Original ResearchThe association between menarche, intensity of training and passive joint ROM in young pre-professional female dancers: A longitudinal follow-up study
Introduction
The passive range of motion (ROM) of a joint is influenced by numerous factors, among them the joint bony architecture (shape of articular surface), the elasticity of the joint capsule and attached ligamentous structures, muscle fat content and tension and the genetic properties of the individual (Koutedakis & Jamurtas, 2004; Medicine, 2010). The passive joint ROM aims at measuring the ’end of range’, limited by soft tissue and muscle fibers. The active ROM refers to the functional ROM, limited mainly by muscle strength and by the antagonist muscle length (Wyon, Smith, & Koutedakis, 2013). Previously, passive joint ROMs were measured and recommended for young dancers (Kivlan, Carcia, Christoforetti, & Martin, 2016; Liederbach, 1997; Steinberg et al., 2006). This was due to the fact that insufficient strength in young dancers might reduce their measured active ROM. During screening of young dancers, it was suggested to measure passive 'dance-related' movement (Liederbach, 1997; Siev-Ner, Barak, Heim, & al., 1997), with only few active joint ROMs that follow the dancer's movements (such as active hip extension for the arabesque movement) (Roussel et al., 2013).
Among dancers, increased joint ROM can create the illusion of perfect movements or positions, therefore regarded as an important predictor of dance performance (Roussel et al., 2013; Srhoj, 2002). The increased joint ROM was also considered by most dance teachers to confer an advantage in the selection process of dancers (W. G. Hamilton, Hamilton, Marshall, & Molnar, 1992; McCormack, Briggs, Hakim, & Grahame, 2004; Quirk, 1994). Studies on classical ballet dancers reported that self-selection of body type already occurs at an early age, leading to dropout of dancers who cannot achieve the ’perfect’ dance movements that are performed by their peers (W. G. Hamilton et al., 1992; McCormack et al., 2004; Misigoj-Durakovic et al., 2001). Teachers frequently promote this process by favoring those dancers who exemplify the aesthetically ’correct body shape’ to become professionals (W. G. Hamilton et al., 1992; McCormack et al., 2004; Misigoj-Durakovic et al., 2001). Although this phenomenon might be restricted mainly to professional ballet schools, selection on the grounds of extreme ROM may also occur in all other dance genres, already at early ages, particularly in the ballet career (W. G. Hamilton et al., 1992; McCormack et al., 2004; Misigoj-Durakovic et al., 2001; Quirk, 1994).
Dancers who subjectively experience a restricted ROM may force the joints beyond their morphological/physiological limits, creating tendon and muscle micro-tears resulting in scar tissue formation. Paradoxically, this may lead to further ROM restrictions, initiating a vicious cycle that may expose the dancer to injury (Steinberg & Siev-Ner, 2017). Furthermore, dancers who lack the required joint ROM for ideal positions often develop compensatory strategies (K. Bennell et al., 1999), which in turn may also lead to injury (Hincapie, Morton, & Cassidy, 2008; Negus, Hopper, & Briffa, 2005). Compensatory strategies such as 'hyperlordosis', 'rolling in' and 'sickling', which compensate for insufficient joint ROM, are mostly adopted by recreational dancers, due to poor technique, inexperience, or lack of physical prerequisites (Negus et al., 2005). When dancers try to achieve the ideal ’turnout’ position, they usually adopt a strategy that involves anterior pelvic tilt ('hyperlordosis'), knee screwing, and pronation ('rolling in') of the feet (Coplan, 2002). Dancers with limited ankle plantar flexion ROM may compensate for this by using poor techniques (such as 'sickling' the foot) that shift much of the load to their adjacent joints, including the knees (Hodgkins, Kennedy, & O'Loughlin, 2008).
During the dancer's growth and developmental stages, the ability to improve/maintain joint ROM is critical, considering the different individual developmental rates and the higher risk for injury at this age (Steinberg & Siev-Ner, 2017). During the 'growth spurt' period the natural tendency of the soft tissue toward elasticity, as previously shown by a number of studies (Bowerman, Whatman, Harris, Bradshaw, & Karin, 2014; Quatman, Ford, Myer, & Hewett, 2006; Steinberg, Hershkovitz, Zeev, Rothschild, & Siev-Ner, 2016; Steinberg et al., 2013; Wild, Steele, & Munro, 2012).
It is of significant importance to determine whether joint ROM can improve during this developmental stage (i.e., onset of menarche) (Bowerman et al., 2014). There is a lack of data addressing this issue in longitudinal follow-up studies, as most previously published studies were cross-sectional studies or longitudinal studies on mature dancers (>16 years old). The cross-sectional studies suggested that an improvement in joint ROM can be obtained by years of vigorous training with hours of prolonged static stretches, performed from a very young age (Gannon & Bird, 1999; Rietveld, 2013).
Nevertheless, in another cross-sectional study conducted on a very large population of dancers at the specific maturation ages of 12–14 years old, it was shown that joint ROM does not improve with age or with increased hours of practice, but is rather preserved due to the dancers' exposure to extensive exercises (Steinberg et al., 2006). In addition, other studies reported a steady decrease in soft tissue laxity and in joint ROM with increasing age in dancers and athletes from 12 to 14 years of age (Ahmad et al., 2006; Steinberg et al., 2016).
The present study is the first to specifically address whether passive joint ROM in young dancers around the age of onset of menarche can be improved with dance training, and to determine its association to menarche.
Section snippets
Methods
Sixty-seven young female dancers from three schools with the same special dance program were recruited for the present study. The dance schools are government-funded public schools supported by the Ministry of Education, following the same teaching program (syllabus), and offering high quality part-time dance training across the country. The reason we examined student dancers from different schools was to rule out the factor of teacher bias. Students typically attend training sessions on
Reliability
Intra-class correlation for the joint ROM measurements ranged between 0.896 and 0.964. Average age of the dancers initially included in the study cohort (Grade 7) was 12.8 ± 0.5 years.
Epidemiological data
Onset of menarche: In Grade 7, 26 (44.1%) dancers had reached menarche (Yes menarche group). In Grade 8 an additional 23 (39.0%) dancers had reached menarche (No/Yes menarche group). Ten dancers (16.9%) had still not reached menarche by the day of the screening in Grade 8 (No menarche group).
Correlations between Grade 7 and Grade 8
Anthropometric
Discussion
This study evaluated passive joint's ROM in young female dancers over a 12-month period. Data were analyzed to assess whether ROM increases over time, and to document the influence of dance training intensity and menarche.
As expected, all anthropometric parameters significantly increased over the 12-month follow-up period (Matthews et al., 2006). The intensity of dance training increased over the follow-up time of the current study. In accordance with reports in a previous study, no association
Conclusions
The main finding of the current study is that passive joint ROM (mainly hip ER, ankle-foot En-pointe and the ER:IR ratio) can improve over one year of dance training around the age onset of menarche. This improvement in ROM was mostly correlated with h/week of dance practice.
Screening and identifying the body structure and the joint ROM of dancers around the age onset of menarche is important in order to be mindful of the dancers' personal morphology and their potential to
Ethical approval
Approval was provided by the Institutional Review Board at Sheba Hospital, Israel, and all subjects gave informed consent prior to participation.
Conflicts of interest
None declared.
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Both authors contributed equally to this work and should be considered as first authors.