Reducing Injury and Increasing Education with Royal Ballet Physiotherapist, Moira McCormack

[00:11] Dr. Linda Bluestein: Welcome to Bendy Bodies with the Hypermobility MD. This is your host, Dr. Linda Bluestein, former ballet dancer, board-certified anesthesiologist, specialist in treating hypermobility disorders, and medical director at Wisconsin Integrative Pain Specialists. Today, Jennifer Milner joins me as a guest co-host. Jennifer is a certified Pilates trainer specializing in dancers and post-injury recoveries. Our guest today for this inaugural episode of Bendy Bodies is Moira McCormack, physiotherapist for the Royal Ballet in London. Moira has been working for many years as a dance specialist physiotherapist with all age groups and now works part-time to allow PhD studies at University College London. Her interests are hypermobility in dance, classical ballet technique, and reducing the risk of injury in the profession. She has also worked in musical theater and contemporary dance, appreciating all dance genres. Moira was trained at the Royal Ballet School, graduating to the Royal Ballet Company. After a dance career including National Ballet of Canada and London Festival Ballet, she completed teacher training in classical ballet working internationally before embarking on a physiotherapy career. Moira lectures for the Master of Science program in Sports Medicine and the Master of Science program in Performing Arts Medicine at UCL. Moira, hello and welcome. Welcome to Bendy Bodies.

[01:38] Moira McCormack: Hello, Linda, and hello, Jennifer.

[01:46] Jennifer Milner: Hello.

[01:49] Dr. Linda Bluestein: Thank you so much for coming on today. We are so excited to chat with you and would love to hear first more about your background. What brought you to where you are today?

[02:00] Moira McCormack: Well, after that career in dance and finally getting to physiotherapy and finally starting to understand how bodies worked and dancers' bodies worked — I worked with very young dancers, I worked with adolescents, and then finally with professional dancers. Observing over the years, I started to see a pattern. As physiotherapists, we're always trying to reduce injury, we're trying to prevent injury, we're trying to educate artistic managements, we're trying to educate teachers. I just started to see this very clear pattern and decided that we needed to know more about it, and then I found the relevant specialists to talk to and ask questions of, and started to understand about what makes the ballet dancer today.
[03:08] I'm not hypermobile myself, and a lot of people get interested in this body type, this physique, because they suffered themselves, and that's definitely not me. It was just observing and trying to understand the really flexible physiques in front of me and the types of injuries they were suffering from. And that's why I've ended up here with this particular interest. Also, I love watching dance, and I love watching classical ballet dancers doing what they love to do, and I also find it very emotional when they fail. And it was from that basis that I find myself here today with my particular interests.

[04:02] Dr. Linda Bluestein: Excellent. And specifically, your work with the Royal Ballet — are you able to fill us in a little bit more on your role there?

[04:11] Moira McCormack: Well, I've worked in the Lower School of the Royal Ballet School where the children start at 11 years old. They also have a program that starts children at 7 years old, and it's a part-time program that brings these children up to a level where they could be chosen to go into the vocational school. And then I've worked with the adolescents up to 17, 18, and the huge push that it takes to get these 18-year-olds out into professional jobs, to get them up to that standard, and to get them into, first of all, of course, the Royal Ballet Company, and then out all over the world.
[05:01] So I see the hoops that they have to jump through and the stresses — the physical stresses and the psychological stresses — and it's something that I find fascinating still. That breadth of experience certainly makes me appreciate what it takes to make it in the profession.

[05:22] Jennifer Milner: Moira, if I could ask a question to follow on that. It's so interesting to me that you were working from the bottom up, starting with the younger students and then moving up. So many companies will start at the top down, and it's a trickle-down effect — the professionals will get the care, but it's been only within the past 5 to 10 years at the most that the students have been getting the attention and the preventative training. So I'm wondering, did you choose that? Were you interested in starting at the bottom, trying to catch it before they were injured, or is that where they put you and you fell in love with it? How did that happen?

