l u m n , s a c r u m a n d rib cage;
b) the A p p e n d i c u l a r Skeleton w h i c h is composed
of the shoulder girdle a n d u p p e r l i m b s and the
i n n o m i n a t e bones a n d lower limbs.
T H E AXIAL SKELETON
T h e skull, w h i c h encases the b r a i n , together w i t h
the j a w bone or m a n d i b l e forms the heaviest p a r t
2 Section 1: A n a t o m y and Physiology

SKULL

7 CERVICAL
VERTEBRAE

7
CERVICAL
VERTEBRAE
MANDIBLE

12 THORACIC
VERTEBRAE
VERTEBRAE
1.2 The Skull and Cervical Spine.

ATLAS
(1st CERVICAL
VERTEBRA)

5 LUMBAR
VERTEBRAE
ODONTOID PEG .
AXIS
(2nd CERVICAL
/ ~ K VERTEBRA)

SACRUM

1.3 Sagittal Section through the Atlas and Axis (the COCCYX
First and Second Cervical Vertebrae).

1.4 Lateral View of the Spinal Column.

of the b o d y ( F i g . 1.2). It sits at the top o f the r i n g a n d it is w i t h o u t the n o r m a l vertebral body.

cervical spine. T h e cervical spine comprises seven
separate vertebrae. T h e first a n d second cervical
vertebrae are h i g h l y specialised a n d totally
different from a l l the others i n the body ( F i g . 1.3).
T h e first cervical vertebra is also called the atlas,
the name b e i n g derived from classical m y t h o l o g y
c o n c e r n i n g the hero w h o h a d to support the whole
w o r l d u p o n his shoulders; the atlas takes the whole
weight o f the skull. It is very m u c h the shape o f a
O n l y a n o d d i n g movement takes place between the
skull a n d the atlas. T h e second cervical vertebra is
k n o w n as the axis because it allows rotation to take
place between the atlas a n d the axis. T h e
movement is made possible because o f a peg w h i c h
extends upwards from the vertebral b o d y o f the
axis. T h i s goes up into the r i n g o f the atlas a n d is
kept i n place by a very strong transverse ligament.
It is k n o w n as the o d o n t o i d peg a n d
 Section 1.1 3

developmentally represents the body o f the atlas. SPINOUS PROCESS

T h e r e m a i n i n g five cervical vertebrae are similar to
the others i n the rest o f the spinal c o l u m n . A s w i l l
ARTICULAR FACET LAMINA
be seen from the d i a g r a m o f the spinal c o l u m n OF SUPERIOR JOINT
(Fig. 1.4), the vertebrae tend to become g r a d u a l l y
larger as they descend. T h e r e are slight variations
in the shape and structure of the vertebrae i n the
cervical, thoracic a n d l u m b a r regions but these
variations need not concern us. T h e diagrams (Figs PEDICLE TRANSVERSE
1.5) show a typical l u m b a r vertebra from above PROCESS
a n d from the side and the various parts have been
named. Some o f these areas w i l l be referred to i n •BODY OF
later sections o f the book. VERTEBRA

As w i l l be seen from the d r a w i n g of two adjacent

vertebrae from the back ( F i g . 1.6), the a r t i c u l a r
processes or facet joints hook over each other.
These are little synovial joints (vide-infra) w h i c h ARTICULAR FACET OF
glide over each other, a l l o w i n g some movement SUPERIOR FACET JOINT

between each vertebra. Between the vertebral

TRANSVERSE
bodies are the intervertebral discs. These discs are PROCESS
BODY .
made up o f tough fibro-cartilage. T h e y act between
the vertebral bodies very m u c h like a piece o f
i n d i a - r u b b e r , p e r m i t t i n g some compression a n d
some stretching to take place as the vertebral bodies
move, one i n relation to the next. It is, however,
PARS
i m p o r t a n t to remember that only a little movement SPINOUS
INTERARTICULARIS PROCESS
takes place between each i n d i v i d u a l vertebra a n d
its adjacent neighbour. It is these small amounts o f ARTICULAR PROCESS 01
movement w h i c h , w h e n added together, produce INFERIOR FACET JOINT
the degree o f flexibility w h i c h is obtainable i n the
1.5 The Parts of a Vertebra. The third lumbar vertebra
spine as a whole. H o w e v e r , there are differences is typical but the shape differs slightly at various levels.
between the various areas o f the spine. T h e cervical The lumbar region is of greatest interest to the dancer.
a n d l u m b a r regions are relatively m o b i l e whereas
the dorsal or thoracic region is relatively i m m o b i l e .
A s w i l l be seen from the lateral d i a g r a m o f the
vertebral c o l u m n ( F i g . 1.7), this does not form a
ARTICULAR SURFACE OF
straight line. T h e r e are four distinct curves. I n the
SUPERIOR FACET JOINT
thoracic a n d sacral regions this curve is convex
towards the back or posteriorly, whereas i n the
l u m b a r a n d cervical regions the curve goes i n the
opposite d i r e c t i o n w i t h the convex o f the curve
directed anteriorly towards the front o f the b o d y .
I n i t i a l l y , i n foetal life, the whole spine is c u r v e d i n
the same direction, w h i c h is that retained by the INTERVERTEBRAL,
□ISC SPINOUS
thoracic a n d sacral areas. These two areas are PROCESS
k n o w n as p r i m a r y curves; later, secondary curves i n
the opposite d i r e c t i o n take place at the cervical a n d
l u m b a r regions. T h e points o f greatest stress are
where the curves change direction a n d these areas
TRANSVERSE
are more liable to sustain injury. T h i s is
PROCESS
p a r t i c u l a r l y so i n the lower regions where the
weight o f the upper part of the b o d y is being Physiology
transmitted d o w n w a r d s , e.g. i n fractures o f the INFERIOR
ARTICULAR FACET
spine the most c o m m o n area is i n the lower
dorsal/upper l u m b a r region, a n d for soft tissue a n d 1.6 Posterior View of T w o Lumbar Vertebrae.
4 Section 1: A n a t o m y a n d P h y s i o l o g y

disc damage this occurs most c o m m o n l y at the

lower l u m b a r area between the 4th/5th l u m b a r
vertebrae a n d the top o f the sacrum.
T h e vertebral c o l u m n ends w i t h the sacrum. T h i s
forms part o f the pelvic girdle together w i t h the
two i n n o m i n a t e bones.
T h e thoracic cage, or rib cage (See F i g . 1.1 on
page x i v ) , is made up o f twelve ribs on each side.
A t the back there are joints between the ribs a n d
the thoracic vertebrae. A t the front the lowest two
ribs, the 11th a n d the 12th, have no attachment to
the sternum or breast bone. T h e r e m a i n i n g ten ribs
SECONDARY are j o i n e d to the sternum w i t h short lengths of h a r d
CURVE cartilage, k n o w n as the costal cartilages, the 8th,
9th and 10th ribs h a v i n g l o n g pieces of costal
cartilage w h i c h combine w i t h that o f the 7th rib
a n d then meet the sternum. T h i s c o m b i n a t i o n
produces the curve that one sees at the lower end o f
the r i b cage from the bottom of the breast bone
c u r v i n g away a n d d o w n w a r d s towards the side,
where the r i b cage at that point forms the upper
part o f the a b d o m e n .

PRIMARY THE APPENDICULAR SKELETON

CURVE T h e Upper LimbsLimbs ( F i g . 1.8)
T h e upper limbs start at the shoulder girdle. T h e
collar bone, or clavicle, is the only bone w h i c h has
an actual j o i n t w i t h the central part o f the skeleton.
T h i s occurs at the inner end where it meets the
sternum. A t the outer end o f the clavicle there is a
joint between it a n d the a c r o m i o n process o f the
scapula or shoulder blade. These joints give little
strength to the attachment o f the shoulder girdle to
the rest of the b o d y a n d the shoulder girdle is i n
SECONDARY reality suspended by powerful muscles w h i c h are
CURVE
attached at one end to the s p i n a l c o l u m n a n d rib
cage and at the other to the clavicle a n d the
scapula. T h e bones of the upper l i m b s comprise the
clavicle a n d scapula w h i c h together form the
shoulder girdle, the humerus, radius a n d u l n a ,
PRIMARY carpal bones, metacarpals a n d phalanges. O f the
CURVE c a r p a l bones the scaphoid is the only one deserving
special m e n t i o n . It is a c o m m o n site for a fracture
in adolescents a n d younger adults following a fall
on the outstretched h a n d . These fractures are
1.7 The Spinal Column showing the Primary and notoriously difficult to show on an X - r a y taken
Secondary Curves. d u r i n g the first two weeks following the injury.
 Section 1.1 5

POSTERIOR ANTERIOR

- CLAVICLE •

SCAPULA -
VERTEBRAL
COLUMN —

HUMERUS -

RIB CAGE

Physiology

JLNA RADIUS

CARPAL B O N E S • METACARPALS

PHALANGES

1.8 The Right Upper L i m b and Shoulder Girdle. In the diagram on the right the rib cage has been omitted as it
would have obscured the front (anterior) surface of the scapula which lies against the back of the rib cage.

T h e Lower LimbsLimbs (Figs 1.9 a n d 1.10)

T h e pelvis is formed by the sacrum a n d coccyx,
w h i c h is the lowest p o r t i o n o f the vertebral c o l u m n ,
a n d the two i n n o m i n a t e bones. These latter j o i n
anteriorly to form the symphysis pubis (a
cartilaginous joint) a n d posteriorly to the sacrum at
the two sacroiliac joints (very strong, of fibrous
tissue a n d cartilage). T h e bones o f the lower l i m b s
comprise the i n n o m i n a t e bone, the femur, the tibia
a n d fibula, the tarsal bones, metatarsals a n d
phalanges. T h e i n n o m i n a t e bone is made up o f
three bones w h i c h have become j o i n e d together to
form one bone - the i l i u m , the i s c h i u m a n d p u b i c
bones. T w o tarsal bones i n p a r t i c u l a r need
recognition - the talus, w h i c h forms part of the
ankle j o i n t a n d the c a l c a n e u m (or os calcis) w h i c h
is the heel bone.
6 Section 1: A n a t o m y a n d Physiology

5th LUMBAR
■VERTEBRA
INNOMINATE
BONE
SACRUM - INNOMINATE
SACRO-ILIAC BONE OF
JOINT PELVIS
SACRUM
SACRUM

COCCYX

SYMPHYSIS
PUBIS

FEMUR
FEMUR

PATELLA -

FIBULA ' TIBIA

TIBIA FIBULA
LC IS
OS C A
LC IS

TALUS
TARSAL BONES
OS C A

TALUS
METATARSALS
OS CALCIS
(HEEL BONE) PHALANGES

1.9 The Right Lower Limb and Hemi-pelvis from the 1.10 The Right Lower Limb and the Pelvis from the
back (posterior). front (anterior).

1.2 The Joints
T h e function o f a j o i n t is to allow movement to
take place between two bones and it is the presence
of joints w h i c h allows the skeleton as a whole to be
flexible. T h e r e are several types of j o i n t a n d these
various types possess different degrees o f m o b i l i t y ,
from the fully mobile j o i n t to the j o i n t w h i c h is
fixed w i t h o u t an appreciable degree of movement.
T y p e s of J o i n t s
T h e first type of j o i n t that we have to consider is
the synovial j o i n t ( F i g . 1.11). T h i s type allows a
free movement range. T h e ends o f the bone are
covered w i t h hyaline cartilage. T h i s is extremely
smooth and shiny a n d allows movements to occur
w i t h very little friction. T h e j o i n t is l u b r i c a t e d by
synovial fluid and is surrounded by a layer o f tissue
called synovial m e m b r a n e . S y n o v i a l m e m b r a n e
 Section 1.2
BONE
C A P S U LE ■
- ARTICULAR
SYNOVIAL - CARTILAGE
MEMBRANE
• CAPSULE
TILA E
GE
C AR TILA G
C AR
1.11 Diagrammatic Coronal Section of a typical
Synovial Joint.
produces the j o i n t fluid a n d also helps to absorb
any debris that might form w i t h i n the j o i n t .
O u t s i d e the synovial m e m b r a n e is a strong capsule
made up o f fibrous tissue. I n a d d i t i o n to the
capsule w h i c h extends completely a r o u n d the j o i n t ,
there are various ligaments present. These m a y be a
local t h i c k e n i n g o f the capsule to give a b a n d o f
m u c h thicker stronger tissue, or they m a y be
separate from the capsule f o r m i n g a very strong
fibrous b a n d . T h e ligaments are present to help
l i m i t the movement o f a j o i n t a n d to give stability
to the j o i n t . I n l i m i t i n g movement o f the j o i n t it
prevents dislocation by stopping a movement g o i n g
further than stability w i l l allow.
V ER TEBR AL
BODY
INTER VER TEBR AL
DISC
V ER TEBR AL
BODY
1.12 Intervertebral Disc.
T h e other i m p o r t a n t type of j o i n t is that w h i c h
has cartilage or fibro-cartilage between the bones.
T h e chief example o f this is the intervertebral disc
l y i n g between the bodies o f adjacent vertebrae ( F i g .
1.12). T h i s type of j o i n t allows a little movement as
the fibro-cartilage is elastic a n d c a n be slightly
7
stretched a n d slightly compressed. A d d i t i o n a l l y , as
it has a certain a m o u n t of elasticity, it acts as a
shock-absorber between the bones. T h u s , i n
j u m p i n g , a l l the intervertebral discs help to absorb
the shock of the l a n d i n g w h i c h w o u l d otherwise be
transmitted up to the skull a n d the b r a i n w i t h a
very m u c h more serious j a r r i n g effect.
T h e final type of j o i n t is the truly fibrous j o i n t
w h i c h allows little or no movement. A n example o f
a fibrous j o i n t w h i c h allows no movement is that
between the flat bones f o r m i n g the vault of the
skull. A n example o f one w h i c h allows a little
movement is that between the lower end of the
tibia a nPhysiology
d fibula.
Joint Movements
O n l y the synovial joints have any significant degree
of movement a n d this includes a l l those joints
w h i c h the l a y m a n w o u l d look u p o n as being a c t u a l
joints. I n order to a v o i d misunderstandings, the
proper term must be used for each plane o f
movement (Figs 1.13, 1.14, 1.15 a n d 1.16).
Physiology
Extension is straightening out a j o i n t so that the
bones f o r m i n g the j o i n t w i l l tend to come into a
straight line w i t h each other.
F l e x i o n is b e n d i n g a j o i n t so that y o u produce a n
angle between the two bones f o r m i n g the j o i n t .
Abduction is a movement t a k i n g the l i m b , or part o f
Physiology
the lPhysiology
i m b , away from the m i d - l i n e .
Adduction Physiology
is b r i n g i n g the part towards the m i d - l i n e .
RotationPhysiology
is a movement at the j o i n t where the part
can rotate u p o n the axis g o i n g t h r o u g h the j o i n t .
Circumduction Physiology
is the a b i l i t y to move the part a r o u n d
in a circle a n d is usually a c o m b i n a t i o n o f flexion,
extension, a b d u c t i o n a n d a d d u c t i o n .
T h e r e are various types o f synovial j o i n t g i v i n g
different possible ranges a n d planes o f movement.
T h e b a l l a n d socket allows a free range i n a l l
directions, e.g. the h i p j o i n t . T h e hinge j o i n t allows
only flexion a n d extension, e.g. the i n t e r p h a l a n g e a l
joints o f the fingers a n d toes.
It is very i m p o r t a n t that the correct t e r m i n o l o g y
is used otherwise confusion w i l l result a n d , w h e n
injuries are being considered, incorrect treatment or
incorrect r e h a b i l i t a t i o n m a y be g i v e n . T h e
difficulty applies very p a r t i c u l a r l y i n the case o f
dancers w h o refer to a good extension o f the l o w e r
l i m b or h i p as the a b i l i t y to lift the leg up against
the trunk. T h i s m o v e m e n t is, i n fact, flexion o f the
hip j o i n t or i f taken out sideways, a c o m b i n a t i o n of
a b d u c t i o n , external rotation a n d flexion. A l t h o u g h
later i n the book it w i l l be seen that the authors
have, whenever possible, tried to accept the
8 Section 1: A n a t o m y a n d P h y s i o l o g y

EXTENSION

EXTERNAL INTERNAL
FLEXION ROTATION ROTATION
RR

1.13 Flexion and Extension of the Knee Joint. 1.15 External and Internal Rotation of the H i p Joint.

ABDUCTION

CIRCUMDUCTION RR

ADDUCTION

1.14 Abduction and Adduction of the H i p Joint. 1.16 Circumduction of the H i p Joint.

terminology used by dancers, in an area such as this particular j o i n t . S t a r t i n g from w i t h i n a n d w o r k i n g

where infinite confusion c o u l d occur w i t h possibly
dangerous results, use o f the correct a n a t o m i c a l
terminology is m u t u a l l y advantageous.
T h e r e are various l i m i t i n g factors w h e n
considering the range of movement i n any
outwards, the first factor is w h e n bone comes up
against bone from the two sides o f the j o i n t w h e n it
is being moved in any one p a r t i c u l a r d i r e c t i o n .
H o w e v e r , i n the majority of joints, before that
takes place the capsule and ligaments w i l l l i m i t the
 Section 1.2
range o f movement. These give the second l i m i t i n g
factor. W i t h early t r a i n i n g ligaments can be
stretched to a certain extent, thus increasing the
range o f movement above that n o r m a l l y expected
from that p a r t i c u l a r j o i n t . T h e next factor is
tension i n the muscles c o n t r o l l i n g the j o i n t
movement; these can be relatively easily stretched
a n d the muscles can be actively lengthened. F i n a l l y ,
apposition o f soft parts m a y prevent further
movement t a k i n g place, e.g. someone w i t h fat
thighs a n d fat calves w i l l be unable to flex the knee
as f u l l y as i f they d i d not have this excess tissue.
A c t i v i t y at the limits o f the range o f movement o f a
j o i n t w i l l g r a d u a l l y stretch soft tissues, p a r t i c u l a r l y
before the age o f puberty, thus increasing the range
of available movement. T h e r e is, however, a
considerable v a r i a t i o n from one person to the next
in their n a t u r a l range o f movement i n any
p a r t i c u l a r j o i n t . T h i s is i n part due to a v a r i a t i o n i n
actual a n a t o m i c a l shape of the j o i n t but also some
people have, as part o f their congenital m a k e u p ,
very lax ligaments a n d very stretchable soft tissues
a n d it is these people w h o i n lay terms are often
referred to as being double-jointed a n d w h o , i n
extreme cases, can become contortionists.
Important Joints
T H E U P P E R LIMBS
T h e j o i n t between the scapula and the humerus is a
b a l l a n d socket j o i n t ( F i g . 1.17). T h e socket is very
flattened a n d more like a saucer. It is k n o w n as the
glenoid cavity. A s a result o f the shallowness o f the
j o i n t a very wide range o f movement is possible
between the upper a r m a n d the trunk. H o w e v e r ,
this range o f movement does not take place entirely
between the scapula a n d the humerus; m u c h o f it,
p a r t i c u l a r l y elevation o f the a r m , is made up by the
scapula itself sliding over the chest w a l l . A t the
lower end o f the humerus there is the elbow j o i n t
(Figs 1.18 a n d 1.19) w h i c h gives an a r t i c u l a t i o n
the upper ends o f the radius a n d u l n a . T h e j o i n t
between the u l n a a n d the lower end o f the humerus
is a straightforward hinge j o i n t but at the upper
end o f the radius the j o i n t is rather more c o m p l e x
as it allows the radius to hinge up and d o w n i n
relation to the humerus a n d also allows the radius
to rotate i n relation to the u l n a and the humerus. A
s i m i l a r rotatory movement takes place at the lower
end o f the radius a n d u l n a . T h i s allows the
movement o f p r o n a t i o n a n d supination where the
h a n d c a n be held either p a l m d o w n or p a l m u p
w i t h this rotation t a k i n g place entirely w i t h i n the
forearm. A s w i l l be seen from the skeletal d i a g r a m
(Fig. 1.19) the bones o f the wrist a n d h a n d are
9
ACROMION PROCESS CLAVICLE
OF SCAPULA -----
CORACOID
PROCESS OF
SCAPULA
HUMERUS -
g l e n o id
SCAPULA
-
LA
U
AP
SC
1.17 The Right Shoulder Joint.
c o m p l e x . M o s t o f the wrist movement is an up a n d
d o w n hinge action but there is a certain a m o u n t o f
sideways movement o f a b d u c t i o n a n d a d d u c t i o n
available ( c o n d y l o i d j o i n t ) . T h e joints i n the fingers
between the metacarpals a n d the phalanges are also
all o f a c o n d y l o i d type. T h o s e between the
phalanges themselves are p u r e l y hinge. H o w e v e r , at
the base o f the t h u m b the j o i n t between the
m e t a c a r p a l a n d the c a r p a l bones does a l l o w some
sliding a n d rotation so that the t h u m b c a n not only
be flexed a n d extended but also a b d u c t e d ,
adducted a n d c i r c u m d u c t e d to enable it to be
brought across the h a n d i n opposition to the
various fingers. W i t h o u t this movement the g r i p
w h i c h we use i n the h a n d w o u l d be non-existent
a n d the extremely fine precision movements a n d
uses o f the h a n d w o u l d be impossible.
T H E L O W E R LIMBS
T h e pelvis is formed by the s a c r u m , w h i c h is p a r t
of the a x i a l skeleton, a n d the two i n n o m i n a t e bones
at the front ( F i g . 1.20). T h e r e is a j o i n t between
the sacrum a n d the i n n o m i n a t e bones at each side.
T h i s j o i n t is extremely strong w i t h m a n y ligaments
crossing w i t h i n the j o i n t a n d also some
fibro-cartilage. V e r y little movement takes place at
the sacro-iliac j o i n t . A n t e r i o r l y the i n n o m i n a t e
bones come together at the symphysis pubis, a n d
once again very little movement takes place at this
j o i n t where there is fibro-cartilage between the
bones. D u r i n g pregnancy the fibro-cartilage a n d
ligaments soften, g i v i n g far greater m o b i l i t y a n d
a l l o w i n g delivery to take place. D e l i v e r y is also
10 Section 1: A n a t o m y a n d Physiology

1.18A (left) The Elbow Joint.

A . P . X-ray view.

1.18B (right) The Elbow Joint.

Lateral X-ray view.

FOREARM SUPINATED FOREARM PRONATED

HUMERUS

RADIUS ULNA ULNA

RADIUS

TH U M B C ARPAL BONES .

THUMB
M ETAC AR PAL BONES

PHALANGES

! Pc tHTtu.

1.19 The Right Forearm and Hand.

 Section 1.2 11

made very m u c h easier for the female by a

difference i n shape o f her pelvis from that o f the
male. 5th LUMBAR VERTEBRA
A t the sides of the i n n o m i n a t e bones are the h i p
joints ( F i g . 1.21). These are very large ball a n d
SACRO-ILIAC JOINT
socket joints but, unlike the shoulder joints, the
a c e t a b u l u m , w h i c h is the socket or cup part o f the
j o i n t , is very deep. T h e head of the femur forms a
b a l l w h i c h sits inside the a c e t a b u l u m . A s a result INNOMINATE
the j o i n t is very strong a n d extremely stable. Y o u BONE OF
PELVIS
w i l l see from the d i a g r a m that the head o f the SACRUM
femur is j o i n e d onto the shaft o f the bone by a
neck o f bone called the femoral neck. A s result of
this the shaft o f the femur stands out a little w a y HEAD OF FEMUR -
from the pelvis, g i v i n g a far greater range of
movement i n a l l directions than w o u l d be possible
GREATER
i f the b a l l was directly at the top o f the shaft. TROCHANTER
A t the lower end o f the femur is the knee j o i n t .
A s far as its action is concerned this is m a i n l y a
hinge j o i n t but as w i l l be seen from the d i a g r a m PUBIS
(Fig. 1.22) it is potentially a very unstable j o i n t
because the upper end of the tibia, w h i c h forms the
other side o f the j o i n t from the femur, is almost M
LESSER IU
completely flat. S t r u c t u r a l l y it is a c o n d y l o i d j o i n t CH
TROCHANTER IS
but functionally a hinge j o i n t . I f it were not for the
ISCHIUM
ligaments the lower end o f the femur w o u l d be able
to slide a r o u n d i n a l l directions on the tibia. I n
1.20 The Right Hemi-pelvis and H i p Joint.

INNOMINATE
BONE -----------

SUPERIOR
CAPSULE OF HIP HEAD OF FEMUR
ACETABULUM

SYNOVIAL . PUBO-FEMORAL
MEMBRANE LIGAMENT

HEAD OF
FEMUR

ILIO-FEMORAL
LIGAMENTS
INFERIOR
CAPSULE 11 1

11 11
1.21 A . Section through the Right H i p Joint (Diagrammatic). B. Ligaments at the front of the Right H i p Joint.
12 Section 1: A n a t o m y and Physiology

ANTERIOR LATERAL
(PATELLA REMOVED)

FEMUR-

PATELLA
CONDYLE
OF FEMUR

TIBIAL PLATEAU -

TIBIA

FIBULA

FIBULA
FIBULA

1.22 The Bones of the Right Knee Joint from front and side.

■QUADRICEPS TENDON

CONDYLE
-O F FEMUR PATELLA

CRUCIATE
LIGAMENTS
LATERAL LIGAMENT
POSTERIOR
• PATELLAR TENDON
LIGAMENT

MEDIAL
LIGAMENT

TIBIA
•FIBULA
I fA P «E N T i* _ £

A B

1.23 A . The Right Knee Joint. View from in front with the knee flexed, looking at the end of the femur and the
upper end of the tibia.

B. Diagrammatic view of the Knee Joint from the side.

 Section 1.2 13

ANTERIOR
QUADRICEPS
MUSCLE
ANTERIOR CRUCIATE
LIGAMENT (CUT END)

QUADRICEP!
TENDON LATERAL
MENISCUS
MEDIAL MENISCUS
FEMUR
PATELLA
POSTERIOR CRUCIATE
LATERAL LIGAMENT (CUT END)
LIGAMENT
• PATELLAR POSTERIOR
TENDON
The Right Knee Joint
(latera
(latera
(latera The Right
(lateral
Knee
view).
Joint (lateral view).
(latera
(latera
The Right Knee Joint (lateral

TIBIA
FIBULA
LA RL
• PA TE

1.24 The Right Knee Joint (lateral view).

FIBULA
a d d i t i o n to the hinge movement there is a very
small a m o u n t o f rotation possible w h e n the knee is TIBIA
p a r t l y flexed but not w h e n it is fully extended.
LATERAL
T h e diagrams (Figs 1.23 a n d 24) show the
MALLEOLUS
ligaments w h i c h stabilise the knee. T h e lateral
collateral ligament runs from the lower end o f the TALUS
femur laterally to the upper end of the fibula a n d is
cord-like. T h e m e d i a l collateral ligament runs from CUBOID
the lower end o f the femur m e d i a l l y to the upper NAVICULy
end o f the t i b i a a n d is strap-like. W i t h i n the j o i n t
are the cruciate ligaments, so-called because they 3 CUNEIFORM
5 METATARSALS ■
cross over. T h e y extend from the notch between the BONES
condyles o f the lower end of the femur to the front
a n d back o f the plateau at the upper end o f the PHALANGES
R

t i b i a . T h e y c a n be seen i n the d i a g r a m . T h e knee is

LA
EL

p e c u l i a r (but not unique) i n possessing two menisci

AT

or semi-lunar cartilages as they are c o m m o n l y

•P

called ( F i g . 1.25). These are composed o f

fibro-cartilage a a a n d are attached at the outer edges
to the capsule o f the j o i n t . T h e inner margins are
free. T h e y help to slightly deepen'the j o i n t at the
upper end o f the t i b i a p r o d u c i n g two shallow
saucers. I n a d d i t i o n they move very slightly w h e n
the j o i n t is bent a n d straightened d u r i n g n o r m a l
activities a n d as a result help to circulate the
synovial fluid a r o u n d the inside o f the j o i n t . T h e
cartilages themselves take no weight i n the n o r m a l
function o f the knee. H o w e v e r , i f a p a r t l y flexed
knee is twisted whilst weight-bearing, a cartilage
1.26 The Right Ankle Joint and Foot.
can be trapped between the femur a n d the t i b i a
a n d the twist c a n produce a tear i n the cartilage.
A n t e r i o r l y lies the quadriceps muscle w h i c h leads
into the quadriceps tendon, the patella a n d the
patellar tendon. These together help to give
anterior stability. Posteriorly the posterior capsule,
aided by the hamstrings, gives stability.
14 Section 1: A n a t o m y a n d Physiology

TIBIA

TALUS. DELTOID LIGAMENT

(MEDIAL LIGAMENT)

1»t METATARSAL

OS CALCIS
(HEEL BONE)

NAVICULA
TALUS.

MEDIAL
CUNEIFORM

1.27 Ligaments of the Medial Side of the Right Ankle Joint.

F IB U LA - TIBIA

ANTERIOR TIBIO-FIBULAR
LIGAMENT
POSTERIOR TIBIO-FIBULAR
LIGAMENT
TALUS
LATERAL -
MALLEOLUS ANTERIOR TALO-FIBULAR
LIGAMENT
CALCANEO-FIBULAR
LIGAMENT

OS CALCIS -

CUBOID 5th METATARSAL

1.28 Ligaments of the Lateral Side of the Right Ankle Joint.

A t the lower end o f the tibia lies the ankle

j o i n t . T h i s is a hinge j o i n t where no other type of
movement is available ( F i g . 1.26). T h e j o i n t is very
stable. T h i s stability is m a i n t a i n e d o n the lateral
side by the lower end o f the fibula w h i c h forms the
side o f the ankle j o i n t . M e d i a l l y there is a
d o w n w a r d projection o f bone from the lower end
of the t i b i a f o r m i n g the m e d i a l malleous a n d g i v i n g
m e d i a l stability. T h e collateral ligaments o f the
ankle are extremely i m p o r t a n t i n m a i n t a i n i n g ankle
stability a n d they are frequently the site o f injury,
p a r t i c u l a r l y the lateral ligament. T h e m e d i a l
ligament or deltoid ligament, so-called because o f
its shape, can be seen i n the d i a g r a m ( F i g . 1.27).
T h e lateral ligament is more complex ( F i g . 1.28).
INVERSION EVERSION
T h e p o r t i o n most c o m m o n l y d a m a g e d is the
anterior talo-fibular ligament. 1.29 Inversion and Eversion.
 Section 1.2-1.3 15

L i k e the h a n d , the joints o f the foot itself are

STRIATED (SKELETAL)
complex. I n the tarsal region rotatory movement is Voluntary muscle
possible, a l l o w i n g inversion a n d eversion. T h i s
largely takes place a r o u n d the talus. T h e upper
part o f the talus forms the hinge of the ankle j o i n t .
T h e lower part o f the talus articulates w i t h the
c a l c a n e u m a n d this bone, together w i t h the other NUCLEUS
bones o f the foot, can rotate a r o u n d the talus. I n
the anterior part o f the talus there is the head o f
the bone a n d this sits i n the saucer-like socket o f the SARCOLEMMA
n a v i c u l a r , f o r m i n g the axis o f rotation for inversion
a n d e v e r s i o n ( F i g . 1.29). Some inversion a n d
eversion also takes place i n the anterior tarsal bones
a n d between the tarsal bones a n d the p r o x i m a l ends
UNSTRIATED (BOWEL WALL, ETC.)
of the metatarsals. A s i n the fingers, the joints
Involuntary muscle
between the metatarsals a n d the phalanges are
c o n d y l o i d a n d between the phalanges themselves,
simple hinge joints.

NUCLEUS

1.3 The Muscles

General Considerations

Muscles are the meaty parts o f the b o d y a n d are

responsible for a l l movements that take place
w i t h i n the b o d y .
CARDIAC (HEART) muscle
T Y P E S OF MUSCLE FIBRES

T h e r e are three different types o f muscle ( F i g . 1.30)

a n d they have very specific a n d different functions.
NUCLEUS
Striatedthe or Skeletalthe M u s c l e
T h i s muscle is also referred to as v o l u n t a r y muscle
because it c a n be controlled at w i l l by the b r a i n
a n d nervous system. It includes the muscles
c o n t r o l l i n g the limbs, muscles o f facial expression
a n d the muscles o f respiration. It is k n o w n as 1.30 Diagram of the three types of Muscle Fibres.
striated muscle because w h e n sections o f the muscle
are e x a m i n e d under a microscope the cells have the
appearance o f possessing striations or stripes. It
m a y also be referred to as striped muscle ( F i g .
1.30). T h e striated muscle fibres are gathered
together i n bundles a n d these bundles are
surrounded by fibrous tissue, sometimes also called
areola tissue or connective tissue. T h e various attached to the bone. T h e fleshy muscle m a y come
bundles o f muscle fibres are themselves assembled together to form a b a n d or sheet o f w h i t e fibrous
a n d r u n l o n g i t u d i n a l l y i n the muscle as a whole. A tissue w h i c h m a y then be attached itself to the bone
large n u m b e r o f muscle bundles are b o u n d together or, as is seen p a r t i c u l a r l y i n the extremities, this
by areola tissue to form one a n a t o m i c a l l y n a m e d fibrous tissue m a y form a l o n g tendon w h i c h is
muscle. usually r o u n d or o v a l i n cross-section. These
A t the ends o f the muscles there are attachments tendoqs allow the p u l l o f the muscle to be exerted
to the bone. These m a y be i n the form o f a direct some distance a w a y w i t h o u t the presence o f the
attachment where the fleshy part o f the muscle is muscle b u l k p r o d u c i n g a n u n w i e l d y o r g a n . H e n c e
16 Section 1: A n a t o m y and Physiology

INTEROSSEOUS
the muscles w h i c h are largely responsible for
MEMBRANE
flexion a n d extension o f the fingers a n d toes end TIBIA
before they reach the wrist or ankle and the action
BLOOD
of the muscle is then carried d o w n v i a a tendon to
VESSEL
the tips o f the digits. T h i s allows a very m u c h more
slender a n d functionally useful organ to be
developed.
T h e groups o f muscles themselves are i n their
turn surrounded by dense unstretchable fibrous
tissue w h i c h is k n o w n as fascia. I n the d i a g r a m o f
the cross-section o f a l i m b ( F i g . 1.31), i n this case
the leg, about a t h i r d of the way d o w n from the
knee, it is possible to see how these layers are made
up. T h e skin surrounds the l i m b as a whole.
Beneath this is a layer o f fatty tissue w h i c h is called
the superficial fascia. T h e n comes the deep fascia
FIBULA
w h i c h is the dense fibrous tissue w h i c h is DEEP
unstretchable. T h i s envelope o f deep fascia contains FASCIA
the various muscles themselves; there are often
extensions o f fibrous tissue from the deep fascia
passing between the different muscles. These layers
are usually less dense than the fascial layer itself. A t SUPERFICIAL BLOOD VESSELS
this level there is also a very dense b a n d o f fibrous FASCIA (FAT) AND NERVES
tissue connecting the two bones of the leg, the t i b i a
a n d fibula; this is k n o w n as the interosseous 1.31 Cross-section of the Leer (upper third).
m e m b r a n e . N o t only does it help to h o l d the two
bones together, but it also gives an a d d i t i o n a l area of course) can achieve a m a z i n g l y delicate control o f
for the attachment o f the muscles. actual movements. I n those areas o f the b o d y
where very fine control is required the muscle fibres
T h e whole muscle is attached at each end, one
a n d nerve fibres are far more numerous (e.g. those
called the o r i g i n and the other the insertion. T h e
concerned w i t h the use o f the hand) than i n areas
o r i g i n is that end w h i c h i n general use o f the part
where less facility is required.
remains static a n d the insertion is at the end w h i c h
T h e stimulation d o w n the nerve fibre is electrical
is p u l l e d a n d moves. A l s o the o r i g i n , as far as the
but the stimulation between the nerve e n d i n g and
limbs are concerned, is usually the p r o x i m a l end,
the muscle fibre is c h e m i c a l i n nature. E v e n at rest
i.e. the end nearer to the trunk. H o w e v e r , their
a few fibres are being constantly stimulated i n turn
roles c a n be reversed; for example, i f a n object is
a n d this maintains what is k n o w n as muscle tone.
grasped by the h a n d either the object can be pulled
T h e r e are two types o f v o l u n t a r y muscle fibre a n d
towards a stationary trunk, or the trunk can be
these are referred to as fast a n d slow fibres. T h e
p u l l e d towards a stationary object.
p r o p o r t i o n o f different fibres i n an i n d i v i d u a l
T h e action o f each muscle as a whole is
muscle determines whether the muscle as a whole is
controlled by one or more nerves. M a n y muscles
more suited to a prolonged s u p p o r t i n g role or to
have their nerve supply from several different
quick, r a p i d response action.
nerves; w h e n these nerves enter the muscle they
g r a d u a l l y d i v i d e d o w n u n t i l an i n d i v i d u a l nerve Unstriated or I n v o l u n t a r y M u s c l e
fibre reaches an i n d i v i d u a l muscle fibre. W h e n the T h i s is the name given to the muscle w h i c h controls
nerve fibre is stimulated it w i l l i n its t u r n stimulate various internal organs o f the body ( F i g . 1.30).
the muscle fibre to contract completely. It cannot T h i s type o f muscle is i n the whole o f the
stimulate the muscle fibre to contract p a r t i a l l y . T h i s alimentary tract a n d also a r o u n d m u c h smaller
is k n o w n as the a l l - o r - n o t h i n g law. T h i s contraction structures such as glands a n d blood vessels. T h e
shortens the muscle fibre. D e p e n d i n g u p o n the conscious portion o f the b r a i n has no c o n t r o l at a l l
n u m b e r o f muscle fibres stimulated so w i l l depend over the action o f these muscles, hence the name
(a) the power or strength exerted and (b) the i n v o l u n t a r y muscle. It is also k n o w n as unstriated
a m o u n t the whole muscle w i l l shorten. B y a very muscle because on microscopic e x a m i n a t i o n there
h i g h l y developed a n d sophisticated neuro-muscular are no striations or stripes as were found i n the
control system the h u m a n being (or other animals, skeletal muscle.
 Section 1.3 17

1.32 First Order Lever (balanced,

with equal arms and equal weights).

LOAD

1.33 First Order Lever (balanced,

with unequal arms and weights).
/LOADS Distance x load = distance x effort. In
this case 2 x 2 = 4 x 1 .
This may be found where the skull
joins the cervical spine. The pull of
the muscles in the back of the neck
a 1 balances the weight of the front of
the skull, the face and the mandible.

1.34 A . Second Order Lever. The

/L O A D ! load is nearer to the fulcrum than
the effort. The force applied by the
load will be greater than that
required by the effort.

B. (below) Second Order Lever, as

occurs at the foot and ankle with the
A dancer on demi-pointe.

Cardiac Muscle B
T h i s is the t h i r d type o f muscle a n d is only found
i n the heart ( F i g . 1.30).
C a r d i a c muscle w i l l contract w i t h o u t s t i m u l a t i o n , DIRECTION OF PULL
but the rate a n d r h y t h m is under the control o f OF THE CALF MUSCLE
THROUGH THE
nervous impulses. T h e c o n t r o l o f cardiac muscle
TIBIA -ACHILLES TENDON
w i l l be dealt w i t h later.

A C T I O N OF MUSCLES
TIBIALIS
Before passing on to the i n d i v i d u a l muscles it is ANTERIOR OS CALCIS
i m p o r t a n t to consider h o w muscles themselves
produce movements.

Muscles and Levers TIBIALIS

It must be emphasised that muscles c a n only POSTERIOR ■FLEXOR HALLUCIS
contract a n d therefore p u l l , they c a n never at any LONGUS TENDON

time push. M o v e m e n t s are therefore brought about

by using the bones as levers; there are three types o f
orders o f levers, a first-order lever being like a
see-saw ( F i g . 1.32), w i t h the b a l a n c i n g point
referred to as the f u l c r u m . A t one end o f the lever
is the ' l o a d ' a n d at the other end is the muscle
action p r o d u c i n g 'effort'. I f no movement is t a k i n g ANTERIOR
place the part is i n e q u i l i b r i u m a n d the force WEIGHT
a p p l i e d by the ' l o a d ' a n d the force a p p l i e d by the OF BODV
18 Section 1: A n a t o m y a n d Physiology
A seven times) than the force of the
'effort' are balanced out, though this does not mean
that the actual n u m b e r o f kilograms being exerted
at these two points is necessarily the same. A n y o n e
using a lever i n order to try to move something
heavy w i l l realise that the longer the lever, the less
force needs to be a p p l i e d to move the object. T h i s
can be very s i m p l y w o r k e d out a n d expressed as an
equation: the 'effort' m u l t i p l i e d by the distance o f
the 'effort' from the fulcrum equals the ' l o a d '
m u l t i p l i e d by the distance o f the ' l o a d ' from the
f u l c r u m . A s the d i a g r a m shows ( F i g . 1.33), i f the
' l o a d ' is two units a n d the distance o f the ' l o a d ' is
three units, these figures m u l t i p l i e d together give
the figure o f six. O n the other side o f the f u l c r u m ,
i f the distance o f the 'effort' is six units from the
fulcrum then the 'effort' required to move the
' l o a d ' w i l l o n l y be one unit because the 'effort' a n d
distance m u l t i p l i e d together w i l l also produce a six.
A n example o f a first-order lever is the head, on the
spine, where the weight o f the face is counteracted
by the muscles i n the back o f the neck.
In the limbs the other two types o f lever are very
m u c h more c o m m o n . I n a second-order lever ( F i g .
1.34) the 'weight' or ' l o a d ' w i l l lie nearer to the
fulcrum or point o f movement than the 'effort' —
i n this case the muscle contraction. T h i s is well seen
i n the foot w h e n a dancer rises onto h a l f pointe; the
fulcrum is at the b a l l o f the foot, the weight o f the
b o d y is being transmitted d o w n through the shin
bone a n d ankle a n d the lifting force is by means o f
the c a l f muscle w h i c h is inserted through the
A c h i l l e s tendon into the back o f the heel. O n c e
again, because o f the levers the distance from the
f u l c r u m at the b a l l o f the foot to the ankle j o i n t is
less t h a n the distance from the f u l c r u m to the back
of the heel, so the effort i n the c a l f muscle is
slightly less than the actual weight o f the body. It is
o n l y slightly less because the differences i n the two
distances from the fulcrum is only small.
F i n a l l y i n the third-order lever ( F i g . 1.35) the
'effort' or muscle contraction lies between the
f u l c r u m a n d the weight or ' l o a d ' . T h i s is seen at the
elbow j o i n t , where the biceps a n d brachialis muscles
are inserted just i n front o f the elbow but the
1.35 A . T h i r d Order Lever. The
effort is nearer to the fulcrum than
LOAN the load. The force of the effort
therefore has to be greater than the
force of the load.
B. (below) T h i r d Order Lever. In
this instance the force of the effort
has to be very much greater (about
load.
B
DIRECTION OF
PULL THROUGH
BICEPS
AND
- BRACHIALIS
ANTERIOR
LOAD
weight that is being lifted is situated further from
the elbow, usually i n the region o f the h a n d .
Because o f the great difference i n distances from
the fulcrum between the 'effort' a n d the ' l o a d ' the
actual force that is required to do the lifting is very
m u c h greater than the actual weight o f the ' l o a d ' .
T h i s is because the distance between the f u l c r u m
a n d the insertion o f the muscle is very short,
whereas the distance from the f u l c r u m to the h a n d ,
w h i c h m a y be c a r r y i n g the weight, is about seven
times greater; hence i f the weight being lifted i n the
h a n d is only one k i l o g r a m , the force o f contraction
in the biceps muscle to lift this must be i n the order
of seven kilograms. I f measurements are done i n
other areas o f the body, p a r t i c u l a r l y the lower
limbs, it w i l l be seen that the a c t u a l force required
in the contracting muscle c a n be several times the
body weight a n d , w h e n j u m p i n g , this may reach
between a h a l f and three-quarters o f a ton (500 -
700 kilograms).
A further i m p o r t a n t aspect o f the use o f levers is
the difference i n distance m o v e d by the 'effort' a n d
the ' l o a d ' . I n first-order levers this c a n be either the
'effort' or the ' l o a d ' h a v i n g to move further. I n
 Section 1.3
second-order levers the 'effort' has to move further
than the ' l o a d ' , because the 'effort' is further from
the fulcrum. T h u s the muscles p r o d u c i n g the
movement have to shorten more than the distance
the ' l o a d ' w i l l move. I n third-order levers, w h i c h
are the commonest type i n the body, the 'effort'
moves a m u c h shorter distance than the ' l o a d ' T h i s
has the great advantage o f a l l o w i n g a large
movement to be made w i t h o n l y very slight
shortening o f the muscles p r o d u c i n g the
movements.
M u s c l e Contraction
Contraction
A muscle contracts as a whole by the separate
contraction o f its i n d i v i d u a l muscle fibres. A t rest, a
few nerve impulses are constantly being supplied to
the muscles so that some fibres are always
c o n t r a c t i n g a n d m a i n t a i n i n g what is k n o w n as
'tone' i n the muscle. I n other words, the whole
muscle never relaxes completely. D u r i n g a
v o l u n t a r y movement, d e p e n d i n g u p o n the power
required, a n increasing n u m b e r o f muscle fibres w i l l
contract at the same time, a n d then i n succession,
i n order to m a i n t a i n the muscle contraction a n d to
control its speed.
T h e muscle groups do not act singly but always
i n concert w i t h other muscle groups; i f this were
not to h a p p e n the movement w o u l d be largely
u n c o n t r o l l e d . F o r example, w h e n p i c k i n g up a c u p
of tea to carry it to the m o u t h , i f the muscle groups
i n i t i a t i n g the action contracted by themselves the
tea w o u l d be t h r o w n into the face o f the drinker!
A l l movements are carefully controlled. T h e most
i m p o r t a n t i n i t i a t i n g g r o u p is k n o w n as the ' p r i m e
m o v e r ' . T h e groups o f muscles acting i n the
opposite d i r e c t i o n are k n o w n as antagonists. D u r i n g
a movement the antagonist group w i l l also be
m a i n t a i n i n g some contraction a n d w i l l relax
g r a d u a l l y i n a compensatory manner. G r a v i t y also
plays an i m p o r t a n t part a n d w i l l frequently act
w i t h either the p r i m e mover or w i t h the antagonist
a n d m a y at times p r a c t i c a l l y eliminate the action i n
the antagonist, especially w h e n lifting.
M o d e r n electrical tests on muscles ( E . M . G .
testing) have shown that, m u c h o f the time, the
antagonist muscles are not actually being
stimulated d u r i n g a movement a n d that their
antagonistic c o n t r o l l i n g action is taking place by
means o f elastic recoil. W h e t h e r this happens or
whether there is actually some active c o n t r a c t i o n i n
the antagonist w i l l depend u p o n the movement
w h i c h is t a k i n g place: whether it is finely
controlled, whether it is t a k i n g place w i t h or
w i t h o u t the assistance o f gravity, etc. I n a d d i t i o n ,
the p r i m e m o v e r or the antagonist m a y receive help
19
from other groups o f muscles w h i c h are k n o w n as
synergists. These tend to act as co-ordinators o f
movements. T h e y also help to counteract any
u n w a n t e d d i r e c t i o n a l force i n the p r i m e mover. A s
an example: the pectoralis major, w h e n c o n t r a c t i n g
to move the humerus i n relation to the scapula, also
exerts a dislocating force on the shoulder j o i n t (the
scapulo-humeral j o i n t ) . T h e coraco-brachialis is a
synergistic muscle for this movement a n d by
contracting, not o n l y aids the movement o f the
a r m , but also by acting at a different angle to the
pectoralis major counteracts the dislocating
component o f the force exerted by the latter.
D u r i n g different movements, first one g r o u p a n d
then another w i l l be p r i m e movers, antagonists or
synergists. It is because o f this c o m b i n e d action o f
the muscle groups that, d u r i n g regimes o f
strengthening exercises, not o n l y d o the p r i m e
movers have to be exercised, but also the
antagonistic a n d synergistic groups. It is the a c t i o n
of the various groups w h i c h produce a w e l l
balanced a n d controlled movement. A l t h o u g h the
groups o f muscles are a l l composed o f v o l u n t a r y
muscles, the antagonistic a n d synergistic actions are
controlled reflexly. So just as they can be made to
contract reflexly they c a n also be i n h i b i t e d reflexly,
as m a y occur w i t h injury or p a i n .
N E U R O - M U S C U L A R GO-ORDINATION A N D ENGRAMS
Individual muscles can rarely act alone. T h e r e is a
prime mover or agonist. T h e r e are synergistic
groups which assist the prime mover. T h e r e are
antagonist groups w h i c h oppose the prime mover.
T h e r e are stabilisers w h i c h fix joints i n order to
allow the movement to take place. C o - o r d i n a t i o n
t r a i n i n g develops p r e - p r o g r a m m e d a u t o m a t i c
m u l t i - m u s c u l a r patterns. These are k n o w n as
engrams. Constant, exact repetitions or practice w i l l
produce an engram, a c o n d i t i o n where i n d i v i d u a l
muscles or movements are not consciously
considered. Proprioceptive feedback gives sub-
conscious a n d conscious m o n i t o r i n g o f the
movement a n d shows whether it was successful o r
not. These automatic engrams c a n only be
developed by v o l u n t a r y repetition o f the precise
p r o g r a m m e . T h i s must be followed accurately
otherwise the i n p u t o f i n f o r m a t i o n w i l l v a r y each
time a n d the engram cannot be developed. It
follows that i n i t i a l l y the pattern must be slow
enough to be accurate.
A n engram allows a c o m p l i c a t e d movement to be
performed far more r a p i d l y than w o u l d be possible
if conscious thought o f each part o f the pattern
were required. A t the same time as the movements
are o c c u r r i n g , the engram w i l l also produce
20 Section 1: A n a t o m y a n d P h y s i o l o g y
i n h i b i t i o n o f u n w a n t e d movements. T h i s i n h i b i t i o n
is a n essential part o f the regulation o f
c o - o r d i n a t i o n . I n h i b i t i o n cannot be produced
directly a n d consciously a n d is achieved by regular
and accurate repetition of the pattern of desired
movements. C o - o r d i n a t i o n of the most r a p i d ,
c o m p l e x a n d skilful actions is automated by
engrams rather than by a v o l u n t a r y controlled
series o f movements. T h e activation o f the
engram(s) engram(s)is v o l u n t a r y a n d under conscious control.
In l e a r n i n g exercise patterns a n d , o f course, far
more i m p o r t a n t l y i n l e a r n i n g dance technique, or
for that matter any other technique, accuracy is
absolutely v i t a l i n order to develop the correct
e n g r a m . I f inaccuracies are allowed d u r i n g the
development o f a technique, this w i l l produce ' b a d
habits' a n d these very inaccuracies or bad habits
w i l l themselves become an engram. O n c e this has
taken place, the modification o f the faulty e n g r a m
w i l l be extremely difficult a n d m a y call for that
p o r t i o n o f the technique to be learned again from
scratch. H e n c e the i m p o r t a n c e o f l e a r n i n g any
complex series o f movements accurately from the
start. A s already stated, i n order to achieve
accuracy the pattern w i l l have to be learned slowly.
T h e n u m b e r o f repetitions required to produce a
really well-developed engram numbers i n hundreds
of thousands or millions a n d not just hundreds or
thousands. H o w e v e r , this is not as bad as it sounds
because an action is usually made up o f a series o f
engrams. It is the sum o f the engrams w h i c h
produces the final result. A s already mentioned, the
i n i t i a t i o n o f a n engram is under v o l u n t a r y a n d
conscious c o n t r o l although the constituent parts of
the e n g r a m are themselves not by that stage under
v o l u n t a r y control. W h a t the m i n d does is to select
the stored engrams, put them together a n d produce
the desired result.
T h e use o f engrams is p r o b a b l y seen a n d
appreciated best w h e n one considers a m u s i c i a n
such as a pianist or organist. I n this case, the
symbols o n a page w i l l initiate engrams w h i c h allow
the fingers, a n d i n an organist the feet as w e l l , to
perform the c o m p l e x series o f manoeuvres.
It has to be a d m i t t e d that some o l d proverbs
certainly appear nowadays to have a scientific basis,
e.g. practice makes perfect (the formation o f the
engram); y o u cannot teach an o l d d o g new tricks
(the difficulty i n t r y i n g to change a n engram).
R E D A N D W H I T E MUSCLE FIBRES
It m i g h t be felt that this subject is too abstruse to
be i n c l u d e d i n a book o f this type at a l l . H o w e v e r ,
the excuse for i n c l u d i n g a few sentences on the
subject is that dancers frequently ask about this as
they have either read about it or heard about it
and feel that they should be d o i n g something about
red a n d white fibres i n order to i m p r o v e their o w n
performance.
Because o f the presence o f red meat and white
meat i n fowls, it has long been thought that there
might be a difference between types o f muscle
fibre. H o w e v e r , i n m a m m a l s there is not this overall
appearance of red meat a n d white meat.
Nevertheless, w i t h i n muscles themselves there have
been shown to be variations i n the type o f muscle
fibre, some being dark a n d some being light.
T h e ' r e d ' fibres are also k n o w n as slow twitch
fibres a n d are also called T y p e 1 fibres. T h e y tend
to proliferate i n endurance t r a i n i n g .
' W h i t e ' fibres are also k n o w n as fast t w i t c h fibres
or T y p e 2 fibres a n d they tend to proliferate i n
sprint-type exercise.
B o t h fibre types are n o r m a l l y extremely stable
and do not change from one type to another.
T y p e 1 slow twitch fibres metabolise by o x i d a t i v e
phosphorylation a n d thus are high i n aerobic
capacity. T h e y have a slow speed o f c o n t r a c t i o n
(hence the name slow twitch) a n d they are also
slow to fatigue. These fibres are small i n diameter.
T h e y have a l o w threshold o f recruitment (i.e. they
respond early to electrical s t i m u l a t i o n from the
nerve fibres) a n d they generate low forces but
because o f the l o w threshold a n d early recruitment
they contract more frequently than T y p e 2 fibres.
T y p e 2 fast twitch fibres metabolise by glycolysis.
T h e y have a fast speed of c o n t r a c t i o n (hence fast
twitch) a n d are also fast to fatigue. These muscle
fibres are large i n diameter. T h e y have a h i g h level
of recruitment (i.e. they need m u c h more electrical
stimulation to make them contract) a n d they
generate h i g h forces. H o w e v e r , they contract less
frequently than the T y p e 1 fibres.
T o complicate matters a little further, there is
also an intermediate fibre w h i c h is a sub type of
T y p e 2. It is a fast oxidative glycolytic fibre
( F . O . G . fibre). These F . O . G . fibres have a fast
speed o f contraction a n d an intermediate rate of
fatigue.
H a v i n g said a l l that, the best advice to the
dancer is that he forgets about his red a n d white
fibres a n d that he contents himself w i t h c a r r y i n g
out his proper exercise programmes, a l l o w i n g his
various types of fibres to look after themselves.
Individual M u s c l e s
T R U N K MUSCLES
As w i l l be seen from the diagrams (Figs 1.36, 1.37
and 1.38) there are a large n u m b e r o f t r u n k
 21

STERNOMASTOID
1.36 Muscles of the Front of the
Trunk. TRAPEZIUS

CLAVICLE

DELTOID

PECTORALIS MAJOR

LATISSIMUS DORSI

SERRATUS ANTERIOR
LINEA ALBA
RECTUS ABDOMINIS (CUT)

RECTUS ABDOMINIS - EXTERNAL OBLIQUE

INTERNAL OBLIQUE

TRANSVERSUS

■ CUT END OF
RECTUS ABDOMINIS
) n .V « £ H T K £

STERNOMASTOID -

TRAPEZIUS-

ACROMION

DELTOID

INFRASPINATUS

TERES MAJOR

TRICEPS ■

LATISSIMUS DORSI

GLUTEUS MEDIUS

GLUTEUS MAXIMUS - 1.37 Superficial Muscles of the

Back of the Trunk.
22 Section 1: A n a t o m y a n d Physiology

muscles. T h e diagrams show the major muscles a n d

name them. D e t a i l e d knowledge o f the names o f
the i n d i v i d u a l muscles is unnecessary for dancers; it
is usually more convenient to consider the muscles
in groups a n d from the w a y they act rather than b y
their a n a t o m i c a l names. H o w e v e r , it is helpful to be
familiar w i t h the more i m p o r t a n t muscles a n d
groups by name.
T h e trunk as a whole is supported and stabilised
SPINAL at the back by the l o n g sacro-spinalis muscles w h i c h
COLUMN RIBS extend from the pelvis to the base o f the skull a n d
m a n y other smaller muscles, and at the front by the
anterior neck muscles, the intercostal muscles and
other muscles attached to the rib cage a n d , from
the dancer's point o f view, possibly one o f the most
SACRO-SPINALIS i m p o r t a n t groups i n the body, the a b d o m i n a l
(ERECTOR SPINAE) muscles. T h e muscles o f the a b d o m i n a l w a l l lie i n
several layers. R u n n i n g d o w n the centre o f the
a b d o m e n are two stout muscles, one on each side o f
the m i d - l i n e , the right a n d left rectus abdominis.
T h e r e are then two oblique layers, the external a n d
QUADRATUS internal obliques, the latter l y i n g deep to the
LUMBORUM former, a n d then finally a transverse layer o f
muscles. A contraction o f these various layers gives
strength and support to the anterior part o f the
PELVIS
trunk a n d plays a very i m p o r t a n t part i n
m a i n t a i n i n g the proper curves i n the spinal c o l u m n .
A t the sides of the trunk, the quadratus l u m b o r u m
R
IO
R
TE
AN

1.39 (below) Muscles of the Right Shoulder.

1.38 Deep Muscles of the Back of the Trunk. A . View from the front
with the rib cage removed (vide Fig. 1.8).

B. View from the back.

ANTERIOR SUPRASPINATUS

CLAVICLE

SUPRASPINATUS

DELTOID
SUBSCAPULARIS
DELTOID

INFRASPINATUS

HUMERUS

HUMERUS
LONG HEAD
OF TRICEPS
TERES MAJOR
1 -N fW K T J c A

A B
 Section 1.3
SPINE
ILIAC CREST
OF PELVIS _
ILIACUS
PSOAS MAJOR
ADDUCTORS
FEMUR
IO R
ANTER
1.40 Muscles of the Right H i p (view from the front).
muscle helps the lateral portions o f the a b d o m i n a l
muscles to give lateral strength. T h e large muscles
of the shoulder girdle, n a m e l y latissimus dorsi,
serratus anterior, trapezius a n d pectoralis major,
p l a y a n extremely i m p o r t a n t part i n the
stabilisation o f the upper part o f the trunk,
a l t h o u g h as w i l l be seen from the diagrams ( F i g .
1.37) the latissimus dorsi takes o r i g i n from the
m i d - p a r t o f the back right d o w n to the pelvis
t h r o u g h the l u m b o - d o r s a l fascia. E x t r e m e l y
i m p o r t a n t l y it also sends a slip o f muscle to the
lower angle o f the scapula, thus h e l p i n g
considerably i n the stabilisation o f the scapula o n
the trunk.
U P P E R LIMB MUSCLES
In a d d i t i o n to the shoulder girdle muscles shown i n
previous diagrams, F i g . 1.39 shows various other
groups a r o u n d the shoulder girdle. T h e deltoid
muscle a n d the other short muscles arising from the
scapula w h i c h are inserted into the upper end o f
23
the humerus are a l l responsible for the various
movements between the humerus and the scapula.
S h o u l d e r movements take place at this j o i n t
between the humerus a n d the scapula a n d also at
what has been termed the scapulo-thoracic j o i n t .
T h i s is not a true j o i n t i n the proper m e a n i n g o f
the w o r d but the scapula is only connected to the
rest o f the trunk by the joints between the two ends
of the clavicle; otherwise it is held and suspended
by a l l the muscles that r u n from the trunk into
either the scapula or the upper part of the
humerus. A s a result, the scapula is free to move
a r o u n d the chest w a l l a n d elevation of the a r m is a
c o m b i n a t i o n o f movements at the j o i n t between the
humerus a n d the scapula a n d between the scapula
a n d the chest w a l l .
Below the shoulder j o i n t the muscles c a n be
considered entirely as groups; i n the a r m there are
the flexors a n d extensors o f the elbow, i n the
forearm the flexors a n d extensors o f the wrist a n d
the muscles w h i c h rotate the h a n d a n d wrist i n
relation to the elbow a n d then flexors a n d extensors
of the fingers. W h e n strengthening muscles for use,
such as lifting i n the pas de deux work,
consideration has o n l y to be given to the
strengthening o f groups o f muscles rather than
i n d i v i d u a l muscles.
L O W E R LIMB MUSCLES
A r o u n d the h i p there are several s m a l l muscles
w h i c h are responsible for rotation o f the femur, but
they are not very strong. M o s t o f the them rotate
the femur laterally or t u r n the leg out. R a t h e r t h a n
acting as weak h i p rotators their function is that o f
stabilisation o f the h i p j o i n t . T h e i r role c a n be
considered as a c t i n g as adjustable ligaments.
H o w e v e r , the t u r n out is carried out i n the erect
posture m a i n l y b y the a d d u c t o r g r o u p o f muscles
(Fig. 1.40). T h e gluteus m a x i m u s ( F i g . 1.41), w h i c h
is a very large muscle, extends the h i p (remember
the true m e a n i n g o f extension). A b d u c t i o n of the
hip is carried out largely b y the tensor fasciae latae
a n d the gluteus medius a n d gluteus m i n i m u s (Figs
1.42 a n d 1.43). F l e x i o n o f the h i p j o i n t is largely
carried out by the psoas major a n d iliacus muscles,
(Fig. 1.44), w i t h some help from sartorius. I n the
thigh, a d d i t i o n a l l y , the rectus femoris, w h i c h is p a r t
of the quadriceps muscle, also crosses the front o f
the h i p j o i n t a n d w i l l help to flex the h i p ( F i g .
1.45). T h e quadriceps muscle w h i c h comprises the
rectus' femoris, the vastus medialis, vastus
intermedius a n d vastus lateralis extends the knee
very powerfully ( F i g . 1.46).
F o r the dancer a n d a l l athletes the vastus
medialis p o r t i o n o f the quadriceps muscle is
24 Section 1: A n a t o m y a n d P h y s i o l o g y

p a r t i c u l a r l y i m p o r t a n t and contracts powerfully
d u r i n g the last fifteen degrees o f extension o f the
knee. After any injury the medialis is the first part
of the muscle w h i c h tends to waste a n d is usually
the most difficult to b u i l d up again. F l e x i o n of the
knee is carried out by the hamstring muscles w h i c h
lie at the back o f the thigh ( F i g . 1.47). These also
pass b e h i n d the h i p j o i n t a n d therefore act
a d d i t i o n a l l y as h i p extensors. W h e n the knee is
semi-flexed the biceps femoris portion o f the
hamstrings can rotate the tibia externally. Internal
rotation o f the tibia is brought about by the
popliteus muscle w h i c h lies deeply b e h i n d the knee.
N e i t h e r external or internal rotation o f t i b i a is a
strong movement. R o t a t i o n o f the t i b i a at the knee
plays no part i n rond de j a m b e en l ' a i r . W h e n the
knee is fully extended, no rotation is possible
between the tibia and the femur i n the n o r m a l
knee.

GLUTEUS MEDIUS
GLUTEUS MEDIUS

TENSOR
FASCIAE LATAE
TENSOR
FASCIAE LATAE
GLUTEUS -
MAXIMUS

ILIO-TIBIAL -
TRACT
(FASCIA LATA)

ANTERIOR

A B
1.41
1.41 Muscles
M uscles of
o f the
the Right
R ig h t H i p..
H ip A
A.. From
F ro m bbehind.
e h in d . B.
B. From
F ro m the
the side.
side.

- GLUTEUS GLUTEUS
MINIMUS MEDIUS

A B C
1.42 Muscles of the Right H i p . A . From behind, showing gluteus minimus with gluteus medius removed.

B. From behind, showing gluteus medius.

C. From the side, showing gluteus medius.

 Section 1.3 25

GLUTEUS
MEDIUS

PSOAS MINOR
PSOAS MAJOR

GLUTEUS ILIACUS -
TENSOR
MINIMUS
FASCIAE LATAE
■ ILIACUS

ILIO-TIBIAL
TRACT (CUT EDGE)

SARTORIUS

PELVIS ■

SACRUM

F
I w
y

1.43 Muscles of the Right

H i p . View from the side to
£
' I
JT
show gluteus medius and
minimus, tensor fasciae latae 1.44 (above) Muscles of the
and the ilio-tibial tract. Right H i p . The main hip
flexors.

RECTUS FEMORIi

PATELLA

PATELLAR TENDON

1.45 (left) The Right Rectus

TIBIA Femoris Muscle. (This is a
part of the quadriceps muscle
US
and is the only portion to cross
$</
C-

d*
the front of the hip joint. It
acts as a hip flexor as well as a
r knee extensor.)
26 Section 1: A n a t o m y a n d Physiology

PELVIS
PELVIS

SACRUM

TENSOR HIP JOINT

FASCIAE LATAE

FEMUR

RECTUS
FEMORIS

BICEPS FEMORIS
VASTUS SEMITENDINOSUS
LATERALIS VASTUS

LE US
MEDIALIS

SOUS
SEMIMEMBRANOSUS-

SO LE
POSTERIOR
PATELLA
ASPECT OF
FEMORAL
PATELLAR CONDYLES
TENDON TIBIA

TIBIA

1.46 The Right Quadriceps Muscle. The vastus 1.47 The Right Hamstring Muscles.
intermedius is hidden by the rectus femoris.

B e l o w the knee ( F i g . 1.48) i n the anterior
c o m p a r t m e n t or front o f leg are the muscles w h i c h
extend or (as is more c o m m o n l y called) dorsi-flex
the ankle, foot a n d toes. A t the back o f the leg are
the c a l f muscles ( F i g . 1.49), consisting o f the
gastrocnemius a n d soleus muscles. These j o i n
together at their lower ends to form the Achilles
tendon. T h i s is responsible for the powerful
plantar-flexion o f the foot. T h e gastrocnemius
muscle has two heads p r o x i m a l l y w h i c h pass b e h i n d
the knee j o i n t to take origin from the the back o f
the lower end o f the femur. It also helps to flex the
knee. T h e soleus muscle lies deep to the
gastrocnemius muscle a n d its o r i g i n is i n the leg
below the knee j o i n t . T w i s t i n g the foot i n t o
inversion is carried out by the c o m b i n e d a c t i o n o f
the tibialis posterior a n d the tibialis anterior, l y i n g
respectively, as their name suggests, at the back a n d
the front o f the leg. I n simple dorsi-flexion a n d
plantar-flexion they help to reinforce these
movements, tibialis anterior dorsi-flexing a n d
tibialis posterior plantar-flexing the ankle a n d foot.
I n the lateral part of the leg ( F i g . 1.50) the
peroneal muscles are responsible for twisting the
foot outwards (eversion). T h e l o n g extensors and
l o n g flexors o f the toes as they cross the front a n d
back of the ankle also assist i n ankle movements.
 Section 1.3 27

FEMUR

TIBIA

TIBIALIS
ANTERIOR G ASTRO CNEM IUS
G ASTRO CNEM IUS

EXTENSOR CALF
DIGITORUM M USCLES
LONGUS ------
SOLEUS

SOLEUS
EXTENSOR
HALLUCIS
LONGUS -
u
ACH ILLES TEND ON
£
r
X

SO LE US
Z

- ILIO-TIBIAL
1.48 (above) The Right Leg, from the front.
TR A CT
BICEPS FEMORIS
1.49 (above right) The Right Leg, from the back. Note (LA TER AL - VASTUS
that the gastrocnemius muscle has two heads which cross HAM STRING) LATERALIS
the back of the knee and therefore help flex the knee as
well as plantar-flex the foot and ankle.

PATELLA
G ASTRO CNEM IUS

TIBIALIS
SOLEUS ANTERIOR LYING
IN TH E
ANTERIO R
PERONEUS - EXTENSOR
C O M P A R TM E N T
LONGUS DIGITORUM
LONGUS
PERONEUS
BREVIS

ACHILLES
TENDON

1.50 (right) The Lateral Side of the Right Leg.

PERONEUS
28 Section 1: A n a t o m y a n d Physiology

TEND ON
O F FLEXOR
HALLUCIS
LUM BR ICALS - LONGUS

FLEXOR
TEN D O N HALLUCIS
O F FLEXOR BREVIS 1.53 A Well Pointed Foot. The toes are stretched so
DIGITORUM that there is maximum stretch at the front of the ankle.
LONGUS

ABD UC TO R
HALLUCIS

FLEXOR
ACCESSO RIUS (L
y
*-
<5
$
5

1.51 The Sole of the Right Foot (Superficial Muscles).

1.54 A Badly Pointed Foot. The intrinsic muscles are

weak, so the toes become curled by the unopposed long
flexors. As a result there is increased tension along the
Achilles tendon and the curled toes prevent the front of
the ankle being stretched. Note also the absence of a
AD D U C TO R _ contraction in the soleus muscle which in Fig. 1.53 is
ADDUCTO R
HALLU CIS visible below the marked bulge of the contracting
HALLUCIS
(TR AN SVERSE gastrocnemius muscle.
HEAD) (OBLIQUE
HEAD)
IN TER O SSEO U S
M USCLES
FLEXOR
HALLUCIS
FLEXOR DIGITI
BREVIS
MINIMI BREVIS
W i t h i n the foot itself are the intrinsic muscles o f
the foot (Figs 1.51 a n d 1.52); these are made up o f
BASE OF '
5th M ETATAR SAL the interosseous muscles a n d the l u m b r i c a l muscles.
A l t h o u g h small, they are o f the utmost i m p o r t a n c e
SO LE US

FLEXOR to the dancer as strength there helps to m a i n t a i n

ACCESSORIUS the transverse metatarsal a r c h across the foot. T h e y
(C U T ENDS) are solely responsible for keeping the toes straight
when the foot is pointed h a r d ( F i g . 1.53); w i t h o u t
the action o f the intrinsic muscles the long flexors
cause the toes to c u r l w h e n the foot is pointed ( F i g .
1.52 The Sole of the Right Foot (Deep Muscles). 1.54).
 Section 1.3
Muscles which Move Individual Portions of
the Body
I n this section w i l l be described the more i m p o r t a n t
muscles w h i c h move joints w h i c h are o f p a r t i c u l a r
interest to dancers. It w o u l d be totally unrealistic to
describe a l l the muscles i n the b o d y a n d their
actions a n d it w o u l d be equally unrealistic i n
considering any p a r t i c u l a r j o i n t to m e n t i o n or
expect any readers to memorise the names o f a l l the
muscles concerned. W e are, therefore, g o i n g to
consider only the m a i n muscles; those that are
p a r t i c u l a r l y i m p o r t a n t for the dancer are p r i n t e d i n
b o l d type.
S t a r t i n g centrally we w i l l consider the head a n d
trunk followed b y the upper a n d lower limbs.
HEAD AND TRUNK
T h e trunk is s y m m e t r i c a l a n d i f split d o w n the
centre into left a n d right halves each side w o u l d be
a m i r r o r image o f the other as far as the muscles
a n d skeleton are concerned. T h e muscles therefore
occur i n pairs w i t h one on either side o f the b o d y .
W h e n both sides act together the spine w i l l be
either flexed or extended. I f one side alone acts,
then it w i l l either flex the spine laterally or rotate it
or c a r r y out a c o m b i n a t i o n o f flexion a n d rotation.
T h e spine as a whole is capable o f flexion,
extension, lateral flexion i n each direction a n d
rotation i n each d i r e c t i o n . T h e most m o b i l e
portions o f the spine are i n the cervical a n d l u m b a r
regions. T h e dorsal (thoracic spine) has a very
m u c h more l i m i t e d range o f movements. I n the
neck, flexion is brought about by the sterno-mastoid
a n d extension by the splenius a n d the semispinalis
capitis. I n the rest o f the spine extension is b r o u g h t
about b y the s a c r o s p i n a l i s (erector spinae) a n d
the q u a d r a t u s l u m b o r u m . F l e x i o n is brought
about largely by the a b d o m i n a l muscles, the rectus
a b d o m i n i s a n d the external a n d i n t e r n a l
obliques. F l e x i o n is helped b y the psoas m a j o r
w h i c h crosses the front o f the h i p j o i n t a n d the
psoas m i n o r . T h e psoas major is also a flexor o f the
hip a n d an i n t e r n a l rotator o f the h i p . A l l these
muscles w h e n acting on one side alone w i l l laterally
flex a n d / o r rotate the spine a n d trunk. T h e
quadratus l u m b o r u m i n p a r t i c u l a r has the a d d e d
function o f steadying the b o t t o m r i b w h i c h ,
through the a d d i t i o n a l action o f the various
muscles o f the r i b cage, has the effect o f steadying
the whole r i b cage.
T H E RIB C A G E
T h e external a n d i n t e r n a l intercostal muscles,
w h i c h are the equivalent o f the external a n d
29
i n t e r n a l o b l i q u e muscles o f the a b d o m i n a l w a l l ,
both help to raise the ribs. T h i s action is assisted b y
the s e r r a t u s p o s t e r i o r s u p e r i o r . T h i s latter
muscle c a n p l a y a n i m p o r t a n t part i n creating
tension i n dancers i f they are b r e a t h i n g incorrectly.
It runs from the 2 n d to the 5th ribs upwards a n d
backwards across to the m i d - l i n e to the large
ligament (the l i g a m e n t u m nuchae) at the back o f
the neck a n d to the spinous processes o f the u p p e r
three thoracic vertabrae. T h e intercostals, as their
name implies, lie between the ribs. T h e r e are eleven
pairs, corresponding to the intercostal spaces
between the twelve ribs, a n d the muscles r u n from
one r i b to the next. T h e y p l a y a n i m p o r t a n t p a r t i n
respiration because by raising the ribs they increase
the capacity o f the rib cage thus h e l p i n g to d r a w i n
air. T h i s c o m b i n e d w i t h the action o f the
d i a p h r a g m produces i n s p i r a t i o n .
T H E S H O U L D E R JOINT
T h i s as a whole is an extremely c o m p l e x j o i n t . T h e
m u s c u l a r c o n t r o l is therefore e q u a l l y c o m p l e x .
M o v e m e n t o f the shoulder takes place at two sites:
1. at the b a l l a n d socket j o i n t between the
humerus a n d the scapula;
2. by the scapula sliding over the chest w a l l at the
so-called scapulo-thoracic j o i n t . T h i s is not a
genuine j o i n t but as the scapula is o n l y
attached to the trunk b y muscles it is able to
move relatively freely i n relation to the r i b
cage.
M o v e m e n t s o f the shoulder are usually b y a
c o m b i n a t i o n o f movements at these two sites. A s a
result the range o f the shoulder is very free. F l e x i o n
(to the front) a n d a b d u c t i o n (sideways) both have
a range o f 180°. It is possible to elevate the a r m
from h a n g i n g vertically at the side to v e r t i c a l l y
above the head, either by b r i n g i n g the a r m
forwards a n d upwards or b y m o v i n g it sideways
a n d upwards. F l e x i o n a n d a b d u c t i o n both end u p
w i t h the a r m i n the same position. E x t e n s i o n
(backwards) a n d rotation are very m u c h more
l i m i t e d . I n the use o f the a r m i n heavy w o r k , e.g.
for the boys w h e n they are lifting i n d o u b l e w o r k ,
stabilisation o f the scapula itself is extremely
i m p o r t a n t . T h e muscles w h i c h move the scapula are
also responsible for stabilising it. T h e largest o f
these muscles is the trapezius. T h i s muscle takes
o r i g i n from the base o f the skull a n d a l l the
thoracic vertebrae a n d is inserted into the spine o f
the scapula a n d the clavicle. T h e s e r r a t u s
a n t e r i o r is also a large muscle that passes from the
ribs anteriorly a r o u n d the r i b cage a n d deep to the
scapula to be inserted into the m e d i a l (or spinal)
border o f the scapula. I f it is weak it allows
30 Section 1: A n a t o m y a n d Physiology
w i n g i n g o f the scapula, that is, the m e d i a l border
of the scapula stands out away from the r i b cage,
p a r t i c u l a r l y when the a r m is used to push
something. T h e r h o m b o i d m a j o r a n d r h o m b o i d
m i n o r are also i m p o r t a n t i n stabilising the scapula.
A l l these muscles as well as stabilising the scapula
do, o f course, play a part i n actual movements o f
the scapula. Stabilisation is achieved by a balance
of forces between the different muscles contracting
a n d p u l l i n g i n their various directions.
A r o u n d the actual shoulder j o i n t are what is
k n o w n as the short rotators. These are the
s u b s c a p u l a r i s , teres m i n o r and i n f r a s p i n a t u s
muscles, a l l o f w h i c h play a part i n rotating the
arm. T h e s u p r a s p i n a t u s does not actually rotate
the a r m but plays a small part i n a b d u c t i n g it.
H o w e v e r , the most i m p o r t a n t action of a l l these
four muscles is i n stabilising the head o f the
humerus i n the glenoid cavity. A s given i n the
earlier description o f the shoulder joint, the glenoid
cavity or socket is, i n fact, very shallow, like a
saucer, a n d has little or no inherent stability o f its
own. Therefore, d u r i n g movements o f the humerus
in relation to the scapula, these four muscles act i n
order to steady the head o f the humerus i n the
glenoid. T h e y have been referred to as adjustable
ligaments a n d their action is far more like this than
the action w h i c h is generally associated w i t h
muscles. O f the larger muscles, that w h i c h actually
flexes, abducts a n d extends the humerus i n relation
to the scapula is the deltoid muscle. T h e front
p o r t i o n o f this muscle w i l l flex the a r m forwards,
the m i d d l e p o r t i o n w i l l abduct the a r m sideways
a n d the back portion w i l l extend the a r m
backwards.
T h e l a t i s s i m u s d o r s i is an extremely i m p o r t a n t
muscle. It takes origin from the bottom six thoracic
vertebrae a n d indirectly from a l l the l u m b a r
vertebrae a n d from the iliac crest. It is finally
inserted into the humerus where it acts as an
a d d u c t o r o f the a r m but, on the way, it passes a
very significant slip to the inferior angle of the
scapula. T h i s plays a very i m p o r t a n t role i n the
stabilisation o f the shoulder girdle. A s as a d d u c t o r
of the a r m it is helped by pectoralis m a j o r a n d
teres m a j o r . T h e pectoralis major also pulls the
a r m forwards a n d m e d i a l l y . T h e pectoralis major
a n d latissimus dorsi are the most i m p o r t a n t muscles
w h e n lifting the body, for example - i f the b o d y is
being lifted by the arms from an a r m c h a i r or w h e n
p u l l i n g the b o d y up w h e n c l i m b i n g .
THE ELBOW
T h e elbow is essentially a hinge joint, although
rotation o f the head o f the radius against the lower
end o f the humerus takes place i n order to give
p r o n a t i o n a n d supination o f the forearm.
N o r m a l l y , full extension occurs w h e n the a r m and
forearm are i n a straight line. H o w e v e r ,
hyperextension or swayback elbows are not
p a r t i c u l a r l y u n c o m m o n and when excessive can
amount to as m u c h as 25°. F l e x i o n is from the fully
extended position to a p p r o x i m a t e l y 140°. It is
limited by the forearm c o m i n g up against the
upper a r m . A s a result, an increase i n muscle bulk
or fat w i l l decrease the possible range of flexion b y
the interposition between forearm a n d a r m of the
soft tissues.
Extension o f the elbow is achieved by the
triceps muscle, so called because it has three heads
of origin. It is the only muscle l y i n g at the back o f
the a r m a n d is the m a i n extensor o f the elbow.
Extension is helped by a small muscle, the
anconeus, w h i c h lies just at the back o f the elbow.
F l e x i o n is achieved by the b r a c h i a l i s , w h i c h lies
deeply i n the front o f the a r m a n d the
b r a c h i o r a d i a l i s , most o f w h i c h lies below the
elbow a n d extends along the forearm. M o r e
superficially i n the a r m lies the biceps (biceps
b r a c h i i is its correct name, to distinguish it from the
biceps femoris w h i c h is the lateral h a m s t r i n g
muscle) w h i c h stands out so obviously w h e n the
supinated forearm is braced i n flexion. A s well as
flexing the elbow it has the a d d i t i o n a l function o f
supinating the forearm. T h e muscle also helps to
flex the a r m i n relation to the scapula as it takes
origin from the scapula.
L o w e r d o w n a n d l y i n g i n the forearm the
s u p i n a t o r muscle helps the biceps to supinate the
forearm. P r o n a t i o n is carried out b y the p r o n a t o r
teres and the p r o n a t o r q u a d r a t u s . T h e muscles
l y i n g more distally i n the forearm need not really
concern dancers greatly. T h e y are responsible, o f
course, for flexion a n d extension o f the wrist and
flexion and extension of the fingers. T h e movements
of the fingers are also aided by the s m a l l intrinsic
muscles of the hands.
T H E HIP
T h e h i p is a very stable b a l l a n d socket j o i n t . T h e
socket is deep w i t h a r o u n d head, thus resisting
dislocation i n any direction, unlike the shoulder
j o i n t where the socket is extremely shallow. A s the
socket is deep the j o i n t is not as fully m o b i l e as the
shoulder j o i n t . H o w e v e r , to a certain extent what
w o u l d otherwise be a more m a r k e d l i m i t a t i o n of
movement has been overcome by offsetting the
head by means o f a femoral neck w h i c h leads d o w n
at an angle to the upper end o f the femoral shaft.
A s a result the h i p can be flexed to a very m u c h
 Section 1.3
greater extent than w o u l d otherwise be possible.
F l e x i o n is o n l y l i m i t e d by the thigh c o m i n g up
against the anterior w a l l o f the trunk, extension is,
however, l i m i t e d by tension i n the capsule,
ligaments a n d other soft tissues. I n a d d i t i o n to
flexion a n d extension, rotation is relatively free as
well as a b d u c t i o n a n d a d d u c t i o n .
A l t h o u g h the muscles o f the lower l i m b are o f
m u c h greater importance a n d interest to the
dancers i n m a n y ways than those i n the upper
limbs we w i l l still try to simplify matters by
concentrating only on the major muscles. It is
i m p o r t a n t to remember that these muscles w h i c h
are described are nearly always being aided by
several other muscles w h i c h have not been referred
to by name. It must also be remembered that
several muscles i n the lower l i m b cross more than
one j o i n t a n d a n i n d i v i d u a l muscle m a y therefore
act as a flexor or extensor o f both joints or as a
flexor o f one j o i n t a n d an extensor o f another.
A t the h i p j o i n t (as i n the shoulder j o i n t ) there
are several s m a l l muscles k n o w n as the s m a l l
rotators. T h e o b t u r a t o r internus, the g e m e l l u s
s u p e r i o r a n d g e m e l l u s inferior, the
p y r i f o r m i s , the q u a d r a t u s f e m o r i s a n d the
o b t u r a t o r externus a l l have a n action i n
externally rotating the femur. H o w e v e r , the a c t u a l
movements p r o d u c e d by these muscles are relatively
weak. T h e i r great i m p o r t a n c e is i n stabilising the
hip j o i n t a n d , just as i n the case of the short
rotators o f the shoulder j o i n t , they act more as
adjustable ligaments. T h e i r function is also o f great
i m p o r t a n c e i n l i m i t i n g the m e d i a l rotation o f the
femur w h i c h w o u l d otherwise take place d u r i n g the
action o f the large strong flexor muscles as these are
also m e d i a l rotators. T h e also help to prevent
excessive i n t e r n a l rotation. T h e y m a y therefore be
strained on a bad l a n d i n g a n d the pyriformis
subsequently c a n go into painful spasm.
T h e most i m p o r t a n t h i p flexor is the ilio-psoas
muscle. T h i s is made up o f the psoas major a n d the
iliacus. B o t h these muscles are inserted into the
lesser trochanter o f the femur so, as w e l l as flexing
the h i p , they w i l l rotate the femur m e d i a l l y a n d it
is this latter movement w h i c h is opposed by the
short rotators.
T h e most i m p o r t a n t lateral rotator o f the femur
at the h i p j o i n t is the a d d u c t o r group o f muscles
(see Section 1.11 T u r n - o u t , page 54). T h e three
adductors are large strong muscles o c c u p y i n g most
of the inner side o f the thigh. A s their name implies
they also adduct the thigh, p u l l i n g the two thighs
together aided b y gracilis. W h e n the dancer is
standing o n one leg they help to stabilise the pelvis
by a c t i n g against the abductors. It is the balance
31
between these two groups o f muscles, the adductors
a n d abductors, plus the balance between the flexors
a n d the extensors, w h i c h stabilises the pelvis w h e n
the dancer is w o r k i n g , p a r t i c u l a r l y the s u p p o r t i n g
leg. It is o n l y by a c h i e v i n g a really stable pelvis i n
relation to the lower l i m b on the supporting side
that the w o r k i n g leg c a n relax sufficiently to
produce the necessary fluidity o f action. Weakness
in any o f these groups leads to instability, muscle
tension a n d muscle injury. A b d u c t i o n o f the femur
is carried out by the gluteus m e d i u s a n d gluteus
m i n i m u s both o f w h i c h are inserted i n t o the
greater trochanter o f the femur. T h e tensor
fasciae latae, w h i c h is inserted into the very stout
b a n d o f fascia l a t a r u n n i n g d o w n the outer side o f
the thigh a n d e n d i n g i n the upper part o f the t i b i a ,
also helps to abduct the h i p . A d d i t i o n a l l y , the
tensor fasciae latae helps to extend the knee. I f
tight, it c a n play a significant part i n lateral
t r a c k i n g o f the patella a n d the p r o d u c t i o n o f
anterior knee p a i n (see Section 3.30). T h e gluteus
m a x i m u s has i n the m a i n a different function
from the other two gluteii a n d is the most
i m p o r t a n t h i p extensor. It also helps to tense the
fascia lata a n d has a m u c h lesser function therefore
i n h e l p i n g to abduct the femur. A s it is a h i p
extensor, w h e n the dancer has the trunk flexed
forwards at the hips the gluteus m a x i m u s rotates
the pelvis i n order to lift the trunk u p r i g h t a g a i n .
THE KNEE
T h e knee j o i n t is, i n practice, a hinge j o i n t . W h e n it
is fully extended there is no rotation possible
between the lower end o f the femur a n d the u p p e r
end o f the t i b i a . W i t h the knee slightly flexed there
is some rotation possible between the femur a n d the
tibia but this o n l y amounts to about 15° i n either
d i r e c t i o n . E x t e n s i o n o f the knee, a l t h o u g h n o r m a l l y
o c c u r r i n g fully w h e n the thigh a n d leg are i n a
straight line, is very frequently greater t h a n this,
g i v i n g a certain a m o u n t o f hyperextension
p r o d u c i n g the familiar swayback knees. F l e x i o n is,
in most people, l i m i t e d b y the c a l f muscle c o m i n g
up against the back o f the t h i g h . S t r o n g collateral
ligaments prevent any a b d u c t i o n or a d d u c t i o n o f
the knee.
T h e movement o f extension is achieved by the
q u a d r i c e p s muscle. A s its n a m e implies this is
made up o f four parts. T h e r e c t u s f e m o r i s takes
o r i g i n from the pelvis above the a c e t a b u l u m a n d
crosses the front o f the h i p j o i n t to be inserted v i a
the c o m b i n e d quadriceps tendon, patella a n d
patellar tendon i n t o the upper part o f the front o f
the t i b i a . Therefore as w e l l as e x t e n d i n g the knee it
32 Section 1: A n a t o m y a n d P h y s i o l o g y
w i l l help to flex the h i p . T h e vastus lateralis,
vastus i n t e r m e d i u s a n d vastus m e d i a l i s a l l
take their o r i g i n from the shaft of the femur. T h e y
do not cross the h i p j o i n t . T h e y , together w i t h the
rectus femoris, j o i n together at their lower ends to
form the quadriceps tendon. T h i s is inserted into
the patella, w h i c h at its lower pole gives o r i g i n to
the patellar tendon w h i c h is inserted into the front
of the upper end o f the tibia. T h e vastus medialis is
p a r t i c u l a r l y i m p o r t a n t i n dancers a n d other
athletes. It is largely responsible for the final 15° o f
extension. It also opposes the lateral t r a c k i n g o f the
patella w h i c h w o u l d otherwise take place b y the
action o f the vastus lateralis a n d the tensor fasciae
latae, the latter through the i n t e r m e d i a r y of the
fascia lata itself. I n any knee injury the vastus
medialis is the first p o r t i o n that weakens a n d wastes
a n d i n r e h a b i l i t a t i o n is the most difficult to b u i l d
up again. Its importance is referred to o n m a n y
occasions i n Section 3.
F l e x i o n o f the knee is brought about by the
hamstrings. These are the s e m i t e n d i n o s u s a n d
s e m i m e m b r a n o s u s l y i n g on the m e d i a l side o f
the back o f the thigh a n d the biceps f e m o r i s
l y i n g o n the lateral side o f the back o f the thigh. A s
well as flexing the knee they also act as h i p
extensors as they cross the back o f the h i p j o i n t
t a k i n g o r i g i n from the pelvis, apart from the short
head o f the biceps w h i c h takes its o r i g i n from the
back o f the femoral shaft. W h e n the m e d i a l
(semitendinosus a n d semimembranosus) hamstrings
a n d lateral (biceps femoris) hamstrings are not
balanced up i n strength, either following a n injury
or due to incorrect w o r k i n g , they c a n produce
uneven rotational forces at the knee w h e n the j o i n t
is a n y t h i n g other than fully extended. I n the
semi-flexed situation injury is more likely to occur.
F l e x i o n o f the knee is aided slightly by the
gracilis a n d the s a r t o r i u s . T h e latter also acts as a
flexor o f the h i p . It helps to abduct the h i p a n d
rotate the femur externally. A s a result o f these
actions i f the dancer is straining to o v e r t u r n the
feet, pushes back on the knee a n d gets into the
weightback situation, a great deal o f strain occurs
at the upper end o f the sartorius a n d this muscle
then becomes a frequent site o f the so-called g r o i n
strain. A s w i l l be seen i n Section 5, g r o i n strains
are usually a result o f incorrect weight placement.
A t the back o f the knee is a s m a l l muscle called
the popliteus, w h i c h helps to flex the knee a n d it
also w i l l rotate the tibia m e d i a l l y (internally).
W h e n the knee is flexed the m e d i a l a n d lateral
hamstrings w i l l also a i d i n rotating the tibia at the
knee, the m e d i a l hamstrings (semitendinosus a n d
semimembranosus) h e l p i n g to rotate the t i b i a
m e d i a l l y , a n d the lateral hamstrings (biceps
femoris) h e l p i n g to rotate the knee laterally.
H o w e v e r , as has been mentioned earlier, w h e n the
knee is fully extended there is no rotation possible
at the knee j o i n t . T h e ligaments lock it i n order to
prevent rotation, therefore any excessive r o t a t i o n a l
force w i l l produce damage w i t h i n the knee. A s the
knee starts to flex, then an increasing a m o u n t o f
rotation is available between the t i b i a a n d the knee
but this o n l y amounts to about 15° i n each
direction at the m a x i m u m . It is not u n t i l the knee
reaches about 45° o f flexion that significant active
rotation o f the t i b i a i n relation to the femur occurs.
A t less than this a m o u n t o f flexion, the movement
is extremely weak, a l t h o u g h this is not to i m p l y that
the rotational movement even at 45° o f flexion a n d
greater, is p a r t i c u l a r l y strong.
T H E A N K L E , FOOT A N D TOES
These joints are considered together because m a n y
of the muscles concerned w i l l act o n a l l the joints.
T h e g a s t r o c n e m i u s is the superficial muscle at the
back o f the c a l f a n d leads us into this section from
the knee, because it takes its o r i g i n from the lower
end o f the femur above the back o f the knee. It
therefore acts as a knee flexor assisting the
hamstrings. A s it passes t h r o u g h the leg it joins w i t h
the soleus. These two together form the Achilles
tendon w h i c h is inserted into the back o f the os
calcis or heel bone. T h e gastrocnemius a n d soleus
together act as plantar-flexors o f the ankle. T h e
p l a n t a r i s is a small muscle w h i c h also arises from
the back o f the lower end o f the femur. It has a
very l o n g tendon a n d is also inserted into the os
calcis. It acts i n a similar fashion to the
gastrocnemius by h e l p i n g to flex the knee a n d to
plantar-flex the ankle. Plantar-flexion is helped by
the long flexors o f the toes.
D u e to the arrangement o f the bones i n the h i n d
foot a n d foot as a whole, w h e n the ankle is
plantar-flexed it takes w i t h it the whole o f the foot,
because the m o b i l i t y o f the foot w i t h i n itself i n the
direction o f dorsi-flexion a n d plantar-flexion is not
very great. Therefore, w h e n one considers
dorsi-flexion a n d plantar-flexion o f the ankle, one
can consider the movement o f the whole foot i n
those two directions.
Dorsi-flexion o f the ankle a n d foot is carried out
by the actions o f several muscles, the t i b i a l i s
anterior, the extensor h a l l u c i s longus, the
peroneus tertius a n d the l o n g extensors o f the
toes. H o w e v e r , a l l these muscles have other actions
in addition.
 Section 1.3—1.4 33

Inversion a n d eversion o f the foot take place i n 1. that p a r t associated generally w i t h the muscles
the tarsal bones or h i n d foot. Essentially, the talus m o v i n g the b o d y a n d l i m b s a n d the associated
remains fixed i n the ankle j o i n t as far as inversion sensory perceptions, a n d
a n d eversion are concerned, merely m o v i n g as a 2. the other part, k n o w n as the a u t o m o n i c
hinge i n dorsi-flexion a n d plantar-flexion. Inversion nervous system, w h i c h supplies the nerves to
a n d eversion take place a l o n g a line through the i n v o l u n t a r y a n d c a r d i a c muscles a n d to glands.
axis o f the talus, the movement o c c u r r i n g m a i n l y i n H o w e v e r , these two systems are closely related;
the sub-taloid a n d talo-navicular joints, a l t h o u g h to reflex arcs are i n v o l v e d i n b o t h systems a n d the
a certain extent there is some inversion a n d eversion higher senses o f c o n t r o l o f each are i n the b r a i n .
i n the m i d tarsal joints i n the m i d d l e o f the foot. T h e nervous system, as a l l other systems, is based
Inversion o f the foot is obtained by a c o m b i n e d u p o n i n d i v i d u a l cells k n o w n as neurones a n d ,
action o f the t i b i a l i s p o s t e r i o r a n d the t i b i a l i s unlike other cells, they have extensions from the cell
anterior. E v e r s i o n o f the foot is carried out b y the (Fig. 1.55). O n e type o f extension is c a l l e d the
action o f the peroneal muscles. T h e l o n g extensors d e n d r o n ; this m a y be single or m u l t i p l e a n d passes
of the toes, as they cross i n front o f the ankle, d o impulses towards the cell b o d y . T h e other type o f
have a n action as mentioned i n dorsi-flexing the extension k n o w n as the a x o n conducts impulses
ankle a n d at the same time i n extending the toes. a w a y from the cell b o d y . T h e v o l u n t a r y nerves a n d
E x t e n s i o n at the foot a n d ankle is synonymous w i t h those associated w i t h sensation are s u r r o u n d e d b y a
the expression dorsi-flexion, the latter expression
being more c o m m o n l y used w h e n a p p l i e d to the
ankle a n d foot. T h e l o n g flexors o f the toes cause
them to c u r l as they flex at both the
metatarsophalangeal a n d the interphalangeal joints.
DENDRITE
A d d i t i o n a l l y , the l o n g flexors o f the toes w i l l help
to plantar-flex the ankle a n d foot, plantar-flexion
here b e i n g synonymous w i t h flexion w h e n a p p l i e d
to the ankle a n d to the foot.
A d d i t i o n a l l y , i n the foot as i n the h a n d , there are NUCLEUS OF
NERVE CELL
m a n y s m a l l muscles w h i c h are k n o w n as the
i n t r i n s i c m u s c l e s . These are responsible for
opposing the c l a w i n g effect o f the l o n g flexors o f DENDRON
the toes, so that w h e n the toes are flexed at the
metatarsophalangeal joints, the intrinsic muscles by
their a c t i o n w i l l help to keep the i n t e r p h a l a n g e a l
joints straight. T h u s i n a w e l l pointed foot, we see
the plantar-flexors o f the ankle a n d foot w o r k i n g
a n d assisted by the l o n g flexors o f the toes but the
actual flexion effect o f the last g r o u p o f muscles o n
the toes is counteracted by a strong action o f the AXON -
intrinsic muscles, keeping the toes straight i n the
pointed foot. Some o f the intrinsic muscles also
have a n effect i n m a i n t a i n i n g the transverse a r c h
across the forefoot. I f the transverse a r c h drops due
to weakness o f the intrinsic muscles, then p a i n c a n
develop under the heads o f the metatarsals ( k n o w n
as anterior metatarsalgia).

