Strengthening Precision with Monica Lorenzo, MS, ATC

[01:15] Dr. Linda Bluestein: Welcome back to the Bendy Bodies Podcast, where we speak with experts bringing you state-of-the-art information to help you improve your wellbeing, enhance your performance, and optimize career longevity. This is co-host Jennifer Milner here with the Hypermobility MD, Linda Bluestein.

[01:31] Jennifer Milner: We are so glad you are here to learn tips to help you self-manage your conditions and live your best bendy life. This information is for educational purposes only and is not a substitute for medical advice.
[01:44] I'm Jennifer Milner, a former professional ballet and Broadway dancer, and I struggled my whole career with hypermobility-related issues and injuries. Now I train dancers and want to make sure the next generation of hypermobile artists are better equipped to work to their fullest potential.

[02:01] Dr. Linda Bluestein: And I'm Linda Bluestein, and I started this podcast to educate the hypermobile community because despite being a physician, I experienced decades of symptoms before being finally diagnosed with hypermobile EDS. I get how frustrating it can be to be gaslit and feel completely alone in your journey.

[02:19] Jennifer Milner: Our guest today is Monica Lorenzo, founder of Romofit and a corrective exercise specialist who has trained lots of dancers, including working with dance teams like the Knicks City Dancers, as well as the Rockettes and Cirque du Soleil. Hello, Monica, and welcome to Bendy Bodies.

[02:35] Monica Lorenzo, MS, ATC: Thank you so much. I'm so glad to be here.

[02:38] Jennifer Milner: We're thrilled to get to chat with you today.

[02:41] Monica Lorenzo, MS, ATC: Likewise. I'm very excited for this chat.

[02:44] Jennifer Milner: Well, so before we jump into the topic that we wanted to talk with you about today, could you just tell our listeners a little bit about yourself?

[02:53] Monica Lorenzo, MS, ATC: Absolutely. So I am an athletic trainer based in New York City, and I started my journey as a performer myself. So I grew up in Queens, New York, at a local dance studio. I started dancing and then transitioned into the competitive aspect of the dance world. So I was trained in all different aspects of dance, and then I attended LaGuardia School of Performing Arts for high school as a dance major. And that's where I really deepened my classical training in ballet and the Graham technique in modern.
[03:22] While I was a dancer in high school, you start that journey of looking for your university. And at the time — this was many years ago — the return from injury for the performing athlete was something that I didn't see. I fortunately had never suffered a really bad injury. However, I never saw a performer recover from a bad injury. Unfortunately, I just saw that the career basically ended. So as I was searching on my journey for university, the fear of a career-ending injury was looming over my mind. And I was scared. I said, well, what if something happens to me? How do I feed myself in a post-injury world as a dancer?
[04:03] So discussing this with my ballet teacher at LaGuardia, she said, why don't you think about the world of physical therapy? If you ever choose to bridge your two worlds between PT, you can work with artists. And that may be an avenue for you to go down in the future. And for some reason, that just didn't seem abnormal to me. It wasn't something that made me say no, absolutely not. A light bulb went off. So I'm really grateful for that conversation with her because that then started my journey.
[04:31] I decided to look into universities that had physical therapy and also dance as well, because I wasn't ready to finish my dance career. I wanted to continue to train and I felt I was in New York and I had a great variety of performance choreographers, teachers, and instructors that I could keep training and look towards building a career as a professional dancer, but supplement with an academic degree on the side as well. Just in case I got hurt, I could continue to support myself.
[04:59] That transitioned me into interning at a physical therapy clinic. And at the time, the director said to me, why don't you look into athletic training as your undergraduate degree? I think that would be great. Mind you, I can take a step back. I chose Stony Brook University as my university in Long Island because I could stay in New York City, continue to train as a dancer and audition and be on that circuit, and then attend graduate school for physical therapy. So my undergraduate at the time was biology and business.
[05:29] I never met an athletic trainer. I didn't know anything about that career whatsoever when I started this journey. And so the director of the physical therapy clinic said, why don't you think about athletic training for your undergraduate degree? You're a performer, you're excelling as an aide in this area, you really have passion. And I said, I don't know what an athletic trainer is. What is that?
[05:46] And so he instructed me a little bit about the profession of athletic training, and the assistant athletic trainer to the Radio City Rockettes worked for the same facility on an opposite shift. And he said, I would really love to introduce you to Meg Schneider. She's the assistant at Radio City and she comes in later that day and I'll connect both of you. And you're already enrolled at Stony Brook University, which has a great athletic training program. So ding, ding, ding. I was like, okay, cool, this is great.
[06:20] And that afternoon Meg actually came into the PT clinic early. We connected immediately. She took me under her wing and brought me over to Radio City. I learned about their athletic training in-house, full-care athletic training program that was originated by a Rockette herself, Elaine Winslow Redmond. And honestly, within the first day, I knew that this was my calling. I made a phone call immediately to the director of curriculum at Stony Brook University and transitioned to the athletic training program there. And the rest is history.
[06:56] That's how I became an athletic trainer. I felt that for me, the full-encompassed care of caring for a team was what I thought my physical therapy life would be, if that makes sense. So the injury prevention, working with the team from beginning to end, and having that sideline care was something that I envisioned as a physical therapist. But realizing that athletic training is really what housed more of that curriculum, and more of the job protocol.
[07:27] Learning under the wing of Elaine Winslow at Radio City really showed me that caring for the performing athlete was more of my calling than being a professional performer myself. So I made that transition about my sophomore year of university, and I never looked back. I didn't feel like I was losing any part of myself. I felt like I was gaining a greater part of myself.
[07:52] So from that moment on, once I transitioned, that was it. I knew I wanted to work with performing artists, and I wanted to provide them the care that I had never seen nor received. And I also wanted to provide athletic trainers jobs in the performing arts because as I continued my educational journey and my professional career, I realized that many athletic training roles are lacking in the performing arts, and they are great assets to working in conjunction with all the medical community that works with performing artists. So that became one of my missions as I continued on and built my companies, and now I service dance teams with athletic training programs.