[06:08] Moira McCormack: I think I most enjoy working with the adolescents, the young dancers who are growing madly, and I really like that age group. And I think I fell into it actually because I was working in a clinic in London. It was one of the first dance medicine clinics, so all sorts of dancers came to see you — from the vocational, the professionals, and the amateur dancers of all sorts.
[06:43] I must admit I was most interested at that time in the young dancer — the Dancer in Training — because I was interested in the basic training that children get to give them that first step up into the vocational schools, and how important that first training is in forming those movement patterns, making that dancer understand what technique is. So it was really from the training point of view that I was interested in working with young dancers as a physiotherapist, because I felt that the training, the alignment, the biomechanics went hand in hand with treating stresses and strains and injuries, and trying to suss out exactly what has caused this injury. So often in the young dancer it is technique, or deficits in technique, and technique that requires correction.

[07:53] Jennifer Milner: That makes a lot of sense, thank you.

[07:55] Moira McCormack: Definitely.

[07:58] Dr. Linda Bluestein: And so we already talked about this a little bit, but could you go into just a little bit more detail in terms of your research in joint hypermobility and what really moved you to actually pursue research in that?

[08:12] Moira McCormack: Well, there were questions in my mind, and then I remember going to a meeting where Professor Rodney Graham was giving a talk on a certain subject to do with hypermobility. He used to hold these hypermobility clubs, he called it. All sorts of professionals would go along about every 6 weeks to the hypermobility club, and Professor Graham would have an interesting subject — always to do with hypermobility — that everyone would listen to a presentation, ask questions, and consider whether they could take anything from that presentation back to their own work.
[08:57] So he was the one who really got me interested. I did remind him that when I was a student physiotherapist, I had done a ward round with him at a small hospital somewhere in southeast London, and he had been very caring and interested in the fact that I had been a ballet dancer. So we got together later, much later on, and then of course I discovered he'd done a good study at the Royal Ballet School in the early '70s, and he was so interested in dance and dancers. I then suggested to him, why don't we do that again? Why don't we look at the dancers in the Royal Ballet School — but more than that, let's look at the lower school and let's look at the professional company and let's put the whole picture together. And that's what led to the paper that we did together with Dr. Alan Hakim and Janet Briggs, who's also a physiotherapist, still a physiotherapist at White Lodge, the lower school. So we all got together, did the research, and came up with that prevalence of hypermobility and benign joint hypermobility syndrome in this particular organization.

[10:36] Dr. Linda Bluestein: We're going to go into some more details about those studies in just a little bit, and that was just such fabulous work that you did, so I'm really excited to hear more about that. Can you tell me what you feel are the factors that are most influential in the dancer regarding joint hypermobility and also joint instability? For example, how significant is the degree to which someone has joint hypermobility, or which joints are hypermobile or unstable, or whether or not they have other symptoms? What things do you think are most influential?