1.4 The Nervous System

T h e nervous system comprises the b r a i n , the s p i n a l
c o r d a n d p e r i p h e r a l nerves. T h e nervous system is 1.55 A Typical Nerve Cell. The arrows show the
further s u b - d i v i d e d into two parts: direction of the electrical impulses in the nerve.
34 Section 1: A n a t o m y a n d Physiology
fatty sheath a n d are k n o w n as medullated nerves or
white fibres; whereas the autonomic nerve fibres do
not have this fatty layer a n d are k n o w n as
non-medullated or grey fibres because of the actual
colour difference. T h e neurones a l l have a specific
function; sensory neurones are those w h i c h receive
s t i m u l i a n d pass them centrally to the spinal cord
a n d from there, where necessary, to the b r a i n .
M o t o r neurones are those w h i c h pass impulses from
the b r a i n a n d from the spinal cord to the muscles.
T h e sensory nerves not only receive a n d perceive
what we w o u l d consider sensations, such as hot,
c o l d , p a i n , etc. but also they are responsible for
transmitting messages concerned w i t h tension
w i t h i n muscles, tendons a n d ligaments a n d
information regarding co-ordination a n d spacial
relationships. It is the c o m b i n a t i o n o f these
mechanisms w h i c h enable y o u , for instance, to
place the tip o f y o u r finger on y o u r nose or any
other part o f y o u r b o d y without the necessity o f
w a t c h i n g it i n m o t i o n .
T h e V o l u n t a r y or S o m a t i c N e r v o u s S y s t e m
T h e term v o l u n t a r y , although c o m m o n l y a p p l i e d , is
not a p a r t i c u l a r l y satisfactory name for this p o r t i o n
of the system but it is used to distinguish the major
part o f the nervous system from the a u t o n o m i c
nervous system (vide infra). Somatic nervous
system is a better though less used name.
It is p r o b a b l y easier w h e n considering the action
of the nervous system to start peripherally, rather
than centrally. I f we consider a case where an
i n d i v i d u a l nerve is d i v i d e d , this w i l l cut through
both sensory a n d motor nerves; the result w i l l be
that no sensation o f any sort can reach the spinal
cord or the b r a i n . T h e part w i l l feel n u m b a n d
there w i l l be no appreciation o f where it is i n space.
D i v i s i o n o f the motor nerve w i l l prevent any
movement at a l l i n the distribution o f that d i v i d e d
nerve; the muscles supplied by the nerve w i l l lose
all tone as no electrical impulses can travel across
the division i n the nerve. T h i s therefore w i l l
produce w h a t is k n o w n as flaccid paralysis, i n other
words the muscle w i l l be completely soft a n d
toneless to the observer's touch.
N o w take a case o f a division across the spinal
cord itself; the spinal cord w i l l be n o r m a l , both
above a n d below the level o f division, but there w i l l
be no c o n d u c t i o n i n either direction across the
division. W e have therefore intact nerves g o i n g
from the spinal cord to the muscle a n d from the
muscle, skin a n d other tissues back to the spinal
c o r d . W i t h i n the spinal c o r d there are some nerve
connections directly between the sensory nerves a n d
the motor nerves. These three pathways between
them produce what is k n o w n as a reflex arc. I n
p r i m i t i v e creatures where there is little or no b r a i n ,
the entire organism functions by means o f these
very simple reflex arcs. T a k e n at its simplest a
reflex arc consists o f
a) a sensory receptor;
b) a sensory neurone;
c) a synapse (which is where one nerve e n d i n g
makes contact w i t h another nerve ending);
d) a motor neurone, a n d
e) an effector cell.
T h e d r a w i n g ( F i g . 1.56) shows a simple reflex arc
from a sensory receptor (e.g. p a i n appreciation) to
the spinal c o r d , v i a an intermediate neurone k n o w n
as an i n t e r n u n i c i a l neurone to the motor neurone
w h i c h w i l l supply a muscle fibre causing a
contraction. I n the simplest reflex arc the
i n t e r n u n i c i a l neurones m a y be missing.
T h e r e are reflexes w i t h i n the spinal c o r d , passing
impulses up and d o w n to leave at higher or lower
levels, as well as those going i n a n d out at the same
level. T h e r e are also more h i g h l y developed reflexes
going up a n d d o w n the spinal cord to a n d from the
brain.
Reflex actions play a v i t a l role i n
a) c o n t r o l o f the internal organs;
b) c o n t r o l l i n g the tone i n v o l u n t a r y muscles;
c) p r o d u c i n g controlled i n h i b i t i o n o f antagonistic
groups of muscles;
d) causing protective reactions.
In the division o f the spinal cord i n a higher a n i m a l
such as a m a m m a l , the a n i m a l is reduced below the
level o f the division to a p r i m i t i v e type o f state.
A l t h o u g h the b r a i n cannot receive or transmit any
messages, certain functions still occur below the
level o f division. M u s c l e tone, for instance, is
actually increased i n these reflex arcs, because of
the lack o f modification from the higher centres.
A l t h o u g h v o l u n t a r y movement has been abolished
a n d the muscle is paralysed i n that sense, the
increased tone produces what is k n o w n as spastic
paralysis because the affected muscles tend usually
to be i n spasm because o f the increased tone.
V a r i o u s reflex arcs c a n be initiated by s t i m u l i . F o r
example heat, cold or p a i n w i l l produce a
w i t h d r a w a l reflex w i t h o u t the b r a i n perceiving
a n y t h i n g . I n the absence o f injury these p r i m i t i v e
reflexes are modified by nerve impulses transmitted
from the higher centres. I n the n o r m a l a n i m a l there
are i n n u m e r a b l e reflex arcs not o n l y from the
periphery to the spinal cord a n d b r a i n but also
w i t h i n the different sections o f the b r a i n itself,
c o n t i n u a l l y modifying, altering a n d c o n t r o l l i n g a l l
aspects o f function.
 Section 1.4
1.56 Illustration of a Reflex
Arc in the Nervous System.
SENSORY
NEURONE
T h e neurological system as a whole is extremely
c o m p l i c a t e d , but i n w h a t is possibly a n
over-simplification, it might be considered that
development from p r i m i t i v e life to the h u m a n state
has progressed from below upwards, starting w i t h a
reflex arc a n d proceeding w i t h the development o f
the p o r t i o n o f the b r a i n nearest the spinal c o r d , the
h i n d - b r a i n , the cerebellum a n d m i d - b r a i n a n d
finally to the cerebral hemispheres or fore-brain.
T h e b r a i n a n d cerebellum have a very w r i n k l e d or
convoluted surface i n order to increase the
available surface area of the b r a i n . W i t h the higher
m a m m a l s , a n d p a r t i c u l a r l y w i t h primates,
increasingly c o m p l i c a t e d series o f movements can
be learned consciously, a n d once mastered can be
reproduced without obvious conscious thought
about each i n d i v i d u a l part o f the total c o m p l e x
action. T h i s does not, however, mean that once
learnt, these complex actions are then brought
about i n the lower levels o f the spinal c o r d . These
actions are still initiated a n d controlled w i t h i n the
b r a i n a n d it is a misnomer to refer to these c o m p l e x
actions as reflex actions.
The Autonomic Nervous System
O n c e again this is not a very satisfactory name as it
implies by the name a u t o n o m i c that it is
self-controlling, whereas it is i n fact closely linked
w i t h the somatic system a n d its highest centres are
in the b r a i n .
T h i s is the system that controls the i n v o l u n t a r y
a n d cardiac muscles a n d the glands. T h e a u t o n o m i c
system itself is d i v i d e d into two parts - the
sympathetic system and the parasympathetic
35
INTER NUNCIAL NEURONE
M O TO R
1 NEURONE
M USCLE
system. T h e two systems act against each other a n d
are therefore called antagonistic. T h e sympathetic
system is a s t i m u l a t o r y system a n d acts w i t h
a d r e n a l i n to prepare the b o d y for a c t i o n . I n i t i a l l y
this was, o f course, to either fight an enemy or flee
from h i m , but i n the more m o d e r n situation it w i l l
produce the keyed-up feeling required for social
confrontations such as examinations, performances
or arguments w i t h other people. It is the
sympathetic system a n d the a d r e n a l i n w h i c h
increase the pulse rate a n d blood pressure o n these
occasions a n d produce a feeling o f 'butterflies' i n
the stomach b y d i v e r t i n g the b l o o d s u p p l y , from
the a l i m e n t a r y tract i n p a r t i c u l a r , to other areas
w h i c h are needed for the 'figurative fight'. T h e
parasympathetic system is i n h i b i t o r y i n type a n d
tends to produce rest a n d r e l a x a t i o n i n the b o d y
a n d aids digestion b y increasing the b l o o d s u p p l y to
the a b d o m i n a l organs. T h e sympathetic a n d
parasympathetic systems have their m a i n nerve
supplies outside the spinal c o r d , starting i n w h a t is
k n o w as g a n g l i a a n d then r u n n i n g up a n d d o w n
inside the trunk. P a r a s y m p a t h e t i c a n d sympathetic
nerve fibres travel w i t h the o r d i n a r y m o t o r a n d
sensory nerves to the l i m b s a n d muscles.
T h e Sensory S y s t e m
T h e r e are three types o f sensory endings:
1. those w h i c h c a n detect s t i m u l i c o m i n g from
outside the body. These are k n o w n as
exteroceptors.
2. endings w h i c h sense s t i m u l i from w i t h i n the
body, p a r t i c u l a r l y the i n t e r n a l organs, such as
the a l i m e n t a r y tract. K n o w n as enteroceptors.
36 Section 1: A n a t o m y a n d P h y s i o l o g y
3. those w h i c h can detect the tension i n the
muscles a n d tendons. These are k n o w n as
proprioceptors.
S t i m u l a t i o n o f the exteroceptors produces a
conscious awareness o f the type o f stimulus.
H o w e v e r , we are not n o r m a l l y aware o f the
s t i m u l a t i o n o f enteroceptors a n d proprioceptors
except for a feeling o f hunger or unless it reaches
the point where the stimulus is so great that it is
interpreted as a feeling o f p a i n . T h e exteroceptors
are responsible for p r o d u c i n g a variety o f conscious
effects; these are sight, taste, smell, touch,
temperature, p a i n , hearing a n d balance. T h e latter
two are both detected w i t h i n the ear.
O v e r - s t i m u l a t i o n o f touch, temperature a n d even o f
h e a r i n g m a y be interpreted as p a i n .
SKIN SENSATION
T e m p e r a t u r e a n d p a i n are protective types o f
sensation. T o u c h is largely connected w i t h the use
of the l i m b s a n d movement. A person w i t h a n u m b
h a n d or even a n u m b finger finds that the use o f
the h a n d i n p i c k i n g things up a n d p a r t i c u l a r l y i n
fine a n d skilled uses is seriously i m p a i r e d . T h e y w i l l
not k n o w that they are h o l d i n g something or h o w
tightly they are h o l d i n g it a n d they therefore tend
to d r o p objects. T h e y w i l l frequently be under the
misapprehension that the h a n d is weak, a l t h o u g h
this is not i n fact the case. Loss o f sensibility to
touch i n the feet produces a s t a m p i n g gait because
the person cannot feel the feet t o u c h i n g the g r o u n d
a n d therefore the necessary s t i m u l a t i o n to initiate
the reflex arcs is absent. A s far as the dancer or
athlete is concerned we c a n pass over the taste a n d
smell modalities.
A U R A L SENSATIONS: SOUND A N D B A L A N C E
A l t h o u g h the appreciation of music i n both p i t c h
a n d r h y t h m is i m p o r t a n t to a dancer, h e a r i n g
problems are not something u p o n w h i c h we need
d w e l l i n a w o r k such as this. Balance is, however,
SUPERIOR
SEM I-CIRCULAR
CANALS LATERAL
POSTERIOR
ANTERIOR
extremely i m p o r t a n t . T h e organs o f balance are
situated i n the inner ear: there are three
semi-circular canals l y i n g i n different planes to each
other ( F i g . 1.57). T h e cells inside the canals have
hair-like processes a n d the canals themselves are
filled w i t h fluid. H e a r i n g a p p r e c i a t i o n takes place
in the cochlea.
T h e movement o f fluid w i t h i n the canals
stimulates the hair-like processes a n d it is this
interpretation o f the stimuli w h i c h produces a sense
of balance. Diseases o f the inner ear can produce a
sensation o f falling or dizziness, k n o w n as vertigo.
T h i s is often temporary i n nature a n d frequently
associated w i t h a c o l d a n d possibly a m i d d l e ear or
inner ear infection. T h e ability to balance is a
c o m b i n a t i o n o f the i n f o r m a t i o n received from the
inner ear, the i n f o r m a t i o n received from the
proprioceptors i n the muscles a n d also the
information received from the eyes. T h e eyes are
the least i m p o r t a n t as the n o r m a l person has no
difficulty i n w a l k i n g or standing i n total darkness.
H o w e v e r , i f there is damage to the inner ear, then
the visual reflexes c a n take over to a certain extent.
In these circumstances i f the person then closes his
eyes there w i l l be a tendency to fall over.
VISUAL SENSATION
V i s u a l defects w i t h w h i c h one is b o r n are most
c o m m o n l y caused by too l o n g or too short a n eye
b a l l a n d these defects can be corrected by
spectacles or by contact lenses. A s there is a small
distance between the eyes, the a c t u a l field of vision
in each eye is slightly different a n d it is this slight
difference i n field o f vision w h i c h the b r a i n can
interpret to produce a stereoscopic or 3 - D effect.
T h i s gives a n accurate j u d g m e n t o f distance,
a l l o w i n g objects to be touched or picked u p
extremely accurately. I n a person b o r n w i t h
m o n o c u l a r vision the b r a i n compensates extremely
efficiently for this defect a n d such a person is
C O C H LE A
ANTERIOR
ANTERIOR
ANTERIOR
 Section 1.4-1.5
HAIR
SEB AC EO U S G LAND
1.58 Diagram of a
Cross-section of the Skin. ilf
usually only at a disadvantage i n r a p i d b a l l games.
H o w e v e r , i f vision is lost i n one eye later on i n life
the i n d i v i d u a l has far greater difficulty i n
compensating. A s a result there can be problems
p i c k i n g up objects a n d d r i v i n g vehicles.
1.5 The Skin
T h e skin comprises two layers o f tissue ( F i g . 1.58):
the epidermis, w h i c h is the superficial or outer part
a n d the dermis w h i c h is the deeper part. T h e
dermis contains nerves a n d blood vessels; the
epidermis has neither nerves nor blood vessels. I n
the deeper layers o f the epidermis are l i v i n g cells
w h i c h proliferate, p u s h i n g the more superficial cells
towards the surface. A s they get nearer to the
surface they become flattened a n d then die, g i v i n g
layers o f dead, h o r n y cells. T h e epidermis is b e i n g
constantly renewed by g r o w t h from the deeper
layers a n d the superficial h o r n y cells are constantly
shed. T h i s is p a r t i c u l a r l y w e l l demonstrated w h e n a
part has been encased i n plaster o f Paris a n d the
dead, h o r n y cells are then only too apparent where
they have not been w o r n a w a y but are still l y i n g i n
place, g i v i n g the appearance o f a scaly reptile-type
skin. F r i c t i o n a n d pressure both stimulate the
g r o w t h o f the cells o f the deeper part o f the
epidermis, t h i c k e n i n g up the e p i d e r m a l layer. T h i s
is n o r m a l o n the soles a n d the palms, p a r t i c u l a r l y i n
those w h o w a l k bare-footed or w h o do heavy
m a n u a l labour. I n certain areas this thickness m a y
be localised, p r o d u c i n g a callosity.
37
D U C T O F SW EAT GLAND
EPIDERMIS
DERMIS
SW EAT G LAND
PAPILLA O F HAIR
T h e skin is not permeable to water. T h i s is not to
prevent the r a i n from getting i n but to prevent
water b e i n g lost from the b o d y . T h e epidermis is
also a protective m e c h a n i s m that prevents the entry
of germs.
T h e skin contains two types o f glands ( F i g . 1.58):
1. the sweat glands - the chief function o f w h i c h
is to help cool the b o d y . W h e n the temperature
of the b o d y rises the sweat glands secrete sweat;
this covers the skin a n d evaporates. I n order to
be turned from a l i q u i d into a gas, i.e.
evaporate, energy has to be absorbed; this is
done i n the form o f heat absorption from the
b o d y a n d thus the p r o d u c t i o n o f the c o o l i n g
effect. T h e sweat contains various types o f salt
a n d some waste materials from the body. T h e
sweat c a n be looked u p o n as p l a y i n g a m i n o r
part i n the excretion o f these materials.
H o w e v e r , i n a hot c l i m a t e where sweating is
profuse the b o d y is able to regulate the a m o u n t
of electrolytes or salts i n the sweat a n d decrease
the loss to p r a c t i c a l l y n i l . W e r e this not the case
there w o u l d be a serious d e p l e t i o n o f essential
electrolytes i n the b o d y .
2. the sebaceous glands, w h i c h p r o d u c e a n o i l y
secretion k n o w n as sebum w h i c h lubricates the
h o r n y e p i d e r m a l cells a n d the hairs to prevent
them from b e c o m i n g brittle. ( M a m m a r y glands
w h i c h produce m i l k are specialist forms o f
sebaceous glands.)
T h e skin contains nerve endings w h i c h perceive
temperature a n d t o u c h . P a i n endings are at a
deeper level.
38 Section 1: A n a t o m y a n d P h y s i o l o g y
1.6 The Gardio-vascular
System
T h i s system comprises the blood w h i c h circulates
a r o u n d the arteries, veins and capillaries, the heart
w h i c h pumps the blood through the b l o o d vessels,
a n d the arteries, veins and capillaries themselves.
The Blood
T h e b l o o d consists of two portions: there is a l i q u i d
part w h i c h accounts for just over h a l f the v o l u m e
of the whole blood and a cellular part w h i c h
accounts for just under half.
T h e cells themselves are o f two m a i n types - the
red cells a n d the white cells. T h e red cells do not
have nuclei by the time they enter the b l o o d
stream. T h e y are responsible for c a r r y i n g the
oxygen a n d give the blood its red colour. T h e r e are
about four a n d a h a l f to five m i l l i o n red b l o o d cells
i n each c u b i c millimetre o f b l o o d . T h e red pigment
i n the red blood cells is haemoglobin; this c a n
c o m b i n e very easily w i t h oxygen a n d equally easily
c a n shed the oxygen again a n d it is by this method
that oxygen is transported a r o u n d the body, taking
it from the air i n the lungs to release it where
required i n the tissues. T h e red blood cells o n l y
exist i n the blood stream for three to four months
before being broken d o w n . T h e y are m a i n l y
p r o d u c e d i n the red bone m a r r o w w h i c h contains
what is k n o w n as erythropoietic tissue - the red
m a r r o w i n adult life is largely confined to the flat
bones, e.g. the pelvis a n d the scapula, a n d the ends
of the l o n g bones. I n c h i l d h o o d most o f the bones
c o n t a i n red m a r r o w but this q u a n t i t y decreases i n
adult life. I n these inactive sites, the red m a r r o w
becomes yellow m a r r o w w h i c h does not c o n t a i n
erythropoietic tissue. H o w e v e r , i f d e m a n d suddenly
becomes great, even i n adult life the yellow bone
m a r r o w can revert to red bone m a r r o w a n d start
p r o d u c i n g the red corpuscles once more. T h i s m a y
be stimulated by chronic blood loss, e.g. w h e n
b l o o d is lost g r a d u a l l y over a l o n g period as i n a
bleeding ulcer, etc.
W h e n the cells are broken d o w n after three to
four months the i r o n is retained i n the b o d y a n d is
stored i n the liver to be used again for m a k i n g
further red corpuscles. T h e other products from the
b r e a k d o w n o f the haemoglobin are excreted i n the
bile w h i c h passes into the a l i m e n t a r y tract a n d
hence out o f the body i n the faeces. T h e white
b l o o d corpuscles, w h i c h are also k n o w n as
leucocytes, are fewer i n n u m b e r than the red
corpuscles. T h e r e are four thousand to ten
thousand per cubic m i l l i m e t r e o f b l o o d , but various
diseases c a n produce a very m a r k e d increase i n the
n u m b e r o f white cells. T h e white cells themselves
are d i v i d e d into two types: p o l y m o r p h o n u c l e a r
leucocytes or granulocytes 6 0 - 7 5 % a n d
m o n o n u c l e a r leucocytes or non-granulocytes
2 5 - 4 0 % . T h e granulocytes have large irregular
nuclei w h i c h are lobulated. T h e y are s u b d i v i d e d by
their staining characteristics w h e n e x a m i n e d
microscopically: neutrophils 6 0 - 7 0 % , eosinophils
2 - 4 % a n d basophils 0.5-2%.
ANTERIORT h e neutrophils are
those most concerned w i t h the attack on bacteria
a n d foreign particles. T h e y r a p i d l y collect at any
site o f infection or invasion by foreign matter,
where they act by s u r r o u n d i n g these particles or
organisms by w h a t is k n o w n as a m o e b o i d
movements. I n this action the i n d i v i d u a l cells come
up against the foreign body or particle and then
surround it - the cell membrane breaks d o w n a n d
the foreign particle is taken into the cell itself a n d
the cell m e m b r a n e reforms. T h e eosinophils
increase i n numbers as a result o f allergic reactions.
T h e basophils manufacture h e p a r i n , w h i c h helps to
prevent blood clotting i n the b l o o d vessels a n d
histamine w h i c h causes the s m a l l b l o o d vessels to
dilate, usually as a result o f local injury. T h e
basophils are, however, by no means the sole source
of either h e p a r i n or histamine.
T h e other group o f white cells are the
m o n o n u c l e a r leucocytes, each h a v i n g a large r o u n d
nucleus. T h e y form some 2 5 % o f the white blood
cells; the majority o f these are lymphocytes w h i c h
are associated w i t h i m m u n o l o g i c a l responses.
T h e r e is a t h i r d n o n - l i q u i d component to b l o o d .
These are the platelets; they are very small a n d are
not cells. T h e b l o o d platelets are associated w i t h the
clotting o f b l o o d . T h e m e c h a n i s m o f blood clotting
is extremely complex a n d there are a large n u m b e r
of factors i n v o l v e d ; it is the interaction o f these
various factors w h i c h produces c l o t t i n g at the
proper time. I f one or more o f the factors is missing
then blood clotting m a y not occur. T h i s happens i n
diseases such as h a e m o p h i l i a . I n a greatly
over-simplified scheme, c l o t t i n g is p r o d u c e d by the
p r o d u c t i o n o f thrombokinase from b l o o d platelets
a n d injured tissue, this then acts w i t h a substance
called p r o t h r o m b i n i n the plasma, f o r m i n g
t h r o m b i n . T h i s action c a n o n l y take place i f there is
c a l c i u m present i n the b l o o d as is the n o r m a l state
of affairs. T h e t h r o m b i n then acts w i t h a protein i n
the blood k n o w n as fibrinogen p r o d u c i n g fibrin.
T h i s fibrin w i l l form a net w h i c h g r a d u a l l y
becomes denser w i t h the formation o f more fibrin.
T h e red a n d white corpuscles get caught u p i n this
net a n d form the clot. S e r u m is the l i q u i d that
ANTERIOR
 Section 1.6 39

remains after a clot has formed, i.e. when a l l the

M USCULAR WALL
clotting factors a n d cells have been removed.
T h e b l o o d is the transport system o f the body
a n d as such has a variety o f different functions:
1. It carries gases a r o u n d the body. O x y g e n is
carried m a i n l y i n c o m b i n a t i o n w i t h
h a e m o g l o b i n i n the red b l o o d cells and is
required by the tissues as part o f their
metabolism. A small amount o f oxygen is
actually dissolved i n the plasma. C a r b o n
d i o x i d e is returned from the tissues to the lungs t
i n both the red cells a n d the plasma. N i t r o g e n
is also c a r r i e d a r o u n d the body dissolved i n the ARTERY
p l a s m a . T h i s is an inert gas a n d forms the b u l k
of the air that we breathe. It is this nitrogen i n VALVES
the b l o o d stream w h i c h causes the problems
w i t h deep sea d i v i n g ; w i t h an increased air
pressure being breathed, a far greater a m o u n t
of nitrogen becomes dissolved i n the b l o o d . I f
the d i v e r is brought to the surface a n d
therefore to a reduced pressure too r a p i d l y , the
nitrogen w i l l no longer r e m a i n dissolved i n the
b l o o d because o f this decrease i n pressure a n d
it w i l l form bubbles i n the b l o o d stream. These
bubbles c a n block the small c a p i l l a r y vessels
a n d this results i n death o f the tissues w h i c h
w o u l d n o r m a l l y be supplied by these capillaries. VEIN
2. F o o d products are carried to the tissues o f the
b o d y a n d waste m a t e r i a l from tissue 1.59 Cross-section of an Artery and a Vein. Note the
metabolism is carried either as c a r b o n d i o x i d e muscular wall in the artery which is absent in the vein.
to the lungs or as other waste products to the
kidneys where it is excreted i n the urine. electrolytes, food substances a n d gases c a n pass
V a r i o u s salts a n d electrolytes are carried through the walls into the tissues a n d waste
a r o u n d the body i n the plasma. M a n y o f these substances c a n pass back a g a i n . T h e capillaries then
are required by the cells although they cannot g r a d u a l l y j o i n together to form venules a n d veins.
be looked u p o n as a true food item. These have rather thicker walls than the capillaries
3. W h i t e b l o o d corpuscles are constantly but are very m u c h thinner t h a n arteries ( F i g . 1.59).
transported a r o u n d the b l o o d stream so that T h e veins have very little muscle i n their walls a n d
they c a n be readily available as part o f the are far less elastic than the arteries.
defence system against infection or the A s c a n be seen from the schematic d i a g r a m ( F i g .
penetration b y any foreign m a t e r i a l . 1.60) o f the c i r c u l a t i o n , the heart (Figs 1.61 a n d
4. H e a t is carried to the skin for r e m o v a l by a 1.62) is a d o u b l e p u m p . E a c h p u m p is d i v i d e d into
c o m b i n a t i o n o f sweating a n d r a d i a t i o n . two parts, an a t r i u m w h i c h receives the b l o o d
w h i c h it then passes t h r o u g h to a ventricle w h i c h
gives the powerful c o n t r a c t i o n to push the b l o o d
C i r c u l a t i o n o f the B l o o d
a r o u n d the c i r c u l a t i o n . B l o o d r e t u r n i n g from the
O b v i o u s l y i n order to perform the functions that m a i n part o f the b o d y enters the right a t r i u m a n d
have been described the b l o o d has to travel a r o u n d passes from there to the right ventricle; from the
the body. T h e heart pumps the b l o o d d o w n right ventricle it is p u m p e d to the lungs v i a the
t h r o u g h the arteries into g r a d u a l l y decreasing sizes p u l m o n a r y artery a n d then a r o u n d the capillaries
of vessels u n t i l the capillaries are reached. T h e of the lungs where it c a n get r i d o f the c a r b o n
arteries a n d the smaller arteries (arterioles) have d i o x i d e a n d absorb o x y g e n . T h e b l o o d g o i n g to the
m u s c u l a r walls w h i c h stretch a n d contract ( F i g . lungs is de-oxygenated a n d full o f c a r b o n d i o x i d e ;
1.59). T h e capillaries have extremely t h i n walls the b l o o d l e a v i n g the lungs has lost most o f its
w h i c h are o n l y one cell thick, so that salts, c a r b o n d i o x i d e a n d is l o a d e d w i t h o x y g e n . F r o m
40 Section 1: A n a t o m y a n d P h y s i o l o g y

CAPILLARIES OF COM M ON C AR O TID AR TER IES

HEAD AND NECK RIGH7 LEFT
AND UPPER LIMBS

RIGHT
CAPILLARIES
SUBCLAVIAN
OF LUNGS
AR TER Y j
AND VEIN 1

ARCH OF AORTA

RIGHT
PULM ONARY - PULMONARY
RIGHT LEFT AR TER Y ------- TRUNK
SIDE OF SIDE OF
HEART-? HEART
AURICLE
AURICLE OF LEFT
OF RIGHT ATRIUM
. CAPILLARIES ATRIUM
O F TRUNK
AND LOWER LEFT
LIMBS VENTRICLE
RIGHT
VENTRICLE
S
U
LE
SO

1.60 Diagrammatic Representation of the Circulation. 1.61 The Heart.

the lungs, v i a the p u l m o n a r y veins, it enters the left
side o f the heart i n the left a t r i u m , passes from
there to the left ventricle a n d is then p u m p e d
a r o u n d the systemic c i r c u l a t i o n , as it is k n o w n . T h e
c i r c u l a t i o n g o i n g through the lungs is k n o w n as the
p u l m o n a r y c i r c u l a t i o n . F a r greater effort is required
from the heart to p u m p the blood r o u n d the very
m u c h larger systemic c i r c u l a t i o n , so the left side o f
the heart has thicker muscle than the right side. I n
its p u m p i n g action the atria first contract, filling
the ventricles w h i c h expand to accept the b l o o d .
T h e ventricles thereafter i m m e d i a t e l y contract,
g i v i n g the familiar heart sound o f ' l u b - d u p ' , these
being the contractions o f the atria followed by the
ventricles. T h e r e are valves at the entrance to each
of the four chambers o f the heart i n order to
prevent the b l o o d being pushed back i n the
direction from w h i c h it came by the contraction o f
the heart muscle.
T h e rate o f the heart beat is controlled by a
special area o f cardiac muscle k n o w n as the
sinu-atrial node. T h i s produces a r h y t h m i c
contraction a n d it acts completely i n isolation. T h e
wave o f contraction o f the muscles spreads through
the atrial muscles causing a complete contraction o f
each a t r i u m ; it does not spread d i r e c t l y to the
ventricle but the impulses go v i a another special
node o f cardiac muscle, k n o w n as the
atrio-ventricular node, a n d then d o w n a special
bundle called the atrio-ventricular b u n d l e . T h i s
causes the stimulation o f the v e n t r i c u l a r muscle
w h i c h begins at the apex of the ventricle, squeezing
the blood up into the aorta a n d o n i n t o the arteries.
A l t h o u g h the sinu-atrial node has its o w n
completely independent r h y t h m i c c o n t r a c t i o n this is
m o d u l a t e d by s t i m u l i from the sympathetic a n d
para-sympathetic nerves. Para-sympathetic
stimulation causes a slowing i n the rate o f the heart
beat a n d sympathetic s t i m u l a t i o n causes an
acceleration o f the heart rate.
F r o m the left side o f the heart the b l o o d is
squeezed into the major artery w h i c h is k n o w n as
 Section 1.6
LE F T COMM ON
CAR O TID AR TER Y
T O LUNG
PULM ONARY VEIN
SUPERIOR VENA CAVA
RIGHT ATRIUM
INFERIOR VENA CAVA
1.62 Diagram of the Circulation of the Blood within the Heart and Great Vessels.
the aorta; this then sub-divides into the lesser
arteries a n d arterioles a n d then the capillaries, as
described earlier. A s the ventricle contracts the
pressure i n the aorta rises a n d this pressure is, o f
course, transmitted d o w n through the rest o f the
c i r c u l a t i o n . T o accommodate the blood the aorta
a n d arteries e x p a n d ; w h e n the ventricle ceases to
contract, valves between the aorta a n d the ventricle
close due to the pressure o f the b l o o d i n the aorta.
F o l l o w i n g this the muscles i n the walls o f the
arteries contract as a direct result o f the stimulus o f
the stretching o f the vessel walls. T h i s then acts as a
secondary p u m p , squeezing the blood further out to
the periphery. It also has a secondary effect o f
m a i n t a i n i n g a pressure i n the arteries i n between
the v e n t r i c u l a r contractions. I f this d i d not occur
the pressure w o u l d rise d u r i n g the v e n t r i c u l a r
contractions a n d then d r o p a w a y to n o t h i n g w h e n
the ventricles ceased to contract.
It is this c o m b i n e d mechanism w h i c h gives the
two readings w h i c h are obtained w h e n the blood
41
LE FT SUBCLAVIAN AR TER Y
^ ARCH OF AO R TA
PULM ONARY AR TER Y
T O LUNG
PULM ONARY
VEINS
L E F T VENTRICLE
Ivtf
I^
I 7
.
I
I'.-:
AO R TA
pressure is taken w i t h a s p h y g m o m a n o m e t e r d u r i n g
a m e d i c a l e x a m i n a t i o n . T h e top pressure o f about
120 millimetres o f m e r c u r y , w h i c h is the average i n
a healthy adult, is the pressure w h i c h is reached at
its m a x i m u m w h e n the ventricle is c o n t r a c t i n g .
W h e n the ventricles relax pressure falls to about 80
millimetres o f m e r c u r y a n d it is the c o m b i n a t i o n o f
elasticity a n d m u s c u l a r c o n t r a c t i o n i n the walls o f
the arteries w h i c h m a i n t a i n s the pressure from
falling below this level at the time o f the heart
muscle relaxation. T h e wave o f pressure passing
d o w n through the arterial tree is detected as a pulse
at various sites i n the b o d y where a n artery c a n be
compressed between a n e x a m i n i n g finger a n d some
firm, but deeper structure. T h e pulse rate
corresponds to each c o n t r a c t i o n o f the heart
muscle, so i n this w a y the heart rate c a n be
measured very s i m p l y .
I n the n o r m a l , undiseased heart the pulse rate,
that is the heart contractions, are c o m p l e t e l y
regular a n d only the rate changes. T h e rate is
42 Section 1: A n a t o m y a n d P h y s i o l o g y
increased by the sympathetic nervous system or the
release o f a d r e n a l i n into the b l o o d system a n d is a
n a t u r a l response to a n increase i n d e m a n d b y the
rest o f the b o d y for oxygenated b l o o d . T h e increase
i n heart rate is p a r t i c u l a r l y apparent on exercise
but everyone has been equally aware o f an increase
i n heart rate d u r i n g periods o f stress a n d
nervousness. T h i s latter increase is produced by
sympathetic nervous stimulation. Irregularity of the
pulse, w h i c h reflects irregularity o f the heart beat,
occurs o n l y i n a diseased heart, notably i n those
people w h o have suffered from heart attacks or
c o r o n a r y thrombosis. T h i s can cause damage to the
very special portions o f cardiac muscle, the
sinu-atrial node a n d the atrio-ventricular node a n d
the c o n d u c t i n g pathways, thus interfering w i t h the
n o r m a l s t i m u l a t i o n o f the cardiac muscle.
I n n o r m a l , healthy people there is a v a r i a t i o n i n
heart rate corresponding to inspiration a n d
e x p i r a t i o n d u r i n g respiration. O n inspiration the
heart rate w i l l increase slightly a n d on e x p i r a t i o n it
w i l l decrease a little. It is possible to detect this very
easily i n oneself b y breathing deeply a n d slowly
w i t h a finger o n the pulse.
T h e c i r c u l a t i o n through the lungs v i a the
p u l m o n a r y arteries a n d capillaries a n d back by the
p u l m o n a r y veins is mechanically very s i m i l a r to the
systemic c i r c u l a t i o n through the aorta, arteries a n d
major veins. H o w e v e r , the pressures w i t h i n the
p u l m o n a r y c i r c u l a t i o n are less than those on the
systemic side.
I n the systemic c i r c u l a t i o n the b l o o d flows from
the aorta, arteries a n d arterioles to the capillaries
w h i c h form what is k n o w n as the c a p i l l a r y bed, a
gigantic mesh-work o f minute vessels where the
actual exchange o f oxygen, c a r b o n dioxide, food
a n d waste products occurs.
F r o m the capillaries the blood passes into tiny
veins or venules a n d from there into g r a d u a l l y
larger veins, a n d so back v i a the vena c a v a to the
right side o f the heart. D u r i n g the heart beat the
pulse w a v e is lost i n the c a p i l l a r y system. Therefore
the pressure w i t h i n the veins remains at a far more
constant level. T h e r e are, however, three totally
separate factors w h i c h affect the pressure w i t h i n the
veins; the first is gravity - i n the standing person
from the level o f the heart d o w n w a r d s there is the
height o f the c o l u m n o f b l o o d above the level at
w h i c h it m i g h t be measured i n any one p a r t i c u l a r
vein, thus i n the veins o f the feet there is a c o l u m n
of b l o o d about four feet h i g h i n a six-foot person.
Q u i t e a lot o f pressure is therefore required to push
this c o l u m n o f b l o o d up towards the heart. T h i s is
aided b y valves w i t h i n the veins preventing the
blood from flowing i n the w r o n g direction a l o n g
the veins. I f the valves become incompetent a n d
fail to h o l d the b l o o d back the veins become very
distended a n d it is this factor w h i c h produces w h a t
is k n o w n as varicose veins. A b o v e the level o f the
heart there is o f course negative pressure as the
blood drains d o w n h i l l from the head a n d neck
towards the heart.
T h e second factor w h i c h aids the flow o f b l o o d
along the veins is muscular c o n t r a c t i o n ; m a n y veins
pass i n between muscles i n the l i m b s a n d trunk a n d
as these muscles contract a n d tighten they w i l l
squeeze the b l o o d a l o n g i n one d i r e c t i o n , i.e.
towards the heart. T h i s one-directional flow is
brought about by the presence o f the valves i n the
veins, as already mentioned, w h i c h o n l y a l l o w the
blood to pass i n one d i r e c t i o n . T h i s effect o f the
body muscles i n a i d i n g the c i r c u l a t i o n is sometimes
referred to as the p e r i p h e r a l p u m p .
T h e t h i r d factor associated w i t h the c i r c u l a t i o n is
respiration: w h e n i n s p i r a t i o n takes place, that is
breathing i n , the contraction o f the d i a p h r a g m a n d
the contraction o f the muscles between the ribs
increases the size o f the chest c a v i t y , this produces a
negative pressure w i t h i n the chest c a v i t y , sucking
air into the lungs; at the same time this negative
pressure w i l l also affect the large veins w i t h i n the
chest p r o d u c i n g a slight negative pressure w i t h i n
them, h e l p i n g to d r a w the b l o o d u p from the
peripheral c i r c u l a t i o n .
The Lymphatic System
W h i l e not strictly p a r t o f the cardio-vascular system
the l y m p h a t i c system m a y be considered i n this
chapter as the l y m p h finally drains i n t o the general
circulation.
I n the capillaries o f the general c i r c u l a t i o n the
walls are extremely t h i n so that some o f the l i q u i d
p o r t i o n o f the b l o o d can pass t h r o u g h . O n c e
outside it forms tissue fluid, or interstitial fluid,
l y i n g between the cells i n tissue spaces. M u c h o f
this passes back into the b l o o d stream but the
l y m p h a t i c system serves to d r a i n any excess. It w i l l
also remove any particulate matter a n d large
molecules, such as protein, w h i c h cannot pass
directly into the b l o o d because o f their size. These
particles or molecules are c a r r i e d i n the l y m p h . T h e
l y m p h a t i c system starts as very fine capillaries
w h i c h open directly into the tissue spaces so there
are no walls for the tissue fluid a n d s m a l l particles
to pass through. O n c e gathered into these
capillaries the fluid is k n o w n as l y m p h . T h e l y m p h
capillaries j o i n together to form l y m p h a t i c vessels
w h i c h , like veins, have valves, t h o u g h they are far
more numerous. T h e l y m p h vessels w i l l j o i n
 Section 1.6-1.7 43

together a n d a l o n g their course w i l l pass through

l y m p h glands or nodes. These l y m p h nodes tend to
become grouped together i n various parts o f the
b o d y n o t a b l y the groins, axillae, inside the trunk - M OUTH
a l o n g the base o f the vessels c o m i n g from the
a l i m e n t a r y tract a n d i n the central part o f the
chest. These l y m p h nodes act as filters to prevent
u n w a n t e d matter, such as bacteria, from g a i n i n g
access to the b l o o d stream. I f they intercept a
OESO PH A G US
significant a m o u n t o f infected material c o n t a i n i n g a
large n u m b e r o f bacteria the l y m p h glands
themselves c a n become painful, swollen a n d
inflamed. T h i s is p a r t i c u l a r l y well shown i n
tonsilitis because the tonsils themselves are little
masses o f l y m p h g l a n d tissue. After passing through
the l y m p h nodes i n the l y m p h c i r c u l a t i o n the
STO M A C H
l y m p h vessels converge a n d g r a d u a l l y produce
larger l y m p h vessels w h i c h finally d r a i n into the
large veins before they reach the heart.

DUODENUM

1.7 The Alimentary Canal and

- CO LO N
Digestion
The Alimentary Canal

T h i s runs from the m o u t h as a continuous tube to

the anus ( F i g . 1.63). F o o d is taken into the m o u t h , SM ALL
INTESTINE
where the particle size is b r o k e n d o w n by c h e w i n g (JE JU N U M
before the b a l l o f food, or bolus, is swallowed. AND ILEUM )
W h e n this happens the back o f the nasal c a v i t y is
closed by the soft palate. T h e roof o f the m o u t h is
made up o f two portions, the front h a l f being the
APPENDIX
h a r d palate w h i c h is fixed, a n d the back h a l f being
I PffCmv-C.
the soft palate, w h i c h is movable. T h i s latter palate R ECTUM
c a n be lifted up, closing the nasopharynx so that
food cannot enter this area. A t the same time the ANUS
l a r y n x , w h i c h lies at the b e g i n n i n g o f the 1.63 Diagram of the Alimentary Canal.
respiratory tubes or trachea, is pulled upwards a n d
forwards a n d is closed by a fold o f tissue k n o w n as
the glottis. T h i s prevents food entering the trachea. two other ducts w h i c h have j o i n e d together just
F r o m the p h a r y n x the bolus enters a tube k n o w n as before entering the l u m e n o f the d u o d e n u m . These
the oesophagus w h i c h extends from the are
o r o - p h a r y n x (mouth a n d throat) d o w n through the a) the bile duct c o m i n g from the gall b l a d d e r a n d
chest c a v i t y a n d t h r o u g h a hole or hiatus i n the the liver to b r i n g bile a n d bile salts, a n d
d i a p h r a m to enter the stomach. T h e stomach acts b) the pancreatic duct w h i c h brings digestive
m e c h a n i c a l l y as a large receptacle to c o n t a i n the enzymes from the pancreas.
mass o f food from a meal before it is passed o n for F o l l o w i n g the d u o d e n u m there is the r e m a i n d e r o f
further digestive processes, as well as i n i t i a t i n g some the small intestine c o m p r i s i n g the j e j u n u m a n d then
of the c h e m i c a l digestive processes. F o l l o w i n g the the i l e u m . T h e latter leads into the c a e c u m , w h i c h
stomach there is a short length o f small bowel is the b e g i n n i n g o f the large b o w e l a n d from w h i c h
k n o w n as the d u o d e n u m . L e a d i n g into the the a p p e n d i x arises. T h e r e m a i n d e r o f the large
d u o d e n u m is a d u c t (or tube) w h i c h is made u p o f bowel is made u p o f the ascending, transverse a n d
44 Section 1: A n a t o m y a n d Physiology
descending parts o f the c o l o n w h i c h lead into the
r e c t u m . T h e rectum is another reservoir, this time
for the residue o f the food w h i c h forms the faeces.
Digestion
Digestion commences i n the m o u t h . T h e contents o f
the a l i m e n t a r y tract are propelled a l o n g by waves
o f m u s c u l a r contraction k n o w n as peristalsis. T h i s
peristaltic wave starts at the b e g i n n i n g o f the
oesophagus a n d is not under v o l u n t a r y c o n t r o l . I f
the peristaltic waves become excessive as i n an
infection such as gastro-enteritis, they are perceived
as severe spasms o f p a i n or colic. A t other times the
peristaltic wave is not n o r m a l l y felt.
D u r i n g the m e c h a n i c a l b r e a k d o w n o f food by
c h e w i n g , saliva is m i x e d w i t h the food. T h i s helps
to lubricate the food bolus so that it can be
swallowed more easily a n d it also contains the first
of the digestive enzymes - p t y a l i n . P t y a l i n is the
only digestive enzyme acting i n the m o u t h a n d its
role is to start the b r e a k d o w n o f starch, although its
effect is not very significant i n the overall process o f
starch digestion. I f some starchy food such as bread
or potato is chewed a n d m o v e d a r o u n d the m o u t h
for a short p e r i o d the b r e a k d o w n o f starch c a n be
detected b y the slight sweetening o f the chewed
m a t e r i a l as the starch is changed to simple sugars.
A n enzyme is a complex c h e m i c a l a n d acts as a
b i o c h e m i c a l catalyst. Digestive processes are
brought about by various enzymes i n order to
break d o w n the large complex food molecules into
m u c h simpler molecules w h i c h can be absorbed
t h r o u g h the w a l l o f the digestive tract a n d pass v i a
the b l o o d stream to the liver. V a r i o u s enzymes
enter the a l i m e n t a r y tract at different levels.
E a c h enzyme is very specific i n its action a n d c a n
o n l y initiate or control one c h e m i c a l process.
I n d i v i d u a l enzymes can only act i n a very n a r r o w
range o f p H (the measure o f a c i d i t y or a l k a l i n i t y ) .
T h e y a l l act o p t i m a l l y at body temperature a n d are
destroyed by heat, thus cooked foods have a l l the
enzymes that they m a y contain destroyed by the
c o o k i n g . F o o d substances a l l have to be absorbed
t h r o u g h the w a l l o f the alimentary tract i n order to
give any benefit a n d large complex molecules
cannot pass through. W i t h o u t the necessary enzyme
this m o l e c u l a r b r e a k d o w n cannot occur. F o r
example, h u m a n beings, although omniverous
(eating flesh a n d vegetables), have no enzyme to
break d o w n cellulose w h i c h as a result passes
straight t h r o u g h the bowel as roughage. Therefore
h u m a n s c o u l d not live off grass, whereas herbivores
d o produce such an enzyme a n d can break d o w n
cellulose to produce usable carbohydrates.
I n the stomach the food is t e m p o r a r i l y stored
a n d at the same time mixes w i t h further secretions
from the w a l l o f the stomach. Part o f the secretion
is acid i n order to adjust the p H o f the contents
a n d allow the gastric enzymes w h i c h are also
secreted to w o r k at the correct degree o f a c i d i t y .
T h e r e is little absorption o f food substances
through the stomach w a l l apart from possibly some
simple sugars a n d alcohol. F o o d substances are
passed i n small quantities at a time from the
stomach into the d u o d e n u m . S e p a r a t i n g these two
areas is a muscular valve or sphincter w h i c h opens
periodically i n order to allow further food to pass
into the d u o d e n u m from the stomach.
In the d u o d e n u m further enzymes are i n t r o d u c e d
to the food. Intestinal juice c o n t a i n i n g a variety o f
enzymes is produced by the glands i n the d u o d e n a l
w a l l . Bile w h i c h is p r o d u c e d i n the liver enters v i a
the c o m b i n e d b i l i a r y a n d pancreatic ducts. T h e bile
contains bile salts a n d bile pigment. Bile salts are
concerned w i t h the emulsification o f fats a n d they
assist i n the absorption o f the b r e a k d o w n products
of the fat, p a r t i c u l a r l y fatty acids. T h e bile
pigments are waste materials w h i c h have been
p r o d u c e d by the liver, largely from the b r e a k d o w n
of red b l o o d cells. T h e i r injection i n t o the small
bowel at the d u o d e n u m is one o f the methods by
w h i c h they are removed from the b o d y . T h r o u g h
the same c o m b i n e d o p e n i n g i n the d u o d e n a l w a l l ,
pancreatic j u i c e is i n t r o d u c e d into the d u o d e n u m .
T h i s contains enzymes w h i c h help further w i t h the
digestion o f fat a n d enzymes w h i c h a i d i n the
b r e a k d o w n o f sugar a n d proteins.
T h e function o f the pancreas does not cease w i t h
the enzymes w h i c h are i n t r o d u c e d i n t o the bowel;
w i t h i n the substance o f the pancreas are w h a t is
k n o w n as endocrine glands. These are glands w h i c h
produce substances w h i c h are secreted d i r e c t l y into
the blood stream. I n the pancreas the endocrine
glands are present i n w h a t is k n o w n as the Islets o f
Langerhans. These islets produce two hormones,
insulin a n d glucagon. T h e insulin lowers the level
of sugar i n the blood and helps the b o d y cells to
store it as glycogen. G l u c a g o n raises the level of
sugar i n b l o o d by s t i m u l a t i n g the b r e a k d o w n of
glycogen back into simple sugars. It is the lack o f
insulin due to a fault i n the pancreas, w h i c h causes
diabetes mellitus.
I n its passage through the rest o f the s m a l l
bowel, enzymes continue to act o n the food
products, g r a d u a l l y b r e a k i n g them d o w n . W h e n
this b r e a k d o w n has progressed sufficiently the
nutrients are slowly absorbed into the intestinal
w a l l . M o s t o f this absorption has taken place by the
time the food has reached the c a e c u m a n d most o f
 Section 1.7
w h a t remains then are waste products i n a
s e m i - l i q u i d state. T h e m a i n function o f the large
b o w e l is the absorption o f water from the food
residues i n order to prevent too m u c h being lost
from the body. T h i s also reduces the b u l k o f the
waste matter to a solid form so it takes up less
space. O n l y a very small a m o u n t o f absorption o f
r e m a i n i n g nutrients from the digested food takes
place t h r o u g h the large intestine walls. T h e a m o u n t
absorbed is relatively insignificant.
F u n c t i o n s o f the L i v e r
T h e liver is extremely complex a n d has m a n y
functions w h i c h c a n be considered under three
m a i n headings.
SECRETORY
B i l e is p r o d u c e d by the liver a n d contains bile
pigments a n d bile salts. T h e bile pigments are
largely p r o d u c e d b y the b r e a k d o w n o f aged red
b l o o d cells. T h e y enter the d u o d e n u m a n d are then
largely r e m o v e d from the b o d y i n the faeces, but a
small q u a n t i t y is re-absorbed through the w a l l o f
the s m a l l intestine a n d enters the general b l o o d
c i r c u l a t i o n from w h i c h it is removed i n the kidneys
a n d excreted i n the urine. Bile pigments are largely
responsible for the yellow colour o f the urine.
T h e bile salts also reach the d u o d e n u m a l o n g the
bile d u c t a n d their role is to emulsify fats to a i d
further b r e a k d o w n a n d absorption. O n c e bile has
been formed i n the liver, most o f it is concentrated
a n d stored t e m p o r a r i l y i n the gall b l a d d e r w h i c h is
a p o u c h formed as a n off-shoot o f the bile duct. It
is i n the g a l l b l a d d e r that stones can form. These
m a y comprise a n excess o f bile pigments or they
m a y be crystaline deposits o f bile salts.
H e p a r i n is also p r o d u c e d by the liver but passes
directly into the b l o o d stream. Its function is to
help prevent c l o t t i n g o f b l o o d as it passes r o u n d i n
the n o r m a l c i r c u l a t i o n o f the body.
STORAGE
a) G l y c o g e n is stored i n the liver. It is formed
from glucose a n d is the c h e m i c a l form i n w h i c h
it is stored. It c a n be made extremely q u i c k l y
a n d broken d o w n to glucose again equally
r a p i d l y w h e n required. G l y c o g e n is also stored
i n the muscles. W h e n glucose is required as a
result o f exercise or fasting (both o f w h i c h w i l l
produce a fall i n the blood-sugar level) glucose
is very r a p i d l y formed b y the re-conversion o f
glycogen. After a meal, glucose w h i c h is
p r o d u c e d from the digestion o f carbohydrate
a n d is not i m m e d i a t e l y required for
45
m e t a b o l i s m is stored as glycogen. T h i s
replenishes the glycogen stores w h i c h m a y have
become depleted between meals.
b) T h e liver is a storage site for v i t a m i n s A , the B
c o m p l e x a n d D . O r i g i n a l l y the v i t a m i n s are
absorbed from the food as they cannot be
manufactured i n the h u m a n body. F r o m the
storage depots i n the liver the v i t a m i n s c a n be
released as a n d w h e n required.
c) I r o n is stored following the b r e a k d o w n o f o l d
red b l o o d corpuscles; it is then released for the
synthesis o f h a e m o g l o b i n w h i c h is r e q u i r e d for
new red corpuscles.
METABOLIC
T h e liver is responsible for the utilisation o f
proteins, fats a n d carbohydrates for the general
n u t r i t i o n o f the b o d y . These substances, w h i c h are
m a i n l y i n a very c o m p l e x form w h e n they are
taken as food, have to be b r o k e n d o w n i n t o far
simpler substances to m a k e them suitable for
utilisation b y the b o d y . F o l l o w i n g the b r e a k d o w n
of proteins into a m i n o acids w h i c h are very m u c h
simpler c h e m i c a l chains, the liver w i l l then
synthesise new proteins as a n d w h e n required for
the various p h y s i o l o g i c a l functions o f the b o d y .
A l t h o u g h the h u m a n liver c a n also synthesise m a n y
of the necessary a m i n o acids from basic simple
molecules, there are certain a m i n o acids w h i c h it
cannot produce. These are k n o w n as 'essential
a m i n o acids'. T h e y must be present i n the diet
either as a m i n o acids or as more c o m p l e x p r o t e i n
forms, otherwise the b o d y w i l l come deficient i n
t h e m a n d w i l l not function.
I f too m u c h glucose is present a n d the glycogen
stores are full, the excess c a r b o h y d r a t e is converted
into fat b y the liver a n d is then stored elsewhere i n
the b o d y . M o s t poisonous substances w h i c h are
taken w i t h the food are detoxicated b y the liver.
D e t o x i c a t i o n means that the l i v e r changes the
c h e m i c a l structure o f these substances so that they
are no longer poisonous. F o l l o w i n g that they m a y
be passed back into the b l o o d stream to be r e m o v e d
by the kidneys or they m a y be excreted i n the bile
a n d t h r o u g h the b o w e l . I n a d d i t i o n there are some
potentially poisonous substances w h i c h are
p r o d u c e d as a result o f n o r m a l p r o t e i n m e t a b o l i s m
i n the b o d y . F o r example, a m m o n i a is i m m e d i a t e l y
converted into urea b y the liver. T h e urea then
passes i n t o the c i r c u l a t i o n a n d is excreted by the
kidneys i n the urine. D u r i n g the process o f
detoxication the liver cells c a n be d a m a g e d b y
various poisonous substances w h i c h have been
ingested. A l t h o u g h new cells c a n be p r o d u c e d
sometimes this does not always take place a n d the
46 Section 1: A n a t o m y a n d P h y s i o l o g y

dead liver cells are replaced by fibrous tissue, thus m u c h o f the particulate matter a n d the air is
g r a d u a l l y destroying the functional capabilities o f moistened a n d w a r m e d . F r o m the nose it passes v i a
the liver a n d l e a d i n g to liver failure. P r o b a b l y the the naso-pharynx through the l a r y n x into the
commonest substance w h i c h can cause these trachea. T h e trachea divides into right a n d left
problems i n the liver is an excess intake o f alcohol. bronchus, each o f w h i c h supply one l u n g . E a c h
V a r i o u s drugs a n d some industrial chemicals also bronchus branches into bronchioles a n d continue to
cause liver damage. b r a n c h , decreasing steadily i n size u n t i l each
terminal b r a n c h leads into a little a i r sac or
alveolus ( F i g . 1.65). T h e walls of the alveoli are
very t h i n so that oxygen (and other gases) c a n pass
through into the b l o o d stream a n d c a r b o n d i o x i d e
1.8 The Respiratory System can pass back from the b l o o d into the alveoli a n d
hence be expelled through the nose to the outside.
T h e respiratory system includes the a n a t o m i c a l
structures w h i c h allow oxygen to be introduced into D u r i n g breathing, i n s p i r a t i o n a n d e x p i r a t i o n are
the b o d y a n d c a r b o n dioxide to be removed from n o r m a l l y reflexly controlled but they c a n u p to a
the b o d y as well as the actual c h e m i c a l a n d certain point be modified v o l u n t a r i l y . B e y o n d this
physiological processes o f respiration. point the reflexes c a n no longer be suppressed by
the v o l u n t a r y centres o f the b r a i n a n d w i l l once
more take over. Inspiration is b r o u g h t a b o u t
A n a t o m y of the R e s p i r a t o r y S y s t e m m e c h a n i c a l l y by a contraction o f the d i a p h r a m
A s c a n be seen from the d i a g r a m ( F i g . 1.64), air w h i c h descends towards the a b d o m i n a l c a v i t y ,
enters v i a the nose. T h e r e , small hairs filter out increasing the available height w i t h i n the chest
cavity. T h e intercostal muscles between the ribs
contract at the same time a n d as a result the ribs
swing outwards a n d upwards increasing the
diameter o f the chest cavity. T h i s increase i n the
chest capacity sucks air into the lungs t h r o u g h the
respiratory passages.
E x p i r a t i o n is n o r m a l l y brought a b o u t by a
NASAL passive elastic recoil o f the d i a p h r a m a n d the rib
CAVITY cage w h e n contraction o f the muscles ceases a n d
they relax. F o r c i b l e e x p i r a t i o n begins to o c c u r w h e n
physiological demands b r i n g about a n increased
rate a n d depth o f respiration. A l t h o u g h quiet
inspiration involves m a i n l y the d i a p h r a m a n d
intercostal muscles, deeper i n s p i r a t i o n or p a n t i n g
involves i n a d d i t i o n the muscles a r o u n d the
TR A CH EA shoulder girdle a n d some o f the muscles i n the
back. These a d d i t i o n a l muscles are sometimes
referred to as the accessory muscles o f respiration.
LEFT Forceful e x p i r a t i o n involves a very strong
LUNG contraction of the muscles o f the a b d o m i n a l w a l l .
RIGHT T h e latissimus dorsi a n d serratus posterior muscles
LUNG LE FT are those m a i n l y i n v o l v e d i n the back. T h e lungs
MAIN cannot be completely emptied even b y a very
BRONCHUS
forceful e x p i r a t i o n a n d the residual a i r amounts to
about one litre. O n m a x i m u m i n s p i r a t i o n a b o u t a
SM ALL further three a n d a h a l f litres o f air c a n be d r a w n
BRONCHUS into the lungs w h i c h w i l l then m i x w i t h the residual
air. N o r m a l l y , at rest, about h a l f a litre o f a i r is
inspired a n d expired on each cycle.

LUNG 1.64 Diagram of the Respiratory Passages.

 Section 1.8
CAPILLARIES
ALVEOLUS
BRONCHIOLE
IMP
1.65 Alveolus in Lung. This shows the terminal part of
the air-passage (the alveolus) with the mass of capillaries
in close proximity which allows the interchange of gases
between the air in the alveoli and the blood in the
capillaries.
Respiration
R e s p i r a t i o n m a y be considered i n two parts:
1. external respiration;
2. i n t e r n a l or tissue respiration.
EXTERNAL RESPIRATION
E x t e r n a l respiration takes place i n the lungs. A i r
w h i c h contains the oxygen required for tissue
m e t a b o l i s m is carried to the lungs through the
respiratory passages, e n d i n g u p i n the alveoli. T h e
walls o f the alveoli have a large n u m b e r o f
capillaries c o n t a i n i n g b l o o d a n d the separation
between the b l o o d stream a n d the air i n the alveoli
is about two cells thick. A t this point oxygen passes
from the alveoli into the deoxygenated b l o o d w h i c h
is b e i n g b r o u g h t from the right side o f the heart. A t
the same time the c a r b o n d i o x i d e from the b l o o d
passes i n the opposite d i r e c t i o n from the b l o o d
stream t h r o u g h into the alveoli. T h e expired air
therefore contains a decreased a m o u n t o f oxygen
a n d a n increased a m o u n t o f c a r b o n d i o x i d e
c o m p a r e d w i t h the inspired air.
I N T E R N A L O R TISSUE R E S P I R A T I O N
I n t e r n a l or tissue respiration takes place i n every
l i v i n g cell o f the b o d y . It is the m e c h a n i s m w h i c h
provides the energy w h i c h is required for a l l b o d i l y
activity. T h e commonest energy-producing m a t e r i a l
to be o x i d i z e d is carbohydrate i n the form o f
glucose. T h e glucose combines w i t h oxygen to give
47
c a r b o n d i o x i d e , water a n d energy. T h i s reaction is
aided by a n enzyme. Substances other than the
carbohydrates m a y also be o x i d i z e d . These require
different enzymes as a l l enzymes are extremely
specific i n their action. I f fat is o x i d i z e d , rather
more oxygen is required than i f c a r b o h y d r a t e is
oxidized.
T r a n s p o r t of Oxygen and C a r b o n Dioxide
In the alveoli i n the lungs the oxygen i n the air
becomes dissolved i n a t h i n film o f moisture o n the
cell walls. It then passes b y diffusion t h r o u g h the
cells into the b l o o d plasma. M o s t o f the oxygen
w h i c h diffuses through combines w i t h the
h a e m o g l o b i n i n the b l o o d to form o x y h a e m o g l o b i n
w i t h a very s m a l l a m o u n t r e m a i n i n g dissolved i n
the b l o o d plasma. T h e presence o f the h a e m o g l o b i n
allows about seventy times as m u c h o x y g e n to be
carried a r o u n d the b l o o d stream as o x y h a e m o g l o b i n
than w o u l d take place b y a simple solution o f
oxygen i n the b l o o d plasma. A t the cells where the
oxygen is utilised c a r b o n d i o x i d e is p r o d u c e d . T h i s
c a r b o n d i o x i d e dissolves to form c a r b o n i c a c i d ,
w h i c h is carried m a i n l y as bicarbonate i n the
plasma. T h e r e is also a s m a l l a m o u n t o f dissolved
carbonic acid a n d some o f the c a r b o n d i o x i d e w i l l
c o m b i n e w i t h the h a e m o g l o b i n once the o x y g e n has
been displaced i n order to produce
carbaminohaemoglobin.
W h e n the deoxygenated b l o o d returns to the
lungs the c a r b a m i n o h a e m o g l o b i n breaks d o w n to
liberate c a r b o n i c a c i d . Some o f the bicarbonate w i l l
also break d o w n to liberate further c a r b o n i c a c i d
w h i c h diffuses across the cell m e m b r a n e into the
alveoli o f the lungs a n d hence to the outside air.
C o n t r o l of R e s p i r a t i o n
T h e c o n t r o l o f the rate o f respiration is largely
reflex a l t h o u g h it c a n be modified to a c e r t a i n
extent v o l u n t a r i l y . T h e m a i n c o n t r o l l i n g factor is
the a c i d i t y o f the b l o o d as d e t e r m i n e d b y the level
of c a r b o n i c a c i d . T h e greater the a m o u n t o f c a r b o n
d i o x i d e being p r o d u c e d i n the tissues, the higher
the level o f b l o o d c a r b o n i c a c i d a n d the more a c i d
the b l o o d . T h i s alteration i n a c i d i t y is detected b y
the respiratory c o n t r o l centres a n d the d e p t h a n d
rate o f i n s p i r a t i o n a n d e x p i r a t i o n w i l l be increased
to allow the extra c a r b o n d i o x i d e to be r e m o v e d
through the lungs. A decrease i n o x y g e n level o f the
blood w i l l also stimulate reflex centres a n d cause a n
increase' i n rate o f d e p t h o f respiration, b u t a fall i n
oxygen level is m u c h less o f a stimulus t h a n a n
increase i n c a r b o n d i o x i d e i n the form o f c a r b o n i c
48 Section 1: A n a t o m y a n d P h y s i o l o g y
a c i d . B y far the most i m p o r t a n t factor is the acidity
as reflected i n p H level o f the blood.
I n c i d e n t a l l y , there are two forms o f oxide o f
c a r b o n . C a r b o n m o n o x i d e is p r o d u c e d by exhaust
gases a n d w h e n carboniferous fuels are
i n c o m p l e t e l y o x i d i z e d . C a r b o n m o n o x i d e is
extremely poisonous because it combines w i t h the
h a e m o g l o b i n i n the b l o o d , preventing the
c o m b i n a t i o n o f oxygen, a n d thus kills by d e p r i v i n g
the tissues o f the oxygen they require. C a r b o n
d i o x i d e is formed w h e n carboniferous fuels (which
of course includes glucose a n d other foods) are
completely o x i d i z e d .
It is not itself poisonous as it is easily displaced
by oxygen at the h a e m o g l o b i n molecule. H o w e v e r ,
i n h a l a t i o n o f very h i g h levels o f c a r b o n d i o x i d e w i l l
produce very r a p i d a n d severe changes i n the p H o f
the b l o o d . T h i s increase i n acidity due to the
increase i n carbonic acid totally upsets the acid
base balance i n the b o d y a n d death m a y follow
very r a p i d l y .
S m o k i n g cigarettes produces a significant a m o u n t
of c a r b o n m o n o x i d e . T h i s combines as described
w i t h the h a e m o g l o b i n , interfering w i t h oxygen
transport. Therefore the smoker w i l l be less able
than the non-smoker to provide the muscles w i t h
the necessary increase i n oxygen d e m a n d e d by any
athletic a c t i v i t y , i n c l u d i n g d a n c i n g . A s a result his
performance w i l l be a little less good than it w o u l d
have been i f he were a non-smoker.
1.9 The Excretory System
T h e excretory system is made up o f two kidneys,
two ureters, a bladder a n d an urethra ( F i g . 1.66).
F r o m each k i d n e y there is a ureter w h i c h goes
d o w n to the u r i n a r y bladder, from w h i c h the
urethra carries the urine to the outside. T h e kidneys
lie w i t h i n the upper part of the a b d o m i n a l c a v i t y
b e h i n d the liver a n d stomach. H o w e v e r , they are
surrounded by fat a n d are not free-floating w i t h i n
the a b d o m i n a l cavity. T h e ureters r u n d o w n the
posterior a b d o m i n a l w a l l to enter the bladder
w h i c h lies w i t h i n the pelvis. T h e actual excretory
functions only take place i n the kidneys. T h e
ureters, b l a d d e r a n d urethra are there to transport
a n d store the urine a n d allow intermittent discharge
externally. W i t h o u t the storage capacity o f the
b l a d d e r there w o u l d be a constant d r i p o f urine
occurring.
B l o o d is carried to each kidney by a large renal
artery a n d is returned from the kidney by a renal
v e i n o n each side. W i t h i n the substance o f the
INFERIOR VENA CAVA
, ADRENAL
G LAND
LE FT
RENAL
A R TER Y
-L E F T
RIGHT -
RENAL
KIDNEY
VEIN
AO R TA
UR ETER
BLADDER
ER
D
D
LA
B
UR ETHR A —
1.66 The Excretory System.
kidney the arteries d i v i d e to form smaller vessels.
T h e point where excretory a c t i v i t y occurs is k n o w n
as the glomerulus ( F i g . 1.67). T h i s is a knot o f
capillaries. T h e vessel s u p p l y i n g this knot is w i d e r
i n diameter than the vessel c a r r y i n g the b l o o d
away. A s a result the blood w i t h i n the glomerulus is
under increased pressure. A t this p o i n t some o f the
fluid component o f the blood is filtered t h r o u g h the
cells walls into a collection p o r t i o n k n o w n as
B o w m a n ' s capsule. T h e cell membranes between
the blood stream a n d B o w m a n ' s capsule are such
that the b l o o d corpuscles a n d the b l o o d proteins are
unable to pass t h r o u g h a n d so r e m a i n w i t h i n the
blood. T h e fluid w h i c h passes t h r o u g h to B o w m a n ' s
capsule is made up o f water w i t h s m a l l amounts o f
various salts a n d nitrogenous waste products
p r o d u c e d by the b r e a k d o w n o f proteins. T h i s latter
is largely i n the form o f urea. A t this point there is
also some sugar, water-soluble v i t a m i n s a n d various
other substances that are n o r m a l l y present i n the
blood stream.
T h e l i q u i d passes from B o w m a n ' s capsule to the
first convoluted tubule where a l l the sugar, v i t a m i n s
a n d some o f the other substances a n d some water
are absorbed again ( F i g . 1.68). F r o m there it passes
through the L o o p o f H e n l e where further water is
 Section 1.9 49

BOW M AN'S CAPSULE

1.67 A Glomerulus and Bowman's
Capsule.

FIRST C O N V O LU TE D
TU B U L E

G LO M ER ULUS

absorbed. It is at this point that the a m o u n t o f

water w h i c h is absorbed w i l l v a r y i n order to adjust
the osmotic pressure o f the blood correctly.
F o l l o w i n g the L o o p o f H e n l e is the second
c o n v o l u t e d tubule where the p H is adjusted. U r i n e
is n o r m a l l y o n the slightly acid side. F o l l o w i n g the
second c o n v o l u t e d tubule is the collecting duct.
T h i s w i l l j o i n w i t h other collecting ducts from other
1.68 Diagram of a Renal Tubule.
c o n v o l u t e d tubules. F i n a l l y a l l j o i n i n g together they
G LO M ER U LU S
form the pelvis o f the k i d n e y , l e a d i n g into the
SECOND
u p p e r end o f the ureter at the point where it leaves
C O N V O LU TE D
the k i d n e y . T h e kidneys are extremely efficient at TU B U L E
stabilising the water a n d electrolyte balance i n the BO W M AN'S
b o d y , w h i c h is o n l y able to tolerate very small C APSULE
variations from the n o r m a l ratio between the
various electrolytes a n d the water. T h e c o n t r o l is
v i a hormones. T h e p i t u i t a r y g l a n d produces a FIR ST
h o r m o n e w h i c h encourages water retention w h i l e C O N V U LU TE D C O LL E C TIN G
TUBULE DUCT
the hormones o f the a d r e n a l cortex encourage the
retention o f s o d i u m a n d a n increased loss o f
potassium. I f a great deal o f fluid is taken by
m o u t h the urine increases i n q u a n t i t y a n d becomes
very d i l u t e . T h i s is achieved by a decrease i n the
absorption o f water from the L o o p o f H e n l e .
H o w e v e r , i n hot climates w h e n there is a
considerable a m o u n t o f perspiration the urine
o u t p u t decreases i n q u a n t i t y a n d becomes very
m u c h more concentrated. T h e sensation o f thirst is
b r o u g h t about b y a very small increase i n the
osmotic pressure o f the blood affecting certain cells
- LOOP
i n the b r a i n .
OF
T h e kidneys have a n a d d i t i o n a l function HENLE
i n a s m u c h as they produce two hormones, r e n i n a n d
erythropoietin. R e n i n affects the maintenance o f
b l o o d pressure. I f pressure w i t h i n the renal artery
decreases then some quantities o f renin are released
i n order to stimulate a n increase i n the b l o o d
50 Section 1: A n a t o m y a n d P h y s i o l o g y
pressure. S h o u l d the blood pressure fall below a
certain level, as m a y occur i n states o f surgical
shock where there has been a considerable loss o f
b l o o d , then filtration from the glomerulus into
B o w m a n ' s capsule ceases a n d the person enters a
state o f renal failure. Unless this is corrected, death
w i l l follow because of the steady increase i n the
nitrogenous waste products a n d the total upset o f
the salt a n d water balance of the body.
T h e second hormone, erythropoietin, helps to
control the p r o d u c t i o n o f red blood cells.
1.10 The Endrocrine System
T h e endocrine system comprises a n u m b e r o f
endocrine organs. These are glands w h i c h pass their
secretions, k n o w n as hormones, directly into the
b l o o d stream. T h e glands have no ducts i n w h i c h to
collect the secretions, unlike those glands w h i c h lie
in the walls o f the a l i m e n t a r y tract. A hormone is a
c o m p o u n d formed w i t h i n the g l a n d . It is carried
from the g l a n d i n the blood a n d its action is to
influence the activity of another organ or organs.
T h e two regulating systems o f the body, i.e. the
nervous system a n d the endocrine system, are very
closely l i n k e d . I n some instances the p r o d u c t i o n o f
hormones is controlled directly by nervous impulses.
T h e m a i n function of the endocrine system as a
whole is to m a i n t a i n homeostasis, i.e. the constancy
of the i n t e r n a l environment o f the body. The
mode o f action o f hormones is b i o c h e m i c a l l y
extremely c o m p l i c a t e d a n d outside the scope o f this
book.
T h e actual endocrine glands are: the p i t u i t a r y
g l a n d , w h i c h has anterior a n d posterior lobes w i t h
separate functions a n d w h i c h lies i n the base of the
skull, closely associated w i t h the b r a i n ; the t h y r o i d
a n d p a r a t h y r o i d glands, w h i c h are a n a t o m i c a l l y
i n t i m a t e l y associated, l y i n g i n the front o f the lower
part o f the neck; the adrenal glands, composing the
cortex a n d m e d u l l a , w i t h separate functions a n d
l y i n g like little caps on the superior poles o f each
kidney. A p a r t from these well localised glands there
are scattered areas of cells i n various other organs,
i n p a r t i c u l a r the so-called Islets o f L a n g e r h a n s i n
the pancreas, the interstitial cells i n the testes a n d
the follicular cells i n the ovaries. T h e r e are also
some cells i n the walls o f the stomach a n d small
intestine. I n pregnancy some cells o f the placenta
can have a temporary endocrine effect.
T h e anterior lobe o f the p i t u i t a r y g l a n d is
sometimes said to be the conductor o f the endocrine
orchestra. T h i s lobe is regulated by hormones
produced i n the h y p o t h a l a m u s o f the b r a i n . T h e
hormones secreted by the anterior lobe o f the
p i t u i t a r y then i n their turn regulate the activities o f
the various other endocrine organs. N o r m a l l y it is
the concentration o f hormones i n the b l o o d
c i r c u l a t i o n w h i c h w i l l regulate the s t i m u l a t i o n or
otherwise of the further p r o d u c t i o n o f h o r m o n e . I n
other words, i f the hormone level is h i g h , this w i l l
tend to suppress the stimulatory effects w h i c h
w o u l d encourage the p r o d u c t i o n o f further
hormone ( F i g . 1.69). Conversely, i f the level o f
hormone i n the blood stream falls to a l o w level,
this w i l l then stimulate the a c t i v i t y o f the endocrine
glands to produce more h o r m o n e . I n most
hormones their life i n the blood stream is relatively
short, sometimes only a few minutes, before being
destroyed. T h i s enables the e q u i l i b r i u m to be very
accurately a n d constantly adjusted. T h e hormones
in the blood stream are either de-activated b y the
liver or excreted t h r o u g h the k i d n e y .
T h e endocrine glands themselves c a n be the
subject o f disease a n d this m a y result i n either the
over-production or u n d e r - p r o d u c t i o n o f the
relevant hormone. P r o b a b l y the c o m m o n c o n d i t i o n
that is seen a n d w i t h w h i c h most people w i l l at least
be acquainted, is that o f thyrotoxicosis, w h e n the
thyroid g l a n d produces a n excess o f h o r m o n e , one
of the side effects o f w h i c h is to produce the
staring, pop-eyed appearance o f a patient w h o is
thyrotoxic. A d d i t i o n a l l y , the patient tends to be
very overactive, lose weight, a n d feel hot a n d sweat
freely. I n general the over-action or under-action o f
an endocrine g l a n d also produces changes i n the
p r o d u c t i o n o f hormones from other endocrine
organs due to the close relationship that there is
between one endocrine g l a n d a n d another. T h i s
means that w h e n there is, for instance, a n
over-production o f h o r m o n e b y a diseased g l a n d ,
the c l i n i c a l picture becomes c o m p l i c a t e d because o f
the other endocrine effects w h i c h also become
manifest, even though the other endocrine glands
themselves are not the subject o f disease.
T h e symptoms w h i c h are caused b y the
alteration i n hormone level from the diseased g l a n d
are k n o w n as p r i m a r y symptoms. S e c o n d a r y
symptoms are those w h i c h are p r o d u c e d b y the
v a r i a t i o n i n hormone level at the other endocrine
glands w h i c h are not themselves the seat o f the
disease. It is this widespread upset i n the endrocrine
pattern produced by an excess or l a c k o f h o r m o n e
that makes the a d m i n i s t r a t i o n o f steroid drugs such
as cortisone a potentially hazardous process and not
a treatment that should be u n d e r t a k e n l i g h t l y a n d
without proper consideration o f the potential and
grave side effects. It must be emphasised that this
 Section 1.10
PRODUCTION OF HORM ONE I
STIM U LA TE S G LAND II
ENDOCRINE
GLAND
I H
INCREASE IN BLO O D LEVEL
ANTERIOR
r nunnuncn
HIBITS G LAND I
ANTERIOR
1.69 Diagrammatic representation of the interaction of
hormones between two endocrine glands.
o n l y applies w h e n cortisone is given by m o u t h . T h e
steroid w h i c h is used for injection to control local
effects d u r i n g the course o f treatment o f various
local injuries or inflammations does not have these
side effects. T h i s p r e p a r a t i o n o f the steroid (usually
hydrocortisone acetate) is not absorbed generally
into the c i r c u l a t i o n as it is a suspension a n d remains
where it has been placed. It does, however, have its
own c o m p l i c a t i o n s w h i c h are o f a local nature a n d
these w i l l be considered later i n the section o n
injury a n d the treatment o f injuries (see Section
2.5 M e d i c a l a n d S u r g i c a l Treatments, page 92).
A c t i o n s o f the E n d o c r i n e Glands
These w i l l be dealt w i t h very briefly as any great
detail w o u l d be irrelevant to the probable
requirements o f the reader.
THE PITUITARY GLAND
T h e anterior p i t u i t a r y g l a n d produces six
hormones. T h e g r o w t h h o r m o n e is secreted i n
greatest q u a n t i t y d u r i n g c h i l d h o o d but there is
some secretion d u r i n g the rest o f adult life i n order
to m a i n t a i n n o r m a l body structure a n d function.
O c c a s i o n a l l y it is administered c l i n i c a l l y i n a c h i l d
who is very small a n d underdeveloped. H o w e v e r ,
like the use o f any other hormone, its
a d m i n i s t r a t i o n is fraught w i t h undesirable side
effects a n d dangers a n d its use should not be
undertaken lightly.
T h e t h y r o t r o p h i c h o r m o n e stimulates the t h y r o i d ,
h e l p i n g to c o n t r o l the level o f t h y r o x i n w h i c h is
p r o d u c e d b y the t h y r o i d g l a n d . T h e
adrenocorticotrophic hormone stimulates the cortex
of the a d r e n a l g l a n d to produce its hormones.
These hormones from the adrenal cortex are
associated w i t h the regulation o f c a r b o h y d r a t e
51
ENDOCRINE
GLAND
HORM ONE II
ENEN
TETE
R SR S
BLO
B LO
O DO D
STRE/>
STRE/>
metabolism a n d , less i m p o r t a n t l y , m a k e sex
hormone production.
T h e follicular s t i m u l a t i n g hormone, the
l u t e i n i z i n g h o r m o n e a n d p r o l a c t i n a l l have activities
on the gonads (ovaries a n d testes), are responsible
for the m a t u r a t i o n o f the o v a a n d spermatozoa,
a n d are associated i n part w i t h the d e v e l o p m e n t
a n d regulation o f menstruation a n d the
post-pregnancy regulation o f m i l k p r o d u c t i o n .
T h e regulation o f the p r o d u c t i o n o f anterior
p i t u i t a r y hormones is t h r o u g h the h y p o t h a l a m u s i n
the b r a i n , w h i c h produces s t i m u l a t i n g o r i n h i b i t i n g
hormones acting o n the anterior p i t u i t a r y . T h e
regulation is also c o n t r o l l e d by the level o f h o r m o n e
p r o d u c e d by the other endocrine glands o n w h i c h
the anterior p i t u i t a r y itself has a n effect.
T h e r e are two hormones from the posterior
p i t u i t a r y . T h e most i m p o r t a n t h o r m o n e p r o d u c e d is
vasopressin, the chief action o f w h i c h is as an
anti-diuretic h o r m o n e . I n other words, it acts o n
the kidney, increasing the a m o u n t o f water w h i c h is
absorbed from the collecting tubules, thus
preventing excessive water loss from the b o d y .
A d d i t i o n a l l y , it has a very m i n o r effect o n the
maintenance o f arterial b l o o d pressure b y causing
contraction o f the smooth muscle i n the b l o o d
vessel walls. T h i s latter effect was the first one
discovered b y researchers, hence the n a m e g i v e n to
the h o r m o n e . T h e other h o r m o n e w h i c h is
p r o d u c e d by the posterior p i t u i t a r y , o x y t o c i n , o n l y
has an effect i n the female d u r i n g c h i l d b i r t h a n d
lactation. L i k e the anterior p i t u i t a r y , the posterior
p i t u i t a r y secretions are c o n t r o l l e d by the
h y p o t h a l a m u s i n the b r a i n .
THE THYROID GLAND
T h e t h y r o i d g l a n d produces t h y r o x i n a n d a n
associated hormone, b o t h o f w h i c h stimulate cell
52 Section 1: A n a t o m y a n d P h y s i o l o g y
metabolism. A d d i t i o n a l l y , the g l a n d produces
c a l c i t o n i n ( t h y r o c a l c i t o n i n ) , w h i c h prevents the
transfer o f c a l c i u m from the bones to the b l o o d
stream. It thus brings about a l o w e r i n g o f c a l c i u m
i n the b l o o d stream as it still allows the transfer o f
c a l c i u m from the blood plasma into the bones. T h e
c o n t r o l o f p r o d u c t i o n o f the hormones from the
t h y r o i d is b y the anterior p i t u i t a r y .
T h e r e are four p a r a t h y r o i d glands, w h i c h lie
closely a p p l i e d to the back of the t h y r o i d g l a n d .
T h e y produce a p a r a t h y r o i d hormone w h i c h is
responsible for a n increase i n the concentration o f
c a l c i u m i n the b l o o d . T h e action is by increasing
the absorption o f c a l c i u m from the urine while still
i n the kidneys. It increases the b r e a k d o w n o f
c a l c i u m i n the bone, thus pushing it into the
c i r c u l a t i o n , a n d it also increases the absorption o f
c a l c i u m from the intestine i n the presence o f
adequate quantities o f v i t a m i n D .
THE ADRENAL GLANDS
T h e a d r e n a l glands consist o f the cortex a n d the
m e d u l l a . T h e cortex produces hormones w h i c h
regulate the electrolyte a n d water balance i n the
body, sexual function a n d carbohydrate
metabolism, T h e adrenal m e d u l l a produces two
forms o f a d r e n a l i n . T h e effect o f a d r e n a l i n is to
increase the rate o f the heart a n d increase the
capacity o f the heart to push the blood through the
c i r c u l a t i o n a n d therefore raises the blood pressure.
It also constricts the blood vessels s u p p l y i n g a l l the
a l i m e n t a r y tract and constricts the blood vessels o f
the skin. T h i s is the reason w h y people go pale w i t h
fright or i n other situations o f stress, caused by
b l o o d b e i n g diverted to the heart a n d skeletal
muscles so as to deal w i t h the emergency w h i c h
may have arisen. It also has a general arousal
function so as to make the person more alert. It is
sometimes referred to as the fight or flight h o r m o n e
because i n more p r i m i t i v e conditions it was to
prepare someone to either fight the attacker or r u n
a w a y . U n d e r present d a y conditions, it is the
h o r m o n e w h i c h produces the feelings o f
apprehension, increased pulse rate a n d butterflies i n
the stomach before examinations, performances or
times o f m o d e r n stress. T h e action o f the a d r e n a l
m e d u l l a is stimulated b y nerve impulses through
the sympathetic system.
T h e testes a n d ovaries are responsible for the
p r o d u c t i o n o f sex hormones, testosterone i n the
m a l e a n d oestrogen a n d progesterone i n the female.
A t puberty the levels increase greatly a n d the
balance alters. T h i s produces the secondary sex
characteristics, the general m a t u r a t i o n o f the b o d y
a n d the onset o f menstruation i n the female. I n
particular, after the onset o f puberty a n d m a t u r i t y
it becomes difficult a n d p r o b a b l y impossible to
stretch fibrous tissue such as there is i n the
ligaments a n d capsules.
T h e Islets o f L a n g e r h a n s i n the pancreas produce
two hormones, insulin a n d g l u c a g o n . These two
hormones are responsible for regulating the
transport o f glucose and its storage by c h a n g i n g it
into glycogen a n d also the b r e a k d o w n o f glycogen
to produce glucose w h e n required (see Section 1.7
Digestion, page 44). It is the lack o f p r o d u c t i o n o f
insulin w h i c h produces the w e l l - k n o w n c o n d i t i o n o f
diabetes mellitus.
1.11 Anatomical Points Relevant
to Ballet
T h e overall use o f the muscles is directed at
attaining correct stance and weight placement. T o
this end the muscles can be considered i n groups
rather than as i n d i v i d u a l s . C o r r e c t use of these
various groups starts at the head a n d shoulder
girdle a n d encompasses a l l the groups d o w n
through the trunk a n d legs to the feet. It is only
w h e n a l l groups are w o r k i n g correctly
correctly and i n balance
with each other that correct stance a n d weight
placement w i l l be obtained a n d the dancer w i l l be
completely stable i n a l l the m a n y a n d v a r i e d
positions required d u r i n g the execution o f ballet
technique.
Stance a n d M u s c l e G r o u p i n g s ( F i g . 1.70)
T r u n k stabilisation is achieved by the spine
extensors, i.e. the l o n g back muscles assisted b y the
short muscles between the i n d i v i d u a l vertebrae, a n d
the trunk flexors w h i c h are made u p largely o f the
a b d o m i n a l muscles. T h e trunk has to be balanced
on the lower limbs. T h i s is achieved by the balance
betwen the h i p extensors (the gluteals) a n d the h i p
flexors, w h i c h between them c o n t r o l the t i l t i n g o f
the pelvis.
T h e knees i n m a n y people are relaxed w h e n
standing still a n d stabilisation is achieved b y the
ligaments alone. H o w e v e r , i n most dancers there is
usually some degree o f hyperextension o f the knees
(swayback knees) w h i c h varies from m i l d to very
m a r k e d a n d i n these instances the knee has to be
stabilised i n neutral b y contractions o c c u r r i n g i n
the quadriceps a n d h a m s t r i n g muscles. O f course, it
is perfectly possible for a person even w i t h very
m a r k e d swayback knees to allow t h e m to d r o p into
hyperextension a n d stand thus, w h i c h unfortunately
 Section 1.11 53

1.70 The main muscle

groups controlling,
posture when standing.
I FLEXORS OF
HEAD AND NECK

EXTENSORS
O F SPINE
FLEXORS OF SPINE
M AINLY ABDO M INALS
AND PSOAS
EXTENSORS OF HIP

KNEE LO CKED ON
LIG AM ENTS -_____

DORSIFLEXORS OF
PLANTAR FLEXORS ANKLE AND FO O T
O F ANKLE AND FOO T

A
A . and B. From the side. B

LA TER A L FLEXORS OF TR U N K
ON EACH SIDE

C
C.
C. and
and D
D.. From
From the front.
the front I

one frequently sees h a p p e n i n g i n dancers. H o w e v e r , plantar-flex the foot (i.e. a m o v e m e n t i n the

this position i n dance pushes the weight m u c h too
far back a n d leads to technical faults a n d injuries.
T h e rectus femoris muscle, w h i c h is part o f the
quadriceps c o m p l e x , a n d a l l the h a m s t r i n g muscles,
cross i n front o f a n d b e h i n d the h i p j o i n t
respectively so they also play a role i n stabilising
the pelvis i n relation to the thighs.
B e l o w the knee, stability depends u p o n a
constant interaction between the c a l f muscles w h i c h
direction o f p o i n t i n g the foot) a n d the muscles i n
the front o f the leg w h i c h dorsi-flex the foot. I n the
foot itself the intrinsic muscles are m a i n t a i n i n g the
l o n g i t u d i n a l a n d transverse arches as w e l l as the
general foot posture. N o t e also that the superficial
c a l f muscle - the gastrocnemius - crosses b e h i n d
the knee, t a k i n g its o r i g i n from the back o f the
lower end o f the femur, so it also plays a part i n
knee posture.
54 Section 1: A n a t o m y a n d Physiology

1.71 Standing correctly on one foot, showing the line of 1.72 Standing on one foot incorrectly. The pelvis and
centre of gravity falling through the supporting foot. The the trunk are mis-aligned and crooked.
pelvis and trunk remain aligned correctly.