[08:28] Jennifer Milner: Wow. That is a really serendipitous and also very focused and sort of single-minded path. I don't know if it can be fortuitous and focused at the same time, but it was — that was a really interesting journey.

[08:38] Monica Lorenzo, MS, ATC: I would describe it like that.

[08:39] Jennifer Milner: Yeah. Thank you for describing it because I think a lot of people don't really understand what athletic trainers do and don't know exactly what they are other than someone who trains you, which is not really what you go to school for, right? Not like a strength and conditioning coach or something, although that's part of it. So that's really great.
[08:55] And there are so many different paths we could go down with you. But we want to talk about your experience with precision dance, which doesn't just apply to precision dance, right? It also applies to synchronized swimming, competitive gymnastics, anything that's being part of a team. But if you're training with a team of Arabian horses, it's hard as a zebra to fit in and look like everybody else, right? So that's where I think your information is going to be really helpful.
[09:29] So you're an athletic trainer for the Rockettes. You've worked with the New York Knicks dance team. How is precision dance different than other forms of dance? Let's start with that.

[09:39] Monica Lorenzo, MS, ATC: Sure. I would describe precision dance — this is my unique description — each performer is performing within their plexiglass sphere, if that makes sense. So you're in this plexiglass sphere where everybody has their boundary line, and your choreography is fitting within that sphere. You can't really push yourself out of that sphere because now you're out of alignment from your teammate next to you.
[10:06] And I want to say plexiglass because there is some movement. So that movement is your creative edge where you can push yourself all the way to the edges, but you do have to still stay within your sphere in order to execute the movement and the pictures and to execute the creative vision that the choreographer and designer have placed on you as a performer.
[10:26] So that's how I describe that, whereas in a non-precision style of dance, you can push your limits a little bit further and your own creative edge and your own creative execution will be highlighted rather than you having to stay within this sphere so that you can stay within the imagery that's being placed upon you, if that makes sense.

[10:48] Jennifer Milner: Yeah, that's a great description.

[10:49] Dr. Linda Bluestein: That is a great description.

[10:51] Jennifer Milner: So how might that make precision dance a bit more challenging for hypermobile dancers than, say, for the dancers in something like Cirque du Soleil or a different type of dance company? If you're hypermobile and you're trying to do precision dance, what are some of the challenges that you might face?