[11:18] Moira McCormack: Well, because of where I work, I'm not really going to see any of those seriously Ehlers-Danlos hypermobility type dancers. I know that in the company we have some dancers who are verging towards that, but at the school when they do their auditions, they will probably be deselecting anyone with a real hypermobility disorder. It will become apparent, I think, in the movement patterns when the dancer does their first audition, and then when they go through the physiotherapy assessment, it will be picked up, and then there will be question marks. So we probably won't be seeing the really severely hypermobile children, and they won't make it up the ladder into the Upper School and into the Company because usually it's an injury situation that will eventually — I hate the phrase "weeding them out," but I'm afraid that is what happens — and it becomes too difficult. When a young dancer has injury after injury, it really becomes so much of a challenge that they opt out. They tend to opt out themselves.
[12:42] When we've got our hypermobile, really hypermobile dancers who will have other qualities that are selected by the school — the aesthetic qualities, their movement and their proportions, their face, the beauty, all of that will get them into a school — as physiotherapists we will be aware of this particular vulnerability. And those dancers, fortunately, I can now say we have the ways and means to protect them, to strengthen them, to give them more control, to monitor them very carefully, and allow them to survive. So we can do that, but it also becomes apparent as the workload goes up, the challenges become more. It's not just dancing half a day, which you do from 11 to 15 — it becomes dancing for a whole day after that. So those stresses and strains will often guide the dancer whether they're going to make it or not, and guide the school whether they should allow the dancer to progress to the Upper School.
[14:15] Progressing from School to Company is completely the artistic management of the Company — it's their business to select from the School who they want to come into the Company. We would never interfere with any of that, because the very flexible dancers, the really hypermobile types, will make great dancers if they are looked after, if they are educated, and if they survive.
[14:50] To go back to your point about the range of movement, Linda — the range of movement and the severity of the joint hypermobility. If we have a huge passive range of movement where those legs go all over the place and the spine extends fantastically, that's great as long as there is control. So if your passive range is massive in your hip doing a grand battement devant, but the strength to hold a développé is far less than that, we know that there's a huge deficit there in control and strength. That is what, as a dancer and as your healthcare team around you, we'll be working on — to make that deficit smaller and smaller so that that développé is controlled practically through your whole range. That's a tall order, but that is what our work is about.
[16:06] Then the joint instability we talk about — if you can do a great grand battement and the hip goes up freely and with ease and control, that's wonderful. But if that hip also has a bit of excursion within the hip joint as it goes up, and we end up with an impingement at the front of the hip because the articulation of the hip has not been totally controlled, and the head of the femur moves freely, slides freely within the acetabulum, then we are going to be in for problems. We have to work very hard on stabilizing that joint, decreasing the amount of instability, the amount of excursion, and only allow it to articulate through the range of movement in flexion — or if we're going à la seconde, to abduction and flexion — but we have to stabilize before the extreme ranges are used. It's that sort of principle for all of the joints throughout the body: deep stabilization first before great range of movement.

[17:55] Jennifer Milner: Yes.

[17:56] Dr. Linda Bluestein: You explained that very well, and it makes a lot of sense. For any of our listeners who want just a quick visual about that, I tend to think of Gumby versus Raggedy Ann — the green Gumby, which some of our listeners are probably way too young to know, you can kind of bend all over the place, but Raggedy Ann is just kind of floppy, and we don't want that. That's a real concern. You explained that very, very well, and that's so important. We'll get more into this later with social media and the influence that it has, because that introduces a whole other factor into this for sure. When you first started researching hypermobility, did you observe that there were more hypermobile dancers at any particular level, whether it be pre-adolescent or adolescent, pre-professional, or professional?

[18:58] Moira McCormack: Not really, because they all have to be hypermobile. All the dancers in a vocational school are chosen for their hypermobility. It's that spectrum of hypermobility that we are concerned about. Every vocational school will have a scattering of more extreme hypermobiles, and you can see them. You walk into a studio and you can pick them out as you watch them work. Same with the upper school, the 16 to 18s — you can see that type of movement, that range of movement, and at that age, that slight loss of control, but you think, oh, there's potential there. That's why they are selected. The artistic staff see the flexibility and they immediately think, oh, there's something more we can get out of these dancers.
[19:59] And then in the Company, we still see those dancers that have been selected into the profession, but the deficits start to become a little bit more noticeable. Certainly within a hard-working classical ballet company, the challenges are on — the challenges to stamina, robustness, that ability to keep going, work long hours, not much time to recover, 6 days a week, and evenings as well with performances. That's when the deficits start to become apparent, and then the dancer tends to accumulate lots of small injuries. Often in spite of being shown what we've got to do — we've got to get all that control, we do our Pilates and we do very specific dance-centered Pilates exercises to get that control, we've got the gym and we have our trainers who sort out a program to increase strength — we still see our more flexible dancers start to fail, unfortunately.
[21:35] So we see them all the way through, but I think our research that we did way back looking at how as you go through the ranks of the company, the very hypermobile dancers tend to become less and less — and in our principal ranks, yes, hardly any.

[21:58] Jennifer Milner: Are you talking about the 2004 research article?

[22:01] Moira McCormack: Yes. And I think that holds today.

[22:05] Dr. Linda Bluestein: That's great. We will have a link to that article so that people can access it. And yes, I was hoping that you would comment on that excellent article that you published.