A s w i l l be seen when standing correctly on one

ANTERIOR
foot, the line o f the centre of gravity is m o v e d
sideways so it falls through the supporting foot
( F i g . 1.71).
N o t e that the trunk a n d pelvis do not alter. T h e
h i p o n the s u p p o r t i n g leg is adducted a n d stability
is achieved by the interaction between the
adductors a n d the abductors (gluteus medius,
gluteus m i n i m u s a n d tensor fasciae latae. Gluteus
m a x i m u s is a h i p extensor).
U n f o r t u n a t e l y a n d only too often the adjustment
of the line o f centre o f gravity is made totally
incorrectly a n d the subsequent rather bizarre
posture remains uncorrected ( F i g . 1.72).
I n the turn-out position the stance remains
basically the same but the area o f weight bearing
on the floor is m u c h n a r r o w e r from front to back so
the postural muscles have to be even more finely
a n d accurately tuned to m a i n t a i n correct balance
w i t h the m i n i m u m o f effort.

T u r n - o u t ( F i g . 1.73)
1.73 The turn-out position correctly held.
T h e constraints w h i c h l i m i t the possible range o f
turn-out at the h i p are (a) bony, (b) capsule and
ligaments a n d (c) muscles. T h e configuration o f the
bones o f the h i p j o i n t produce a n absolute
l i m i t a t i o n i n the possible range w h i c h cannot be
 Section 1.11 55

altered b y exercises or stretching. These b o n y limits 1.74 Plié.

are made u p o f the depth o f the a c e t a b u l u m (the
socket) a n d the angle at w h i c h the head a n d neck h rom the front.
of the femur are set on the shaft o f the femur.
S u r r o u n d i n g the h i p j o i n t is the capsule a n d
various ligaments. T h e latter are n o t a b l y the
ilio-femoral ligaments or Y - s h a p e d ligament, the
ischio-femoral ligament a n d the pubo-femoral
ligament. Tightness i n these fibrous soft tissues w i l l
l i m i t turn-out. It is extremely difficult to stretch
ligaments a n d , to a lesser extent, j o i n t capsules after
the age o f puberty because the fibrous tissue, o f
w h i c h these are composed, becomes mature a n d
p r a c t i c a l l y non-stretchable.
Tightness i n muscles, usually the adductors, c a n
p l a y a p a r t i n l i m i t i n g turn-out but i f these are
i n v o l v e d i n the restriction ( w h i c h is rare, except
w h e n it occurs secondarily following an injury) they
can usually be stretched out gently.
C o n t r o l o f turn-out is b y interaction between the
external rotators a n d the i n t e r n a l rotators o f the
hip j o i n t . T h e most i m p o r t a n t external rotator is
the a d d u c t o r g r o u p o f muscles. T h e s m a l l muscles
a r o u n d the h i p j o i n t are stabilisers o f the j o i n t a n d
play little part i n either external rotation or
i n t e r n a l rotation. T h e y should be looked u p o n as
adjustable ligaments. T h e external rotation effect o f
the adductors is b a l a n c e d m a i n l y by the ilio-psoas
muscle aided to a m u c h lesser extent b y various From the side.
other muscles.
T h e r e is no active external rotation (turn-out)
possible at any level o f the leg below the h i p j o i n t .
A s m a l l a m o u n t o f extra turn-out c a n be obtained
w h e n standing because o f friction between the foot
a n d the floor w h i c h c a n be used to give a passive
external rotation force to the w h o l e leg a n d this c a n
produce a rotation between the knee a n d the foot.
T h i s passive external rotation c a n produce very
d a m a g i n g results (see Section 5.7). W h e n the knee
is flexed there is some active a n d passive rotation
possible w i t h i n the knee j o i n t but this does not
occur w h e n the knee is extended.

P l i é ( F i g . 1.74) Note that the knee is

reasonably well aligned
T h e posture a n d the pelvis r e m a i n u n c h a n g e d over the foot but is not
d u r i n g a plié. I n p a r t i c u l a r the l u m b a r spine quite perfect, though
better in the boy. If
becomes neither lordotic nor over-flattened (tucking there is any degree of
of pelvis). T h e hips are flexed a n d turn-out is tibial torsion (which is
m a i n t a i n e d b y the adductors. H i p flexion is very common in
a c c o m p a n i e d b y knee flexion brought about by a dancers) then it will
controlled r e l a x a t i o n o f the quadriceps muscles. never be possible to
obtain 'exact alignment
T h e hamstrings p l a y little part as it is g r a v i t y w h i c h as the foot is externally
w i l l be b r i n g i n g the b o d y d o w n into the plié rotated in relation to the
position a n d it is gravity w h i c h is opposed by the knee.
56 Section 1: A n a t o m y a n d Physiology

1.75 Plié.

W i t h the knees in front of

the feet and the feet rolling.

From the front. From the side.

quadriceps w h i c h are r e l a x i n g slowly. A n k l e O n rising from a plié care must be taken to

dorsi-flexion is largely passive a n d the calf muscles
g r a d u a l l y relax. A s the plié progresses to a g r a n d
plié a n d the heels leave the floor the ankle
dorsi-flexion is still a passive movement. H o w e v e r ,
d u r i n g the whole range o f plié the intrinsic muscles
are a c t i n g to m a i n t a i n foot posture i n the same
m a n n e r as w h e n standing. T h i s is achieved b y the
n a t u r a l maintenance o f good tone a n d strong
intrinsic muscles a n d not by an active
over-contraction.
R i s i n g from the plié is brought about by active
c o n t r a c t i o n o f the quadriceps a n d the h i p extensors.
T h i s is achieved by pushing d o w n on the floor w i t h
the feet a n d not merely b y straightening the knees.
T u r n - o u t is m a i n t a i n e d the whole time b y the
adductors. A n k l e movements r e m a i n passive but the
heels should be a l l o w e d to come d o w n onto the
floor as soon as possible a n d not kept off the floor,
w h i c h w o u l d require a n active c a l f muscle
c o n t r a c t i o n a n d produce strain o f the quadriceps.
C a r e must be taken to ensure that the knees a n d
feet r e m a i n aligned, p a r t i c u l a r l y w h e n g o i n g d o w n
as far as a g r a n d plié, as it is only too easy to allow
the heels to s w i n g forward a n d the feet to r o l l ,
p r o d u c i n g an over-turned situation w h e n c o m i n g
out o f the plié ( F i g . 1.75).
m a i n t a i n the weight correctly over the feet
otherwise there is a m a r k e d tendency to come u p
w i t h the weight too far back. T h i s c a n o c c u r even
i f the weight has been correct at the start o f the
plié a n d while g o i n g d o w n into the full plié. T h e r e
is a great tendency to push the weight back as the
dancer comes up.
Note: I n order to m a i n t a i n the correct
alignment a n d weight placement throughout
both the plié a n d the rise, it is essential that
the dancer feels the contact w i t h the floor
through the feet a n d that he a c t u a l l y pushes
d o w n into the floor so that he has the
sensation that he is pushing himself u p from
below. T h i s is p a r t i c u l a r l y i m p o r t a n t i n
c o m i n g up from the plié w h e n the dancer
must not feel that he is merely straightening
his knees.
 Section 1.11 57

T e n d u ( F i g . 1.76)

T h i s term means stretched a n d its m a i n benefit

w h e n correctly c a r r i e d out is its effect o n the feet.
It is very i m p o r t a n t that the correct placement i n
the trunk a n d s u p p o r t i n g leg is m a i n t a i n e d
throughout, otherwise the exercise is totally useless.
I f the position o f these other areas is incorrect a n d
the weight is back the tendu becomes ineffective
and the muscles i n the feet are not stimulated a n d
therefore do not benefit.

1.76 Tendu.

Note that the stretch carries on to Incorrect tendu with the toes curled. This is a younger dancer still in training
the tips of the toes, which remain whose intrinsic muscles have not yet fully strengthened.
straight.
58 Section 1: A n a t o m y a n d Physiology
To half pointe (demi-pointe or à demi).
T o three-quarter pointe (à trois quarts).
1.77 Rise.
R i s e ( F i g . 1.77)
T h e trunk a n d pelvis move as one a n d come
slightly forward w i t h the line o f the centre o f
gravity, to lie over the toes w h e n the rise is
completed. T h i s is achieved by pushing up from the
floor w i t h the forefoot i n order to m a i n t a i n correct
a l i g n m e n t a n d weight-bearing. A n a t o m i c a l l y , the
c a l f muscles contract, lifting the heel a n d hindfoot
against g r a v i t y . A t the same time the tone is
m a i n t a i n e d i n the gluteals, the adductors, the
hamstrings a n d the knee extensors (quadriceps)
giving the feeling o f being lifted u p from above
and not pushed up from below. I n the presence o f
swayback knees the balance between the quadriceps
and hamstrings is exceptionally i m p o r t a n t i n order
to m a i n t a i n correct knee c o n t r o l .
T h e rise can stop at either h a l f pointe or
three-quarter pointe. See Note, page 56)
 Section 1.11 59

P o i n t e (Figs 1.78 a n d 1.79)

T o achieve a position on pointe the progression is as

through a rise to h a l f pointe then to three-quarter
pointe a n d finally to full pointe, using the same
muscles a n d the whole movement being fully
controlled. C o m i n g d o w n from pointe is just as
controlled a n d i n the reverse order. T o m a i n t a i n
full c o n t r o l throughout necessitates strength i n the
intrinsic muscles just as i m p o r t a n t l y as i n the c a l f
a n d i n the other leg muscles, a l l o f w h i c h have to
work m u c h harder to produce the rise.
O n c e o n pointe the base becomes very small so
that weight transference has to be very accurate.
T h i s requires even finer c o n t r o l o f total position
a n d line o f head, trunk a n d limbs.
O n pointe, relative strength a n d stability are the
c r u c i a l factors required to m a i n t a i n the position.
R e l a t i v e strength does not m e a n pure brute
1.78 O n Pointe. This is reached by means of a relevé in
strength but rather the accurate a n d delicate
which the dancer passes through the various levels of
balance between one muscle g r o u p a n d another. pointe to reach the full pointe position (sur la pointe).
H o w e v e r , a d d i t i o n a l l y , inherent (rather than
acquired) proprioceptive skills are a n essential part
of the maintenance o f balance o n pointe, a l t h o u g h
practise c a n still a n d w i l l i m p r o v e these skills. T h e
a b i l i t y to balance, w h i c h is a c o m b i n a t i o n o f
proprioceptive feedback, efficiency o f the balance
mechanisms i n the m i d d l e ear a n d to a very m i n o r
degree visual reflexes, is very v a r i a b l e from one
i n d i v i d u a l to another a n d a skill w h i c h c a n only be
i m p r o v e d to a l i m i t e d extent. It is certainly
associated also w i t h the speed o f response
(subconscious) to the various stimuli from the
different sources.

A G E T O START POINTE WORK

F o r m a n y years it has been said that twelve is the

age to start pointe w o r k . T h i s is, however, totally
1.79 O n Pointe. X - r a y of a dancer on pointe.
incorrect a n d there is no p a r t i c u l a r age at w h i c h
pointe w o r k should be c o m m e n c e d . T h e o n l y factor
w h i c h matters is the state o f development o f the
c h i l d a n d to be d o g m a t i c about a n age does not
make any reference to the child's m a t u r i t y or
immaturity.
T h e r e is no shame a n d certainly no disadvantage
i n starting pointe w o r k later rather than earlier.
S t a r t i n g before the c h i l d is physically a n d
technically ready is potentially very h a r m f u l .
W a i t i n g u n t i l the correct time, as far as that
i n d i v i d u a l c h i l d is concerned, w i l l have very
positive advantages. T h e r e w i l l be far less risk o f
injury. She w i l l be able to achieve the correct
technique more readily a n d accurately a n d w i l l
progress more speedily, being able to g a i n
60 Section 1: A n a t o m y a n d Physiology

confidence more r a p i d l y than i f she started before

being p h y s i c a l l y ready.
P o i n t e w o r k should not begin u n t i l g r o w t h has
settled i n the feet. Strength must have been
achieved i n the feet a n d a r o u n d the ankles w i t h full
control o f a l l the relevant joints. H o w e v e r , it does
not end w i t h the feet. It is as i m p o r t a n t for
strength to be present a n d well controlled higher
up, i n p a r t i c u l a r c h i l d r e n must be able to h o l d the
turn-out at the hips a n d be generally stable a r o u n d
the hips w h e n o n b o t h legs or o n one leg alone.
A d d i t i o n a l l y , they must be strong a n d stable i n the
trunk. I f there is any weakness or inadequate
control o f the muscles i n the trunk, h i p a n d thigh
1.80A A n over-pointed foot. T o come up onto pointe
area then they w i l l become extremely unstable a n d
with the foot in this position places an excessive strain on
unsafe w h e n c o m i n g up onto pointe. F a r better the capsules and ligaments of the dorsum of the foot as
results are obtained i f the onset o f pointe w o r k is the line of the centre of gravity falls in front of the toes
deferred u n t i l c h i l d r e n are ready physically. (i.e. in front of the dorsal aspect).
C e r t a i n l y , pointe w o r k should be avoided i f the feet
a n d b o d y are still soft, very m o b i l e a n d floppy.
G r e a t c a u t i o n is required w h e n d e a l i n g w i t h any
c h i l d w h o has h y p e r m o b i l e feet a n d ankles.
A l t h o u g h this excessively pointed foot can look very
pleasing w h e n it is the w o r k i n g leg a n d the foot is
i n the air, it is the type o f foot that is at greatest
risk once pointe work has started. It is at this time
that, i f a l l o w e d to come up onto the over-pointed
foot, the c h i l d can sustain lasting damage a l o n g the
d o r s u m o f the foot a n d the front o f the ankle ( F i g .
1.80). Before a student w i t h this type o f foot can
start pointe w o r k safely he or she has to d o a
considerable a m o u n t o f work to strengthen a l l the
muscles o f the feet a n d the ankles so that a really
well controlled foot is held i n the correct a n d not i n
the over-pointed position.
T h e r e are certainly w e l l - k n o w n dancers w h o 1.80B The same foot in the correct position for dancing
on pointe.
were not strong enough to start their pointe work
u n t i l they were over the age o f sixteen a n d this has
p r o v e d no h a n d i c a p i n their career.
 SECTION T W O
Injuries:
Patholoery, Causes. Treatment, Prevention. Nutrition
2.1 Patho-physiology of Injury:
Inflammation and Healing
Injuries to tissues c a n arise from a variety o f causes:
m e c h a n i c a l , burns, c h e m i c a l , action o f bacteria,
action o f viruses, etc. H o w e v e r , i n this book we are
really o n l y interested i n injury w h i c h is caused
m e c h a n i c a l l y . These injuries i n c l u d e sprains, muscle
tears, fractures, bruises a n d occasionally cuts a n d
abrasions.
Inflammation
A n y injury, whatever the cause, produces
i n f l a m m a t i o n . I n f l a m m a t i o n is a response w h i c h
occurs i n the s u r v i v i n g adjacent tissues at any
injured site. T h e r e is a general view that
i n f l a m m a t i o n is something w h i c h is undesirable a n d
should be a v o i d e d , because the first t h i n g that
springs to m i n d w h e n one considers i n f l a m m a t i o n is
something very painful such as a boil, sore throat
or similar infection w h i c h has p r o d u c e d an
i n f l a m m a t o r y response. A s bacterial infection o f
tissue is one form o f injury it therefore produces an
i n f l a m m a t i o n , hence the feeling that the
i n f l a m m a t i o n itself is undesirable. H o w e v e r , the
opposite is the case, i n f l a m m a t i o n is a very
beneficial t h i n g . It is a n a t u r a l protective a n d
defensive m e c h a n i s m w h i c h the b o d y has developed
in order to deal w i t h any type o f injury.
If the i n f l a m m a t o r y response is absent d r a m a t i c
a n d disastrous effects can arise. E v e r y o n e nowadays
hears o f patients w h o have been treated w i t h
special drugs to prevent i n f l a m m a t i o n , p a r t i c u l a r l y
following various o r g a n transplant operations a n d
also, o f course, i n a slightly different form i n the
conditions k n o w n as A I D S ( A c q u i r e d I m m u n e
Deficiency S y n d r o m e ) . W i t h o u t the i n f l a m m a t o r y
response, there is a very h i g h incidence o f severe
infections w h i c h c a n spread extremely r a p i d l y a n d
are frequently lethal. It is this i n a b i l i t y o f the b o d y
to c o n t r o l infections that renders patients so
vulnerable w h e n they have h a d immunosuppressive
therapy, as it is k n o w n . It is i m p o r t a n t therefore
that it is understood from the b e g i n n i n g that the
i n f l a m m a t o r y reaction is a desirable c o n d i t i o n .
Whatsoever the type o f injury to the tissue the
result i n the n o r m a l person is a n acute
i n f l a m m a t o r y response.
THE SIGNS O F I N F L A M M A T I O N
T h e signs o f i n f l a m m a t i o n were described some
2000 years or more ago a n d have been taught ever
since. U n t i l the current century they were always
described i n L a t i n as 'calor, rubor, dolor, t u m o r '
a n d Tunctio laesa' or i n E n g l i s h 'heat, redness,
p a i n , swelling a n d loss o f function.'
H e a t - calor
H e a t accompanies the redness o f the h y p e r a e m i a
a n d is due to the increased b l o o d flow. It is o n l y
appreciated at the skin surface because this is
usually cooler t h a n the i n t e r n a l b o d y temperature,
so w i t h the increased b l o o d s u p p l y the skin
temperature is raised up to, or nearly u p to, the
inside o f the body, i.e. 3 7 ° C . (98.4°F.) T h e r e is,
therefore, a localised increase i n w a r m t h c o m p a r e d
w i t h the s u r r o u n d i n g skin.
Redness - rubor
T h e redness appears early. It is due to the
d i l a t a t i o n o f the arterioles i n the area. T h i s allows
the capillaries to fill u p a n d become distended v e r y
q u i c k l y . It is sometimes k n o w n also as h y p e r a e m i a ,
w h i c h means an increased b l o o d flow.
P a i n - dolor
T h e r e are various causes for the p a i n w h i c h is
associated w i t h a n i n f l a m m a t o r y reaction as distinct
from the p a i n w h i c h is p r o d u c e d by the a c t u a l
injury, for example a s p r a i n or a fracture, b o t h o f
w h i c h are painful i n their o w n right. T h e
i n f l a m m a t o r y p a i n m a y be p r o d u c e d b y local
s t i m u l a t i o n o f nerve endings due to an alteration in
the local p H level (the a c i d a l k a l i balance) or b y
the release o f certain chemicals such as histamine
w h i c h also stimulates the nerve endings. S w e l l i n g
w i t h i n the inflamed tissues causes p a i n due to the
increase i n pressure.
SwellingANTERIOR
- tumor
L o c a l swelling always occurs i n the presence o f
i n f l a m m a t i o n a n d is due to the spread i n t o the
tissues o f fluid a n d cells from the b l o o d stream.
T h i s w i l l be considered a g a i n shortly.
62 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n
Loss of F u n c t i o n -functio
ANTERIOR laesa
Loss o f or altered function occurs w i t h
i n f l a m m a t i o n . P a i n m a y well i n h i b i t muscular
action a n d swelling w i l l also l i m i t movements o f
joints. H o w e v e r , apart from these very obvious
causes of loss o f function the u n d e r l y i n g reason for
the alteration i n function i n the presence of
i n f l a m m a t i o n at other sites is not really understood.
T h e most likely e x p l a n a t i o n is that the function
becomes i n h i b i t e d to allow the part to rest.
TISSUE C H A N G E S IN I N F L A M M A T I O N
F lANTERIOR
uid Changes
A s mentioned above, the redness a n d heat are
b r o u g h t about by the d i l a t a t i o n of arterioles w h i c h
leads to engorgement o f the capillaries. W i t h the
d i l a t a t i o n o f the capillaries there is an alteration i n
p e r m e a b i l i t y o f the walls o f these tiny vessels.
Instead o f retaining the large protein molecules
w i t h i n the c i r c u l a t i o n a n d not a l l o w i n g them to
cross the cellular barrier o f the c a p i l l a r y walls, the
p e r m e a b i l i t y o f the walls changes a n d some large
protein molecules can pass out into the tissue fluid.
A s a result the osmotic balance between the tissue
fluid and the blood alters a n d further amounts o f
water are d r a w n out into the tissue fluid, p r o d u c i n g
the local swelling. T h i s increase i n vascular
p e r m e a b i l i t y is the most i m p o r t a n t factor i n the
causation o f the swelling. H o w e v e r , there is a less
i m p o r t a n t factor i n that the d i l a t a t i o n produces an
increase i n the pressure o f the blood w i t h i n the
engorged vessels a n d this increased pressure w i l l
also a i d the p u s h i n g out o f water into the tissues.
T h e endothelial cells w h i c h line the small vessels
and largely form the walls o f the c a p i l l a r y vessels
act i n a physical sense as a semi-permeable
m e m b r a n e . A semi-permeable m e m b r a n e is any sort
of m e m b r a n e or layer w h i c h allows water a n d small
molecules to pass through but keeps back the larger
molecules. It acts very m u c h like a sieve. I n n o r m a l
circumstances the plasma proteins i n the b l o o d
c i r c u l a t i o n are large molecules w h i c h cannot pass
through the semi-permeable m e m b r a n e . T h e
concentration o f large molecules on one side o f the
semi-permeable m e m b r a n e exerts a force w h i c h is
knows as a n osmotic force, d r a w i n g fluid a n d
smaller molecules, d e p e n d i n g u p o n the p e r m e a b i l i t y
of the semi-permeable membrane, through into the
b l o o d i n a n attempt to dilute d o w n the
concentration o f large molecules. T h i s osmotic force
is also k n o w n as the osmotic pressure. I n
i n f l a m m a t i o n , the p e r m e a b i l i t y o f the endothelial
cells alters a n d as a result the large protein
molecules can pass through so that they enter the
tissue fluid. Therefore the difference i n osmotic
force between the two sides o f the semi-permeable
m e m b r a n e alters a n d , due to the proteins w h i c h
have been exuded into the tissue fluid, there is n o w
a force there d r a w i n g more water out into the
tissue spaces. T h e fluid w h i c h passes out i n t o the
tissues as a result o f the i n f l a m m a t i o n is k n o w n as
the exudate.
T h e l y m p h a t i c system also plays an i m p o r t a n t
part i n acute i n f l a m m a t i o n . T h e l i n i n g cells of the
very small lymphatics separate a little, a l l o w i n g
material from the spaces i n the tissues to d r a i n into
the l y m p h a t i c s . T h e r e is thus a very great increase
in the flow o f l y m p h d r a i n i n g from an area o f
i n f l a m m a t i o n . T h i s l y m p h is c a r r y i n g not o n l y
n o r m a l tissue fluid w i t h the extra p l a s m a protein
and blood cells but also various agents w h i c h m a y
have caused the i n f l a m m a t i o n . I n a n injury, of
course, these are only the products o f tissue damage
but i f the i n f l a m m a t i o n has been brought about b y
infection or penetration by foreign m a t e r i a l , this
material or the bacteria w i l l get into the l y m p h
system a n d w i l l be carried a l o n g i n the l y m p h a t i c s .
T h e y w i l l then reach the regional l y m p h nodes
w h i c h act as filters.
A s was decribed i n the first section o f the book,
the l y m p h nodes or l y m p h glands filter out any
foreign material. A s a result the regional l y m p h
nodes themselves c a n become inflamed. E v e r y o n e
w i l l have experienced a sore, infected throat at
some time i n their lives a n d w i l l have found that
the glands at the angles o f the j a w become enlarged
and tender. T h i s is because the glands at that site
are a c t i n g as the filters for the l y m p h w h i c h has
been flowing from the sore throat. A s a result of the
infection a n d the bacteria w h i c h the glands have
filtered out, they themselves become the site o f
i n f l a m m a t i o n but, due to their c a p a b i l i t y to
concentrate the white blood cells, they are able to
deal w i t h the bacteria or other materials a n d
prevent them passing through into the rest o f the
blood stream. O c c a s i o n a l l y , i f the infection is
severe, it can get t h r o u g h the l y m p h nodes. It then
stands an excellent chance o f being filtered out b y
more central nodes but i f these nodes are also
overcome it can reach the general c i r c u l a t i o n ,
p r o d u c i n g a generalised infection throughout the
body a n d severe illness i n the person concerned.
A s far as i n j u r y is concerned, there is usually at
most some cell debris or b r e a k d o w n products of
b l o o d w h i c h have to be filtered out, so any
i n f l a m m a t o r y changes w h i c h m a y o c c u r i n the
regional l y m p h glands are o n l y m i l d .
 Section 2.1 63

CANTERIOR
ell Changes
I n the early stages o f the acute i n f l a m m a t i o n , the
arterioles a n d capillaries are dilated a n d the flow o f
b l o o d i n t o the inflamed area is greatly increased.
H o w e v e r , shortly after that, as the fluid passes out
of the capillaries a n d very s m a l l vessels into the
tissues, the concentration o f cells left b e h i n d i n the
b l o o d increases a n d the b l o o d becomes more sticky,
i.e. the viscosity increases. A s a result o f this, the
c i r c u l a t i o n w i t h i n the area slows d o w n . W i t h the
s l o w i n g o f the b l o o d flow the white b l o o d cells or M ARGINATED
W HITE BLO O D CELL
leucocytes move to the periphery o f the stream
adjacent to the l i n i n g o f the b l o o d vessels. T h i s
p h e n o m e n o n is knows as m a r g i n a t i o n because the
leucocytes are m o v i n g towards the m a r g i n o f the
b l o o d stream i n these s m a l l vessels. W h e n the NUCLEUS OF C ELL
OF C APILLAR Y WALL
leucocytes reach the linings o f the b l o o d vessels, or
the e n d o t h e l i u m , they tend to stick to the
endothelial l i n i n g . T h i s is k n o w n as p a v e m e n t i n g
•W HITE BLO O D CELL
because under the microscope it has an appearance
PASSING BETW EEN
m u c h like that o f a c o b b l e d street. T h e leucocytes TW O C ELLS OF
then push their w a y through the walls o f these tiny CAPILLAR Y WALL
vessels. T h e y penetrate the vessel w a l l i n a n
a m o e b o i d fashion b y inserting a s m a l l p o r t i o n o f
their tissue t h r o u g h the space between two cells i n
the l i n i n g w a l l a n d then g r a d u a l l y squeezing the
rest o f the cell tissue o f the leucocyte through this
space. It w o u l d be m u c h the same i f y o u p i c k e d u p 2.1 Diagram showing margination of the white cells
a jellyfish from the shore a n d then started to push along the walls of a capillary and two white blood cells
it t h r o u g h a s m a l l knot hole i n a piece o f w o o d . A s passing through the capillary wall. The capillary wall is
itself made up of cells each with its own nucleus. The
a jellyfish, is so completely m o b i l e , y o u w o u l d push
white cell passes out between two cells forming the
a s m a l l p o r t i o n t h r o u g h a n d as y o u went o n capillary wall and not through a cell body.
pushing, the b o d y w o u l d n a r r o w d o w n , the j e l l y
fish w o u l d slowly go t h r o u g h the hole so that more
a n d more o f it appeared o n the other side, w h i c h
w o u l d get larger, u n t i l finally the last bit went
t h r o u g h w i t h o u t any damage at a l l to the jellyfish white b l o o d cell a n d they have different actions.
(Fig. 2.1). T h i s type o f action is k n o w n as T h e first cells a p p e a r i n g i n large numbers w i t h i n
a m o e b o i d movement because the very p r i m i t i v e the exudates at i n f l a m m a t o r y sites are the
cells, or amoebae, move a l o n g like this. T h e p o r t i o n neutrophils, n a m e d thus because o f their neutral
of cell they i n i t i a l l y put out is k n o w n as the staining characteristics. T h e y are the commonest
p s e u d o p o d i u m w h i c h , translated literally, means w h i t e cell i n the o r d i n a r y b l o o d c i r c u l a t i o n a n d
false foot. have a very short life. T h e r e are large numbers
T h u s the leucocytes or white cells move from the kept i n reserve i n the bone m a r r o w w h i c h c a n be
capillaries into the tissue fluid so that they c a n d e a l released w h e n r e q u i r e d . A t the site o f
as necessary w i t h the cause o f the i n f l a m m a t i o n . i n f l a m m a t i o n , they are able to e n g u l f bacteria or
O n c e t h r o u g h i n t o the tissue fluid, the leucocytes foreign materials b y p u t t i n g out p s e u d o p o d i a a n d
move very specifically i n the d i r e c t i o n r e q u i r e d . spreading a r o u n d the particle a n d t a k i n g it w i t h i n
T h i s is brought about b y c h e m i c a l s t i m u l a t i o n a n d itself. T h i s process is called phagocytosis. O n c e it
the process is k n o w n as chemotaxis. T h e has been enveloped w i t h i n the cell, the particle or
chemotactic signals w h i c h attract leucocytes c a n b a c t e r i u m w i l l be destroyed or digested b y various
emanate from infectious agents, damage to tissues enzymes w i t h i n the cell. I n a n acute infection, i f a
a n d substances p r o d u c e d by the proteins w h i c h sample o f b l o o d is taken a n d the w h i t e cells
have passed out from the b l o o d stream by osmosis. counted, there w i l l be a greatly increased n u m b e r
T h e r e are several different types o f leucocyte or of neutrophils per c u b i c m i l l i m e t r e o f b l o o d a n d
64 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
this increase is taken as evidence o f infection w h e n
a b l o o d count is carried out.
T h e eosinophil is another type o f b l o o d cell. It is
i n m u c h smaller numbers i n the b l o o d stream. It
becomes d y e d a bright red w h e n the stain eosin is
used, hence its name. A l t h o u g h it w i l l respond i n
m u c h the same w a y as the neutrophils a n d w i l l k i l l
some bacteria, it is basically a cell w h i c h gathers i n
m u c h larger numbers w h e n the i n f l a m m a t i o n is o f
the allergic type. T h u s i n allergic conditions, the
count o f eosinophils i n a b l o o d sample is increased.
T h e t h i r d type o f white blood cell w h i c h comes
i n the g r o u p o f granulocytes is the basophil. These
cells are called granulocytes because the cytoplasm
of the cell has large granules. I n the basophil these
granules stain a dark blue whereas i n the other two
types o f granulocyte the n e u t r o p h i l stains lavender
a n d the eosinophil stains red. T h e basophils are
only present i n very small numbers i n exudates.
T h e y are stimulated to release the contents o f their
granules into the s u r r o u n d i n g fluid i n non-specific
a n d i m m u n o l o g i c a l reactions.
T h e monocyte is a different form o f white b l o o d
cell a n d , unlike the granulocytes, the c y t o p l a s m has
very few granules. Its life is about four times longer
than the granulocytes. M o n o c y t e s enter the exudate
i n s m a l l numbers a n d at a smaller rate than the
neutrophils but w i t h the passage o f time their
n u m b e r increases steadily. W h e n a monocyte is
w i t h i n the exudate it is usually called a macrophage
a n d d u r i n g n o r m a l circumstances it w i l l often be
w a n d e r i n g a r o u n d through the connective tissue
spaces i n the b o d y a n d it is sometimes then referred
to as a histiocyte. Basically, these three names refer
to the same type o f cell. Its functions are very
m u c h like those o f the neutrophils i n a s m u c h as it is
able to absorb particles a n d bacteria into itself a n d
k i l l a n d digest them. W h e n i n the tissue, its life
cycle is different from the n e u t r o p h i l i n that it c a n
survive for very l o n g periods. T h e n e u t r o p h i l , as
w i t h the other granulocytes, cannot sub-divide a n d
form new cells. T h e macrophage or monocyte is,
however, capable o f cell division w h e n i n the tissue
fluid a n d it c a n also synthesise or b u i l d - u p a variety
of different enzymes w i t h i n its o w n cell. T h u s it is
able to respond a n d deal w i t h a variety o f different
noxious agents. Sometimes the macrophages w i l l
j o i n together to form one large cell w i t h several
nuclei. These are k n o w n as m u l t i n u c l e a t e d giant
cells.
A s mentioned, the macrophages are not only seen
i n the exudates at sites o f i n f l a m m a t i o n but they
are also n o r m a l l y distributed a r o u n d the b o d y a n d
are not o n l y i n the b l o o d stream as monocytes.
T h e y m a y also be fixed a n d line the vessels i n the
spleen, the liver and the bone m a r r o w a n d also the
walls o f the l y m p h a t i c system. T h e i r m a i n function
is phagocytic, i.e. the ingestion o f particles w h i c h
w o u l d otherwise be harmful to the b o d y as a whole.
T h e y act as the street cleaners o f the body. T h e y
are constantly w o r k i n g because i n m a n y aspects o f
d a i l y life there is a release o f a large n u m b e r of
bacteria into the b l o o d stream, for example, eating
a n d teeth cleaning w i l l produce a lot o f organisms
i n the b l o o d stream. These r a p i d l y get removed b y
the phagocytic activities o f the macrophages. As a
result, these episodes o f what is k n o w n as
bacteraemia are very short-lived a n d cause no harm
at a l l .
T h e last type o f leucocyte, w h i c h is the
l y m p h o c y t e , is only present i n very small numbers
i n exudates. H o w e v e r , i f the exudate becomes o l d
a n d the i n f l a m m a t o r y reactions becomes chronic,
the n u m b e r o f lymphocytes increases m a r k e d l y .
T h e y are seen therefore i n chronic infections such
as tuberculosis. T h e functions o f lymphocytes are
largely i n the p r o d u c t i o n o f various aspects o f the
i m m u n e reactions a n d are outside the scope of this
book.
It w i l l n o w have been seen that the i n f l a m m a t i o n
is i n fact a good or beneficial t h i n g from the body's
point o f view. T h e increased b l o o d supply has
brought cells to clear up the tissue damage or
infection. It has brought proteins a n d electrolytes to
help w i t h tissue repair a n d w i l l also i n various
conditions have brought antibodies. T h e exudate
can also start to form a clot, w h i c h is made u p o f
fibrils of protein w h i c h w o r k very m u c h like a
scaffold as the first stages o f tissue repair. T h i s w i l l
be mentioned a little later.
Types ANTERIOR
of Inflammation
T h e r e are three different types o f i n f l a m m a t o r y
reaction. T h e n o r m a l one following an injury such
as a cut or a n infection such as a b o i l is k n o w n as
an acute i n f l a m m a t i o n . T h e i n f l a m m a t i o n w i l l
develop r a p i d l y w i t h the various aspects w h i c h have
been described. T h i s w i l l be followed by repair a n d
healing a l l t a k i n g place over a relatively short
period. I f the infection is one w h i c h is k n o w n as
chronic, then there is a n advanced repair process
going on but at the same time the i n f l a m m a t o r y
c o n d i t i o n persists, so for a very extended period
there is c o n t i n u i n g i n f l a m m a t i o n w i t h c o n t i n u i n g
attempts at repair alongside this. I n c h r o n i c
i n f l a m m a t i o n the aspects o f acute i n f l a m m a t i o n are
m u c h less m a r k e d , i.e. there is less swelling and
p a i n , although both these m a y persist to some
extent as does also some degree o f interference w i t h
function; heat is usually absent. A sub-acute
 Section 2.1
infection is a n intermediate between acute a n d
c h r o n i c infection, where there is some evidence o f
repair but there is also some i n f l a m m a t i o n a n d
e x u d a t i o n g o i n g o n . It is often experienced b y the
subject as a n area w h i c h does not seem to get really
b a d a n d yet does not seem to get better. W h e n one
refers to a n i n f l a m m a t i o n o f a p a r t i c u l a r part, it is
usually n a m e d b y t a k i n g the p a r t i c u l a r inflamed
part a n d a d d i n g the four letters 'itis' as i n tonsillitis
or appendicitis. A r t h r i t i s is also w e l l k n o w n a n d
applies to an inflamed j o i n t . I f it is a n injured j o i n t
w h i c h is painful a n d swollen, it w i l l often be
referred to as a traumatic arthritis, i.e. a n arthritis
w h i c h has been p r o d u c e d by t r a u m a .
Inflammations are also sometimes further
described by the type o f exudate w h i c h is
p r o d u c e d . W h i l e there is no need to go deeply into
this as there are m a n y different types o f exudate, it
is w o r t h m e n t i o n i n g a serous exudate w h i c h is one
composed largely o f fluid a n d protein a n d has very
few w h i t e cells. F o r the dancer the most c o m m o n
serous exudate that they w i l l see is the fluid w h i c h
is present i n a blister. T h e swelling i n a d a m a g e d
j o i n t m a y be a serous exudate w i t h very few cells,
or i f the damage has been great a n d there has been
actually some tearing, the fluid i n the j o i n t m a y
c o n t a i n a greater or lesser a m o u n t o f b l o o d , i n
w h i c h case it m a y be called an haemarthrosis.
A n o t h e r type o f exudate w h i c h is well k n o w n is, o f
course, pus. I n this the neutrophils are i n such great
numbers as to colour the fluid a n d make it w h i t e .
T h e pus also contains products o f digestion a n d
disintegration o f the d a m a g e d tissue.
Sequelae ofANTERIOR
ANTERIOR
ANTERIOR Inflammation
C o n s i d e r i n g as we are i n this book injuries rather
than other conditions, we need to consider w h a t
happens after the i n i t i a l acute i n f l a m m a t o r y
response to the injury. T h e result w i l l depend
largely o n the degree o f damage to the tissues. I f
there has been very little or no destruction o f
tissues, the i n f l a m m a t i o n w i l l settle a n d w h a t is
k n o w n as resolution w i l l take place a n d the tissues
w i l l return to n o r m a l . A n example o f this w o u l d be
a s m a l l blister where the skin gets d a m a g e d . T h e
exudate forms underneath the skin to give the
actual blister, the skin over the blister breaks, the
exudate is discharged, the area dries a n d heals w i t h
the dead e p i t h e l i u m slowly peeling off, l e a v i n g once
again n o r m a l skin at that site.
I f there has been a significant degree o f tissue
destruction then resolution cannot occur, i.e. the
tissues cannot return to n o r m a l . I n this case, the
area where the tissue has been destroyed has to be
repaired. R e p a i r c a n occur i n two different ways.
65
T h e first a n d best w a y is b y cell regeneration. T h i s
occurs w h e n the n e i g h b o u r i n g u n d a m a g e d cells
d i v i d e a n d reproduce a n d proliferate, r e p l a c i n g the
d a m a g e d tissues w i t h new cells w h i c h are i d e n t i c a l
to those w h i c h have been lost, thus r e p l a c i n g the
whole area w i t h the same k i n d o f cell. T h e other
m e t h o d o f repair is brought about by the
proliferation o f fibrous tissue, or connective tissue
w h i c h produces a scar. D u e to the differing abilities
of the various kinds o f cells a n d tissues to
regenerate, repair is usually b y a c o m b i n a t i o n o f
regeneration a n d scar formation. T h e a b i l i t y to
regenerate depends entirely u p o n the a b i l i t y o f the
cells i n a p a r t i c u l a r tissue to sub-divide a n d
produce new i d e n t i c a l cells. Tissues such as the skin
a n d the l i n i n g o f the w h o l e o f the gastrointestinal
tract c a n regenerate very w e l l . Some o f the i n t e r n a l
organs such as the liver a n d k i d n e y c a n also
regenerate p r o v i d e d that the areas o f damage are
not too great. U n f o r t u n a t e l y for the dancer,
regeneration i n muscle is n o r m a l l y very l i m i t e d a n d
h e a l i n g is largely b y scar tissue. H e a r t muscle
cannot regenerate at a l l a n d heals entirely by scar
tissue. E q u a l l y i m p o r t a n t l y , there is no regeneration
at a l l o f d a m a g e d nerve cells. R e c o v e r y after heart
attacks occurs because n e i g h b o u r i n g cells a n d the
rest o f the heart muscle take over the function.
H o w e v e r , i f the damage is too great the r e m a i n i n g
heart muscle w i l l be u n a b l e to cope p r o p e r l y a n d
heart failure w i l l occur. S i m i l a r l y , i n the b r a i n , i f
cells have been destroyed by a stroke, w h i c h is
either a haemorrhage or a thrombosis i n the b r a i n ,
they cannot be repaired or regenerate. A n y
function w h i c h does return is b y adjacent cells
t a k i n g over the a c t u a l n e u r o l o g i c a l functions o f the
destroyed cells.
H o w e v e r , repair by scar tissue (fibrous tissue) is a
very efficient a n d satisfactory repair process
a l t h o u g h obviously not as functionally good as the
o r i g i n a l tissue. T h e repair comes about i n the
following manner. Into the d a m a g e d area there is
a n i n g r o w t h o f proliferating connective tissue so
that the d a m a g e d area becomes w h a t is k n o w n as
organised, the process b e i n g k n o w n as organisation.
T h e i n g r o w i n g tissue is referred to as g r a n u l a t i o n
tissue. T h i s is m a d e up o f proliferating fibroblasts
w h i c h produce fibrous tissue a n d proliferating
c a p i l l a r y buds w h i c h form new c a p i l l a r y vessels,
together w i t h some w h i t e b l o o d cells from the
i n f l a m m a t o r y process a n d the fluid parts o f the
exudate a n d loose connective tissue.
O r g a n i s a t i o n is already o c c u r r i n g w i t h i n several
days o f the start o f the i n f l a m m a t i o n . B y the end o f
a week the g r a n u l a t i o n tissue is still loose so that
the w o u n d c a n be easily p u l l e d apart. H o w e v e r ,
 66 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
after about a week the fibroblasts i n the
g r a n u l a t i o n tissue produce substances w h i c h lead to
the f o r m a t i o n of the protein called collagen. T h e
collagen appears as fibrils w i t h i n the g r a n u l a t i o n
tissue. A s time passes the a m o u n t of collagen is
g r a d u a l l y increased a n d becomes steadily more
dense. It is the dense collagen w h i c h forms the
actual scar a n d this process takes about two weeks
to achieve sufficient strength to h o l d the w o u n d
together. O v e r the following weeks the collagen
continues to increase i n strength. T h e lines o f the
fibrils that have been l a i d d o w n i n the collagen
g r a d u a l l y become more regular so instead o f being
higgledy-piggledy as w i l l be the state to begin w i t h ,
they become more arranged u p o n the lines o f
tension. I n the early days this scar has a h i g h
vascularity a n d therefore looks pink. W i t h the
passage o f time the scar loses the p i n k colour a n d
becomes white, the length o f time v a r y i n g from
person to person. A l s o v a r y i n g i n i n d i v i d u a l s is the
a m o u n t o f scar tissue w h i c h is l a i d d o w n .
Sometimes the scar becomes extremely thickened
a n d this is then often referred to as a keloid scar. It
m a y also be very i r r i t a t i n g .
H e a l i n g o f Injuries
T h e r e are two patterns o f healing. T h e first is
k n o w n as h e a l i n g by first intention, or p r i m a r y
healing. T h e second type is referred to as h e a l i n g
by second intention. T h e most desirable form is
healing b y first intention.
H E A L I N G B Y FIRST I N T E N T I O N
I f we consider a very simple injury such as a w o u n d
caused by a clean cut i n the skin, where the edges
have been brought together, we can see w h a t
happens i n healing by first intention. I m m e d i a t e l y
after the w o u n d occurs, there is bleeding, the
w o u n d edges are b o u n d together b y a b l o o d clot, i n
w h i c h the stringy fibre acts as a b i n d i n g m a t e r i a l .
A t the edges o f the w o u n d an acute i n f l a m m a t o r y
reaction develops i n exactly the fashion that has
been described earlier. T h e various cells pass into
the b l o o d clot a n d the macrophages i n p a r t i c u l a r
begin to destroy it. A s the d e m o l i t i o n o f the b l o o d
clot takes place, g r a n u l a t i o n tissue grows into the
area a n d after a few days the w o u n d is crossed
completely b y the g r a n u l a t i o n tissue. O b v i o u s l y the
length o f time taken to bridge the w o u n d depends
u p o n the size o f any gap. H o w e v e r , i n p r i m a r y
healing, the gap should be m i n i m a l .
D u r i n g this time, i n a skin w o u n d , the e p i t h e l i u m
at the surface begins to regenerate a n d after some
days there is a t h i n layer o f e p i t h e l i u m across the
w o u n d surface. T h i s e p i t h e l i u m g r a d u a l l y thickens
a n d becomes mature so that it looks like the
adjacent skin. I n the deeper layers, the g r a n u l a t i o n
tissue has m a t u r e d to form a scar w h i c h is a dense
collection o f collagen or white connective tissue. I n
the skin, i f the edges have been really well opposed,
the final scarring at the surface m a y be p r a c t i c a l l y
invisible. I n skin wounds w h i c h gape, the reason for
p u t t i n g i n stitches is to h o l d the edges close together
so that h e a l i n g c a n take place by first intention.
HEALING BY SECOND INTENTION
H e a l i n g by second intention is largely s i m i l a r to
that w h i c h has already been described. H o w e v e r , it
occurs i n wounds or injuries where the edges cannot
be brought together a n d opposed. T h i s m a y h a p p e n
at the skin level i f there is tissue loss or i f the
w o u n d is g a p i n g a n d is not stitched up, or it can
occur i n deeper layers of tissue. I n order to fill the
gap, very m u c h more g r a n u l a t i o n tissue is required
a n d at the skin surface very m u c h more
regeneration o f the epithelial cells. A s a result, a
very m u c h larger scar is formed. Because the
collagen is l a i d d o w n i n the g r a n u l a t i o n tissue a n d
then matures, this leaves a dense mass of collagen
or fibrous tissue. A t the skin, this leaves a very
obvious scar. It must be remembered that i n deeper
layers a similar mass o f scar tissue w i l l also form i n
order to fill a gap. A s was mentioned above,
different tissues have different powers o f actual
regeneration o f cells. Therefore, i n m a n y areas
where an injury occurs, the d a m a g e d area is
repaired m a i n l y or totally b y fibrous scar tissue.
T h i s scar tissue can become adherent to adjacent
structures. T h e presence o f the mass o f scar tissue
i n , for example a muscle, c a n i m p a i r the function
of the muscle as a whole. It is therefore extremely
i m p o r t a n t w h e n a n injury occurs to a v o i d further
damage a n d hence the proliferation o f scar tissue.
I f an injured part is exercised too early or unwisely,
the the a m o u n t o f scar tissue formed can be
increased considerably.
Essentially, h e a l i n g o f any d a m a g e d tissue i n the
body is similar to that w h i c h has been described.
L o c a l variations occur because o f different types o f
cells and their ability or otherwise to regenerate.
E v e n i n bone, the actual healing process is similar.
H o w e v e r , w i t h the formation o f the g r a n u l a t i o n
tissue a n d a c c o m p a n y i n g the m i g r a t i o n o f the cells
are two types o f bone ceil - the osteoblasts w h i c h
are responsible for l a y i n g d o w n new bone a n d the
osteoclasts w h i c h are responsible for eating away
the bone. I n i t i a l l y , i n a fracture the b r o k e n bone
ends are slightly eaten a w a y by osteoclasts a n d the
various minerals are released. T h i s gives a very h i g h
 Section 2.1-2.2
level o f concentration o f the minerals required for
bone repair. T h e h e a l i n g takes place w i t h the
formation o f g r a n u l a t i o n tissue a n d collagen a n d
along this scaffold that has been l a i d d o w n ,
osteoblasts w i l l produce bone. T h i s bone w h i c h is
put d o w n is done i n a totally r a n d o m m a n n e r .
W i t h the passage o f time a n d the action o f the
osteoclasts, this new bone is eaten a w a y a n d relaid
so that the lines o f the bony mesh are l y i n g i n the
right d i r e c t i o n . T h e bone slowly becomes mature
and the outline becomes remodelled to a v a r i a b l e
extent so that it tends to resume its o l d shape. T h i s
happens p a r t i c u l a r l y well i n c h i l d r e n before they
have stopped g r o w i n g . T h e i m m a t u r e bone w h i c h is
i n i t i a l l y l a i d d o w n d u r i n g the process o f h e a l i n g o f
the fracture is relatively soft a n d springy. T h e
hardness o f bone that we recognise is brought
about by the various m i n e r a l salts i n the bone. A s
the new bone is formed, the m i n e r a l salts are
g r a d u a l l y brought i n a n d l a i d d o w n a n d the bone
hardens a n d becomes solid.
FACTORS AFFECTING HEALING
T h e most i m p o r t a n t factor associated w i t h h e a l i n g
is the presence o f a good b l o o d supply to the
d a m a g e d area. I f the b l o o d s u p p l y is very poor, the
i n f l a m m a t o r y processes do not take place
adequately. T h i s w i l l lead to very slow or
inadequate h e a l i n g a n d also predisposes to infection
because o f the deficiency o f the body's protective
mechanisms, largely due to the inadequate n u m b e r
of white blood cells reaching the area. I f the
d a m a g e d part does not have adequate rest, the
newly formed g r a n u l a t i o n tissue c a n be repeatedly
d a m a g e d , w h i c h w i l l again affect the b l o o d s u p p l y
to the area a n d also increase the a m o u n t o f fibrous
tissue w h i c h is l a i d d o w n . Infection from the
beginning, for example i n a d i r t y w o u n d , c a n also
i m p a i r the h e a l i n g processes as can other
non-infected foreign m a t e r i a l .
E v e n i f h e a l i n g has taken place n o r m a l l y , the
scar tissue itself c a n cause problems. It m a y become
stuck to local structures fixing them together,
p r o d u c i n g w h a t are called adhesions. A s scar tissue
matures, it terfds to shorten or contract. A s a result,
movements o f a part m a y become l i m i t e d resulting
i n permanent post-injury stiffness. A scar w h i c h
contracts i n the skin can produce a m a r k e d
disfigurement a n d it takes little i m a g i n a t i o n to
realise the l i m i t a t i o n o f movement w h i c h can o c c u r
by similar contractures o c c u r r i n g i n the deeper
tissues w h e n they are d a m a g e d . A l s o , as already
mentioned, at skin level a n excessive a m o u n t o f
collagen m a y be formed l e a d i n g to a very
p r o m i n e n t scar w h i c h is k n o w n as a keloid scar.
67
T h i s is usually o f cosmetic i m p o r t a n c e only,
a l t h o u g h at a n area where r u b b i n g c a n occur, the
scar c a n tend to break d o w n repeatedly a n d
become sore. O c c a s i o n a l l y , d u r i n g the process o f
healing, small d a m a g e d nerve fibres can produce a
l u m p o f nerve fibres i n the area o f healing. T h i s is
k n o w n as a n e u r o m a a n d a n e u r o m a c a n produce a
very painful or tender area w i t h i n the scar.
T h e p r i m a r y a i m o f any form o f treatment is to
o b t a i n h e a l i n g b y first i n t e n t i o n . T h i s w i l l produce
the shortest recovery time, the m i n i m u m a m o u n t o f
scar tissue a n d hence the m a x i m u m return to full
and n o r m a l function.
2.2 Types of Injury
H a v i n g discussed the patho-physiology o f injury
and h o w h e a l i n g occurs we are n o w g o i n g to
describe various types o f injury w i t h consideration
of h o w the injury affects different parts a n d
structures i n the body. A l t h o u g h the general
principles o u t l i n e d above a p p l y to a l l types o f
injury, because o f differences i n the structures i n
the b o d y , the response to injury w i l l v a r y between
different structures a n d hence sometimes p r o d u c e
variations i n the h e a l i n g processes.
J o i n t Injuries
I n considering the joints we w i l l i n c l u d e not o n l y
the b o n y parts o f the j o i n t but also the capsule a n d
any external ligaments that are s u p p o r t i n g the
joints, a n y i n t e r n a l ligaments o f the j o i n t , and the
synovial l i n i n g o f the j o i n t . I n a d d i t i o n , i n the knee
there are flaps o f cartilage k n o w n as menisci or
semi-lunar cartilages w h i c h stick out i n the j o i n t
and are themselves subject to injury. T h e
t e m p o r o - m a n d i b u l a r j o i n t of the j a w is the only
other j o i n t to possess a meniscus.
T h e commonest injury to a j o i n t is a sprain
affecting one or more o f its ligaments a n d usually
the capsule a n d synovial l i n i n g i n a d d i t i o n . A
sprain occurs w h e n the fibrous tissue o f the
ligament or capsule is stretched a n d this is
a c c o m p a n i e d b y w h a t are k n o w n as micro-tears
w i t h i n the substance o f the l i g a m e n t a n d capsule.
I n these micro-tears a v a r y i n g n u m b e r o f fibres are
a c t u a l l y t o r n . I f the s p r a i n is more severe there c a n
be a c t u a l lengthening o f the l i g a m e n t as these t o r n
fibres tend to p u l l out past each other. I f the force
continues the l i g a m e n t c a n r u p t u r e a n d a gap
occur.
T h e first structure to take the strain i n an
a b n o r m a l m o v e m e n t is usually one o f the ligaments
68 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n

a r o u n d that j o i n t . I f the stretch continues the

adjacent capsule becomes i n v o l v e d a n d then the
u n d e r l y i n g synovial m e m b r a n e l i n i n g the j o i n t
itself. A sprain produces local bleeding where the
various fibres have been torn a n d this frequently
shows superficially as discolouration beneath the
skin, i.e. bruising. T h i s p a r t i c u l a r l y applies to joints
w h i c h have little o v e r l y i n g tissue, such as the ankle.
I n deep joints (e.g. the hip) this bleeding is not
usually visible i n the subcutaneous tissues. I f there
is any damage or i r r i t a t i o n o f the synovial l i n i n g o f
the j o i n t there w i l l be an o u t p o u r i n g o f fluid into
the j o i n t , causing the whole j o i n t to become
swollen. T h i s fluid is produced by the synovial
m e m b r a n e a n d represents an attempt to flush away
or dilute the irritant source. T h i s is seen i n
a n y t h i n g more serious than a very m i n o r sprain.
F r e q u e n t l y the effusion is merely an excess o f
synovial fluid secreted by the irritated synovial
l i n i n g . I f there has been any damage to the
synovial l i n i n g bleeding w i l l occur into the j o i n t ,
p r o d u c i n g an haemarthrosis. A n effusion or 2.2A A n X-ray of an ankle, showing that the talus is
haemarthrosis is always painful, m a i n l y due to the tilting during a forced passive inversion.
increase i n tension i n the j o i n t although the b l o o d
itself is a n i r r i t a n t a n d causes p a i n . B o t h are
i n d i c a t i v e o f serious injury. T h e only w a y to
differentiate between an effusion a n d an
haemarthrosis is to aspirate the j o i n t w i t h a needle
a n d syringe. Sometimes an haemarthrosis is due to
a fracture o f the bone w i t h the fracture line
entering the j o i n t . X - r a y s are required i n order to
exclude or to confirm a fracture.
It is very i m p o r t a n t to determine whether a
sprain is relatively m i n o r or whether it has
progressed to the stage where there is a complete
rupture o f a ligament. T h i s m a y be obvious o n
c l i n i c a l e x a m i n a t i o n but sometimes the e x a m i n a t i o n
causes too m u c h p a i n for the patient to tolerate the
proper testing o f the ligaments. I n these cases it
m a y be necessary to administer an anaesthetic i n
order to test the stability of the j o i n t . X - r a y s are
taken at the same time i n order to demonstrate
whether there is any instability o f the j o i n t w h e n it
is strained i n one or other direction ( F i g . 2.2). I n
the case o f damage to internal ligaments w i t h i n a
knee (the cruciate ligaments) or possible injury to a
meniscus o f the knee, then arthroscopy is 2.2B The same X-ray without any inversion strain
i n v a l u a b l e . A n arthroscope is a fine telescope w h i c h applied, showing that there is a normal appearance
despite the presence of ligament damage.
is inserted into the j o i n t through a s m a l l w o u n d ,
m a k i n g possible direct inspection inside the j o i n t . It
is possible to carry out some operative procedures
using the arthroscope; r e m o v a l o f portions o f
d a m a g e d meniscus can frequently be carried out
w i t h the help o f the arthroscope a n d w i t h o u t
o p e n i n g the j o i n t widely. H o w e v e r , for most
 Section 2.2 69

conditions w i t h i n the knee a n d certainly w i t h

injuries affecting other joints that require surgery,
open operations are inevitable.
I f significant ligament damage is undiagnosed
early, the c o n d i t i o n c a n progress to a c h r o n i c s p r a i n
or, i f the ligament has been greatly stretched, or A
r u p t u r e d , to c h r o n i c j o i n t instability.
I f there is any instability i n the j o i n t , the dancer
feels very unsafe on that j o i n t a n d it tends to give
w a y frequently. T h i s m a y or m a y not be
a c c o m p a n i e d b y repeated swelling a r o u n d the area
as well as by p a i n . L a t e repair of undiagnosed
r u p t u r e d ligaments is not very satisfactory a n d the
B
results are far worse than repair o f r u p t u r e d
ligaments i m m e d i a t e l y after the injury. B y
i m m e d i a t e one means w i t h i n the first twenty-four
or at most forty-eight hours. F a i l u r e to institute
surgery w h e n necessary m a y result i n a degree o f
instability sufficient to prevent the dancer getting
back to full w o r k w i t h confidence. A late repair,
a l t h o u g h i m p r o v i n g the situation, m a y still fail to
C
give the required stability to enable the dancer to
perform fully.
Sometimes a feeling o f instability i n the j o i n t is
due to damage to the nerve ends w h i c h lie i n the
capsule a n d ligaments. T h i s c a n be i m p r o v e d by
intensive physiotherapy i n various forms. T h e ankle
is the most c o m m o n j o i n t to be affected i n this
m a n n e r a n d here the b a l a n c i n g b o a r d is one o f the
most v i t a l parts o f the r e h a b i l i t a t i o n p r o g r a m m e . D
(See Figs 3.4, 3.5 a n d 3.6 on page 107.)
W i t h i n the j o i n t itself there c a n occur 2.3 A . Greenstick fracture.
B. Transverse fracture.
occasionally w h a t is k n o w n as a n osteo-chondral C. Comminuted fracture where there are several
fracture where a c h i p o f the a r t i c u l a r cartilage a n d fragments.
a s m a l l fragment o f the u n d e r l y i n g bone is D . Compound fracture where the bone comes
d a m a g e d a n d separates from the j o i n t surface. T h i s through the skin.
is u n c o m m o n i n dancers as it usually follows a
direct b l o w on the unprotected surface o f a j o i n t , fractures there is a break i n the skin a n d sometimes
such as the front o f the flexed knee. H o w e v e r , i n the bone a c t u a l l y comes t h r o u g h the skin. Severe
certain types o f inversion injury o f the ankle, a fractures are u n c o m m o n i n dancers.
fragment can be knocked off the dome o f the talus. T h e commonest type o f fracture is that affecting
the 5th metatarsal. T h i s is p r o d u c e d by a forcible
inversion injury. Fractures c a n take from six weeks
Bone Injuries to m a n y months to heal. U s u a l l y they are
i m m o b i l i s e d w i t h a plaster o f Paris cast.
ACUTE FRACTURES O c c a s i o n a l l y i n t e r n a l fixation - plates a n d screws -
I n bones the c o m m o n injury is a fracture w h e n the is r e q u i r e d . T h e r e are a few fractures w h i c h c a n be
bone is broken. A fracture is merely the m e d i c a l treated by simple strapping. D u r i n g i m m o b i l i s a t i o n
name for a broken bone ( F i g . 2.3). I n c h i l d r e n the dancer should spend a great deal o f time
these fractures m a y be o f the greenstick type where exercising a l l the other groups o f muscles i n the
the fracture is o n l y p a r t i a l a n d is a c c o m p a n i e d b y b o d y that have not been i m m o b i l i s e d b y the
some b e n d i n g o f the unfractured part o f the bone. plaster. O n c e the plaster is r e m o v e d then time has
Sometimes fractures are a c c o m p a n i e d b y to be spent strengthening up muscles w h i c h have
fragmentation o f the broken ends a n d these are become weak as a result o f the i m m o b i l i s a t i o n .
k n o w n as c o m m i n u t e d fractures. I n c o m p o u n d M a n y fractures w i l l be the site o f a c h i n g even
70 Section 2: Injuries: C a u s e s , T r e a t m e n t , Prevention
though the fracture has united satisfactorily.
A l t h o u g h uncomfortable this is not o f serious
significance a n d i n the l o n g term g r a d u a l l y settles.
F r e q u e n t l y the a c h i n g becomes more p r o n o u n c e d i n
cold or d a m p weather. It does not stop the dancer
performing fully and certainly does not mean that
there is a n y t h i n g w r o n g w i t h the h e a l i n g o f the
fracture.
O b v i o u s l y it is o f importance to diagnose a
fracture early a n d to this end X - r a y s are usually
required although a c l i n i c a l diagnosis of a fracture
is usually fairly straightforward a n d o n l y requires
X - r a y confirmation.
STRESS F R A C T U R E S
These are p a r t i c u l a r l y c o m m o n i n dancers a n d are
more frequently seen than actual acute fractures.
T h e y occur as a result o f repeated local stress on
one area o f the bone a n d come o n g r a d u a l l y . I f a
bone is subjected to recurrent forces or stresses that
are somewhat different from those experienced i n
everyday activities - w a l k i n g , stair c l i m b i n g ,
r u n n i n g relatively short distances, etc. or i f these
everyday activities are excessive - the area o f bone
that is being stressed w i l l respond i n i t i a l l y by
g r a d u a l l y thickening up the h a r d cortex. T h i s is
well seen i n dancers, especially i n the 2 n d
metatarsal w h i c h , p a r t i c u l a r l y i f it is long, c a n
often be seen to be very m u c h thickened on an
X - r a y . W h e n the stress ends, e.g. w h e n the dancer
retires, the stress thickening w i l l g r a d u a l l y
disappear a n d the bone w i l l return to a n o r m a l
X - r a y appearance.
I f the stress is more intensive a n d p a r t i c u l a r l y i f
it is well localised, small cracks w i l l develop i n the
bone. T h e local response is to invoke the
i n f l a m m a t o r y a n d healing mechanism. H o w e v e r , i f
the stress continues the c r a c k i n g m a y proceed faster
than the healing i n w h i c h case a stress fracture or
even m u l t i p l e stress fractures (as often seen i n the
tibia) w i l l occur. T h i s produces a g r a d u a l increase
i n the a m o u n t of p a i n experienced by the dancer.
I n i t i a l l y it w i l l only trouble them w h i l e they are
actually d a n c i n g , but as the stress fracture increases
the p a i n becomes more continuous u n t i l eventually
the p a i n is present a l l the time that there is any
type of activity, although it w i l l usually disappear
w h e n the part is being rested completely. I f the
presence o f a stress fracture is ignored it c a n
progress eventually to a complete fracture o f the
bone. A d d i t i o n a l l y , the longer the dancer continues
to w o r k w i t h a stress fracture, the longer it w i l l take
to heal. T h e history a n d e x a m i n a t i o n should enable
the diagnosis o f a stress facture to be made w i t h o u t
m u c h difficulty. Persistent p a i n on activity, w h i c h is
well localised to one area, is suggestive o f a stress
fracture. W h e n examined, this area, i f the bone is
superficial, w i l l reveal a local area o f w a r m t h , well
localised tenderness and palpable t h i c k e n i n g . These
findings are h i g h l y i n d i c a t i v e o f a stress fracture.
E a r l y treatment i n the form o f rest from d a n c i n g
activity should be undertaken.
Stress fractures usually do not show up i f X - r a y s
are taken i n the early days. I n the case o f the
metatarsal it m a y be two weeks before there is any
evidence o f a stress fracture. I n the tibia ( F i g . 2.4)
or the pars interarticularis o f the spine it m a y be
several months before any X - r a y changes are
visible. It is most i m p o r t a n t that treatment is not
delayed u n t i l there are positive X - r a y findings
otherwise the length of time for h e a l i n g a n d
recovery can be lengthened to m a n y months. It is
possible to confirm the presence o f a stress fracture
by a radio-isotope bone scan. T h e radio-active
isotope is concentrated at the stress fracture site,
p r o d u c i n g what is k n o w n as a 'hot spot'.
As w i t h other injuries, d u r i n g the period of rest
from d a n c i n g , the dancer c a n still do a whole series
of exercises i n order to keep the b o d y i n good
physical t r i m . T h i s p r o g r a m m e o f exercises should
be w o r k e d out w i t h the help o f an experienced
physiotherapist so as to ensure that no strain is put
on the site o f the stress fracture.
Associated w i t h bone but not an actual b o n y
injury is a c o n d i t i o n k n o w n as a sub-periosteal
h a e m a t o m a ( F i g . 2.5). T h i s results from a direct
blow to relatively superficial bone such as the shin.
Bleeding occurs between the periosteum a n d the
bone, lifting the periosteum from the bone a n d
p r o d u c i n g an extremely painful l u m p . T r e a t m e n t is
symptomatic only. V e r y rarely the h a e m a t o m a c a n
become infected, p r o d u c i n g an osteomyelitis. T h i s is
certainly more likely to happen i f someone is
injudicious enough to try to put a needle i n t o it to
aspirate the b l o o d . A n a d d i t i o n a l sequel to a
sub-periosteal h a e m a t o m a is that the blood m a y not
be completely absorbed a n d some o f this residual
blood m a y be converted into bone, l e a v i n g a small
bony l u m p at the site of the h a e m a t o m a .
T e n d o n Injuries
T e n d o n s r u n from the muscle belly to the point o f
inserti6n o f the muscle. T h e y are present because
they enable the p u l l o f the muscle to be taken to
the point o f the tendon attachment w i t h o u t h a v i n g
the b u l k o f the muscle g o i n g the w h o l e distance.
T h u s tendons are found, as described i n Section 1,
in areas where b u l k is disadvantageous, such as
from the forearm to the h a n d a n d the leg to the
 Section 2.2 71

place either i n someone w h o is not i n the h a b i t o f

t a k i n g m u c h exercise or i n a situation where
someone w h o is physically fit suddenly demands a
large n u m b e r o f repetitions o f a m o v e m e n t
r o
i n v o l v i n g one or more tendons repeatedly. I f
treated by rest this is usually sufficient to allow the
symptoms to settle. Sometimes resolution can be
speeded up w i t h the use o f ultrasound or ice.