[11:09] Monica Lorenzo, MS, ATC: That's a great question. I wanted to actually preface this with my first encounter with somebody diagnosed with EDS wasn't a performing athlete. It was actually a private client of mine. I worked alongside a physician and was providing strength and conditioning for athletes, either at the end range of traditional physical therapy returning to sport, working one-on-one with them to bring them back to their full sport. And that was when I was introduced to EDS.
[11:37] I wasn't introduced to this dysfunction in my academic career. So that was really interesting for me because it's like, oh my gosh, now Pandora's box was open. Because I said to myself, I bet so-and-so has this. I bet so-and-so has this. All of these performers that had been in my roster — I felt like I opened up a whole new avenue of understanding of their body and their mobility, and was able to let them know to go for further testing and to see if they actually were diagnosed with these disorders. And so that really was helpful for me.
[12:13] That was where I started my educational journey on understanding how to work with the hypermobile athlete — not with the performing artist first, which was, like I said, really interesting.
[12:25] In transitioning this to working with a performing athlete, so in precision style dance specifically, if you're hypermobile, a lot of the visuals that we'll see is sometimes they'll have slower execution of hitting that end range of motion or that picture. And they will also have moments where they don't have that same proprioceptive awareness. So their end range is going to feel kind of off, and they're always going to feel like they're being pushed.
[12:52] I like to use this analogy — remember the tickle test when you were a young child? You put your forearm out and your friend would tickle you from the wrist and you would have to let them know when they got to the crease of your elbow with your eyes closed. And you're always just a few centimeters off from the center crease of that elbow. So I would describe that as the experience that the hypermobile athlete may be feeling, where they feel that they're being told to be put in this one position, but they're not responding to the same cues that their colleague may be receiving.
[13:24] So they have to now realign and reassess their proprioceptive awareness through specific cueing that I will work with them on, or whoever else is training alongside with them. We'll break down some choreography cues alongside with their strength training to reevaluate and retrain their proprioceptive awareness in that capacity of that choreography, if that makes sense.

[13:48] Jennifer Milner: Yeah, that's fascinating.

[13:49] Dr. Linda Bluestein: And do you notice a difference in terms of movement quality with hypermobile dancers, like in terms of speed and the precision, clarity, that kind of thing?

[14:00] Monica Lorenzo, MS, ATC: Yes. Sometimes for my hypermobile athletes that don't have that muscle hypertrophy — that have been undertrained or haven't worked with a specialist to make sure that they are prepared for this style of dance — you will notice that they're not hitting movements as sharp. That's the best way I can describe it from a choreographer's standpoint, where they're not actually able to execute that almost-bounce that you'll receive when you hit an end range with a tight snap. They have a little bit more of a rebound to their movement. So they'll hit a pose or they'll hit a picture and where they're now at the perceived end range of motion, instead of having a solid stop, they'll have a little bit more of a bounce, or a length to their movement. And then they'll have a lag in transition to the next piece of movement in their choreography.

[14:53] Jennifer Milner: And I see that too in dance. If someone is hypermobile, especially if they tend towards more EDS or somewhere on the disorder spectrum, their energy sort of dissipates rather than stays in there ready to attack, ready to be gathered back up and used again. So you see them land from a jump and the energy just all goes out, and then they have to gather it all back up again to try to move. Or they'll finish a pose and you'll almost visibly see the energy kind of continue to trickle off of them. It's really interesting once you know what you're looking at, right?

[15:26] Monica Lorenzo, MS, ATC: Exactly. I like that analogy. It's like energy leaking almost, instead of being able to contain it. So that really brings us back into that plexiglass sphere, right? If we have a little bit of a hypermobile dysfunction, there are almost like punctured holes in your plexiglass where you're spewing a little bit more energy out, not being able to sustain that within your circle.

[15:50] Dr. Linda Bluestein: Oh, I like that. As someone who works with a lot of dancers but not in the capacity that the two of you are — I'm working more on their fatigue and their sleep and those kinds of things — that fatigue piece is really huge for a lot of dancers. And it really makes sense with what both of you are saying, why they might feel that.