[23:20] Moira McCormack: It's quite old and it has its faults — we know that — but it was interesting at the time just to see that pattern. And of course, everything that we try to do within the Company to prevent injury and prolong careers, we will still get those dancers that fall through the net for all sorts of reasons.
[23:49] I find that hypermobile dancers have to work harder than a lot of the others. They have to be extremely organized. They have to make sure that they have their control and their strength woven into their schedules every single week. It's hard to take holidays — you can't go away for a week and do nothing. I think hypermobile dancers decondition faster than a more tightly knit type of physique. So to keep that baseline work going — just baseline — and still have a holiday is really, really important.
[24:36] The recovery is terribly important, and dancers still find it very difficult to understand how to recover. I say, but that's being professional — you've got to push yourself one day, and the next day you have to back off a bit. We have dancers in the Company who simply can't jump every single day. We have male dancers who can't jump every day. They have to jump hard for one day and then recover the next. And I think it's even more important for the hypermobile dancers because of muscle strength and what it takes to keep that muscle strength high enough to cope with the challenges of a week, a month, 3 months in a program where they're performing and rehearsing often many different ballets at the same time.

[25:41] Dr. Linda Bluestein: That's an excellent point. So you're saying that rather than maybe some non-hypermobile dancers who can have a load that stays fairly consistent from one day to the next — and who might even be able to take a week off and not lose as much ground — the hypermobile dancers may need to actually have some rest days from certain activities or decrease the load on certain joints even during the week, but likewise they would also have more trouble if they take a whole week off.

[26:14] Moira McCormack: Yes, and I think that is our job within a healthcare department — to make them aware of that and to educate them. Then it's up to the dancer to take that on board and be very, very clever about how they organize their week and how they organize their energy, where they push and when they pull back. That's very hard to tell any dancer and get them to really understand it, but I think it's even more important with the hypermobile dancer because we do see that they fatigue easily, they find it hard to get that stamina up and keep it up, they find it hard to strengthen and then keep the strength there. But with the right information, the right support, many do manage it.
[27:13] I learn from them. I watch them and I watch how, once they've really become very experienced, they work and how they organize their energies. That's when we learn from those very clever ones. And something I wanted to add — there's not much room for, and I want to put this in a respectful way, a lazy dancer. You get some of those really beautifully hypermobile dancers that look gorgeous, the legs are all over the place, they find it easy. And there's a temptation to settle back a bit and rely on how they look and what they can get away with. But when the challenges are really on and the workload goes right up, that's when they fail. So there's not much room for a dancer who isn't willing to put in the effort and put in the brain power — thinking things through — and then the discipline, of course, to carry it all out.

[28:34] Jennifer Milner: So I hope all my hypermobile dancers are listening to this, because you have just given so much for dancers to unpack just in the past 5 minutes. About how they decondition more quickly, about how recovery is harder, about how they have to plan their weeks very specifically and deliberately, and about how you cannot depend on your naturally beautiful body to carry you throughout your career — that you have got to put in the work and maintain what you've got. There's so much greatness in what you just said. Thank you so much.

[29:08] Moira McCormack: You put it in a nutshell there, Jennifer.

[29:15] Dr. Linda Bluestein: And that nutshell, I think, speaks to how dancers are, of course, artists, but also athletes. And that also holds true for hypermobile artists and athletes in general. I'm thinking of other people I know — patients — and those exact same strategies would work for them as well.

[29:39] Moira McCormack: Yes, you can't be an artist and really express yourself unless you have a basis of real stamina and strength and you're on top of everything. If you're struggling, the artistic side of your performance really goes out the window.

[30:00] Jennifer Milner: I 100% agree with that, and I have worked with an extremely well-known performer who came to me — she was in her 60s when we started working together. And I said, what do you want to get out of these sessions? She was just about to start a new show, and she said, I need you to get me to the point where I don't have to think about it when I go on stage. I have to get enough strength and enough biomechanical correctness in it that when I go out on stage, I can just let it go and perform. And that's so true, especially with the hypermobile dancer — giving themselves that strength and that position of strength to move from, so that they can layer the artistry on top of it.