TENDON RUPTURE - PARTIAL AND COMPLETE

P a r t i a l rupture o f a tendon is a more serious injury

and is a k i n to the s p r a i n w h i c h occurs i n the
ligaments. A dancer experiences sudden p a i n a n d
may a c t u a l l y hear or feel something give way. A
p a r t i a l rupture results i n the tearing o f some o f the
fibres o f the tendon w h i l e other fibres r e m a i n
intact. T h e r e w i l l be local bleeding at the site o f the
p a r t i a l rupture a n d this w i l l manifest itself as a
local tender swelling. I f the tendon is superficial, a n
increase i n w a r m t h c a n be felt b y the e x a m i n i n g
fingers. Rest, w i t h or w i t h o u t a n y i m m o b i l i s a t i o n , is
2.4 A stress fracture in the mid-shaft of the tibia. usually a l l that is r e q u i r e d i n order to allow h e a l i n g
of the p a r t i a l rupture to take place. O c c a s i o n a l l y
however, surgical repair is i n d i c a t e d i f it is
considered that the p a r t i a l rupture is fairly
extensive or i f there is d o u b t about whether there
may or m a y not be a total r u p t u r e o f the tendon. I f
PERIOSTEUM SUB-P ER IO STEAL adequate rest is not a l l o w e d for h e a l i n g to take
H A FM ATO M A
place, then the c o n d i t i o n can progress to a c h r o n i c
state where a c o m b i n a t i o n o f h e a l i n g a n d further
tearing is t a k i n g place at the same time. T h i s
n o r m a l l y occurs i f a d a n c e r does not take the
necessary time off to a l l o w complete h e a l i n g to take
place. After the period o f rest a n exercise
p r o g r a m m e is r e q u i r e d i n order to strengthen u p
the muscles w h i c h have been affected b y the p e r i o d
BONE of rest.
2.5 A sub-periosteal haematoma. A total rupture o f a tendon i n dancers is
fortunately very u n c o m m o n . I n the p o p u l a t i o n as a
whole the commonest tendon r u p t u r e is where one
of the extensor tendons is p u l l e d off the distal
p h a l a n x o f the finger, causing the p h a l a n x to d r o o p
d o w n into p a r t i a l flexion; this is k n o w n as a m a l l e t
finger. T h i s also occurs i n b a l l games w h e n the end
of the finger is struck. V e r y occasionally i n dancers
the major tendons are r u p t u r e d , i.e. the A c h i l l e s
foot. T e n d o n s are very strong. T h e r e is very little tendon, the patellar tendon a n d the quadriceps
stretch i n them a n d because they have to slide u p tendon. A l m o s t i n v a r i a b l y this happens because o f
and d o w n w i t h o u t i m p e d i m e n t they have a poor a sudden violent c o n t r a c t i o n o f the muscle. T h i s
blood supply. m a y take place because the d a n c e r misses his
footing or slips from a p r o p . M o r e c o m m o n l y it
TENDONITIS
happens i n the m a t u r e dancer o r dance teacher
T e n d o n i t i s is merely an i r r i t a t i o n o f a tendon who is d e m o n s t r a t i n g a large j u m p or
w i t h o u t any significant damage to the fibres. It is unaccustomed routine w h i c h needs a sudden
caused b y unaccustomed exertion. T h i s m a y take explosive burst o f muscle power.
72 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
Immediate diagnosis is vital. Initially the diagnosis
is fairly obvious but i f some hours have elapsed the
local swelling may be sufficient to disguise what was
earlier an easily felt gap. Urgent repair in the first
twenty-four hours is essential i f a satisfactory
functional result is to be obtained. Even so, the
rupture of a major tendon will usually lead to the
dancer failing to regain the same level of activity
which was pertaining before the rupture. A p a r t from
the immediate and skilful surgical repair, the
post-operative physiotherapy plays a vital part in the
satisfactory recovery of the patient. T h e treatment
includes a full rehabilitation programme and a great
deal of hard work by the patient.
TENOSYNOVITIS A N D PERITENDONITIS
T h e tissues s u r r o u n d i n g the tendon can be the site
of i n f l a m m a t i o n and irritation. I n those tendons
w h i c h have a proper sheath the i n f l a m m a t i o n w i l l
affect this tendon sheath p r o d u c i n g what is k n o w n
as tenosynovitis. Some tendons, for example the
A c h i l l e s tendon and the patellar tendon, do not
have a sheath but the soft tissue a r o u n d the tendon
can become inflamed i n exactly the same w a y as
the tendon sheath. T h i s is k n o w n as peritendonitis.
In both tenosynovitis a n d peritendonitis the
c o n d i t i o n tends to be triggered off by over-use o f
the tendon. T h i s c a n be caused by either faulty
technique where the tendon is being repeatedly
over-stressed or by too m a n y repetitions o f the same
movement. C l i n i c a l e x a m i n a t i o n usually shows that
there is some swelling a n d tenderness a l o n g the line
of the affected tendon a n d sheath. M o v e m e n t s are
painful a n d frequently the e x a m i n i n g finger can
feel a crepitus or grating/creaking sensation over
the m o v i n g tendon.
T r e a t m e n t is by rest w h i c h usually produces
r a p i d relief. I n other cases ice, ultrasound a n d
physiotherapy measures are required a n d some
form o f splintage m a y assist. I n l o n g standing cases,
an injection o f steroid w i l l be helpful. O n l y on very
rare occasions is an actual surgical decompression
of the tendon sheath required. T h i s is only
necessary w h e n the c o n d i t i o n has become c h r o n i c
and is not responding to conservative treatment. B y
then it has usually led to some t h i c k e n i n g a n d
scarring of the tendon sheath or the peritendinous
tissues. O c c a s i o n a l l y , there is a local cause such as
pressure o n a tendon. I n dancers this is sometimes
seen at the lower end of the Achilles tendon near its
insertion, where b a d l y fitting shoes c a n cause
pressure. I n sportsmen the h i g h backs o f the shoes
or a shoe tab c a n cause great i r r i t a t i o n o f the
A c h i l l e s tendon. O b v i o u s l y where there is a l o c a l
cause, this must be removed.
T E N D O N INSERTION INJURIES
These occur at the site where the tendon goes into
the bone a n d are usually i n the form o f a strain.
A d e q u a t e rest is an essential part o f treatment.
U l t r a s o u n d , ice a n d occasionally steroid injections
may be required. F r e q u e n t l y the response to
treatment is slow a n d treatment m a y be p r o l o n g e d .
Use of steroids i n any type o f t e n d o n injury
should be confined to c h r o n i c injuries o n l y . M a n y
authorities believe that steroid injections c a n
pre-dispose to a total rupture o f the tendon.
C e r t a i n l y injections o f steroids s h o u l d never be
made into the tendon itself but o n l y into the tissues
a r o u n d the tendon, either w i t h i n the tendon sheath
or i n the peritendinous tissues. R e p e a t e d injections
of steroids should be avoided as this is c e r t a i n l y
more likely to lead to a tendon rupture. A s at a l l
other sites, steroid injections should not be looked
u p o n as a quick cure to get the dancer back to full
performance. After the steroid injection, even i f the
symptoms are relieved, a proper course o f
rehabilitation exercises must be instituted to
prevent the c o n d i t i o n r a p i d l y r e c u r r i n g or
progressing to a more serious injury.
M u s c l e Injuries
Fortunately, serious muscle injuries are not
p a r t i c u l a r l y c o m m o n i n dancers a l t h o u g h m i n o r
muscle pulls a n d strains are quite frequent.
Muscles m a y be d a m a g e d b y direct blows, such
as a n inadvertent kick or striking a p r o p or scenery.
T h i s can produce bruising w i t h possibly some
a c t u a l damage to a few o f the fibres. A short period
of rest a c c o m p a n i e d by ice a n d ultrasound followed
by some gentle graduated exercises a n d stretching
usually produces a r a p i d resolution o f the
condition.
MUSCLE TEARS
A c t u a l tears o f the muscle m a y occur. U s u a l l y ,
these are only m i n o r a n d p a r t i a l , i.e. the tear does
not extend right across the muscle a n d only involves
a p o r t i o n o f the muscle belly. It is usually k n o w n as
a pulled muscle a n d w i l l o c c u r i n most
circumstances because o f a n i n c o - o r d i n a t e d
contraction o f the muscle or part o f the muscle,
frequently associated w i t h an i m p r o p e r or
incomplete w a r m - u p or h a v i n g to w o r k i n a n
environment w h i c h is too c o l d , possibly standing
a r o u n d between sudden bursts o f activity. T h e tear
may be centrally w i t h i n the substance o f the muscle
or i n the periphery o f the muscle. T h e latter tends
to cause less m a r k e d p a i n a n d interference w i t h use
 Section 2.2-2.3
than the former. I n a central muscle tear the
central swelling w h i c h occurs exerts pressure a l l
a r o u n d the periphery, whereas i n a peripheral tear
the bleeding is able to disperse a n d m a y track a l o n g
the muscle, a p p e a r i n g at some distance from the
site of the tear. H o w e v e r , h a v i n g said that, it is
frequently difficult or impossible to differentiate
between the two types o f tear. It is often o n l y
because recovery is t a k i n g very m u c h longer than
anticipated that one can come to the definite
conclusion that it was a central tear w h i c h h a d
taken place. I f extensive b r u i s i n g has appeared, this
w i l l be a peripheral tear so the dancer can be
confident that recovery w i l l be fairly r a p i d . A
central tear w i l l n o r m a l l y take three or four weeks
to heal a n d allow recovery to take place. T r e a t m e n t
is i n i t i a l l y by rest, i n order to minimise the a m o u n t
of bleeding a n d to prevent any further tearing.
A p p l i c a t i o n o f ice w i l l hel p to decrease the a m o u n t
of bleeding as w i l l also compression by a firm
bandage. E l e v a t i o n o f the injured l i m b w i l l help to
decrease the pressure i n the injured area.
E a r l y active a n d passive movements are
instituted once it is certain that bleeding has ceased.
T h e degree o f exercise must be regulated b y p a i n .
Injudicious exercise can aggravate the situation. A s
the c o n d i t i o n settles, a g r a d u a l increase i n resisted
exercises is required to b u i l d up the muscle. T h i s is
a c c o m p a n i e d b y regular, gentle stretching so that
the scar tissue at the tear does not contract. T h e
more time every day that the dancer can spend o n
the graduated exercises, the more r a p i d a n d
satisfactory the recovery. A short period o f exercise
once a day w i t h n o t h i n g i n between is not
conducive to a r a p i d recovery.
It is essential that the muscles return to full
strength before the dancer is a l l o w e d to return to
full d a n c i n g . H o w e v e r , w i t h care, a g r a d u a l return
to class can be used as part o f the r e h a b i l i t a t i o n
programme.
O c c a s i o n a l l y , muscle damage can be c o m p l i c a t e d
by formation o f bone w i t h i n the healing area o f
muscle. T h i s is caused by damage to the periosteum
at the same time as the muscle injury, l e a d i n g to
spillage o f bone cells into the muscle h a e m a t o m a .
T h i s bone formation produces a great deal o f p a i n
a n d there is m a r k e d l i m i t a t i o n o f movement. A
very firm swelling can be felt deeply w i t h i n the
muscle a n d this swelling g r a d u a l l y becomes harder.
X - r a y s w i l l show that bone is starting to form i n
the muscle. T h e only treatment is to rest the muscle
completely. A n y sort o f activity w i l l aggravate the
situation a n d increase the ossification. N o form o f
physiotherapy helps a n d is certainly
contra-indicated, as treatment is nearly always
73
d e t r i m e n t a l to recovery. O n l y w h e n the bone has
m a t u r e d a n d there is no risk o f it increasing c a n
active physiotherapy start again. A satisfactory
recovery usually occurs i f these i n i t i a l precautions
are taken conscientiously. O n l y rarely is it necessary
to remove the l u m p o f bone. U n f o r t u n a t e l y , this
itself m a y lead to further spillage o f bone cells a n d
the c o n d i t i o n c a n recur, so surgery should certainly
not be undertaken lightly.
M U S C L E STIFFNESS
M u s c l e stiffness usually follows unaccustomed
exercise. It is therefore experienced most frequently
w h e n the dancer returns to w o r k after a period o f
h o l i d a y . O c c a s i o n a l l y it c a n occur i f the dancer has
to undertake a sudden increase i n w o r k l o a d . T h e
causes o f the stiffness m a y possibly be due to v e r y
tiny ruptures o f the muscle fibres o c c u r r i n g i n the
incompletely trained muscle, g i v i n g rise to local
swelling a n d causing p a i n a n d i n f l a m m a t i o n .
A n o t h e r possible cause is the a c c u m u l a t i o n o f
various waste products w h i c h are not removed as
r a p i d l y i n u n t r a i n e d as i n trained muscle. H o w e v e r ,
neither o f these theories has been p r o v e d .
W h a t e v e r the cause o f the stiffness, the treatment
is to continue w i t h regular classes a n d to g r a d u a l l y
b u i l d up the w o r k . It is i m p o r t a n t that classes are
carried out i n a w a r m atmosphere a n d that they
are designed to give adequate w a r m - u p w i t h a
graduated increase i n the a m o u n t o f w o r k . Class
should finish w i t h an adequate w a r m - d o w n .
2.3 Causes and Complications of
Dance Injuries
A l l dance i n j u r i e s a r e caused by faulty faultyfaulty
technique.
D a n c e i n j u r i e s a r e not a n Act of God.
T h e r e is no d o u b t that this is the most i m p o r t a n t
fact the dancer or dance teacher must understand.
W h e n t r y i n g to determine the cause o f a n injury
the first question w h i c h must be asked b y the
professional dancer or student, b y the dance
teacher or by the m e d i c a l attendant is ' W h a t
technical fault has led to this injury?' O n c e they
have started asking this question they are at least
part w a y to m a k i n g the right diagnosis a n d
instituting the correct treatment a n d r e m e d i a l
measures. T h e a i m must be a full recovery as
r a p i d l y ,as possible a n d , e q u a l l y i m p o r t a n t l y , the
prevention o f recurrences o f the same i n j u r y .
74 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
A l w a y s remember that the cause or causes o f
injury m a y not be apparent except on detailed a n d
meticulous observation a n d e x a m i n a t i o n .
A s m a l l percentage o f injuries are best called
dance-related injuries a n d are not dance injuries as
such. U n d e r this heading w o u l d be i n c l u d e d
injuries w h i c h are sustained d u r i n g the course of
d a n c i n g but arising more from the e n v i r o n m e n t a l
conditions than from faulty technique a n d
o c c u r r i n g i n the absence o f any fault i n technique.
T h e r e is also the dancer w h o is suffering from an
injury w h i c h is neither a dance injury nor a
dance-related injury. I f a dancer has been r u n over
by a m o t o r car or has fallen downstairs, he is not
suffering from an injury related i n any w a y to his
d a n c i n g a n d is merely an injured dancer.
T r e a t m e n t w i l l obviously follow standard lines but,
d u r i n g r e h a b i l i t a t i o n , w h i c h should start from the
early stages o f treatment, consideration should a n d
must be given to the fact that the patient is a dancer
a n d w i l l be required to return to a very h i g h level
of activity. Therefore, most aspects o f treatment
described under that for specific dance injuries c a n
be a p p l i e d to injuries sustained from non-dance
causes. I n fact, i f m e d i c a l personnel treating
injuries i n general were to a p p l y the intensive
r e h a b i l i t a t i o n methods to the average members o f
the p o p u l a t i o n , they w o u l d o b t a i n very m u c h more
satisfactory results, given the wishes a n d dedication
of the patient to follow what might be considered a
fairly rigorous rehabilitation p r o g r a m m e .
C a u s e s o f Dance Injuries
INJURIES C A U S E D B Y F A U L T Y TECHNIQUE
A n a t o m i c aANTERIOR
l Causes
A s most dancers are not a n a t o m i c a l l y perfect for
dance, there w i l l be physical limitations a n d
constraints w h i c h m a y play a part i n preventing the
development o f a perfect technique. C e r t a i n l y the
commonest a n a t o m i c a l cause o f potential problems
a n d injuries is l i m i t a t i o n o f turn-out (external
rotation) o f the hips.
It is i m p o r t a n t for the dance student a n d the
teacher o f the student to realise a n d appreciate as
early as possible the exact a n a t o m i c a l limitations
present so that the student can learn to w o r k w i t h i n
his true physical range. D u r i n g their early years
students must learn to make the best use o f a l l
aspects o f their physical potential but should not
attempt to go beyond that. Reference to Section
5.7 w i l l enable y o u to appreciate a l l the troubles
a n d problems that can arise i f dancers attempt to
t u r n the feet out further than the hips a l l o w , i.e. b y
attempting to exceed their p h y s i c a l p o t e n t i a l or
limits.
L a c k of T e c hANTERIOR
nical Knowledge
D u r i n g student years y o u n g dancers w i l l be more
prone to injury as they try to put i n t o effect
technique w h i c h they are i n the m i d d l e o f l e a r n i n g .
M a n y injuries are seen d u r i n g this phase o f their
career, a l t h o u g h fortunately they are usually m i n o r ,
p a r t i c u l a r l y i f facilities are r e a d i l y a v a i l a b l e for
early diagnosis a n d treatment. If, however, these
facilities are not available, it is also at this stage o f
their lives that the injury c a n become long-term
a n d persistent. T h i s is usually a result o f a failure
to appreciate the actual cause o f the injury so that
the y o u n g students d o not receive the technical help
w h i c h is needed to prevent the injury b e c o m i n g
recurrent or c h r o n i c .
B a d Teaching
It is i n the causation o f injury that the b a d teacher
can excel. T h e y c o m m o n l y fail to appreciate the
a n a t o m i c a l limitations w h i c h are b e i n g experienced
by a student. T h e y fail to recognise areas o f
weakness w h i c h m a y be exacerbated at some
p a r t i c u l a r time by a g r o w t h spurt, b y a m e d i c a l
illness such as g l a n d u l a r fever, or by some other
extraneous p r o b l e m . T h e y c a n fail to notice
technical faults w h i c h the c h i l d is d e v e l o p i n g and,
even worse, they c a n be teaching technical faults
w h i c h can b r i n g about injury or c o m p o u n d the i l l
effects o f injuries w h i c h have already been suffered.
O v e r t u r n i n g the feet i n relation to the hips is
p r o b a b l y the commonest single teaching fault, e.g.
d e m a n d i n g a flat or 180° turn-out at the feet w h i c h
is not matched at the hips. A s a general rule the
feet should not be turned out further than the
available turn-out at the hips. P u t t i n g c h i l d r e n on
to pointe too early a n d before they are strong
enough or pushing them into examinations or other
situations w i t h w h i c h they are not ready to cope,
can also produce very significant problems.
N o n - a p p l i c a t i o n of Correct Technique
ANTERIOR
T h i s situation includes professional dancers w h o are
technically fully trained but w h o for various
reasons m a y allow their technique to slip. T h i s is
p a r t i c u l a r l y prone to h a p p e n w h e n they become
tired. It is seen frequently d u r i n g the course o f a
l o n g tour. I n this situation, as the tour progresses,
the injury rate g r a d u a l l y increases due to a
c o m b i n a t i o n o f m a n y performances, a great deal o f
travel w i t h insufficient rest between performance
venues a n d frequently, inadequate conditions for
performance a n d o f hotel-type facilities.
 Section 2.3
I n this sub-section should also be i n c l u d e d
injuries w h i c h are p r o d u c e d by b a d choreography,
where the choreographer m a y , d u r i n g the never
e n d i n g search for something totally new, e m b a r k o n
a routine w h i c h is so bizarre or a w k w a r d that it is
i n c a p a b l e o f being carried out w i t h any type o f
established technique. I n this situation dancers m a y
become injured w h i l e they are t r y i n g to develop a
technique i n order to carry out the required
routine, or injury m a y follow the sudden
unaccustomed use o f an area o f the b o d y , e.g.
muscle g r o u p or type o f movement, w h i c h has been
little used i n the past a n d w o u l d , i f it were to
r e m a i n injury free, require g r a d u a l l y increasing use
and development.
E N V I R O N M E N T A L CAUSES O F INJURY
These causes w i l l produce w h a t m i g h t be termed
dance-related injuries, a l t h o u g h the e n v i r o n m e n t
may i n fact contribute to genuine dance injuries
themselves. O v e r most o f these e n v i r o n m e n t a l
causes the dancer personally w i l l have little or no
control, a l t h o u g h the experienced professional
should be able to recognise the potential dangers
and at least make representations for an
i m p r o v e m e n t or correction o f whatever defect is
present.
A m o n g the e n v i r o n m e n t a l causes are inadequate
facilities. T h i s p a r t i c u l a r l y applies to a lack o f d a i l y
class opportunities as pertains i n m a n y stage shows
w h i c h involve a great deal o f d a n c i n g , as opposed
to professional dance companies where the d a i l y
class is part o f the routine w o r k i n g o f the c o m p a n y .
I n a large t o w n it m a y be possible for the dancer to
go out a n d j o i n an open class i f one is available.
H o w e v e r , i n some areas adequate classes m a y not
be held a n d it is i n this situation that the
management, i f they fail to provide facilities for
their dancers to c a r r y out a d a i l y class o f their o w n ,
w o u l d be creating an e n v i r o n m e n t a l cause for the
development o f injuries a m o n g the dancers
concerned. I f the dancer has no access to a space
large enough for h i m even to construct his o w n
d a i l y class, he w i l l be i n the situation where he has
to go into the show each evening w i t h o u t any
adequate p r e p a r a t i o n earlier i n the day. It is at
times such as this that injury rates c a n be seen to
rise steadily. It is certainly i n the management's
o w n interest either to provide the actual facilities
for a d a i l y class for a l l their dancers i n c l u d i n g , i f
possible, someone to take the class, or else to m a k e
arrangements for the dancer to have the
o p p o r t u n i t y to attend an outside class. T h i s failure
on the part o f management a n d promoters is
p r o b a b l y as m u c h due to their lack o f a p p r e c i a t i o n
75
of the requirements o f their dancers as a n y
deliberate disregard o f these necessities. F r o m this
point o f view the dancers themselves, together w i t h
their representatives, must take some o f the b l a m e
for not insisting o n the provision o f adequate
facilities.
A m o n g the genuine e n v i r o n m e n t a l causes w h i c h
may predispose to injury are (a) temperature (b)
floor.
Temperature
ANTERIOR
T h e a m b i e n t temperature i n w h i c h the dancer is
expected to take class, rehearse or perform must be
such that they do not become c h i l l e d before, d u r i n g
or after any o f these activities. T h e a m b i e n t
temperature s h o u l d not be a l l o w e d to fall below
6 8 - 7 0 ° F . A s has been m e n t i o n e d i n the causes o f
injuries (Section 2.2 M u s c l e Tears, page 72),
muscle injuries i n p a r t i c u l a r are far more likely to
occur i f the dancer is inadequately w a r m e d - u p .
Excessively h i g h temperatures, a l t h o u g h not
predisposing directly to injury, have their o w n
complications, n o t a b l y the p r o d u c t i o n o f excessive
sweating l e a d i n g to loss o f water a n d electrolytes
( m a i n l y salt). I f this loss is adequately replaced
then no h a r m w i l l accrue. H o w e v e r , there is a
tendency for the dancer to i n a d e q u a t e l y replace the
fluid loss a n d this c a n lead to muscle cramps a n d
spasms as well as more serious m e d i c a l problems i f
it occurs over a longer p e r i o d .
The Floor
T h i s is a n extremely i m p o r t a n t factor i n
e n v i r o n m e n t a l causes o f injury. T h e a c t u a l floor
construction is o f the greatest i m p o r t a n c e to the
dancer. U n f o r t u n a t e l y , i n m a n y m o d e r n theatres
and i n studios w h i c h are not purpose-constructed
the u n d e r l y i n g f o u n d a t i o n for the floor is
reinforced concrete. T h e sight o f a w o o d e n floor
should not delude the dancer into t h i n k i n g the
w o o d has been sprung. O n l y too frequently it has
been l a i d directly o n a concrete surface, or u p o n
rolled steel joists. T h e lack o f s p r i n g c a n p r o d u c e
m a n y injuries, n o t a b l y foot problems, injuries i n the
l u m b a r region o f the spine, i n the muscles w h i c h
are associated w i t h take off a n d l a n d i n g a n d i n the
bones, m a i n l y the t i b i a a n d the metatarsals, w h i c h
can be the site o f stress fractures. F l o o r construction
is a c o m p l i c a t e d subject a n d outside the sphere o f
this book. H o w e v e r , it does appear that p r o v i d e d
classes a n d rehearsals are c a r r i e d out o n a floor
w h i c h is completely suitable for d a n c i n g , then
occasional performances w h i c h are c a r r i e d out o n
inadequate floor constructions m a y be acceptable
p r o v i d e d the inadequate floor is covered w i t h t w o
layers o f special cushioned v i n y l . A l t h o u g h this is
76 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n
the current t h i n k i n g , further experience m a y indeed
show that even this covering o f a solid floor is, i n
the l o n g term, inadequate, p a r t i c u l a r l y i f
performances are regularly held on that type of
surface as opposed to a short series i n one
p a r t i c u l a r theatre or television studio.
A second factor i n floor construction applies to
stages. M a n y t o u r i n g companies w i l l find that they
have to w o r k o n a heavily raked stage. W h i l e this is
eminently satisfactory for n o r m a l theatrical
productions i n g i v i n g the audience a far better
view, it does pose great problems for dancers. T h e
presence o f a rake not only predisposes to the
development o f injuries but it can also delay
recovery from m i n o r injuries w h i c h are insufficient
to stop the dancer from w o r k i n g . P r e d o m i n a n t l y , a
raked stage w i l l cause a weight back situation w i t h
all its associated problems (see Section 5).
A d d i t i o n a l l y , m o v i n g across a rake poses different
problems. U n f o r t u n a t e l y , there is n o t h i n g that can
be done about the presence o f a raked stage but it
behoves the dancer a n d the m e d i c a l attendants to
be aware o f the possible dangers.
F i n a l l y , w h e n considering the floor, the actual
surface is i m p o r t a n t . T h e difficulties associated w i t h
a slippery surface are obvious. Less obvious,
however, is the over-use of rosin. Unless the floor is
cleaned regularly, the rosin can b u i l d up,
frequently i n irregular a n d uneven patches. T h i s
can result i n a dancer suddenly finding that his foot
is sticking to the floor w i t h potentially disastrous
consequences i f he is i n the process o f a turn, w h e n
the transmitted twist between the fixed foot a n d the
m o v i n g b o d y c a n produce serious injury at the
ankle or knee.
G e n e r a l C o m p l i c a t i o n s o f Injury
EFFECTS ON T H E W H O L E BODY
Decrease
ANTERIOR in ANTERIOR
Cardiorespiratory
ANTERIOR Fitness
ANTERIOR
A s a result o f the enforced decrease i n activity
following a n injury, the cardio-respiratory fitness o f
the dancer w i l l decline. I n other words, w h e n he
returns to exercise, he w i l l get out o f breath more
r a p i d l y , his pulse rate w i l l increase to a higher level
and he w i l l feel his heart p o u n d i n g for a given
activity. These effects are largely brought about
because the stroke v o l u m e o f the heart w i l l have
decreased. I n other words, the a m o u n t o f blood
p u m p e d out o n each contraction o f the heart w i l l
be less, hence to get the same a m o u n t o f blood to
the various organs, i n p a r t i c u l a r the muscles, the
heart w i l l have to beat more q u i c k l y . I n the trained
person, the heart w i l l on each stroke p u m p out a
larger v o l u m e o f blood t h a n i n the u n t r a i n e d heart,
therefore the athlete can m a i n t a i n a n increased
blood flow to the muscle b y a c o m b i n a t i o n o f
increased v o l u m e from the heart o n each stroke as
well as an increased stroke rate. I n the u n t r a i n e d
heart, the d e m a n d for more o x y g e n a n d a greater
requirement for the r e m o v a l o f c a r b o n d i o x i d e w i l l
result merely i n an increase i n heart rate, w i t h little
a b i l i t y to increase the v o l u m e o f b l o o d o n each
stroke. T h i s at the l i m i t w i l l produce a situation
where the heart w i l l reach such a rate that
inadequate time is given for the heart to fill
between each c o n t r a c t i o n so that a further increase
in rate w o u l d be self-defeating. D u r i n g the course
of t r a i n i n g the heart responds by a greater
relaxation between each c o n t r a c t i o n , w h i c h allows
a greater v o l u m e o f filling, thus increasing the
q u a n t i t y o f blood p u m p e d out o n each c o n t r a c t i o n .
O n the respiratory side, the chest capacity a n d
lungs w i l l undergo a similar a d a p t a t i o n so that the
v o l u m e o f a i r w h i c h is breathed i n a n d out o n each
occasion becomes very m u c h greater.
Generalised
ANTERIORM u s cANTERIOR
le Wasting
T h i s comes about due to i n a c t i v i t y . A s a result o f
the lack o f d e m a n d the bulk o f the muscles w i l l
g r a d u a l l y decrease (muscle wasting), the tone w i l l
go d o w n , as w i l l also the strength o f c o n t r a c t i o n o f
each muscle. I f the i n a c t i v i t y is prolonged, the
muscles w i l l become increasingly flabby. D u r i n g
this period they w i l l also tend to shorten a little,
thus slightly decreasing the a v a i l a b l e range o f
movement.
Increase i n Body
ANTERIORANTERIOR Weight
T h i s is by no means inevitable. H o w e v e r , eating
patterns are i n general psychologically based rather
than o c c u r r i n g as a result o f d e m a n d . Therefore,
although the calorie requirements are greatly
decreased as a result o f the decrease i n activity, the
calorie intake w i l l p r o b a b l y r e m a i n very m u c h the
same. These extra a n d superfluous calories w i l l
inevitably be l a i d d o w n as fat as they cannot be
metabolised. I f eating is controlled sensibly
following an injury, then this weight increase need
not occur, a l t h o u g h at the same time an adequate
balance o f nutrients must be m a i n t a i n e d i n order to
facilitate r a p i d h e a l i n g (see Section 2.7).
Psychological
ANTERIOR Effects
These m a y be more or less noticeable d e p e n d i n g
u p o n the m e n t a l make-up o f the i n d i v i d u a l dancer.
H o w e v e r , i f the injury is such that the dancer has
to be off w o r k , a general feeling o f depression is not
u n c o m m o n . T h i s seems to reach its peak w h e n
dancers have been off about five weeks, at w h i c h
 Section 2.3
time most o f them w i l l become very depressed, w i l l
sleep b a d l y a n d generally feel that no progress is
being made at a l l . I f this is anticipated a n d the
dancer strongly reassured, he w i l l usually get over
this p e r i o d w i t h o u t very m u c h difficulty. I f it is
k n o w n beforehand that he is g o i n g to be off for a
period o f m a n y weeks, then it c a n be helpful to
w a r n h i m that he is g o i n g to feel like this i n due
course but that it is a perfectly n o r m a l reaction
that happens to a l l dancers a n d that he w i l l
weather it perfectly satisfactorily.
LOCAL EFFECTS
PersistentANTERIOR Swelling
A l t h o u g h swelling follows most injuries, it w i l l
n o r m a l l y settle fairly r a p i d l y . N o t unusually, the
swelling m a y be such that it has disappeared w h e n
the dancer gets u p each m o r n i n g but then
g r a d u a l l y recurs d u r i n g the day. T h i s type o f
swelling c a n be helped by elevation from time to
time d u r i n g the d a y but w i l l g r a d u a l l y lessen a n d
disappear d u r i n g the course o f treatment a n d the
n o r m a l h e a l i n g processes. T h e dancer merely needs
reassurance. H o w e v e r , the swelling m a y become
more permanent. I f it is still present first t h i n g i n
the m o r n i n g , p a r t i c u l a r l y i f the dancer has been
elevating the foot o f the bed, it m a y have more
serious significance. I n the early days the swelling
w i l l be due to retention o f fluid locally a n d this c a n
d r a i n a w a y . If, however, drainage is for a n y reason
inadequate, either because the part has not been
elevated sufficiently or because there has been more
local damage than h a d been realised, the swollen
area m a y become i n v a d e d w i t h fibrous tissue a n d
permanent t h i c k e n i n g a n d scarring c a n result,
hence the i m p o r t a n c e o f the early e l i m i n a t i o n o f
swelling as part o f the i n i t i a l a n d c o n t i n u i n g
treatment process.
H o w e v e r , this invasion w i t h scar tissue w i l l not
take place i f the situation is such that the swelling
has always disappeared after a night's rest w i t h
elevation o f the injured part. P e r m a n e n t
thickening, a l t h o u g h it m a y be inevitable i f the
injury is serious w i t h considerable soft tissue
damage, c a n unfortunately o c c u r just as c o m m o n l y
as a result o f inadequate treatment a n d advice to
the dancer. It is i n these latter circumstances that it
is totally a v o i d a b l e a n d to allow it to develop is
unforgivable.
L oANTERIOR
c a l VascularANTERIOR Effects
These m a y p l a y a part i n the development o f
persistent swelling. T h e r e m a y be damage to the
local small vessels, p a r t i c u l a r l y the capillaries a n d
l y m p h a t i c s , w h i c h interfere w i t h the resorption o f
77
tissue fluid. E l e v a t i o n o f the injured part becomes
even more essential i n order to a i d the d r a i n a g e o f
tissue fluid b y the use o f g r a v i t y . W i t h the passage
of time, d a m a g e d vessels w i l l usually reform
themselves a n d blocked channels w i l l become
reopened or new ones w i l l develop. D u r i n g this part
of the h e a l i n g phase, assistance c a n be g i v e n to the
n o r m a l b o d y processes b y m i n i m i s i n g swelling a n d
a i d i n g resorption o f the fluid b y ice a n d elevation
and other l o c a l methods.
Less c o m m o n are local aberrant vascular
responses resulting i n greatly increased b l o o d flow
w i t h flushing or constriction o f vessels w i t h
b l a n c h i n g . These effects m a y be caused b y the
nervous system b u t n o r m a l l y w i l l settle
spontaneously. A t the p e r i p h e r y o f the u p p e r o r
lower limbs there is a rare vascular p h e n o m e n o n
(Sudek's dystrophy) where the bones o f the h a n d
and wrist or foot a n d ankle become p a r t i a l l y
de-mineralised. T h e skin becomes tense a n d shiny
and the tissues tend to be swollen. T h e exact causes
for the onset o f this s y n d r o m e are unclear but there
is no d o u b t that it c a n be aggravated b y
i m m o b i l i s a t i o n . U n f o r t u n a t e l y , because o f
persistent p a i n associated w i t h the c o n d i t i o n there is
a tendency to p r o l o n g the p e r i o d o f i m m o b i l i s a t i o n
and this makes the situation very m u c h worse. It
can be helped b y active movements a n d use a n d
therefore activity o f the part is to be encouraged
p r o v i d e d that this is c o m p a t i b l e w i t h the h e a l i n g o f
any u n d e r l y i n g fracture. F o r t u n a t e l y , the c o n d i t i o n
is n o r m a l l y self-limiting a n d recovery w i l l be
spontaneous, t h o u g h possibly slow.
L o c a lANTERIOR
M u s c l e ANTERIOR
Wasting
T h e causes o f this are the same as described above
for general muscle wasting. H o w e v e r , due to the
local i n a c t i v i t y o f the injured part, the muscle
wasting i n this area w i l l be rather greater,
p a r t i c u l a r l y i f the l i m b has h a d to be i m m o b i l i s e d
because o f a fracture. T h e muscle w a s t i n g w i l l
occur r a p i d l y a n d c a n be noticeable w i t h i n two to
three days of a n injury. B y the e n d o f this time the
decrease i n tone o f the muscle c a n be easily felt b y
the e x a m i n i n g fingers a n d there c a n even be a
measurable difference w h e n c o m p a r e d w i t h the
other l i m b . M u s c l e w a s t i n g a n d weakness can be
m i n i m i s e d by exercising as m u c h as the injury o r
i m m o b i l i s a t i o n w i l l a l l o w . It is v e r y i m p o r t a n t to
try to develop some sort o f suitable exercise routine
w h i c h c a n be i n i t i a t e d early a n d a p p l i e d
throughout the r e h a b i l i t a t i o n p e r i o d (see Section
2.5).
Stiffness
ANTERIOR of
ANTERIOR Joints
F o l l o w i n g i n a c t i v i t y the w h o l e b o d y w i l l tend to
78 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
feel rather stiffer. I f there has been i m m o b i l i s a t i o n
of a j o i n t or joints d u r i n g the course o f treatment
then, once the i m m o b i l i s a t i o n is discontinued, the
joints w i l l be found to have stiffened up to a greater
or lesser extent. T h i s stiffness occurs i n the soft
tissues a r o u n d the j o i n t , i.e. the capsule a n d the
ligaments, i n the soft tissue planes between the
various structures and w i t h i n the muscles
themselves w h i c h m a y have very slightly shortened.
A d d i t i o n a l l y , a weaker muscle is usually less able to
relax a n d lengthen than a trained muscle, so this
w i l l also contribute to some loss o f movement
range. I n the n o r m a l course of events, p r o v i d e d the
j o i n t itself has not been the site o f damage, this
post-immobilisation or post-inactivity stiffness w i l l
wear off fairly r a p i d l y a n d full m o b i l i t y w i l l be
regained. O n c e again, exercise is the most
i m p o r t a n t factor i n the regaining of a full
movement range, together w i t h general
strengthening o f the muscle groups w h i c h c o n t r o l
the joints. If, unfortunately, there has been some
damage to the j o i n t itself, p a r t i c u l a r l y w i t h i n the
j o i n t , then some restriction of movement m a y be
permanent.
2.4 The Treatment of Injuries -
General Principles
T h e most i m p o r t a n t fact to recognise is that
treatment itself does not heal injuries. Injuries heal
by the processes described i n Section 2.1 a n d are
entirely brought about by the b o d y alone.
T r e a t m e n t c a n be considered as h a v i n g p r i m a r y
a n d secondary aims.
The P r i m a r y A i m of Treatment
It must, i n essence, be the provision o f the o p t i m u m
conditions so that the body's n a t u r a l processes o f
healing c a n w o r k i n the most efficient a n d r a p i d
m a n n e r . These o p t i m u m conditions are rest,
maintenance o f a good b l o o d c i r c u l a t i o n a n d a
ready supply o f the necessary nutrients.
REST OF T H E INJURED PART
T h e rest w i l l allow healing to proceed u n i m p e d e d .
M o v e m e n t m a y cause damage to the g r a n u l a t i o n
a n d other h e a l i n g tissue, thus resulting i n the end i n
a great increase i n the amount o f scar tissue that is
formed.
Disadvantages of Rest
ANTERIOR
I f the area rested is too widespread, for example
i n v o l v i n g the whole l i m b or even the whole person,
then this w i l l have a three-fold undesirable effect.
First, there w i l l be a decrease i n s t i m u l a t i o n o f the
circulation. Second, unnecessary muscle wasting
w i l l occur. T h i r d , i f rest is very p r o l o n g e d the bones
become de-mineralised. Ideally, therefore, the
actual area o f injury alone should have rest a n d a l l
the other areas should be encouraged to r e m a i n
active.
Effects of I m m o b i l i s a t i o n
T h e collagen a n d other tissues o f the fibrous
network, such as areola tissue, become h a r d a n d
dense w i t h loss of suppleness d u r i n g periods of
i m m o b i l i s a t i o n . It w i l l start to occur after a few
days. T h e time taken to recover m o b i l i t y depends
on the length o f the i m m o b i l i s a t i o n . H o w e v e r , the
recovery time to regain full m o t i o n is not a simple
a r i t h m e t i c a l progression but a geometrical
progression. T h i s means that i m m o b i l i s a t i o n for,
say, four weeks, w i l l not take merely twice as l o n g
to recover from as i m m o b i l i s a t i o n for two weeks
but w i l l take four to five times as l o n g .
MAINTENANCE OF A D E Q U A T E CIRCULATION
A good b l o o d supply is essential as has been
explained i n Section 2.1. T h e b l o o d stream is
responsible for b r i n g i n g most o f the necessary cells,
proteins, minerals a n d other requirements for
satisfactory healing to take place. Therefore, a good
c i r c u l a t i o n o f b l o o d is to be encouraged a n d factors
w h i c h c a n interefere w i t h the b l o o d supply have to
be eliminated as far as possible. P r o b a b l y the most
i m p o r t a n t factor w h i c h intereferes w i t h the b l o o d
supply to the injured part is local swelling.
F o l l o w i n g the injury there is a great o u t p o u r i n g o f
blood a n d fluid into the tissues. T h i s should become
absorbed b y the lymphatics a n d c i r c u l a t i o n .
H o w e v e r , this reabsorption c a n become i m p a i r e d
a n d the swelling can become greatly aggravated b y
the effects o f gravity a n d by local i n a c t i v i t y . T h e
heart w i l l have no difficulty p u m p i n g b l o o d to the
injured part i n n o r m a l circumstances but drainage
via the veins or l y m p h a t i c s c a n be greatly h i n d e r e d
by increased pressure due to local swelling a n d by
the effects o f gravity. I f the swelling increases too
greatly it c a n actually restrict the flow o f b l o o d into
the part a n d therefore interfere w i t h h e a l i n g . T h i s
can occur to such a degree that the areas adjacent
to the d a m a g e d tissue c a n start to die from lack o f
blood supply a n d this produces w h a t is k n o w n as
tissue necrosis. T w o i m p o r t a n t a n d relatively simple
measures c a n be used to help to decrease this local
swelling a n d m a i n t a i n an adequate c i r c u l a t i o n .
a) E l e v a t i o n I f the injured part, usually the foot
or some other p o r t i o n o f the l o w e r l i m b i n the
 Section 2.4-2.5
dancer, is elevated, gravity can be used to
advantage to help the swelling d r a i n a w a y
from the injury.
b) Ice L o c a l a p p l i c a t i o n o f ice packs or cold
packs help to reduce the swelling. N B . C a r e
should be taken w i t h the use o f ice packs,
p a r t i c u l a r l y i f they have been stored i n a deep
freeze where the n o r m a l temperature is 0 ° F
(minus 18°C). (See Section 2.5 T e c h n i q u e o f
A p p l i c a t i o n , page 81.)
T h e measures w h i c h are taken to minimise bleeding
a n d swelling at the site o f injury are not a
c o n t r a d i c t i o n o f the statement that a good c i r c u l a t i o n
must be m a i n t a i n e d . B l o o d c i r c u l a t i o n implies that
the b l o o d is taken to a part a n d then removed
a g a i n v i a the veins. I f there is bleeding at a site o f
a n injury this b l o o d is lost to the c i r c u l a t i o n as well
as increasing local swelling. T h e ideal is to ensure
that there is m i n i m u m bleeding following the injury
but also then to m a i n t a i n the m a x i m u m c i r c u l a t i o n .
c) Pressure bandaging
ANTERIOR T h e purpose o f this is to
m i n i m i s e bleeding at the injury site. T h e
compression should a i m to a p p l y enough
pressure to c o n t r o l the b l o o d loss into the
tissues but at the same time not to be so
excessive that the c i r c u l a t i o n becomes
i m p a i r e d . Less pressure is required to impede
or stop the venous return than to impede or
stop the arterial inflow. I f the venous return
alone is i m p a i r e d then the effect w i l l be to
increase rather than decrease swelling because
the arterial b l o o d w i l l continue to be p u m p e d
into the area. Unless properly a p p l i e d ,
compression is better avoided. It is only o f
value u n t i l local bleeding has stopped a n d
should then be discontinued.
E l e v a t i o n a n d ice are easily instituted b y the
patient or helpers a n d , i f carried out i m m e d i a t e l y ,
can p l a y a great part i n the r a p i d recovery from a n
injury. These simple measures, a c c o m p a n i e d by a
short p e r i o d o f rest for the injured part, m a y be a l l
that is required to allow satisfactory resolution to
take place.
I n a c h i e v i n g the p r i m a r y aims o f treatment (i.e.
r a p i d h e a l i n g w i t h m i n i m u m scarring) the
physiotherapist has a part to p l a y b y the use o f
ultrasound, etc. T h i s w i l l be described later.
ADEQUATE NUTRITION
T h i s m a y sound a strange statement w h e n a p p l i e d
as it is to a society affluent enough to afford to
m a i n t a i n dance companies a n d similar 'luxuries'.
H o w e v e r , as w i l l be described i n Section 2.7 o n
N u t r i t i o n , m a n y dancers (as w e l l as other athletes)
79
have very bizarre ideas o f w h a t they should be
eating. These faulty eating patterns are frequently
associated w i t h very undesirable attempts to
achieve a weight far lower than is healthy. W i t h o u t
an adequate supply o f nutrients the b o d y cannot
properly repair tissue damage from injury or even
m a i n t a i n tissues i n the best c o n d i t i o n following the
n o r m a l cycles o f cell b r e a k d o w n a n d r e p a i r that
constantly o c c u r i n a l l l i v i n g organisms. D u r i n g the
whole o f life various tissues i n the b o d y are i n a
state o f change a n d replacement. T h e r e is a
continuous change over o f the constituent parts o f
cells. T h e various b o d y proteins are b e i n g b r o k e n
d o w n a n d rebuilt, the minerals are b e i n g m o v e d
a r o u n d a n d cells that die are b e i n g replaced d a i l y
by the m i l l i o n . T h i s is one o f the characteristics
w h i c h makes a l i v i n g organism as opposed to
something like a l u m p o f rock w h i c h , however
c h e m i c a l l y c o m p l e x it m a y be, does not alter w i t h i n
itself.
T h e Secondary A i m o f T r e a t m e n t
T h i s is so to arrange a r e h a b i l i t a t i o n p r o g r a m m e
that, w h i l e the p r i m a r y aims o f treatment are not
jeopardised, the rest o f the b o d y c a n be kept i n the
best possible p h y s i c a l c o n d i t i o n . T h i s includes
m a i n t a i n i n g cardio-vascular a n d respiratory fitness
as w e l l as ensuring that a l l possible muscle groups
are kept strong a n d active a n d are not a l l o w e d to
waste or weaken. T o this end the most i m p o r t a n t
action is to construct a n exercise p r o g r a m m e for the
p a r t i c u l a r dancer for his or her p a r t i c u l a r injury.
I t must be recognised I t must be thatrecognised
r e h a b i l i t a t i o n , if i t is to
achieve Ithe greatestbe recognised
t must success, starts beimmediately
I t must I t must bef orecognised
recognised llowing
injury I t and
must i t be
is recognised
not something
I t must be which
recognised isI t commenced days or
must be recognised
weeksformlater.
2.5 Specific Treatments of
Injuries
A l t h o u g h most forms o f treatment have to be
administered b y a physiotherapist or i n the case o f
more sophisticated treatments, b y a n o r t h o p a e d i c
surgeon, there are certainly some measures w h i c h
can be a p p l i e d satisfactorily b y the d a n c e r himself.
These are c o l d therapy or ice, elevation, rest o f the
injured part a n d exercise. T h e latter, o f course, c a n
only be c a r r i e d out by the subject a n d no t h i r d
party c a n d o exercises for h i m .
First A i d Measures
I n most acute injuries, i.e. a n i n j u r y w h i c h happens
80 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
suddenly as opposed to a chronic injury w h i c h
comes o n very slowly a n d insidiously a n d is usually
the result o f recurrent m i n o r traumas, there are
certain measures w h i c h should be carried out as
soon as possible by the dancer. I f carried out
i m m e d i a t e l y they can have a very beneficial effect
i n d r a m a t i c a l l y decreasing the time d u r i n g w h i c h
the dancer w i l l be p a r t i a l l y or w h o l l y incapacitated.
ICE
A s soon as the injury has occurred, ice should be
a p p l i e d to a n d a r o u n d the injured area. T h e actual
technique o f a p p l i c a t i o n w i l l be described a little
later under the specific physiotherapy treatments
(see page 81).
ELEVATION
T h e i c i n g should be a c c o m p a n i e d by elevation o f
the injured part i n order to discourage swelling. A s
most dancers' injuries occur i n the lower
extremities, g r a v i t y plays a very i m p o r t a n t part i n
increasing the a m o u n t o f swelling. I f the leg is
elevated then g r a v i t y w i l l assist i n the drainage o f
fluid from the injured area.
REST
Rest w i l l encourage early healing to take place
w i t h o u t extra disturbance o f the d a m a g e d tissues.
In other words, don't carry on w i t h the class or
performance i f the injury is a n y t h i n g other than o f
a t r i v i a l nature. T a k e a taxi home rather than w a l k
a l o n g distance or stand on p u b l i c transport. O n c e
home, continue w i t h the ice a n d elevation. These
simple measures p r o m p t l y applied can frequently
halve the length o f time for recovery.
COMPRESSION
F i r m b a n d a g i n g to compress the injured area is
often advised. T h e purpose is to arrest the local
bleeding w h i c h occurs at the site o f any injury.
W h i l e theoretically advantageous it can have
undesirable complications. I n order to arrest the
local bleeding the pressure must be sufficient to
compress the vessels. I f this compression is
m a i n t a i n e d for too long, or i f too extensive, then
interference w i t h essential blood supply can occur
a n d there m a y be local tissue necrosis (death). I f
used, it should be for a relatively brief period.
O n c e bleeding at the site o f injury has ceased,
compression can no longer be o f any benefit.
In the case o f a m i l d strain it might well be
possible to continue class or performing w i t h the
use o f supporting b a n d a g i n g or strapping.
H o w e v e r , it is i m p o r t a n t to be certain that there is
no serious u n d e r l y i n g injury before this action is
taken. I m m e d i a t e l y after a n injury the d a m a g e d
part can r a p i d l y become slightly n u m b a n d d u r i n g
this period the injured person m a y not be aware o f
the possible serious nature o f any damage. T o
continue activity i n the presence o f a fracture can
greatly p r o l o n g the actual recovery period or even
do more significant damage.
In this short section on first a i d measures, a
cautionary w o r d against the use o f p a i n - k i l l i n g
tablets or even more powerful p a i n - k i l l i n g injections
w o u l d be i n order. I f the p a i n is sufficient to
interfere w i t h a performance then nine times out o f
ten disguising the p a i n w i t h tablets or injections to
allow the performance to continue is merely going
to hide t e m p o r a r i l y a significant u n d e r l y i n g injury.
T o perform i n that state is g o i n g very greatly to
increase the period o f recovery a n d m a y indeed
cause such further damage that the dancer's career
m a y be r u i n e d - either because he w i l l never be
physically capable o f r e t u r n i n g to dance or because
the recovery is so prologed that he m a y lose his j o b .
N e v e r forget that p a i n is a protective m e c h a n i s m
p r o v i d e d b y nature i n order to stop further damage
taking place a n d to allow recovery to take place i n
the shortest possible time. A n o t h e r protective
mechanism w h i c h some people w i l l try to abolish
w i t h o u t due consideration o f the consequences or o f
the next steps i n the progress o f treatment, is
muscle spasm. M u s c l e spasm is nature's w a y o f
p r o v i d i n g splintage to an injured part. T h e muscles
a r o u n d the d a m a g e d area w i l l tighten u p i n order
to attempt to i m m o b i l i s e the area. I n other words,
to provide local rest to the part i n order to permit
healing to take place as r a p i d l y a n d successfully as
possible. T h e a b o l i t i o n o f muscle spasm b y drugs or
other methods w i t h o u t due regard to w h a t is t a k i n g
place underneath a n d w i t h o u t proper consideration
of the next line o f treatment can be almost as
d a m a g i n g as the injudicious use o f p a i n - k i l l i n g
drugs. T h e a b o l i t i o n or relief o f muscle spasm at
the correct time, i.e. d u r i n g the course of proper
treatment, is h i g h l y desirable, but certainly not i n
order to allow the dancer to continue performance
regardless o f consequences.
T h e dancer should always remember that
following injury the responses o f the b o d y that have
been p r o v i d e d by nature have been developed by
evolutionary processes to p r o v i d e the o p t i m u m
conditions for healing o f the injured part. It is only
w h e n adequateformtreatment is p r o v i d e d that nature's
own protective mechanisms c a n be removed. It
cannot be over emphasised that far too m a n y
dancers a n d other athletes have h a d their
convalescence unnecessarily p r o l o n g e d by unwise
treatment p r o v i d e d either b y themselves or by their
 Section 2.5
friends or by ignorant advisors.
It is obviously i n the dancers' a n d their
employers' greatest interest that the injury should
cause the shortest possible time off w o r k or classes
a n d that recovery should be as complete as possible.
A n incomplete recovery c a n be very troublesome as
it usually leads to recurrent injuries, either o f the
same part or elsewhere.
Physiotherapy Treatments
COLD THERAPY
T h i s is usually loosely referred to as ice. H o w e v e r ,
the cold c a n be a p p l i e d by various methods as
described under the T e c h n i q u e s o f A p p l i c a t i o n o n
this page. T h e uses o f cold therapy are for
a) relief o f muscle spasm;
b) mechanical trauma;
c) p a i n relief;
d) arthritis;
e) burns.
T h e last two - arthritis a n d burns - are not
relevant to this book.
I n M u s cform
le Spasm
T h e use o f c o l d therapy i n muscle spasm c a n
decrease the actual tone i n the muscle itself,
p r o v i d e d that the muscle temperature is lowered. I f
the muscle temperature is not lowered then the tone
is not decreased a n d the muscle spasm is not
relieved. C o o l i n g o f the skin alone m a y , i n fact,
increase the spasm. It m a y take from ten to as l o n g
as thirty minutes, d e p e n d i n g u p o n the a m o u n t o f
fat present, to produce a decrease i n the
temperature o f the muscle. H o w e v e r , the effect,
once achieved, is l o n g lasting due to the i n s u l a t i n g
effect p r o d u c e d b y the vaso-constriction i n the fat
layer. T h e fat itself is a n excellent insulator a n d the
insulation effects are i m p r o v e d b y the
vaso-contriction o f the b l o o d vessels i n the fat, i.e.
the shutting d o w n o f the b l o o d vessels.
Decreasing the spasm i n an antagonistic muscle
w i l l free the protagonist a n d c a n enhance its
performance b y up to 5 0 % . T h e effect o n the
muscle c a n also help facilitation techniques.
In Mechanical Trauma
C o l d therapy c a n be used advantageously i n
m e c h a n i c a l t r a u m a . T h e t r a u m a should be acute,
i.e. o f recent onset, but it should not be used i n
severe t r a u m a . T h e cold works by vaso-constriction
(shutting down) o f the b l o o d vessels w h i c h i n t u r n
reduces swelling a n d bleeding. T o this end it is as
well to remember the great benefits o f a p p l y i n g ice
81
as soon as possible after the injury a n d before there
has been very m u c h swelling or bleeding. T h e
vaso-constriction is p r o d u c e d b y its effect o n the
sympathetic fibres a n d also directly b y l o w e r i n g the
temperature o f the b l o o d w i t h i n the b l o o d vessels.
In Pain Relief
P a i n relief b y the use o f c o l d therapy is b r o u g h t
about b y several pathways. T h e p a i n m a y be
decreased b y a direct effect on the sensory endings
of the nerves a n d o n the p a i n nerve fibres. It also
works b y r e l i e v i n g muscle spasm, w h i c h c a n itself
be causing p a i n w i t h i n the muscles. A d d i t i o n a l l y ,
p a i n can be relieved i n d i r e c t l y b y decreasing
swelling. T h e presence o f swelling w i l l cause p a i n
because o f increased tension (pressure) w i t h i n the
tissues. F i n a l l y , the relief by the use o f c o l d c a n
take place because the cold is a c t i n g as a
counter-irritant. P a i n relief b y a counter-irritant
has been used for thousands o f years a n d is usually
the basis for the various analgesic ointments, balms
a n d linaments that are r u b b e d i n t o the skin.
Technique form of formApplication
Compresses c a n be used. These are u s u a l l y o f terry
towelling w h i c h is soaked i n m e l t i n g ice a n d water.
T h i s m i x t u r e gives a temperature o f 0 ° C . T h e terry
towelling is r u n g out a n d then p l a c e d o n a n d
a r o u n d the affected part.
T h e part itself c a n be immersed i n the ice a n d
water m i x t u r e . Massage using blocks o f ice c a n be
carried out. G e l packs c a n be frozen i n a freezer
c o m p a r t m e n t o f a refrigerator. T h e y are
p a r t i c u l a r l y useful because, w h e n frozen, they d o
not become solid a n d c a n be m o u l d e d a r o u n d a
part.
Note: G r e a t care must be taken w i t h massage
w i t h blocks o f ice or w i t h gel packs. T h e
freezer c o m p a r t m e n t o f a refrigerator or deep
freezer is n o r m a l l y set at m i n u s 18°C (0°F) for
the adequate preservation o f food. Therefore
ice straight from a freezer w i l l be at that
temperature. Ice does not reach 0 ° C (32°F)
u n t i l it starts to melt. H e n c e the great safety
a n d value o f a m i x t u r e o f ice a n d water. T h e
surface o f a block o f ice w h i c h is very cold
m a y w e l l adhere to the skin a n d cause
damage unless the surface o f the ice has
reached the temperature o f 0 ° C a n d has
started to melt. G e l packs are just as
dangerous because, as they are m a l l e a b l e , it
can be very easily forgotten that they are at a
very l o w temperature. T h e y s h o u l d not
therefore be a p p l i e d directly to the s k i n
straight from a deep freeze. Before
a p p l i c a t i o n they c a n be placed i n a b o w l o f
82 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
c o l d water, a l t h o u g h this is an uncertain
m e t h o d o f raising their temperature. W h e n
a p p l i e d to the patient some terry towelling
can be p u t o n the skin first a n d then the cold
pack a p p l i e d o n top o f that. A l t e r n a t i v e l y , the
skin c a n be oiled before the cold pack is
a p p l i e d . T h e o i l w i l l prevent any adherence
a n d w i l l also act as a very slight insulating
layer. O v e r - c o l d packs c a n produce frostbite
(cold burns). O n c e a cold pack has been
a p p l i e d it should be lifted from the skin every
m i n u t e to make certain that the skin is not
being b l a n c h e d , i n d i c a t i n g that cooling is
excessive.
T h e skin itself cools r a p i d l y but there is a very
m u c h slower reduction i n muscle temperature. T h i s
rate o f d r o p w i l l depend largely o n the thickness o f
the fat layer. It w i l l take at least ten minutes i n a
t h i n person a n d up to h a l f an hour i n an obese
person to begin to cool the u n d e r l y i n g muscle.
W h e n c o o l i n g is a p p l i e d i n t r a u m a it should be
carried out early before any considerable swelling
has developed. It can w i t h advantage be c o m b i n e d
w i t h elevation o f the part a n d also sometimes w i t h
simultaneous compression. O n c e swelling a n d
bleeding are m i n i m i s e d a n d are not likely to recur,
further c o o l i n g a p p l i c a t i o n of the part serves no
purpose. (This, o f course, does not a p p l y w h e n
c o o l i n g is being a p p l i e d for the relief o f muscle
spasms.) C o o l i n g over an excessive period m a y
retard h e a l i n g because o f the vaso-constriction o f
the b l o o d vessels. It was seen i n Section 2.1 that
one o f the prerequisites of satisfactory h e a l i n g was
a n adequate b l o o d supply. Bleeding into a n area
must not be confused w i t h blood supply. T h e
bleeding produces no satisfactory purpose a n d
merely increases the tension w i t h i n the tissues.
B l o o d s u p p l y implies that the blood is not only
brought to the part w i t h the necessary cells a n d
nutrients but also that metabolites and other
substances are being removed from the area, i.e. for
a good blood supply y o u need not only a n adequate
arterial flow a n d supply but also a n adequate
venous drainage. S w e l l i n g a n d increase o f pressure
w i t h i n the injured part w i l l interfere more w i t h the
venous a n d l y m p h a t i c drainage than it w i l l w i t h the
arterial supply w h i c h is c o m i n g i n at a far greater
pressure.
H E A T T H E R A P Y ! METHODS A N D EFFECTS
M e t h o d s o f a p p l i c a t i o n o f heat are sub-divided into
those that heat the superficial tissues only a n d those
that heat the deeper layers. H o t packs, infra-red
a n d similar radiant heat sources heat only the
superficial tissues w h i l e shortwave d i a t h e r m y ,
m i c r o w a v e a n d ultrasound a l l heat deeply. A l l these
different modalities w o r k b y p r o d u c i n g temperature
elevation but the reasons for their i n d i v i d u a l choice
comes from the fact that they w i l l selectively heat
different areas o f the body a n d w i l l p r o d u c e a peak
of temperature i n different locations.
It is i m p o r t a n t to remember that none o f these
forms o f heat is a cure i n itself but it c a n be
extremely v a l u a b l e i n association w i t h other
therapies.
T h e most i m p o r t a n t factors i n d e t e r m i n i n g the
intensity o f the reactions o f the b o d y are
a) the level o f the tissue temperature attained. T o
obtain therapeutic benefit the range o f
temperature lies between 40° a n d 4 5 ° C ;
b) the d u r a t i o n at w h i c h the temperature remains
elevated to g a i n therapeutic benefit; this should
be from 3 to 30 minutes;
c) the rate at w h i c h the temperature rises w i t h i n
the tissues being treated;
d) the size o f the area that is heated.
T h e physiological responses to heat therapy are as
follows:
1. A rise i n temperature increases the extensibility
of collagen. T h e heat w i l l produce changes i n
the fibrous tissue w h i c h makes u p tendons, j o i n t
capsules, ligaments a n d scars. T h i s enables
them to be stretched very m u c h more easily. I n
order to attain this the heating needs to be b y
one o f the deep methods o f a p p l i c a t i o n ; pure
skin heating is useless. T h e h e a t i n g has to be
vigorous i n order to produce a n adequate rise
of temperature i n the area to be stretched. A
steady stretch is very m u c h more effective t h a n
intermittent stretching or short term stretching.
It is for exactly the same reasons that stretching
should be done towards the end o f a class w h e n
the body is w a r m e d up rather t h a n at the
b e g i n n i n g o f a class or before a class. C e r t a i n l y
stretching should never be c a r r i e d out w h e n the
person or part is c o l d . I n those circumstances,
instead o f stretching, the tissue w i l l tend to
become torn.
2. H e a t w i l l decrease j o i n t stiffness, i n p a r t by its
effect o n the fibrous tissues a r o u n d the j o i n t
a n d i n part by its effects w i t h i n the j o i n t itself.
3. H e a t i n g produces p a i n relief b y its effect on the
peripheral nerves a n d nerve endings.
4. H e a t i n g w i l l decrease muscle spasm b y its
direct effect on the muscle spindles w h i c h
makes them less sensitive to stretch s t i m u l i . T h i s
is also another reason for only stretching w h e n
the muscles are w a r m .
5. H e a t i n g w i l l increase the b l o o d flow b y the
 Section 2.5
direct effects o f temperature on the b l o o d
vessels as w e l l as by reflex mechanisms.
6. H e a t i n g assists i n the resolution o f the
i n f l a m m a t o r y swelling a n d exudates by its
effect on the tissue a n d on cellular function.
temperatur
Distant temperatur
Reactions to H e a t i n g
I f the skin i n one area is heated an increase i n
b l o o d flow is produced i n other parts o f the body,
a l t h o u g h this increase i n b l o o d flow w i l l be less
than i n the heated area. I f the u n d e r l y i n g muscle
itself is not heated its vessels m a y actually constrict
because b l o o d is b e i n g diverted from inactive
organs to the skin for heat exchange a n d body
temperature c o n t r o l . O f interest is the observation
that has been made that w h e n heat is applied to
the a b d o m i n a l w a l l the l i n i n g o f the stomach
blanches (whitens because o f a decrease i n b l o o d
supply) a n d there is a fall i n acid level i n the
stomach. H e a t on the a b d o m i n a l w a l l also causes
relaxation o f the smooth muscle i n the
gastro-intestinal tract a n d i n the uterus, hence the
beneficial effects on p a i n b y the use o f a hot water
bottle o n the a b d o m e n at times o f a b d o m i n a l pains
from the gastro-intestinal tract a n d i n
dysmenorroea.
H e a t i n g m a y be vigorous or m i l d . I n vigorous
heating the tissue temperature i n the deeper
structures is elevated a n d it is p a r t i c u l a r l y i n d i c a t e d
w h e n scar tissue is to be stretched. A l t h o u g h
superficial heating tends to be m i l d , i f it is a p p l i e d
to a very s m a l l part such as a finger, the
temperature of the whole part c a n become very
significantly elevated.
Contra-indications
temperatur to the Use of H e a t
1. I n anaesthetic areas damage m a y be caused by
heat because o f the i n a b i l i t y o f the person
being treated to detect any over-heating. I n
most instances the physiotherapist relies u p o n
the patient to i n f o r m her i f the part is
b e c o m i n g too w a r m .
2. Regions w i t h an inadequate b l o o d supply
should not be heated because the increase i n
w a r m t h w i l l also increase metabolic d e m a n d . I f
there is a n inadequate vascular response, as
w o u l d be the case w i t h poor b l o o d supply, the
increase i n metabolic d e m a n d m a y i n fact lead
to ischaemic necrosis (death o f the tissues due
to inadequate b l o o d s u p p l y ) .
3. A n y bleeding tendency is increased by h e a t i n g
because o f the increase i n b l o o d flow a n d
vascularity.
4. I f an acute i n f l a m m a t o r y response is present,
this w i l l be aggravated b y vigorous heating but
m a y be helped by m i l d heating.
83
5. H e a t is also contra-indicated i n m a n y acute
m e c h a n i c a l problems. F o r instance, a n acute
prolapse o f an intervertebral disc, w h e n the rise
i n temperature p r o d u c e d b y a n increase i n heat
w i l l result i n a n increase i n local swelling. I f a
nerve is already under pressure from the disc
prolapse, the pressure on the nerve w i l l be
increased, possibly w i t h serious results.
H o w e v e r , i n a n acute m e c h a n i c a l p r o b l e m ,
m i l d superificial heat m a y help by r e l i e v i n g
secondary spasm.
W h i l e gentle superficial heat is u n l i k e l y ever to d o
any h a r m , none o f the deep heat modalities s h o u l d
be a p p l i e d except by a fully trained
physiotherapist. Severe a n d lasting d a m a g e c a n be
caused by any o f the sophisticated deep h e a t i n g
methods, some of w h i c h also have n o n - t h e r m a l
effects. I n no circumstances should the dancer be
tempted to use one o f these machines either o n
himself or on a friend.
temperatur
SELECT ION OF MODALITY OF H E A T
Superficial
temperatur Heating
T h i s c a n be a p p l i e d by hot packs, paraffin w a x
baths, infra-red or heat tunnels. H o w e v e r , it is as
well to remember that a very s m a l l part such as a
finger m a y , even w i t h superficial heat, have a rise
in temperature o f the w h o l e part, merely because of
the small b u l k o f tissue.
H o t packs m a y be obtained by w r i n g i n g out
terry towelling i n hot water a n d then a p p l y i n g to
the part. H o w e v e r , they have the disadvantage o f
c o o l i n g r a p i d l y . G e l packs c a n be used hot as w e l l
as cold a n d these have the advantage o f r e t a i n i n g
their heat for a very m u c h longer p e r i o d . Paraffin
wax baths have t r a d i t i o n a l l y been used for m a n y
decades for the treatment o f hands a n d feet. T h e y
are p a r t i c u l a r l y beneficial i n the treatment o f h a n d
injuries a n d r h e u m a t o i d arthritis but have little
a p p l i c a t i o n i n the treatment o f sports a n d dance
injuries.
Infra-red or radiant heat is p r o d u c e d b y special
bulbs or heating elements. It uses the red end o f the
spectrum, g o i n g into the adjacent infra-red
wavelengths. It has very superficial penetration,
reaching the skin a n d o n l y the most superficial
parts o f the subcutaneous tissues.
T h e Effects of Superficial
temperaturHeating
Benefit c a n be derived for p a i n relief by being a
counter-irritant. It can also produce some deep
responses reflexly but these are o f little v a l u e or
significance a l t h o u g h there c a n be some relief o f
muscle spasm. I n the m a i n , superficial heat w i l l
produce a feeling o f comfort a n d r e l a x a t i o n i n the
patient a n d w i l l help from that p o i n t o f v i e w .
84 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n
Contrast
temperatur Baths
These really fall i n a section o f their o w n , using as
they do b o t h hot a n d c o l d . T h e y achieve their
benefit b y p r o d u c i n g a h y p e r a e m i a (an increase i n
b l o o d flow) b y alternately submerging the part i n
hot water a n d i n cold water. I n sports a n d dance
injuries they are p a r t i c u l a r l y useful for feet a n d
ankles. T h e hot water should be at a temperature
of between 40° a n d 4 4 ° C a n d the cold water at
between 15° a n d 2 0 ° C , a l t h o u g h some authorities
r e c o m m e n d a m u c h lower temperature t h a n this for
the c o l d b a t h .
T h e contrast baths are used by i m m e r s i n g the
part i n the hot water for ten minutes i n i t i a l l y a n d
then transferring to the cold water for one minute.
T h e cycles are then continued w i t h four minutes i n
the hot b a t h a n d one minute i n the cold bath for a
period o f h a l f a n hour. Contrast baths are
something that c a n be very safely a n d satisfactorily
c a r r i e d out at home by the dancer. T h e y are very
effective a n d achieve their results by increasing the
b l o o d supply. E n d w i t h the cold bath.
Dtemperatur
E Etemperatur
P HEATING
D i a t h e r m y is a name w h i c h covers a variety o f
different methods o f heat p r o d u c t i o n , a l l a c t i n g i n
the deeper layers. E n e r g y is converted into heat at
an interface, for instance between subcutaneous
tissue a n d a muscular layer or between a muscle
layer a n d bone.
T h e pattern o f heating w i l l v a r y between the
different d i a t h e r m y modalities. T h e temperature
d i s t r i b u t i o n is also modified b y the different
physical properties o f the various tissues, e.g. b y
their specific heat (this is the a m o u n t o f heat
energy w h i c h is required to elevate that p a r t i c u l a r
tissue b y 1°C - tissues a n d a l l other matter have
v a r y i n g specific heats) or by their differing t h e r m a l
conductivities (some substances, e.g. metals,
c o n d u c t heat very q u i c k l y a n d effectively, whereas
others such as w o o d conduct heat very slowly).
Short-Wave Diathermy ( S . W . D . )
temperatur
T h i s is the a p p l i c a t i o n o f h i g h frequency currents
for therapeutic purposes. A l l S . W . D . machines have
three components,
temperatur namely, a power supply, an
oscillating circuit a n d the patient's circuit. T h e
a l l o w e d oscillating frequencies are 13.66, 27.33, a n d
40.98 megaherz ( M H z ) . T h e most c o m m o n l y used
frequency is 27.33 M H z w h i c h is equivalent to a
wavelength o f 11 metres. T h e patient's o w n
electrical impedence (resistance to the passage of an
electrical current) forms part o f the patient's
circuit. Therefore the m a c h i n e has to be tuned for
each i n d i v i d u a l patient. T h e actual current flow
t h r o u g h the patient can then be regulated after
t u n i n g b y v a r y i n g the i n d u c t i v e c o u p l i n g o f the
h i g h frequency oscillating circuit a n d the patient's
circuit. It is not possible to measure the h i g h
frequency current flow t h r o u g h the patient. T h e
physiotherapist is guided b y the feeling o f w a r m t h
on the part o f the patient. L o w w a r m t h indicates a
low dose. A h i g h w a r m t h u p to the l i m i t o f
tolerance is required for a h i g h dose, hence the
i m p o r t a n c e o f h a v i n g n o r m a l sensibility i n the p a r t
being treated. A n anaesthetic area is a very definite
contra-indication to the use o f S . W . D .
Basically, the treatment is a p p l i e d by the part
being treated l y i n g between two c a p a c i t a t o r plates.
These c a n v a r y i n shape atemperatur
nd flexibility.
T h e r e are certain precautions w h i c h must be
taken. M e t a l l i c objects w i l l undergo selective
heating, so a l l watches, jewellery, etc. are r e m o v e d
before treatment starts. T h e patient must be treated
on a w o o d e n a n d not a m e t a l c o u c h . I f the circuit
is not tuned correctly, small movements o f the
patient m a y alter the impedence o f the circuit,
causing resonance. A s a result, there m a y be a surge
of increased current flow a n d possibly burns of the
patient. I n t e r n a l metal such as pacemakers or
artificial joints (unlikely i n dancers) a n d m e t a l
plates or screws used to fix bygone fractures (quite
possible i n dancers or athletes) are definite
contra-indications to short-wave d i a t h e r m y a n d
must be reported to the physiotherapist before
treatment starts, i f the physiotherapist has not
already m a d e enquiries about their possible
presence. H o w e v e r , surgical i m p l a n t s such as plates
and screws, i f far removed from the site o f
treatment, do not impose a n y p a r t i c u l a r risk.
C o n t a c t lenses m a y cause hot spots a n d a l t h o u g h
n o r m a l l y nowhere near the area o f treatment, it is
advisable to remove them before treatment starts.
Microwave
These are very h i g h frequency currents a n d are
usually either 2456 M H z or 915 M H z i n m e d i c a l
a p p l i c a t i o n . T h e latter are rather better a n d
produce heating more deeply. These very h i g h
frequency currents are selectively absorbed b y
water a n d hence allow selective h e a t i n g o f certain
tissues such as muscles w h i c h c o n t a i n a lot o f water,
but relatively little heating o f bone w h i c h contains
very little water. (Hence the use o f m i c r o w a v e i n
cooking, w h e n the food - a l l o f w h i c h has a h i g h
water content - is heated a n d cooked, w h i l e the
dish remains cold u n t i l it is w a r m e d by direct
c o n d u c t i o n from the hot food.)
Therapeutic
temperatur Effects
temperatur M i c r o w a v e c a n selectively a n d
easily heat the musculature a n d c a n also selectively
 Section 2.5
heat a j o i n t , p r o v i d e d it has o n l y a little soft tissue
covering.
Side Effects T h e eyes, w h i c h c o n t a i n a great deal o f
water, c a n be selectively heated a n d must be
carefully a v o i d e d . M i c r o w a v e c a n produce a
decrease i n bone growth. It should not be used i n
anaesthetic areas or i n the presence o f buried metal.
N o n - T h e r m a l Effects M i c r o w a v e m a y also have
some n o n - t h e r m a l effects but these are not fully
understood a n d must therefore be discounted for
therapeutic purposes.
Ultrasound
T h e ultrasound m a c h i n e produces a h i g h frequency
alternating current o f 0.8 M H z to 1.00 M H z . T h i s
is converted b y a crystal transducer into m e c h a n i c a l
sound waves - acoustic vibrations. T h e sound b e a m
p r o d u c e d b y the ultrasound head is almost
c y l i n d r i c a l i n shape. T h e intensity is expressed i n
watts per square centimetre (watts/cm2). T h e
m a x i m u m that should be used is four watts/cm2.
M o s t c o m m o n l y , the a p p l i c a t i o n is at less t h a n one
w a t t / c m 2 . L i k e a u d i b l e sound waves, ultrasound
waves are propagated b y compression waves.
Therefore p r o p a g a t i o n depends u p o n the presence
of a m e d i u m capable o f b e i n g compressed. A s the
wave passes t h r o u g h the tissues it produces
powerful m e c h a n i c a l forces, a m o n g the effects o f
w h i c h m a y be the p r o d u c t i o n o f small, gas filled
cavities from dissolved gases. These cavities then
collapse, causing shock waves. A s the sound is
th e tissues it becomes absorbed a n d
passe d t h r o u g h
converted into heat. R e m e m b e r a basic l a w o f
physics, i.e. that energy c a n neither be created nor
destroyed. It is therefore converted from one form
of energy to another form o f energy, i n this case
from sound to heat, a l t h o u g h i n i t i a l l y it was
electrical energy w h i c h was converted to sound.
T h e penetration o f ultrasound into muscle is very
satisfactory. T h e temperature d i s t r i b u t i o n p r o d u c e d
by u l t r a s o u n d is different from the other modalities
- short-wave d i a t h e r m y a n d m i c r o w a v e .
U l t r a s o u n d causes very little superficial temperature
elevation a n d has a greater depth o f penetration
into the muscles a n d soft tissues t h a n S . W . D . or
m i c r o w a v e . T h e ultrasound selectively heats
interfaces between tissues o f different acoustic
impedence because o f reflection, formation o f sheer
waves a n d selective absorption. E v e n the
temperature i n joints covered by a great depth o f
soft tissues c a n be raised therapeutically by
u l t r a s o u n d . ( F o r example, i n the h i p , w h i c h is not
greatly affected by either short-wave d i a t h e r m y or
microwave.)
Effects of U l t r a s o u n d These are due to the heating
85
effects o f ultrasound a n d are s i m i l a r to the effects
p r o d u c e d b y the other agents, a l t h o u g h as
mentioned, ultrasound c a n penetrate far m o r e
deeply.
N o n - T h e r m a l Effects U l t r a s o u n d increases the
permeability o f tissue membranes. C a v i t a t i o n c a n
be p r o d u c e d a n d this c a n cause tissue damage. It is
evidenced b y petechial haemorrhages (small red
spots o n the skin) but these o n l y o c c u r at h i g h
intensities o f ultrasound a n d a p o o r a p p l i c a t i o n
technique. H o w e v e r , w i t h a poor technique,
c a v i t a t i o n c a n be p r o d u c e d at even one to two
watts/cm2. W i t h good stroking technique,
intensities o f u p to four watts/cm2 are safe
a l t h o u g h usually quite unnecessary. I n certain
situations ultrasound c a n speed u p h e a l i n g processes
but this m a i n l y occurs i n c h r o n i c rather t h a n i n
acute lesions.
Side Effects U l t r a s o u n d c a n cause nerve d a m a g e
due to a concentration o f heat at the interface w i t h
the nerve a n d also w i t h i n the nerve at the
interfaces between the nerve fibres.
U l t r a s o u n d is, however, the o n l y deep h e a t i n g
method that c a n be used safely w i t h b u r i e d m e t a l
because a l t h o u g h there is a n increase i n heat at the
metal interface due to reflection, the m e t a l carries
away the heat more q u i c k l y t h a n any effective or
d a m a g i n g rise i n temperature that c a n be
produced.
It must be stressed again that none o f these
pieces o f apparatus, short-wave, m i c r o w a v e or
ultrasound, should be used by a patient or by
anyone other t h a n a fully qualified physiotherapist.
U l t r a s o u n d i n p a r t i c u l a r c a n seem very innocuous
a n d the dancer m a y be tempted to a p p l y it h i m s e l f
w i t h very unfortunate results. A l s o there c a n be n o
excuse whatsoever for a n y physiotherapist, however
busy, w h o allows a patient to a p p l y the u l t r a s o u n d
himself, even w h e n under p a r t i a l supervision.
Despite using a l o w wattage a p o o r a p p l i c a t i o n
technique or use at a site o v e r l y i n g a very sensitive
structure, such as a nerve, c a n produce damage.
INTERFERENTIAL THERAPY
T w o m e d i u m frequency currents between 4000 a n d
4100 H e r z generate l o w frequency impulses
between 0 a n d 100 H e r z i n the area i n w h i c h the
m e d i u m frequency currents are superimposed. A t
this site they produce a n interference pattern.
D e p e n d i n g o n the l o w frequency current
wavelength p r o d u c e d the result c a n be analgesic
(pain k i l l i n g ) , c a n stimulate muscle contractions o r
can increase the b l o o d supply. T h e selected results
can be used to make the active form o f treatment,
e.g. exercises, more easily c a r r i e d out b y either p a i n
86 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n
relief or by s t i m u l a t i n g muscles. The hyperaemic
effect c a n be o f value i n increasing the rate of
healing, i n c l u d i n g the stimulation of the healing
process i n stress fractures. I n competent hands
interferential therapy is safe a n d effective a n d can
be used i n the presence o f buried metal. H o w e v e r ,
in the hands o f the careless or unskilled it is at best
useless a n d at worst can cause the patient
considerable discomfort; either by p r o d u c i n g
electric shocks by a l l o w i n g the machine to surge or
by causing the muscles to go into very painful
spasms by over-stimulation. L i k e the other
machines it should not be used b y the untrained
person.
FARADISM
T h i s is the direct stimulation o f the nerve endings
i n the muscle itself by the use o f electric currents at
the make a n d break phases i n order to produce
muscle contractions. Its use is re-educative, as by
m a k i n g a muscle or group o f muscles contract the
patient w i l l appreciate i n the conscious part o f the
b r a i n not o n l y the movement that is required but
also the sensation engendered by the muscle
contracture. T h i s sensation is brought about by a
c o m b i n a t i o n o f sensory responses to stretch i n the
muscle tendons a n d by proprioceptors affected by
j o i n t movements. T h e patient must be encouraged
to reinforce the contraction by v o l u n t a r i l y c o p y i n g
the c o n t r a c t i o n produced by the s t i m u l a t i n g
current. T h e s t i m u l a t i o n can be decreased a n d then
discontinued i n due course but the patient w i l l still
be able to reproduce the contraction actively. It is
only by active contraction o f a muscle that it c a n
be significantly strengthened. M e r e passive
c o n t r a c t i o n by faradism alone has little effect i n
strengthening muscles. Its commonest use is i n
faradic foot baths where, try h o w he may, the
average patient w i t h poorly functioning intrinsics is
quite unable to v o l u n t a r i l y produce the desired
movements. O n c e the patient 'gets the feel' o f what
should be h a p p e n i n g by using faradic stimulation
he c a n then begin to reproduce the same
c o n t r a c t i o n v o l u n t a r i l y . It is i m p o r t a n t that the
patient realises that for it to be effective he must
w o r k with the s t i m u l a t i n g current; little benefit w i l l
accrue i f he remains completely passive.
F a r a d i s m c a n be o f help i n i n i t i a t i n g muscle
contractions i n other areas o f i n h i b i t i o n , e.g. the
quadriceps after a knee operation. H e r e as
elsewhere it is re-educative a n d not a definitive
treatment. M a n y dancers find it advantageous to
o w n their o w n small faradic machine, e n a b l i n g
them to c a r r y out regular faradic foot baths i n
order to keep the intrinsic muscles w o r k i n g
efficiently a n d under c o n t r o l . It is surprising h o w
easy it is to lose the conscious c o n t r o l o f these
muscles to the point that, however m u c h the dancer
puts i n mental effort a n d tries to get t h e m to w o r k ,
there seems to be a complete loss o f c o n t i n u i t y
between b r a i n a n d muscle. T h i s is p r o b a b l y because
from an evolutionary point o f view these muscles
are on their w a y out as we no longer use the feet
for g r i p p i n g , as do the apes. It is i n the
maintenance o f conscious c o n t r o l that the faradic
machine plays a v i t a l role.
In passing, it must be said that faradic
stimulation does not produce weight loss, r e d u c t i o n
of fat i n selected areas or redistribution o f fat.
T h e r e are machines sold c o m m e r c i a l l y to the p u b l i c
w h i c h c l a i m just these benefits. T h e y are expensive
and quite useless for their alleged purposes.
T R A N S C U T A N E O U S N E R V E STIMULATION (T.N.S. B U T
T . E . N . S . IN T H E USA)
T h i s is carried out by a very s m a l l battery-operated
machine w h i c h c a n be w o r n on the belt or carried
i n a pocket. Electrodes at the end o f wires are stuck
to the skin a n d a p p l y s m a l l electric currents i n
order to stimulate the nerves a n d relieve p a i n .
( M o d e o f action - It is thought to work b y closing
a neuro-electrical 'gate' i n the s p i n a l c o r d , thus
preventing p a i n impulses from ascending the spinal
cord past this point a n d hence failing to reach the
level o f consciousness. A n alternative theory is that
it works by s t i m u l a t i n g the p r o d u c t i o n o f
endorphins. These are analgesic substances w h i c h
occur n a t u r a l l y w i t h i n the body. R e c e n t l y they
have been arousing a great deal o f interest a n d
have been referred to as n a t u r a l l y p r o d u c e d
morphine-like substances. T h e a c t i o n o f the T . N . S .
m a y be a c o m b i n a t i o n o f these two theories.) B y its
repeated use it can g r a d u a l l y produce longer
periods o f p a i n relief, leading i n the end i n m a n y
cases to the complete relief o f p a i n , e n a b l i n g the
T . N . S . machine to be discarded. A s the electrodes
are stuck onto the skin, there is no i n v a s i o n o f the
body and it has no attendant risks.
ACUPUNCTURE
T h i s p r o b a b l y works i n a similar fashion to T . N . S .
H o w e v e r , because o f the possibility o f the
transference of viruses such as hepatitis or even
A I D S , i f the needles that are used are not
completely sterile, it is less safe t h a n T . N . S .
ACUPRESSURE
T h i s is by the external a p p l i c a t i o n o f pressure to
the acupuncture points. It works i n a s i m i l a r
manner but is p r o b a b l y less effective. A s it is
 Section 2.5
non-invasive it is safer than acupuncture a n d
carries no risk o f infection.
TRACTION
T r a c t i o n , or a p u l l i n g o n a part, c a n be a p p l i e d
either m a n u a l l y or through a machine. C o m m o n l y ,
a m a c h i n e is used for cervical a n d l u m b a r s p i n a l
t r a c t i o n . It is more effective a n d easier to a p p l y
t h a n m a n u a l traction, w h i c h r a p i d l y tires the
physiotherapist w h o cannot m a i n t a i n a heavy p u l l
for very l o n g . I n the cervical spine, the traction is
exerted t h r o u g h a halter w h i c h grips the back o f
the head a n d the c h i n . I n the l u m b a r spine,
t r a c t i o n is a p p l i e d by means o f a pelvic corset.
H e a v y weights c a n be a p p l i e d for a short p e r i o d o f
time to a n out-patient but i f a patient is to have
continuous traction i n bed, as i n a n acute neck or
l u m b a r c o n d i t i o n , then the weights have to be
relatively l o w , about 2 £ kilograms i n the cervical
region a n d about 4 £ to 7 kilograms i n the l u m b a r
region, otherwise they cannot be tolerated for any
length o f time.
T r a c t i o n p r o b a b l y exerts its beneficial effects b y
the stretch w h i c h is a p p l i e d to the soft tissues. A
continuous gentle stretch w i l l tend to abolish muscle
spasm. It m a y very slightly open up the facet joints
between the vertebral bodies (see Section 1.2 for
facet j o i n t s ) . B y relieving pressure from w i t h i n the
small facet joints, p a i n w i l l be eased. T r a c t i o n is
p a r t i c u l a r l y beneficial i n various pains o r i g i n a t i n g
i n the cervical spine, whether from the
intervertebral discs or from the soft tissues a n d i n
the l u m b a r region from symptoms o r i g i n a t i n g i n
the l u m b a r discs, especially i f there is referred p a i n
d o w n one or more nerve roots p r o d u c i n g sciatica.
D u r i n g the course o f treatment, traction is
frequently a p p l i e d to various other joints. T h i s is
merely part o f a general stretching o f the soft
tissues a n d really should be considered more under
the h e a d i n g o f passive stretching rather than
genuine traction.
W e n o w come to those treatments where
m a c h i n e r y is not required.
MASSAGE
T h i s is u n d o u b t e d l y the oldest o f a l l remedial
treatments a n d was certainly being used more t h a n
3000 years ago. E v e n w i t h o u t being looked u p o n as
a definite treatment, massage is instinctively used
by b o t h m a n a n d animals w h o w i l l n a t u r a l l y tend
to r u b a painful area.
Effects
temperaturof Massage
temperatur
1. Reflex-
B y s t i m u l a t i o n o f the p e r i p h e r a l receptors
w h i c h transmit impulses to the spinal c o r d a n d
87
b r a i n to produce sensations o f pleasure or
relaxation. T h e relaxation is both o f muscle
a n d o f m e n t a l tension.
2. Mechanical -
a) It increases b l o o d c i r c u l a t i o n by assisting the
return o f b l o o d a n d l y m p h i f the massage is
a p p l i e d w i t h the greatest pressure towards the
centre o f the b o d y .
b) It c a n produce i n t r a - m u s c u l a r m o t i o n a n d
m a y be effective i n stretching adhesions
between muscle fibres.
It is very i m p o r t a n t to remember that massage
cannot b u i l d u p muscle strength, nor c a n it
dissipate fat. O v e r a l l , a p a r t from p r o d u c i n g a
pleasurable relaxation, the effects are m i n i m a l .
H o w e v e r , w i t h care, it is quite harmless.
temperatur
Contra-indications
Massage must be a v o i d e d i n local infections a n d i n
any case o f thrombo-phlebitis or suspected
thrombo-phlebitis.
M O B Itemperatur
LISATIONS
T h i s is a term used for gentle, non-violent passive
movements of joints. It is a p p l i e d to areas o f the
spine as well as i n the more p e r i p h e r a l joints. T h e
useful results are p r o d u c e d b y a gentle repetitive
stretching o f capsules a n d ligaments w h i c h w i l l
g r a d u a l l y d i m i n i s h or abolish the p a i n f u l impulses
being transmitted from nerve endings w i t h i n those
structures. These impulses are often reflexly causing
muscle spasm so a secondary benefit o f
mobilisations is the relief o f this spasm. T h e
mobilisations (also called M a i t l a n d mobilisations)
are a p p l i e d b y oscillating passive movements
w i t h o u t forceful techniques. I n the spine their use is
very m u c h safer a n d has a m u c h more localised
effect than the violent m a n i p u l a t i o n s used b y
osteopaths a m d chiropractors.
MANIPULATIONS
T h i s term (together w i t h expressions such as T h r u s t
T e c h n i q u e s a n d G r a d e V ) is used to describe a
forceful passive m o v e m e n t o f s m a l l a m p l i t u d e a n d
h i g h velocity. T h e proponents o f m a n i p u l a t i o n d o
not agree about its use or its m e c h a n i s m (as
e x a m i n a t i o n o f the literature w i l l show). H o w e v e r ,
p r o v i d e d that one c a n accept that its use is
e m p i r i c a l a n d not a n a t o m i c a l l y specific,
p a r t i c u l a r l y i n the spine, it c a n sometimes be useful
i n relieving acute p a i n . It has neverthless significant
risks attached to its use. I n the spine, m a n i p u l a t i o n
is just as likely to increase a disc prolapse w i t h the
unfortunate p r o d u c t i o n o f nerve d a m a g e , as it is to
relieve p a i n . Fractures c a n occur w i t h fragile bones
a n d j o i n t i n s t a b i l i t y c a n be increased. It s h o u l d
88 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n
never be used i n the presence o f i n f l a m m a t i o n or i n
suspected or possible m a l i g n a n t disease.
T h e r e are some people w h o have a sense o f
increased m o b i l i t y a n d well-being after
m a n i p u l a t i o n o f a n o r m a l j o i n t or joints, a l t h o u g h
others w i l l feel stiff a n d sore. I n the former group,
the p r o p h y l a c t i c use o f m a n i p u l a t i o n i n the hope
that injuries w i l l be prevented has no foundation o f
proof. C o n t i n u e d m a n i p u l a t i o n o f a n o r m a l j o i n t is
considered b y m a n y to be harmful i n the longer
t e r m a n d m a y possibly lead to the onset o f
osteo-arthritis i n these joints. It is well recognised
that osteo-arthritis frequently occurs early i n joints
subjected to the repeated stress o f certain activities
or sports a n d so-called p r o p h y l a c t i c m a n i p u l a t i o n
p r o b a b l y falls into this category. T h e dancer should
certainly beware o f those w h o r e c o m m e n d weekly
m a n i p u l a t i o n s as a routine. M a n a g e m e n t s or others
i n a u t h o r i t y w h o send their dancers off for this type
of treatment must also be aware that they c o u l d be
legally liable for any damage that ensues i n the
short or l o n g term.
STRETCHING
S t r e t c h i n g c a n be passive, assisted active or
completely active. A s has already been mentioned,
stretching is effective i f the tissues to be stretched
are w a r m (see Section 2.5 D e e p H e a t i n g , page 84).
T o be most effective, the stretch should be
prolonged a n d steady rather than intermittent or
frequent, short-term stretches. A n y stretch has to be
a p p l i e d w i t h care i n order to avoid damage to the
tissues. I f tissues are torn d u r i n g stretching, then
h e a l i n g has to take place. A s was described i n
Section 2.1, a l l h e a l i n g is b y scar tissue, i.e. fibrous
tissue. W i t h the passage of time scar tissue tends to
contract a n d this m a y well make the tightness,
w h i c h the stretching was originally a i m e d to relieve,
worse t h a n before the stretching started. C e r t a i n l y
any forcible stretching c a n only be h a r m f u l a n d
w i l l tend to be totally counter-productive.
T h e a i m o f any stretching is to g a i n a n
elongation o f the tight tissues w i t h o u t any bleeding
into the tissues. T h i s c a n only be p r o d u c e d
g r a d u a l l y over a period a n d must never be rushed.
After a n injury, the tissues, even though apparently
healed, c a n still be very sensitive i n the early stages
a n d m a y respond very b a d l y to stretching. T h i s c a n
lead to further contracture rather t h a n to the
desired stretch. It is i m p o r t a n t , therefore, that
following injury stretching does not take place u n t i l
the a p p r o p r i a t e time i n the convalescent period
w h i c h w i l l tend to be later, rather than sooner. It is
quite impossible to lay d o w n any general time scale
a n d it is here that the advice o f a physiotherapist
experienced i n the treatment o f sports a n d dance
injuries is i n v a l u a b l e .
Passive stretching is, as its n a m e implies, c a r r i e d
out entirely by the therapist. A c t i v e stretching is
that carried out b y patient or d a n c e r alone. Assisted
active stretching is a c o m b i n a t i o n o f stretch a p p l i e d
by the physiotherapist a n d by the patient. A g a i n it
must be emphasised that the dancer must be aware
of w h a t he is t r y i n g to achieve a n d the best w a y to
go about it. T h e essential points are:
1. the dancer must be w a r m ;
2. gentle stretching should be c a r r i e d out after the
pre-class w a r m - u p a n d again d u r i n g the course
of class once the muscles are really w a r m , e.g.
at the end o f barre;
3. the stretch should be steady a n d prolonged a n d
not forcible;
4. sudden forcible stretches, j e r k i n g , b o u n c i n g a n d
similar stretching effects are undesirable a n d
usually counter-productive;
5. a weak muscle should never be stretched.
Stretching i n this case must be deferred u n t i l
the muscle has been adequately strengthened.
Stretching must always be a c c o m p a n i e d b y
exercises to strengthen the muscles;
6. Stretching must be i n the l o n g i t u d i n a l d i r e c t i o n
of the fibres i n the tissue being stretched.
Stretching across the fibres achieves n o t h i n g
a n d m a y cause tearing. Stretching o f tight
areas is frequently not best c a r r i e d out i n the
direction o f the apparent tightness.
Consideration must be given to w h a t p a r t i c u l a r
structures are causing the tightness a n d i n
w h i c h direction their fibres r u n . O n l y then c a n
the stretch be carried out i n the correct
direction. A j o i n t w h i c h seems tight i n one
p a r t i c u l a r direction (e.g. tightness o f turn-out
at the hip) m a y need i n d i v i d u a l stretching
programmes i n two or more different directions
i n order to o b t a i n the desired increase i n
mobility.
Specifically, two of the worst things that c a n still be
found h a p p e n i n g from time to time is seeing a
dancer, c o m m o n l y a student, l y i n g i n the frog
position w i t h someone standing o n their knees
trying to push them apart a n d d o w n to the floor.
Q u i t e apart from the damage that this is g o i n g to
do to the soft tissues, the turn-out i n the frog
position bears no relation at a l l to the turn-out at
the hips w h e n the legs a n d hips are straight i n the
w o r k i n g position (see Section 5.8). T h e other
a b o m i n a t i o n is to see a g i r l student w i t h her
forefeet (toes a n d metatarsal region) under a p i a n o
or radiator leaning back i n order to ' i m p r o v e ' her
pointe. T h e r e are, unfortunately, still some older
 Section 2.5
teachers a r o u n d w h o advocate this as the o n l y
m e t h o d o f i m p r o v i n g the pointe. These two
different actions c a n be at best useless a n d at worst
actively h a r m f u l . T h e y w i l l certainly produce no
benefit o n either turn-out or pointe.
EXERCISES: T H E I R VALUE
I n b o t h dance a n d sports injuries, a suitable
p r o g r a m m e o f exercises is by far a n d away the
most i m p o r t a n t part o f treatment a n d
r e h a b i l i t a t i o n . A l l earlier physiotherapy treatments
that have been described, a l t h o u g h effective i n
m a n y conditions a n d a i d i n g the h e a l i n g processes,
cannot i n themselves i n a n y w a y produce a full
return to n o r m a l function a n d strength. O n l y
exercises c a n strengthen muscles. O n l y exercises c a n
help to mobilise joints satisfactorily a n d
p e r m a n e n t l y . T h o s e treating dancers, as w e l l as
dancers themselves, must realise the i m p o r t a n c e o f
proper exercise programmes. I f treatment is
confined merely to something easy a n d q u i c k to
relieve the current symptoms a n d p a i n , this w i l l
leave a n y u n d e r l y i n g weakness o r weaknesses that
have developed as a result o f the injury or have
been the cause o f the injury to r e m a i n uncorrected.
A s a result the i n j u r y is likely to recur o r further
injuries at other sites w i l l be likely to occur.
After a n y sort o f i n j u r y the muscles i n v o l v e d i n
that part, as w e l l as more distant groups, are g o i n g
to weaken. T h i s is the n a t u r a l response o f the b o d y
w h e n muscles are not used for however brief a
period. E v e r y injury w i l l increase the w e a k e n i n g
a n d as the w e a k e n i n g itself increases, so w i l l the
l i a b i l i t y to further injuries.
T H E AIM OF EXERCISE
Cardio-respiratory
temperatur Fitness
temperatur
A n y form o f general exercise benefits the
cardio-vascular a n d respiratory systems. It produces
w h a t is k n o w n as cardio-respiratory fitness, i.e. it
stimulates a n d strengthens the heart, the general
c i r c u l a t i o n , the respiratory capacity a n d the w a y
the b o d y c a n d e a l w i t h metabolites (the
by-products o f tissue metabolism w h i c h are
increased i n exercise). H e n c e it produces a n
increase i n the person's tolerance o f exercise. I n
order to increase cardio-respiratory fitness, exercise
must be taken d a i l y to such a n extent that the
person becomes out o f breath a n d the heart rate
increases. W i t h the increase i n heart rate there is
also a n increase i n the capacity o f the heart so that
the v o l u m e o f b l o o d pushed out o n each
contraction is increased. T h e trained heart w i l l be
able to push out a far greater v o l u m e o f b l o o d o n
each stroke t h a n the u n t r a i n e d heart. I n order to
89
achieve cardio-respiratory fitness the best forms o f
exercise are s w i m m i n g , c y c l i n g , either o n a n o r m a l
bicycle or using a static bicycle, cross c o u n t r y
skiing, either a c t u a l or using a cross c o u n t r y skiing
machine, r u n n i n g or even very brisk w a l k i n g .
A l t h o u g h r u n n i n g a n d j o g g i n g are p o p u l a r they d o
have some serious d r a w b a c k s . F o r most people the
r u n n i n g w i l l i n e v i t a b l y m e a n d o i n g so o n the
pavements or o n the r o a d . T h i s , despite the best o f
r u n n i n g shoes, produces repeated j a r r i n g a n d leads
to problems w i t h the back, knees, feet a n d ankles.
It is better i f the r u n n i n g c a n be c a r r i e d out o n
grass. I f not, one o f the other forms o f exercise is
far less likely to cause injury.
Increase to M temperatur
temperatur uscle Strength
Exercise is essential to strengthen the skeletal
muscles i n the b o d y . Exercise i n this form m a y be
directed at certain muscle groups that the dancer or
sportsman wishes p a r t i c u l a r l y to strengthen or it
m a y be a more general strengthening p r o g r a m m e .
It is i m p o r t a n t to emphasise that not o n l y s h o u l d
muscle groups be strong, but they must also be
b a l a n c e d . It is obviously unhelpful to have a g r o u p
of muscles o n one side o f the b o d y m u c h stronger
than the same g r o u p o n the other. T h e r e is a
n o r m a l tendency for this to h a p p e n because most
people have a preferred side for w o r k i n g a n d this
side w i l l therefore usually have more exercise for
the muscle groups concerned.
Increase
temperatur of M o b i l i t y and Joint
temperatur Range
Exercises i n dancers a n d certain sportsmen are
designed to increase m o b i l i t y a n d j o i n t range. T h i s
is, o f course, a c c o m p a n i e d b y stretching o f the soft
tissues. H o w e v e r , pure stretching does not
necessarily or effectively increase the range o f
movements o f the joints. It is e q u a l l y i m p o r t a n t i f
not more i m p o r t a n t to exercise the muscles groups
c o n t r o l l i n g the movement o f a j o i n t i n o r d e r to
strengthen them. O n l y too frequently a dancer w i l l
think that he has some restriction at a j o i n t whereas
a n e x a m i n a t i o n o f the range o f movements w i l l
show that the range is i n fact full, but the dancer is
unable to use the a v a i l a b l e range o f m o v e m e n t
because the c o n t r o l l i n g muscles are not strong
enough. Therefore i n a d d i t i o n to pure m o b i l i s a t i o n
exercises, attention has to be given to strengthening
the groups o f muscles c o n t r o l l i n g the j o i n t so that
the full range o f m o v e m e n t c a n be used w i t h
complete muscle c o n t r o l throughout its range.
temperatur
TYPES OF EXERCISE
Passive Exercises
temperatur
These have very little place as far as sportsmen a n d
dancers are concerned. Passive exercises are where a
90 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n

j o i n t or part is m o v e d by another person i n order to operation w h e n even the resistance o f g r a v i t y c a n