[16:12] Monica Lorenzo, MS, ATC: Absolutely. And that is a big marker as well, looking for fatigue post any type of rehearsal or training. I still think that there are many athletic trainers out there who are still undereducated in hypermobility dysfunction and being able to assess this in their athletes. So understanding that fatigue is something that is really important to look at when you are evaluating and comparing your athlete to the other performers that you may be working with. And then, obviously, we're tackling nutrition and all of the corrective exercises that go along with working with your hypermobile athlete, but fatigue is something that I've noticed colleagues have missed when it comes to the evaluation process. So understanding that, and the energy leaking — I think that's a great cue to utilize.

[17:02] Jennifer Milner: I'm definitely going to use that in my repertoire now.

[17:05] Dr. Linda Bluestein: I like that a lot.

[17:07] Jennifer Milner: Well, and if people are curious about the fatigue issue, we have done an episode on fatigue for people with hypermobility. So be sure to go back and check that out. I have no idea what episode number it is. Dr. Bluestein, do you remember?

[17:17] Dr. Linda Bluestein: I don't remember the number, but we did two back-to-back episodes, I believe, during Fatigue Awareness Month — one with Bendy Bodies registered dietitian nutritionist Kristin Koskinen, and the other one was with physician Alan Pocinki. We can link those in the show notes.

[17:42] Jennifer Milner: Absolutely. So getting back to training the hypermobile dancer — if you have seen this, if you've seen the energy leakage, if they've come to you, you mentioned that you help them figure out the cues in a way that they understand and can start to feel in their bodies. What else would you suggest a hypermobile dancer seeking to do precision work might add to her conditioning routine?

[18:04] Monica Lorenzo, MS, ATC: So strength training is everything when it comes to working with all of my athletes. To back up a little bit — I'm fortunate that once all of my athletes are hired, we take them through a pre-screening process. The Rockettes do this. I've implemented this with the Knicks City Dancers. And we also service the Brooklyn Nets entertainment teams and the Golden State Warriors entertainment teams. They have full athletic training staff that are caring for their athletes.
Post-hire, they are taken through a functional analysis where we're looking at range of motion, manual muscle testing, and taking them through a functional dance screen specific to their style, because all these different teams have different styles. And then they receive a strength and conditioning program that we will work alongside with them and something that they can utilize on their own during their home care practice time.
[18:52] So strength training for me is absolutely everything. Working with each individual athlete at whatever baseline they're providing me at that time is what I'm going to build their strength training program on. Hypertrophy of their musculoskeletal system is something that I really want to address immediately. We're always going to make sure that they have proper nutrition and that all of their vitals and blood work are fully in alignment and they're not predisposed to any overtraining issues that may be outside of our box.
Once we implement that, we go directly into our strength and conditioning programming. For the entertainment teams, preseason gives me a good two months where we can work through all of the strength and conditioning. Cueing, when it comes to my hypermobile athlete, is everything. Making sure that when we're in any positioning, they're not reaching beyond that range of motion, that they're not putting themselves into a dysfunctional pattern. So working through their muscle activation patterning is something that I really focus on with the hypermobile athlete.
[20:03] A lot of times they're always taught to restrain themselves when it comes to precision style dance. So you see that they're initiating their movement and their energy from their limbs rather than initiating movement and energy source from their core. That's something that I've really noticed when evaluating my athletes — and not just the hypermobile athlete, but your typical athlete who doesn't suffer from any hypermobility. So core stability and core activation initiation in their biomechanical movement is number one.
[20:38] Now, working with my hypermobile athlete in conjunction alongside others — it's so interesting when you train them all together in a group style setting. It's a great learning tool for my hypermobile athlete to now see where their non-hypermobile teammate is in body placement, also through movement and muscle activation.
I'll give a quick example with a deadlift. When we're standing in a deadlift position — feet about hip-width apart, any type of resistance held in your hands — as we lower down into that deadlift position, keeping the torso in a flat back, any dancer who has flexibility can go all the way down to their toes 99% of the time. Now, when we're looking at hip rotation, it's just simple cueing. They don't even realize that they're going into external rotation at their hips when they're trying to drop all the way down. So just those typical cues — okay, let's talk about the adductors and just firing up our adductors. Now, where are our external rotators, where are our internal rotators? And having them rebalance the way that they're initiating their movement in a deadlift.
So just saying, okay, we have two little tennis balls on the inside of our inner thighs and we're going to tap those two little tennis balls together when we're now in this position, just four degrees down. Okay, let's go five degrees down. Let's continue on. And then coming back up, that light bulb aha moment — oh my gosh, I know how to actually control my movement and control my musculoskeletal output. It immediately shifts the way that they now understand their bodies and they don't feel inhibited. They feel empowered. So that's been the way that I've been able to transition training for that hypermobile athlete alongside my non-hypermobile athlete.