[30:46] Moira McCormack: Exactly. That's exactly what we're on about here.

[30:51] Dr. Linda Bluestein: Fabulous. The article that we were just discussing, that you published in 2004, and then you also published a follow-up article in 2009 — the first one was called Joint Laxity and the Benign Joint Hypermobility Syndrome in Student and Professional Ballet Dancers. In that study, you found an 11-fold increase in hypermobility in dancers in both the ballet school and the professional company. And you also commented in that article about joint pain being more common in the dancers, especially who had other features of — at that time we used the phrase benign joint hypermobility syndrome, which we've since replaced — especially if they had stretchy skin and joint dislocations. I'm curious if you believe that still holds true in terms of joint pain in different places of the body being more common in dancers who have these other features — the stretchy skin and apparent joint dislocations.

[32:04] Moira McCormack: Yes, well, dancers often talk about being used to pain and dancing in pain, and I do think that pain is just part of the job. Our dancers at Royal Ballet who have a very high workload are often working with a problem, but they're managing it. They know that it's a dodgy ankle that they're looking after, but it's strong enough and they're maintaining it enough and they're coming for treatment and they're holding it all together, so they're still able to get on stage and fulfill all their work commitments.
[32:45] So they do talk about working in pain — certain joints or their backs, their spines being painful — but saying, I'm managing it, I know what it is, it's been diagnosed, I know what treatment helps, I know what I have to do to make it feel better, and I can get back on stage with confidence. They also still suffer from quite a lot of soft tissue injuries, especially tendinopathies. It's one of the bugbears because once a tendon starts to become reactive, we know that it takes quite a long time to rehab it, turn it around, develop the strength, settle down the tendon, and get going again. It has a prolonged healing time, and that's what that follow-up paper really told us — we've got a lot of tendon problems. At that time, the research into tendinopathy wasn't as advanced as it is today. Thankfully we now have a good understanding of how to treat tendinopathy and how to prevent it. So our approach to a lot of soft tissue injuries is now much more organized and educated, and we can explain exactly what's going on to the dancer and what the prognosis is.

[34:21] Dr. Linda Bluestein: That's excellent, and as somebody who has a lot of tendinopathies myself, I would love to hear if you're able to elaborate at all on what the newer strategies are that you're using for treating tendinopathies.

[34:37] Moira McCormack: A lot of it is to do with developing strength in the muscle that the tendon belongs to. So if it's patellar tendinopathy, you've got to go for quads — quads have to be much stronger than dancers think they should be. Landing from an entrelacé or a grand jeté en tournant, landing and holding that fondu with your leg in a high arabesque — the stresses that go through that tendon are enormous. Our female dancers are in the gym doing single leg squats, double leg squats, and lifting the weight of their own bodies. They're using a leg press with high load through the quads, through the tendon, to prevent — if they've had tendinopathy before, they have their own workout to prevent it coming back again, and that is high load and really good strength.
[35:46] And it's also the use of isometric exercises just before a big rehearsal — you do your isometrics on your quads to just prepare yourself for that particular rehearsal. So there is some really good stuff out there that we can use with our dancers, and then they take the ball and run with it. It's up to them to do their preventative work. Of course, there's that cycle of pain where you're not being able to do your exercises because of pain — that vicious cycle you get into with tendinopathy. It's trial and error with every single physique, looking for how you're going to help each different physique cope with the stresses and move through the tendinopathy to recovery.

[36:59] Jennifer Milner: It's true that with tendinopathies there is no one-size-fits-all.

[37:04] Moira McCormack: No.

[37:05] Jennifer Milner: And trying to find that unique pathway — I think just in the past few years our approach to tendinopathies has changed so much. Acknowledging that there isn't really a one-size-fits-all, in general, are there interventions — or I don't even want to say interventions, pre-interventions — to help improve the longevity of a hypermobile dancer's career? You had mentioned Pilates or this or that at the beginning. What are some things you have seen be useful over the long term?