m a i n t a i n full m o b i l i t y i n a j o i n t . T h i s is a p p l i c a b l e be more than the muscle c a n contend w i t h , yet the
p a r t i c u l a r l y where there has been paralysis o f a physiotherapist does not w a n t a n exercise w i t h
l i m b . Passive exercises are undertaken i n order to gravity totally eliminated. S i m i l a r l y the faradic
prevent contractures o c c u r r i n g a r o u n d a j o i n t . machine, by i n i t i a t i n g a c o n t r a c t i o n w h i c h is
Passive exercises do n o t h i n g to strengthen the reinforced by the patient's o w n efforts, c a n help to
muscles concerned. produce a far more satisfactory muscle response.
Exercises for i n d i v i d u a l muscles groups a n d the
ActivetemperaturExercises methods b y w h i c h they are c a r r i e d out w i l l be
A c t i v e exercises are those w h i c h are carried out by considered i n detail i n Section 4.
the dancer a n d they entail an active contraction o f
the groups o f muscles concerned. T h i s contraction EXERCISE TRAINING
can be either isometric, temperatur w h e n the muscle is
I n the dancer, exercise t r a i n i n g is a i m e d at
contracted h a r dtemperaturbut the actual movement is
strengthening various groups o f muscles i n w h i c h
prevented due to increasing resistance being
strength is required but w h i c h m a y have been
a p p l i e d , or the c o n t r a c t i o n c a n be isotonic, where
temperatur
neglected d u r i n g o r d i n a r y classes due to the w a y
the resistance remains constant but the j o i n t moves.
that the classes themselves have been structured, or
O n l y active exercises can increase muscle strength.
due to the type o f dance w h i c h is p r e d o m i n a n t l y
N o r m a l l y , resistance i n some form is required a n d
filling the dancer's w o r k i n g day. Basically it must
the c o m m o n m e t h o d o f a p p l y i n g this resistance is to
be realised that the muscle groups have t w o m a i n
use weights. E a r l y i n the t r a i n i n g p r o g r a m m e the
functions. T h e r e is that w h i c h everybody
resistance m a y merely be gravity, p a r t i c u l a r l y
appreciates, i.e. the muscles are required i n order to
following a n operation. B u t soon the dancer w i l l
move the different parts o f the b o d y a n d the limbs.
need to use some weights or other form o f
H o w e v e r , equally i m p o r t a n t a n d frequently neither
resistance. O c c a s i o n a l l y the resistance m a y be
recognised or given enough attention is the
p r o v i d e d by the physiotherapist w h o is supervising
requirement that the muscles must also produce
treatment i f it is following an injury. T h e resistance
stability i n b o t h trunk a n d limbs. W i t h o u t complete
can take two forms - very heavy resistance where
stability i n the s u p p o r t i n g parts, the w o r k i n g parts
the patient is o n l y able to exercise the muscle
cannot achieve their best results. T h i s strength a n d
against this resistance for a relatively few n u m b e r
stability has to be achieved throughout the w h o l e
of contractions. These are referred to as h i g h
organism, starting at the centre a n d w o r k i n g
resistance l o w repetition exercises. T h e alternative is
outwards. A n y area that is neglected w i l l prevent
to have a relatively l o w resistance (in using a
the whole from w o r k i n g satisfactorily. T h e effects
weight this w i l l often be somewhere between one
of weakness i n p a r t i c u l a r areas w i l l be discussed i n
and four kilograms) w i t h a far greater n u m b e r o f
Section 5. H o w e v e r , a few general considerations
contractions or movements. These are l o w
can be dealt w i t h here.
resistance h i g h repetition exercises. T h e y are
preferable a n d p r o b a b l y more effective at b u i l d i n g In the presence o f muscle groups there are
up muscle strength than the h i g h resistance l o w several different effects. Firstly, i n the weak groups,
repetition exercises w h i c h used to be favoured a i f they are t r y i n g to stabilise an area w h i c h is
decade or two ago. supporting a w o r k i n g part, they w i l l tend to tire
r a p i d l y . T h e y w i l l then go into spasm. T h i s spasm
It is n o w generally recognised that w o r k w i t h very
w i l l spill over as tension a n d affect other areas,
heavy weights can produce actual muscle damage,
i n c l u d i n g the w o r k i n g areas, thus i m p a i r i n g the
increase the rate o f wear w i t h i n the joints
performance o f whatever action is t a k i n g place.
themselves a n d c a n predispose to the development
Secondly, because o f the weakness i n the s u p p o r t i n g
of osteo-arthritis. It c a n produce a n u n n a t u r a l a n d
area, there w i l l be a feeling o f insecurity a n d this
undesirable increase i n muscle bulk. It is less
insecurity w i l l itself cause tension i n the w o r k i n g
effective i n p r o d u c i n g muscle strength than the l o w
area a n d prevent proper relaxation o f the
resistance h i g h repetition m e t h o d .
antagonistic muscle groups, interfering w i t h the
Active Assisted Exercises
temperatur fluidity of the movements (see Section 1.3 M u s c l e
T h i s is a form o f c o m b i n a t i o n exercise where, C o n t r a c t i o n , page 19). T h i r d l y , the weakness w i l l
a l t h o u g h the patient is actively c o n t r a c t i n g the generally b r i n g about a l i m i t a t i o n o f range o f
muscle, he is also receiving some assistance from the movement. T h i s is because the weakness prevents
physiotherapist. T h i s can be p a r t i c u l a r l y helpful i n complete control o f the joints a n d , w i t h o u t this
the early days following an injury or after an control, a full relaxation o f the muscles opposing a
 Section 2.5
movement cannot be achieved a n d hence there w i l l
be a n interference w i t h the full range o f
movements at the j o i n t or joints.
O n l y too frequently dancers m a y be t r y i n g to
stretch areas w h i c h they consider are tight w h e n i n
reality there is no genuine tightness present a n d the
lack o f adequate range o f movement is merely due
to weakness o f the muscle groups c o n t r o l l i n g that
part. T a k e n overall, a dancer w h o appears tight i n
the joints is far more likely to be i n need o f
strengthening than stretching. It is obviously v i t a l
i n the i n i t i a l stages to determine w h i c h actual cause
is present so that the appropriate series o f exercises
can be w o r k e d out.
T h e other i m p o r t a n t aspect o f exercise t r a i n i n g is
to realise a n d fully c o m p r e h e n d the importance of
temperatur
balance between the various muscle groups. A n y
temperatur
i m b a l a n c e c a n o n l y lead to instability w i t h its
attendant problems. O n l y too often one sees
dancers w h o have quite r i g h t l y felt that they are
weak i n one p a r t i c u l a r area a n d have been given
exercises for that area w i t h o u t any exercises b e i n g
given to the opposing groups or the synergistic
groups. A s a result, a pre-existing i m b a l a n c e c a n be
aggravated a n d the situation made worse. It is not
exercise a n d muscle b u i l d - u p as such w h i c h has
been at fault but merely the p r o g r a m m e w h i c h has
been devised for that p a r t i c u l a r dancer. It is also
extremely i m p o r t a n t to realise that the weakness
m a y be i n groups o f muscles somewhat removed
from the area where the dancer feels that there is a
p r o b l e m , or even where the casual observer thinks
the p r o b l e m lies. T h i s is p a r t i c u l a r l y seen where a
dancer m a y be h a v i n g difficulties or even injuries
a r o u n d the h i p region a n d a l t h o u g h receiving
treatment a n d exercise a r o u n d that area, the feet
can be completely neglected. T h e y m a y i n fact
have been the i n i t i a l cause o f the p r o b l e m a n d be
r e q u i r i n g a great deal o f w o r k i n order to
strengthen them up a n d give support at the b o t t o m
end of the p i l l a r .
I n d o i n g exercises to strengthen muscles, there
are a w h o l e variety o f methods that c a n be
e m p l o y e d . A p p a r a t u s such as is found i n
professional g y m n a s i a is far from being essential
a n d basically the o n l y benefit that it gives is
possibly to make it a little easier from the
psychological point o f view to c a r r y out the
exercises. O t h e r w i s e , a l l exercises c a n be done using
weights, n o r m a l l y i n the region o f two to five
kilograms, w h i c h c a n be fixed to the part b y using
V e l c r o strapping. F r e q u e n t l y , no actual weights are
required at a l l a n d the weight o f the limbs against
g r a v i t y is a l l that is necessary.
I f weights are used, this c a n be done i n two
91
ways. U s i n g a lower weight w i t h a higher n u m b e r
of repetitions is felt to be the most advantageous.
T h e muscles must be exercised to fatigue a n d it is
this exercising to fatigue w h i c h is the essential p a r t
of the t r a i n i n g p r o g r a m m e to strengthen the
muscles. S h o u l d a h i g h weight, l o w repetition
regime be used, this does not i m p l y that the muscle
has to struggle to cope w i t h this level o f weight, as
this w o u l d be totally counter-productive. W h e n
exercising to strengthen muscles it is absolutely
essential that the muscles are w o r k e d throughout
their effective range. T h e y must be able to exert
full power through the full range o f movement
possible at the j o i n t they c o n t r o l . I n other words
the exercise regime must be directed at a c h i e v i n g
w o r k against resistance t h r o u g h the arc from full
extension to full flexion. I f the regime is so
constructed that the muscle is o n l y exercised
through a part o f this range far less satisfactory
results w i l l be obtained.
W e see a different picture w h e n considering
isometric a n d isotonic exercises as the effects o f
these cannot be equated w i t h each other. Isometric
exercises are those w h i c h are carried out w i t h the
muscle r e m a i n i n g at the same length but the
resistance v a r y i n g . Isotonic exercises are those
carried out where the length o f the muscle alters
but the resistance remains constant. It has been
shown b y experiment that i f an exercise p r o g r a m m e
is made up using isotonic exercises only, then the
benefits achieved are not transferable a n d the
person w i l l continue to perform best at the isotonic
type o f exercise on w h i c h he trained. S i m i l a r l y a n
isometric p r o g r a m m e w i l l not produce a n equal
i m p r o v e m e n t i n isotonic performance. T h i s shows
that it is i m p o r t a n t therefore to b u i l d up a n
exercise p r o g r a m m e of a c o m b i n a t i o n o f b o t h
isometric a n d isotonic exercises.
C o n c e r n is often expressed b y girls a n d female
dancers about the possible adverse effects o f
exercise programmes o n their general appearance.
H o w e v e r , they have n o t h i n g to fear. T h e proper
strengthening o f the correct muscle groups w i l l
usually produce a n i m p r o v e m e n t i n their o v e r a l l
outline a n d silhouette. T h e y certainly have no
reason to believe that because they are d o i n g a lot
of exercise a n d b u i l d i n g u p muscle that they w i l l
start to look like M i s s A t l a s . It is impossible for a
female w i t h n o r m a l endocrine function to achieve
that type o f muscle b u i l d - u p . I n order to d o so, she
has to take hormones.
FATIGUE
It is w o r t h repeating that i n order to increase
muscle strength significantly the muscle has to be
92 Section 2: Injuries: C a u s e s , T r e a t m e n t , Prevention
exercised to the point o f fatigue. I f a muscle is
exercised well w i t h i n its capabilities, it has, as it
were, no incentive to become stronger.
(Physiologists thoroughly disapprove o f the w a y the
last statement was framed, i m p l y i n g as it does that
muscles or other tissues have independent thought
processes or psyches o f their own!). I n order to
strengthen a muscle it is necessary to w o r k it to the
point where it tires.
W h a t is meant by fatigue? It has been defined as
the i n a b i l i t y to carry out the assigned task i n the
assigned m a n n e r under specific conditions k n o w n to
the subject as a result o f p r i o r activity. H o w e v e r ,
this is a b e h a v i o u r a l definition. Physiologically, the
point o f fatigue is very m u c h more difficult to
measure. It m a y be done by measurement o f the
m a x i m u m aerobic capacity after w h i c h the oxygen
c o n s u m p t i o n does not increase despite an increased
performance o f work. T h i s extra w o r k is anaerobic
a n d the onset o f fatigue w i l l q u i c k l y result i n a
failure to continue the w o r k at that intensity.
A l t e r n a t i v e l y , electrical activity can be measured
e l e c t r o m y o g r a p h i c a l l y d u r i n g a m a x i m a l isometric
c o n t r a c t i o n . W h e n the electrical activity increases
at the time that the m e c h a n i c a l force is decreasing,
this shows that despite a c o n t i n u i n g full effort by
the subject, fatigue is o c c u r r i n g i n that muscle.
U n f o r t u n a t e l y , both o f these methods o f
d e t e r m i n i n g fatigue can really only be c a r r i e d out
i n the l a b o r a t o r y a n d as a result the physiotherapist
has to push the dancer, or the dancer has to push
himself, to continue w i t h the p r o g r a m m e of
exercises u n t i l it is felt that genuine fatigue o f the
muscle is o c c u r r i n g .
M e d i c a l and Surgical Treatments
I n dance injuries as well as sports injuries, the role
of the orthopaedic surgeon or sports p h y s i c i a n is
largely one o f diagnosis. M o s t treatment is
conservative (i.e. non-operative) a n d w i l l be a p p l i e d
by the dance physiotherapist. T h e orthopaedic
surgeon is there to examine the patient a n d make
a n accurate diagnosis o f the u n d e r l y i n g p r o b l e m
a n d to exclude fractures or other significant injuries
w h i c h m i g h t need special treatment; then, i n
conjunction w i t h the physiotherapist, to devise a
p r o g r a m m e o f treatment a n d r e h a b i l i t a t i o n ,
i n c l u d i n g technical correction, that is most suitable
for that patient w i t h that p a r t i c u l a r injury. E v e r y
patient a n d every injury is slightly different a n d
needs to be assessed carefully. T h e r e are, however,
some treatments that can only be administered b y
the orthopaedic surgeon.
DRUGS
S i m p l e analgesics such as p a r a c e t a m o l a n d soluble
aspirin c a n be very beneficial i n h e l p i n g the patient
i n the early stages after an injury but certainly
should not be used merely to allow the patient to
continue a performance i n the face o f an
undiagnosed injury. T h e most i m p o r t a n t
p r e l i m i n a r y to any type o f treatment is a n accurate
diagnosis.
N o n - S t e r o i d a l A n t i - i n f l a m m atemperatur
tory Drugs
These are Brufen, N a p r o s y n , I n d o c i d a n d a
m u l t i t u d e o f others. T h e i r action is to decrease the
i n f l a m m a t o r y response w h i c h occurs following a n y
type o f injury as well as i n other disease processes.
A s explained i n Section 2.1, the i n f l a m m a t o r y
response is part o f the healing process a n d it is
absolutely essential for recovery o f a n injured part.
Interference w i t h the i n f l a m m a t o r y response w i l l
decrease the rate o f healing and w i l l be totally
counter-productive. T h e r e is, therefore, very little
i n d i c a t i o n for the use of these a n t i - i n f l a m m a t o r y
drugs. O c c a s i o n a l l y , the i n f l a m m a t o r y response as a
result o f the injury is excessive a n d i n these cases an
anti-inflammatory d r u g m a y be helpful a n d
beneficial, i n w h i c h case a very accurate diagnosis is
essential before they are administered.
T h e indiscriminate use o f these drugs c a n only be
deplored. W i t h o u t an accurate diagnosis, t a k i n g a n
anti-inflammatory d r u g m a y well mask some
significant u n d e r l y i n g p r o b l e m w h i c h i n the longer
term c o u l d cause serious damage a n d disability.
T h e y are a l l prescription-only drugs a n d
a d m i n i s t r a t i o n by anyone other t h a n a registered
medical practitioner is, o f course, illegal. Q u i t e
apart from the undesirable effects that have already
been mentioned i n relation to the actual injury, a l l
anti-inflammatory drugs have side effects o f greater
or lesser importance. I n p a r t i c u l a r , they c a n all
cause upsets o f the gastro-intestinal tract, i n c l u d i n g
gastric haemorrhage a n d ulceration. I f they are
used i n the presence o f a peptic ulcer they m a y
cause an exacerbation o f the c o n d i t i o n a n d a
possible perforation.
Hydrocortisone
temperatur Acetate and S i mtemperatur
temperatur i l atemperatur
r Preparations
These drugs, w h i c h are given by injection, certainly
have a l i m i t e d a p p l i c a t i o n i n the treatment of
dance a n d sports injuries. T h e i r action is b y
abolishing the i n f l a m m a t o r y response but, because
they are suspensions o f the steroid, their action is
entirely local. T h e y have no general effects
elsewhere i n the b o d y a n d they certainly produce
none o f the side effects that are brought about b y
steroids that are administered by m o u t h . I n any
case, the dose that is given in-one injection of
 Section 2.5
H y d r o c o r t i s o n e Acetate amounts to about one
temperatur
twelfth o f the body's d a i l y output o f n a t u r a l l y
occurring Hydrocortisone.
I n order to be effective, H y d r o c o r t i s o n e Acetate,
w h i c h is the insoluble form o f H y d r o c o r t i s o n e a n d
is the one used i n the treatment o f injuries, has to
be placed at the exact area where the lesion to be
treated lies. It m a y increase the p a i n l o c a l l y for
some twentyfour hours a n d is frequently given
together w i t h a local anaesthetic. Its m a i n use is
where a n injury has become c h r o n i c , i.e. there is a
very l o w grade i n f l a m m a t i o n still present a n d the
healing process is incomplete. It is t y p i c a l l y o f value
i n conditions such as tennis elbow, c h r o n i c
tenosynovitis a n d c h r o n i c tendonitis.
Contra-indicationstemperatur are as follows:
1. H y d r o c o r t i s o n e shouldtemperatur
never be used i n a n acute
injury as it w i l l totally stop the h e a l i n g
processes.
2. It should never be used i f a fracture is suspected
or possible, e.g. a stress fracture.
3. I n relation to the large tendons (Achilles
tendon, patellar tendon, etc.) it should be used
w i t h c a u t i o n a n d p r o b a b l y only one injection
given. It should never be given into the tendon
itself but merely into the tissues s u r r o u n d i n g
the tendon. O n e o f the reasons for the great
c a u t i o n here is that i f the tendon itself is the
site o f damage, the presence o f the
H y d r o c o r t i s o n e m a y abolish the h e a l i n g process
w h i c h is t a k i n g place a n d result i n a complete
rupture o f the tendon. S i m i l a r l y , i f it is injected
into the tendon rather t h a n into the
peritendinous structures, it c a n cause damage
to the tendon a n d subsequent rupture.
4. It should never be given i f the diagnosis is
u n c e r t a i n or for w a n t o f a n y t h i n g better to
advise.
5. A s far as dancers a n d sportsmen are concerned,
H y d r o c o r t i s o n e should never be given into a
j o i n t . T h e indications for i n t r a - a r t i c u l a r
steroids are usually confined to those people
who have a r t h r i t i c conditions o f the joints a n d
this is not n o r m a l l y found i n dancers or
sportsmen d u r i n g their active careers. It s h o u l d
certainly not be given w h e n the j o i n t is merely
recovering from a n injury.
6. T h e a d m i n i s t r a t i o n o f either a local
anaesthetic, or o f steroids p a r t i c u l a r l y , merely
to enable a dancer or sportsman to perform,
can o n l y be c o n d e m n e d . It is asking for a n
exacerbation o f that injury w i t h the conversion
of w h a t is possibly a m i n o r injury to something
that is major.
93
Oral
Steroids
I n some quarters o r a l steroids (cortisone,
prednisone, etc.) are administered for 3 - 4 days
following an injury on the grounds that it reduces
or prevents swelling.
H o w e v e r , it does this b y suppressing the
i n f l a m m a t o r y processes i n a l l their aspects a n d not
just the swelling. A s seen from Section 2.1, this w i l l
totally interfere w i t h the early phases o f the h e a l i n g
processes. W h i l e this m a y not matter i f the injury is
really t r i v i a l , i f there is any significant tissue
damage the delay i n the onset o f the h e a l i n g
processes c a n only be disadvantageous. A l s o b y the
suppression o f these i n f l a m m a t o r y processes the
dancer m a y be encouraged to continue full
activities w i t h potentially serious or disastrous
results.
A further c o m p l i c a t i o n is that b y the
a d m i n i s t r a t i o n o f o r a l steroids the n a t u r a l b o d y
p r o d u c t i o n o f its o w n steroids becomes suppressed,
together w i t h more widespread alterations i n other
h o r m o n e levels. T h e suppression o f n a t u r a l steroid
p r o d u c t i o n even for 4—5 days m a y lead to a m u c h
longer period o f h o r m o n e i m b a l a n c e before the
b o d y finally settles d o w n i n t o e q u i l i b r i u m a g a i n .
Use o f oral steroids i n dancers is unwise,
unnecessary a n d c a n only be c o n d e m n e d .
OPERATIONS
S u r g i c a l operations should only be u n d e r t a k e n
w h e n there is a very specific i n d i c a t i o n , w h e n a n
accurate diagnosis has been m a d e a n d w h e n
conservative treatment has failed or is not
indicated.
These statements m a y seem so obvious that they
are not w o r t h p r i n t i n g . H o w e v e r , far too m a n y
dancers are subjected to totally unnecessary surgery
for a variety o f reasons. O n the part o f the
orthopaedic surgeon there m a y be a lack o f
knowledge about dance or sports injuries, l e a d i n g to
an inadequate or inaccurate diagnosis. T h e surgeon
may opt for an operation because he lacks the
knowledge a n d u n d e r s t a n d i n g to r e c o m m e n d the
correct type o f conservative treatment. A n e x a m p l e
of this is the totally unnecessary surgery w h i c h is so
often undertaken to remove spurs or areas o f
calcification w h i c h m a y be seen o n a n X - r a y b u t
are irrelevant to the patient's symptoms. Before
e m b a r k i n g o n any operation there must be a n
absolute i n d i c a t i o n for surgery w h i c h must be
understood b y b o t h the surgeon a n d b y the patient.
Surgery sometimes appears to come about
unnecessarily due to pressure from the dancer
himself. O n l y too n a t u r a l l y , the dancer is anxious
to get better a n d return to w o r k as q u i c k l y as
94 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
possible a n d surgery m a y appear to be the easiest
and quickest w a y to achieve this end. T h e dancer
may have been shown an X - r a y w h i c h shows a spur
and then, far more justifiably than the surgeon, has
fallen into the trap o f saying that that is something
that s h o u l d not be there, therefore it must be
causing the symptoms, thus pressuring the surgeon,
who m a y be a little reluctant, to c a r r y i n g out an
operation. O n l y too often, dancers are seen w h o
have undergone surgery a n d i n the longer r u n are
no better as a result a n d often worse.
It should be realised by everybody that these
little spurs a n d calcifications nearly always
represent o l d m i n o r damage to ligament a n d
capsular attachments a n d they have formed merely
as part o f the healing process. O n c e they have
reached that stage, they i n themselves are very
rarely the source of symptoms.
T h e other aspect w h i c h has to be remembered is
that after any operation there is i n e v i t a b l y g o i n g to
be a period where the dancer is unable to do
a n y t h i n g other than rest while the wounds a n d
tissues heal. D u r i n g this time the muscles w i l l
weaken generally throughout the b o d y a n d more so
in the l i m b w h i c h h a d the surgery. H e w i l l then
have a period where he g r a d u a l l y progresses back
to w o r k . O n l y too often, i f the o r i g i n a l cause for
the symptoms h a d been treated simply, possibly
w i t h a short period o f rest but certainly w i t h
progessive treatment i n c l u d i n g technical help i f
necessary, then resolution w o u l d have taken place
w i t h o u t any form o f surgery a n d usually far more
q u i c k l y a n d completely.
F i n a l l y , it must always be remembered that any
operation, however small, carries risks. T h e
anaesthetic itself has a definite, though small, risk.
A n y w o u n d that is made i n the skin has a risk o f
infection. T h e post-operative complications include
deep vein thromboses. A l t h o u g h the percentage o f
patients w h o suffer from any o f these complications
is fortunately very small, the complications do exist
and surgery should not be undertaken lightly or
unnecessarily. Ignorance on the part o f the
orthopaedic surgeon is no excuse for surgery.
Alternative T h e r a p i e s
M u c h as their exponents w o u l d like to persuade
people otherwise, a l l the alternative therapies are
a i m e d at merely relieving symptoms. T h i s neglects
that very i m p o r t a n t aspect o f proper treatment
w h i c h is to so construct a p r o g r a m m e of treatment
and r e h a b i l i t a t i o n as to prevent f u r t h e r injury, or
recurrenttemperatur
injury, of the same a r e a .
ACUPUNCTURE A N D ACUPRESSURE
T h i s has already been mentioned following the
section on Transcutaneous N e r v e S t i m u l a t i o n . I n
certain people and certain conditions it c a n be v e r y
effective i n relieving p a i n . It does b y its very
nature, however, penetrate the skin a n d is therefore
not without potential dangers. E v e n sticking a
needle into someone does carry a very trifling risk.
T h e greatest danger is by visiting a n acupuncturist
who does not use disposable needles. I n the
consulting r o o m sterilisation o f re-usable needles
can be difficult, viruses are mostly not destroyed b y
simple b o i l i n g a n d a higher temperature w i t h a
steam autoclave is required. Inadequately sterilised
needles can c o m m o n l y transmit diseases such as
hepatitis or A I D S .
M a n y physiotherapists n o w use acupuncture i n
conjunction w i t h the more c o n v e n t i o n a l therapies.
Acupressure is a v a r i a n t o f a c u p u n c t u r e where
pressure is a p p l i e d to the various points instead o f
inserting a needle. It is, as previously stated,
harmless a n d free from the problems o f virus
transmission.
OSTEOPATHY
T h e conventional osteopath (see note at e n d o f this
section) w i l l m a i n t a i n that most symptoms arise
from spinal vertebral m a l a l i g n m e n t or possibly
from some m a l a l i g n m e n t o f some other joints a n d
muscles. T h e osteopathic treatment consists o f
forcible m a n i p u l a t i o n s to 'put back' the m a l a l i g n e d
j o i n t or to stretch soft tissues and adhesions. T h e
manipulations m a y also be a c c o m p a n i e d b y some
massage of the soft tissues.
CHIROPRACTIC
T h i s is somewhat similar to the c o n v e n t i o n a l
osteopathic treatment although the theory relies
even more o n spinal m a n i p u l a t i o n . T h e
chiropractor maintains that the cause of most
symptoms is a vertebral m a l a l i g n m e n t . T h e
manipulations tend to be even more forcible.
M o s t people w h o take themselves off to the
osteopath or c h i r o p r a c t o r w i l l be suffering from
some form o f back p a i n , a l t h o u g h occasionally they
w i l l take disorders o f other joints. F o r t u n a t e l y , most
back disorders arise from soft tissues, ligaments a n d
facet joints a n d although they m a y not respond
p a r t i c u l a r l y well to the m a n i p u l a t i v e procedures,
usually no real h a r m is done. Those patients who
are likely to benefit most from this type o f
m a n i p u l a t i v e procedure are those w h o have
developed a sudden acute neck p a i n , frequently
w i t h the head to one side w i t h l i m i t a t i o n o f
 Section 2.5-2.6
movement, or a sudden l u m b a r back p a i n w i t h
s i m i l a r l i m i t a t i o n o f movement a n d often a tilt to
the side. H e r e a n early m a n i p u l a t i o n c a n frequently
settle things satisfactorily. H o w e v e r , these
manoeuvres are w i t h i n the a m b i t o f the p r o p e r l y
trained physiotherapist w h o w i l l usually choose to
use w h a t the physiotherapist w i l l call mobilisations
(vide supra) i n order to achieve the same result.
T h e m a i n h a z a r d i n c o n v e n t i o n a l osteopathy a n d
chiropractic is w h e n the neck or back p a i n is due to
a disc prolapse. A forcible m a n i p u l a t i o n i n those
circumstances, a l t h o u g h it m a y shift the disc
prolapse a w a y from the nerve root where it is
causing symptoms, c a n e q u a l l y w e l l cause a further
a n d massive disc prolapse, p r o d u c i n g paralysis.
P r o d u c t i o n o f q u a d r i p l e g i a (paralysis from the neck
d o w n ) o r p a r a p l e g i a (paralysis from the waist
down) is b y no means u n k n o w n following forcible
spinal m a n i p u l a t i v e procedures.
Note:Note:I have used the expression ' c o n v e n t i o n a l
osteopathy' because i n the U n i t e d States the
w h o l e role a n d position o f the osteopath has
altered r a d i c a l l y . T h e r e the osteopath receives
very m u c h the same sort o f t r a i n i n g as the
m e d i c a l student. O n c e qualified as a D o c t o r
of Osteopathy, his career a m d further
t r a i n i n g from then o n tends to be similar to
the m e d i c a l student w h o qualifies as a n M . D . ,
a n d he c a n proceed into any o f the fields o f
medicine a n d surgery b y following the same
sort o f t r a i n i n g as the n e w l y qualified M e d i c a l
D o c t o r . A t present i n the U n i t e d K i n g d o m
most osteopaths still fulfil their t r a d i t i o n a l
m a n i p u l a t i v e role. T h e B r i t i s h S c h o o l o f
O s t e o p a t h y is g i v i n g a proper f o r m a l t r a i n i n g
to osteopaths so that the a p p r o a c h o f the
rising generation o f osteopaths w i l l be
different from that o f their relatively
u n t r a i n e d forbears. It is therefore difficult at
present for patients to k n o w exactly where
they stand i f they decide to opt for some
osteopathic treatment.
2.6 The Prevention of Injury
A l t h o u g h the methods for the prevention o f injury
can be deduced w h e n r e a d i n g the other Sections,
the m a i n factors i n the prevention w i l l be
summarised.
95
The Development and Maintenance of Good
Technique
A s described i n Section 2.3, the cause o f dance
injuries is faulty technique, therefore conversely i f a
good technique is developed a n d m a i n t a i n e d , the
chance o f sustaining a dance injury is m i n i m i s e d .
O f great help i n m a i n t a i n i n g a good technical level
of d a n c i n g is regular attendance at a class r u n b y a
competent and
temperatur observant
temperatur teacher. A s i n a l l activities,
whether m e n t a l or physical, it is o n l y too easy for
technique, the a p p l i c a t i o n o f technique a n d m e n t a l
attitudes to g r a d u a l l y deteriorate w i t h the passage
of time. E v e n serious self-appraisal a n d
self-criticism m a y not be sufficient to prevent the
development o f errors a n d flaws i n technique.
H o w e v e r , b y attending a really good class
regularly, the chances o f injury c a n be kept to a
minimum.
The Development and Maintenance of
M u s c l e Strength a n d J o i n t M o b i l i t y
I n the prevention o f injury, the i m p o r t a n c e o f
m a i n t a i n i n g adequate muscle strength cannot be
over-emphasised. H o w e v e r , it must also be stressed
that this does not m e a n a n over development o f
b u l k such as one sees i n weight lifters a n d i n those
people c o m p e t i n g i n the ' M r A t l a s ' contests. P u r e
b u l k does not necessarily equate w i t h desirable
strength. O v e r - b u l k y muscles c a n be a distinct
disadvantage to a dancer for they not o n l y look
unsightly but also m a y m a k e dance more difficult.
F o r example, over-development a r o u n d the
shoulder girdle a n d arms, due to a n excessive
enthusiasm for weight lifting, c a n raise the centre
of g r a v i t y o f the b o d y a n d make the d a n c e r rather
more unstable w h e n he tries to balance.
A d d i t i o n a l l y , b u l k y muscles c a n get i n the w a y at
the extremes o f j o i n t m o v e m e n t range.
C o r r e c t muscle balance is as i m p o r t a n t as muscle
strength; firstly, between one side o f the b o d y a n d
the other a n d one l i m b a n d the opposite l i m b a n d
secondly, between the various groups w h i c h c o n t r o l
the movements o f a p a r t i c u l a r j o i n t or joints. A
good instance o f this is the over-emphasis w h i c h is
so often p l a c e d o n b u i l d i n g up the quadriceps
muscles i n the t h i g h to the neglect o f the other
groups i n that region, i.e. the adductors, the
hamstrings a n d the gluteals. T h e i l l effects o f
muscle i m b a l a n c e are m e n t i o n e d elsewhere,
p a r t i c u l a r l y i n Sections 3 a n d 5.
J o i n t m o b i l i t y goes h a n d i n h a n d w i t h muscle
strength. I f the muscles c o n t r o l l i n g a j o i n t are
weak, then the j o i n t w i l l not be stabilised
96 Section 2: Injuries: Causes, T r e a t m e n t , P r e v e n t i o n
sufficiently for it to be used satisfactorily i n its full
range. Therefore i n m a i n t a i n i n g muscle strength
a n d balance, j o i n t m o b i l i t y w i l l also tend to be
m a i n t a i n e d . A l s o p l a y i n g a very significant part i n
a c h i e v i n g the fullest possible m o b i l i t y o f a j o i n t is
the necessity to exercise the c o n t r o l l i n g muscle
groups t h r o u g h the f u l l range o f their movement.
F o r instance, the muscle group c o n t r o l l i n g
extension o f a j o i n t must be able to act powerfully
throughout the full range o f movement, from full
flexion to full extension a n d not d u r i n g only part o f
that range. I n order to achieve this it is essential
that a n y exercise p r o g r a m m e is directed at
p r o v i d i n g a correct exercise pattern for that muscle
g r o u p throughout this range. Only when the muscles
c o n t r o l l i n g the j o i n t are strong, can the range then be
temperatur
increased temperatur
to the anatomically temperatur
f u l l range temperatur
by gentle graduated
stretching.
temperatur Stretching must go h a n d i n h a n d w i t h a n
exercise p r o g r a m m e to strengthen the muscle
groups. A weak muscle must never be stretched.
The Preservation of Cardio-respiratory
Fitness
T h i s w i l l n o r m a l l y occur as a result o f any exercise
p r o g r a m m e that the dancer is c a r r y i n g out i n order
to m a i n t a i n his muscle strength a n d j o i n t m o b i l i t y .
A n y form o f general exercise w i l l have its effect o n
the cardio-vascular a n d respiratory systems i n
h e l p i n g to m a i n t a i n them i n the peak o f c o n d i t i o n .
H o w e v e r , d u r i n g v a c a t i o n periods it can be helpful
i f the dancer continues to do some form o f exercise,
not necessarily related to dance, as a recreational
activity. T h i s c a n take the form o f s w i m m i n g ,
c y c l i n g or tennis, w h i c h m a y be more appropriate
d u r i n g a h o l i d a y . A s previously stated, i n order to
m a i n t a i n cardio-respiratory fitness it is essential that
the exercise is vigorous enough to make the person
concerned short o f breath. T h i s w i l l ensure that
d u r i n g these times the cardiac output is called u p o n
to increase. It is this regular d e m a n d o n the
cardio-vascular system w h i c h maintains it i n a state
o f physiological fitness.
O n a more general line, the dancer, as w i t h any
other athlete, should a v o i d any action w h i c h abuses
his b o d y a n d , i n p a r t i c u l a r , the cardio-vascular a n d
respiratory systems, as these are so essential for the
maintenance o f a good performance. T o this end,
the avoidance o f s m o k i n g plays an extremely
i m p o r t a n t part. N o t only are there the long-term i l l
effects o f cigarette s m o k i n g o n the lungs a n d the
c o r o n a r y arteries but there is also the constant
effect o n the b l o o d stream. D u r i n g the s m o k i n g o f
cigarettes a very significant a m o u n t o f c a r b o n
m o n o x i d e is i n h a l e d a n d , as was described i n
Section 1.8, this carbon m o n o x i d e combines w i t h
the h a e m o g l o b i n i n the b l o o d , preventing it from
c a r r y i n g the oxygen a r o u n d the b l o o d stream, thus
d e p r i v i n g the tissues (particularly the muscles i n the
case of an athletic performance) o f the m a x i m u m
amount o f oxygen. Excessive c o n s u m p t i o n o f
alcohol can have a direct effect o n both cardiac a n d
skeletal muscle, p r o d u c i n g an a c t u a l deterioration
i n both.
Good Nutrition
T h e maintenance o f a satisfactory n u t r i t i o n a l state
is essential i n the prevent o f injury a n d also i n the
healing o f injuries. (See Section 2.7.)
T h e O r t h o p a e d i c A s s e s s m e n t o f the D a n c e r
i n the P r e v e n t i o n of Injury
O n e o f the most i m p o r t a n t aspects i n the
prevention o f dance injuries is i n the assessment o f
students before they are accepted b y professional
schools. T h i s c o u l d , w i t h great advantage, be
extended to an assessment o f each dancer w h e n
they are first taken into a C o m p a n y .
T h e purpose o f this orthopaedic e x a m i n a t i o n is
to determine whether there are a n y a n a t o m i c a l
areas w h i c h are likely to cause physical problems
d u r i n g a dance t r a i n i n g or, w h e n assessing adults,
whether there is a n y t h i n g that is g o i n g to cause a n y
p a r t i c u l a r p r o b l e m w i t h different types o f dance.
A l t h o u g h there are occasionally p h y s i c a l aspects o f
a person w h i c h c a n preclude any satisfactory
p a r t i c i p a t i o n i n dance, i n most instances a l t h o u g h
someone m a y be unsuitable physically for certain
forms o f dance, for example classical ballet, there
are other types o f dance w i t h w h i c h they w o u l d
cope perfectly satisfactorily. A careful assessment
can therefore be used to guide a y o u n g dancer
along the right lines. T h e orthopaedic assessment
can be a great help w h e n a teacher has a student
who is apparently finding difficulty w i t h some o f
the technical aspects o f the work. F r e q u e n t l y there
is some physical aspect o f the dancer w h i c h ,
although not very obvious, is sufficient to make
certain areas o f dance technique difficult to c a r r y
out correctly.
B y the time students have got t h r o u g h a l l the
p r e l i m i n a r y auditions, before attending for a final
a u d i t i o n at a professional dance school, the
a u d i t i o n i n g panel w i l l have rejected most o f those
applicants w h o are obviously unsuitable. W e r e the
p o p u l a t i o n to be e x a m i n e d o r t h o p a e d i c a l l y at
r a n d o m w i t h a view to their suitability for dance,
then large numbers w o u l d be found to be
unsuitable. H o w e v e r , i n the professional schools the
 Section 2.6
a u d i t i o n i n g panels w i l l have rejected most o f those
applicants w h o are physically unsuited to dance
before they are actually sent for an orthopaedic
assessment.
It is always i m p o r t a n t to remember that artistic
talent c a n overcome m a n y apparent physical
problems. I f a student does show great potential
talent then it is usually right to give them the
chance to dance b y a l l o w i n g them to start t r a i n i n g .
T h e i r progress should be carefully m o n i t o r e d i n
order to determine whether they are o v e r c o m i n g
these difficulties. I n these circumstances it is very
i m p o r t a n t that a l l the teachers a n d the student are
fully aware o f any potential physical problems that
are present a n d w h i c h m a y cause technical
difficulties or injury either d u r i n g t r a i n i n g or later
i n a professional career. T h e orthopaedic surgeon
must, therefore, have two thoughts i n his m i n d
w h i l e d o i n g the assessment - first, whether there is
any p h y s i c a l p r o b l e m w h i c h calls for an outright
rejection, for example a n established
spondylolisthesis, a n d secondly, to note carefully
those areas w h i c h are potential p r o b l e m points.
D u r i n g the course o f this assessment there m a y be
some aspects w h i c h c a n be amenable to early help
from the physiotherapist or teacher, usually i n the
form o f special exercises to strengthen or mobilise a
p a r t i c u l a r area or areas.
F i g . 2.6 is a r e p r o d u c t i o n o f the c a r d that we
have used for m a n y years for the orthopaedic
assessment o f both students a n d professional
dancers. It is largely self-explanatory. T h e presence
of a tight trapezius is noted because this w i l l affect
head movements, p a r t i c u l a r l y i f there is some
l i m i t a t i o n o f rotation was well as o f lateral flexion.
A t the shoulders a discrepancy i n level c a n be very
suggestive o f a n u n d e r l y i n g a b n o r m a l i t y such as a
scoliosis or leg length discrepancy. H o w e v e r , the
majority o f cases where the shoulders are at
different levels is purely postural a n d possibly
associated to some extent w i t h the c a r r y i n g o f
heavy bags o n one or other side. ( T h e old-fashioned
school satchel h a d a great deal to c o m m e n d it as it
d i d m e a n that the l o a d i n g o f the shoulders was
equal.) U n d e r 'shoulder line' we are l o o k i n g for
those c h i l d r e n w h o have their shoulders forward,
thus a p p e a r i n g to n a r r o w their chests. A l t h o u g h the
braced back shoulders o f the o l d m i l i t a r y stance
was a very poor position, e q u a l l y b a d is the
n a r r o w i n g caused b y shoulder girdles that have
rotated forwards a r o u n d the chest.
W i n g i n g o f the scapula is very indicative o f
upper trunk weakness. F r e q u e n t l y the scapulae
stand out sufficiently to slip a h a n d between the
m e d i a l border o f the scapula a n d the chest w a l l .
97
T h i s is often part o f a scapula rotation a n d due to
some weakness o f the latissimus dorsi, so that the
slip to the inferior pole o f the scapula does not act
sufficiently to h o l d the scapula d o w n . I n i m p r o v i n g
the posture the scapula has to be held d o w n , largely
by the l a t i s s i m u m dorsi, a n d must not be braced
backwards.
U n d e r 'elevation' we are l o o k i n g at the c o m b i n e d
a b d u c t i o n a n d flexion o f the shoulders. T h i s is o f
great i m p o r t a n c e i n the boys as i f there is some
restriction it means that w h e n lifting they are
unable to h o l d the g i r l u p above their heads
w i t h o u t t i l t i n g b a c k w a r d s i n the l u m b a r region o f
the spine.
I n the arms the presence o f swayback elbows is
looked for as w e l l as h y p e r m o b i l e wrists as part o f a
general i n d i c a t i o n o f the presence o f h y p e r m o b i l i t y .
H y p e r m o b i l i t y i n a dancer is a very potent cause o f
injury, as is mentioned elsewhere i n this book. I f a
student or dancer is h y p e r m o b i l e they then have to
w o r k far harder at m a i n t a i n i n g muscle strength i n
order to c o n t r o l the h y p e r m o b i l i t y o f their joints.
I n the wrists, p a r t i c u l a r l y i n boys, one is l o o k i n g
for any restriction o f dorsi-flexion as this c a n also
cause problems w h e n lifting.
I n the back, the presence o f a scoliosis or
kyphosis is noted. I n c h i l d r e n , this orthopaedic
assessment m a y be the first time that they have
been looked at thoroughly by a n y m e d i c a l
practitioner so occasionally a hitherto undetected
scoliosis is p i c k e d u p a n d c a n be referred for
treatment. A very m i l d scoliosis is no
c o n t r a - i n d i c a t i o n to d a n c i n g , but i n the younger
student the parents should be w a r n e d that there is a
possibility that the scoliosis w i l l progress as part o f
the n a t u r a l history o f the c o n d i t i o n a n d that the
c h i l d w i l l have to r e m a i n under observation. D a n c e
t r a i n i n g i n no w a y aggravates a scoliosis. I n fact,
the opposite occurs a n d the extra exercise o f
d a n c i n g , coupled possibly w i t h side shift exercises
a n d other trunk exercises, c a n a c t u a l l y be beneficial
i n stopping the progress o f a scoliosis or i n reversing
the c o n d i t i o n .
A t the knees, the presence o f hyperextension or
swayback is observed. T h e h e a d i n g 'patellae' refers,
i n fact, to the presence o f t i b i a l rotation. W h e n the
feet are p o i n t i n g straight forwards i f there is any
tibial rotation or torsion then the patellae w i l l p o i n t
inwards (the so-called squint patellae) a n d the
a m o u n t o f rotation is measured a n d noted.
T h e presence o f a t i b i a l b o w , whether it affects
the whole tibia or whether it is just the l o w e r
quarter, is assessed. A lower t i b i a l b o w w i l l produce
an angle at the ankle j o i n t so that the plane
t h r o u g h the ankle j o i n t is not p a r a l l e l to the knee.
 THE REMEDIAL DANCE CLINIC
Work:
Work: 78 Harley S t r e e t , London, W.1N 1AE.

Work:
Address: N a m e :.

Christian Name:

Age: d.o.b.

Tel. No. Home:

Work: G.P.

Company: School:

Referred by:

HEIGHT : C.R. HEAD: A.P. Lateral.

WEIGHT PELVIS: A.S.I.S. I.C. G.T. Shoulder width

NECK: Length, Tight Trapezius

Range: Flexion. .E x t e n s n . Lat.Flex R ,L R o t .R L.

SHOULDERS: Level Line. .Winging Scap Elevation R. L

ARMS RANGE:Svay back elbows Wrists:

BACK: Scoliosis Kyphosis:

RANGE: Flexn Extn Lat.FIex.R •L. .Rotation R L

PELVIS: Level. Assymetry.

KNEES: Sway back R. L Patellae R. L.

LEGS: Length R L. Tiblal bow R .L

POINTE: R ■L. Ankle R ■L. Metatarsus R L

B I G TOE EXT; R. L. Big toe posture

LESSER TOES:

I N T R I N S I C S :.

SUB-TALOID: R .L. Mid-Tarsal: R. L. Navlcula.

ACHILLES TENDONS: R ,L

HAMSTRINGS: R. •L

TURNOUT F R O G :,

HIP: Extension R. ,L Flexion R. ,L.

HIP ROTATION FLEXED: Right E.R I .R. .Left E.R. I .R.

HIP ROTATION EXTENSION: Right E.R. I .R. Left E.R. I .R.

OTHER COMMENTS:

EXAMINER: Date:
 Section 2.6-2.7
A s a result the patient w i l l tend to both roll a n d
sickle w i t h the problems that can be associated w i t h
these two factors.
B i g toe extension is p a r t i c u l a r l y i m p o r t a n t . I n the
student a n early d e v e l o p i n g h a l l u x rigidus c a n often
be detected by n o t i n g the restriction w h i c h is
already present i n dorsi-flexion at the 1st
metatarsophalangeal j o i n t . I f there is significant
restriction this is an i m p o r t a n t c o n t r a - i n d i c a t i o n to
proceeding w i t h a dance t r a i n i n g . A l l forms o f
dance c a l l for demi-pointe w o r k a n d as the h a l l u x
rigidus progresses it becomes more a n d more
difficult to get u p onto a reasonable demi-pointe
a n d certainly prevents the dancer getting up onto
three-quarter pointe or performing a correct releve.
'Lesser toes' refers to the presence of any lesser
toe deformities, the relative toe lengths a n d
metatarsal lengths. I n order to o b t a i n a good
support w i t h a foot on b o t h demi-pointe a n d full
pointe it is far more satisfactory to have an even
length o f metatarsals a n d o f toes.
I n the feet, the intrinsic muscles are i m p o r t a n t as
they a l l o w the dancer to o b t a i n a good pointed foot
w i t h straight toes w h e n they are w o r k i n g strongly.
I f the intrinsics are weak w h e n the dancer pointes
the foot the toes claw, due to the action o f the l o n g
flexors.
A c h i l l e s tendons refers to tightness i n the back o f
the calf. D a n c e r s always refer to tight A c h i l l e s
tendons, as do other sportsmen. I n the calf the
gastrocnemius a n d soleus muscles j o i n together at
their l o w e r ends to form the A c h i l l e s tendon. It is
this whole c o m p l e x w h i c h makes for tightness a n d
not the A c h i l l e s tendon alone. A n y tightness i n this
area w i l l , o f course, prevent the dancer g o i n g d o w n
into a good plie. S i m i l a r l y , an assessment o f the
hamstrings for any tightness is i m p o r t a n t ,
p a r t i c u l a r l y i n girls. H o w e v e r , i f the A c h i l l e s
tendons a n d calf muscles a n d the hamstrings are
very loose then the height o f the j u m p becomes
i m p a i r e d , so too m u c h looseness at these sites is a
disadvantage i n boys.
T h e turn-out i n the frog position a n d its genuine
irrelevance to the dancer is discussed later i n the
book w h e n d e a l i n g w i t h turn-out. H o w e v e r , most
dancers a n d teachers look u p o n the frog position as
one o f the methods o f assessing turn-out. Therefore
it is e x a m i n e d for their benefit.
T h e extension o f the h i p is i m p o r t a n t as tightness
i n the front o f the h i p causes a variety o f problems.
T h i s is dealt w i t h later i n the book.
T h e measurement o f h i p rotation w i t h the h i p
flexed to 90° is noted. T h e measurement o f h i p
rotation w i t h the h i p i n full extension is a far more
i m p o r t a n t measurement a n d reflects the degree o f
99
turn-out w h i c h is present w h e n the dancer is
standing, w h i c h is, o f course, the n o r m a l position
during working.
T h e other items o n the form w h i c h have not
been mentioned are really self-explanatory.
Despite the use o f a form such as this the genuine
assessment o f the dancer certainly calls for a lot o f
experience. F o r example, w h e n e x a m i n i n g an area
w h i c h seems to be tight, the general feel o f the
tissues w i l l give an experienced e x a m i n e r a very
good idea o f whether the dancer w i l l be able to
stretch out the area w i t h exercise a n d good
t r a i n i n g . T h i s is something w h i c h cannot be learnt
from a book but only b y practise a n d b y seeing a
large n u m b e r o f dancers a n d dance students a n d
being able to follow their progress over the years.
2-7 Nutrition
E v e r y m e m b e r of the p o p u l a t i o n requires an
adequate standard o f n u t r i t i o n . T h i s must give
sufficient but not an excess o f calories, the correct
balance of protein, fat a n d c a r b o h y d r a t e a n d a l l
the necessary minerals, v i t a m i n s a n d water.
W i t h o u t a correctly b a l a n c e d diet the physiological
m e c h a n i s m o f the b o d y cannot function at the
utmost peak o f efficiency. D a n c e r s a n d athletes are
no different from o r d i n a r y members o f the
p o p u l a t i o n i n this respect. H o w e v e r , dancers have a
disproportionately h i g h n u m b e r o f food fads. T h e y
l a b o u r under a whole variety o f misapprehensions.
T h e y are led astray b y o l d wives' tales w h i c h are
repeated, propagated a n d m u l t i p l i e d b y their elders
a n d b y their colleagues. T h e y are ready victims for
any ill-informed advice that is proffered, whether i n
the p r i n t e d form or v e r b a l l y , w h i c h claims to
enable them to reach or m a i n t a i n their desired level
of a c t i v i t y or give them boundless energy at the
times they need it.
U n f o r t u n a t e l y , these misapprehensions are
aggravated by the fact that m a n y dancers are
either i n relatively p o o r l y p a i d e m p l o y m e n t or are
out o f w o r k a n d have to exist o n a very small
a m o u n t o f money. T h i s does not help t h e m to eat a
sensible a n d satisfactory diet. I n the professional
dance schools, whether they be p r o d u c i n g dancers
h o p i n g for a stage career or dance teachers, there
should certainly be an emphasis o n i n s t r u c t i o n i n
n u t r i t i o n . T h i s w o u l d best be c a r r i e d out b y a
sympathetic d i e t i c i a n w h o c o u l d advise them, not
o n l y o n the elementary basics o f n u t r i t i o n a n d diet,
but w o u l d also help them to p l a n their d a i l y eating
so that it w o u l d fall w i t h i n their l i m i t e d budgets
100 Section 2: Injuries: C a u s e s , T r e a t m e n t , Prevention
a n d yet p r o v i d e a l l the essentials for a healthy
existence. So m a n y of the good books o n the subject
of diet a n d n u t r i t i o n r e c o m m e n d foods that are
beyond the financial reach o f both students a n d
professional dancers. A sensible a n d well-informed
choice o f food a n d meals not only provides
adequate n u t r i t i o n but also helps to prevent the
dancer b e c o m i n g either overweight or underweight.
A good diet is i m p o r t a n t i n m a i n t a i n i n g the h e a l i n g
processes at their peak o f efficiency a n d also helps
to prevent injury by keeping the body i n the best
condition.
Nutritional Requirements
PROTEINS
These are required for muscle a n d tissue
development a n d repair. T h e y also provide essential
a m i n o acids w h i c h are needed for the n o r m a l
metabolism i n the body. Protein is found
p a r t i c u l a r l y i n lean meat, p o u l t r y a n d fish. It also
occurs i n v a r i a b l e amounts i n m i l k a n d d a i r y
products i n c l u d i n g cheese, eggs a n d i n some
vegetables. A l t h o u g h the h u m a n body can convert
carbohydrates a n d fats into most proteins a n d
a m i n o acids (amino acids are substances w h i c h are
obtained from metabolism o f protein) there are
what is k n o w n as essential a m i n o acids w h i c h the
b o d y is incapable o f synthesising. These, therefore,
have to be obtained directly from the diet.
A l t h o u g h these c a n be found i n certain vegetables,
they are far more a b u n d a n t i n a n i m a l protein.
A n i m a l protein is frequently referred to as
first-class protein. I f the total diet is insufficient to
provide enough a m i n o acids, the body w i l l start to
break d o w n its o w n proteins, w h i c h largely means
the m u s c u l a r tissue, i n order to provide the a m i n o
acids that it requires. T h i s c a n h a p p e n i n people
who diet injudiciously or embark u p o n a b a d l y
structured diet.
CARBOHYDRATES
These are required as an energy source. T h i s g r o u p
is d i v i d e d into two, the simple carbohydrates such
as glucose, cane sugar a n d other simple sugars a n d
the c o m p l e x carbohydrates such as starch a n d
complex sugars. T h e simple carbohydrates can be
absorbed a n d metabolised very r a p i d l y whereas the
complex carbohydrates take longer to absorb a n d
metabolise a n d w i l l therefore give a slower release
of energy.
FATS
These p r o v i d e a h i g h energy source. ( H i g h energy
means also h i g h calories.) T h e y are metabolised
a n d used very m u c h more slowly than the c o m p l e x
carbohydrates so their benefit as a n energy source
w i l l be m u c h longer-term. Fats are a v i t a l carrier
for the fat soluble vitamins A a n d D .
VITAMINS
T h e r e is a d a i l y m i n i m u m requirement for
vitamins. W h i l e they are not a food as such,
i n a s m u c h as they d o not provide energy, they are
essential for the proper functioning o f the body.
P r o v i d e d the m i n i m u m requirements are met, there
is no evidence at a l l to show that boosting the
intake by the use of v i t a m i n supplements has any
benefit. It certainly has no effect o n e n h a n c i n g
performance or increasing endurance. A n excessive
intake o f V i t a m i n s A a n d D can be extremely
harmful. T h e former can cause damage to the eyes
a n d the latter upsets the c a l c i u m a n d phosphorous
metabolism a n d balance. A s sufficient intake is
i n c l u d e d i n the diet, it is unwise to supplement
these two vitamins.
A t present there is no evidence that over-dosing
w i t h either the B complex vitamins or w i t h V i t a m i n
C has any harmful effects. B o t h are excreted i n the
urine i f they are i n excess. T h i s is very obvious i n
the case o f the B complex, as y o u w i l l observe i f
you take a couple o f V i t a m i n B tablets following
w h i c h y o u w i l l notice that y o u r urine becomes a
bright yellow. T h e o n l y time w h e n a large dose o f
V i t a m i n C might be helpful is at the onset o f
development o f the c o m m o n cold. Some research
workers have produced possible evidence, a l t h o u g h
it is by no means conclusive, that i f V i t a m i n C is
taken at the rate o f a g r a m m e a day, starting right
at the commencement of c o m m o n cold symptoms,
the course o f the disease is significantly shortened or
even aborted. A l t h o u g h relatively expensive to b u y ,
the dancer m i g h t feel that the chances o f d e r i v i n g
benefit are w o r t h the cost a n d they can certainly
rest assured that they w i l l come to no h a r m . T h e r e
is, however, no evidence whatsoever that t a k i n g
V i t a m i n C i n large doses p e r m a n e n t l y has any
preventive effect at a l l i n respect o f a c t u a l l y
catching a cold.
V i t a m i n B 1 2 is sometimes considered to be an a i d
to performance. T h e r e are some ignorant athletic
trainers w h o d e m a n d that their athletes have an
injection o f V i t a m i n B12 p r i o r to a performance.
A l t h o u g h V i t a m i n B 1 2 by injection certainly gives
m a n y people a feeling o f well-being, there has,
despite intensive investigations, been no evidence
that this extra B12 enhances either the performance
of intricate tasks or increases endurance or sprint
activities. Its use i n these circumstances cannot be
condoned a n d is o n l y another example o f the
 Section 2.7
ill-informed pressing for the unjustified use o f some
or other preparation. E v e r y injection, b r e a c h i n g as
it does the integrity o f the skin surface, carries w i t h
it a very small risk, however m i n i m a l this risk m i g h t
be, a n d the athlete a n d dancer should a v o i d foolish
advice such as this.
MINERALS
T h e r e is a very l o n g list o f essential minerals that
are required i n the diet. M o s t o f these are required
i n very small quantities a n d are adequately
p r o v i d e d i n the d a i l y food intake. T h e only
exceptions are i r o n a n d c a l c i u m , both o f w h i c h can
be very deficient i n dancers. I r o n , p a r t i c u l a r l y , c a n
be l o w i n the female because o f menstruation.
H o w e v e r , as most female dancers are o f
exceptionally l o w weight, m a n y o f them do not
menstruate or only i r r e g u l a r l y a n d occasionally, so
i r o n depletion m a y not be as m a r k e d even w h e n
there is a m i n i m a l intake i n their diet. I f there is
any d o u b t at a l l , then the dancer should consult her
doctor, as a simple blood test w i l l r a p i d l y show
whether there is any a n a e m i a present. T h i s can
readily be corrected w i t h a n i r o n supplement. T h e
requirement is 18 m g d a i l y . I f a dancer is anaemic,
she w i l l certainly not be able to perform at her
best. She w i l l tend to feel tired a n d listless a n d be a
ready candidate for injury a n d various infections.
I n c i d e n t a l l y , research has shown that dancers w h o
weigh less t h a n 45 kilograms do not menstruate a n d
as far as some research has progressed at present i n
A m e r i c a , this seems to be a fairly critical figure.
T h e c a l c i u m requirement is 1200 m g d a i l y . T h i s
can be obtained b y d r i n k i n g 4 - 5 glasses o f m i l k
each d a y . O t h e r w i s e a supplement w i l l be
necessary.
WATER
A sufficient intake is essential for the satisfactory
physiological processes o f the body. T h e kidneys
require a n adequate output o f water i n order to be
able to excrete the waste products o f m e t a b o l i s m . I f
the b o d y is short o f water then the b l o o d v o l u m e
w i l l decrease a n d this c a n interfere w i t h the
transportation o f b o t h nutrients a n d oxygen to the
cells as w e l l as d e l a y i n g the r e m o v a l o f c a r b o n
d i o x i d e a n d metabolites. W a t e r is also essential for
the regulation o f b o d y temperature w h i c h it does
by the p r o d u c t i o n o f sweat. I f dancers become
d e h y d r a t e d , fatigue o f both the muscles a n d the
b o d y as a whole w i l l set i n m u c h earlier a n d they
w i l l become very m u c h more liable to sustain
injury. T h e d e h y d r a t i o n can also cause cramps a n d
heat stroke a n d a genuine exhaustion o f the w h o l e
being. A l s o , a failure to take enough fluid c a n m a k e
101
the dancer i n i t i a l l y feel nauseated, even i n the
absence o f the other effects o f d e h y d r a t i o n , a n d this
nausea c a n itself do n o t h i n g to help performance.
W h e n water is lost t h r o u g h sweating, salt is also
lost. H o w e v e r , the salt is readily replaced w i t h the
diet, a l t h o u g h heavy performances, p a r t i c u l a r l y i n
hot w o r k i n g conditions, m a y call for the a d d i t i o n of
salt. T h i s is very adequately done by t a k i n g some
extra salt at mealtimes a n d the use o f salt tablets is
unnecessary. T h i s a d d i t i o n o f salt is certainly a wise
precaution as a lack o f salt w i l l lead to quite severe
cramps. T h e dancer should take great care to
prevent d e h y d r a t i o n a n d should take plenty o f
water d u r i n g the course o f each 24 hours. F o o d
provides a certain a m o u n t o f water d u r i n g its
metabolism but a d d i t i o n a l fluid w i l l be r e q u i r e d ,
the v o l u m e d e p e n d i n g u p o n the a m b i e n t
temperature a n d the degree of sweating. T h e fluid
does not need to be taken as pure water but c a n be
consumed as fruit squash, some fizzy d r i n k s such as
fizzy orangeade, lemonade or s i m i l a r flavours.
H o w e v e r , the various cola drinks, together w i t h tea
and coffee, should not be i n c l u d e d i n fluid
replacement drinks as they a l l c o n t a i n substances
w h i c h act as diuretics. A diuretic acts d i r e c t l y o n
the k i d n e y i n order to increase the excretion o f
water, so c o n s u m p t i o n of these three items can
increase fluid loss to a greater extent t h a n it
replaces it. A l c o h o l comes under the same h e a d i n g
as it also acts as a diuretic a n d c a n produce
d e h y d r a t i o n . It c e r t a i n l y provides some calories but
should not be looked u p o n as a source o f energy as
it has depressant a n d sedative effects. H o w e v e r , a
little a l c o h o l after a performance m a y help the
dancer to relax a n d to this end a glass o f wine w i l l
do no h a r m .
T h e presence o f d e h y d r a t i o n a n d p r o o f o f its
correction c a n be effectively c a r r i e d out b y regular
w e i g h i n g . T h i s is frequently done i n top class
athletics a n d sports. A deficiency o f one litre o f
fluid w i l l produce a weight loss o f one k i l o g r a m .
W e i g h i n g before a n d after a heavy performance or
class, p a r t i c u l a r l y i n hot conditions, w i l l give a n
accurate i n d i c a t i o n o f the q u a n t i t y o f fluid
replacement r e q u i r e d .
T h e Daily Diet
I n d e c i d i n g w h a t to eat each d a y , it is not
p a r t i c u l a r l y easy or helpful to t h i n k i n terms o f
protein, carbohydrates, fats, v i t a m i n s , minerals a n d
water. It is easier to p r o d u c e a b a l a n c e d set o f
meals b y considering w h a t are k n o w n as food
groups a n d m a k i n g certain that one has sufficient
102 Section 2: Injuries: C a u s e s , T r e a t m e n t , P r e v e n t i o n
out o f each o f the four groups. These groups are as
follows:
THE MEAT GROUP
T w o portions d a i l y (one p o r t i o n is equivalent to
two ounces o f meat w i t h the fat removed, or
p o u l t r y or fish, or two eggs, or four ounces o f
cottage cheese).
THE CEREAL GROUP
F o u r portions d a i l y . ( O n e slice o f bread, preferably
w h o l e m e a l , or two ounces o f cereals such as
cornflakes, or pasta such as spaghetti makes up one
portion.)
T H E MILK G R O U P
T h r e e portions d a i l y . ( O n e p o r t i o n is equivalent to
about h a l f a p i n t of m i l k or yoghurt b o t h o f w h i c h
can be l o w fat or s k i m m e d , or one a n d a h a l f
ounces o f o r d i n a r y cheese.) T h i s g r o u p provides the
c a l c i u m as well as other nutrients.
THE VEGETABLE/FRUIT GROUP
F o u r portions d a i l y . ( O n e p o r t i o n w o u l d be
equivalent to a large h e l p i n g o f vegetables or one
fruit such as an apple, orange, pear, etc.) T h e dark
green leafy vegetables or orange vegetables such as
carrots c o n t a i n V i t a m i n A a n d one p o r t i o n o f these
should be taken four times a week. T h e other
vegetables, p a r t i c u l a r l y citrus fruits such as oranges,
contain V i t a m i n C .
W h e n w o r k i n g out the meals for the day, try to
take one p o r t i o n from each group i n each meal. I f
possible, try to eat three meals a d a y , rather than
t a k i n g more portions o f each g r o u p i n fewer meals.
I n p a r t i c u l a r , try to a v o i d a large m e a l at the end
of the d a y just before g o i n g to bed. T h e best
m e t h o d of c u t t i n g d o w n on calories is to reduce the
fat intake; for example, make certain that the meat
is w e l l t r i m m e d , use s k i m m e d m i l k a n d l o w fat
yoghurt, a n d cottage cheese rather than n o r m a l
cheese. W e i g h t for weight, fat provides twice as
m a n y calories as either carbohydrate or protein,
b o t h of w h i c h provide the same a m o u n t o f calories
for a given weight. I n p l a n n i n g y o u r diet do not
forget that calories equal energy a n d energy is
required to carry out a full dance p r o g r a m m e each
day. A l s o , the b o d y requires a m i n i m u m n u m b e r o f
calories just to keep going, even i f the person
remains perfectly still for each 24 hours. T h e a c t u a l
level o f calories required varies from i n d i v i d u a l to
i n d i v i d u a l a n d depends u p o n their o w n metabolic
rate. T h e basal metabolic rate, w h i c h is that w h i c h
occurs w h e n the person is completely inactive, is
greatly increased d u r i n g any form o f activity.
P r e - p e r f o r m a n c e Intake
A l t h o u g h most dancers w i l l determine for
themselves w h a t they c a n or cannot eat a n d d r i n k
before performances, there are certain guidelines
w h i c h they should try to follow. First, they should
make certain that they are well h y d r a t e d d u r i n g the
course o f each day. T h i s is best achieved b y
d r i n k i n g small amounts fairly frequently a n d
regularly. D u r i n g a performance, p a r t i c u l a r l y i f it
is energetic a n d there is a h i g h temperature, sips o f
water can be taken regularly. B y d o i n g this,
d e h y d r a t i o n a n d excessive thirst c a n be a v o i d e d .
H a l f a pint or a pint o f fluid taken i m m e d i a t e l y
before a performance is as likely to end up over the
conductor as be satisfactorily absorbed by the b o d y
and the dancer should not have let h i m s e l f get i n t o
such a situation as to need this q u a n t i t y .
A v o i d concentrated sweet fluids. These w i l l be
absorbed far more slowly a n d they d o n o t h i n g to
enhance the energy levels or activity. E v e n i f
carbohydrate is taken i n a dilute form, such as a
dilute glucose d r i n k , the effect w i l l be
counter-productive d u r i n g the course o f the
performance. I f the glucose is taken i n a dilute
form it w i l l certainly be absorbed r a p i d l y b u t this
w i l l produce a peak o f glucose i n the blood stream,
the physiological mechanisms o f the body w i l l be
stimulated to deal w i t h this peak a n d metabolise it
and as a result there w i l l be a sudden burst of
insulin poured into the blood stream. T h i s peak o f
blood sugar w i l l then fall a n d there w i l l be a trough
below the n o r m a l level ( F i g . 2.7). T h e dancer m a y
therefore suddenly feel halfway t h r o u g h a
performance that he is excessively tired due to this
troughing effect. I n order to ensure a satisfactory
energy supply d u r i n g the course o f a performance,
a small meal taken one a n d a h a l f to three hours
before the performance w o u l d be far more
satisfactory. F o r energy requirements, this m e a l
should c o n t a i n c o m p l e x carbohydrates such as
starch. T h i s can be readily supplied by eating a
small pasta dish or a s a n d w i c h , followed by a little
fruit. I f taken well before the performance this w i l l
have been digested b y the time the dancer wishes to
start a pre-performance w a r m - u p but the energy
supply w i l l continue throughout the performance.
F o l l o w i n g a performance a large m e a l is not
p a r t i c u l a r l y satisfactory a n d , as was mentioned
earlier, it is far better to try to p r o v i d e for y o u r
food requirements b y t a k i n g several small meals a
day.
H a v i n g indicated some general guidelines for
dancers to p l a n their diet a n d food intake, it is
strongly r e c o m m e n d e d that i f dancers have any
 Section 2.7 103

-J
UJ PEAK
>
LU
_I 2.7 Diagrammatic
oc representation of
<
o peaking and troughing
D
CO of the blood sugar levels
o following an intake of
o glucose, sugar or other
D
-J
CD
TIM E NORM AL BLOOD simple carbohydrate.
SUG AR LEVEL

INTAKE OF
TR O U G H
G LU CO SE OR SUGAR

p a r t i c u l a r concerns about weight or problems w i t h m e a l w i t h o u t b e i n g pressurised to attend class i n

food or diet, they should seek the advice o f their
doctor or a fully qualified dietician. A d i e t i c i a n w i l l
be able to help them to p l a n a n appetising a n d
nutritious diet w h i c h comes w i t h i n their budget a n d
w o u l d also fit i n to their d a i l y w o r k p r o g r a m m e .
I n ensuring that their dancers performed at their
best, management w o u l d be w e l l advised to
consider far more carefully the w a y they structured
their dancers' day. T h e y w o u l d o b t a i n better results
i f they ensured that i n the m i d d l e o f the d a y each
dancer h a d sufficient time to have a n adequate
the m o r n i n g , then o n l y be given time to snatch a
q u i c k snack before b e i n g rushed into rehearsals.
These should be a r r a n g e d to a l l o w those w h o are
performing that evening to get a small m e a l w e l l
before the performance is due. W h i l e it m a y be
thought that these are counsels o f perfection, b o t h
management a n d dancers w o u l d be w e l l r e w a r d e d
by p a y i n g a little more attention to the
physiological demands o f the bodies u p o n w h i c h
they b o t h d e p e n d for their livelihoods.
 SECTION
Specific Injuries: their Cause and Treatment
In this section we w i l l describe the injuries
c o m m o n l y found i n dancers, progressing
systematically through the body rather than d e a l i n g
w i t h the injuries i n the order i n w h i c h they occur
most c o m m o n l y . T h i s latter method w o u l d give a
very h a p h a z a r d a n d rather disjointed layout.
In the discussion o f injuries i n this section, where
necessary we describe the injury, the cause or causes
of the injury a n d follow this w i t h a description o f
the treatment a n d any special complications w h i c h
may occur that are relevant to the dancer. W e have
not i n c l u d e d the various m e d i c a l a n d surgical
complications w h i c h are a l l covered i n standard
textbooks o n injuries suffered by the general p u b l i c
a n d w h i c h do not pertain p a r t i c u l a r l y to dancers.
S i m i l a r l y , we have confined ourselves to discussing
only those injuries w h i c h have some aspect w h i c h is
of specific interest to dancers, e.g. the cause o f the
injury, some aspects o f its treatment, etc.
I n the description o f the causes we hope that the
dancer, dance teacher or m e d i c a l attendant m a y be
able to determine the possible reason w h y the
patient should have sustained the injury. T h i s w i l l
usually be associated w i t h some aspect o f their
dance technique. T h e cause is p a r t i c u l a r l y
i m p o r t a n t w h e n the injury is recurrent a n d d u r i n g
the course o f treatment it is v i t a l to eliminate or
correct a l l possible causes.
A l t h o u g h weak areas, technical faults or
a n a t o m i c a l problems m a y have existed for a l o n g
time w i t h o u t symptoms, it m a y take only a very
small increase i n work, a v a r i a t i o n i n technique or
choreography or work o n a raked stage, etc. to
precipitate quite severe symptoms.
T h e section on treatment indicates the general
lines that treatment should take but the details o f
a p p l i c a t i o n o f the physiotherapy methods or
surgical methods have been assumed to be k n o w n
a n d understood by the physiotherapists or surgeons
concerned w i t h the patient. F o r those i n d o u b t
about treatment or for dancers w h o w o n d e r
whether the treatment that is costing a lot o f
money is relevant, reference can be made to
Sections 2.4 a n d 2.5. U n f o r t u n a t e l y dancers, like
other athletes, are desperate to get better a n d back
to performance or to continue performing w i t h o u t
h a v i n g to take time off. T h e y are therefore
THREE
p a r t i c u l a r l y vulnerable to the undesirable attentions
of the unscrupulous w h o offer the q u i c k cure
(usually ineffective, p a r t i c u l a r l y i n the longer term).
It is essential for those w h o depend for a l i v e l i h o o d
on r e t u r n i n g to a full level o f physical fitness a n d
who usually have very little money to spare for
treatment, that they o b t a i n the correct treatment,
that they attend for the fewest n u m b e r o f
treatments c o m p a t i b l e w i t h full recovery a n d that
they o b t a i n proper value for the m o n e y that they
have to expend. H o w e v e r , it is only proper to
emphasise i n this context that the q u i c k twist or
m a n i p u l a t i o n or the q u i c k injection, is frequently
far from being the most satisfactory m e t h o d o f
o b t a i n i n g permanent relief. It m a y seem a speedy
or cheap answer a n d m a y give short term relief but
it rarely produces a l o n g term cure. F a r more
c o m m o n l y it w i l l lead to recurrent injuries a n d
problems, each of w h i c h m a y be more severe than
the one before, so that finally the dancer ends up
w i t h an extended period off d a n c i n g , whereas a
correct diagnosis followed b y the correct treatment
methods a p p l i e d early w o u l d have prevented a l l the
subsequent misery.
T h e section on special complications tries i n each
case to give some i n d i c a t i o n o f the p r o b l e m that
can a c c o m p a n y a p a r t i c u l a r injury, either i n the
short or l o n g term. A n y factors affecting r e t u r n to
d a n c i n g are mentioned, together w i t h any
precautions w h i c h should be taken to prevent
recurrences. Reference to these little sub-sections
may a i d the practitioner treating the patient i n
a v o i d i n g the less obvious or more remote pitfalls.
3.1 Sprain of the Lateral
Ligament of the Ankle
T h i s is the commonest injury i n dancers a n d usually
affects the anterior fibres, k n o w n as the anterior
talo-fibular ligament. W h e n the patient is i n i t i a l l y
seen it is very i m p o r t a n t to exclude a fracture of
the lateral malleolus (lower end o f the fibula) by
X - r a y s ( F i g . 3.1). A fracture o f the 5th metatarsal
is a c o m m o n l y associated fracture ( F i g . 3.2). It is
 Section 3.1
also e q u a l l y i m p o r t a n t to exclude a complete tear
of the ligament. I n order to see whether the talus
tilts excessively i n the ankle j o i n t mortice ( F i g . 3.3)
it m a y be necessary to c a r r y out special X - r a y s
under general anaesthetic, w h e n the ankle c a n be
forced into inversion, i.e. the foot c a n be turned
inwards. E q u a l l y i m p o r t a n t a n d far more
c o m m o n l y missed is the situation where the d a m a g e
to the ligament affects those fibres w h i c h , b y their
tearing, a l l o w the talus to rotate forwards i n the
105
3.1 (left) Spiral fracture of the
lateral malleolus.
3.2 (right) A fracture (arrowed) of
the base of the 5th metatarsal.
3.3A (left) A n X - r a y showing
tilting of the talus in the mortice of
the ankle joint. This is a stress view
when the foot and ankle are forcibly
inverted and held in that position
while the X - r a y is being taken. Very
frequently this procedure requires an
anaesthetic as it is otherwise too
painful for the patient. The talus can
tilt because the ligaments restraining
this movement have been torn.
3.3B (right) This X - r a y shows the
same patient without passive
inversion. As can be seen, there is no
evidence of any instability on this
standard X-ray view. If there is
doubt about ligament damage then a
stress X - r a y must be carried out.
ankle mortice. O n n o r m a l inversion X - r a y s the
ankle w i l l appear stable. If, however, the hindfoot
is grasped firmly i n one h a n d a n d the leg i n the
other a n d forward t r a c t i o n o f the foot towards to
the toes takes place, then it c a n be seen that the
talus slides forwards i n the ankle mortice a n d at the
same time rotates slightly m e d i a l l y . I f this type o f
instability is missed it leads to c h r o n i c problems for
the dancer a n d the ankle remains p e r m a n e n t l y
unstable.
 106 Section 3: Specific Injuries: T h e i r Cause a n d T r e a t m e n t
CAUSES
T h e lateral ligament o f the ankle is always
d a m a g e d by acute trauma. It follows an inversion
injury. T h i s is often a rather more complex injury
where there is a n element of inversion, an element
of rotation, an element o f excessive plantar-flexion
or, very rarely, dorsi-flexion. I n most injuries the
actual direction o f displacement is not purely i n
one direction or another. It c o m m o n l y occurs when
a dancer falls off pointe, or i n boys d u r i n g g r a n d
allegro. I n boys it is usually the m i d d l e fibres
(calcaneo-fibular ligament) w h i c h are affected, i n
girls it is usually the anterior fibres (anterior
talo-fibular ligament). It seems that, almost as
c o m m o n l y , the injury comes about i n dancers i n a
m a n n e r w h i c h is totally unconnected w i t h d a n c i n g
- they m a y slip off a kerb, fall d o w n stairs or suffer
some other everyday mishap.
Predisposing or Contributory Causes
T h e r e are a whole variety o f factors w h i c h m a y
predispose to an injury o f the lateral ligament.
P r o b a b l y the most important is a previous strain
w h i c h has been inadequately rehabilitated. W e a k
feet (that is, the intrinsic muscles), weak ankle
control, especially the peroneal group o f muscles,
a n d weak c a l f muscles p r o d u c i n g a lack o f control
w h e n l a n d i n g from a j u m p are a l l c o m m o n
precursors o f this injury. L a c k o f control o f the
turn-out allows the knee to turn i n , the leg then
goes out o f alignment over the ankle so the weight
is no longer correctly placed over the foot, resulting
in a weight back situation (Section 5.20). A s a
result this makes the ankle unstable. Badly-fitting
shoes aggravate the problem. A n unstable pelvis,
p r o d u c i n g either a lordotic spine or t u c k i n g i n ,
c o m b i n e d as it usually is w i t h weak trunk muscles,
aggravates the instability at the lower end o f the
leg (Section 5.6). A similar effect is produced by
faulty head posture or faulty j u m p s . W o r k i n g w i t h
tension interferes w i t h control, not only i n this type
of injury but also i n most others. P o o r floor surfaces
are a frequent cause o f problems, p a r t i c u l a r l y i f
they lead to a b a d take-off w h i c h w i l l , o f course,
produce a bad l a n d i n g .
TREATMENT
I n i t i a l l y , the dancer should r e m a i n non-weight
bearing u n t i l fractures are excluded. T h e associated
fractures are those o f the lateral malleolus and the
base o f the 5th metatarsal. D u r i n g this i n i t i a l stage
ice packs should be applied a n d the leg elevated
a n d rested. W i t h very m i n o r strains, once diagnosed
a n d more serious injury excluded, the dancer m a y
continue limited work using a supporting bandage.
H o w e v e r , as i n a l l other injuries, it is essential that
an accurate diagnosis is made before the dancer is
allowed to continue. T h e l o n g term ill-effects o f a
mis-diagnosis cannot be over-emphasised.
Definitive treatment
Icing, elevation a n d rest should be continued. T h e
patient c a n be given ultrasound and/or
interferential therapy a n d should start non-weight
bearing exercises, p a r t i c u l a r l y local exercises w i t h
the leg i n elevation. T h e muscle contraction and
relaxation w i t h the leg elevated helps to get the
swelling d o w n more r a p i d l y . D u r i n g this time
elevation o f the foot o f the bed at night c a n be
very beneficial i n reducing swelling. T h i s applies to
all lower l i m b injuries. T h e exercises should be
carried out for a l l muscle groups a r o u n d the ankle
a n d should be done w i t h the foot pointed, i.e. i n
full plantar-flexion, a n d w i t h the foot at a
right-angle, i.e. i n neutral. These two different
positions are necessary i n order to i n c l u d e a l l the
peroneal muscles i n the exercise p r o g r a m m e . F r o m
the early stages o f treatment the c a l f muscles
should be kept well stretched as there is a tendency
for them to contract. (See Complications below.) A l s o
faradic foot baths a n d intrinsic muscle exercises
should be carried out as these muscles tend to waste
very r a p i d l y . D u r i n g this period the patient can
also spend a great deal o f time d o i n g general
exercises for the rest o f the lower l i m b s a n d trunk.
A s the c o n d i t i o n improves the patient passes
through p a r t i a l weight-bearing exercises a n d finally
to full weight-bearing exercises. U s e o f the
b a l a n c i n g board i n the later stages is very
important. Its use can, however, start w i t h the
patient sitting, w h e n these exercises w i l l be
non-weight bearing w i t h the foot o n the b a l a n c i n g
b o a r d . T h e y help to achieve m o b i l i t y a n d also to
give the patient the feel of a l l the ankle movements
(Fig. 3.4). I n p a r t i a l weight-bearing the b a l a n c i n g
b o a r d can be used at the barre ( F i g . 3.5), w i t h the
dancer facing the barre w i t h the hands supporting
the body. O n c e the patient is fully weight-bearing
then the b a l a n c i n g b o a r d c a n be used i n the n o r m a l
manner ( F i g . 3.6).
A t the time o f the actual injury there is always
damage to nerves a n d nerve endings w i t h i n the
ligaments a n d j o i n t capsule unless the injury is o n l y
trivial. These nerve endings are responsible for
proprioception (appreciation of j o i n t position) and
loss o f or interference w i t h this enhances or is
sometimes totally responsible for residual feelings o f
instability i n the ankle. T h e dancer w i l l feel
insecure on the ankle, suspecting that it w i l l give
way at any moment. H e w i l l lack confidence i n the
j o i n t when t r y i n g to dance or sometimes, i f badly
affected, even w h e n w a l k i n g . T h e b a l a n c i n g b o a r d
 Section 3.1
3.4 The use of the balancing board when sitting. The
correct placement of the foot can be taught while sitting,
in preparation for standing weight-bearing on the board.
is the most effective method i n treating this a n d i n
re-educating the local postural a n d j o i n t c o n t r o l
reflexes.
Complications
A n k l e sprains are p r o b a b l y the most inadequately
treated o f a l l dance a n d sports injuries. So often the
dancer is dismissed w i t h a bandage a n d told the
injury w i l l settle itself. Unless the injury is
107
3.5 The use of the balancing board at the barre. This is
an intermediate stage between sitting and standing freely,
when the dancer still requires a little help with balance.
3.6A (left) The use of the
balancing board standing without
support. The dancer has not yet
achieved the control of her
hyperextended knee and, as can be
seen in the photograph, is still
pushing a great deal of her weight
back on her heel.
3.6B (right) The position is
correctly held. The balancing board
is used to re-educate the postural
reflexes which rapidly become
ineffective following an injury or
even a prolonged break from work.
extremely t r i v i a l , this lack o f adequate treatment
w i l l lead to c h r o n i c ankle problems w i t h recurrent
swelling, persistent p a i n a n d a feeling o f i n s t a b i l i t y
of the ankle w i t h lack o f confidence. A d e q u a t e
vigorous treatment is essential i f this is to be
avoided.
I n almost a l l ankle injuries a n d certainly not i n
lateral ligament sprains o n l y , the A c h i l l e s tendon
(i.e. the c a l f muscles but always looked o n by the
108 Section 3: Specific Injuries: T h e i r C a u s e and T r e a t m e n t
dancers as the Achilles tendon alone) tightens
w i t h i n a few days o f the injury. T h i s tightening is
almost always asymmetrical w i t h i n the muscle so
that later, w h e n the dancer starts to perform a plié
or a fondu, the foot is p u l l e d into a b a d position
p r o d u c i n g r o l l i n g . T h e tightening can be tested for
by passively dorsi-flexing the foot w i t h the patella
i n line w i t h the centre o f the foot a n d pressure
equally placed beneath the metatarsals w i t h the flat
of the h a n d ( F i g . 3.7), taking care not to extend
the toes dorsally above neutral. D u r i n g this
3.7 Testing for tightness of the Achilles tendon
(actually the calf muscle/tendon complex). The foot must
be correctly aligned with the leg and not inverted or
everted. The flat of the hand is used to dorsi-flex the
whole foot while keeping the toes straight.
3.8 Working on a slope to stretch the Achilles
tendon/calf muscle complex. The feet must be kept
parallel.
manoeuvre the tendency o f the foot to go to one o r
other side c a n easily be detected. A l s o the tightness
in the calf can be felt by the free h a n d o f the
examiner. T h e tightness is treated b y interferential
therapy to the whole length o f the c a l f muscles
from the ankle to the origins o f the gastrocnemius
just above the back o f the knee. Passive stretching
is carried out by the physiotherapist. ( N . B . See the
comments on stretching i n Section 2.5, page 88).
L a t e r this stretching can be c o n t i n u e d by the
patient. I n the final stages o f r e h a b i l i t a t i o n a slope
can be used by the patient ( F i g . 3.8). A w a t c h must
he kept for a contracture o f the lateral ligament
due to scarring. T h i s w i l l require very gentle, a n d
certainly not forcible, stretching.
3.2 Rupture of the Lateral
Ligament of the Ankle
T h e causes are the same as for a sprain o f the
lateral ligament. It is essential that the diagnosis is
made i m m e d i a t e l y following the injury. I f missed,
the consequences to the dancer are extremely
serious. A complete rupture o f the ligament or
portion o f the ligament, most c o m m o n l y the
anterior talo-fibular portion, requires surgical
repair. I f i n doubt the injury c a n be confirmed or
excluded b y X - r a y s taken under a general
anaesthetic w h e n the foot a n d ankle can be forcibly
twisted to place the ligament under tension. T h e
X - r a y can show the degree o f instability. It is very
i m p o r t a n t not to miss the c o n d i t i o n o f anterior
instability. T h i s is caused b y rupture of the anterior
talo-fibular ligament and the anterior capsule of the
ankle j o i n t . Its presence c a n be demonstrated by
d r a w i n g the talus forward i n the ankle j o i n t
mortice. N o r m a l l y , the talus should not slide
anteriorly to any appreciable extent (compare w i t h
n o r m a l side). I f there is instability, the talus (and
whole foot below it) w i l l move forward a n d
p r o b a b l y also rotate slightly m e d i a l l y . T h e anterior
drawer test (as it is known) c a n be confirmed to be
positive i f a lateral X - r a y is taken at the same time,
i f necessary under an anaesthetic; the talus w i l l be
seen to slide forward i n relation to the lower end o f
the tibia.
I f there is any doubt about the presence or
otherwise o f a rupture o f the ligament then it is
p r o b a b l y wiser to explore the area rather t h a n w a i t
a n d see whether a n y t h i n g shows u p w i t h the -
passage o f time. A late repair o f a rupture leads to
poor results c o m p a r e d w i t h those following an
immediate repair. I f the injury is severe enough for
there to be doubt as to whether there is a rupture
or not, then the operation, w h i c h basically w i l l o n l y
 Section 3.2-3.6
be through the skin a n d subcutaneous tissues to
inspect the ligament, w i l l a d d little or n o t h i n g to
the period o f convalescence i f the ligament is i n
fact found to be intact.
R e h a b i l i t a t i o n , once the surgical treatment is
completed, is the same as for a sprain o f the lateral
ligament o f the ankle (Section 3.1).
3.3 Sprain of the Medial
Ligament of the Ankle
T h i s is u n c o m m o n i n dancers. It is, however, very
i m p o r t a n t to exclude a fracture o f the m e d i a l
malleolus or a complete rupture o f the ligament,
both o f w h i c h require immediate orthopaedic
treatment. L i g a m e n t rupture w i l l certainly require
surgery a n d a fracture of the m e d i a l malleolus, i f it
is more t h a n just a crack, w i l l p r o b a b l y require
screwing back into place.
CAUSES
C o m m o n l y the injury occurs due to a b a d l a n d i n g
w i t h the weight m a i n l y over the m e d i a l side o f the
foot a n d b i g toe. A s a result the foot rolls a n d
everts.
TREATMENT
T h i s is similar to a sprain o f the lateral ligament.
Special attention must be p a i d to strengthening the
invertors a n d evertors.
Complications
See Section 3.1. A d d i t i o n a l l y , tibialis posterior
tendonitis can ensue due to lack o f proper
strengthening o f the invertors. T h i s produces a
recurrent m i l d eversion strain by the r o l l i n g w h i c h
occurs. A l s o as a result of this rolling, the lateral
ligament c a n become crushed by the i m p i n g e m e n t
of the lateral malleolus a n d the talus.
3.4 Chronic Sprains of the
Lateral and Medial
Ligaments of the Ankle
CAUSES
These most c o m m o n l y follow an acute sprain. A
chronic sprain is the result o f inadequate
post-injury treatment, i.e. poor physiotherapy, the
failure o f the dancer to carry out instructions, or
returning to work too soon after the injury - a
danger w i t h the free-lance dancer. H o w e v e r , a
chronic sprain can also be produced g r a d u a l l y ,
without an acute phase, by faulty technique w h i c h
allows incorrect weight-bearing on the foot.
109
TREATMENT
T h i s is similar to that for the later stages o f an
acute sprain. H o w e v e r , there m a y be a great d e a l
of scarring o f the ligament a n d this m a y require a
lot o f extra attention from the physiotherapist.
V e r y m u c h more effort w i l l have to be put into the
exercises for the various muscle groups. I n this
instance the weakness a n d wasting m a y w e l l , a n d
usually w i l l , have spread to the muscles groups
higher up the leg a n d even i n the trunk. A s a result
of the c h r o n i c sprain, the dancer w i l l have been
w o r k i n g b a d l y . T h e technique before the onset o f
symptoms m a y have been faulty, thus a l l o w i n g a
c h r o n i c sprain to occur, but even i f not faulty
before then, definite faults i n technique w i l l have
set i n as a result o f the c h r o n i c sprain. T h i s means
that a great deal o f time w i l l have to be spent o n
correction.
3.5 Anterior Capsular Sprain of
the Ankle
T h i s injury m a y a c c o m p a n y either lateral or m e d i a l
ligament sprains because o f the hyperflexion
element o f the i n j u r i n g force (plantar-flexion). It is
very i m p o r t a n t to note that injuries are rarely pure
a n d localised a n d nearly always i n v o l v e adjacent
structures. T h e force a p p l i e d is e q u a l l y rarely
purely inversional, eversional, etc. T h e treatment
a n d complications o f anterior capsular s p r a i n are
similar to that i n lateral ligament a n d m e d i a l
ligament sprains. H o w e v e r , a n anterior capsular
sprain is a d d i t i o n a l l y c o m p l i c a t e d i f swayback
knees (hyperextended knees) (Section 5.13) are
present a n d also i f the weight is too far back w h e n
w o r k i n g (Section 5.20). B o t h these produce a n
excessive strain o n the front o f the ankle w h e n o n
pointe. T h i s 'weight back' situation c a n also a p p l y
d u r i n g plies due to the tension anteriorly.
3.6 Fracture of the Lateral
Malleolus
T h i s fracture is caused b y the same m e c h a n i s m as a
sprain o f the lateral ligament. U s u a l l y , there is a n
inversion a n d rotation force, hence the a c t u a l
fracture is most c o m m o n l y spiral or o b l i q u e ( F i g .
3.9). I n most circumstances there is little
displacement a n d complete r e d u c t i o n , even w h e n
displacement is severe, is usually easy a n d complete.
I f the t r a u m a has been severe this fracture m a y
also include a fracture o f this m e d i a l malleolus a n d
the posterior a r t i c u l a r m a r g i n o f the t i b i a , the
degree o f damage e q u a t i n g to the strength o f the
d a m a g i n g force.
110 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
TREATMENT
T h i s is standard orthopaedic care. U s u a l l y a plaster
o f Paris cast is a p p l i e d for 6 weeks (or longer i f a
severe i n j u r y ) . O c c a s i o n a l l y , i f the fracture is
m i n o r , simple elastoplast strapping can be used but
3.9 A spiral fracture of the lateral malleolus.
3.10 A typical transverse fracture of the medial
malleolus. There is also a fracture of the lateral malleolus
present.
this is usually m u c h less comfortable t h a n a plaster
cast. T h e strapping certainly does not i m p l y that
the dancer c a n continue w o r k . Sometimes a n
operation to fix the fracture i n t e r n a l l y w i t h screws
may be necessary.
D u r i n g the period i n plaster the dancer c a n , as i n
other injuries, continue to exercise a l l areas not
i m m o b i l i s e d i n the cast. N o t only w i l l this keep the
muscles strong but by p r o m o t i n g a good c i r c u l a t i o n
w i l l actually increase the rate o f h e a l i n g o f the
fracture w i t h i n the cast.
O n c e out o f plaster the muscle groups that have
been inactive c a n be started o n intensive exercises.
Exercise w i l l also be required to mobilise a l l the
joints w h i c h have been kept i m m o b i l e . U l t r a s o u n d ,
interferential therapy, ice for swelling a n d other
therapeutic aids c a n also help. F r o m here onwards
the treatment pattern is similar to that following a
sprained lateral ligament o f the ankle (Section
3.1).
3.7 Fracture of the Medial
Malleolus
T h i s is caused b y the opposite force to that causing
a lateral m a l l e o l a r fracture i f it has o c c u r r e d as an
isolated fracture. A s stated i n Section 3.6 it c a n
also be associated w i t h the severer degrees o f lateral
malleolar fracture. I n the former situation (isolated
fracture) it is usually oblique or spiral; i n the latter
situation, w h e n associated w i t h a lateral m a l l e o l a r
fracture, it is a transverse fracture as the m e d i a l
malleolus is pulled off by the strain o n the m e d i a l
ligament ( F i g . 3.10).
TREATMENT
T h i s is standard orthopaedic treatment. U s u a l l y ,
m e d i a l m a l l e o l a r fractures require i n t e r n a l fixation
w i t h a screw, though even so n o n - u n i o n remains
c o m m o n . H o w e v e r , this n o n - u n i o n takes place w i t h
the m e d i a l malleolus i n the correct a n a t o m i c a l
position a n d the sound fibrous u n i o n is usually
sufficient to give total stability a n d is mostly
painless. I n the u n u s u a l circumstances where it
remains painful a small bone graft m a y be
required.
F u r t h e r treatment - exercise regimes: treatment
once the fracture has united a n d the general
rehabilitation is as described above for a fracture o f
the lateral malleolus (Section 3.6) a n d the later
stages o f r e h a b i l i t i o n following lateral or m e d i a l
ligament damage (Sections 3.1 a n d 3.3).
 Section 3.7-3.8 111

3.11A A n osteochondral fracture (arrowed) of the dome

of the talus.

3.11B (below) A n X - r a y of a patient demonstrating an

osteochondral fracture (arrowed).