[22:36] Jennifer Milner: What terminology do you like to use for the non-hypermobile athlete?

[22:39] Dr. Linda Bluestein: I feel like we've never picked one. We've always just talked about hypermobility and people who are not hypermobile.

[23:27] Monica Lorenzo, MS, ATC: Yeah, I realized, as we were talking, I was like, wow, I knew I was prepared, but now that I'm talking about comparing and contrasting, I'm having a difficult time. I don't want to label anybody improperly.

Dr. Linda Bluestein: Well, and the tricky thing with that is so many dancers are hypermobile, but they might not have an actual syndrome or connective tissue disorder. I have heard people say "connective tissue typicals," but that's confusing because you can have typical connective tissue but still be hypermobile. Because hypermobile just refers to the range of motion of a joint.

Jennifer Milner: Exactly. These things are a tricky conversation to have. I think it's fascinating that you're training people in a group setting but yet giving them that individual attention, because we learn from each other. And of course we watch each other in dance class and things like that. But it can be really valuable because then you can look at somebody else and see — oh, this is why I'm struggling with this. It just comes so much more easily and more naturally to them because their connective tissue has normal stretchiness and doesn't give way so easily. So I think it's a great way to train people.

[24:23] Monica Lorenzo, MS, ATC: Absolutely. I'm fortunate that as we're training together, there's an open dialogue. So it's not a typical group session where you're just following the instructor along. It's always a small group of athletes that I'll have together, and we can feed off of each other. I will always ask the question of — what sensations are you feeling? Where do you feel this movement? What muscle activations are you feeling at this point in time? So everybody gets to discuss in real time. And then I provide corrective cueing throughout. And we all learn from each other. It's really exciting because I learn atypical cueing patterns based off of each individual performer that I can bring into my toolbox and my roulette of verbiage that I use when I'm training these athletes.
[25:09] Another function that I have to address in all of my athletes is recovery. A lot of times the majority of my athletes, especially on the dance teams, this is not their full-time job. Their full-time job is either as a fitness instructor, a professional dancer, or they're working in corporate America where they're sitting at a desk for most of the day.
[25:32] So I take into account not only that we're working on a performance season — which for the NBA is a very long season — but all the other demands on their bodies. Typically a performer is going to get hired around June or July for their season, then they start rehearsals about a few weeks after hire, and games begin in October. If they don't go into the playoff season, they're finished in early April. But if they go into the playoffs, it can go all the way until June. So that's how long this performance season is.
[25:58] It waves up and down because the majority of these performers are only performing at home games. Sometimes we'll have three or four home games in a week and then they'll have a two-week hiatus while the team is on the road. So you do fluctuate in intensity and frequency. We also have to take into account not only those performance fluctuations, but their rehearsal fluctuations. When we're in an intense performance setting, they're still rehearsing multiple times during the week. So they could be on six days a week with no days off.
[26:29] So how am I transitioning that one day off? How am I advising on their recovery? Recovery and training fluctuate throughout the entire season. We're obviously going to be more intense in our preseason training because that's where we can control things a little bit more. And then during the higher level of intensity — performance and rehearsal season — we're in a maintenance phase. That's what I call that training time. We're in a maintenance phase, also instructing our performers on their recovery.
[27:02] Recovery for them is going to look like maintenance, if that makes sense. So we're going to sustain our core stability. We're going to sustain our exercises that are taking us through that range of motion, maintaining our proprioceptive awareness, and then also biomechanically recovering and allowing tissue to heal and rest. And that's going to include all of your modalities — whether it's an Epsom salt bath, whether you have access to higher technologies like Normatec boots, making sure we're utilizing those on a daily basis.
[27:34] But the basics are going to be your essentials, understanding when they should be working with myofascial release techniques and when they shouldn't, and when they should be listening to their bodies. That last and final piece — listening to their bodies — I've now taught through mindfulness and meditation practices that I implement in all of my trainings.
[27:57] Prior to every single training, we do a quick body scan check-in. I bring everyone into a full mindfulness practice, and at the very end, we go into a true meditation — a theta-based meditation where we work on true recovery connectivity with our bodies as well as body awareness, emotional awareness, and that final theta healing. And I have found that to be the secret sauce when it comes to working with all of my artists and actually implementing huge injury prevention protocols. We obviously track everything, and we've been able to show that since we started with the Knicks entertainment teams in 2009, we've been able to reduce our new injury rate by about 65%, which is huge.