[37:42] Moira McCormack: Well, over the last recent 5 years or so, it's all been strength, strength, strength.

[37:50] Jennifer Milner: Yes.

[37:51] Moira McCormack: But I think all of us working with — well, I have been wanting dancers to do loaded strength work for 20 years, because you look at what they do on stage and you think, control work is always very important, but control work is not going to allow that muscle to absorb high eccentric loads of landing from a very high jump. So it's obvious that you need more strength in the lower limb in dancers. It is strength, but we cannot do without the control. Strength and control dovetail beautifully together. So all the Pilates work and then the gym work — the two go beautifully together.
[38:45] I'm talking about professional dancers and the pre-professionals. We're always careful with loading the younger dancer, the adolescents who are growing. We have to be very careful and organized in loading. But just as if you're getting an adolescent to perfect a grand jeté en tournant, and that hold in an arabesque en fondu, then you've got to put those forces in a very controlled way through that young body so that they can do the technical work in the studio. Those two go together.
[39:28] And then of course it's the stamina work — basic stamina work, swimming, bicycle, cross trainer, all of those things that get the circulation up and get the dancer to exert themselves over a period of time without fatiguing. That's what we go for with the stamina work as a background. You know what you need to do. With the young dancer who is not at a vocational school where things are available and trainers are available to control exercise regimes, it takes a little bit more organization for them to put in those elements as best they can to support their work. And unfortunately, those dancers who are not at vocational schools but are doing a lot of serious training — I've seen it — they lose out. You definitely need a good advisor to help you organize your week so you're putting in all of those elements in a very balanced way.

[40:55] Jennifer Milner: Yes, so it's not just spending more time in the dance studio that makes you a better dancer — it's being smart with your time in the dance studio and knowing what else you need to get outside of the dance studio, whether it's swimming or strength training or control training. It's learning how to put that whole picture together.

[41:15] Moira McCormack: Yes, exactly. And even our young dancers in the companies can fail because they've been so enthusiastic — usually the men, the young men — so enthusiastic that after class they really want to practice again and again their double tours, their révoltades, their manèges, and do all of that wonderful stuff, because they're young and they're in the corps de ballet of the Company and they don't get to do all of that on stage. So they end up wanting to do it all because it's such fun. And they haven't actually put the time into the gym to get that strength. And then they come limping in with problems and bone stress, and then they find out, and then they learn. Of course they learn through those mistakes.

[42:10] Jennifer Milner: Absolutely. And I will say here too that the Royal Ballet and Royal Ballet School are absolutely the gold standard to me for how to integrate dance science and dance medicine into an institution. The work that you have done, taking it from your pre-professionals and your middle school all the way through — it's been such a deliberate and thoughtful approach to building a healthier dancer that I think everyone else should be looking at it and trying to emulate it. You guys are really the gold standard to my mind.

[42:50] Moira McCormack: Well, I feel a cog in the wheel and part of a team, but it is very heartening to see all of that coming together.

[42:59] Dr. Linda Bluestein: It's been great having everybody here today for Bendy Bodies with the Hypermobility MD. Today our guest has been Moira McCormack, physiotherapist for the Royal Ballet Company in London, and please go to bendybodies.org for links to more information. We will have links there to where you can get more information about the different research projects that Moira has done and things for dance teachers, for parents, for dancers themselves. Thank you for listening to this episode. Because it was so packed full of great content, we decided to make our discussion with Moira a two-part series, and we've come to the end of part one. Please be sure to subscribe to the Bendy Bodies Podcast so you'll be notified as soon as we publish part two of our discussion.
[43:44] Thank you, and we'll catch you next time. If you have enjoyed this program, please like, share, subscribe, and leave a review. This podcast is for informational purposes only and is not a substitute for medical advice. Please see your own medical team prior to making any changes to your healthcare. Bendy Bodies original music is by Andrew Savino and sound editing is by Rhett Gill. Thank you so much for tuning in, and we will see you next time on Bendy Bodies with the Hypermobility MD.