When Ross Armstrong moved from the military to working with dancers he noticed that both groups had much to gain from better musculoskeletal screening
To join the army, soldiers undergo basic training, which for some will prove too physically demanding and result in injury. For those who complete their training, screening is particularly important as they will often deploy to regions with limited access to healthcare. So an understanding of the potential strengths and weaknesses of the individual is key to them fulfilling their duties effectively.
Soldiers are susceptible to lower limb injuries due to the demands of tabbing (walking at a fast pace with a rucksack) and military boots tend to be less flexible than modern running shoes. These factors, combined with a heavy training schedule, can, if not properly managed, lead to stress fractures, ‘shin splints’, compartment syndrome and tendinopathies.
While screening military personnel it is vital to identify potential risk factors for lower limb injury. There is a heavy focus on foot type and identifying muscle imbalances that might increase injury risk. If foot type is found to be a risk, then orthotics could manage the load going through the lower limb or, instead of asking soldiers to just run for aerobic fitness training, they could be given a run/walk programme to reduce the time spent running or provided with a lower impact alternative such as cycling.
After leaving the army and having used my interest in musculoskeletal screening in academy football, an opportunity arose to work with dancers which has allowed me to investigate musculoskeletal (MSK) screening, performance and injury as part of my PhD.
MSK screening is becoming increasingly popular in dance, an activity which requires not only strength, speed, and agility but also endurance, flexibility and balance, all of which can potentially be measured by screening methods. These physical attributes require effective functional movement which can be assessed using a variety of objective measures to assess performance, and physiotherapists may need to consider some key factors when performing musculoskeletal screening.
What to screen?
Lower limb injuries are common in dance with the foot and ankle the biggest problem areas. Overuse injuries, such as Achilles tendinopathy, are seen frequently. Different types of dance are associated with different types of injury, for example break dancing has more wrist and hand injuries while in ballet there are more shoulder injuries in men due to the demands of partner lifting. Dancers often go on tour with limited rest periods which increases the injury risk. My clients perform contemporary or ballet and are usually from university dance programmes or dance schools. I tend to screen these dancers on entry as part of the programme, which allows me to identify potential problems that may result in injury and limit performance. It also enables me to provide a specific programme which considers ‘prehab’ and works on the idea that prevention is vital and encourages the dancer to take control of their own health. Sometimes dancers present with longstanding problems. For example, one dancer had difficulty with certain ballet positions due to pain on overhead movement. An assessment suggested the person was suffering from shoulder impingement syndrome and, via pain management strategies, shoulder strengthening and scapula-setting work, the dancer was able to perform the movements as part of an assessed piece of work highlighting the importance of screening.
My research developed a systematic review and meta-analysis of MSK screening tools as a predictor of injury in dancers, using a validated screening tool and highlighting some important considerations. These included the measurements of joint range, posture, hypermobility, movement screening tools, dance specific positions, body mass index, clinical diagnostic tests and strength.
‘Dancers often go on tour with limited rest periods which increase the injury risk’
So which measurements were considered most effective? It is important to assess movement patterns specific to dance, including those positions that are part of the five basic positions of ballet identified as the best predictors of injury. In dance, physiotherapists should always ensure their screening is specific to the demands of the activity
When to screen?
In sport, screening is often performed as an initial assessment in pre-season and repeated throughout the season to provide feedback on potential changes. One aspect that may need to be considered to a greater extent is fatigue, which has been identified as a risk factor for injury. However, as physiotherapists, are we considering this when screening? The answer may be no. A recent international survey of those involved in dance screening revealed that 90% did not screen in a fatigue state. Should we be doing this? The answer may not be straightforward. Two recent dance studies I conducted before and after a dance performance, investigated changes in two MSK screening tools: Functional Movement Screen and Star Excursion Balance Test (SEBT).
The results suggested that the former was influenced by fatigue while the latter was unaffected. The deep squat and in-line lunge were the specific functional movements affected. So, potentially, training of these movements to enhance movement efficiency might be needed to reduce fatigue- induced injury risk. However, the lack of fatigue effect with the SEBT, and its associated movements, may suggest that this screening tool is too easy for dancers. Of course, with soldiers there is little doubt that having tabbed for 15 miles an individual is going to be at greater risk of injury than when commencing an activity, so screening may need to consider this element of fatigue.
Physiotherapists may wish to consider which measurements provide the most useful information and exclude those measurements of limited value. However, this will be specific to the activity and the person to allow appropriate performance goals, which can aid an individual’s motivation. Successful screening requires regular reassessment, which is second nature to physiotherapists and may act as a tool to empower the individual.
I was surprised to find that soldiers and dancers share such similar issues. Although the physical demands of each role are very different, both groups are at risk of injury, particularly in the lower limb. Management of fatigue and introducing screening can help those from widely differing backgrounds to stay fit for longer and allow them to reach their goals.
- Ross Armstrong is a musculoskeletal physiotherapist who works at Edge Hill University and with the Liverpool Football Club Academy
Armstrong, R, Relph, N (2018). Screening tools as a predictor of injury in dance. A systematic review and meta-analysis. Sports Medicine Open 4:33
Armstrong, R, Brogden, C, Milner, D, Norris, D, Greig, M (2018). The Influence of Fatigue on Star Excursion Balance Test Performance in Dancers. Journal of Dance Medicine and Science 22 (3): 142-147.
Armstrong, R, Brogden, C, Milner, D, Norris, D, Greig, M (2018). The effects of fatigue on Functional Movement Screening Performance in dancers. Medical Problems of Performing Artists 33 (3): 213-219.
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