3.8 Osteochondral Fracture of

the Dome of the Talus
T h i s c o n d i t i o n , w h i c h is a s m a l l c h i p fracture
i n v o l v i n g a p o r t i o n o f the a r t i c u l a r cartilage a n d a
small piece o f u n d e r l y i n g bone, occurs w h e n the
fragment is k n o c k e d out o f the dome o f the talus
(where it forms part o f the ankle j o i n t ) b y a
compression force ( F i g . 3.11). T h u s it occurs at the
same time as a sprain o f a n ankle ligament or, more
rarely, a n ankle fracture. T h e osteochondral
fracture m a y be difficult to demonstrate on a n
X - r a y a n d as a result m a y not be found u n t i l very
m u c h later w h e n , as a result o f persistent ankle
symptoms, further X - r a y views are carried out a n d
possibly a n a r t h r o g r a m . ( T h i s is an injection o f a i r
a n d radio-opaque dye into the joint.)

TREATMENT

I f it is detected w h e n fresh a n d i f it has separated,

then the fragment should either be removed i f it is
s m a l l , or else i f it is larger, it should be p i n n e d back
into place. I f it has not separated, then simple
i m m o b i l i s a t i o n m a y allow the fragment to heal i n 3.11C A n X - r a y of a more extensive injury at the same
the correct position. U n f o r t u n a t e l y a n d o n l y too site showing an osteochondritis of the talus
frequently the fragment, b e i n g d e p r i v e d o f its supero-medially and also long-standing damage to the
medial malleolus. These types of changes within a joint
b l o o d supply, separates at a later date a n d forms a
can follow the injudicious injection of Hydrocortisone or
loose b o d y w i t h i n the j o i n t . T h e most i m p o r t a n t other steroids into the joint. In the long term these
aspect o f the c o n d i t i o n is to think o f the possibility changes result in severe osteo-arthritis of the joint.
i f symptoms are persisting for longer t h a n w o u l d be
expected for the o r i g i n a l injury.
 112 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
3.12A
Sickling when
on pointe.
3.9 Achilles Tendonitis
T h e A c h i l l e s tendon does not have a sheath, so
i n f l a m m a t o r y conditions i n this area affect either
the loose fibrous tissues s u r r o u n d i n g the tendon
causing a peritendonitis, or the tendon itself causing
a tendonitis, or both. I n the case o f a tendonitis this
may merely be a n i n f l a m m a t i o n o f the tendon or
there m a y be small micro-tears w i t h i n the substance
o f the tendon or even larger p a r t i a l tears.
CAUSES
Over-use due to extra w o r k following fatigue o f
muscle groups, or weakness o f the feet, the
gastrocnemius, the quadriceps, the hamstrings, or
the gluteals or most or a l l o f these. It is very m u c h
aggravated b y swayback (hyperextended) knees
(Section 5.13), or by w o r k i n g w i t h the weight too
far back (Section 5.20). A l l these factors w i l l cause
over-use o f the gastrocnemius w h i c h has to do
m u c h o f the w o r k w h i c h should be carried out or
aided b y other muscle groups. T h e soleus is
under-used i n this situation because it does not cross
b e h i n d the knee. T h e c o n d i t i o n tends to be
precipitated by a lack o f w o r k o n three-quarter
pointe i n class. A muscle has to be w o r k e d
throughout its full range i n order to g a i n adequate
strength. I f sufficient w o r k is not undertaken o n
three-quarter pointe i n class, it means that the
muscle w i l l not be fully strong so w h e n the foot has
to actually w o r k i n a n d through three-quarter
pointe, A c h i l l e s tendonitis w i l l frequently result.
3.12B Sickling when in the air (fishing).
Three-quarter pointe is necessarily used o n a l l
j u m p s a n d l a n d i n g a n d o n going t h r o u g h the foot
to rise o n to pointe. I f this is the o n l y time that
three-quarter pointe is i n use, then the muscle w i l l
not g a i n sufficient strength to cope adequately.
Achilles tendonitis m a y also be caused b y
tight-fitting shoes a n d ribbons w h i c h cut i n ; b y
shoes w h i c h are too small, causing a c u r l i n g o f the
toes a n d pushing the weight back (Section 5.20);
or shoes that are too wide a n d give no support to
the forefoot, thus d i m i n i s h i n g strength from the
foot d u r i n g j u m p s . R o l l i n g w i t h a n unstable foot
leads to the calf muscle not being w o r k e d correctly.
P o i n t i n g w i t h a sickled foot produces o v e r - w o r k i n g
of the inner (medial) side o f the c a l f muscle a n d
also o f the m e d i a l hamstrings. W o r k i n g w i t h a
sickled foot also tends to produce stretching o f the
m e d i a l side o f the front of the ankle ( F i g . 3.12) a n d
n i p p i n g o f the insertion o f the A c h i l l e s tendon.
A n y t h i n g w h i c h produces a tight pointe, such as a n
os t r i g o n u m or enlarged posterior tubercle o f the
talus, can precipitate an Achilles tendonitis. Also,
failing to get the heel d o w n p r o p e r l y w h e n w o r k i n g
a n d as a result not stretching the c a l f p r o p e r l y m a y
be the cause. W o r k i n g o n a raked stage c a n
aggravate the effects o f all these causes.
TREATMENT
Use ice, ultrasound, interferential (to above the
knee to include the origins o f the gastrocnemius;
use o f interferential over this distance w i l l also
produce a concentration at the m u s c u l o t e n d i n o u s
j u n c t i o n w h i c h is frequently thickened). W h e n the
inflammatory aspects have settled, progressive
strengthening followed by stretching must be
carried out. A t t e n t i o n obviously has to be p a i d to
all possible causes o f the c o n d i t i o n w i t h their
e l i m i n a t i o n a n d correction (for example,
 Section 3.9-3.11
strengthening other weak muscle groups). I f
treatment is prolonged or appears to fail, there w i l l
always be found a hitherto undetected cause, w h i c h
is most c o m m o n l y a technical fault. V e r y rarely, i f
there is a long persisting well localised area o f
tenderness a n d t h i c k e n i n g , a n injection o f
H y d r o c o r t i s o n e Acetate m a y be given once into the
peritendinous tissues - never i n t o the tendon itself.
R e p e a t e d injections or a n injection into the tendon
m a y predispose to a total rupture o f the tendon.
Complications
T h e tendon a n d c a l f must be stretched evenly
(medial versus lateral a n d right versus left)
otherwise as soon as w o r k is started again, a pelvic
tilt w i l l be i n d u c e d w h i c h destroys the whole
balance of the dance technique.
3.10 Rupture of the Achilles
Tendon
A l t h o u g h micro-ruptures or small p a r t i a l ruptures
may occur i n A c h i l l e s tendonitis, we are d e a l i n g
here w i t h complete ruptures. Beware o f missing a
complete rupture a n d o f l a b e l l i n g the c o n d i t i o n as
a p a r t i a l rupture.
CAUSES
T h i s w i l l most c o m m o n l y occur w h e n the tendon is
subjected to sudden unaccustomed stress. T h i s m a y
h a p p e n i n the teacher w h o is out o f t r a i n i n g
a t t e m p t i n g to demonstrate a j u m p , p a r t i c u l a r l y i f
not w a r m e d up. I n the dancer w h o is i n a
physically trained situation it is most c o m m o n l y
associated w i t h an inadequate w a r m - u p or by a n
unprecedented n u m b e r o f repetitions w h i c h c a l l for
explosive calf-muscle action.
DIAGNOSIS
I n i t i a l l y a gap c a n be felt i n the tendon but, soon
after the injury, local swelling m a y mask this a n d
m a k e diagnosis more difficult. P a i n , swelling a n d a n
i n a b i l i t y to stand unsupported o n demi-pointe o n
the affected foot is a n urgent i n d i c a t i o n for a n
orthopaedic surgical o p i n i o n .
TREATMENT
T h i s is b y early ( w i t h i n twenty-four hours) repair
of the rupture. I m m o b i l i s a t i o n i n a simple plaster
of Paris cast has been shown to give less good
results, t h o u g h a large partial rupture, if the diagnosis
is certain, m a y be treated successfully i n plaster o f
Paris w i t h o u t surgery. I f i n d o u b t about whether
the r u p t u r e is complete o r p a r t i a l it is better to look
and see. E v e n w i t h a good surgical repair this
113
injury frequently spells the end o f an active
performing career. After the surgery the
r e h a b i l i t a t i o n starts early w i t h exercises for a l l other
muscle groups. W h e n the post-operative plaster is
removed (usually at six weeks), a n intensive
p r o g r a m m e o f muscle strengthening w i l l be
required followed later b y technical help. It m a y
well be up to six months before full w o r k c a n be
resumed, a l t h o u g h some early class w o r k c a n be
used as part o f a carefully devised r e h a b i l i t a t i o n
programme.
It is possible to manage the post-operative p e r i o d
w i t h o u t a plaster o f Paris cast i f the r e p a i r is
carried out using b r a i d e d stainless steel w i r e . T h e
technique at this site is difficult as too tight a r e p a i r
w i l l cause shortening o f the A c h i l l e s tendon; i f the
frayed tendon ends are not b r o u g h t together
sufficiently the tendon w i l l be too long. A l o n g
tendon w i l l result i n poor elevation w h e n j u m p i n g
as well as other difficulties; a short one w i l l l i m i t the
plié.
3.11 Achilles Tendon Bursitis
T h e A c h i l l e s tendon bursa lies between the t e n d o n
just above its insertion a n d the bone o f the
c a l c a n e u m ( F i g . 3.13). It c a n become the site o f
i n f l a m m a t i o n w i t h t h i c k e n i n g a n d swelling i f it is
irritated.
CAUSES
It m a y be associated w i t h a n A c h i l l e s tendonitis,
especially w i t h the over-use aspects o f that
c o n d i t i o n . It m a y o c c u r alone i n a n over-use
situation or from pressure over a p r o m i n e n c e o f the
posterior part o f the os calcis (calcaneus altus).
TIBIA
ACHILLES
TEN D O N - FO R E F O O T
ACHILLES
TEN D O N '
BURSA —
OS CALCIS
3.13 Diagram showing site of the Achilles tendon bursa,
which provides a cushion between the tendon and the
heel bone (os calcis).
114 Section 3: Specific Injuries: T h e i r C a u s e and T r e a t m e n t

TREATMENT

Use pulsed m i c r o w a v e p a r t i c u l a r l y . Ice,

interferential and ultrasound may prove helpful.
E l i m i n a t i o n o f the cause is required. O n l y very
rarely should a Hydrocortisone injection be
contemplated as the c o n d i t i o n w i l l most c o m m o n l y
settle w i t h o u t it. A B

Complications
N o t h i n g special.

3.12 Os Trigonum and Large

Posterior Tubercle of Talus
C D
I n most, i f not a l l , cases an os t r i g o n u m represents
a stress fracture o f a large posterior tubercle o f the 3.14 A . Normal ankle.
talus ( F i g . 3.14). T h e onset o f the stress fracture B. Large posterior tubercle of the talus.
m a y be the reason for the onset o f symptoms. I n C. Os trigonum.
m a n y instances surgery m a y not be required.
D. Exostosis on the dorsum of the os calcis.
H o w e v e r , once symptoms have started they
frequently do not settle satisfactorily w i t h
O n l y i f conservative treatment fails should
conservative treatment. Nevertheless conservative
surgery be considered. I n this case r e m o v a l o f the
treatment should be undertaken conscientiously.
os t r i g o n u m or enlarged posterior tubercle o f the
S y m p t o m s m a y also be precipitated by weakness
talus w i l l be required. T h e a p p r o a c h surgically
developing i n a previously symptomless foot or calf
should be through the m e d i a l side o f the ankle. A
due to a n illness or stress, e.g. an absence w i t h
lateral a p p r o a c h interferes w i t h the peroneal
influenza i f inadequate convalescence is taken.
tendons a n d their sheaths, greatly p r o l o n g i n g the
S y m p t o m s m a y also be brought about by any
convalescence. I m m e d i a t e l y post-operatively
situation w h i c h causes the dancer to w o r k w i t h the
exercises must be started to both passively a n d
weight back (Section 5.20). T h e symptoms m a y
actively encourage plantar-flexion or p o i n t i n g as
start w h e n the dancer returns, proceeding suddenly
this was the movement w h i c h was l i m i t e d before
from i m m o b i l i t y to full work, a n d this m a y occur
the operation. A few days after the o p e r a t i o n gentle
p a r t i c u l a r l y i n a c o m m e r c i a l dance situation. T h e
non-weight bearing dorsi-flexion should be
actual weakness m a y be far removed from the
commenced actively or assisted actively but not
ankle region, e.g. weak gluteals causing sitting i n
using any passive forcing. W h e n the foot a n d ankle
the h i p a n d the weight being too far back. A
can be dorsi-flexed to neutral then g r a d u a l weight
differently fitting shoe may also start symptoms. I n
bearing can be commenced. O n c e the w o u n d is
a student the symptoms may come g r a d u a l l y due to
healed m u c h more active weight-bearing a n d
the slowly i m p r o v i n g pointe.
dorsi-flexion should be encouraged i n c l u d i n g some
V e r y occasionally similar impingement symptoms pliés, w i t h the dancer supporting himself o n the
m a y be associated w i t h an exostosis on the d o r s u m barre. F a r a d i c foot baths a n d intrinsic exercises c a n
of the os calcis just behind the talo-calcaneal j o i n t . be started even before r e m o v a l o f the sutures. A s
TREATMENT
progress continues, ankle strengthening exercises,
the b a l a n c i n g b o a r d a n d slope w a l k i n g c a n be
O n c e symptoms have started, they m a y be started. T h e more distant groups o f muscles must
impossible to relieve without surgery, but despite
not be neglected.
this every attempt should be made to alleviate the
situation before surgery is undertaken, as often Complications
success c a n be obtained. T h e treatment is directed F o r six months or more post-operatively there w i l l
at strengthening the foot w i t h faradic foot baths be a tendency for the scarring b e h i n d the ankle to
a n d intrinsic muscle exercises, strengthening the contract. A very careful w a t c h must be kept for
quadriceps, adductors and gluteals to eliminate any this a n d gentle stretching must be c o n t i n u e d for a
o v e r w o r k i n g by the calf muscles a n d technical help long time. E a r l y contractures w i l l be shown b y a
to correct any faulty weight transmission. decreasing depth o f d e m i - p l i é s .
 Section 3.12-3.14 115

Inadequate post-operative physiotherapy a n d / o r

inadequate technical correction c a n completely
destroy a n y early i m p r o v e m e n t i n pointe following
the operation as well as a l l o w i n g a g r a d u a l decrease
i n depth o f plié. T h e l o n g term follow-up is too
frequently neglected.

3.13 Tibialis Posterior

Tendonitis and
Tenosynovitis
CAUSES

T h i s is caused b y incorrect weight-bearing (Section 3.15 A n oblique line of the lesser metatarsal heads.
5.17). It is p a r t i c u l a r l y aggravated b y correcting
T h e r e is one c o n d i t i o n w h i c h is exclusive to the
r o l l i n g at the ankle instead o f c a r r y i n g out the
flexor hallucis longus a n d its tendon a n d this occurs
correction higher u p the leg. C o r r e c t i n g at the
at the musculo-tendinous j u n c t i o n . I n this
ankle produces tension aggravated b y weak intrinsic
p a r t i c u l a r muscle the fleshy fibres extend distally as
muscles, especially w h e n associated w i t h a n o b l i q u e
far as the level o f the back o f the ankle j o i n t . T h e
line o f the metatarsal heads ( F i g . 3.15), or d u r i n g
tendon sheath, w h i c h extends past the ankle a n d
pointe w o r k w i t h o l d shoes or badly-fitting shoes, or
through the foot a n d contains the a c t u a l tendon,
failure to h o l d the turn-out correctly, or a
commences just distally to the line o f the ankle
c o m b i n a t i o n o f these factors. T h e c o n d i t i o n is made
j o i n t . A s a result o f this a n a t o m i c a l arrangement,
worse b y w o r k i n g o n a raked stage a n d o n slippery
the situation sometimes arises where full
floor surfaces.
dorsi-flexion o f the great toe at the
TREATMENT metatarso-phalangeal a n d inter-phalangeal joints
pulls not only the tendon b u t also some o f the
U l t r a s o u n d , interferential a n d ice are required.
fleshy part o f the muscle, where it is j o i n i n g the
F a r a d i c foot baths a n d intrinsic muscle exercises are
tendon, into the tube o f the tendon sheath. I f this
always necessary. G e n e r a l strengthening o f a l l
happens recurrently it c a n lead to local swelling at
groups a r o u n d the ankle a n d o f the groups higher
the musculo-tendinous j u n c t i o n where it is being
u p the leg should be carried out. A considerable
pulled i n a n d out o f the tendon sheath. S y m p t o m s
a m o u n t o f technical correction is necessary a n d the
of p a i n m a y be persistent at this site i n w h i c h case
shoes must be checked.
surgery to split open the p r o x i m a l p o r t i o n o f the
Complications tendon sheath w i l l relieve the symptoms.
T h e c o n d i t i o n c a n be very slow to settle a n d it is
difficult to treat satisfactorily. It w i l l tend to niggle CAUSES

on for a l o n g time a n d a great deal o f supportive T h i s c o n d i t i o n is caused b y incorrect weight

treatment is required. T h e j u m p i n g section o f class bearing o n the foot (Section 5.17). It m a y also
work must be carefully regulated d u r i n g arise from a direct b l o w , a not infrequent cause, o r
rehabilitation. by a c u t t i n g pressure from badly-fitting shoes.
Weakness o f the first interosseus muscle m a y
aggravate o r cause the c o n d i t i o n .
3.14 Flexor Hallucis Longus
Tendonitis and TREATMENT

Tenosynovitis
T h i s c o n d i t i o n is a n i n f l a m m a t i o n w h i c h c a n affect
either the tendon or its s u r r o u n d i n g sheath or, most
c o m m o n l y , both elements. Problems c a n occur
anywhere a l o n g its length from the p r o x i m a l e n d
where the muscle fibres pass into the tendon to its
insertion into the base o f the distal p h a l a n x o f the
great toe.
T h i s is b y ultrasound a n d interferential, w h i c h
must include the muscle belly, together w i t h faradic
foot baths a n d intrinsic muscle exercises. T h e
intrinsics i n the former circumstances are usually
very weak a n d cannot extend the i n t e r p h a l a n g e a l
j o i n t o f the great toe fully. A t the same time the
first space (between the 1st a n d 2 n d metatarsals)
opens out due to the weakness o f the first
interosseous. Strengthening o f the intrinsics helps to
 116 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
A B
3.16 Six successive steps in strapping a great toe to help keep the interphalangeal joint straight.
close this space a n d allows the interphalangeal j o i n t
of the great toe to extend, p e r m i t t i n g the weight to
be brought to the correct position from h a v i n g been
too far back (Section 5.20). W h i l e the
strengthening process is going on, special strapping
c a n be a p p l i é d to help keep the interphalangeal
j o i n t o f the great toe straight ( F i g . 3.16).
Complications
T h e c o n d i t i o n is usually very slow to settle a n d
treatment a n d technical correction m a y be required
for a prolonged period.
3.15 Extensor Hallucis Longus
Tendonitis
T h i s m a y occur at a n y level o f the tendon.
CAUSES
D i r e c t blows are not u n c o m m o n . R o l l i n g is a very
potent cause as is also weight back w i t h the toes
c l a w e d (Section 5.20). I n this situation the
extensor hallucis longus tendon tends to become
shortened. Weakness o f the intrinsics prevents
proper extension o f the great toe w h e n w o r k i n g .
E v e n w h e n the toe is not being clawed, the weight
being too far back m a y also cause the toes to
repeatedly lift off the g r o u n d a n d hence tend to
shorten the extensor hallucis longus. A h i g h
l o n g i t u d i n a l a r c h where the plantar surface never
touches the floor, tends to lift the great toe off the
floor. C u t t i n g from the block or v a m p o f the shoe
m a y cause a tendonitis distally. C o m i n g u p o n to
pointe a n d w o r k i n g there w i t h bent toes
(knuckling) c a n cause the situation, p a r t i c u l a r l y i f
it is associated w i t h sickling.
C
TREATMENT
Ice, ultrasound, a n d interferential, faradic foot
baths, intrinsic muscle exercises to strengthen the
intrinsics, strapping the great toe i n order to keep
the interphalangeal j o i n t straight ( F i g . 3.16) a n d
correction o f the u n d e r l y i n g cause are a l l required.
Complications
T h e c o n d i t i o n c a n be difficult to get settled.
Inspection o f everyday shoes should be undertaken
as unsuitable d a i l y footwear c a n delay or prevent
resolution. I f it followed a direct b l o w , there m a y
be other damaged tissues to treat. A d e v e l o p i n g
stress fracture o f the 2 n d metatarsal m a y confuse
matters b y a p p e a r i n g to cause p a i n a l o n g the
extensor hallucis longus tendon.
3.16 Stress Fractures of the
Metatarsals
See also Section 2.2, page 70.
T h e affected metatarsals are c o m m o n l y the 2 n d
and 3rd. O c c a s i o n a l l y the 4 t h or 5 t h metatarsals
may be the site o f the stress fracture. I n dancers it
is very rarely the 1st metatarsal unless the
technique is very poor or the choreographic
circumstances are very unusual. F r a c t u r e i n the 2 n d
or 3 r d metatarsal is usually m i d shaft ( F i g . 3.17),
but a basal stress fracture i n the 2 n d metatarsal is
not u n c o m m o n . B e i n g a superficial bone, diagnosis
is straightforward w i t h local w a r m t h , tenderness
and swelling being easily detected.
CAUSES
Discrepancy o f metatarsal length, for example,
where there is a l o n g 2 n d metatarsal or short 1st
 Section 3.15-3.16 117

D E' F

3.17 (left) X-ray of a stress fracture

of the 2nd metatarsal shaft showing
healing with plentiful callus (new
bone).

3.18 (right) Short 1st metatarsal i n

relation to the 2nd metatarsal. In
this instance the 2nd and 3rd
metatarsals are of equal length.

metatarsal ( F i g . 3.18) or occasionally a l o n g 3 r d classes a l l day. B a d l y - f i t t i n g shoes o r w o r n - o u t shoes

metatarsal. L o n g toes a n d weak forefeet predispose
to a basal fracture o f the 2 n d metatarsal. A
predisposition a n a t o m i c a l l y is greatly aggravated by
weak intrinsic muscles. D a n c i n g o n concrete o r solid
w o o d floors a n d other surfaces w i t h o u t a n y
elasticity or spring m a y fairly r a p i d l y produce a
c r o p o f stress fractures i n a class or c o m p a n y . A
sudden increase i n heavy w o r k l o a d , especially i f a
lot o f pointe w o r k o r j u m p s are required, m a y
produce a stress fracture. T h i s is often seen where
there is a sudden move from corps de ballet to
p r i n c i p a l o r possibly, more c o m m o n l y , the
transition from part-time student w i t h three or four
classes a week to that o f full-time student w i t h
w i t h soft blocks c a n also be a predisposing factor.
F r e q u e n t l y w h e n the discomfort starts, the dancer
w i l l move to wider-fitting shoes, assuming that the
shoe itself is causing the p a i n . T h i s means that the
forefoot w i l l have even less support a n d the
situation w i l l be aggravated.
W e a k intrinsic muscles l e a d i n g to d r o p p i n g o f the
lesser metatarsal heads c a n cause a stress fracture
because o f the a d d i t i o n a l l o a d placed o n the
metatarsal. T h e presence o f even a moderate degree
of h a l l u x rigidus (degenerative arthritis o f the great
toe j o i n t , see Section 3.22) w i l l cause incorrect
weight placement (Section 5.20), because the
dancer cannot rise correctly t h r o u g h the foot as a
118 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t

result o f the l i m i t e d movements i n the 1st

metatarso-phalangeal j o i n t . T h e 5th metatarsal is a
special case, a n d a stress fracture often starts here
as a c o m p l i c a t i o n o f a severe sprain o f the lateral
ligament because the secondary weakness o f ankle
control, p a r t i c u l a r l y laterally, i.e. from the peronei,
places extra weight transmission through the 5th
metatarsal. T h i s tends to be brought about by a too
early return to d a n c i n g following a lateral ligament
sprain. T h e r e are also technical causes o f w h i c h
incorrect weight transmission is the commonest -
r o l l i n g , sickling, over t u r n i n g or failing to h o l d the
turn-out, w o r k i n g w i t h clawed toes and w o r k i n g
w i t h the weight too far back, w h i c h aggravates
weak intrinsics (incorrect weight placement;
Section 5.20).

TREATMENT

Rest is required to allow the fracture to unite.

D u r i n g this period, give exercises to strengthen a l l
deficient groups a n d p a r t i c u l a r l y faradic foot baths
a n d intrinsic muscle exercises. Correct the cause
where possible (anatomical aberrations m a y not be
correctable but a strong forefoot w i l l lessen the
stress on the bone).
Complications
T h e most c o m m o n l y seen c o m p l i c a t i o n is an
interference w i t h healing due to an ill-advised
injection o f H y d r o c o r t i s o n e by someone w h o has
failed to make the i n i t i a l diagnosis and thinks that
he is merely d e a l i n g w i t h a soft tissue lesion. O r a l
anti-inflammatories i n full dose w i l l also very
m a r k e d l y slow h e a l i n g by their suppression o f the
3.19 Osteochondritis of the 2nd metatarsal head (X-ray).
metatarsal a n d the a r t i c u l a r surface begins to
collapse. It is seen not only i n dancers but also i n
sprinters a n d other athletic c h i l d r e n . T h e diagnosis
can be made clinically because of localised
thickening a n d tenderness at the metatarso-
phalangeal j o i n t . T h e diagnosis is confirmed by
X - r a y , w h i c h shows an alteration i n structure o f the
metatarsal head a n d early or even late collapse o f
the articular surface ( F i g . 3.19).
TREATMENT

i n f l a m m a t o r y response w h i c h is a v i t a l part o f the I f the c o n d i t i o n is seen early when collapse o f the

h e a l i n g process (see Section 2.1). It is extremely
i m p o r t a n t to note that X - r a y evidence o f a stress
fracture w i l l not appear for at least ten to fourteen
days after the onset o f symptoms. A l t h o u g h a bone
scan w o u l d show a developing stress fracture, it
should be perfectly possible to make the diagnosis
w i t h a fair degree o f certainty on clinical grounds.
T h e metatarsal bones are extremely superficial a n d
the presence o f local w a r m t h , swelling a n d
tenderness w h i c h is very well localised to the bone
should cause little difficulty i n enabling the
examiner to come to the correct diagnosis.
3.17 Osteochondritis of the Head
of the 2nd or 3rd
Metatarsal
T h i s is a c o n d i t i o n w h i c h occurs i n c h i l d h o o d . It is
p r o b a b l y caused by t r a u m a to the metatarsal head.
A s a result o f this, changes occur i n the head o f the
articular surface is still o n l y m i n o r , then surgery
should be undertaken. T h e neck o f the metatarsal
can be opened a n d the articular surface elevated to
its proper position a n d the head packed w i t h bone
chips, w h i c h can be obtained from the metatarsal
shaft. T h i s is followed by protected weight b e a r i n g
u n t i l consolidation takes place. R e h a b i l i t a t i o n w i l l
necessitate faradic foot baths a n d intrinsic muscle
exercises to strengthen the forefoot w h i c h w i l l have
weakened d u r i n g the period o f convalescence.
H o w e v e r , d u r i n g convalescence the dancer must
spend a considerable a m o u n t o f time exercising a l l
other groups.
Unfortunately, cases usually present very late.
W h e n the patient is first seen w i t h p a i n it m a y be
found that not only is there m a r k e d t h i c k e n i n g a n d
tenderness a r o u n d the metatarsal head a n d
metatarso-phalangeal j o i n t but that there is m a r k e d
restriction o f movement i n the affected j o i n t ,
particularly shown by a greatly decreased range o f
dorsi-flexion. T h i s w i l l be causing problems o n
 Section 3.17-3.19 119

demi-pointe w o r k . A t this stage X - r a y s w i l l show

that the a r t i c u l a r surface has been completely
flattened a n d the metatarsal head broadened,
sometimes w i t h some osteophytic formation.
T r e a t m e n t is a g a i n surgical but it is impossible to
restore the n o r m a l anatomy. Instead, the p r o x i m a l
h a l f o f the p r o x i m a l p h a l a n x o f the toe is excised i n
order to produce a pseudarthrosis a n d restore the
range o f dorsi-flexion o f the toe. A t the same time
it m a y be necessary to t r i m any large osteophytes
from the metatarsal head as occasionally they are
sufficiently p r o m i n e n t to cause local pressure. If,
however, there is no evidence that they are g o i n g to
cause a n y l o c a l pressure, then they should be left
alone. T r e a t m e n t i n the form o f faradic foot baths,
intrinsic muscle exercises, together w i t h active a n d
passive exercises for the toes, c a n start as soon as
the w o u n d is healed. T h e results are usually very
satisfactory. T h e shortening o f the affected toe does
not h a m p e r the dance performance i n any w a y .

3.20A (above)
3.18 Plantar Fascial Strain Rolling with a twist
of the great toe.
T h e p l a n t a r fascia lies i n the sole o f the foot,
From the front.
covered o n l y b y fat a n d skin. It is a very strong
inelastic b a n d o f tissue w h i c h is attached to the heel
bone at the back a n d runs forward to d i v i d e i n t o 3 20B (left) From
little slips w h i c h end u p i n the various tendon the side.
sheaths associated w i t h the toes.
CAUSES

T h i s c o n d i t i o n c a n arise w i t h weak feet,

p a r t i c u l a r l y w h e n associated w i t h a h i g h
l o n g i t u d i n a l arch. It is aggravated b y w e a r i n g shoes
that are too short. It occasionally arises w h e n a
female dancer wears unaccustomed very h i g h heels
a n d then stands i n these shoes for a very l o n g
period.
TREATMENT

I n the i n i t i a l stages, ice a n d faradic foot baths a n d

exercises are most effective. I f the c o n d i t i o n is
c h r o n i c w i t h thickening, then pulsed m i c r o w a v e ,
interferential a n d ultrasound c o m b i n e d w i t h
faradic foot baths a n d intrinisic muscle exercises
w i l l be required a n d the c o n d i t i o n w i l l take
somewhat longer to settle d o w n than i f it is more
acute a n d o f brief d u r a t i o n .
3.19 Capsular Strains of 1st
Metatarso-phalangeal Joint
CAUSES
D i r e c t violence, e.g. stubbing the toe, or l a n d i n g
b a d l y . T h e c o n d i t i o n tends to be c o m m o n e r i n
boys. A n o t h e r p r i m e cause o f symptoms is repeated
technical faults, p a r t i c u l a r l y it they give a twist to
the toe, for example r o l l i n g ( F i g . 3.20) a n d a l l its
causes (see Section 5.17) a n d , o f course, sickling.
T h e c o n d i t i o n tends to be very m u c h worse i f there
is a short 1st metatarsal, or conversely, a l o n g 2 n d
metatarsal w h i c h produces a s i m i l a r o v e r a l l
m e c h a n i c a l effect. Shoes that are too short cause
the great toe to c l a w up. T h e presence o f a h a l l u x
valgus w i l l cause j o i n t strain because, i n rises, as the
weight comes over the toes, there is a further valgus
strain placed o n the great toe a n d o n the m e d i a l
aspect of the j o i n t . I n the presence o f a weak first
interosseous muscle w i t h a p a l p a b l e gap between
 120 Section 3: Specific Injuries: T h e i r C a u s e and T r e a t m e n t
3.21A (left) The sesamoid bones
lying beneath the 1st metatarsal
head. The X-ray is taken from above
looking through the foot.
the 1st a n d 2 n d metatarsal heads, even i n a case
where there is not a congenital metatarsus primus
varus, the situation w o u l d be greatly aggravated, as
w o u l d also be the case where there is general
weakness o f the intrinsics.
In both situations, most of the weight is going
through the great toe j o i n t rather than correctly
d o w n t h r o u g h the centre o f the foot. Shoes that are
too wide give no support at a l l . T h e r e is certainly a
general i n c l i n a t i o n , w h e n there is any sort o f toe
discomfort, for the dancer to go into a w i d e r fitting
a n d this, o f course, makes matters worse. W o r n - o u t
pointe shoes w i l l also stress the great toe j o i n t
greatly. A painful toe, for example an i n g r o w i n g
toenail, painful corns or verrucae w i l l a l l cause a
weight shift. I n m a n y instances the strain m a y be
isolated to the m e d i a l ligament a n d capsule o f the
metatarso-phalangeal j o i n t . W h e n symptoms at this
j o i n t are troublesome there w i l l often be restriction
of movements a n d the clinical appearance o f a
h a l l u x rigidus. H o w e v e r , m o b i l i t y w i l l return when
the capsular strain has been treated adequately.
TREATMENT
Ice, ultrasound i n water, interferential, faradic foot
baths a n d intrinsic muscle exercises are a l l helpful.
S t r a p p i n g o f the great toe to help to m a i n t a i n
alignment can help while treatment is i n progress.
T h e dancer can also carry out hot and cold contrast
baths himself because frequently this c o n d i t i o n
tends to be rather more resistant to treatment i f
c i r c u l a t i o n is not p a r t i c u l a r l y good i n the toes a n d
feet. T h e shoes should be checked carefully,
3.2IB (below) Here the X-ray is
taken looking along the sole of the
foot.
i n c l u d i n g outdoor shoes. F r e q u e n t l y traction on the
great toe, to ensure the correct alignment a n d to
gently stretch any tightness, a c c o m p a n i e d b y
passive movements, can be very beneficial.
Complications
P o o r c i r c u l a t i o n makes the c o n d i t i o n slower to settle
a n d m u c h more difficult to treat. U s u a l l y there is a
technical fault associated w i t h this c o n d i t i o n a n d
this w i l l lead to other injuries i f the technical
aspects are not very carefully checked. A n y
u n d e r l y i n g tendency to h a l l u x rigidus w i l l be
greatly aggravated. T h e c o n d i t i o n m a y also cause a
sesamoiditis i f it persists or is not fully treated, or i f
it is o f l o n g standing. It is often not at all easy to
o b t a i n full resolution o f the c o n d i t i o n because it so
frequently follows b a d w o r k i n g habits w h i c h can be
very difficult to eradicate adequately. A n example
of this is w o r k i n g w i t h the weight back (Section
5.20).
3.20 Sesamoiditis
Beneath the head o f the 1st metatarsal lie two s m a l l
bones w i t h i n the tendons to the great toe ( F i g .
3.21). T h e y are k n o w n as the m e d i a l a n d lateral
sesamoids. T h e y are exactly like a small version o f
the patella or knee cap, w h i c h is a sesamoid bone
l y i n g w i t h i n the tendon formed from the
quadriceps muscle o n its w a y d o w n to be inserted
into the tibia. T h e patella is so large that it has a
name of its o w n , whereas the two sesamoids under
the 1st metatarsal head are small, each b e i n g the
 Section 3.20-3.21 121

3.22A (left) A metatarsus primus

varus with a mild secondary hallux
valgus developing.

3.22B (right) A n X-ray of the same

foot.

size o f a small bean. I n n o r m a l w a l k i n g a n d For local treatment ice, ultrasound, pulsed

r u n n i n g they take the l o a d a n d pressure beneath
the metatarsal head a n d help to distribute it a n d
also protect the tendons w h i c h w o u l d otherwise be
subjected to direct crushing pressure on each pace.
T h e y are surprisingly free o f trouble considering
the great forces transmitted through them a n d their
vulnerable position.
O c c a s i o n a l l y one or both can become inflamed
and painful so that weight bearing is extremely
uncomfortable, this c o n d i t i o n being k n o w n as
sesamoiditis. V e r y rarely a sesamoid can be
fractured as a result o f direct violence. A fracture
must be differentiated from a bipartite or tripartite
sesamoid, w h i c h is a congenital c o n d i t i o n w h e n a
sesamoid is i n two or three separate parts from
b i r t h . A similar c o n d i t i o n can occur i n the patella.
Sesamoiditis presents w i t h local p a i n a n d sometimes
swelling. Tenderness is localised to beneath the
head o f the 1st metatarsal. Passive dorsi-flexion o f
the toe w i t h pressure a p p l i é d beneath the 1st
metatarsal head makes-the tenderness worse.
CAUSES
m i c r o w a v e a n d interferential c a n a l l be used. F e l t
p a d d i n g to t e m p o r a r i l y relieve pressure from
beneath the 1st metatarsal head c a n be helpful.
O n l y too frequently none o f these p h y s i c a l
modalities makes any difference. I f the c o n d i t i o n is
of long-standing then an injection o f
H y d r o c o r t i s o n e Acetate sometimes improves the
symptoms though the results are often
disappointing.
O n l y too often it is just the passage o f time,
frequently very m a n y months, w h i c h allows the
symptoms to subside.
Surgery has n o t h i n g to offer. E x c i s i o n o f the
sesamoid more often than not leaves permanent
residual tenderness. T o risk surgery on the small
chance o f g a i n i n g relief is unwise. W i t h patience
the symptoms w i l l always settle.
3.21 Hallux Valgus and
Bunions
CAUSES

Sesamoiditis is precipitated by direct t r a u m a P r o b a b l y the commonest cause seen i n dancers is

usually brought about by a b a d l a n d i n g . Sometimes
prolonged work on a h a r d surface w i l l cause the
condition.
TREATMENT
Sesamoiditis is frequently extremely slow to settle.
Patience on the part o f the dancer a n d the m e d i c a l
attendant is the most i m p o r t a n t factor.
where there is a congenital metatarsus p r i m u s varus
w h i c h produces a secondary h a l l u x valgus ( F i g .
3.22). L a t e r i n life a h a l l u x valgus ( F i g . 3.23) c a n
appear following the use o f very poor footwear or
if the dancer as a c h i l d is put on pointe far too
early w h e n the feet are not strong enough. It c a n
also be caused by very prolonged r o l l i n g or by weak
forefeet (i.e. w h e n the intrinsics are very weak).
122 Section 3: Specific Injuries: T h e i r C a u s e and T r e a t m e n t
3.23 A severe hallux valgus in the right foot. Note the
over-riding 2nd toe. Sometimes the great toe comes over
the top of the 2nd toe. The left foot has been improved
in appearance by a Keller's operation. This shortens the
great toe moderately. There is a marked decrease in
power of movement so the operation is not suitable for
the dancer who is still working.
&
T h e r e must, however, be an u n d e r l y i n g m i l d h a l l u x
valgus deformity before these other latter causes
w i l l produce ill-effects a n d an a g g r a v a t i o n o f the
already slight valgus posture. O v e r a l l it is surprising
h o w frequently a very severe valgus deformity is
seen w h i c h causes little or no symptoms.
TREATMENT
I n the situation where there is a congenital
metatarsus primus varus a H o h m a n n ' s osteotomy o f
the 1st metatarsal produces a very satisfactory
result ( F i g . 3.24). T h i s corrective operation does not
interfere at a l l w i t h the capsule or ligaments o f the
1st metatarso-phalangeal j o i n t a n d therefore does
not lead to any stiffness i f it is carried out correctly.
It should i d e a l l y be undertaken i n the m i d teens. I f
the deformity is fairly m a r k e d , then it should
3.24 Hohmann's operation. The shaded section in the
first diagram shows the area of bone removed. The
second shows the displacement of the 1st metatarsal head
towards the 2nd metatarsal and the positioning head
securely on the bone peg formed at the end of the shaft.
This is the subject of the X-ray.
The projecting corner of bone at the medial end of the
metatarsal shaft becomes absorbed and remodelled
during union of the osteotomy and subsequent
consolidation.
 Section 3.21-3.22
almost certainly be carried out even i n the absence
of symptoms at that time. T h i s also applies i f there
is a strong family history o f bunions. After about
the m i d to late twenties or possibly the early
thirties, a H o h m a n n ' s operation is usually
contra-indicated, because the alteration i n
mechanics o f the foot are not accommodated well
by a foot o f greater age a n d it m a y leave a painful
foot w i t h tenderness, p a r t i c u l a r l y under the lesser
metatarsal heads.
In the case o f a h a l l u x valgus without a
metatarsus primus varus, operation i n active
professional dancers is contra-indicated a n d no
r a d i c a l surgery should be undertaken before they
have retired from performing. H o w e v e r , i n a
teacher, they w i l l usually cope perfectly
satisfactorily following the standard K e l l e r ' s
operation ( F i g . 3.25). I f the b u n i o n area becomes
repeatedly infected, then it is possible to carry out a
subcapsular excision o f the b o n y osteophyte w i t h a
careful reconstruction o f the m e d i a l capsule. T h e
operation, however, m a y occasionally lead to some
restriction o f movements a n d it should not be
carried out unless there is very definite i n d i c a t i o n
for surgery. T h i s i n d i c a t i o n is largely repeated
episodes o f i n f l a m m a t i o n or infection a n d a risk o f
u n d e r l y i n g b o n y involvement. T h e operation must
be done open so that the soft tissues c a n be
identified clearly a n d preserved. O n e o f the most
i m p o r t a n t aspects o f this operation is the accurate
reconstruction o f the m e d i a l capsule. I f this is not
done then a r a p i d l y increasing valgus deformity
3.25 Diagram of a Keller's operation which is carried
out either for a hallux valgus and bunions or for a hallux
rigidus (osteo-arthritis of the 1st metatarso-phalangeal
joint).
123
w i l l follow this type o f procedure. T o c a r r y out the
operation through a very s m a l l incision a n d b l i n d l y
g r i n d off the p r o m i n e n t bone is totally irresponsible
a n d c a n only be c o n d e m n e d . O n l y too frequently
the capsule is severely d a m a g e d a n d there is
certainly n o o p p o r t u n i t y for its reconstruction.
Conservative treatment i n h a l l u x valgus a n d
bunions is directed at care o f the b u n i o n area. U s e
of a felt r i n g p a d c a n relieve local pressure over the
b u n i o n . Sometimes a wedge between the first a n d
second toes c a n be helpful to support the great toe.
H o w e v e r , this occasionally has the disadvantage
that the pressure is transmitted to the lesser toes
w h i c h causes them to start to drift into valgus.
F a r a d i c foot baths a n d intrinsic muscle exercises
can also help b y strengthening the c o n t r o l o f the
toes.
Complications
R e c u r r e n t blistering. T h i s c a n lead to i n f l a m m a t i o n
a n d infection o f the a c t u a l bunions w h i c h i n
occasional cases c a n progress to b o n y i n v o l v e m e n t .
3.22 Hallux Rigidus
T h i s is a c o n d i t i o n where osteoarthritis
(degenerative arthritis) occurs i n the
metatarso-phalangeal j o i n t o f the great toe. It
derives its name because as the c o n d i t i o n progresses
the toe j o i n t becomes stiffer a n d eventually fixed o r
r i g i d . T h e c o n d i t i o n starts i n c h i l d h o o d a n d is first
evidenced b y l i m i t a t i o n o f movement at the great
toe j o i n t . A t that stage there are rarely a n y X - r a y
changes, although there m a y be some sclerosis o f
the epiphysis at the base o f the p r o x i m a l p h a l a n x
of the great toe. E v e n later, w h e n movements have
become m a r k e d l y restricted, the changes seen o n a n
X - r a y are often relatively m i l d a n d a d v a n c e d
radiological changes are o n l y apparent w h e n the
toe j o i n t is severely affected a n d very stiff.
CAUSES
T h e cause is p r o b a b l y genetic because the c o n d i t i o n
is not usually associated w i t h t r a u m a a n d is
bilateral. H o w e v e r , like a n y other j o i n t , i f there has
been some significant damage to the j o i n t , arthritis
m a y follow. T h i s latter type o f h a l l u x rigidus c a n
start at a n y time i n life d e p e n d i n g u p o n w h e n the
episode o f t r a u m a occurred. T h e c o n d i t i o n ,
whatever the cause, is unfortunately progressive.
T h e range o f movement slowly decreases a n d
because o f the l i m i t a t i o n o f dorsi-flexion, i t causes
various technical problems. These are largely
associated w i t h the difficulty or i m p o s s i b i l i t y i n
achieving correct weight placement (Section 5.20).
 124 Section 3: Specific Injuries: T h e i r Cause a n d T r e a t m e n t
3.26A Silastic replacement of the base of the proximal
phalanx of the great toe.
TREATMENT
Progress can be slowed a n d symptoms alleviated by
gentle traction o n the great toe j o i n t to decrease the
a m o u n t o f stiffness a n d shortening i n the soft
tissues, by gentle active a n d passive exercises a n d ,
of course, by strengthening the intrinsic muscles i n
the forefoot. It is advisable to tell the dancer not to
force three-quarter pointe as t r y i n g to get up too
h i g h tends to make the c o n d i t i o n worse rather t h a n
better. T h e dancer should be guided on h o w h i g h
to go by the degree o f p a i n experienced. Some p a i n
is inevitable i n the very nature o f the c o n d i t i o n but
it should not be extreme. I f symptoms persist
despite conservative treatment a n d p a r t i c u l a r l y i f
the stiffening o f the great toe is causing other
technical problems a n d other injuries, then surgery
should be considered. F o r a dancer this c a n only be
i n the form o f a silastic replacement o f the base o f
the p r o x i m a l p h a l a n x o f the great toe ( F i g . 3.26).
H o w e v e r , this should not be undertaken i n a
student. T h e life o f the silastic replacement is
l i m i t e d , though variable. It is p r o b a b l y w r o n g to
a l l o w students to embark u p o n w h a t w i l l become a
very b r i e f professional career at a n age w h e n they
w o u l d be better c h a n n e l l i n g their energies into
some other j o b for the future. W h e n the silastic
j o i n t fails it c a n be removed. T h i s leaves the toe
somewhat shortened a n d greatly decreased i n power
i n j u m p s , relevés, etc. T h i s latter state is, however,
a situation w h i c h is perfectly satisfactory for
n o r m a l life a n d p r o b a b l y for most dance teachers.
I n a professional dancer the extra w o r k i n g years
w h i c h the silastic replacement w i l l have allowed
w i l l be greatly w e l c o m e d . It is impossible to
forecast pre-operatively how l o n g the prosthesis
m i g h t last but certainly dancers should be w a r n e d
3.26B O n pointe following the replacements.
that it is not g o i n g to last them the rest o f their
anticipated stage career unless they are already o f
somewhat mature years.
But beware! T h e diagnosis o f h a l l u x rigidus m a y
be made w h e n there is only an apparent stiffness o f
the great toe j o i n t . A stiff great toe needs careful
assessment as, w h e n the patient is first seen, there
may appear to be a very genuine restriction o f
movement i n the great toe j o i n t but often the
stiffness is only temporary. T h i s is not a genuine
h a l l u x rigidus. T h e situation can be brought about
by w o r k i n g b a d l y a n d repeatedly t r a u m a t i s i n g the
first metatarso-phalangeal j o i n t . T h i s is seen
p a r t i c u l a r l y i n r o l l i n g w h e n the weight is repeatedly
transmitted at an angle t h r o u g h the metatarso-
phalangeal j o i n t . T h e j o i n t itself c a n become
swollen, painful a n d stiff as a result. H o w e v e r , w i t h
adequate local treatment a n d correction o f the
technical fault, the range o f movement c a n be
satisfactorily restored. O b v i o u s l y , X - r a y s o f the toe
w i l l show that there is no bony a b n o r m a l i t y present
and no evidence o f any degenerative arthritis.
Complications
T h e complications arise from the technical faults
w h i c h result from the alteration o f weight b e a r i n g
line due to the dancer w o r k i n g a w a y from or off
the painful great toe(s). U s u a l l y one side is more
severely affected b y the symptoms o f p a i n a n d
stiffness t h a n the other.
3.23 Ingrowing Toenail
CAUSES
T h i s occasionally appears to be congenital. T h e
c h i l d is seen w i t h very c u r v e d great toenails w i t h
 Section 3.23-3.26
the sides tending to go vertically d o w n into the
flesh. T h i s type o f n a i l is certainly predisposed to
i n g r o w i n g . H o w e v e r , i n the m a i n , i n g r o w i n g
toenails are brought about b y over-tight o r
unsuitable footwear. T h e shoes should be checked
a n d this check must include everyday footwear.
TREATMENT
I n the early stages lifting the corner o f the n a i l a n d
p u t t i n g a little a n i m a l w o o l (not cotton wool) under
the corners m a y be sufficient to stop the n a i l
i n g r o w i n g . A l s o the n a i l should be cut straight
across a n d the corner should not be removed. I f at
the same time the cause o f the c o n d i t i o n is
removed, then usually no further treatment is
necessary. If, however, the i n g r o w i n g persists then a
wedge resection o f the border o f the n a i l is usually
sufficient, p r o v i d e d great care is taken to remove
the corner o f the n a i l b e d . A r a d i c a l operation w i t h
total o b l i t e r a t i o n o f the n a i l b e d is rarely necessary.
O c c a s i o n a l l y after wedge resection a small spike o f
n a i l w i l l regrow b u t this is easily t r i m m e d a n d is
n o r m a l l y painless.
3.24 Corns and Callosities
CAUSES
These are really a n o c c u p a t i o n a l h a z a r d i n dancers.
H o w e v e r , they m a y be greatly aggravated b y
' k n u c k l i n g ' w h e n o n pointe a n d b y badly-fitting
pointe shoes.
TREATMENT
C o r n s a n d callosities must certainly be treated w i t h
respect a n d care i n order to a v o i d infection. G o o d
q u a l i t y professional c h i r o p o d y is required rather
than self-trimming w i t h razor blades or s i m i l a r
implements, w h e n the likelihood o f infection w o u l d
be very m u c h greater. A l l causes must be
eliminated as m u c h as possible.
3.25 Sundry Spurs, Areas of
Calcification, etc.
CAUSES
These spurs etc. usually represent areas o f previous
injury. T h e y are part o f the h e a l i n g process d u r i n g
w h i c h time the d a m a g e d tissue undergoes p a r t i a l
repair b y ossification or calcification. T h e y
frequently o c c u r w h e n the soft tissue damage has
taken place at a b o n y j u n c t i o n . F o r example, i f a
p o r t i o n o f ligament o r capsule is pulled a w a y from
the bone this exposes u n d e r l y i n g r a w bone, bone
125
cells spill out so, as h e a l i n g takes place, it is
a c c o m p a n i e d b y a little spike o f new bone. These
spurs are n o r m a l l y c o i n c i d e n t a l X - r a y findings, i n
other words a n X - r a y is taken because o f a
c o m p l a i n t o f p a i n a n d o n the films one, or
frequently more, o f these little spurs are seen.
H o w e v e r , it cannot be over-emphasised that their
presence does not mean that they are the cause o f
the patient's symptoms. I n fact they very rarely
indeed cause symptoms themselves a n d r e m o v a l o f
spurs, scraping o f calcification o n tendons a n d
other miscellaneous a n d dubious procedures are
totally unnecessary. T h i s type o f surgery is usually
carried out because the true cause o f the symptoms
has not been determined o r investigated o r because
conservative treatment has been inadequate or
incompetent.
A s a result, the dancer has a n unnecessary
anaesthetic a n d operation. T h e subsequent enforced
period o f rest m a y sometimes be a curative factor,
g i v i n g the illusion that the surgery was the correct
procedure. H o w e v e r , o n l y too often, after the
convalescence a n d w h e n the dancer returns to
work, the symptoms o f w h i c h he was c o m p l a i n i n g
before the operation recur because the u n d e r l y i n g
cause has not been corrected. I n these
circumstances the symptoms are very often worse
because the dancer is weaker, further injuries then
occur elsewhere, possibly l e a d i n g to even more
surgery w i t h the u n d e r l y i n g causes still uncorrected.
TREATMENT
O n l y very rarely indeed, a spur m a y i m p i n g e
d u r i n g j o i n t movements a n d justify excision. T h i s is
unusual but even i n these circumstances it is v i t a l to
correct a n y u n d e r l y i n g faults.
3.26 Stress Fractures of the
Fibula
These c o m m o n l y occur some 8 to 12 c m above the
tip o f the lateral malleolus. T h e r e is well localised
w a r m t h , tenderness a n d t h i c k e n i n g . T h e r e s h o u l d
be no real difficulty i n m a k i n g a c l i n i c a l diagnosis
( F i g . 3.27).
CAUSES
T h e m a i n cause o f fibula stress fractures is sickling.
T h i s is frequently associated w i t h weak feet. It is
certainly aggravated b y l o w e r t i b i a l b o w i n g , w h i c h
seems to be c o m m o n i n oriental dancers. T h i s
makes it p a r t i c u l a r l y difficult to strengthen the
inner sides o f the thighs a n d the lateral p a r t o f the
foot (see Section 5.15). F a i l i n g to h o l d the turn-out
126 Section 3: Specific Injuries: T h e i r C a u s e and T r e a t m e n t

3.27 X - r a y of a healing stress fracture of the fibula with

callus (new bone) formation.

at the hips causes stress i n the lower leg. W r o n g

blocks i n pointe shoes c a n cause faulty weight
alignment. U n t r e a t e d ankle sprains can be followed
by the development o f a stress fracture a n d , as a
corollary o f this, the stress fracture may a c c o m p a n y
the development o f a chronic sprain.
TREATMENT
W o r k should be reduced until the patient can do
this altered p r o g r a m m e totally pain-free. I f this
cannot be achieved then the dancer w i l l have to be
off for a short period. L o c a l l y , interferential
therapy should be given. A t the same time as the
reduced d a n c i n g a great deal o f effort should be
made to strengthen a l l weak muscle groups.
P a r t i c u l a r l y i m p o r t a n t is the re-education o f
technique as this c o n d i t i o n is basically an injury
due to faulty technique. I f there is an u n d e r l y i n g
a n a t o m i c a l v a r i a t i o n such as a lower tibial bow,
then the technique should be i m p r o v e d to the
greatest possible extent a n d time given to h e l p i n g
the dancer to w o r k w i t h i n it.
Complications
U n t r e a t e d , the stress fracture may rarely progress
to a complete fracture.
3.27 Stress Fractures of the
Tibia
These are c o m m o n l y at the j u n c t i o n o f the upper
two-thirds a n d lower t h i r d on the m e d i a l border o f
the t i b i a a n d about mid-shaft on the anterior
border ( F i g . 3.28). T h e y m a y occasionally occur
high at the j u n c t i o n o f the upper third and lower
3.28 Stress fractures of the tibiae. These are nearly
symmetrical. In the tibia very little new bone is seen on
the X-rays during the healing process.
two-thirds. Stress fractures m a y occur as a result o f
the tibial shape, for example - b o w i n g a n d the level
of a bow ( F i g 3.29).
CAUSES
P r o b a b l y the most i m p o r t a n t cause is w h e n the
dancer is w o r k i n g w i t h the weight back (Section
5.20). T h i s means that it is i n part associated w i t h
uncontrolled swayback knees. T h i s is i n essence a
situation where the weight is being pushed back
a n d it is the weight back rather t h a n the swayback
knees per se w h i c h can lead to the stress fracture.
W e a k forefeet have the same effect o f altering the
weight alignment as does a failure to h o l d the
turn-out. A weak trunk a n d a lordotic posture a n d
extraneously, a raked stage, can induce a weight
back position, p a r t i c u l a r l y i f the dancer is not
accustomed to w o r k i n g i n that situation, or is not
p a r t i c u l a r l y strong. D a n c i n g o n h a r d floors causes
the forefeet to overtire. T h e muscles cease to work
a n d the weight then moves back. A t the same time
the tiring muscles cause the dancer to crash through
plié, l a n d i n g heavily a n d j a r r i n g the tibia (see
Section 5 for various technical faults w h i c h may
cause stress fractures).
DIAGNOSIS
T h i s must initially be on c l i n i c a l grounds. Careful
e x a m i n a t i o n w i l l show a very definite well localised
area o f thickening, w a r m t h a n d tenderness. T h i s
 Section 3.27 127

3.30 A n isotope bone scan showing a 'hot spot' where a

stress fracture is developing at the junction of the middle
and lower third of the tibia.

3.29 Lower tibial bows.

certainly indicates the presence o f a d e v e l o p i n g

stress fracture. T h i s c a n be detected four to six
weeks, or even more, before X - r a y changes are
present. A bone scan w i l l show a 'hot spot' o f
increased vascular activity at the site o f the
d e v e l o p i n g stress fracture l o n g before any X - r a y
changes o c c u r ( F i g . 3.30). P o o r n u t r i t i o n a l habits
m a y p l a y their part i n the cause o f stress fractures
and certainly c a n cause delay i n healing.

TREATMENT

T h i s must start as soon as the c l i n i c a l diagnosis is

m a d e a n d l o n g before X - r a y changes appear. It is
essential that the dancer is off w o r k , b o t h
performance a n d class. D e l a y i n treatment m a y
more than q u a d r u p l e the length o f time that the
3.31A (left) A stress fracture in the tibia.
dancer is finally off. Conversely i f he is off early this
w i l l a l l o w a fairly r a p i d h e a l i n g o f the stress
3.31 B (right) The stress fracture has become an acute
fracture. L o c a l l y interferential c a n be given to the complete fracture. In this case it was caused when the
tender area a n d this m a y speed u n i o n . A l t h o u g h patient jumped down the last few steps when hurrying to
this is at present not proven, it is certainly harmless. catch a train. A not dissimilar type of jump could have
Exercises should be given for a l l muscle groups. occurred during a performance.
T e c h n i c a l correction is essential a n d w i t h o u t this,
complete recovery a n d non-recurrence is less likely.
A t t e n t i o n should also be p a i d to the general
i f the stress fractures are m u l t i p l e confusion is m o r e
n u t r i t i o n a n d eating habits o f the dancer.
likely but i n these circumstances at least some o f
Complications the fractures should be visible o n an X - r a y . I f
A stress fracture m a y be mis-diagnosed as anterior allowed to progress the stress fracture m a y
c o m p a r t m e n t syndrome but the localised nature o f g r a d u a l l y develop into a complete fracture o f the
the c l i n i c a l findings should prevent this. H o w e v e r , t i b i a ( F i g . 3.31). I n this case u n i o n is desperately
128 Section 3: Specific Injuries: T h e i r C a u s e and T r e a t m e n t
slow a n d m a y take a year or more. T h e only
exception to this w o u l d be the case w h e n a dancer
was u n d e r t a k i n g a b i g j u m p w h i c h produced a
sudden acute fracture at the level o f the stress
fracture. I n these circumstances, i f the stress
fracture h a d not passed through too great a
p r o p o r t i o n o f the shaft diameter, u n i o n could be
expected to be at the same rate as a ' n o r m a l ' type
of fracture o c c u r r i n g as the result of a sudden acute
injury, i.e. some three to four months to achieve
complete u n i o n .
3.28 Anterior Compartment
Syndrome
T h e anterior c o m p a r t m e n t o f the shin is b o u n d e d
by the two bones, the tibia and fibula; by the
interosseous m e m b r a n e w h i c h is a very strong
fibrous sheet o f tissue l y i n g between these two
bones, j o i n i n g them together; a n d then superficially
by the deep fascia ( F i g . 3.32). N o n e o f these
structures are stretchable a n d it is this
non-stretchability w h i c h accounts for the problems
w h i c h occur i n anterior compartment syndrome. I f
there is any swelling (which can arise from injury
or other causes) w i t h i n the anterior compartment,
there w i l l necessarily be a rise i n pressure because
of the non-stretchability o f the structures encasing
the anterior c o m p a r t m e n t . T h i s rise i n pressure w i l l
cause increasing p a i n , often k n o w n as shin splints.
I f the swelling becomes excessive, the rise i n
pressure w i t h i n the tissue can become sufficient to
interfere w i t h or completely obstruct the blood
flow, i n w h i c h event the tissues w i t h i n the
c o m p a r t m e n t w i l l then die from lack o f oxygen.
T h i s situation, where there is greatly increased
pressure, is a surgical emergency a n d urgent
decompression o f the anterior c o m p a r t m e n t
syndrome is required before necrosis (death) o f the
tissues takes place. F o r t u n a t e l y , an anterior
c o m p a r t m e n t o f this degree of severity is rare a n d
the c o n d i t i o n does not usually progress b e y o n d the
m i l d e r , early stages.
CAUSES
T h e commonest cause is unaccustomed exercise or
extra exercise o f the muscle groups w i t h i n the
anterior c o m p a r t m e n t (anterior tibial muscle and
extensors to the toes). T h e extra exercise produces
swelling o f the muscle bellies (as w i l l happen w i t h
any sudden extra excessive use o f muscles) a n d this
causes the symptoms o f shin splints. T h e weight
back situation w i l l also cause extra tension i n these
muscle groups (Section 5.20). W e a k feet produce a
s i m i l a r over-work o f the muscles. O v e r - t i g h t
INTER O SSEO US
TIBIA
^ M EM BRANE
FIBULA
SUPERFICIAL
FASCIA (FAT)
DEEP FASCIA BLO O D VESSELS
AND NERVES
3.32 Cross-section of a leg in the upper third showing
the fascial compartments.
ribbons, b y constricting the lower leg, m a y interfere
w i t h circulation superficially a n d restrict
movement. T h i s can produce an i r r i t a t i o n o f the
tendons o f the tibialis anterior and o f the toe
extensors, p r o d u c i n g a m i l d degree o f anterior
c o m p a r t m e n t syndrome. Short shoes, by causing
c l a w i n g o f the toes, have a similar effect. R o l l i n g
w i l l cause over-work o f the anterior compartment
muscles. I f the dancer is observed i n class, the great
prominence o f the tendons can be seen ( F i g . 3.33).
A similar effect can be brought about by a tight
Achilles tendon restricting the plié. A n t e r i o r
compartment syndrome, usually very m i l d , is
c o m m o n i n first year full-time students a n d also
d u r i n g a g r o w t h spurt. Often d u r i n g periods o f
stress, muscle tension causes the dancer to g r i p the
floor unnecessarily w i t h the toes.
TREATMENT
P r o v i d e d the c o n d i t i o n is not severe enough to
place the circulation i n j e o p a r d y , conservative
treatment is effective. T r e a t m e n t should be carried
out w i t h the leg i n elevation, using ice and
interferential from the ankle to the g r o i n to
stimulate the circulation and venous return. ( M a k e
sure the knee is supported at the back as should be
the situation i n a l l treatments o f any lower l i m b
condition). Exercises are given to strengthen a l l the
other groups i n c l u d i n g the feet, calf, quadriceps,
hamstrings, adductors and gluteals, a l l o f w h i c h are
more likely to be relatively weak i n a dancer who
has shin splints. T h e strengthening o f these other
groups w i l l facilitate the technical correction w h i c h
w i l l be required. A l s o advise the dancer to sleep
 Section 3.28-3.30
3.33 Both photographs illustrate rolling at the feet and
ankles. Also shown is the beginning of the tension which
develops in the front of the ankle.
w i t h the foot o f the bed elevated by about 25 c m .
It is sensible to elevate the legs between classes a n d
w i t h o u t shoes i f the c o n d i t i o n is not severe enough
to w a r r a n t total rest from work. Massage can be
helpful, a l t h o u g h it is time-consuming. F a r a d i s m
under pressure i n elevation can be effective i n more
severe cases, although it is very painful. T i g h t
A c h i l l e s tendons, i f temporary, should not be
neglected i n the treatment p r o g r a m m e . (See
Section 5.14.)
Complications
M u s c l e necrosis m a y occur i f the c o n d i t i o n is severe
a n d remains undiagnosed, thereby not g i v i n g the
patient the benefit of surgical decompression. A
diagnosis o f a stress fracture i n the tibia m a y be
missed as it c a n also arise from the same cause as
the shin splints or, alternatively, a stress fracture
m a y be mis-diagnosed as an anterior c o m p a r t m e n t
syndrome. It is incorrect to call a developing stress
fracture 'shin splints'.
3.29 Calf Muscle Tears
TREATMENT
T h e treatment is described i n the general section on
the treatment o f muscle tears. (Section 2.2 M u s c l e
Tears, page 72).
Complications
C a l f muscle tears are p a r t i c u l a r l y prone to
contracture. T h i s is i n part from the scarring but
also i n part from the inherent tendency of the calf
muscle a n d Achilles tendon complex to tighten up
129
far more r a p i d l y than m i g h t be expected. C a l f
muscle strains m a y present as p a i n b e h i n d the knee
a n d m a y be mis-diagnosed as a h a m s t r i n g p r o b l e m
or a knee injury. R e m e m b e r that the two heads o f
the gastrocnemius are inserted i n the lower end o f
the femur a n d therefore pass b e h i n d the knee j o i n t .
3.30 Anterior Knee Pain
T h i s is a blanket term w h i c h covers conditions i n
patients whose actual pathology a n d precise cause
of the p a i n is not exactly k n o w n , even after
extensive investigations, a l t h o u g h the general
expression anterior knee p a i n does also i n c l u d e
definite conditions w h i c h c a n be diagnosed.
T r e a t m e n t is by a c o m b i n a t i o n a n d v a r i a t i o n o f the
modalities outlined below. W h e n t r y i n g to make a n
accurate diagnosis a n d before c o n c l u d i n g that the
actual cause cannot be determined, it is most
i m p o r t a n t to consider a l l the possible definite
diagnoses a n d eliminate them i n succession.
T i g h t T e n s o r Fasciae Latae
CAUSES
T h i s is usually brought about by muscle i m b a l a n c e
i n the thigh w h e n the m e d i a l side muscles are weak
(less strong - it can h a p p e n i n strong legs a n d it is
the i m b a l a n c e w h i c h is the vital clue). I n these
circumstances the lateral side, i n c l u d i n g the tensor
fasciae latae, is over-used. I n extreme cases the
over-use is readily visible, w i t h b u l g i n g outer sides
130 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
of the thighs a n d apparently very little muscle o n
the i n n e r side, i n c l u d i n g a very underdeveloped
vastus medialis. T h e overall appearance is
reminiscent o f someone w e a r i n g a p a i r of j o d h p u r s .
H o w e v e r , it c a n still occur w i t h little obvious
o u t w a r d developmental difference. I n these cases
the difference i n muscle tension c a n be felt o n
p a l p a t i o n . D u r i n g e x a m i n a t i o n , close observation o f
the patella w i l l show that it moves laterally as well
as p r o x i m a l l y d u r i n g a n isometric quadriceps
contraction. T h i s is diagnostic o f l a t e r a l / m e d i a l
muscle i m b a l a n c e , p r o v i d e d the patient does not
have knock knees.
TREATMENT
T h e soft tissue a n d capsular contraction laterally
w h i c h is m u c h beloved b y proponents o f lateral
release operations, only occurs after there has been
l a t e r a l / m e d i a l muscle i m b a l a n c e a n d never occurs de
novo as a n entity i n its o w n right. L a t e r a l release
procedures, even i f indicated because the soft tissue
tightness has developed beyond the point o f being
stretchable, are useless unless the cause o f the
i m b a l a n c e is diagnosed a n d fully corrected b y
post-operative physiotherapy correctly carried out. I f
this is not achieved the operation w i l l make the
patient worse.
These remarks have been p a r t i c u l a r l y emphasised
because unfortunately only too often dancers a n d
dance students are seen w h o have been the subjects
of a lateral release operation w h i c h has not been
followed u p b y adequate physiotherapy. C e r t a i n l y
i n m a n y o f these cases it is apparent that the
operation was never indicated i n the first place.
Tightness o f the tensor fasciae latae certainly
prevents proper adjustment o f the pelvis or
transference o f the weight. T h i s c a n therefore cause
excessive corrections to take place i n the l u m b a r
spine w i t h injuries o c c u r r i n g there.
Patellar Tendonitis
T h i s usually occurs at the patello-tendinous
j u n c t i o n . It is a n i m f l a m m a t o r y reaction due to
strain at this j u n c t i o n between the bone o f the
patella a n d the tendon.
CAUSES
T h e commonest cause o f patellar tendonitis is
i m b a l a n c e o f the quadriceps between the m e d i a l
a n d lateral components, g i v i n g rise to a n u n e q u a l
p u l l o n the patellar tendon. It is often associated
w i t h r o l l i n g (Section 5.17) or w i t h over-turning
(Section 5.7) or w i t h h a v i n g the body weight too
far back (Section 5.20). It is also frequently
associated w i t h a n over-development o f the lateral
side o f the thigh. I n the presence o f tight Achilles
tendons and/or weak feet, w h e n the dancer lands
he cannot absorb the shock at the feet a n d the
patellar tendon has to take the strain. S t i c k y
surfaces c a n also cause strain i n this area o n any
sort o f twisting due to the increased friction
between the foot a n d the floor.
A period o f r a p i d growth m a y produce
temporary inadequacy o f the quadriceps a n d this
can induce a tendonitis. I n a d e q u a c y o f the
quadriceps c a n also be produced b y p u s h i n g back
on a swayback knee. I n this instance it m a y be
coupled w i t h lateral/medial i m b a l a n c e , b o t h o f
these c o n t r i b u t i n g to the patellar tendonitis. I n the
weight back situation (Section 5.20), the extensor
reflex is not stimulated because the m a i n weight is
on the back o f the heel p a d a n d not towards the
front o f the heel p a d . Pressure at the latter point
w i l l stimulate a m u c h more effective quadriceps
contraction. Tightness at the front o f the h i p
(Section 5.9) prevents a satisfactory quadriceps
p u l l u p . T i g h t hamstrings (Section 5.12) - often
associated w i t h g r o w t h - m a y precipitate a patellar
tendonitis because o f i n h i b i t i o n o f the quadriceps
action b y the tight hamstrings. F i n a l l y , kneeling
routines m a y produce a tendonitis a n d this is often
associated w i t h a n infra-patellar bursitis.
TREATMENT
L o c a l treatment starts w i t h ice, p a r t i c u l a r l y i f there
is a n y swelling, a n d then proceeds to ultrasound
a n d interferential therapy. T h e r e then has to be a
correction o f any muscle imbalance. T h i s is often
helped b y faradic stimulation to the vastus medialis
to reinforce active contraction. A s the c o n d i t i o n
settles, a d d a small weight, either 1 o r 2 kilograms
at most. I f the fascia lata area is tight, benefit
cannot be achieved b y attempts to strengthen or
correct i m b a l a n c e o f muscles w i t h o u t first g i v i n g
interferential to the fascia l a t a followed b y
stretching. T h e n , d u r i n g each treatment session,
follow this w i t h active exercises. T h e r e is also a
need for careful e x a m i n a t i o n for a n y o f the causes
outlined above a n d their e l i m i n a t i o n . W i t h o u t this
taking place local treatment w i l l either be
ineffective or only very temporarily effective.
Complications
Inadequate treatment at a n y o f these stages leads
to the development o f a chronic lesion. Inadequate
treatment is also a precursor o f other injuries
a r o u n d the knee a n d i n p a r t i c u l a r o f the
development o f c h o n d r o m a l a c i a patellae. L a t e r ,
spurs m a y develop at the lower pole o f the patella,
p a r t i c u l a r l y i f early treatment is inadequate a n d
 Section 3.30
the c o n d i t i o n is allowed to become c h r o n i c . T h e
spur itself is very rarely the source o f any symptoms
a n d does not n o r m a l l y require excision. T h e
symptoms w i l l clear w h e n the tendonitis is treated
correctly.
O s g o o d Schlatter's Disease
T h i s is an apophysitis o f the tibial tubercle i n
adolescence, w h i c h is an i n f l a m m a t i o n o f the
g r o w i n g p o r t i o n o f the bone at the upper end o f
the tibia to w h i c h the patellar tendon is attached.
U s u a l l y there is a separate g r o w t h p o r t i o n ,
sometimes it is attached to the epiphysis. A n
apophysis is similar to an epiphysis i n a s m u c h as it is
a separate g r o w i n g p o r t i o n of the bone and does
not become attached to the m a i n part o f the bone
u n t i l g r o w t h ceases. H o w e v e r , unlike the epiphysis,
the apophysis does not take part i n increasing the
length o f the bone. T h e r e are m a n y o f these little
apophyseal areas o f growth throughout the body
a n d they are usually the site of attachment of a
large tendon.
CAUSES
Osgood Schlatter's disease is p r o b a b l y most
c o m m o n l y produced by relative weakness o f the
quadriceps muscle, often associated w i t h a period
of r a p i d g r o w t h . T h i s weakness results i n a j e r k i n g
p u l l o n the lower tendon attachment rather than a n
even controlled p u l l . O n i n i t i a l e x a m i n a t i o n ,
frequently the quadriceps do not appear to be
weak, hence the term relative weakness. T h i s
relative weakness takes into account the level o f
activity w h i c h is being carried out by the person
suffering from O s g o o d Schlatter's disease. It is most
c o m m o n i n c h i l d r e n w h o are keen on games, sports
a n d other activities. H o w e v e r , d u r i n g adolescence
the strength o f the quadriceps m a y not be quite up
to the effort w h i c h is being d e m a n d e d of them a n d
this then results i n the uneven p u l l i n g o n the
tendon a n d subsequent apophysitis.
TREATMENT
T h e dancer should rest off activity i f the c o n d i t i o n
is very painful and there is m a r k e d tenderness over
the tibial tubercle. T h i s area m a y be swollen a n d
w a r m . D u r i n g this time the dancer should
concentrate o n exercises a n d b u i l d up the
quadriceps muscles as well as the adductors,
gluteals a n d hamstrings. C o r r e c t any i m b a l a n c e
and also any tendency to push back on the knee.
T e c h n i c a l correction m a y also be o f value here. A s
the acute p a i n settles, the student can return
g r a d u a l l y to class a n d d a n c i n g .
131
Complications
T h e actual b o n y tibial tubercle c a n become
permanently enlarged i f a lot o f strenuous activity
is continued despite the warnings o f p a i n . T h i s
enlargement is not i n itself o f great significance.
H o w e v e r , girls find it very unsightly. I n boys,
should they be called u p o n to kneel m u c h , it c a n
produce a local painful area later i n life purely
because o f the m e c h a n i c a l prominence. T h e
treatment of O s g o o d Schlatter's disease c a n be
difficult, as continued r a p i d g r o w t h m a y prevent
the patient c a t c h i n g up sufficiently w i t h his
strengthening routines to m a t c h the g r o w t h rate.
C h o n d r o m a l a c i a Patellae
T h i s name is often loosely a p p l i e d to n o n specific
anterior knee p a i n . C h o n d r o m a l a c i a patellae is,
however, a very definite entity a n d the t e r m s h o u l d ,
i f possible, only be a p p l i é d w h e n there are a c t u a l
changes i n the a r t i c u l a r cartilage o n the
retro-patellar surface. T h i s cartilage becomes
yellowed i n patches, it softens, frays a n d then wears
away. A true, well established c h o n d r o m a l a c i a
patellae can be a precursor o f patello-femoral
osteoarthritis.
CAUSES
M o s t c o m m o n l y this is incorrect t r a c k i n g o f the
patella (i.e. muscle imbalance) especially w h e n
associated w i t h overall weakness o f the quadriceps
muscles. It is therefore c o m m o n after a g r o w t h
spurt w h i c h w i l l have caused relative weakness o f
the muscles, hence its frequency d u r i n g adolescence
a n d the teens. Tightness i n the fronts o f the hips
can cause tight quadriceps. I n the presence o f tight
Achilles tendons, the knee tends to be the m a i n
shock absorber a n d this agggravates the c o n d i t i o n .
C h o n d r o m a l a c i a patellae is more c o m m o n l y seen i n
runners, gymnasts a n d dancers than other types o f
athlete. These three groups a l l have a very high
repetition o f p a r t i c u l a r movements. It is also more
c o m m o n i n the presence o f swayback knees. It m a y
occasionally be precipitated by a direct b l o w on the
patella. H o w e v e r , i n this situation it should not be
confused w i t h an osteo-chondral fracture. T h i s is
an acute fracture o c c u r r i n g i n the bone just
beneath the a r t i c u l a r cartilage a n d w i l l often break
out a small fragment o f bone together w i t h the
over-lying cartilage. C h o n d r o m a l a c i a patellae is o f
more g r a d u a l onset a n d , following a b l o w o n the
patella, bruising of the retro-patellar cartilage c a n
take place a n d this c a n then lead to the
chondromalacia.
132 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
TREATMENT
L o c a l treatment comprises pulsed m i c r o w a v e ,
w h i c h is very soothing, plus interferential therapy,
not only from the m i d leg to the m i d thigh, but
also i n a more localised form from just below the
patella to just above. U l t r a s o u n d also m a y be
helpful. Exercises should be directed towards
r e - b a l a n c i n g muscles, quadriceps strengthening a n d
also strengthening o f any other weak muscle
groups, p a r t i c u l a r l y hamstrings, adductors, gluteals
a n d calves, stretching any tightness i n the front o f
the hips a n d also the quadriceps themselves a n d the
c a l f i f they are tight. A small heel (three-quarters
of a n i n c h - 2 cm) c a n prevent the weight being
pushed back too far i n the presence o f swayback
knees a n d s i m i l a r l y a lift inside a ballet shoe. T h i s ,
using orthopaedic felt t e m p o r a r i l y placed there
u n t i l the muscle strengthens, c a n be very helpful.
O n c e the symptoms have i m p r o v e d these aids
should be discarded. C h e c k i n g technical faults is, as
always, o f the greatest importance.
Complications
T r u e c h o n d r o m a l a c i a patellae is very persistent a n d
can be difficult to treat i f it is l o n g established,
a l t h o u g h i f caught early, treatment is very m u c h
easier. A n arthroscopy m a y be required, i f only to
confirm the genuine diagnosis. Surgery, for example
shaving the retro-patellar surface, is disastrous a n d
makes matters worse. A lateral release operation
merely aggravates muscle weakness a n d hence the
i m b a l a n c e is increased, even i f there is some faulty
patella t r a c k i n g . A lateral release should only
follow a muscle strengthening p r o g r a m m e w h e n it
has been demonstrated that there is a true tightness
i n the lateral capsule w h i c h cannot be stretched out.
3.31 Capsular Strains of the
Knee
These m a y occur anywhere a r o u n d the knee but
are rather more c o m m o n posteriorly.
CAUSES
F o r c e d hyperextension o f the knee is p r o b a b l y the
commonest cause a n d i n these cases it m a y also be
associated w i t h a strain o f one or b o t h heads of the
gastrocnemius. T h i s c a n occur i n m a n y dance steps;
for example, l a n d i n g from cabriole w i t h the weight
on the heel, s n a p p i n g the knee backwards.
F r e q u e n t l y there is a significant a m o u n t o f bruising
a n d swelling associated w i t h this injury.
TREATMENT
L o c a l l y ice, ultrasound a n d interferential are used
to decrease the swelling. T h e dancer should
definitely be off u n t i l settled. D u r i n g this stage
strengthening exercises should be undertaken as
wasting w i l l r a p i d l y occur. P a y p a r t i c u l a r attention
to the hamstrings w h i c h are usually neglected i n
knee conditions o f all types.
3.32 Injury of the Medial
Ligament of the Knee
CAUSES
Tears are usually caused by a faulty l a n d i n g or
collision or a fall, w h i c h m a y be precipitated by
sticky floors. Sprains are caused by faulty landings
a n d bad floor surfaces, i.e. m u c h the same as events
a n d conditions that can cause a tear but w h e n the
force is less.
T h e y are also seen i n unusual choreography w i t h
w h i c h the dancer is not familiar a n d i n j u m p i n g off
various stage props. Sickled feet greatly increase the
possibilities o f a bad l a n d i n g and injuries o f various
types to the inner side o f the knee. A n y t h i n g w h i c h
produces tiredness i n the dancer, e.g.
over-rehearsal, p a r t i c u l a r l y o n solid floors, c a n
make the injury more likely to occur,
injury more likely to occur.
TREATMENT
Tears are an urgent orthopaedic p r o b l e m a n d w i l l
require surgery i f complete. I n lesser cases, plaster
of Paris is required unless the damage is very
minor. T h e later stages o f the r e h a b i l i t a t i o n , when
surgery is complete a n d the tear has healed, are the
same as for a sprain, as follows.
F o r sprains; local use o f ice, ultrasound a n d
interferential are indicated. T h e dancer w i l l
p r o b a b l y have to be off d a n c i n g unless the injury is
very m i n o r . Exercises are p a r t i c u l a r l y i m p o r t a n t
d u r i n g the rehabilitation period w i t h special
attention to the quadriceps medialis a n d the
adductors. Correct action o f the foot, w i t h a
b u i l d - u p o f intrinsic muscles a n d correct weight
distribution to prevent sickling, is p a r t i c u l a r l y
important. C a r e should be taken to eliminate any
tendency to overturn the feet, w h i c h always puts a n
excessive strain o n the m e d i a l side o f the knee. A s
in any knee injury, the muscle b u i l d - u p w i l l have to
extend up to the gluteals a n d trunk a n d technical
correction w i l l also have to look at these areas. A n y
pre-existing fault w h i c h m a y not have caused
symptoms or injuries before this ligament sprain,
w i l l certainly aggravate the m e d i a l side o f the knee
once it has been the site of an injury o f any sort.
 Section 3.31-3.35
3.33 Injury of the Lateral
Ligament of the Knee
Injuries here are u n c o m m o n i n dancers a n d usually
only occur as a result o f direct violence, e.g.
collisions a n d falls. I f the rupture is complete, the
lateral popliteal nerve m a y also be severely a n d
permanently d a m a g e d . T h e injury is one r e q u i r i n g
urgent orthopaedic care. T h e r e h a b i l i t a t i o n is
similar to that given to the m e d i a l ligament sprains.
3.34 Injuries of the Cruciate
Ligaments of the Knee
These injuries, similarly to those affecting the
collateral ligaments, c o m m o n l y arise from direct
violence a n d are frequently associated w i t h tearing
of a collateral ligament a n d meniscal damage.
C r u c i a t e ligament injuries are also urgent
orthopaedic problems. R e h a b i l i t a t i o n , i f recovery
ever reaches the stage where the dancer can
contemplate a return to d a n c i n g , is l o n g d r a w n out
because o f the extensive damage. It is similar to
that p e r t a i n i n g to the d a m a g e d collateral ligaments.
U n f o r t u n a t e l y , w h e n there is a cruciate ligament
injury, the damage is usually sufficient to end a
dancer's career. O c c a s i o n a l l y , a dancer or other
athlete c a n sustain serious damage to a cruciate
ligament, most c o m m o n l y the anterior, without
leaving a serious disability. T h i s is, however, the
exception.
3.35 Damage to the Medial
Meniscus of the Knee
T h e meniscus m a y be torn to a v a r y i n g extent
r a n g i n g from a m i n o r tag to a full length tear or a
total avulsion o f the meniscus from its peripheral
attachment. T h e problems arise i n the longer term
(after the i n i t i a l symptoms o f the o r i g i n a l tear have
subsided) because the torn fragment can catch i n
the j o i n t , causing g i v i n g w a y or l o c k i n g of the knee.
CAUSES
T h e tear takes place because the meniscus becomes
trapped between the femoral condyle a n d the t i b i a l
plateau d u r i n g rotation on a bent knee. T h e r e is no
doubt that, by repeated malfunctions o f the knee,
tears can occur g r a d u a l l y a n d w i t h o u t i m m e d i a t e
symptoms. T h i s has been shown by the observation
of a meniscal tear on arthroscopic e x a m i n a t i o n
w h e n there has been no history o f an acute episode.
F r e q u e n t l y the symptoms can be relatively m i n o r
some l o n g time before a final acute episode, the
133
latter o f w h i c h is p r o b a b l y caused b y the tearing o f
the last p o r t i o n o f an already developing tear. T h e
situation is aggravated or caused b y o v e r - t u r n i n g
the feet, b y weakness o f the adductors a n d the
vastus medialis, together w i t h their associated
postural muscles, a n d finally by a m u s c u l a r
i m b a l a n c e causing lack o f c o n t r o l o f the knee.
W e a k adductors w i l l not h o l d the leg correctly
under the b o d y w h e n o n one leg, thus increasing
the strain o n the m e d i a l side o f the knee. I n
a d d i t i o n , the weak adductors w i l l not c o n t r o l the
turn-out at the h i p , aggravating a n y o v e r t u r n i n g at
the foot. W h e n c a r r y i n g the w o r k i n g leg t h r o u g h
from front to side a n d especially also to the back,
the pelvis w i l l not be controlled i n relation to the
supporting leg a n d w i l l also swing r o u n d , causing a
rotation at the knee a n d a secondary o v e r t u r n i n g at
the s u p p o r t i n g foot, as the leg above the foot
rotates inwards ( F i g . 3.34). Isolated technical faults
such as r o l l i n g m a y contribute to meniscal tears.
L i g a m e n t l a x i t y c a n also be a c o n t r i b u t o r y factor,
hence swayback knees c a n be prone to cartilage
tears, especially as they are so often associated w i t h
weak thigh muscles.
TREATMENT
A tear per se does not necessarily require surgery
unless it is causing symptoms, i.e. l o c k i n g or g i v i n g
way or restriction o f movements. I f symptoms are
present, r e m o v a l o f the torn p o r t i o n is required a n d
the current practice is to leave as m u c h as possible
of the n o r m a l meniscus b e h i n d . H o w e v e r ,
correction o f the causes outlined above c o u p l e d
w i t h a muscle strengthening p r o g r a m m e a n d a
g r a d u a l return to full w o r k , w i l l frequently remove
the need for surgery at that stage. I f surgery is
undertaken, the same p r o g r a m m e o f r e h a b i l i t a t i o n
w i l l be required w i t h even more strengthening w o r k
because o f the increased muscle weakness following
even an arthroscopic procedure. I n a l l cases,
thorough technical investigation a n d correction is
required. I n post-operative care, plaster o f Paris
should be avoided as it prevents an early and
effective muscle b u i l d - u p p r o g r a m m e , p a r t i c u l a r l y
i n the vastus medialis. Persistent or recurrent
swelling can be a great enemy o f progress and
needs treatment w i t h ice, elevation o f the foot o f
the bed a n d an increase i n controlled exercises.
Exercise programmes for knee r e h a b i l i t a t i o n are
p r o b a b l y the most misconceived o f any form o f
recovery p r o g r a m m e for any part o f the b o d y .
Pre-operatively, time spent on a regime of
exercises to strengthen a l l relevant groups a n d
rehearsals o f the post-operative exercises c a n pay
great dividends i n very significantly r e d u c i n g the
convalescent a n d r e h a b i l i t a t i o n period.
134 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t

3.34 Over turning on one leg with the working leg at the back. The pelvis is
not supported because of weak adductors. Frequently the pelvis is much more
tilted than in this dancer. However, it is very important to detect minor
degrees of tilt because it produces an apparent discrepancy in leg length. It
can be easily seen in the first photograph that the dancer here would
experience great difficulty in closing to any position without further distortion
of the trunk.

3.36 Damage to the Lateral CAUSES

I n dancers the lateral meniscus tear is c o m m o n l y o f

Meniscus of the Knee
T h i s type o f damage is the same as that w h i c h
affects the m e d i a l meniscus. L a t e r a l meniscus tears
are relatively more c o m m o n i n d a n c i n g t h a n i n
other types o f sport, although the m e d i a l meniscus
is, even i n dancers, more often d a m a g e d than the
lateral.
g r a d u a l onset from repeated m i n o r t r a u m a rather
than presenting as a n acute tear, as happens i n
m e d i a l meniscus damage where the c h r o n i c type
injury is less c o m m o n . T h e tear o f the lateral
meniscus c a n be brought about by a failure to h o l d
the turn-out equally so that the affected side is
back, the foot is rolled a n d the fascia lata is tight.
I f the dancer is looked at carefully w h e n he is
standing turned out i n 1st position it can be seen

3.35A ( far left) In over turning

the feet the patella faces more
anteriorly and is out of line with the
foot. This photograph illustrates the
lack of pull up in the hamstrings.

3.35B (left) Shows the lack of pull

up in the quadriceps, especially the
medialis which, though visible here,
is not contracting to provide full
extension of the knees. The more the
dancer over turns the bigger the gap
between the knees, reducing the
ability to pull up with the thigh
muscles. Additionally, the dancer
becomes increasingly prone to injury
at the knee the more he over turns.
 Section 3.36-3.37
that the knees are not quite fully extended ( F i g .
3.35). F r o m the side the hamstrings c a n be seen to
be failing to p u l l up fully, w h i l e from the front the
failure o f the quadriceps a n d p a r t i c u l a r l y the vastus
medialis to p u l l up a n d contract correctly c a n be
observed. T h i s failure w i l l also i n c l u d e the
adductors. T h e more the dancer overturns, the
w i d e r the gap between the knees a n d the more the
knee w i l l be slightly flexed. W o r k i n g thus o n a
slightly flexed knee w i t h the t i b i a twisted outwards
i n relation to the femur is a p r i m e cause o f injuries
to the menisci inside the knee as well as l i g a m e n t
a n d capsular damage. I n this situation the r o t a t i o n
of the t i b i a c a n produce tightening o f the capsule
a n d other soft tissues postero-laterally despite the
slight flexion o f the knee w h i c h w o u l d otherwise
tend to relax them, whereas the same rotation c a n
tend to slacken the soft tissues postero-medially. A s
a result, the lateral meniscus is c h r o n i c a l l y
compressed a n d g r a d u a l l y becomes the site o f a tear
w h i c h m a y be somewhat degenerative i n nature.
TREATMENT
T h i s is similar to that for the m e d i a l meniscus,
c a l l i n g for arthroscopic e x a m i n a t i o n to confirm the
diagnosis or possibly an a r t h r o g r a m . O n c e the tear
has been confirmed it should be treated i n the
recognised surgical manner, preserving as m u c h o f
the lateral meniscus as possible, i.e. b y p a r t i a l
menisectomy. H o w e v e r , w i t h lateral meniscus
damage the technical faults are often somewhat
different from those o c c u r r i n g i n m e d i a l meniscus
injury but they need just as careful assessment a n d
correction.
135
3.37 Ruptures of the Quadriceps
Tendon or the Patellar
Tendon or Fracture of the
Patella
These injuries c a n be considered together because
the causes are the same. I n each case there is a
d i s r u p t i o n o f the extensor m e c h a n i s m o c c u r r i n g
between the lower part o f the muscle bellies o f the
quadriceps muscle a n d the insertion into the t i b i a l
tubercle. T h e three levels at w h i c h this d i s r u p t i o n
can take place are at the quadriceps tendon just
above the patella, t h r o u g h the patella itself
p r o d u c i n g a transverse fracture o f the patella, o r
t h r o u g h the patellar tendon between the patella
a n d the t i b i a l tuberosity. R u p t u r e s o f the patellar
tendon or transverse fractures o f the patella o c c u r
i n a younger age g r o u p , whereas ruptures of the
quadriceps tendon usually occur slightly later i n
life.
CAUSES
A l l these injuries occur because o f a sudden
explosive c o n t r a c t i o n o f the quadriceps muscle,
p a r t i c u l a r l y i n someone w h o is not at the peak o f
t r a i n i n g , a l t h o u g h a technical mistake or faulty
j u m p c a n produce a s i m i l a r effect. T h e extremely
strong a n d u n c o n t r o l l e d muscle c o n t r a c t i o n causes
the rupture b y p u l l i n g the fibres o f the tendon
apart. I n the case o f the patella fracture this p u l l
also produces a snap back o f the patella onto the
femoral condyles, b r e a k i n g the patella transversely
136 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
across. I n a l l three injuries the contraction o f the
muscle w i l l continue to p u l l the p r o x i m a l part up
the thigh, p r o d u c i n g a gap at the site of the
rupture. E a c h injury is followed by an i m m e d i a t e
and very great swelling due to an extensive
haemorrhage. I f examined shortly after the injury
the blood is still l i q u i d a n d it is usually possible to
feel the actual gap. H o w e v e r , i f some time has
elapsed the b l o o d m a y have started to clot a n d
certainly i f it is a d a y or two later the gap m a y be
difficult to palpate.
W h e n e x a m i n e d i m m e d i a t e l y after the accident
the dancer can be asked to lift the leg up straight.
I f he cannot do so, then a rupture should be
strongly suspected. I n other conditions affecting the
knee, even though fairly serious, the dancer is
usually able w i t h an effort to lift the leg up straight
because, i n the early stage, i n h i b i t i o n o f quadriceps
muscle m a y not yet have taken place. I f some time
has elapsed this i n h i b i t i o n does occur even though
there is no d i s r u p t i o n o f the extensor mechanism
and the patient w i l l be unable to lift his leg. These
tendon ruptures or patellar fractures are a l l acute
orthopaedic emergencies r e q u i r i n g i m m e d i a t e
surgical repair. F a i l u r e to recognise the injury or to
suspect it a n d refer for an orthopaedic o p i n i o n can
make the difference between the dancer being able
eventually to return to a full d a n c i n g career or
otherwise. I f there is a delay this w i l l usually spell
the end o f any return to d a n c i n g or any sort o f
active sport at a competitive level.
TREATMENT
T h i s is by surgical repair. D u r i n g the post-operative
phase an exercise p r o g r a m m e can be devised to
keep the rest o f the body i n as good a c o n d i t i o n as
possible. E v e n while the patient is still i n plaster
some isometric contractions for the muscle groups
on the affected leg can be c o m m e n c e d . O n c e the
plaster has been finally removed intensive exercises
should be instituted i n order to b u i l d up the muscle
groups a n d to mobilise the knee. It is o f value i n
speeding up recovery i f the complete plaster is
removed as early as possible i n order to allow the
patient to come out for exercises but then, after the
exercise p r o g r a m m e , the leg can be i m m o b i l i s e d
again i n a plaster back splint.
It is this early treatment w i t h a carefully devised
p r o g r a m m e o f exercise that is as i m p o r t a n t i n
a l l o w i n g the patient to achieve their utmost
recovery as is the q u a l i t y o f the surgery. I n
competent surgical hands repair using b r a i d e d
stainless steel w i r e c a n practically eliminate the
need for a complete plaster cylinder. (Beware o f the
local heating effect o f shortwave d i a t h e r m y or
m i c r o w a v e w i t h buried wire - both are
contra-indicated. T h e dancer must be told always
to w a r n the physiotherapist about the b u r i e d w i r e
when g o i n g for any type o f treatment at a later
date. H o w e v e r , the g a i n by h a v i n g early access for
treatment outweighs this inconvenience for the
patient i n h a v i n g to remember to i n f o r m future
physiotherapists.)
3.38 Quadriceps Muscle Strains
and Tears
These have been dealt w i t h i n general i n the section
on muscle injuries. (Section 2.2 M u s c l e Tears, page
72). H o w e v e r , it is p a r t i c u l a r l y i m p o r t a n t i n
injuries at this site to ensure that the correct
medial/lateral balance between the parts o f the
quadriceps muscles is restored d u r i n g the treatment
period.
Complications
These are associated w i t h a failure to restore this
medial/lateral balance w i t h its associated problems,
w h i c h have been described under various earlier
headings.
3.39 Adductor Muscle Strains
and Tears
T h e a d d u c t o r muscles are p r o b a b l y the commonest
site of muscle damage. U s u a l l y the tears o c c u r i n
the p r o x i m a l (upper) part o f the a d d u c t o r c o m p l e x
and are brought about by a sudden over-stretching
such as m a y h a p p e n i n forcing splits sitting i n 2 n d
position. I f the tenderness is very h i g h and close to
the bone o f the pelvis an X - r a y should be taken as
sometimes the bony o r i g i n is avulsed together w i t h
a small piece o f bone. T h e i m p o r t a n c e of this is
that i f early stretching is carried out then the
injured area w i l l be irritated a n d further bone cells
w i l l be shed into the h a e m a t o m a (collection o f
blood) i n the d a m a g e d area. A t the time o f the
i n i t i a l avulsion, as the bone has been exposed, there
w i l l already have been some spillage o f bone-
forming cells. E x t r a i r r i t a t i o n w i l l o n l y encourage
the conversion o f the h a e m a t o m a into a mass of
bone instead o f a l l o w i n g the desirable absorption o f
the blood a n d repair w i t h the m i n i m u m of scar
tissue. T h i s bone formation is sometimes seen i n
excess i n horse r i d i n g injuries, w h e n most o f the
adductors c a n be replaced w i t h bone - the so-called
rider's bone. T h i s comes about because o f repeated
injuries a n d damage to the a d d u c t o r muscles.
 Section 3.38-3.40
CAUSES
A s mentioned, the splits i n 2nd position or any
forcible a b d u c t i o n strain can cause the damage. A s
in any muscle injury it is far more c o m m o n i n the
(physically) under-trained dancer or i n the
(technically) b a d l y trained dancer. T h e injury can
range from a m i l d strain to large muscle tears.
TREATMENT
L o c a l l y - ice a n d rest are required i n the early
stages together w i t h ultrasound a n d interferential.
Strengthening exercises should commence as soon as
the i n i t i a l swelling has started to settle (not earlier
than 48 hours because it c a n take this long for the
bleeding to stop). T h e exercises should start gently
a n d , i f the damage is extensive, assisted active
exercises m a y be required before progressing to
exercises against g r a v i t y . T h e early use o f weights is
contra-indicated as i n a l l muscle tears.
T h e treatment is i n i t i a l l y a i m e d at:
1. absorption o f the b l o o d ;
2. h e a l i n g w i t h m i n i m u m o f scar tissue;
3. strengthening the muscle;
4. finally, stretching out the scar tissue.
Stretching should not start u n t i l good muscle tone is
restored (this is part o f a protective m e c h a n i s m a n d
can help to prevent re-tearing). Stretching is a i m e d
at preventing the scar tissue shortening. It should
only be carried out at the end o f the session o f local
treatment a n d exercise a n d w h e n the patient is
w a r m . T h e dancer should be taught h o w to stretch
himself as this w i l l be required for some months
after he returns to d a n c i n g , as there w i l l continue
to be a tendency for the scar tissue to contract u n t i l
it is fully mature. T h i s m a y not take place for some
six to twelve months. I f this gentle controlled
stretching is omitted, even i n apparently m i n o r
cases, a state c a n be arrived at where the adductors
have tightened a n d contracted so that c h r o n i c a n d
recurrent problems ensue a n d become almost
untreatable.
3.40 Groin Strains
These can affect several muscles i n the g r o i n area.
It is more i m p o r t a n t to isolate the cause o f the
injury rather than to w o r r y about w h i c h p a r t i c u l a r
muscle has been strained. T h e commonest site is the
o r i g i n o f the rectus femoris a n d the sartorius.
CAUSES
G r o i n strains are usually brought about by faulty
technique aggravated by any weakness. T h e r e m a y ,
i n fact, be no a c t u a l muscle weakness but the faulty
137
technique encourages the use o f the w r o n g muscles
a n d hence their strain, especially i f a h i g h n u m b e r
of repetitions are c a r r i e d out. O c c a s i o n a l l y the
damage can be caused by over-stretching, as i n the
splits. Weakness or failure o f adequate function o f
the adductors o n the s u p p o r t i n g side w i l l i n h i b i t the
function of the adductors o n the w o r k i n g side,
leading to over-use o f the muscles crossing the front
of the g r o i n . F a i l u r e o f use o f the s u p p o r t i n g
adductors m a y arise from causes outside this area;
for example, trunk faults or foot faults. I n an
exercise sense one or other (right or left) group o f
adductors c a n be isolated but once the dancer is
standing there is considerable stimulatory overflow
functionally from one side to the other, hence the
lack o f correct use i n one a d d u c t o r group w i l l
affect the opposite g r o u p . It follows therefore that a
great deal o f attention must be p a i d to the side
opposite to that w h i c h has been the site o f injury.
T h e weight back situation, however caused, also
leads to g r o i n strains.
E x a m i n e the state o f the hamstrings, the
adductors a n d the fascia l a t a .
I n the hamstrings look for tightness a n d
i m b a l a n c e m e d i a l versus lateral a n d p a r t i c u l a r l y
ask about any past history o f h a m s t r i n g tears. I n
the case o f an o l d h a m s t r i n g i n j u r y the muscle m a y
have been left scarred a n d shortened because o f
inadequate treatment o f the o r i g i n a l i n j u r y ,
possibly o n l y b y rest alone. I f this c o n d i t i o n has
occurred it w i l l then give an u n e q u a l p u l l o n the
pelvis, i n w h i c h case the dancer w i l l lean over the
affected leg, shortening the front o f the h i p and
causing the g r o i n strain.
I n the adductors it is often found that they are
tightened o n the injured g r o i n side. It is d o u b t f u l
whether this tightness preceded the g r o i n injury o r
whether it came o n following the onset o f the
symptoms from the g r o i n . I n a n y case the tightness
of the adductors w i l l require active treatment.
T h e fascia lata is often tight w h e n there is a
g r o i n strain a n d like the adductors it is questionable
whether the tightness was present before the i n j u r y
a n d therefore a c o n t r i b u t i n g factor or whether it
followed the injury. Tightness o f the tensor fasciae
latae a n d o f the fascia l a t a certainly prevents
proper adjustment o f the pelvis o n transference o f
the weight. T h i s c a n therefore cause excessive
corrections to take place i n the l u m b a r spine w i t h
injuries o c c u r r i n g there as w e l l as at the g r o i n .
T r e a t m e n t must i n c l u d e stretching these areas
where relevant b y h o l d / r e l a x techniques o r by static
stretching (not by forced stretching). (See Section
2.5 Stretching, page 88.) I n a d d i t i o n , the dancer
must stretch out the quadriceps muscle.
138 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
I f any g r o i n p a i n is persistent check that this is
not a referred p a i n from a back injury. I n
teenagers, look out for g l a n d u l a r fever developing,
i n w h i c h case they m a y also be c o m p l a i n i n g o f
some tiredness a n d lassitude without a n y t h i n g more
definite to indicate the presence o f a virus infection.
A n unusual cause o f groin p a i n m a y occur w h e n
the leg is elevated to the front or side above 90°.
T h i s is p r o b a b l y brought about by a m i n o r
anatomical abnormality. In normal individuals
there are some fibres from the rectus femoris
inserted into the front o f the h i p j o i n t capsule. O n
h i p flexion they are responsible for p u l l i n g the
capsule a w a y from the j o i n t so that it does not get
n i p p e d . Sometimes these fibres are absent a n d it is
probable that it is i n these circumstances that p a i n
is felt i n the g r o i n because the capsule is caught
between the femoral neck and the pelvis.
TREATMENT
U s u a l l y the local damage is not severe a n d swelling
only occasionally occurs. L o c a l l y , ultrasound
(which is usually best a p p l i é d w i t h the area on
stretch) a n d interferential therapy are n o r m a l l y a l l
that is required. T h e exercise p r o g r a m m e is the
most i m p o r t a n t part o f treatment a n d must
embrace technical correction. I n this c o n d i t i o n , the
p l a n n i n g o f the exercise regime a n d the technical
correction must be very closely allied. O n e cannot
be followed later by the other but must proceed i n
parallel from the b e g i n n i n g of treatment. ( U n l i k e
m a n y other conditions w h e n the technical
correction c a n start towards the end o f the
treatment programme.)
3.41 Hamstring Strains and
Tears
These m a y be a n y t h i n g from m i l d strains to large
tears a n d c a n occur at any level. A s i n the
adductors, damage can occur at the o r i g i n avulsing
the b o n y attachment a n d sometimes p u l l i n g off a
piece o f bone. I f the tenderness is h i g h up i n the
hamstrings, then an X - r a y should be taken i n order
to show whether there has been some b o n y avulsion
or not. T h e potential complications o f b o n y
avulsion are those w h i c h have already been
described for the same event o c c u r r i n g i n the
adductors.
CAUSES
T h e injury c o m m o n l y occurs d u r i n g unwise
stretching, p a r t i c u l a r l y w h e n the dancer is cold.
F a u l t y technique frequently causes the damage,
p a r t i c u l a r l y w h e n the weight is back a n d the
dancer is sitting i n the h i p while the w o r k i n g leg is
raised, as i n a g r a n d battement, battement penchéarabesque,
or even w i t h the leg raised i n 2nd position. I n these
circumstances the upper part o f the h a m s t r i n g
tends to be injured. T h i s basically comes about
because w h e n the dancer is sitting i n the h i p w i t h
the weight back, a l l the other muscle groups a r o u n d
the h i p fail to work correctly so that the upper
hamstring remains unprotected. A d d e d to this,
w h e n the weight is back the hamstrings are
themselves not being w o r k e d correctly a n d are
therefore not i n a state to tolerate stretch w e l l .
O v e r t u r n i n g causes the m e d i a l hamstrings to
over-work a n d this also produces under-use o f the
lateral hamstrings, w h i c h are then unfit for sudden
stretch. A false sense o f w a r m t h c a n be encouraged
by the use o f plastic trousers or other i m p e r m e a b l e
dance wear. These make the skin feel falsely w a r m
a n d c o m m o n l y this is not reflected b y an increased
blood supply more deeply. Therefore w o r k i n g i n
the plastic covering, p a r t i c u l a r l y i f any stretching is
being undertaken, can produce d a m a g i n g results.
A d d i t i o n a l l y , these types o f garments produce a
m a r k e d increase i n the sweating w h i c h is unable to
evaporate through the plastic. W h e n the garment is
removed for class or performance, the sudden
increase i n evaporation produces a m a r k e d local
fall i n temperature a n d this c h i l l i n g makes the
muscle more prone to injury.
TREATMENT
L o c a l l y , ice should be a p p l i é d i f there is swelling or
evidence o f bleeding. U l t r a s o u n d a n d interferential
are used to reduce both swelling a n d p a i n . O n c e
the p a i n a n d swelling are settling, a n exercise
p r o g r a m m e should be c o m m e n c e d a n d this
p r o g r a m m e should also embrace the allied muscle
groups such as the adductors, gluteals a n d
quadriceps, as well as ensuring that the h a m s t r i n g
muscle complex is itself functioning correctly.
Stretching should start gently a n d proceed i n a
manner similar to that described for the adductors.
T r e a t m e n t o f injuries at the upper end o f the
hamstrings can be difficult a n d prolonged.
Extensive technical help is required i f the injury is
chronic, recurrent or o f long-standing.
H a m s t r i n g , a d d u c t o r a n d g r o i n strains are a l l
conditions that only too frequently are treated by
ill-advised injections o f steroids. T h i s is i n part due
to a failure to persist w i t h conservative treatment
a n d i n part, especially i n long-standing cases, due
to the failure to identify the cause a n d to remedy
that adequately. These injections w i l l usually result
i n a treatable c o n d i t i o n b e c o m i n g more difficult to
treat. T h e whole treatment period is prolonged,
 Section 3.41-3.45
encouraging relapses following the apparent i n i t i a l
i m p r o v e m e n t from the injection.
3.42 Clicking Hip
CAUSES
T h i s is, as i n other joints, usually o f no significance
and harmless. It is c o m m o n l y caused by the
ilio-femoral ligament sliding across the femoral
head or by a tight b a n d o f fascia lata s l i p p i n g
backwards a n d forwards over the greater
trochanter. Its greatest p r o b l e m results w h e n the
dancer, usually a student, repeatedly reproduces the
click deliberately to see i f it is still h a p p e n i n g or as
a party piece. T h i s c a n lead to local swelling i n the
soft tissues a r o u n d the ligament a n d the onset o f
symptoms. These r a p i d l y settle w i t h reassurance
a n d avoidance as m u c h as possible o f movements
p r o d u c i n g the click, w h e n the local deep (not
visible) swelling w i l l r a p i d l y disappear.
A l t e r n a t i v e l y , the click m a y be caused by the fascia
lata slipping across the greater trochanter. T h i s c a n
be easily felt a n d , i f the person is t h i n , also seen. It
m a y be associated w i t h tight fascia lata w h i c h w i l l
require stretching out. V e r y rarely indeed local
treatment is ineffective a n d surgery m a y be
necessary for this latter cause o f c l i c k i n g .
3.43 Gluteal Bursitis
CAUSES
T h i s c o n d i t i o n is c o m m o n l y caused by p u l l i n g too
h a r d w i t h the gluteal muscles w h e n w o r k i n g o n the
turn-out, especially i f the dancer also 'tucks' the
buttocks a n d sacrum under at the same time. It
m a y also be precipitated by sitting i n the h i p ,
p a r t i c u l a r l y i f m a n y j u m p s are undertaken w i t h o u t
the dancer ' p u l l i n g u p ' properly. I n this case, the
tensor fasciae latae muscle a n d the fascia l a t a itself
w i l l increase the pressure on the distal part o f the
gluteal tendon a n d insertion. It is sometimes
associated w i t h a c l i c k i n g h i p w h e n the tendon o f
the fascia lata is clicked recurrently over the greater
trochanter.
TREATMENT
L o c a l treatment is by interferential a n d ultrasound.
U s u a l l y the dancer w i l l benefit from 48 hours or so
of rest a n d then a g r a d u a l return w i t h any
technical correction that m a y be required.
Complications
T h e bursitis can become very painful i f it is not
treated a n d p a r t i c u l a r l y i f a n y u n d e r l y i n g technical
139
p r o b l e m is not detected a n d e l i m i n a t e d . I f there has
been tightness o f the fascia lata there w i l l usually
be some a c c o m p a n y i n g quadriceps a n d a d d u c t o r
weakness w h i c h w i l l need special attention to b u i l d
them up.
3.44 Buttock Pain
CAUSES
Buttock p a i n m a y be p r o d u c e d by sciatic nerve root
i r r i t a t i o n i n w h i c h case the p a i n m a y radiate lower
d o w n the thigh or leg or it m a y be merely localised
to the buttock, p r o d u c i n g muscle spasm at that site.
L o c a l l y w i t h i n the buttock the p a i n can be
p r o d u c e d by tension i n the small h i p rotators,
a l t h o u g h even i n these circumstances, the sciatic
nerve as it passes b y these s m a l l rotators m a y be
irritated, p r o d u c i n g some r a d i a t i o n o f p a i n to the
thigh. T h u s the picture m a y be confused as to
whether the p r i m a r y o r i g i n o f the p a i n is w i t h i n the
buttock or whether it is a referred p a i n d o w n the
sciatic nerve due to nerve root pressure i n the back.
Back injuries themselves w i l l frequently produce
buttock p a i n w i t h a very well localised tenderness
w i t h i n the buttock due to secondary muscle spasm.
T e c h n i c a l faults frequently lead to buttock p a i n ,
either because o f misuse o f the lower back or by a
failure to h o l d the turn-out, p a r t i c u l a r l y w h e n
j u m p i n g . T h e reason for failure to h o l d the
turn-out m a y not be p a r t i c u l a r l y obvious a n d m a y
be far removed from the h i p area.
TREATMENT
It is p a r t i c u l a r l y i m p o r t a n t to determine the cause
before starting treatment so that the cause itself
a n d not merely the effect c a n be treated. I f the
p a i n is due to tension i n the s m a l l rotators, i.e. a
genuine local cause, the local treatment should be
directed at release o f the muscle spasm.
Complications
These are largely due to diagnosis failure, i n
p a r t i c u l a r a mis-diagnosis o f a significant p r o b l e m
i n the l u m b a r spine, e.g. a disc prolapse o r a stress
fracture.
3.45 Sacroiliac Strains and
Displacements
These conditions d o not exist i n the d a n c e r or
sportsman. S a c r o i l i a c p a i n (apart from i n
i n f l a m m a t o r y disease) is referred p a i n from the
lower l u m b a r spine. T h e sacroiliac j o i n t is
immensely strong w i t h several very large ligaments
crossing the j o i n t b i n d i n g the two parts together.
140 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
A n y sort o f displacement is not possible i n dance
type injuries. E v e n i n severe accidents the bone
adjacent to the sacroiliac j o i n t is more c o m m o n l y
fractured rather than the sacroiliac j o i n t itself being
disrupted. O n l y i n pregnancy, w h e n a l l the
ligaments a r o u n d the pelvis soften a n d stretch to
allow delivery, is the sacroiliac j o i n t i n a c o n d i t i o n
where it c a n suffer strain. T h e often stated
diagnosis o f chiropracters a n d others alleging that
the sacroiliac j o i n t is 'out' is absolute nonsense a n d
even more so their assertion that they have 'put it
back' b y m a n i p u l a t i o n .
3.46 Pain in the Sacroiliac
Area
T h i s does not arise from w i t h i n the sacroiliac j o i n t
a l t h o u g h there is frequently tenderness over a n d
a r o u n d the j o i n t . T h e p a i n is either referred from
the l u m b a r spine or else it arises from the insertions
of the l o n g back muscles w h i c h are frequently i n a
protective spasm w h e n there is any u n d e r - l y i n g
back injury or l u m b a r disc lesion. Therefore i n
these cases a thorough investigation o f the l u m b a r
region o f the back is required. Tenderness just
above the sacroiliac j o i n t is usually due to a lesion
associated w i t h the 5th l u m b a r vertebra. T h i s m a y
be a facet j o i n t strain or a developing stress
fracture.
TREATMENT
Is o f the u n d e r l y i n g cause.
3.47 Strain of the Muscles
inserted into the Iliac Crest
These w i l l produce local tenderness a n d there is no
real difficulty i n the diagnosis. T r e a t m e n t is usually
straightforward but the strain c a n be due to a
technical fault w h e n one side o f the pelvis is
d r o p p e d , due to inadequate a n d i m b a l a n c e d trunk
musculature. Therefore a possible technical cause
should be investigated a n d eliminated d u r i n g
treatment. Sometimes p a i n , tenderness a n d b r u i s i n g
occur i n this area due to clumsy h a n d l i n g by the
boys, p a r t i c u l a r l y w h e n the boys are not strong
enough to cope adequately w i t h double lifting
work. It can also occur w i t h boys w h o have s m a l l
hands a n d find difficulty i n h a n d l i n g their partner.
3.48 Interspinous Ligament
Damage
These are the ligaments that lie between each
spinous process i n the posterior part o f the
i n d i v i d u a l vertebra.
CAUSES
H y p e r - f l e x i o n m a y sprain an interspinous ligament
a n d even produce tearing i f very forceful.
Hyper-extension c a n cause a n i m p i n g e m e n t o f
adjacent spinous processes w i t h a c r u s h i n g of the
interspinous ligament. T h i s is p a r t i c u l a r l y likely to
occur i n the dancer w h o fails to p u l l up the legs
a n d trunk properly before starting a back bend a n d
as a result w i l l produce a localised hyper-extension
at one level ( F i g . 3.36). Weakness o f the back
muscles m a y fail to control flexion, p a r t i c u l a r l y
w h e n the flexion movement is r a p i d a n d this
carried out repeatedly m a y cause a sprain of the
interspinous ligament.
TREATMENT
L o c a l l y , ultrasound a n d interferential are r e q u i r e d
a n d these are more effective w h e n a p p l i é d w i t h the
spine slightly flexed so as to open u p the
interspinous area. It is best done w i t h the patient
on the side as they seem to move a r o u n d less d u r i n g
treatment i n this position than w h e n l y i n g on their
face slightly flexed over a p i l l o w . T h e c o n d i t i o n is
often slow to settle due to the poor b l o o d supply to
the ligament. A considerable a m o u n t o f w o r k must
be done on strengthening the trunk muscles i n
order to c o n t r o l movements p r o p e r l y a n d to
prevent flexion a n d extension o c c u r r i n g p r i n c i p a l l y
at one or two levels alone.
T h e so called 'kissing spine' is a n i m p i n g e m e n t o f
the spinous processes at one level. It produces a
crushing o f the interspinous ligament as m e n t i o n e d
above, w i t h localised p a i n a n d tenderness. It is
mentioned here merely because it has been
described as a specific c o n d i t i o n w h i c h requires
treatment by surgery. T h e proposed surgical
treatment is to excise the adjacent p o r t i o n o f the
spinous process together w i t h the interspinous
ligament thus preventing the bony processes
touching d u r i n g hyper-extension at this p a r t i c u l a r
level. A s the i m p i n g e m e n t arises because o f a
technical fault a n d a failure to p u l l up a n d spread
the extension movement over the w h o l e l u m b a r
area, surgery is certainly not i n d i c a t e d a n d can o n l y
be condemned. R e m o v a l o f the interspinous
ligament c a n cause a g r a d u a l l y increasing loss of
stability o f the spine at that level w i t h potentially
serious l o n g term results. P r o p e r trunk
 Section 3.46-3.51
3.36 K i n k i n g in the lumbar region on a back bend.
This is due to the dancer failing to pull up the legs and
the trunk (i.e. she does not have the feeling of
lengthening both areas) before starting to bend
backwards. This photograph also shows the presence of a
stiff lower lumbar segment.
strengthening exercises a n d technical correction w i l l
relieve the symptoms w i t h o u t any recourse to
surgery.
3.49 Facet Joint Strains
These joints are small synovial joints i n the
posterior b o n y complex o f each vertebra a n d like
s i m i l a r joints elsewhere c a n be subject to sprains
a n d strains. T h e injury is produced by u n c o n t r o l l e d
movements, p a r t i c u l a r l y w h e n these become
asymmetrical. It occurs most c o m m o n l y d u r i n g
jumping.
DIAGNOSIS
Deep tenderness at the side o f a l u m b a r vertebra or
on both sides i f the c o n d i t i o n is bilateral, a n d p a i n
on hyper-extension w i t h a tilt to one side as w e l l as
backwards, is very suggestive o f a facet j o i n t
p r o b l e m . S i m i l a r l y , p a i n m a y be caused o n flexion
i f there is also c o m b i n e d w i t h this a tilt to one or
other side. T h i s w i l l tend to stretch the s y n o v i u m
a n d capsule o f the facet j o i n t .
TREATMENT
L o c a l treatment to relieve p a i n a n d muscle spasm is
required a n d this should be a c c o m p a n i e d by a
period o f rest from d a n c i n g . A s the i n i t i a l p a i n
settles, an exercise p r o g r a m m e c a n be c o m m e n c e d .
T h i s should be directed at strengthening the trunk
muscles, correction o f any asymmetrical w o r k i n g
a n d also, a n d very i m p o r t a n t l y , at strengthening
the c o n t r o l o f the turn-out, p a r t i c u l a r l y w h e n the
dancer is i n the air. I n these cirumstances the
141
turn-out c a n o n l y be h e l d b y the muscles w o r k i n g
correctly. T h o s e dancers w h o depend u p o n friction
of their feet on the floor to h o l d the turn-out are
p a r t i c u l a r l y prone to this type o f injury, as well as
m a n y other injuries at other levels.
I f the c o n d i t i o n is long-standing, it is occasionally
necessary to inject the facet j o i n t w i t h
H y d r o c o r t i s o n e . T h i s s h o u l d , however, o n l y be
necessary occasionally as most patients w i l l have
settled w i t h n o r m a l conservative treatment. I f a n
injection is to be c a r r i e d out, then i d e a l l y it should
be done using a n X - r a y image intensifer so that the
exact l o c a t i o n o f the p o i n t o f the needle c a n be
visualised p r i o r to injecting the H y d r o c o r t i s o n e .
Complications
A facet j o i n t inflamed b y injury c a n produce a
referred sciatic-type p a i n because the sciatic nerve
roots r u n closely past the facet joints at each level.
T h i s c o n d i t i o n c a n to a certain extent m i m i c a
l u m b a r disc lesion from w h i c h it must be
differentiated. I f there is d o u b t about the
differential diagnosis, then infiltration o f the facet
j o i n t w i t h a local anaesthetic u n d e r visual c o n t r o l ,
using an X - r a y image intensifer, w i l l clarify the
diagnosis, because the l o c a l anaesthetic w i l l
t e m p o r a r i l y relieve symptoms from a facet j o i n t b u t
not from a genuine l u m b a r disc prolapse, p r o v i d e d
the local anaesthetic injection is accurately p l a c e d
into the facet j o i n t .
3.50 Lumbar Disc Prolapse
A l u m b a r disc prolapse or so-called slipped disc is
not p a r t i c u l a r l y c o m m o n i n dancers, despite the
movements w h i c h i n v o l v e the back a n d the heavy
lifting for the boys. I n the acute stages, especially
w h e n there is sciatic nerve root i n v o l v e m e n t , the
treatment is a routine o r t h o p a e d i c p r o b l e m .
H o w e v e r , once the dancer is i n the recovery phase,
considerable attention is p a i d to strengthening the
trunk, gluteal a n d l o w e r l i m b muscles w i t h
p a r t i c u l a r emphasis o n the correction o f any
technical faults.
3.51 Stress Fractures of the
Lumbar Vertebrae
These occur i n the pars interarticularis, most
c o m m o n l y at the L . 4 a n d L . 5 levels. A l t h o u g h the
fracture m a y be u n i l a t e r a l , it is more c o m m o n l y
142 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
3.37 A stress fracture (arrowed) in the pars
interarticularis of the 5th lumbar vertebra.
bilateral, affecting both partes interarticulares at
that p a r t i c u l a r level ( F i g . 3.37). T h e c o n d i t i o n can
occur at any age from early student days through
to mature adult life. I f the stress fracture is not
detected early, the fracture can g r a d u a l l y w i d e n
and separate so that the vertebral body a n d the
whole spine above w i l l slowly slip forward, leaving
the posterior bony r i n g w i t h the spinous process
and inferior a r t i c u l a r facet b e h i n d . O n c e this has
started to occur, there is no chance o f the fracture
u n i t i n g . T h i s c o n d i t i o n w i t h a forward slip is
k n o w n as a spondylolisthesis ( F i g . 3.38).
CAUSES
T h e most i m p o r t a n t single cause o f stress fractures
is a failure to p u l l up at the trunk a n d is associated
w i t h weak trunk muscles, p a r t i c u l a r l y the
a b d o m i n a l s . T h e two major p r e c i p i t a t i n g factors
are a l o r d o t i c posture i n order to try to give more
external rotation (turn-out) at the hips a n d over
t u r n i n g . (Sections 5.6 a n d 5.7).
I n p a r t i c u l a r these faults produce an excessive
a m o u n t o f movement (flexion, extension, lateral
flexion a n d rotation) at one single level instead o f
h a v i n g the movement evenly distributed throughout
the l u m b a r spine. T h e greatest stress occurs at the
point where the l u m b a r spine is attached to the
solidly r i g i d pelvis at the lumbo-sacral j u n c t i o n .
DIAGNOSIS
C l i n i c a l l y the dancer w i l l present w i t h l o w back
p a i n associated w i t h muscle spasm a n d tenderness
3.38 A n X-ray of a spondylolisthesis. The 4th lumbar
vertebra has slipped forwards on the body of the 5th
lumbar vertebra. The single arrow indicates the
mal-alignment of the posterior margins of the two
vertebral bodies. In this instance there is a forward slip
of about 1 cm. The double arrow shows the defect in the
bone which started as a stress fracture (vide Fig. 3.37).
at the sides o f the affected vertebra, about a
centimetre or two from the m i d line. These signs
are very suggestive o f stressing at this level, or the
next stage o f deterioration w h e n there is a n actual
stress fracture present. A s early diagnosis is
extremely i m p o r t a n t . T h e presence o f a fracture
should be strongly suspected w h e n local treatment
and trunk exercises do not r a p i d l y abolish the
muscle spasm. T h e diagnosis can be confirmed by
oblique X - r a y s o f the l u m b a r spine, but X - r a y
changes w i l l not usually be present for some one to
two months, or even longer, from the time o f onset
of symptoms. H e n c e i f a fracture is suspected and
i f X - r a y s appear n o r m a l , a bone scan should be
undertaken. T h i s w i l l show a 'hot spot' at the
fracture site i n the early days o f its development. I f
necessary, due to persistence o f symptoms, there
should be no hesitation i n repeating the scan a few
weeks later.
TREATMENT
A patient w i t h a stress fracture requires a plaster o f
Paris jacket for four months. D u r i n g this time the
patient should be encouraged to exercise a l l l i m b
muscles. W h e n pain-free i n the plaster, the dancer
may return to some l i m i t e d barre w o r k , keeping the
legs l o w . W h e n the plaster cast is finally removed, a
temporary corset should be fitted. T h e dancer then
embarks u p o n an intensive course o f trunk muscle
strengthening exercises. W h e n c o n t r o l o f the trunk
is regained, the corset can be g r a d u a l l y discarded.
 Section 3.51-3.52
O n starting class w o r k , a l t h o u g h the back w i l l be
protected b y the temporary corset, the legs must be
kept l o w a n d port de bras l i m i t e d a n d trunk
movements kept from extreme flexion a n d
extension, a l t h o u g h the corset w i l l tend to prevent
this h a p p e n i n g . W h e n the corset is discarded for
class, care must still be exercised to l i m i t the range
of flexion a n d extension u n t i l strength builds u p
satisfactorily. F r o m the time class is c o m m e n c e d a
careful w a t c h must be kept for the original technical
fault which precipitated the injury. T h e muscular
b u i l d - u p a n d r e h a b i l i t a t i o n w i l l take at least two
months before the dancer c a n g r a d u a l l y increase
w o r k towards a full a n d n o r m a l class. A plaster o f
Paris cast is required as the i n i t i a l treatment i n
order to prevent the dancer from m o v i n g the spine
excessively. It must not be considered to completely
immobilise the spine, w h i c h w o u l d be impossible.
H e n c e the need for a supervised p r o g r a m m e o f
l i m b exercises a n d careful a n d l i m i t e d barre w o r k .
T h e plaster m a y require c h a n g i n g once or twice
d u r i n g the four months because loss o f trunk b u l k
w i l l take place a n d the plaster jacket w i l l become
loose.
A s an alternative, a n d o n l y to be considered i n
dancers w h o c a n be relied u p o n 100% to obey
instructions, the plaster c a n be omitted a n d a
lightweight corset used instead. D u r i n g the four
m o n t h period, d u r i n g w h i c h it is hoped that u n i o n
of the stress fracture w i l l take place, trunk muscle
exercises can be carried out. These should be almost
isometric. T h e corset c a n be removed for these
supervised exercise sessions but must be r e - a p p l i é d
i m m e d i a t e l y after the end o f treatment. B y almost
isometric exercises we mean exercises that use o n l y
a s m a l l range o f movement, not genuine isometric
exercises w h i c h , by definition, should have no
actual movement t a k i n g place. It is essential that
d u r i n g this four m o n t h healing period the dancer
does n o t h i n g that puts the spine through excessive
movement or under stress. I f there is any suggestion
that the dancer is not c o m p l y i n g , then a plaster cast
should be a p p l i é d . After the first few weeks the
dancer c a n do l i m i t e d barre w o r k i n the corset
under very close supervision. A t the end o f the four
m o n t h p e r i o d , the further r e h a b i l i t a t i o n follows
that w h i c h w o u l d take place w h e n a plaster o f Paris
cast has been removed. H o w e v e r , the dancer w i l l be
m u c h further advanced w i t h his muscle b u i l d - u p
because o f the exercise p r o g r a m m e he has been
able to follow i n the absence o f a plaster. T h i s
shortens the r e h a b i l i t a t i o n period very significantly
a n d to a well w o r t h w h i l e extent. H o w e v e r , it must
be emphasised that the method is o n l y a p p l i c a b l e i n
really w e l l disciplined dancers w h o are g o i n g to be
143
under very close supervision from conscientious a n d
aware staff. I f there is a n y doubt, a plaster o f Paris
cast should be used. W e have found the m e t h o d
w i t h o u t plaster very effective, a l t h o u g h the n u m b e r
of dancers for w h i c h it is suitable is very l i m i t e d .
3.52 Dorsal and Upper Spinal
Pain
T h i s c a n occur at various levels from the m i d
dorsal region upwards. It is frequently acutely
painful a n d often produces girdle p a i n , i.e. p a i n
r a d i a t i n g a r o u n d the chest w a l l , sometimes as far as
the sternum. E v e n more frequently, the p a i n
radiates to the scapula area o f the back. I n the
upper spine, especially the cervical region, it c a n be
a c c o m p a n i e d b y head p a i n a n d shoulder a n d a r m
pain.
CAUSES
It is usually brought o n b y w o r k i n g w i t h tension i n
the upper trunk, shoulder girdle or neck a n d is
often associated w i t h weakness o f the muscles, not
o n l y i n these areas but also i n the lower back a n d
i n the muscle groups c o n t r o l l i n g turn-out. T h e two
latter areas - lower back a n d turn-out — w h e n
weak, not o n l y m a k e dancers feel insecure w h i l e
w o r k i n g a n d thus increase tension higher, but w i l l
also encourage rotation o f one or other side o f the
upper trunk i n relation to the l o w e r trunk a n d
pelvis. I n these dancers the u p p e r b o d y weight is i n
the w r o n g place. It m a y also be associated w i t h
swayback knees or a n y t h i n g else g i v i n g rise to
w r o n g weight placement.
I n boys it c a n also be associated w i t h incorrect
lifting. O v e r - d e v e l o p m e n t o f the shoulder girdle i n
boys due to ill-advised weight t r a i n i n g c a n produce
s i m i l a r effects because o f the relatively weaker a n d
often neglected lower trunk. T h e mass o f muscle at
the top o f the trunk makes balance more difficult
a n d , w h e n j u m p i n g , the u p p e r t r u n k c a n frequently
be observed from the side to be back b e h i n d a n
i m a g i n a r y line passing t h r o u g h the centre o f
gravity a n d d o w n t h r o u g h the greater trochanters.
A n o t h e r cause is b r o u g h t about b y dancers w h o are
told to flatten their scapulae to the chest w a l l a n d
do so by rotating their shoulder joints too far
forward. T h i s tends to m a k e the pectoral muscles
contract vigorously a n d g r a d u a l l y tighten. It also
makes for a great deal o f tension a r o u n d the
shoulder girdle. F l a t t e n i n g the shoulder blades w i l l
take place n a t u r a l l y as the trunk muscles are
generally strengthened. T h e latissimus dorsi plays
a n i m p o r t a n t part i n the c o n t r o l o f the scapulae.
144 Section 3: Specific Injuries: T h e i r C a u s e a n d T r e a t m e n t
TREATMENT
A c u t e dorsal p a i n can usually be relieved b y
M a i t l a n d mobilisations but it is vital to remember
that this method o f p a i n relief is only the b e g i n n i n g
of treatment a n d not an end i n itself. O n c e the
acute p a i n has been relieved, either by the
mobilisations or by ultrasound, interferential or
other methods, the cause w i l l have to be
investigated - usually a technical fault - a n d
e l i m i n a t e d a n d any necessary strengthening
exercises at various levels w i l l have to be instituted.
A m o n g c o m m o n l y neglected technical faults are
incorrect a r m movements related to dance.
U n f o r t u n a t e l y , a r m movements are only too often
ignored as a potential cause of problems.
3.53 Acute Torticollis
T h i s is a c o n d i t i o n where because of p a i n the head
is tilted to one side. It is also k n o w n as acute w r y
neck a n d is often referred to by patients as a crick
i n the neck.
CAUSES
It is quite c o m m o n i n adolescence a n d is not
necessarily associated w i t h dance. I n dancers,
whether students or professionals, it is often
precipitated by trunk instability and by a tendency
to sit i n one or other h i p , because y o u n g dancers
are usually very p r e d o m i n a n t l y right or left sided
(right or left handed). W i t h training, this
predominance o f one side or another is decreased
w h e n d a n c i n g though it often remains to a greater
or lesser extent. M o s t dancers never achieve a
complete equalisation. T h e y nearly a l l have a
preferred side on w h i c h to work.
TREATMENT
L o c a l treatment i n the form o f ultrasound a n d
interferential can help. Massage is p a r t i c u l a r l y
useful i n this c o n d i t i o n a n d often some neck
traction w i l l help to give i n i t i a l relief. A s it is often
associated w i t h a fault elsewhere, this requires
e l i m i n a t i o n a n d correction to prevent recurrences.
3.54 Shoulder and A r m
Problems
These are not p a r t i c u l a r l y c o m m o n i n dancers. A
supraspinatus tendonitis or sub a c r o m i a l bursitis
can occur i n boys, following a lot o f lifting.
Frequently, as i n general members o f the
p o p u l a t i o n , a local injection o f steroid w i l l relieve
these two conditions.
R e c u r r e n t dislocations o f a shoulder i n i t i a l l y
follow a fall, as i n the case o f non-dancers. T h e
i m p o r t a n t aspect i n dancers is that, i f surgical
repair is necessary, then the method used must be
one w h i c h does not l i m i t shoulder movements. T o
this end, the coracoid transfer operation (Bristow or
B o n n i n operation) is the best choice, p r o d u c i n g as it
does complete stability w i t h o u t any l i m i t a t i o n o f
external rotation as always occurs i n the P u t t i - P l a t t
or B a n k a r t procedures.
O t h e r upper l i m b injuries usually follow a fall or
similar t r a u m a a n d are not really dance injuries b u t
merely injuries w h i c h h a p p e n to occur i n a dancer.
T h e y are a l l treated by standard orthopaedic
measures. T h e o n l y i m p o r t a n t point w o r t h m a k i n g
is that d u r i n g treatment (plaster o f Paris, etc.) the
dancer c a n work out or have w o r k e d out for h i m a
p r o g r a m m e o f general exercise to keep the rest o f
the body as fit as possible.
 SECTION
Strengthening Exercises
In this Section we describe a variety o f
straightforward exercises w h i c h c a n be performed
by any dancer or student (or anyone else) w h o
wishes to strengthen u p various portions o f the
body. T h e photographs should be studied i n
conjunction w i t h the captions before e m b a r k i n g
u p o n each exercise. I n some cases there are several
exercises w h i c h are graduated a c c o r d i n g to
difficulty a n d strength required, so start w i t h the
easiest. It is i m p o r t a n t to c a r r y out each exercise
accurately. T h e y a l l need to be performed slowly
w i t h the b o d y or l i m b under full c o n t r o l the whole
time. T h e various groups o f muscles being exercised
must be kept firmly tightened throughout the
exercise, e.g. i n a lifting exercise the muscles can be
made to w o r k just as h a r d d u r i n g the controlled
l o w e r i n g phase as w h e n lifting, thus utilising the
time taken to best advantage. T h e r e should be
complete relaxation between each cycle o f an
exercise, e.g. tighten, lift, h o l d , lower, relax a n d
then repeat. I f this relaxation is omitted then the
muscle m a y go into c r a m p . A good routine is to
count five slowly for each phase o f the cycle -
tighten (5), lift slowly (5), h o l d (5), lower (5), relax
(5).
T h e dancer a n d student c a n w i t h benefit take a
comprehensive selection o f exercises a n d put them
into a regular d a i l y routine. T h e strengthening
achieved w i l l go a l o n g w a y toward h e l p i n g i n
injury prevention.
These exercises are not designed to i m p r o v e
cardio-respiratory fitness, although they w i l l have a
slight beneficial effect. A different type o f exercise
p r o g r a m m e w i l l be required a d d i t i o n a l l y for this,
e.g. s w i m m i n g , c y c l i n g , etc. Exercises are specific i n
FOUR
their end result. ' T a k i n g exercise' as such w i l l not
produce a l l - r o u n d fitness a n d strength o f a l l areas.
A specific p r o g r a m m e needs to be devised to meet
the requirements o f the i n d i v i d u a l . These exercises
are m a i n l y devised to be a n adjunct to class (or
other forms o f exercise for non-dancers) a n d are
not a n alternative.
W e have tried to select a cross-section o f exercises
w h i c h should be readily understood a n d correctly
performed w i t h o u t confusion as to purpose or
m e t h o d o f performance. T h e y are o b v i o u s l y only a
very small n u m b e r o f the possible variations but
m a y p r o v i d e some help to the dancer w h o wishes to
a v o i d the time a n d expense o f visiting a
physiotherapist to be taught exercises. H o w e v e r , i f
i n d o u b t as to whether y o u are i n fact d o i n g the
exercise correctly then some competent professional
help w o u l d be advisable. I f an exercise seems
p a r t i c u l a r l y easy a n d effortless y o u m a y be d o i n g it
incorrectly.
T h e exercises have been demonstrated b y a m a l e
dancer o n l y because the muscles are usually more
visible t h a n i n a g i r l .
Remember:
1. A l l the exercises must be c a r r i e d out slowly a n d
u n d e r full c o n t r o l . D o not bounce.
2. A l w a y s try to tighten the muscles b e i n g
exercised that little bit more especially d u r i n g a
' h o l d phase'.
3. R e p e a t the exercise w i t h the other side o f the
b o d y or the other l i m b . A weaker g r o u p m a y
require more repetitions t h a n its counterpart
but even so d o not neglect the 'good side'.
146 Section 4: Strengthening E x e r c i s e s

4.1 4.2
4.1 4.2 4.3 4.4
Abdominal exercises for the straight muscle fibres (rectus abdominis). These are carried out by means of sit-ups. The
knees are flexed to prevent the lumbar spine from becoming lordotic. The shoulder girdle must not do the main bulk
of the work. The abdominal muscles must be used as hard on the way down as on the way up.

4.5 4.6 4.7

This is the incorrect way to do abdominal exercises. Lifting
legs straight produces a lumbar hyperextension (lordosis)
and can lead to lumbar back strains. The figures clearly
show the marked lordosis that can be produced. In Fig.
4.7 the hand under the lumbar spine is merely to
demonstrate the large gap between the spine and the
floor.
4.5

4.8 4.9
4.8 4.9
Abdominal exercises for the straight fibres requiring more control and a more powerful use of the muscles.
 Section 4: Strengthening E x e r c i s e s 147

4.3 4.4

4.6 4.7

4.10 4.11

4.10 4.11
Abdominal exercises for the cross fibres (external and internal oblique muscles). The basic starting position is as tor
sit-ups. The twisting motion begins as soon as the movement is initiated. D o alternate sides, working first one and then
the other.
 148 Section 4: Strengthening E x e r c i s e s

4.12 4.13
4.12 4.13 4.14 4.15
Exercises for the back extensor muscles. Start lying with the shoulder blades pulled down and the buttocks held
firmly. Then, while the arms are kept in contact with the floor, the head and shoulders are lifted by the back
extensors. They are not pushed up by the arms. The waist is pulled in during the exercise.

4.16 4.17 4.18

Exercises for the back extensor muscles - a progression
from the previous exercise. The shoulder blades are
pulled down to prevent neck tension. The waist is pulled
in. The buttocks are held tightly.
4.16

4.19 4.16
4.19 4.20 4.21 4.22
Exercises for the back extensor muscles - a progression from the previous exercise. The same rules apply. The exercise
requires more powerful use of the muscles.
 Section 4: Strengthening E x e r c i s e s 149

4.14 4.15

4.17 4.18

4.21 4.22
150 Section 4: Strengthening E x e r c i s e s

4.23 4.24 4.25

Exercises for the back extensor muscles - very much
more advanced. The same rules apply. Repeat the
exercise using alternate arms.
4.23

4.28

4.26 4.27
4.26 4.27 4.28
Exercises for the back extensor muscles with some rotation. Repeat on the other side. The same rules apply as for
previous extensor exercises. Fig. 4.28 shows a side view of the exercise.
 Section 4: Strengthening E x e r c i s e s 151

4.24 4.25

4.29
Exercises for the back extensor muscles with some
rotation, more advanced with the arm out. Repeat on the
other side. The same rules apply as before.
There are many other exercises for the extensor
muscles of the back but these particular exercises have
been devised for people without equipment.
4.29

4.30 4.31 4.32

4.30 4.31 4.32
Simple side exercises standing. Care must be taken not to twist the pelvis and the waist. The waist must be pulled i n
during the exercises and must be pulled in harder on the way up. Do the exercise on alternate sides. Do not bounce.
152 Section 4: Strengthening E x e r c i s e s

4.33 4.34 4.35 4.36

Exercises for strengthening the lateral trunk muscles (lateral flexors). Start
with the right arm above the head, waist pulled in. Bend over to the left.
Bring the left arm up until nearly parallel to the right arm. Slowly stand up
straight with both arms above the head. Lower the right arm. Repeat exercise
bending over to the right. Keep waist well pulled in throughout the exercise,
pulled in harder when coming up. Also pull shoulder blades down when
coming up otherwise shoulders will tend to become elevated.
4.33

4.37 4.38
4.37 4.38
Exercises for strengthening lateral trunk muscles. A progression from the previous exercise. The lower elbow and
forearm are used for balance only and not for total support. Pull waist in well. The legs and trunk must be kept lined
up. Repeat the exercise the same number of times on the other side.
 Section 4: Strengthening E x e r c i s e s 153

4.34 4.35 4.36

4.39 4.40
4.39 4.40
Exercises for strengthening the lateral trunk muscles. A further progression from the previous exercises. The legs must
be kept lined up with the trunk and pressed together. They should also have the feeling of being 'lengthened', that is,
pushed distally away from the trunk to avoid bunching up of the lateral flexor muscles. Keep the waist (the
abdominal muscles) well pulled in during the exercise.
154 Section 4: Strengthening E x e r c i s e s

4.41 4.42 4.43 4.44 4.45 4.46 4.47 4.48 4.49

Quadriceps exercises. The same exercise seen from the side and from the front in two different dancers. Fig. 4.49
snows well that the vastus medialis is contracting very firmly. The hip, knee-cap and the centre of the foot must be
kept lined up. The pelvis is kept square with the weight equally on both buttocks. The knee is allowed to flex slightly
over a pillow during the relaxation phase. The trunk must lean back away from the leg because it leaves the hip more
free. Repeat with the other leg.

4.41 4.42

4.43 4.44
 Section 4: Strengthening E x e r c i s e s 155

4.45 4.46

4.48

4.47

4.49
156 Section 4: Strengthening Exercises

4.50 4.51

4.50 4.51 4.52 4.53

Exercises for strengthening the adductor muscles in the thigh. The upper leg is flexed at the hip to a right-angle (90°)
in order to allow the lower leg which is being exercised freedom to move. The upper leg must be supported in order to
keep the pelvis square with the floor - it must not rotate either forwards or backwards. This support may be a folded
pillow as in Figs 4.50 and 4.51 or stool as in Figs 4.52 and 4.53, or even a low bed. Support the head on the elbow.
The exercising leg must be kept with the knee-cap pointing forwards throughout the exercise. Do not pull the leg into
the hip when lifting it; feel that the leg is lengthened. Pull in the abdominal muscles. Repeat with the other leg.

4.56

4.56 4.57 4.58 4.59

Adductor muscle exercises. Slightly more difficult exercises than the foregoing.
The leg is carried forward and lifted.
 Section 4: Strengthening E x e r c i s e s 157

4.52 4.53

4.54 4.55
The same exercise seen from above.

4.54 4.55
4.57 4.58 4.59
 158 Section 4: Strengthening E x e r c i s e s

4.60 4.61 4.62

Adductor muscle
exercises. Similar to the
last exercise but the leg
is carried backwards and
then lifted.
4.60 4.61 4.62

4.63 4.64 4.65 4.66

4.71 4.72 4.73 4.74

4.63 4.64 4.65 4.66 4.67 4.68 4.69 4.70 4.71 4.72 4.73 4.74 4.75 4.76 4.77 4.78 4.79
Exercises for the gluteal muscles (abductors). This exercise is carried out lying on the side with the underneath leg
bent at hip and knee. The back is kept straight. The top leg must be kept lined up with the trunk. The knee-cap must
face forwards. Lift the leg stretching it downwards, i.e. a feeling of lengthening the leg. Carry out the exercise slowly.
Control the lowering of the leg as well as the lifting.
 Section 4: Strengthening E x e r c i s e s 159

4.67 4.68 4.69 4.70

4.75 4.76 4.77 4.78

4.79
160 Section 4: Strengthening E x e r c i s e s

4.80 4.81 4.82

Exercises for hip extensors (gluteus maximus). Straight
leg. The leg must be lined up with the trunk. Pelvis must
not be twisted or move. This is purely a leg movement.
The pillow is to keep the lumbar spine as flat as possible.
Carry out with alternate legs.

4.83 4.84 4.85 4.86

H i p extensor exercises. Progression from the previous exercise. Start straight.
When the leg is elevated take it out to the side in abduction and then across
the other leg into adduction and then back to the mid-line. Pelvis must be
kept flat and must not twist.
4.83

4.87 4.88 4.89

Hamstring exercises. Start lying flat. The legs must be
lined up with the trunk. Flex the knee without any
rotation of the thigh. The heel lines up with the centre of
the buttocks on the same side.
 Section 4: Strengthening E x e r c i s e s 161

4.80 4.81 4.82

4.84 4.85 4.86

4.87 4.88 4.89

162 Section 4: Strengthening E x e r c i s e s

4.90 4.91 4.92

Hamstring exercises. Side view. Keep the gluteal
(buttock) muscles held tightly during the exercises in
order to prevent the hip flexing.
4.90

4.93 4.94

4.93
4.93 4.94
4.94 4.95 4.96
Peroneal muscle exercises. These are better done with the knee extended. Carry out the exercise first in some degree of
plantar-flexion (not full plantar-flexion, i.e. not with the foot fully pointed) and repeat with the foot and ankle at a
right-angle.

4.97 4.98

4.97 4.98 4.99

Intrinsic muscle exercises. Fig. 4.97 shows the dancer's right foot working. Fig. 4.98 shows the left foot working. Fig.
4.99 shows both feet working.
 Section 4: Strengthening E x e r c i s e s 163

4.91 4.92

4.95 4.96

4.99 4.100

4.100
Calf muscle and Achilles tendon stretch. Keep the foot
flat on the floor, the heel down and the knee straight.
Stretch gently.
164 Section 4: Strengthening Exercises

Further exercise for the abdominal muscles.

These are stabilization exercises for the trunk. T h e spine and pelvis are held still and the lower limbs are used to
challenge the abdominal obliques, transversus abdominis and the back muscles i n their role as stabilizers.

4.101 4.102
4.101 4.102
The initial position is assumed with abdominal muscles engaged and the abdomen held flat. The lumbar spine is held in its
normal alignment, neither arched nor tucked under. The shoulders are held down with no tension in the neck. (Breathing is
from a sideways movement of the ribs with no lifting of the chest.)

4.103 4.104
Incorrect. The pelvis here is overly tucked under. Incorrect. The abdominals are not sufficiently activated
with transversus not pulling the abdomen flat.
 Section 4: Strengthening Exercises 165

4.105 4.106
4.105 4.106
From the initial position each knee is allowed to fall out to the side by about 45°, and returned without rocking of the pelvis
towards the working side. The abdomen is held flat throughout.
166 Section 4: Strengthening Exercises

4.107 4.108
From the initial position the thigh is lifted to a 90° angle at The second leg joins the first.
the hip. If the thigh is lifted less than 90°, control of the
pelvis, abdominal muscles and lumbar spine is significantly
challenged. Lifting further than 90° is easier and the
exercise must be carefully graded to ability. This exercise
alone, lifting and returning alternate legs, is the preliminary
exercise to prepare for the following sequences.

4.109 4.110
Abdominal control is reinforced. Either leg is lowered to the floor and then joined by the
next. The exercise is repeated starting with alternate legs.
 Section 4: Strengthening Exercises 167

4.111
Starting position. Arms and legs at 90° to the trunk. The
shoulders are held down strongly by latissimus dorsi muscles
and the abdominal muscles must be well activated.

4.112 4.113
The right leg extends while the left arm is raised. The lower The right leg and left arm return to the starting position to
the extending leg, the more the pelvis and abdominals are reinforce abdominals and latissimus dorsi before the oppo-
challenged. The lumbar spine must not arch. site limbs move.
168 Section 4: Strengthening Exercises

4.114
Starting position. This must be correctly placed. The spine must be held in
its normal curves with the lumbar spine neither rounded nor arched. The
abdominals must be fully engaged and the shoulders held down with scapu-
lae held flat.

4.114

4.115 4.116 4.117

The knee is brought forwards to the The knee is swept through towards a The leg is extended in line with the
chest but the spine is held still. The parallel arabesque line. trunk and behind the hip.
trunk remains sauare.

4.118 4.119
4.119
Releasing the opposite arm further Follow these with a good stretch for the spinal sensors,
challenges trunk control but the initial
exercises must be mastered first.
 Section 4: Strengthening Exercises 169

4.120 4.121
Incorrect. Weight bearing through Correct. Better positioning of the spine and shoulder blade.
arms is an effective way to feel
scapular stabilization. Here the
shoulder blades are winging out in a
weak position. Make sure they are
held down against the chest wall
with a good neckline as in photo-
graph 4.121

4.122 4.123 4.124

This exercise encourages control of The use of the arm makes this exer- Follow these exercises with a stretch
extension in thoracic spine with good cise more difficult to control. for the thoracic spine extensors.
use of latissimus dorsi holding the
shoulders down.
170 Section 4: Strengthening Exercises

4.125 4.126
In this exercise a lightweight rubber exer- The view from the back should show good
cise band is used. The elbows are held to scapular control. The exercise should be
the waist. The chest is held open and the practised without the band initially as the
shoulders are held down. As the hands band significantly increases resistance.
move apart the band is stretched. The
shoulder joints rotate outwards and the
muscles around the scapulae are strongly
activated.

4.127 4.128
4.127 4.128
Simple rotation exercises for the thoracic spine should be practised regularly to reduce
tightness and promote awareness of the part of the spine used in épaulement.
 Section 4: Strengthening Exercises 171

4.129 4.130
4.129 4.130
This exercise for latissimus dorsi uses the exercise band attached to the barre.
From an initial good posture the band is pulled downwards and just behind the
body. The shoulder girdle and pelvis remain square with the chest open and no
tension is taken in the neck.

4.131 4.132 4.133

Follow this with a stretch for those
muscles.
A good breathing pattern is important
for all exercises. While the abdominals
are pulled in, breathing must be from
a sideways excursion of the lower ribs.
Reinforce this by feeling the use of the
ribs in the supine position. N o lifting
of the sternum must be involved.
In the sitting position the exercise
band can be tensioned about the rib
cage. O n the breath in feel the lower
ribs expand sideways and backwards
into the band, again with no lifting of
the chest in front.
172 Section 4: Strengthening Exercises

4.134
4.134 4.135 4.136
4.136
The initial position involves side lying
with a well aligned spine and head 4.135 4.136
resting on the arm. The knees are The top knee lifts gently with little effort. The large seat muscle, gluteus maximus
bent at 90° with feet in line with the is not used but instead the underlying gluteal muscles can be felt. These help with
spine. control of turnout and should accompany exercises for the adductors.

4.137
This is an adductor exercise using the
exercise band for resistance. The legs
are placed apart from each other. The
working leg pulls across the midline in
parallel towards the other leg which is
bent up stabilizing the position. The
trunk should remain square.
4.138
4.138
The same exercise is executed with a
turned out leg. The ankle and foot can
be pointed or flexed. Do not allow
knees to fully hyper extend and make
sure the band is above the knee to
avoid strain,
 Section 4: Strengthening Exercises 173

4.139 4.140
4.139 4.140
This simple inside thigh exercise encourages coordinated use of the adductor, gluteal
and lower abdominal muscles.

4.141 4.142
4.142
Follow this by an adductor stretch. This shows an effective stretch for the
right gluteal muscles.

4.143 4.144
4.143 4.144
Controlled hamstring stretches.
174 Section 4: Strengthening Exercises

4.145 4.146
4.145 4.146
Proprioception exercises improve all the balance mechanisms. Simply practising differ-
ent positions with the eyes closed improves the coordination required to balance and
increases reflex reactions, especially in the foot and ankle.

4.147 4.148
4.147 4.148
Working on the wobble board performing simple movements in parallel and turnout
improves not only control of the foot and ankle, but all the postural muscles. In turnout
the external rotators are vigorously exercised.
 Section 4: Strengthening Exercises 175

4.149
This is an exercise for stability of th
the left
leg and foot. The exercise band is loope
looped
around the right ankle. The left knee must
be held over the foot and the alignment of
the foot perfectly maintained.
4.150
The right foot stretches the band forwards
while the left foot retains its stability with
all muscles of the ankle working. Increase
repetitions as the weight bearing leg
becomes accustomed to the exercise.

4.151 4.152
4.151 4.152
This exercise can be executed in different directions including stretching the band away
from the standing leg and towards it. It is important to relax and stretch the calf in
between exercises.
176 Section 4: Strengthening Exercises
4.153
The exercise band can be used to
exercise the calf and encourage a
lengthened use of the foot and toes.
4.155
A lightweight band can be used to
encourage strength in the first toe as it
pulls down without curling.
4.154
When held to the opposite side of the
body the band will bias the contrac-
tion of the outer calf muscles.
4.156
The same band can be used to
encourage good use of the outer toes
and outer foot. The outer toes too
must be lengthened as they point
downwards against the band.
 Section 4: Strengthening Exercises 177

4.157 4.158
4.157 4.158
The foot requires added exercises to encourage fine control. This exercise -
attempting to spread the toes and squeeze them together - can be added to those in
photographs 4.97-4.99.

4.159 4.160
4.159 4.160
Exercise to improve abduction strength of the first toe will further protect against
the forced valgus position imposed by ballet shoes.

A l l intrinsic exercises for the foot are readily managed by young students
and prepare the immature foot for the rigours ahead.
 SECTION
Technical Faults and Anatomical Variations:
Their Causes, Consequences and Treatment
All forms of treatment are relatively
pointless without complete correction of any
fault in technique
T e c h n i c a l faults m a y arise for various reasons.
T h e y c a n occur as a result o f the a n a t o m i c a l
structure o f the body, for example, restriction o f
turn-out being l i m i t e d by the bony a n d soft tissue
configuration a r o u n d the hips. T h e y m a y arise
because o f b a d teaching or equally because o f
inattention or laziness o f the student. O n c e faulty
technique has been learned it becomes extremely
difficult to correct a n d eradicate. Therefore poor
teaching i n the early days o f a student's life m a y
continue its effects throughout his professional
career. U n f o r t u n a t e l y , these faults w i l l tend to
increase w i t h the passage o f time, p a r t i c u l a r l y i f the
dancer is w o r k i n g i n the situation where there is no
continued teaching or correction from a ballet
master or ballet mistress.
All dance injuries arise from technical faults
Injuries from mishaps outside the dancer's control,
for example, falls downstairs or being d r o p p e d by a
partner, etc. cannot really be classed as dance
injuries. It should also be understood that, i n
general, the technical faults are frequently
relatively m i n o r but despite that they can produce
major problems for the dancer, either i n the actual
treatment o f the injury itself or more often i n the
prevention o f recurrences of the same injury. I n
general also, a major fault is unlikely to pass
uncorrected except i n the most inadequate o f
teaching situations. C e r t a i n l y the most i m p o r t a n t
difference between the good teacher a n d the
indifferent teacher is the ability o f the former to
detect s m a l l flaws i n technique a n d to b r i n g about
an accurate a n d complete correction i n the student.
A good teacher w i l l not allow a student to progress
to more difficult a n d d e m a n d i n g w o r k u n t i l he has
mastered the details o f the basic techniques. It is
impossible to overstress the importance o f technical
FIVE
faults i n their relation to both p r i m a r y a n d
recurrent injuries i n dancers.
It must also be pointed out that even i n the case
of a n o n - d a n c i n g injury, w h e n the dancer starts to
return to class he m a y as a result o f this injury start
to develop technical faults, p a r t i c u l a r l y i f he has
returned to class before the injury has settled fully
a n d before the r e h a b i l i t a t i o n is p r o p e r l y completed.
V e r y frequently technical faults are very closely
allied one w i t h another, a l t h o u g h their l o c a t i o n
m a y be w i d e l y separated a n a t o m i c a l l y . O n l y too
c o m m o n l y technical faults do not occur i n isolation
a n d this calls for a very careful assessment o f the
dancer. T h e detection o f one technical fault w h i c h
m i g h t have caused a n injury certainly does not rule
out the presence o f others w h i c h c o u l d be equally
or j o i n t l y responsible.
C o a c h i n g classes i n v o l v i n g technical correction
are a n essential part o f the r e h a b i l i t a t i o n o f an
injured dancer, even i f the injury is only m i n o r . A
dancer presenting w i t h an injury gives an ideal
o p p o r t u n i t y for a careful assessment o f a n y
technical faults. Referral to a c o a c h i n g session
should usually form part o f the treatment process.
These c o a c h i n g classes are best c a r r i e d out on a
one-to-one or one-to-two or at most three basis. It
is impossible to c a r r y out a n adequate technical
correction class after injuries w i t h more t h a n that
n u m b e r o f i n d i v i d u a l s . T h e r e is no doubt that
regular i n d i v i d u a l assessments o f a l l students w i t h a
p a r t i c u l a r eye for correct technique, w o u l d play a n
i m p o r t a n t part i n the prevention o f injuries.
T h e teaching o f something such as dance and
certainly the technical correction aspects, calls for a
great deal o f attention being p a i d to the really
accurate repetition o f movements a n d movement
patterns. T h e more c o m p l i c a t e d these patterns o f
movement become, the more i m p o r t a n t it is to take
time to ensure that they are learned correctly from
the beginning. Short cuts w i l l never lead to
satisfactory results. D a n c e teaching is a form of
co-ordination t r a i n i n g w h i c h develops
p r e - p r o g r a m m e d automatic m u l t i - m u s c u l a r
patterns. T h e p r e - p r o g r a m m i n g is developed w i t h i n
the b r a i n . It is automatic because m u c h o f it does
not i n the end require conscious thought. It is
m u l t i - m u s c u l a r because m a n y different muscle
groups are used i n order to produce the desired
 Section 5.1
series o f movements. These p r e - p r o g r a m m e d
automatic m u l t i - m u s c u l a r patterns are k n o w n as
engrams. (Section 1.3 N e u r o - m u s c u l a r
C o - o r d i n a t i o n a n d E n g r a m s , page 19.)
It requires constant exact repetitions i n order to
produce a n e n g r a m so that conscious thought is not
given to i n d i v i d u a l muscles or movements.
Proprioceptive feedback gives both sub-conscious
a n d conscious m o n i t o r i n g o f the movement a n d it is
this w h i c h gives the conscious m i n d the knowledge
of whether the movement was carried out
successfully or not. These a u t o m a t i c engrams can
o n l y be developed by v o l u n t a r y repetition o f the
precise p r o g r a m m e without any variation at all from one
repetition to the next. T h i s must be done extremely
accurately, otherwise the i n p u t o f information w i l l
v a r y o n each occasion a n d the e n g r a m cannot be
developed. It follows therefore that initially the pattern
must be slow enough to be accurate. A n engram allows a
complicated movement to be performed far more
r a p i d l y than w o u l d be possible i f conscious thought
o f each part o f the pattern o f movement were
required. It is i m p o r t a n t also to realise that at the
same time as the movements are o c c u r r i n g , the
e n g r a m w i l l also produce an i n h i b i t i o n o f unwanted
movements. T h i s i n h i b i t i o n is an essential part o f
the regulation o f co-ordination. I n h i b i t i o n cannot
be p r o d u c e d directly a n d consciously. It is only
achieved by regular, active repetition o f the pattern
of desired movements. C o - o r d i n a t i o n o f the most
Individual Technical Faults
5.1 Discrepancy in Shoulder
Level
T h i s is often brought about b y weakness o f one
side. A s a result o f this weakness there can be an
over-compensation so that the weaker shoulder is
held higher or, conversely, w i t h o u t this
compensation the shoulder that is weaker m a y be
lower ( F i g . 5.1). O n l y careful e x a m i n a t i o n w i l l
demonstrate w h i c h pertains i n a p a r t i c u l a r
i n d i v i d u a l . E l e v a t i o n o f one side m a y also be
brought about by unequal muscle tension caused b y
u n b a l a n c e d weight d i s t r i b u t i o n i n the lower part o f
the body.
T h e presence o f a scoliosis w i l l usually cause
elevation o f a shoulder, p a r t i c u l a r l y i f the scoliosis
is i n the m i d or upper dorsal region. T h e presence
of a scoliosis should be eliminated as a cause o f the
shoulder elevation at the i n i t i a l m e d i c a l
examination.
179
r a p i d , c o m p l e x a n d skilful actions is automated by
engrams rather than b y a v o l u n t a r y controlled
series o f movements.
T h e a c t i v a t i o n o f the engram(s) is v o l u n t a r y a n d
under conscious c o n t r o l . I n l e a r n i n g exercise
patterns a n d i n l e a r n i n g dance technique, or a n y
other movement technique, accuracy is absolutely
v i t a l i n order to develop the correct e n g r a m . I f
inaccuracies are a l l o w e d d u r i n g the development o f
technique, this w i l l produce ' b a d habits' a n d these
inaccuracies or ' b a d habits' w i l l themselves become
a n e n g r a m . O n c e this has taken place the
modification o f the e n g r a m w i l l be extremely
difficult a n d w i l l usually c a l l for that p o r t i o n o f the
technique to be learned again from scratch. H e n c e
the i m p o r t a n c e o f l e a r n i n g any c o m p l e x series o f
movements accurately from the start. A s previously
stated, i n order to achieve accuracy the pattern w i l l
have to be learned slowly, a n d the n u m b e r o f
repetitions required to produce a really well
developed e n g r a m is almost i n n u m e r a b l e . H o w e v e r ,
this is not as b a d as it sounds because a n action is
usually made u p o f a series o f engrams. It is the
sum o f the engrams w h i c h produces the final result.
T h e i n i t i a t i o n o f a n e n g r a m is under v o l u n t a r y a n d
conscious c o n t r o l , a l t h o u g h the constituent parts o f
the e n g r a m are themselves not b y that stage u n d e r
direct v o l u n t a r y c o n t r o l . W h a t the m i n d does is to
select the stored engrams a n d put them together i n
order to produce the desired result.
5.1 Discrepancy in shoulder level.
180 Section 5: T e c h n i c a l F a u l t s and A n a t o m i c a l
T h e r e are also some u n c o m m o n local a n a t o m i c a l
variants w h i c h cause shoulder elevation. These
usually prevent a correction of the shoulder level
discrepancy by postural adjustment alone.
L e g length inequality may be reflected i n
differing shoulder heights as well as i n a pelvic tilt.
Inequality o f turn-out produces a swinging back
of one side o f the pelvis, a one-sided trunk
weakness and frequently alteration i n shoulder
height on one side. S i t t i n g i n one hip w i l l cause a
s i m i l a r picture.
T h e uneven shoulder level may follow an injury
w h i c h has caused the dancer to take the weight off
the painful side. T h i s alteration can r a p i d l y develop
into a habit, so that even when the injury is cured
a n d the p a i n has disappeared, the postural
alteration remains.
O n e general cause o f elevation of one shoulder is
the h a b i t u a l c a r r y i n g on that side of heavy bags,
only too frequently starting i n students at a very
early age. I n m a n y schools the c h i l d r e n have to
take a l l the school books for the day backwards a n d
forwards m o r n i n g a n d evening. D a n c e students
m a y a d d i t i o n a l l y be c a r r y i n g several changes o f
c l o t h i n g as well as school books. Use of the
old-fashioned school satchel or a rucksack w o r n
correctly, taking the weight evenly on both
shoulders, w o u l d prevent the development o f this
shoulder level inequality.
P r o b a b l y equally frequently the c o n d i t i o n
develops as a postural bad habit w h i c h is not
helped by the total lack o f postural correction a n d
postural awareness that seems to be general i n a l l
schools today. T h e r e was a great deal to be said for
the old-fashioned school teacher w h o insisted that
the c h i l d r e n sat up straight at their desks.
TREATMENT
A n exercise p r o g r a m m e is c o m p i l e d to achieve the
correction o f any associated faults a n d this must be
a c c o m p a n i e d by constant postural correction.
U n d e r l y i n g structural abnormalities m a y well call
for referral for an orthopaedic o p i n i o n . I f the
shoulder level discrepancy is an isolated fault, it
should be realised that its presence w i l l have
p r o d u c e d an alteration i n the weight-bearing line
a n d hence a weakness a n d imbalance at the level o f
the lower trunk, the gluteals, the hamstrings,
adductors, quadriceps and even i n the lower leg.
Therefore, the exercise regime should be directed at
strengthening a n d b a l a n c i n g a l l these areas.
Variations
5.2 Tension around the Neck
and Shoulders
T h i s should be considered i n two sections, (a)
tension in the upper fibres o f the trapezius and (b)
tension i n the pectoralis muscles. B o t h are caused
by inaccurate placement o f arms a n d / o r inaccurate
fixation of the scapulae. T h e former usually comes
about because the arms are held too far back w i t h
the elbows behind the line o f the shoulders. It can
also occur even i f the arms are held forward i n the
correct position, but this being achieved by d r a w i n g
the scapulae a r o u n d the chest w a l l . A l t h o u g h this
has the effect of flattening the scapulae against the
chest w a l l , it does it by creating a great deal of
tension in the pectoralis muscles as well as spasm i n
the trapezii.
T h e mechanism by w h i c h the arms are taken too
far back is (a) by leading w i t h the elbow rather
than w i t h the h a n d ( F i g . 5.2) or (b) by over
t u r n i n g the feet, w h i c h causes the upper part of the
trunk to sway backwards so that i n o b t a i n i n g a
comfortable balance, the arms are taken backwards
even more than the upper trunk ( F i g . 5.3).
Weakness and instability o f the lower trunk
produces tension i n the shoulder girdle because the
feeling o f insecurity produces an attempt at
stability by tensing the upper trunk muscles.
S w a y b a c k knees w h i c h are pushed back cause the
pelvis to tilt forward, the l u m b a r spine to become
lordotic a n d i n compensation the upper trunk goes
backwards a n d this i n t u r n alters the scapular
fixation and scapular movements, p r o d u c i n g
increasing trapezius spasm.
A scoliosis, w h e n present, always produces some
tension to a variable degree d u r i n g w o r k i n g . T h i s is
brought about because the compensatory curve
above the scoliosis engenders some postural
correction also, w h i c h then induces the tension.
T h i s postural compensation is often exaggerated as
an attempt is made to put the centre o f g r a v i t y
over the base (i.e. the feet). I n order to m i n i m i s e or
obviate the tension, corrective measures to o b t a i n
the best possible posture i n the circumstances of the
scoliosis must be instituted. These corrections must
start at the feet a n d legs a n d work upwards. Unless
the base is correct it is impossible to get the back i n
the best position. T h e situation is often c o m p l i c a t e d
by a pelvic tilt associated w i t h the scoliosis, g i v i n g
an apparent and sometimes a true leg length
inequality. Likewise, a leg length i n e q u a l i t y
o c c u r r i n g i n the absence o f a scoliosis w i l l , by
p r o d u c i n g a compensatory pelvic tilt, frequently
lead to the development o f tension higher i n the
back.
 Section 5.2-5.3
A kyphosis, or i n its lesser degree, a rather more
r o u n d e d dorsal spine than n o r m a l , can also lead to
tension a r o u n d the neck a n d shoulders. Its presence
is really a c o n t r a - i n d i c a t i o n to a performing career
in dance because there are no satisfactory corrective
measures. I f at all m a r k e d , it is rarely i f ever totally
postural, although a bad posture can exaggerate the
kyphotic appearance. T h e commonest u n d e r l y i n g
cause is Scheuermann's disease i n adolescence. T h i s
is an osteochondritis o f the g r o w t h plates at the
upper a n d lower parts of each vertebral body.
W h e n the Scheuermann's disease finally settles w i t h
the cessation of g r o w t h , it m a y have left each of
the vertebral bodies slightly wedge-shaped,
n a r r o w e r anteriorly, thus p r o d u c i n g a forward
curve o f the spine (see Section 5.5).
Sometimes, a n d p a r t i c u l a r l y d u r i n g g r o w t h
spurts, a c h i l d can apparently become m i l d l y
k y p h o t i c but this is correctable w i t h suitable
exercises a n d attention to posture a n d is, i n any
case, usually self-correcting.
TREATMENT
T r e a t m e n t o f the tension is by correction o f the
u n d e r l y i n g fault. Often p a i n is present i n the
muscles concerned a n d frequently there is chest
p a i n caused by spasm of the pectorals i n p a r t i c u l a r ,
as well as being referred from the origins o f the
trapezius at the spinous processes and interspinous
ligaments. W h e r e there is muscle p a i n , i n i t i a l
treatment m a y be directed at relief o f the muscle
spasm a n d p a i n by the physiotherapist using
interferential, ultrasound or massage. T h i s w i l l
181
5.2 (far left) Leading with the
elbows and arms too far back. She is
also failing to hold her turn-out
correctly. The tension in the neck
muscle can be seen.
5.3 (left) Failing to hold the
turn-out correctly. There is a
compensatory tilt backwards of the
trunk with the result that the arms
arc taken even further back and lie
well behind the line of the hip joint.
facilitate the identification a n d correction o f the
u n d e r l y i n g technical faults p r o d u c i n g the spasm.
In most causes o f tension a n d especially i n those
w i t h a scoliosis, b r e a t h i n g exercises should be
taught. U p p e r chest breathers need education to
use the whole chest a n d the d i a p h r a g m . Scoliotics
need instruction to encourage the equal expansion
of both sides of the chest as there is always a
tendency for someone w i t h a scoliosis to use the side
of the chest o n the convex aspect o f the curve more
than the other side o f the chest. A s a result, there is
a g r a d u a l further collapse o f the chest on the
concave side a n d an increase in the postural
component o f the scoliosis. A l s o , i n a i d i n g
correction as far as possible o f the scoliosis, very
significant benefit can be obtained by a suitable
exercise p r o g r a m m e to strengthen the muscles. I n
this context attention should be p a i d to the muscle
groups i n the legs. F r e q u e n t l y there is weakness o f
more than one group, resulting i n an incorrect
weight placement d o w n at that level. W i t h o u t
correction here, a less satisfactory result w i l l be
obtained i n the back a n d the chest.
5.3 Discrepancy in the Length of
the Clavicles
T h i s w i l l produce a difference i n b r e a d t h between
the two shoulder girdles. A s a result there w i l l be a
tendency to work w i t h the weight placed more
towards the broader side. Therefore muscle
development becomes u n e q u a l i n the trunk a n d
 182 Section 5: T e c h n i c a l F a u l t s and A n a t o m i c a l V a r i a t i o n s

neck. F r e q u e n t l y the narrow side w i l l become

tighter generally, m a i n l y a r o u n d the shoulder
affecting i n p a r t i c u l a r the pectorals and also slightly
restricting elevation o f that a r m . T h i s discrepancy
in c l a v i c u l a r length is often merely an aberration
d u r i n g g r o w t h and the difference i n w i d t h is not
necessarily permanent.

TREATMENT

Ensure that muscle strength and b u i l d - u p is

equalised on the two sides o f the body and also
ensure that any tight areas are stretched out
equally. N o t h i n g can be done to alter the actual
structural difference i f it does not correct itself
spontaneously.

5.4 Scoliosis
T h i s is a lateral curvature of a segment o f the
spine. T h i s curvature is accompanied by a m a r k e d
r o t a t i o n a l element ( F i g . 5.4). I f it is very m a r k e d
then aesthetically it w i l l be unacceptable i n a
professional dancer. Therefore i n the assessment of
dancers the examiner is looking for relatively m i l d
degrees o f scoliosis w h i c h may not be immediately
apparent on initial observation. T h e area affected
by the curvature i n the scoliosis is very m u c h stiffer
than n o r m a l . A s most scolioses are i n the dorsal
spine, this i n itself is frequently not o f major
i m p o r t a n c e i f the scoliosis is only m i l d a n d does not
constitute a cosmetic disability. H o w e v e r , i n the
l u m b a r region, the a c c o m p a n y i n g stiffness can
make the back as a whole too stiff to allow the
movements required for ballet. Below the neck
level, most of the movements o f flexion and
extension a n d lateral flexion a n d rotation take place
in the l u m b a r region.
In the majority of cases the cause of a scoliosis is
totally u n k n o w n . T h i s is called an idiopathic
scoliosis. R a r e l y nowadays a scoliosis is due to
paralysis o f a group or groups of muscles. T h i s used
to be relatively c o m m o n when poliomyelitis
epidemics occurred at regular intervals. T h e r e are
some very rare conditions o f the nerves and nervous
system w h i c h can also lead to a scoliosis.
If the presence of a scoliosis is suspected, the
student should be referred to an orthopaedic
surgeon for an o p i n i o n . T h e r e are m a n y different
forms o f treatment w h i c h can help the condition
a n d may well be indicated in the i n d i v i d u a l case. I f
the scoliosis is m i l d , great benefit can frequently be
obtained by suitable exercises. Sometimes the use of
an electrical muscle stimulator w o r n at night can
b r i n g about very marked improvement in the
5.4 A n X-ray of a scoliosis with the measurement lines
drawn in. Here there is a 20° dorsal scoliosis and a 12°
lumbar scoliosis. A scoliosis at a single level is more
common. It is usually in the dorsal region of the spine.
degree o f curvature. I n more severe cases,
mechanical b r a c i n g or surgery m a y be required.
Osteopathic or spinal manipulations w i l l not cure a
scoliosis and are not indicated as a method o f
treatment. F o r c i b l e manipulations m a y produce
actual damage to the bones and joints a n d
aggravate the situation.
T h e presence o f even a m a r k e d scoliosis is not a
contra-indication i n itself to the c h i l d u n d e r t a k i n g
ballet classes. D a n c i n g can even be helpful i n
exercising the scoliotic areas and i n strengthening
up the muscles. T h e exercise from the ballet classes
w i l l be i n a d d i t i o n to side shift a n d other exercises
w h i c h m a y have been prescribed by the
orthopaedic surgeon looking after the child as a
patient. H o w e v e r , it should be made clear to the
c h i l d and to the parents that the classes are for fun
only a n d are not a prelude to a possible
professional career. E v e n i f the y o u n g dancer can
manage the technical aspects o f ballet, the presence
of an obvious scoliosis w i l l be u n a p p e a l i n g when
they come to a u d i t i o n for places i n companies and
dance groups a n d attempts at a professional career
are sure to end w i t h great disappointment.
E v e n i n m i l d scolioses, difficulty c a n be
experienced i n centralising the line o f weight-
bearing a n d usually the weight is to one side, i.e.
towards the apparently shorter side. A s a result,
groin, adductor a n d low back strains are c o m m o n .
 Section 5.4-5.5 183

F r e q u e n t l y the hamstrings o n one side are very

m u c h tighter than the other a n d this c a n lead to
h a m s t r i n g injuries. T h e tightness arises because o f
the frequent presence o f a pelvic tilt associated w i t h
a scoliosis but, once established, the tight
hamstrings w i l l themselves repeatedly exert a
rotational p u l l o n the pelvis (Section 5.20). V e r y
often, o n the looser hamstring side a swayback knee
m a y develop, causing its o w n p a r t i c u l a r difficulties
(see Section 5.13).
Because o f the rotational element o f the scoliosis, SECONDARY
CURVE
difficulties m a y be experienced w i t h a r m positions,
causing muscle tension a n d strains a r o u n d the
shoulder girdle i n attempting to achieve correct
arm placements. I n a d d i t i o n , i n a dorsal scoliosis,
the r i b cage o n the two sides is different, that o n
the concave side being compressed a n d w i t h a
decrease i n v o l u m e .
T h e presence o f a m i l d scoliosis w h i c h is not
obvious cosmetically, m a y be suspected i f the
student appears to have difficulty achieving correct
PRIM ARY
head positions; i f there is one shoulder higher than
CURVE
the other; i f there is a pelvic tilt or prominence o f
one side o f the pelvis; a forward rotation o f the
pelvis o n one side; or i f there is a leg length
discrepancy. A n y o f these factors calls for a careful
e x a m i n a t i o n o f the spine.
It should be emphasised again that i f a scoliosis is
suspected, the c h i l d should be referred for a n
orthopaedic o p i n i o n . D e l a y i n seeking specialist
advice should be avoided as a n early scoliosis m a y
well be correctable i f treated properly initially. SECONDARY
CURVE
TREATMENT

T r e a t m e n t o f the actual scoliosis is a n orthopaedic

p r o b l e m . Exercises c a n certainly be beneficial i n
strengthening the muscle groups to decrease as
m u c h as possible the postural elements o f the curve.
Side shift exercises are helpful. T h e use o f a n PRIM ARY
electrical muscle stimulator at night really falls CURVE
w i t h i n the sphere o f the treatment w h i c h w i l l be
ordered by the orthopaedic surgeon under whose
care the c h i l d is.
T h e r e h a b i l i t a t i o n programme should start b y
5.5 Diagram showing the primary and secondary
strengthening the feet a n d leg muscles a n d by curves. In foetal life, the whole spine is curved forwards
ensuring that the position is correct. I f the legs a n d in the direction of the primary curve. The secondary
feet are not correct then all attempts to strengthen curves in the neck and lumbar regions gradually develop
a n d align the pelvis a n d trunk w i l l be u n a v a i l i n g . after birth and are in the opposite direction to the
primary curve.

5.5 Kyphosis
T h i s is a forward flexion o f the spine o c c u r r i n g
most c o m m o n l y i n the dorsal region. T h e r e is
already a p r i m a r y curve at this level ( F i g . 5.5) a n d
 184 Section 5: T e c h n i c a l F a u l t s a n d A n a t o m i c a l V a r i a t i o n s
5.6A Line drawing showing a
kyphosis in the dorsal region with a
compensatory lumbar lordosis below
it.
a kyphosis is an increase i n the curve beyond the
n o r m a l l i m i t ( F i g . 5.6). It m a y arise as a result o f
Scheuermann's disease i n c h i l d h o o d when, due to
the osteochondritis affecting the end plates at the
top a n d b o t t o m o f each vertebral body, these
become somewhat wedge-shaped, narrower
anteriorly, thus resulting i n a curve. Frequently,
however, there is no apparent cause for the
kyphosis.
T h e presence o f a kyphosis is aesthetically
displeasing, but functionally, any damage or injury
is p r o d u c e d i n the l u m b a r region. A s a result o f the
forward curve i n the dorsal region, a compensatory
lordosis is inevitable (see Section 5.6 for the
associated problems). A d d i t i o n a l l y , the head a n d
neck have to be extended more than n o r m a l l y i n
order to a l l o w the person to look forward
horizontally.
W i t h the presence o f either a scoliosis or a
kyphosis the resulting loss i n m o b i l i t y i n these
regions decreases the shock absorption o f the spine
as a whole. A s a result, injuries of a l l types i n the
l u m b a r region become m u c h more frequent a n d the
l u m b a r spine is constantly at risk. I n the presence
of a kyphosis, w h i c h inevitably leads to a
compensatory lordosis, very m u c h more a d d i t i o n a l
strain is placed on the l u m b a r spine as the dancer
attempts to assume the correct position required by
dance technique.
TREATMENT
T h e r e is no specific treatment for a structural
kyphosis. H o w e v e r , the posture c a n be helped by
strengthening exercises for a l l the trunk muscles to
5.6B A n X-ray of
a severe kyphosis.
decrease as m u c h as possible any postural
component o f the curve. D u r i n g treatment, the
weight position must be corrected as far as possible.
W i t h the compensatory lordosis the pelvis w i l l be
tilted forward a n d as a result o f this the weight w i l l
be pushed back. A s the kyphosis is fixed, a n d
therefore the lordosis i n this case cannot be
completely eliminated, full correction of the weight
position w i l l not be possible.
D u e to the frequency o f l u m b a r spine injuries
associated w i t h kyphoses, m u c h attention must be
given to trunk strengthening exercises to try to
provide the m a x i m u m possible protection for the
l u m b a r region o f the back (see Section 5.6
Treatment, page 173).
T h e rehabilitation p r o g r a m m e should start by
strengthening the feet and leg muscles and ensuring
that the position is correct. I f the legs a n d feet are
incorrect, a l l attempts to strengthen a n d a l i g n the
pelvis a n d trunk w i l l be u n a v a i l i n g .
5.6 Lordosis
T h i s is the name given to the posture w h e n the
l u m b a r spine is hyper-extended or, i n other words,
very m u c h h o l l o w e d . T h e r e is n o r m a l l y a l u m b a r
curve but i n a lordosis this n o r m a l curve is greatly
exaggerated ( F i g . 5.7). It is a postural c o n d i t i o n
and can be corrected, i.e. it is not a fixed curve as is
the case w i t h the scoliosis a n d kyphosis described
earlier. H o w e v e r , i n the presence o f a kyphosis i n
the dorsal spine, correction w i l l p r o d u c e such a
forward tilt o f the upper h a l f o f the t r u n k that it
 Section 5.6 185

5.7 Three lordotic postures from the side.

5.8 Kyphotic posture with

correction of the compensatory
lordosis (which was seen in Fig.
5.6A). As a result the head pokes
forwards and the neck has to be
hyperextended.

5.9 Pelvic tilt due to tightness at

the fronts of the hips and a
secondary lordosis.

becomes i m p r a c t i c a l ( F i g . 5.8). S i m i l a r l y , a fixed 4. Weakness o f the gluteals. (3 a n d 4 usually go

pelvic tilt due to very marked tightness i n the fronts together, a l t h o u g h not i n v a r i a b l y so.)
of the hips w i l l produce a similar difficulty i n Weakness o f the hamstrings is also c o m m o n l y
correction ( F i g . 5.9). associated w i t h weak gluteals.
5. W o r k i n g over turned out at the feet i n
CAUSES O F A LORDOSIS relation to the hips w i l l produce a forward tilt
1. D o r s a l kyphosis (Section 5.5). of the pelvis ( F i g . 5.10). T h i s m a y be due to a
2. A forward pelvic tilt due to tightness i n the genuine l i m i t a t i o n o f turn-out at the hips or a
fronts o f the hips (Section 5.9). failure to h o l d the available turn-out (Section
3. Weakness o f the a b d o m i n a l muscles. 5.7).
186 Section 5: T e c h n i c a l F a u l t s a n d A n a t o m i c a l
5.10 Over turned feet producing 5.11 Swayback knees producing
a forward tilt of the pelvis. a compensatory pelvic tilt and a
lordosis.
6. Weakness o f the adductors produces a failure
to h o l d the turn-out a n d results i n the same
p r o b l e m as 5 (Section 5.10).
7. S w a y b a c k knees produce a compensatory
pelvic tilt a n d a lordosis ( F i g . 5.11) i n order to
b r i n g the line o f weight-bearing through the
feet. H a v i n g been displaced backwards by the
swayback knees being pushed back, the line o f
weight-bearing must be brought forward i n
order to m a i n t a i n balance (Section 5.13).
8. A tibial b o w (Section 5.15) produces
weight-bearing more laterally a n d this makes
it difficult to get a h o l d o n the inner sides o f
the thighs. T h i s results i n a situation similar to
that associated w i t h adductors w h i c h are weak
(Section 5.10).
9. Weakness o f the forefeet (Section 5.18)
causes the weight to be pushed back w i t h
similar consequences to those associated w i t h
other causes for the weight being back
(Section 5.20).
10. A n y other technical fault w h i c h causes the
weight to be taken too far back w i l l produce a
compensatory lordosis.
11. W o r k i n g w i t h the arms too far back causes
the upper trunk to tilt backwards a n d this w i l l
produce a compensatory lordosis i n order to
b r i n g the weight forward. It is often
a c c o m p a n i e d b y a forward p o k i n g chin, w h i c h
is also part o f a n attempt to m a i n t a i n balance
(Fig. 5.12).
Variations
5.12 Lordosis because the arms are
too far back. This also produces a
forward poking chin.
12. T i g h t shoes produce c u r l i n g o f the toes w i t h
the consequence that the weight w i l l be
pushed back, p r o d u c i n g a lordosis.
13. I n some dancers there appears to be a
n a t u r a l l y o c c u r r i n g lordosis w h i c h , although
initially postural a n d theoretically therefore
correctable, c a n i n practice prove almost
impossible to i m p r o v e o r fully correct. I n
some o f these people the lordosis, w h i c h has
been present since they started to w a l k , c a n
become at least partly fixed as they a p p r o a c h
maturity. It is then uncorrectable, even w h e n
they lie flat o n their backs a n d p u l l their knees
up to their chests. N o r m a l l y this manoeuvre
rotates the pelvis a n d flattens the l u m b a r
spine. I f this does not occur, then it c a n be
accepted that there is at least a degree o f
lordosis w h i c h is uncorrectable as the
necessary m o b i l i t y is l a c k i n g . It must be
emphasised that the a i m is to achieve the
normal lumbar curve a n d not to flatten this curve
out w h e n w o r k i n g . T h i s is as undesirable as a n
exaggerated curve or lordosis. H o w e v e r , unless
the spine is supple enought to be able to attain
this flattening, it is not possible for the dancer
to work satisfactorily, as forward flexion o f
the trunk i n the l u m b a r region cannot take
place a n d forward b e n d i n g c a n only occur at
the hips.
14. T i g h t hamstrings m a y also contribute to a
lordosis (Section 5.12).

Consequences o f a L o r d o s i s
These are the same as the Consequences o f the
W e i g h t Back S i t u a t i o n (Section 5.20).
TREATMENT
T h i s must be b y e l i m i n a t i o n o f the cause o f the
lordosis whether this be weakness o f muscle groups,
faulty technique p r o d u c i n g lordosis secondarily, or
an incorrect weight-bearing line.
T h e r e h a b i l i t a t i o n p r o g r a m m e w i l l certainly be
based o n a p r o g r a m m e o f trunk strengthening
exercises, as well as strengthening a n d b a l a n c i n g the
various muscle groups i n the lower limbs.
T h e r e h a b i l i t a t i o n p r o g r a m m e should start b y
strengthening the feet a n d leg muscles a n d ensuring
that the position is correct. I f the legs a n d feet are
not correct, a l l attempts to strengthen a n d align the
pelvis a n d trunk a n d eliminate the lordosis w i l l be
unavailing.
5.7 Over Turning
B y this is meant that the foot a n d lower leg are
being turned out (externally rotated) beyond the
degree o f turn-out available at the h i p j o i n t ( F i g .
5.13). T h e over turned foot m a y reflect either a n
a n a t o m i c a l l i m i t a t i o n o f the degree o f turn-out
required b y ballet technique, or it m a y be due to a
lack o f correct muscular control o f the turn-out,
therefore p r o d u c i n g a n apparent restriction i n
turn-out at the hips, w i t h over turned feet.
too frequently the degree o f turn-out being
d e m a n d e d m a y be too great to be realistic. V e r y
few dancers have flat turn-out (180°) a n d even i f
they d o , they cannot work like this because o f the
difficulty i n a c h i e v i n g correct balance. Therefore
they tend to d r o p into the lordotic position, thus
weakening the trunk muscles.
M u c h more disastrous than a n y o f the above is
the m e t h o d o f teaching w h i c h demands a flat 180°
turn-out at the feet, despite the fact that the hips
may not a p p r o a c h a n y t h i n g like this degree o f
external rotation. T h e results o f this method o f
teaching m a y be
1. A m a r k e d pelvic tilt forward w i t h the
development o f a lordosis.
2. Severe weakening o f the trunk muscles,
p a r t i c u l a r l y the abdominals.
3. A greatly increased rate o f injury i n the l u m b a r
spine, i n c l u d i n g stress fractures. O n average it
takes a b a d teacher eight months to so weaken
a previously adequately strong dancer that the
risk o f a serious back injury is i m m i n e n t .
Section 5.6-5.7 187
5.13 Over turned
feet in relation to the
hips.
4. G e n e r a l sequential w e a k e n i n g o f the various
muscle groups from above d o w n w a r d s - the
abdominals, the back extensors, the latissimus
dorsi (as the shoulders are b a c k ) , the glutei, the
hamstrings (especially the lateral hamstrings),
the adductors a n d the vastus medialis, the
lateral part o f the calf muscle a n d the lateral
intrinsic muscles o f the feet. T h i s i n total
produces complete i m b a l a n c e o f the legs. M o s t
of these muscle groups are required i n order to
Only h o l d the turn-out so their g r a d u a l l y increasing
weakness brought about b y being m a d e to w o r k
grossly over turned, causes increasing difficulty
in h o l d i n g the a v a i l a b l e turn-out. T h i s becomes
especially noticeable w h e n they leave the barre
to start centre w o r k . D u r i n g barre w o r k the
dancer w i l l g r i p the barre tightly to give
support i n the unattainable (at the hips) flat,
turned out position. Teachers w h o d e m a n d this
flat turn-out demonstrate their total ignorance
of the mechanics o f the b o d y a n d by this
c u l p a b l e attitude must accept complete
responsibility for injuries they cause to their
students. T h e situation is not only a cause o f
injuries but it is also greatly d e t r i m e n t a l to the
development o f a good technique.
U n f o r t u n a t e l y , m a n y teachers w h o insist o n a flat
turn-out at the feet believe that they are following
the R u s s i a n method o f teaching. T h i s is a d o u b l e
misunderstanding o f the situation. Firstly, a n d
i m p o r t a n t l y , the body types that are reaching this
stage o f t r a i n i n g are different. Secondly, the g r o u n d
work leading up to this method o f teaching is quite
188 Section 5: T e c h n i c a l Faults a n d A n a t o m i c a l V a r i a t i o n s
different and far more thorough. A s a result the
c h i l d w i l l be far more mobile and m u c h stronger
before a nearly flat turn-out is required o f h i m or
her.
In the Western w o r l d where the selection o f
correct body types is far less rigorous and
d e m a n d i n g than i n the Russian schools, it is quite
w r o n g to try to follow the Russian method w i t h the
students. O n l y a small proportion w i l l be able to
cope satisfactorily w i t h this method.
5.14 (far left) Over turned feet
with rolling and a valgus strain on
the big toe.
5.15 (left) Over turned foot on
demi-pointe with valgus pressure on
the great toe.
5.16A (far left) Sickling on
demi-pointe with the weight being
transmitted down the medial side of
the foot. Doctors and
physiotherapists would refer to this
as sickling out but dancers would
usually call it sickling in (because of
the direction that the ankle goes as
opposed to the direction the foot
takes).
5.16B (left) Sickling on demi-pointe
with the weight being transmitted
down the lateral side of the foot.
This is a precursor to sickling in the
opposite direction when on full
pointe (see Fig. 5.17).
T h e schools have two choices: either a very m u c h
more rigorous selection o f the correct body type,
plus adequate preparatory g r o u n d w o r k i n the
training, or else accepting less satisfactory bodies
with the a c c o m p a n y i n g knowledge that a flat
turn-out cannot be achieved w i t h o u t a h i g h injury
rate. T h e schools cannot have it b o t h ways and a
little more insight into the whole o f the R u s s i a n
methods instead o f a superficial a n d p a r t i a l
knowledge w o u l d greatly help matters. F o r
 Section 5.7 189

example, a tendu w i l l fail to be effective behind the

hindfoot as the unstable supporting leg inhibits the
correct muscle action i n the w o r k i n g (tendu) foot.
A n o t h e r example is that over t u r n i n g w i l l cause the
dancer to sit i n the supporting h i p , thus effectively
p r o d u c i n g a leg length discrepancy as well as
i n h i b i t i n g proper muscle contraction a n d control o f
the supporting hip. A s a result, there w i l l be
insufficient space to move the leg i n a l l directions
because it w i l l tend to strike the floor. T o a v o i d
this, the dancer w i l l hitch at the waist on the
w o r k i n g side. O n c e he does this the weight comes
off the supporting leg even further and the pelvis
a n d trunk w i l l wave a r o u n d i n an unsupported
fashion even more than before.
A l t h o u g h a student or dancer w i l l usually over
turn on both sides, the over t u r n i n g m a y sometimes
be confined to one side only. E v e n i f both sides are
over turned, frequently or even usually the over
t u r n i n g w i l l not be s y m m e t r i c a l but one side w i l l be
forced out to a greater extent than the other. T h e
5.17 Sickling on full pointe with the weight being
a b i l i t y to over turn lies i n the use o f friction transmitted down the medial side of the foot.
between the foot a n d the floor. T h i s friction c a n be
increased by the use o f rosin. It is impossible to
over turn i f the foot is not on the floor. 2. Injuries of the 1st Metatarso-phalangeal Joint.
These come about m a i n l y as a result of the
r o l l i n g but m a y occur even i f the r o l l i n g is
corrected or absent. T h e weight w i l l still be
Consequences o f O v e r T u r n i n g
back due to over t u r n i n g , the use o f the w r o n g
1. Rolling. T h i s puts a strain on the great toe muscles a n d the friction o f the floor. T h e
tending to push it into a valgus position ( F i g . injury m a y be due to valgus strain or to
5.14). T h i s can cause damage to the capsule rotation o f the great toe (Section 3.19).
and ligament of the m e d i a l side o f the j o i n t , 3. Clawing of the Toes and Intrinsic Muscle Weakness.
aggravated by actual local pressure there, T h i s is caused by the weight being back a n d
w h i c h w i l l occur as the rolled foot is pressed the failure o f the muscles i n the thigh to h o l d
on the floor. A n y u n d e r l y i n g valgus deformity the turn-out. T h e toes c l a w i n an attempt to
w i l l be increased by the r o l l i n g , especially h o l d o n at floor level a n d this increases
d u r i n g work on demi-pointe, d u r i n g relevés intrinsic weakness due to their lack o f proper
a n d d u r i n g pointe work ( F i g . 5.15). I n the use a n d function (Section 5.18).
latter, the rolling w i l l change d u r i n g the relevé 4. Stress Fractures i n the t i b i a a n d fibula can
into a sickle position w i t h the weight m e d i a l l y occur, i n part due to the lack o f shock
through the foot. T h e situation c a n be absorption by the weak feet a n d i n part by
complicated by the presence o f lower tibial the rotational twist transmitted d o w n the over
bows or sway back knees. I n both these turned leg (Sections 3.26 a n d 3.27).
instances, the n a t u r a l weight-bearing line is 5. Anterior Compartment Syndrome c a n be i n d u c e d
back a n d at demi-pointe the foot w i l l tend to for similar reasons (Section 3.28).
be sickled ( F i g . 5.16), i.e. the foot has the 6. Tibialis Posterior Tenosynovitis occurs because o f
weight on the outer side. A s the relevé an attempt to correct the rolled feet at the
continues the direction o f sickling changes to foot a n d ankle level instead o f at the hips
the opposite situation so that the weight is (Section 3.13).
medially w h e n they reach full pointe ( F i g . 7. Injuries of the Medial Side of the Knee. These m a y
5.17). Therefore, the observer may be misled be tears o f the m e d i a l meniscus or sprains o f
if the dancer is only seen o n demi-pointe. F o r the m e d i a l ligament, both o f w h i c h w i l l o c c u r
further complications o f r o l l i n g see Section as a result o f the twist at the knee ( F i g . 5.18)
5.17. (Sections 3.31, 3.32 a n d 3.35).
190 Section 5: T e c h n i c a l Faults a n d A n a t o m i c a l
5.18 Over turning showing tension on the inner side of
the knee.
8. Chondromalacia Patellae and Patellar Tendonitis.
These are b o t h i n d u c e d or aggravated because
the rotation at the knee brings about lateral
t r a c k i n g o f the patella (Section 3.30).
9. Weakness of the Lateral Hamstrings. T h i s is
i n d u c e d by rotation at the knee. T h e u n e q u a l
p u l l then exerted by the lateral and m e d i a l
hamstrings leaves the lateral meniscus more
likely to sustain an injury. T h e weakened
hamstrings are also more likely to be injured
(Section 3.41).
10. The Adductors weaken because they do not
function fully i n the over turned position. T h e
adductors become more prone to injury due to
the lack o f stability o f the pelvis by their o w n
weakness, especially d u r i n g grands battements
w h e n either adductor m a y be injured, i.e. that
on the s u p p p o r t i n g side or that on the
w o r k i n g side. (Sections 5.10 a n d 3.30).
11. Lordosis. T h i s w i l l occur i n over t u r n i n g as the
pelvis rotates forward i n an attempt to
increase the available turn-out at the hips. I n
most people, any flexion at the h i p joints w i l l
increase the apparent degree of external
rotation available (Section 5.6). Associated
w i t h this w i l l be a tightening at the fronts of
the hips w h i c h m a y be real or apparent. T h i s
is aggravated by over action of the quadriceps
(but not the medialis) w h i c h are used to g r i p
i n a weight back situation. A s the rectus
femoris crosses the front o f the h i p , it w i l l also
Variations
add to the forces causing the pelvis to rotate
forward.
12. Groin strains. These are not infrequent as a
direct result o f the over t u r n i n g c o u p l e d w i t h
the associated muscle weakness (Section
3.40).
TREATMENT
Basically the dancer should a v o i d t u r n i n g the feet
out further than the available turn-out at the hips.
In a student who has been over t u r n i n g , any o f
the above complications m a y need i n d i v i d u a l
treatment a n d the various weak muscle groups w i l l
certainly need a considerable p r o g r a m m e o f
strengthening exercises. A great a m o u n t of
technical correction w i l l be required to u n d o the
h a r m caused by the previous b a d teaching.
5.8 Restriction of Turn-out at
the Hips
E v e r y b o d y has a n a n a t o m i c a l l i m i t to their range
of external rotation o f the hips (i.e. turn-out). T h i s
range cannot be exceeded. I n the y o u n g student,
l i m i t a t i o n due to ligament tightness c a n be
g r a d u a l l y i m p r o v e d by correct w o r k i n g a n d gentle
judicious stretching. T h i s is most likely to be
achieved before puberty.
A p p a r e n t l i m i t a t i o n m a y be due to tightness at
the fronts o f the hips (Section 5.9) or frequently
by weakness o f the muscles c o n t r o l l i n g the turn-out,
especially the adductors (Section 5.10).
F o r classical dance the lower l i m i t o f external
rotation at the h i p is about 45°. A n y t h i n g less w i l l
tend to produce greater or lesser problems. T h e
method o f measurement o f turn-out is p a r t i c u l a r l y
important. O n l y too frequently, p a r t i c u l a r l y i n
auditions, one sees c h i l d r e n being put into the frog
position ( F i g . 5.19) under the misapprehension that
the degree o f turn-out is being assessed. I n most
people, the frog position w i l l appear to have a very
m u c h greater range o f turn-out than a c t u a l l y exists
w h e n the hips are fully extended. T h e following
series o f photographs show h o w misleading the frog
position can be w h e n assessing turn-out ( F i g . 5.20).
It is when the hips are extended, i.e. w h e n the
person is standing up straight w i t h the legs i n line
w i t h the trunk, that they are i n their n o r m a l
w o r k i n g position for d a n c i n g . T h e m e t h o d for
assessing the degree o f turn-out at each h i p is
shown i n the a c c o m p a n y i n g photographs ( F i g .
5.21). T h e h i p w h i c h is not being measured is
flexed up. C a r e must be taken to m a k e certain that
the h i p w h i c h is being assessed is held i n the fully
 Section 5.8 191

5.19 Frog position in an audition. 5.20A Frog position - very good.

5.20B Hips extended (as in standing position) and fully
turned out (externally rotated). This demonstrates very
well the great discrepancy which frequently occurs
between an assessment of turn-out in the frog position
and the true turn-out when the dancer is standing.
5.20C Hips extended and internally rotated, showing
that the total joint range in rotation is full but that most
of it is in internal rotation.

extended position as, i f it is allowed to flex even a

small amount, the apparent degree o f turn-out c a n
be increased m a r k e d l y .
It is possible to measure turn-out w i t h the dancer
l y i n g o n his face but the results can be misleading.
I n this position it is very m u c h easier for the dancer
to d r o p the l u m b a r spine into the lordotic posture,
thus p r o d u c i n g flexion o f the h i p a n d an apparent
increase i n the turn-out.
T h e problems associated w i t h a restriction o f 5.21 Assessing turn-out accurately with the leg over the
turn-out are those dealt w i t h under over t u r n i n g end of the couch, keeping the hip being examined fully
(Section 5.7). extended. The other leg is flexed out of the way.
 192 Section 5: T e c h n i c a l Faults and A n a t o m i c a l V a r i a t i o n s
TREATMENT
T h e muscles c o n t r o l l i n g turn-out, m a i n l y the
adductors, must be strengthened i n order to control
a n d h o l d the best available a m o u n t o f turn-out.
A d d i t i o n a l l y , m a n y other groups m a y also require
strengthening, notably the trunk, the glutei and the
feet. Posture, weight position a n d weight
transference must be corrected. Gentle a n d
progressive stretching c a n be carried out under
controlled conditions once the strengthening
p r o g r a m m e is under w a y . Stretching must not take
place i n the presence o f weak muscles. I n the
stretching, attention must be given to any tightness
i n the fronts o f the hips.
Muscles must be stretched i n the line i n w h i c h
they w o r k a n d function. T h i s is not necessarily i n
the l o n g i t u d i n a l line of the l i m b . Cross stretching is
u n p r o d u c t i v e a n d achieves nothing.
T h e c o m m o n method used, i n the v a i n hope that
turn-out is being stretched, is sitting or l y i n g i n the
frog position. I n this situation the hips are flexed,
nearly always g i v i n g an apparent increase i n
turn-out range. M o r e important, this is not the
position i n w h i c h the hips are w o r k i n g when the
dancer is standing or m o v i n g when turned out. H e
does this w i t h the hips extended, i.e. standing up
straight, apart from the relatively infrequent
occasions w h e n going d o w n into a plié or fondu at
w h i c h time the h i p is indeed flexing. L y i n g i n frogs
is not stretching the actual structures w h i c h are
tight. The end results of various structures being tight can
be restriction of turn-out. It is necessary to assess and
define w h i c h o f the various structures associated
w i t h the turn-out are tight a n d then to stretch these
i n d i v i d u a l l y . Frequently, this means that the stretch is not
in the actual direction of turn-out. F o r instance, i f there
is tightness at the front of the h i p , it is a cross p u l l
on these structures w h i c h causes a l i m i t a t i o n o f
turn-out but the actual stretch of these tissues must
be l o n g i t u d i n a l to their fibres a n d not, i n this
instance, i n the actual direction o f turn-out. T h i s
w o u l d be u n p r o d u c t i v e .
It is noteworthy that although the adductors are
the m a i n muscles w h i c h turn the h i p out and hold
it turned out, tightness i n portions o f the adductors
as a whole m a y actually limit external rotation.
These portions have to relax while the bulk o f the
muscle concerned is contracting. Therefore the
adductors themselves m a y need some gentle
stretching i n order to i m p r o v e turn-out.
A d d i t i o n a l l y , it is of great importance to note
that a well stretched muscle (not over-stretched)
w i l l contract m u c h more efficiently a n d strongly.
5.9 Tightness at the Fronts of
the Hips
As this impliés, there is restriction o f full extension
of the h i p j o i n t , extension m e a n i n g c a r r y i n g the leg
backwards i n relation to the trunk.
It is assessed by the following method ( F i g . 5.22).
T h e tightness m a y lie i n any o f the anterior
structures. T h e most superficial is the rectus femoris
portion o f the quadriceps. T h e rectus femoris
crosses the front of the h i p j o i n t . It a n d the other
three components o f the quadriceps c a n be part o f
a generalised tightness. A l s o superficially placed is
the tensor faciae latae w h i c h m a y be tight. Deeper,
the restriction may be caused by the ilio-psoas
w h i c h is an internal rotator as well as a flexor o f
the h i p . I n a d d i t i o n to l i m i t i n g extension it c a n also
restrict external rotation. Restriction o f external
rotation or turn-out is an overall c o m p l i c a t i o n of
tightness o f the front o f the h i p . A d d i t i o n a l l y ,
pectineus a n d adductor brevis as well as the
anterior capsule of the h i p can a l l p l a y a part i n
the tightness at the front o f the j o i n t .
CAUSES
A l t h o u g h the tightness frequently exists i n its o w n
right it may be precipitated or aggravated by any
one o f the following.
1. Lordosis, when the forward tilt o f the pelvis
w i l l g r a d u a l l y lead to tightening o f the anterior
structures (Section 5.6).
2. A n y technical or a n a t o m i c a l fault w h i c h causes
a forward rotation o f the pelvis resulting i n a
secondary shortening of the structures i n the
front of the hips. I f long-standing it can
progress to an actual tightness or contracture.
3. Tightness o f the hamstrings w i l l lead to a
tendency to work w i t h the knees very slightly
flexed thus preventing the h i p from fully
straightening (Section 5.12).
EFFECTS
1. T h e p r o d u c t i o n o f a lordotic posture a n d all its
associated problems (Section 5.6).
2. Restriction o f turn-out. T h i s m a y be brought
about by two factors:
(a) actual limitation as occurs when the ilio-psoas
or other strictures w h i c h l i m i t external rotation
are tight, or
(b) apparent l i m i t a t i o n by prevention of the
external rotators from acting effectively i n
t u r n i n g out and i n h o l d i n g the turn-out.
 Section 5.9-5.11
TREATMENT
I n i t i a l l y this is b y exercise o f a l l the weakened
muscle groups where applicable (trunk, hamstrings,
adductors a n d gluteals, etc.). T h e n w h e n a l l these
groups are b e c o m i n g stronger a n d alongside the
c o n t i n u i n g strengthening p r o g r a m m e any tight
groups or areas, e.g. tensor fascia lata, hamstrings,
quadriceps or adductors are stretched out gently.
In general, these stretching techniques o f the
different groups a n d structures should be well
understood by a competent physiotherapist so
detailed descriptions have been omitted. H o w e v e r ,
it cannot be repeated often enough that stretching
should be gentle a n d g r a d u a l a n d never forcible,
great care being taken not to tear any tissues
otherwise scarring a n d contracture w i l l occur.
5.10 Weakness of Adductors
These are the muscles w h i c h produce a n d h o l d the
turn-out position. I n dance they need to be very
strong to produce the turn-out a n d then to hold it.
T h e y are n a t u r a l l y , i n the average person, rather a
weak g r o u p a n d they c a n be weakened further b y
overstretching. T h e weakness c a n also have the
opposite effect a n d lead to the adductors b e c o m i n g
tight.
CAUSES
T h e most i m p o r t a n t cause o f weakness o f the
adductors is the execution o f an incorrect technique.
1. S i t t i n g i n the h i p .
2. R o l l i n g (Section 5.17).
3. W e i g h t too far back (Section 5.20).
193
5.22A (far left) Assessing tightness
at the front of the hip, this
photograph showing the normal
range required for a dancer.
5.22B (left) A tight hip with
limited extension.
4. O v e r t u r n i n g (Section 5.7).
5. S w a y b a c k knees (Section 5.13).
6. W e a k forefeet preventing correct weight
placement (Section 5.18).
7. Lordosis (frequently a postural fault i n c h i l d r e n
w h i c h becomes a technical fault i f the teacher
fails to correct it) (Section 5.6).
TREATMENT
T h i s is b y exercising i n order to strengthen the
adductors. T h e y should be stretched gently i f tight,
a n d technique should be corrected - a l l else is
pointless i f a fault i n technique remains.
5.11 Quadriceps Insufficiency
T h i s means weakness o f the quadriceps c o m p l e x
(vastus medialis, vastus intermedius, vastus lateralis
a n d rectus femoris). T h i s weakness m a y be total
weakness where a l l muscle groups i n the b o d y are
weak; a relative weakness c o m p a r e d w i t h other
muscle groups; a differential weakness w i t h one leg
c o m p a r e d to the other; a weakness w i t h i n the
complex where one part is weak c o m p a r e d to the
others. T h i s latter occurs m a i n l y a n d c o m m o n l y
where the vastus medialis is differentially weak
compared w i t h the other three components.
CAUSES
1. S w a y b a c k knees are a potent cause o f
quadriceps insufficiency i n dancers because o f a
failure to p u l l u p , w h i c h results i n the weight
being allowed to r e m a i n too far back. T h e
dancer w i l l then relax into the posterior capsule
 194 Section 5: T e c h n i c a l F a u l t s and A n a t o m i c a l
and the muscles do n o t h i n g to support the knee
(Section 5.13).
2. T i g h t hamstrings w h i c h cause the dancer to
work w i t h slightly flexed knees w i l l weaken the
quadriceps b y m a k i n g them w o r k inadequately.
It is also frequently seen that some people walk
and stand w i t h o u t ever fully extending the
knees a n d this is p a r t i c u l a r l y noticeable i n
w o m e n w h o wear very h i g h heels (Section
5.12).
3. After even a m i n o r knee injury the quadriceps
w i l l waste a n d weaken w i t h i n two to three days
so a special effort w i l l be required to strengthen
them again, together w i t h other associated or
affected muscle groups. I n this context special
care should be taken to ensure that the vastus
medialis is built up and that the quadriceps
strength is balanced out between the two legs
(Section 5.11).
RESULTS
1. A n t e r i o r knee p a i n (Section 3.30). Note
p a r t i c u l a r l y that lack o f balance between
various muscles w h i c h make up the whole
quadriceps (especially vastus medialis weakness)
leads to lateral tracking o f the patella.
2. A n increased risk o f knee injury, notably
meniscal damage (Section 3.35). A l s o it can
lead to rupture of the quadriceps tendon or the
patellar tendon (Section 3.37). A teacher w h o
suddenly demonstrates a step r e q u i r i n g an
explosive contraction o f the quadriceps, e.g. a
big j u m p , is p a r t i c u l a r l y at risk.
3. Weakness of the vastus medialis prevents full
l o c k i n g o f the knee i n extension (Section 5.11).
T h i s can lead to a decrease i n use of a n d a
tightening of the lateral hamstrings (Section 5.12).
4. C a l f over-development w i l l occur because the
c a l f muscles are taking more o f the load i n
l a n d i n g a n d expending more force i n j u m p i n g .
T h i s i n turn can lead to an Achilles tendonitis
(Section 3.9) and an anterior compartment
syndrome (Section 3.28) as well as anterior
foot strains.
TREATMENT
T h i s is by strengthening exercises. B a l a n c i n g out
w i t h i n the quadriceps is essential. T h i s usually calls
for extra work on strengthening the vastus medialis.
T h i s part o f the quadriceps complex only contracts
effectively in the last 15° o f extension
(straightening) o f the knee. B a l a n c i n g out between
the two legs is required. T h e r e should be correction
of any technical fault w h i c h may have lead to the
o r i g i n a l weakness.
Variations
5.12 Tightness of the
Hamstrings
CAUSES
1. T h e hamstrings can be n a t u r a l l y tight to the
extent that m a n y people cannot lift their legs
w i t h the knees straight to a 90° angle. A s the
hamstrings cross b e h i n d the knee flexion o f the
knee w i l l allow full h i p flexion to take place
even i n the presence o f tight hamstrings. T h e
flexion of the knee relaxes the h a m s t r i n g
muscles. A s w i l l be recalled from Section 1 o n
A n a t o m y , the hamstrings act as h i p extensors
and knee flexors.
2. T h e hamstrings tend to tighten as a n o r m a l
course o f affairs d u r i n g any g r o w t h spurt, as do
all other muscle groups. T h i s is because the
bones grow d u r i n g g r o w t h spurts more r a p i d l y
than the soft tissues. T h i s tightening w i l l ease
up a n d the student w i l l regain the previous
flexibility
4.16once the g r o w t h spurt has stopped.
3. W o r k i n g w i t h the weight back from any o f its
m a n y causes w i l l tend to cause a forward
rotation of the pelvis (Section 5.20). T h e knees
tend to flex slightly a n d the hamstrings then
weaken a n d tighten. I n p a r t i c u l a r , the lateral
hamstrings tighten and weaken i n this situation.
Associated w i t h the weakening a n d tightening
of the hamstrings there are frequently weak
quadriceps due to a failure to lock the knee. I n
over t u r n i n g , the hamstrings cannot be utilised
to their full extent because the pelvis becomes
tipped forwards. Also the twist at the knee w i l l
cause an i m b a l a n c e between the m e d i a l and
lateral hamstrings w i t h differential w e a k e n i n g
and tightening.
RESULTS
1. A n y tightness w i l l aggravate the weight back
situation w h i c h m a y i n itself have been the
precipitating factor, so there c a n be a vicious
circle o f deterioration (Section 5.20).
2. Tightness, of course, predisposes to h a m s t r i n g
injuries, both pulls and tears (Section 3.41).
3. U n e q u a l tightness (medial versus lateral) can
aggravate rotational pulls on the knee w h e n it
is partly flexed a n d therefore predisposed to
meniscal damage (Section 3.35).
4. L i k e quadriceps insufficiency a n d weakness,
tightness of the hamstrings w i l l put an overload
on the calf muscles w i t h resulting muscle
injuries a n d Achilles tendon problems.
(Sections 3.9, 3.10 a n d 3.11).
 Section 5.12-5.13 195

5. H a m s t r i n g s w h i c h are not being pulled u p a n d

used correctly w i l l lead to tightening o f the
tensor fasciae latae as this muscle tries to
stabilise the pelvis. T h i s overwork laterally w i l l
spread to the lateral quadriceps, a n d as a direct
result o f this, lateral t r a c k i n g o f the patella w i l l
occur a n d then anterior knee p a i n (Section
3.30). T h i s lateral tracking cannot be fully
corrected b y merely quadriceps medialis
exercises a n d b u i l d - u p without first dealing
w i t h h a m s t r i n g tightness a n d weakness a n d
stretching the tensor fasciae latae.

TREATMENT

C o r r e c t the u n d e r l y i n g causes, e.g. weight

placement a n d technique; strengthen a l l weak
groups a n d gently stretch out the tight areas. A s i n
other situations treatment w i l l be ineffective i f the
technical faults remain uncorrected.

5.23A Swayback knees, from the front.

5.13 Swayback Knees
T h i s name is given to knees w h i c h hyperextend
beyond neutral (neutral is w h e n the line between
the thigh a n d the shin is 180°). Hyperextension
from that point c a n be as m u c h as 20° or even
more ( F i g . 5.23).

CAUSES

T h i s hyperextension or swayback is a n a t u r a l l y
o c c u r r i n g situation i n anyone w h o is fairly
loose-jointed a n d is w i t h i n the range o f n o r m a l
v a r i a t i o n from one i n d i v i d u a l to the next. It c a n
however be aggravated by incorrect w o r k i n g .
T h e question is often raised as to whether ballet
t r a i n i n g causes swaybacks. T h i s is almost certainly
not the case. A s such knees give a very pleasing line
aesthetically i n the w o r k i n g leg, students w i t h
swaybacks (among other attributes) w i l l tend to be
preferentially selected, as evidenced b y the large
n u m b e r o f dancers w i t h swayback knees. H o w e v e r ,
h a v i n g said that, there is no doubt that b a d
teachers m a y aggravate a n d increase the amount o f
swayback b y a l l o w i n g the dancer to push the knee 5.23B Swayback knees, from the side.
back o n the supporting leg instead o f teaching h i m
to p u l l u p w i t h the thighs a n d then keep the knee
i n neutral.

RESULTS W e i g h t back a n d swayback knees w i l l lead to the

T h e most i m p o r t a n t feature o f swayback knees is
the creation o f the weight back situation, together
w i t h a l l its problems w h i c h have been mentioned so
repeatedly. S w a y b a c k knees are, together w i t h weak
forefeet, the most i m p o r t a n t a n d potent cause o f
the weight back situation (Section 5.20).
a d o p t i o n o f a lordotic posture a n d w o r k i n g w i t h
the a r m line too far back. Associated w i t h these is a
m a r k e d tendency for these dancers to be poor
breathers, this weakness being related to the faulty
trunk posture. T h e y w i l l be upper chest breathers
and this w i l l cause upper trunk tension.
 196 Section 5: T e c h n i c a l F a u l t s a n d A n a t o m i c a l V a r i a t i o n s
TREATMENT
Exercises are given to strengthen a l l the weak
groups w h i c h w i l l be i n p a r t i c u l a r the adductors,
vastus medialis, hamstrings a n d gluteals. I n the
lower leg the deep calf muscles w i l l not be used and
w i l l need strengthening. Swaybacks are always
associated w i t h weak feet, so m u c h attention needs
to be p a i d to strengthening the intrinsic muscles.
A l o n g s i d e this the trunk muscles, p a r t i c u l a r l y the
a b d o m i n a l s (cross fibres a n d l o n g i t u d i n a l fibres),
the trunk extensors a n d latissimus dorsi need to be
strengthened a n d the lordotic posture corrected.
B r e a t h i n g exercises using lateral expansion are
necessary.
O n l y too often treatment and technical
correction is confined to the knee region w i t h total
neglect o f the feet a n d even more often o f the
trunk. I n these cases the weight back w i l l persist
w i t h a c o n t i n u a t i o n o f the dancer's problems often
l e a d i n g h i m to the w r o n g assumption that the
treatment received was incorrect, whereas the true
situation is that the treatment was not extensive or
widespread enough to encompass the whole
situation. U n f o r t u n a t e l y , any c o n d i t i o n that is only
p a r t i a l l y corrected due to insufficient or too
localised treatment tends to lead the dancer to
assume that any treatment received was w r o n g
rather t h a n inadequate.
5.14 Tight Achilles Tendons
A l t h o u g h this expression is i n c o m m o n usage what
is, i n fact, meant is tightness o f the calf muscle a n d
A c h i l l e s tendon complex a n d not just the tendon
alone. V e r y frequently the tightness is confined to
the gastrocnemius muscle so that when the knee is
flexed, a l l o w i n g the gastrocnemius to relax, the
ankle c a n be dorsi-flexed very freely, showing that
the soleus is not tight. ( R e m e m b e r that the
gastrocnemius takes its origin from the lower end o f
the femur a n d therefore crosses b e h i n d the knee,
whereas the soleus muscle w h i c h lies deep to the
gastrocnemius takes its origin below the knee joint.)
CAUSES
A s w i t h tight hamstrings the tightness can merely
be part o f a general tightness, although occasionally
it m a y appear to be confined to the calf a n d
A c h i l l e s tendon area. T h i s type o f tightness tends to
be permanent, although it can be helped to a very
l i m i t e d extent.
F a r more often the tightness w h i c h seems to be
present w h e n w o r k i n g is only apparent a n d is not
real, so that w h e n the foot a n d ankle are
dorsi-flexed passively a full range is obtained.
Therefore this type of 'tightness' is due to faulty
technique, usually associated w i t h weakness o f
various muscle groups. It often accompanies
swayback knees a n d weight back. W h e n the weight
is pushed onto the back o f the heel instead o f being
distributed between the heel a n d the forefoot the
calf muscles cannot w o r k properly or be stretched
out fully when weight-bearing. W e i g h t back also
tends to weaken the calf muscles a n d this c a n be
a c c o m p a n i e d by tension a n d tightening i n them
because of their lack of strength i n a controlled
relaxation situation.
If the weight is back the dancer cannot utilise
the full depth o f the plié. W h e n t r y i n g to d o so,
visible tension is present i n the dorsi-flexors o f the
ankle a n d this can be seen to be obviously
prominent at the front o f the ankle i n this case.
Shoes that are too short c a n lead to this
h a p p e n i n g because the toes are c u r l e d up, p u s h i n g
the weight back. T h i s happens to boys more than
girls a n d m a y be the only cause o f the weight back,
without any other u n d e r l y i n g a n a t o m i c a l or
technical p r o b l e m .
A n t e r i o r knee p a i n (Section 3.30) can be
associated w i t h a tightening o f the c a l f a n d the
Achilles tendon complex. T h i s is p r i m a r i l y brought
about by the weight being back, i n w h i c h case the
quadriceps are used as a brake w h e n j u m p i n g
rather than using the calf muscles a n d quadriceps
equally. It is more c o m m o n i n boys because they
are used to m u c h bigger j u m p s . A s the calf is
under-used it w i l l tend to tighten a n d this m a y then
lead to an Achilles tendonitis (Section 3.9) as well
as a l l the various problems described i n the section
on anterior knee p a i n (Section 3.30).
Achilles tendonitis (Section 3.9) a n d A c h i l l e s
bursitis (Section 3.11) are both very frequently
associated w i t h tightness and/or weakness o f the
calf muscles (not only when there is anterior knee
p a i n ) . F o l l o w i n g on from this there c a n then
develop anterior c o m p a r t m e n t syndrome (Section
3.28) a n d stress fractures o f the tibia (Section
3.27). A l l these problems being greatly aggravated
by solid floors.
TREATMENT
Strengthening first a n d then gentle stretching of the
calf muscles must be carried out (the actual
Achilles tendon cannot be stretched). T h e c o n d i t i o n
requires technical faults to be identified a n d
corrected as m u c h as or more than almost any
other technical or a n a t o m i c a l p r o b l e m . T o g e t h e r
w i t h its associated Achilles tendonitis a n d bursitis it
is p r o b a b l y the commonest source o f apparent
treatment failures.
 Section 5.14-5.15
5.24A The whole tibial bow. 5.24B The lower tibial bow.
5.15 Tibial Bow
A l t h o u g h the t i b i a has a n a t u r a l m i l d curve, w h i c h
is convex laterally, this can c o m m o n l y be
exaggerated w h e n it is k n o w n as a tibial bow. T h e
b o w c a n affect the whole length o f the t i b i a or,
more usually, the lower t h i r d ( F i g . 5.24).
CAUSES
T h i s is a n a n a t o m i c a l v a r i a t i o n of n o r m a l g r o w t h .
O t h e r causes .such as V i t a m i n D deficiency are
extremely rare nowadays i n affluent societies.
RESULTS
M o s t o f the problems are brought about because
the ankle j o i n t is slightly angled i n relation to the
centre line o f the leg ( F i g . 5.25). A s a n a t u r a l result
of this the foot is rolled w h e n standing flat. Dancers
have to w o r k very m u c h harder to h o l d the
turn-out a n d not to over t u r n , otherwise this r o l l i n g
becomes greatly exaggerated. T h e y need to w o r k
conscientiously on the inner side of thigh exercises
(Section 5.17).
197
5.25 The lower tibial bow.
The foot on the left of the
photograph is aligned with the leg as
a whole. The foot on the right is
aligned with the lower end of the
tibia and the ankle. In the presence
of lower tibial bows the dancer has
of necessity to work with the foot
aligned with the leg.
Stress injuries o f the lower t i b i a a n d fibula
(Sections 3.26 a n d 3.27) are more c o m m o n as a
result o f the a b n o r m a l foot posture p r o d u c e d b y
the bow. I n a d d i t i o n , soft tissue problems a r o u n d
the lower fibula occur.
W h e n the foot is pointed it is sickled i n n a t u r a l l y
a n d this needs correction. S i m i l a r l y , w h e n on
demi-pointe the foot w i l l tend to assume the same
sickle position u n t i l corrected. O n pointe the dancer
finds it very h a r d to get u p into the right position
a n d m a y sickle i n either direction, m u c h d e p e n d i n g
u p o n toe length variations a n d foot strength or
weakness. These latter factors contribute towards
the greater tendency for stress fractures o f the 2 n d
metatarsal to occur (Section 3.16) w i t h tibial bows.
TREATMENT
A great deal o f exercise is required to strengthen
the adductors, the gluteals and the hamstrings to
give stability i n the upper leg. W o r k is required to
strengthen the c a l f muscle equally. F r e q u e n t l y there
is, as a consequence o f the faulty foot position,
 198 Section 5: T e c h n i c a l F a u l t s and A n a t o m i c a l
weakness o f the lateral part o f the calf w h i c h tends
to be present because o f the overwork o f the m e d i a l
portion. Exercise to strengthen the intrinsic muscles
of the feet are essential. A c c o m p a n y i n g this,
technical help is required to g a i n the hold o f the
turn-out a n d adjust the weight-bearing line through
the leg. O n c e that is achieved it w i l l have to be
followed w i t h correction o f the foot position to the
o p t i m u m . T h e foot position correction cannot be
carried out before the upper part o f the leg is
correct. A n y attempts to do so merely compounds
the p r o b l e m .
5.16 Posterior Block of the Ankle
Joint
B y this is meant an interference w i t h full
plantar-flexion at the j o i n t due to a bony
prominence i m p i n g i n g between the d o r s u m o f the
os calcis a n d the posterior articular m a r g i n o f the
tibia ( F i g . 5.26). T h e causes for this are an os
t r i g o n u m or a large posterior tubercle o f the talus
or, more rarely, a bony prominence or exostosis on
the d o r s u m o f the posterior part of the os calcis or
finally an osteophyte on the posterior angle o f the
talus. T h i s latter is an acquired prominence w h i c h
comes as a result o f repeated m i n o r injuries and
early degenerative change. T h e first three are
situations w i t h w h i c h the dancer is born and occur
n o r m a l l y i n a certain percentage o f the p o p u l a t i o n .
A l t h o u g h the os t r i g o n u m has been described by
anatomists a n d given its o w n name as a separate
little bone o c c u r r i n g at the back o f the ankle i n
some 14—15% o f the p o p u l a t i o n , studies o f sections
of the os t r i g o n u m , i n cases where this has
necessitated removal in dancers, suggest that at
least some are i n fact stress fractures w h i c h have
occurred i n the large posterior tubercle o f the talus.
It m a y well be that i n every case the os t r i g o n u m is
a stress fracture o f the posterior tubercle and was
not at b i r t h a separate bone. H o w e v e r , as far as the
dancer is concerned, whether or not this is the case
is purely academic.
CAUSES
T h e symptoms are produced by the presence o f a
piece o f bone interfering w i t h the full rotation o f
the talus i n the ankle mortice d u r i n g plantar-
flexion. A s the talus rotates towards the plantar-
flexed position (or full pointe) the heel bone or os
calcis rises towards the posterior a r t i c u l a r m a r g i n o f
the tibia. T h e bony prominence projecting beyond
the posterior angle o f the talus comes between the
d o r s u m o f the os calcis a n d the posterior a r t i c u l a r
m a r g i n o f the tibia. W h e n this happens the capsule
Variations
A B
C D
5.26 A . Lateral of a normal ankle.
B. Lateral of an ankle with a large posterior
tubercle of the talus.
C. Lateral of an ankle with an os trigonum.
D. Lateral of an ankle with an exostosis on the
dorsum of the os calcis.
and the u n d e r l y i n g s y n o v i u m w i l l be squeezed
between the two bony surfaces and these soft tissues
are the source of the p a i n . W h e n this local pressure
is repeated local swelling develops a n d this is
followed by thickening of the soft tissues. T h e
symptoms w i l l steadily increase a n d p o i n t i n g o f the
foot becomes more difficult a n d painful.
Symptoms are unusual before the mid-teens. It is
not u n t i l this time that the student has achieved the
m a x i m u m natural point and therefore any further
plantar-flexion o f the ankle is prevented by the
bony block. Also about this time i n a professional
dance school the amount and pressure o f w o r k is
increasing greatly. A s a result the soft tissues do not
have time to settle between one class a n d the next
as w o u l d happen i n students w h o were only d o i n g
one or two classes a week. T h e c o n d i t i o n tends to
be far more c o m m o n i n girls w h o are w o r k i n g for a
far better pointed foot and w h o are d a n c i n g a lot
of the time on pointe. H o w e v e r , i n boys w h o are
putting i n efforts at b i g j u m p s or h a v i n g to rise
onto three-quarter pointe there m a y be a
precipitation o f symptoms. Before this stage i n their
career the amount a n d pressure o f w o r k has usually
been insufficient for a full pointe to have been
 Section 5.16 199

5.27A A n X-ray showing an os
trigonum just about to impinge on
the posterior articular margin of the
lower end of the tibia. Remember
that soft tissues (synovium and
capsule in this case) are being
trapped and squeezed between the
two bones. These soft tissues cannot
be seen on an X-ray.
5.27B Os trigonum with the ankle 5.27C A n X-ray of the same
in neutral dorsi-flexion/plantar- patient following removal of the os
flexion showing the large distance trigonum.
between the os trigonum and the
posterior articular margins of the
lower end of the tibia. Comparison
with Fig. 5.27A gives an excellent
impression of the actual range of
movement which occurs at the ankle
joint (a hinge joint).

developed. It is o n l y g r a d u a l l y that stretching o f 3. R e c u r r e n t c a l f muscle strains, usually a r o u n d

the soft tissues has occurred a n d has allowed
m a x i m u m rotation o f the talus into plantar-flexion.
E v e n w h e n there is a n os t r i g o n u m or s i m i l a r b o n y
prominence, i n m a n y instances, despite the m i l d
l i m i t a t i o n o f full plantar-flexion at the ankle j o i n t ,
the mid-tarsal region w i l l have been mobile enough
to have p r o d u c e d compensation a n d a satisfactory
p o i n t i n g o f the foot. I n these instances symptoms
do not usually develop.
SYMPTOMATOLOGY
1. U s u a l l y the dancer complains o f a painful
A c h i l l e s tendon a n d general discomfort b e h i n d
the ankle a n d a r o u n d the Achilles tendon area.
T h i s tends to increase w i t h w o r k a n d settles
w i t h rest.
2. P a i n over the anterior a n d antero-lateral aspect
o f the ankle is not at a l l u n c o m m o n a n d this
m a y be a c c o m p a n i e d by swelling. T h e attempts
at i m p r o v i n g the pointe throws a strain on the
antero-lateral aspect o f the ankle a n d the
anterior capsule. H e n c e the p a i n .
the region o f the musculo-tendinous j u n c t i o n ,
are not u n c o m m o n a n d they m a y be
a c c o m p a n i e d b y more or less p a i n a r o u n d the
A c h i l l e s tendon a n d the posterior part of the
ankle (Section 3.9).
4. Sometimes the student w i l l present w i t h p a i n
under the p l a n t a r aspect o f the foot brought
about by straining to pointe the foot. V e r y
frequently the dancer w i l l c u r l the toes i n a n
effort to i m p r o v e the pointe (Section 3.18).
5. O n l y rarely d o the dancers c o m p l a i n o f very
well localised p a i n at the back o f the ankle
j o i n t itself.
C l i n i c a l e x a m i n a t i o n w i l l reveal very w e l l
localised tenderness at the back o f the ankle
j o i n t a n d frequently the l u m p o f the b o n y
prominence c a n a c t u a l l y be felt. X - r a y s w i l l
show the presence o f either a large posterior
tubercle o f the talus or a n os t r i g o n u m or, far
less c o m m o n l y , a p r o m i n e n c e on the d o r s u m o f
the posterior part o f the os calcis. O c c a s i o n a l l y
a degenerative-type osteophyte w i l l be seen.
H o w e v e r , it is i m p o r t a n t to emphasise that the
presence o f a n y o f these does not m e a n they
200 Section 5: T e c h n i c a l Faults and A n a t o m i c a l V a r i a t i o n s
are the cause of the patient's symptoms. O n l y
too frequently the symptoms are precipitated
by weakness o f the intrinsics, by lack of proper
control of the ankle and foot and by general
weakness of the muscles around the lower leg
and foot.
TREATMENT
I n i t i a l l y , every effort should be made to relieve the
symptoms by conservative measures. Strengthening
up the muscle groups and the intrinsic muscles
together w i t h local treatment such as interferential
therapy may be sufficient. O n l y i f this fails should
operation be considered in order to remove the
prominent piece o f bone ( F i g . 5.27).
If operation is undertaken it is essential that the
aftercare is treated seriously. T h e leg should be
elevated u n t i l the swelling has settled. E a r l y
exercises are instituted both in order to retain the
increased plantar-flexion or p o i n t i n g that has been
gained by the operation and also to prevent the
scar tissue contracting at the back of the ankle
w h i c h has been the site of the operation. W a l k i n g
can be allowed as soon as the foot can be
dorsi-flexed to the neutral position but the w a l k i n g
should be limited and the foot kept well elevated in
order to decrease any tendency for swelling. O n c e
the stitches have been removed treatment should be
directed at reduction of any swelling, general
strengthening of the intrinsic muscles of the foot
and o f all the muscle groups c o n t r o l l i n g the foot
and ankle. T h e ankle joint should be actively
mobilised d u r i n g the whole phase of treatment but
passive mobilisation should in general be avoided.
If the treatment has been efficiently carried out
the dancer should be fit by the end of four weeks to
start a gentle barre and work from there for a
g r a d u a l return to class. D u r i n g this period he will
also need some technical help and correction. E v e n
after the dancer has returned to full work a careful
follow-up should be continued for a m i n i m u m of
six months as d u r i n g this period there is usually a
tendency for some contraction to occur in the
tissues at the back of the ankle and this w i l l result
in a g r a d u a l decrease in the depth of the plié. T h e
follow-up is required in order to treat any
suggestion of contracture by vigorous and active
exercises a n d p r o b a b l y also some passive stretching.
W h e n stretching the foot in the plié it is extremely
i m p o r t a n t that the posterior stretch is evenly
a p p l i é d and that one or other side is not allowed to
become tight.
5.17 Rolling
T h e nature o f rolling is best seen i n the
a c c o m p a n y i n g photograph ( F i g . 5.28).
CAUSES
1. W e a k intrinsic muscles i n the feet (Section
5.18) and weak lower leg muscles w h i c h can
occur n o r m a l l y d u r i n g a period o f r a p i d
growth make the occurrence of r o l l i n g almost
inevitable. I n this instance the r o l l i n g normally-
ceases after the growth spurt has ended.
2. O v e r t u r n i n g (Section 5.7). T h e r e is a very
fine division between the adequately turned out
and over turning. O n c e the dancer has gone
past the former a n d starts to over turn then
rolling at the foot is inevitable, p r o d u c i n g
many faults.
3. Incorrect teaching of placement and the
resulting over t u r n i n g can lead to r o l l i n g .
C e r t a i n l y rolling is a natural consequence of
the weight back situation and it becomes a
compensatory mechanism i n t r y i n g to m a i n t a i n
balance (Section 5.20).
4. F a i l u r e to adjust to a raked stage may also lead
to rolling.
RESULTS
1. T h e turn-out is not under correct control
because when the foot is rolled the weight is
back and as a result the muscles around the h i p
cannot be correctly held. T h e r e w i l l also be a
tendency for the dancer to adopt a lordotic
posture (Section 5.6).
2. A strain is exerted on the inner (medial) side o f
the knee (Sections 3.32 and 3.35).
3. T h e r e is a lack of adequate function of the calf
muscles and of the peronei. T h e tibialis
anterior and tibialis posterior become more
liable to strain. T e n d o n i t i s can be the end
result, particularly in the tibialis posterior
(Section 3.13).
4. D a m a g e to the lateral ligament o f the ankle
can occur because it becomes crushed on the
flat foot and stretched on the rise because on
rising the foot w o u l d go in the opposite
direction to the rolling i n order to m a i n t a i n
balance (Section 3.1).
5. Strain of the structures along the m e d i a l border
of the foot,.strain of the l o n g i t u d i n a l arch and
of the plantar fascia in its m e d i a l part are a l l
associated with rolling (Section 3.18).
 Section 5.17-5.18
6. Because the majority o f the weight is taken on
the m e d i a l part of the foot the great toe takes
most of the strain. T h i s causes sprains o f the
capsule of the 1st metatarso-phalangeal j o i n t
(Section 3.19), sesamoiditis (Section 3.20)
(these two little bones lie under the 1st
metatarsal head) a n d frequently a twist i n the
great toe w h i c h can finally end w i t h a
permanent rotation at the metatarso-
phalangeal j o i n t , a n d severe valgus strains
occur, thus aggravating any tendency towards
a h a l l u x valgus deformity (Section 3.21). I n
the longer term this valgus pressure (i.e.
pressure from the m e d i a l side directed laterally)
can cause some valgus deformities o f a l l the
toes a n d of the distal part of the forefoot.
7. C o n t i n u e d incorrect weight transference leads
to stress fractures o f the metatarsals - m a i n l y
the 2 n d (Section 3.16).
8. T h e r o l l i n g w i l l cause not only a valgus posture
in the great toe but w i l l also cause a flexion at
the interphalangeal j o i n t o f the toe w i t h a
hyperextension at the metatarso-phalangeal
j o i n t a n d , following that, an increased tension
in the extensor hallucis longus tendon a n d an
extensor hallucis longus tendonitis (Section
3.15).
TREATMENT
Identification a n d correction o f a l l the u n d e r l y i n g
technical faults a n d strengthening exercises for a l l
the weakened muscle groups is essential. T h i s can
201
5.28A (far left) Rolling, shown
without a shoe.
5.28B (left) The effect on the foot
is less obvious in a shoe although it
still occurs to the same extent.
c o m m o n l y require exercise regimes from the trunk
d o w n w a r d s . A l t h o u g h the treatment is relatively
easy it can be very time-consuming for the dancer
but i n the l o n g term is a protective measure a n d
w i l l save a great deal o f injury time i n the future.
5.18 Weak Intrinsic Muscles of
the Feet
These are the small muscles w h i c h m a i n t a i n the
transverse arch a n d allow the toes to be extended at
the interphalangeal joints w h i l e they are being
flexed at the metatarso-phalangeal joints. T h e y also
spread the toes a n d p u l l the toes together
(adduction and a b d u c t i o n ) . W h e n correctly used
they prevent c l a w i n g o f the toes.
RESULTS
1. W e a k intrinsic muscles interefere w i t h the
correct transmission o f weight through the foot,
the result of w h i c h is that the weight is almost
entirely taken on the heel instead o f being
distributed between the forefoot a n d the heel
(Section 5.20).
2. O n pointe the toes cannot be held extended
(straight) i n the absence of strong intrinsic
muscles and they w i l l c l a w u p i n the shoes. A t
the extreme the dancer w i l l be on pointe on the
knuckles o f the toes. T h i s is k n o w n i n the
U n i t e d States o f A m e r i c a as ' k n u c k l i n g ' . A l s o
on pointe the weight w i l l be pushed back
(Section 5.20) a n d as a result there is a greatly
202 Section 5: T e c h n i c a l Faults a n d A n a t o m i c a l Variations

increased tension i n the structures at the back

of the ankle, n o t a b l y p r o d u c i n g an Achilles
tendonitis (Section 3.9) a n d bursitis (Section
3.11) a n d / o r a tibialis posterior tendonitis
(Section 3.13), depending on the i n d i v i d u a l
b u i l d - u p o f the dancer. A small os t r i g o n u m
w h i c h w o u l d otherwise have been symptomless
can start to cause p a i n and symptoms.
3. O n j u m p s or l a n d i n g or d u r i n g relevés there is
an incorrect weight transference through the
foot because o f the weakness o f the forefoot.
T h e l a n d i n g w i l l be heavy a n d the dancer w i l l
crash d o w n w i t h the weight back (Section
5.20). I f a j u m p is started w i t h the weight
5.29 Long 2nd metatarsal and 2nd toe. Here the
incorrect the l a n d i n g w i l l also have an incorrect situation is aggravated by the presence also of a short 1st
weight placement, frequently l e a d i n g to shin metatarsal.
(Section 3.27) a n d knee injuries (Sections
3.30, 3.31, 3.32, a n d 3.35).

TREATMENT

F a r a d i c foot baths and intrinsic muscle exercises

and correction o f technique, together w i t h
correction o f weight placement, are the essentials of
treatment. Inspect shoes i n order to make sure that
they are fitting well a n d g i v i n g adequate support.
T h e y must not be too wide or too short. T h e steel
i n the sole o f some shoes, used by some dancers w h o
have weak intrinsics, prevents correct use o f the
feet i n relevés as the dancer cannot go through the
foot correctly i n order to achieve the o p t i m u m
position for pointe work. Therefore this type o f
shoe only aggravates the situation a n d makes the
muscles a n d feet even weaker.

5.19 Variations in the Length of

the Toes and of the 5.31 A Sloping (oblique) line of metatarsal heads. This
Metatarsals is a difficult foot on demi-pointe.

T h e ideal forefoot is one where the toes a n d

metatarsals are a l l about the same length across the
foot from the first toe. Inevitably the lateral side o f
the foot, i.e. the 4th and 5th toes a n d metatarsals,
tend to be a little shorter but w h e n this slope is not
very m a r k e d the dancer has a foot that is stable on
both demi-pointe a n d o n full pointe. C o n s i d e r i n g
the metatarsals first, there can be considerable
variations i n length. It is quite c o m m o n to have a
2nd metatarsal w h i c h is m a r k e d l y longer than
either the 1st or the 3rd ( F i g . 5.29). A n o t h e r fairly
c o m m o n v a r i a t i o n is a very short 1st metatarsal
(Fig. 5.30) w i t h the lesser metatarsals m u c h o f a
length. A n o t h e r v a r i a t i o n is where the lesser
metatarsals shorten quite m a r k e d l y progressively
towards the 5th metatarsal, g i v i n g a sloping line o f
metatarsal heads ( F i g . 5.31). I n a l l these instances
the dancer w i l l have greater or lesser difficulty
when o n demi-pointe, the degree o f difficulty
depending upon the p a r t i c u l a r a n a t o m i c a l v a r i a t i o n
w h i c h is present.
As far as the toes themselves are concerned, the
length o f the toes m a y m i r r o r what is h a p p e n i n g at
the metatarsals. H o w e v e r , one also sees variations
in actual length of the toes even i f the metatarsals
themselves are o f a fairly even length ( F i g . 5.32).
 Section 5.19 203

5.30A (above) Short 1st metatarsal.

5.30B (right) A n X-ray showing the short 1st

metatarsal.

5.3IB Here the situation is made much worse by also

having very short lesser toes. This foot is extremely
difficult for both demi-pointe and pointe work.

T h e commonest situation is where there is a l o n g

2nd toe either w i t h or without an a c c o m p a n y i n g
long 2nd metatarsal. T h i s gives the so-called
'classical foot' as is seen i n most o f the Greek
statues a n d also, very frequently, i n fifteenth-,
sixteenth- a n d seventeenth-century paintings. T h i s
is, however, no comfort to the dancer as
discrepancies i n toe lengths cause considerable
problems when d o i n g pointe work. A l o n g 2 n d toe
is inevitably going to become flexed up d u r i n g
pointe work.
5.32 Long 2nd and 3rd toes. In this particular foot the
first three metatarsals are much the same length, giving a
very stable foot for demi-pointe despite the short 5th toe
and metatarsals. O n pointe work the larger 2nd and 3rd
toes make it more difficult even though here the
discrepancy in length between 1st and 2nd is not as great
as frequently occurs.
204 Section 5: T e c h n i c a l F a u l t s a n d A n a t o m i c a l Variations

5.33A Unequal
metatarsal lengths—short
1st metatarsal; 2nd and
3rd metatarsals equal
length; and 4th and 5th
metatarsals very much
shorter.
5.33B Sickling, with
weight being transmitted
laterally.
5.33C Sickling, with
weight being transmitted
medially.
5.33D In best position
achievable.
When on demi-pointe, the
weight is taken only on
the 2nd and 3rd
metatarsal heads with
some support from the 1st
and 4th toes and the 5th
toe only just touching the
floor.

RESULTS

Discrepancies i n metatarsal lengths cause m a r k e d

unsteadiness a n d instability on demi-pointe. T h i s
can cause strains o f either the m e d i a l or lateral
sides of the foot a n d ankle (Sections 3.1, 3.3 and
3.4) d e p e n d i n g u p o n the nature o f the metatarsal
length discrepancy and the w a y i n w h i c h the foot
w i l l tend to fall. O n half-pointe the foot m a y be
either sickled inwards or outwards i n a n attempt to
gain stability ( F i g . 5.33).
I n toe length discrepancy on full pointe the
problems tend to be associated more locally w i t h
the toes themselves a n d the difficulty i n
satisfactorily fitting the shoe into the blocks. L o c a l
damage to the toes can occur i n the form o f
blistering a n d m a r k e d callosity formation (Section
3.24). A d d i t i o n a l l y , the foot itself c a n be somewhat
unstable o n pointe.
I n b o t h situations, but p a r t i c u l a r l y i n metatarsal 5.34 Stress fracture
of the 2nd metatarsal.
length discrepancies, stress fractures of the longer
Healed with plentiful
metatarsal or metatarsals are very c o m m o n ( F i g . callus (new bone)
5.34) (Section 3.16). formation.

TREATMENT

A great deal o f attention must be p a i d to

strengthening the intrinsic muscles o f the foot a n d
to strengthening a l l the muscle groups c o n t r o l l i n g
the foot a n d the ankle. A lot o f technical help m a y
be required i n order to get the dancer adjusted to
the o p t i m u m position on both demi-pointe a n d
pointe. It is i m p o r t a n t to try a n d correct any
tendency to sickling one w a y or the other.
 Section 5.20 205

5.20 Incorrect Weight Placement

T h i s usually means that the weight is too far back.
W h e n weight transmission is correct the line runs
d o w n vertically from the mastoid processes just
behind the ears through the centres o f the shoulder,
hip, knee a n d ankle joints to j o i n the sole at the
anterior edge o f the heel p a d . O c c a s i o n a l l y a
dancer w i l l overcorrect a n d take the weight too far
forward so that it passes through the balls o f the
feet a n d , i n these instances, the heels are frequently
slightly lifted from the g r o u n d .

C a u s e s of the Weight Back Situation

1. Lordosis (Section 5.6).
2. K y p h o s i s a n d a stiff thoracic spine produce a
compensatory lordosis (Section 5.6) w h i c h
tilts the pelvis and moves the weight back.
3. Scoliosis w i l l frequently produce a pelvic tilt
often a c c o m p a n i e d by pelvic rotation
(Section 5.4).
4. Tightness at the fronts o f the hips (Section
5.9) produces a forward rotation o f the pelvis
a n d pushes the weight back on the legs.
5. W e a k trunk muscles cause tension i n the
upper back muscles w h i c h on movement
makes the upper trunk fall back as a result o f
the lack o f control o f the m i d d l e o f the trunk.
T h i s is a c c o m p a n i e d by prominence o f the
front o f the r i b cage a n d relaxation o f the
a b d o m i n a l muscles. Frequently this is
a c c o m p a n i e d by upper chest breathing w h i c h
aggravates the p r o b l e m by p r o d u c i n g even
more tension i n the upper back muscles,
i n c l u d i n g the trapezius.
6. W e a k a b d o m i n a l muscles, gluteals, hamstrings
a n d adductors (namely any muscle g r o u p
w h i c h takes part i n the stabilisation o f the
pelvis) can together or i n d i v i d u a l l y a l l o w a
pelvic tilt.
7. O v e r t u r n i n g o f the feet associated w i t h either
a genuine l i m i t a t i o n o f the external rotation
available i n the h i p or lack o f muscle c o n t r o l
of an adequate turn-out produces a forward
tilt (Section 5.7).
8. Inappropriate muscle development. T h i s m a y
be produced either by faulty teaching or by
heavy weight resisted exercises or by
o^r-indulgence i n unsuitable recreational
pursuits such as gymnastics, r i d i n g or skating.
W h i l e these latter can be perfectly satisfactory
for pleasure, i f carried to excess they m a y lead
to over-development o f muscle groups
unhelpful to dance.
5.35 Although weight bearing is distributed throughout the sole
of the foot, the line of weight transmission from the centre of
gravity of the dancer should pass through the heavy black line
shown above.
9. L a c k o f c o n t r o l o f hyper-extended knees
(Section 5.13) because pushing back the
knees causes relaxation o f the muscle groups
c o n t r o l l i n g the pelvis.
10. T i b i a l b o w i n g (Section 5.15) because o f its
tendency to produce r o l l i n g w h e n flat, a n d
sickling w h e n rising. T h e b o w i n g alters the
line o f weight transmission from the centre o f
gravity.
11. T i g h t pointe renders the dancer i n c a p a b l e o f
rising correctly through the foot to achieve
correct h a l f a n d three-quarter pointe. T h e
weight is therefore taken back. W h e n j u m p i n g
the tight pointe prevents the dancer going u p
through the foot or c o m i n g d o w n through the
foot correctly. T h e y start the j u m p w i t h the
weight back a n d l a n d w i t h the weight back.
T h i s is a potent cause o f anterior leg problems
a n d stress injuries o f metatarsals (see also
Section 5.16).
12. Stiff b i g toe joints (Section 3.22) push the
weight on to the outer sides o f the feet w h e n
rising instead o f t a k i n g it through the centre
of the foot. A s a result the weight is pushed
back.
206 Section 5: T e c h n i c a l F a u l t s a n d A n a t o m i c a l Variations

13. S l o p i n g line o f metatarsal heads also pushes 9. Stress fractures o f tibia a n d fibula (Sections
the weight o n to the outer side o f the foot i n a 3.27, 3.26).
similar fashion to stiff b i g toe joints. 10. A n t e r i o r compartment syndrome (Section
14. W e a k intrinsic muscles o f the feet 3.28).
a c c o m p a n i e d b y c l a w i n g o f the toes pushes 11. C a l f injuries (Section 3.29).
the weight back too far o n the heels. 12. Achilles tendonitis (Section 3.9).
15. T i g h t shoes w i l l produce c l a w i n g o f the toes 13. Extensor hallucis longus tendonitis (Section
w i t h similar results to 14. 3.15).
16. G r o w t h spurts cause a generalised decrease i n 14. Stress fractures o f metatarsals (Section 3.15).
muscular control. A s a result any o f these 15. W e a k e n i n g o f the intrinsic muscles due to lack
affected areas can cause the weight to be of proper use (Section 5.18).
taken too far back whether the weakness be at 16. D a m a g e to b i g toe joints (Section 3.19).
the feet, i n the trunk or anywhere i n between.
TREATMENT

T h i s is really a misnomer because the weight back

situation is not an injury. It is, however, one o f the
Consequences o f the Weight Back Situation
most c o m m o n a n d i m p o r t a n t faults i n the dancer
1. L o w back strains. a n d its correction is essential. T h i s c a n only be
2. Stress fractures o f the partes intra-articulares achieved by first d e t e r m i n i n g w h i c h cause o r causes
(Section 3.51). (often multiple) are p r o d u c i n g the weight back
3. G r o i n injuries (Section 3.40). state. Considerable effort a n d attention must then
4. B u t t o c k p a i n (Section 3.44). be p a i d to correcting and e l i m i n a t i n g a l l these
5. H a m s t r i n g injuries at various levels (Section causes. T r e a t m e n t m a y i n fact be necessary but this
3.41). w i l l be aimed at any injuries w h i c h have arisen
6. A d d u c t o r muscle injuries (Section 3.39). secondarily to the weight back situation. As in all
7. A n t e r i o r knee p a i n (Section 3.30). other cases of injury simple treatment of the injury alone,
8. Strains o f the back o f the knee j o i n t (Section without any correction of the underlying technical fault, will
3.31) be useless.
 Index

Page references i n b o l d denote illustrations

abdominal muscle weakness 185, 187 carpal 4, 5, 9, 10

abduction, see joint movements 7, 8 cervical spine 2, 2, 3
abductor hallucis 28 clavicle 4, 5, 9, 9, 21, 29;
acetabulum 11, 11 unequal lengths 181-2
Achilles tendon 26, 27 coccyx 1, 6
Achilles tendon bursitis 113-114, 196, 202 cuboid 13, 14
Achilles tendon complex 129 cuneiform 13, 14
Achilles tendon, femur 5, 6, 11, 11
rupture of 113; fibula 5, 6, 13, 14, 14
stretching 107, 108, 108; humerus 4, 5, 9, 9, 10
tightness 108, 108, 128, 130 131, 196 ilium 5
Achilles tendonitis 112-13, 194, 195, 196, 199, 201 innominate bone 1, 5, 6, 9
acupressure 86, 94 ischium 5
acupuncture 86, 94 lateral malleolus 13
adduction, see joint movements 7, 8 metacarpal bones 4, 5, 9, 10
adductor hallucis 28 metatarsals 5, 6, 13, 14
adductor muscles of hip 23, 23, 31, 55; navicula 13, 14
tears of 136-7; odontoid peg 2, 2
weakness of 133, 137, 186, 187, 190, 193 os calcis 5, 6, 14, 198
adrenal gland 52 patella 6, 12, 13, 13, 25;
alveolus 46, 47 fractured 135
amino acids 45 pelvis 1, 5, 6, 9
ankle joint 13, 14, 15, 32 phalanges 4, 5, 6, 9, 10, 13
anterior compartment syndrome 128-9, 189, 194, 196 pubic bone 5
anterior foot strain 194 radius 4, 5, 9, 10
anterior knee pain 129-32, 194, 195, 196 ribs 4, 29
anterior talo-fibular ligament 14, 14, 104; sacrum 1, 6, 9
sprain of 104 scaphoid 4
anterior tibio-fibular ligament 14 scapula 4, 5, 9, 23, 29
anti-inflammatory drugs 92 shoulder girdle 4, 5
alimentary canal 43, 43 skull 1,2
aorta 40, 40, 41 sternum 4
artery 39, 39 talus 5, 6, 13
atrium 39, 40, 41 tarsal bones 5, 6, 14, 15
autonomic nervous system 35 tibia 5, 6, 11, 13, 14, 14
axon 33, 33 ulna 4, 5, 9, 10
vertebral column 1
balance 36 brachialis 30
balancing board 106, 107 brachio-radialis 30
biceps femoris 26, 27, 32 brain 1
bile 45 bronchus 46, 46
bile duct 43, 44 bunions 121, 122
blood 38
blood cells 38 caecum 43
blood pressure 41 calf muscle strains 199
bone scan 127 callosity 37, 125, 204
bones carbon dioxide 39, 47
general 1 cardio-vascular system 38
208 Index

carpal bones 4, 5, 9, 10 exercise types 89

cartilage 1 exercises:
hyaline (articular) 6, 7 abdominal 146
cartilages of knee, see meniscus adductors of hip 156
capillary 39, 40 extensors of back 148
capsule of joint 7, 7, 11 extensors of hip (gluteals) 158
carbohydrate 45, 99 hamstrings 160
causes of dance injuries 74 intrinsics of feet 162
cervical spine 2, 2, 3 quadriceps 154
chiropractic 94 extension, see joint movements 7, 8
chondromalacia patellae 130, 131, 190 extensor digitorum longus 27
chronic sprain of ankle 109 extensor hallucis longus 32;
circulation of the blood 39, 40 tendonitis of 116, 201
circumduction, see joint movements 7, 8 external oblique 21, 22, 29
clavicle 4, 5, 9, 9, 21, 29; exteroceptors 35, 36
unequal length 181-2
clicking hip 139 facet joint strain 141
coccyx 1, 6 faradic footbaths 86
cochlea 36, 36 faradism 86
cold therapy 81 fascia, deep 16, 16
colon 43, 44, 45 fascia lata 24, 31;
complication of injury 76 tightness of 129, 137
contrast baths 84 fascia, superficial 16, 16
corns 125 fat 45, 99
cruciate ligaments of knee 12, 13, 13; fatigue 91
injury of 133 femur 5, 6, 11, 11
cuboid 13, 14 fibula 5, 6, 13, 14, 14
cuneiform 13,14 first aid treatment 79
flexion, see joint movements 7, 8
daily diet 101 flexor accessorius 28
deltoid 21, 22, 33, 10 flexor digiti minimi brevis 28
deltoid ligament, see medial ligament of ankle 14, 14 flexor digitorium longus tendon 28
dendrite 33 flexor hallucis brevis 28
dendron 33, 33 flexor hallucis longus tendon 28
dermis 37, 37 flexor hallucis longus, tendonitis, tenosynovitis 115-16
diabetes mellitus 44 fluid balance 101
digestion 44 foot 32
disc-intervertebral, fractures-general 69, 69
see intervertebral disc 4, 7, 7; fracture of base of 5th metatarsal 104, 105
prolapse of 14 fracture of lateral malleous 104, 105, 105, 109-10, 110
dorsal spinal pain 143-4 fracture of medial malleolus 110, 110
duodenum 43, 43, 44 fracture of patella 135-6
frog position 190, 191, 192
ear 36, 36
effector cell 34 gastrocnemius 26, 27, 32
elbow joint 9, 10 gemellus inferior 31
electrolytes 39 gemellus superior 31
endrocrine system 50 glomerulus 48, 49
engrams 19 glucose 45
enteroceptors 35, 36 gluteal bursitis 139
enzymes 44 gluteal muscle weakness 185
epidermis 37, 37 gluteus maximus 21, 23, 24, 31
eversion 14, 27, 33 gluteus medius 21, 23, 24, 25, 31
excretory system 48, 48 gluteus minimus 23, 24, 25, 31
exercise aims 89 glycogen 45
exercise training 90 gonad 51
 Index 209

gracilis 32 joints:
groin strains 137-8, 190 ankle joint 13, 14, 15, 32;
chronic sprain of 109
hallux rigidus 117, 123-4; elbow 9, 10
silastic replacement in 124, 124 first metatarso-phalangeal, strain of 119, 201
hallux valgus 121-3, 121,201 general 6, 7
haemoglobin 47 hip 1, 11,11, 30
hamstrings 13, 24, 183; knee 11, 12, 13, 13,31
tears of 138-9, 194; sacro-iliac 1, 5, 6, 9; strains of 139-40
tightness of 137, 187, 192, 194 shoulder 4, 5, 9, 9, 23, 29
healing of injuries 66, 67 symphysis pubis 1, 5, 6, 9
heart 39, 40, 40,41,41 synovial 6, 7
heart rate 41, 42
heat therapy 82 Keller's operation 123, 123
hip joint 1, 11, 11, 30 knee joint 11, 12, 13, 13, 31
Hohmann's operation 122, 122 kidney 48, 48
hormones 50, 51 knuckling 117, 201
hot packs 83 kyphosis 180, 183-4, 184, 185
humerus 4, 5, 9, 9, 10
hydrocortisone acetate 92 lateral hamstrings; weakness of 190;
tightness of 194
ice 81 lateral ligament of ankle;
ileum 43, 43 sprain of 104-8;
iliacus 23, 25, 31 rupture of 108-9;
ilio-femoral ligament 11 pain in 200
ilio-psoas 31 lateral ligament of knee 12, 13, 13;
ilio-tibial tract, see fascia lata 24, 27, 31 injury of 132-3
ilium 5 lateral malleolus 13
incorrect weight bearing 115; lateral tracking of patella 195
see also weight back latissimus dorsi 21, 23, 30
inflammation 61, 62, 63, 64, 65 leg length inequality 180
ingrowing toenail 124-5 levers 17, 17, 18, 18
infra-patella bursitis 130 ligament injury; general 67
infra-red heat 83 ligaments:
infra-spinatus 21, 22, 30 anterior talo-fibular ligament 14, 14, 104;
internuncial neurone 34, 35 sprain of 104
injury: anterior tibio-fibular ligament 14
complications 76 cruciate of knee 12, 13, 13;
general 67 injury of 133
innominate bone 1, 5, 6, 9 deltoid ligament, see medial ligaments of ankle 14, 14
interferential therapy 85 ilio-femoral 11
internal oblique 21, 22, 29 interspinous; damage of 140
interosseous muscles 28, 28 lateral of ankle;
interspinous ligament; damage of 140 sprain of 104-8;
intervertebral disc, see disc - intervertebral 4, 7, 7; rupture of 108-9;
prolapse 141 pain in 200
intrinsic muscles 28, 33; lateral of knee 12, 13, 13;
weakness of 115, 117, 121, 125, 126, 186, 189, 193, injury of 132-3
200, 201-2 medial of ankle 14, 14;
inversion 14, 26, 33 sprain of 109
ischium 5 medial of knee 12, 13;
islets of Langerhans 44 injury of 132, 189, 200
posterior tibio-fibular 14
jejunum 43, 43 pubo-femoral 11
joint movements 7, 8, 14 liver 45
joint types 6, 7 long extensors of toes 32
210 Index

long flexors of toes 32 gluteus maximus 21, 23, 24, 31

long metatarsals 116, 119, 202, 202 gluteus medius 21, 23, 24, 25, 31
lordosis 106, 126, 142, 180, 184-7, 185, 190, 192, 193, 195, gluteus minimus 23, 24, 25, 31
200 gracilis 32
lumbrical muscles 28, 28 hamstring 13, 24, 183; tears of 138-9, 194;
lung 46, 46 tightness of 137, 187, 192, 194
lymphatic system 42, 43 iliacus 23, 25, 31
ilio-psoas 31
manipulation 87 infraspinatus 21, 22, 30
massage 87 internal oblique 21, 22, 29
medial ligament of ankle 14, 14; sprain of 109 interosseous 28, 28
medial ligament of knee 12, 13; injury of 132, 189, 200 intrinsic 28, 33; weakness 115, 117, 121, 125, 126,
meniscus 13, 13; lateral; injury of 134-5, 194; medial; 186, 189, 193, 200, 201-2
injury of 133, 189, 194 latissimus dorsi 21, 23, 30
metacarpal bones 4, 5, 9, 10 long extensors of toes 32
metatarsal bones 5, 6, 13, 14 long flexors of toes 32
metatarsal heads; oblique line 115, 115, 202 lumbricals 28, 28
metatarsals; long 116, 119, 202, 202; short 116, 119, 202, obturator externus 31
203, 204 obturator internus 31
metatarso-phalangeal joint - first; strain of 119, 201 pectoralis major 21, 23, 30
metatarsus primus varus 121, 121 peroneus brevis 26, 27
microwave 84 peroneus longus 26, 27
minerals 99 plantaris 32
mobilisations 87 popliteus 24, 32
motor nerve 34 pronator quadratus 30
motor neurone 34, 35 pronator teres 30
muscle: psoas major 23, 23, 25, 29
antagonist 19 psoas minor 25, 29
cardiac 15, 15, 17 pyriformis 31
general 15 quadratus femoris 31
prime mover 19 quadratus lumborum 22, 22, 29
striated (skeletal) 15, 15, 16 quadriceps 13, 23, 31, 55, 56; weakness of 193
synergist 19 rectus abdominis 21, 22, 29
unstriated 15, 15, 16 rectus femoris 23, 25, 26, 31
muscle contraction 19 rhomboid major 30
muscle fibres, red and white 20 rhomboid minor 30
muscle injuries 72 sacro-spinalis (erector spinae) 22, 22, 29
muscle tension 180-81 sartorius 25, 32
muscles: semi-membranosus 26, 32
abductor hallucis 28 semi-tendinosus 26, 32
adductor hallucis 28 serratus anterior 21, 23, 29
adductors of hip 23, 23, 31, 55; tears of 136-7; serratus superior 29
weakness of 133, 137, 186, 187, 190, 193 soleus 26, 27, 32
biceps femoris 26, 27, 32 sternomastoid 21, 29
brachialis 30 subscapularis 30
brachioradialis 30 supinator 30
deltoid 21, 22, 23, 30 supraspinatus 30
extensor digitorum longus 27 tensor fasciae latae 23, 24, 25, 26, 31;
extensor hallucis longus 32 tightness of 129, 137, 195
external oblique 21, 22, 29 teres major 21, 22, 30
flexor accessorius 28 teres minor 30
flexor digiti mimimi brevis 28 tibialis anterior 26, 27, 32, 33
flexor hallucis brevis 28 tibialis posterior 26, 33
gastrocnemius 26, 27, 32 transversus 21, 22
gemellus inferior 31 trapezius 21, 23, 29
gemellus superior 31 triceps 21, 22, 30
 Index 211

vastus intermedius 23, 32 pulmonary vein 40, 41

vastus lateralis 23, 26, 27, 32 pyriformis 31
vastus medialis 23, 26, 32
quadratus femoris 31
navicula 13, 14 quadratus lumborum 22, 22, 29
nerve cell 33 quadriceps 13, 23, 31, 55, 56;
neurone 33 rupture of 194;
neuro-muscular co-ordination 19 weakness of 193
nutrition 99 quadriceps insufficiency 193-4

obturator externus 31 radius 4, 5, 9, 10

obturator internus 31 rectus abdominis 21, 22, 29
oesophagus 43, 43 rectus femoris 23, 25, 26, 31
odontoid peg 2, 2 reflex arc 34, 35
orthopaedic assessment of the dancer 96 respiratory system 46
os calcis 5, 6, 14, 198 restriction of turn-out 190, 191, 192
Osgood-Schlatter's disease 131 rhomboid major 30
osteochondral fracture of talus 111, 111 rhomboid minor 30
osteochondritis of heads of metatarsals 118-19, 118 ribs 4, 29
osteopathy 94 rise 58, 58
os trigonum 112, 114-15,114, 198, 198, 202 rolling 56, 56, 112, 115, 117, 119, 119, 121, 128,129, 130,
over turning the feet 130, 133, 142, 185, 187-90, 187, 188, 188, 189, 193, 197, 200-1, 201
190, 193, 200 rond de jambe en l'air 24
oxygen 38, 39, 47 rotation; see joint movements 7, 8
rupture of patellar tendon 135-6
pancreatic duct 43, 44 rupture of quadriceps tendon 135-6, 194
parasympathetic nervous system 35
patella 6, 12, 13, 13, 25; fracture of 135 sacro-iliac joint 1, 5, 6, 9;
patellar tendon 12, 13, 13, 25, 26, 194 strains of 139-40
patellar tendonitis 130, 192 sacro-spinalis (erector spinae) 22, 22, 29
pectoralis major 21, 23, 30 sacrum 1, 6, 9
pelvic tilt 180, 185, 187, 192 sartorius 25, 32
pelvis 1, 5, 6, 9 scaphoid 4
peroneus brevis 26, 27 scapula 4, 5, 9, 23, 29
peroneus longus 26, 27 scoliosis 179, 180, 182-3, 182
phalanges 4, 5, 6, 9, 10, 13 semi-circular canals 36, 36
pituitary gland 51 semi-lunar cartilage; see meniscus
plantar fascial strain 119 semi-membranosus 26, 32
plantaris 32 semi-tendinosus 26, 32
plié 55, 55 sensory nerve 34
pointe 59, 59, 60; age to start 59 sensory nervous system 35
popliteus 24, 32 sensory neurone 34, 35
posterior block of the ankle joint 198-200, 198, 199 sensory receptor 34
posterior tibio-fibular ligament 14 serratus anterior 21, 23, 29
posterior tubercle of talus 112, 114-15, 114, 198, 198 serratus posterior superior 29
pre-performance food and fluid intake 102 sesamoiditis 120-1, 120, 201
pronator quadratus 30 short metatarsals 116, 119, 202, 203, 204
pronator teres 30 shortwave diathermy 84
proprioceptive feedback 19 shoulder girdle 4, 5
proprioceptors 36 shoulder level 179-80, 179
protein 45, 99 shoulder joint 4, 5, 9, 9, 23, 29
psoas major 23, 23, 25, 29 sickling 112, 112, 119, 125, 188, 189, 197, 204, 204
psoas minor 25, 29 silastic replacement of great toe joint 124, 124
pubic bone 5 sinu-atrial node 41
pubo-femoral ligament 11 skeleton facing page 1
pulmonary artery 40, 41 skeleton; appendicular skeleton 1
212 Index

skeleton; axial skeleton 1 tibialis posterior 26, 33

skin 37, 37 tibialis posterior, tendonitis and tenosynovitis 109, 115, 189,
skull 1, 2 200, 202
soleus 26, 27, 32 tightness at the fronts of the hips 131, 185, 190, 192-3, 193
somatic nervous system, see voluntary nervous system 34 tilting of talus 105, 105
spinal column 2 T.N.S. 86
spinal cord 1 toes 32; long 202, 202, 203, 203
spondylolisthesis 142, 142 torticollis 144
sprain, see joints trachea 46, 46
stance 52, 53 traction 87
sternomastoid 21, 29 transcutaneous nerve stimulation 86
sternum 4 transversus 21, 22
steroids 92, 93 trapezius 21, 23, 29
stomach 43, 43, 44 triceps 21, 22, 30
strain, ^ j o i n t s turn-out 54, 54, 125, 143;
strapping 116, 116 assessment of 191;
stress fractures 70, 71; failure to hold 106, 139;
of fibula 125-6, 126, 189, 197; limitation of 185;
of metatarsals 116-18, 117, 197, 201, 204; restriction of 192
of tibia 126-8, 126, 127, 189, 196, 197;
of vertebra 141-2, 142, 187 ulna 4, 5, 9, 10
stretching 88, 192; ultrasound 85
calf muscle and Achilles tendon 163
subscapulars 30 variations in metatarsal and toe lengths 202-4, 202, 203,
supinator 30 204
supraspinatus 30 vastus intermedius 23, 32
swayback knees 109, 126, 130, 143, 180, 183, 186, 193, vastus lateralis 23, 26, 27, 32
195-6, 195, 196 vastus medialis 23, 26, 32, 133
sympathetic nervous system 35 vein 39, 39
symphysis pubis 1, 5, 6, 9 ventricle 39, 40, 41
synapse 34 vertebrae; atlas and axis 2, 2;
synovial fluid 68 cervical 2, 2;
synovium (synovial membrane) 6, 7, 11 lumbar 2, 3, 3;
thoracic 2, 4
talus 5, 6, 13 vertebral column 1
tarsal bones 5, 6, 14, 15 vision 36
tendon rupture 71, 135 vitamins 45, 99
tendonitis 71 voluntary nervous system 34
tendu 57, 57
tenosynovitis 72 water 101
tension - muscle 180-81 weak feet 106, 112, 117, 119, 121, 126, 128, 130, 186, 195,
tensor fasciae latae 23, 24, 25, 26, 31; 202
tightness of 195 weak lower trunk 180
teres major 21, 22, 30 weak trunk muscles 142, 187
teres minor 30 weight back 109, 112, 116, 126, 128, 130, 137, 138, 193,
thoracic cage 1, 4 194, 195, 196, 200, 201,205
thyroid gland 51 weight placement, incorrect 205
tibia 5, 6, 11, 13, 14, 14 weight wrong 143
tibial bow 125, 186, 197-8, 197 white blood corpuscles (cells) 38
tibialis anterior 26, 27, 32, 33 wobble board; see balancing board 106, 107
tibialis anterior tendonitis 200