[28:54] Jennifer Milner: That is huge. That is huge. And one of the things we were curious about is how you help dancers maintain during a long period. I think so many people think that if you're training for a year-round program, for a year-round contract, you're going to continue training and possibly change what type of leg exercises or arm exercises you do. But it's great to hear you lay out that it's a completely different way of looking at it — that you really start out in the beginning by preparing people for the right cueing, preparing them to find their box, getting them strong for the things they need to be strong for, making sure everybody's doing it the same way, getting them to peak performance level, and then starting to figure out how do we maintain that? How do we not get injured? How do we stay healthy? How do we help you recover?
[29:42] So it's not just about continuing to pound away with the exercises. It's learning how to advise the dancers — and this is something I have to do as well. This is the part where you have to pull back. This is the part where you stop running five miles every morning. This is the part where you buy yourself the Epsom salts, and it's part of your training.

[30:05] Monica Lorenzo, MS, ATC: Absolutely.

[30:06] Jennifer Milner: So it's really important. Thank you so much for outlining all of that. Something like the Knicks has a year-round season, and I love that you've structured it to fit the ebbs and flows. And I think people don't realize that with something like the Rockettes, even though the Christmas season is maybe two months long and not nearly as long a season, it's still quite intense. I had friends who were Rockettes around 2000 and 2004, and they were doing multiple shows a day. It was incredibly difficult on their bodies, and there wasn't the training program that's in place now. There was still a massive amount of care that had to go into that, and I don't think people realize quite how demanding and intense a season like that can be. So can you talk a little bit about that for the Rockettes?

[30:54] Monica Lorenzo, MS, ATC: Absolutely. That's a great question, and many people don't understand the intensity of the Christmas Spectacular. It is — we like to say — a beast in its own. These performers are contracted from mid-September until early January, and their rehearsal time is about a month to a month and a half, six days a week from 10 AM to 5 PM. Sometimes they may have to go over a little bit afterwards depending on costume fittings or if there's choreography that needs to be evaluated or processed, but those are the confines. And they only have one recovery day, and the same is sustained throughout the show.
[31:29] Then once we transition from rehearsals into shows, these performers in New York City specifically — there are two casts that are performing all the shows — but each cast could perform up to five shows in one day. At minimum it's two, and five has been the cap. On a six-show day, the cast is usually split three and three. But just thinking about that — it's an hour and a half show. And we've clocked it in the past: the Rockettes were on the stage for 45 minutes of that hour and a half show. And we're talking precision style dance, and you have to be on. There is no "I'm just going to muscle through this performance." You are a precision style dancer who has to hit these positions, and if you're tired, you cannot be off five degrees. Your five degrees have to always be exactly where they have to be.
[32:25] So as an athletic training staff, the way that we tackle this program is working with the performing artists a little bit beforehand if we can, because it's not mandatory for them to work with us beforehand. But throughout the season, it's really working on sustainability and maintenance. Their strength and conditioning is not elevated during the season — it's on maintenance mode. And then we're also addressing any issues that they may come in with, because they do receive a prescreening.
[32:52] The postseason is really where we fire things up for them in terms of building hypertrophy on their musculoskeletal system and addressing any predispositions we're seeing that may have developed throughout the season. So we'll do a postseason decline — recovery-based — and then an increase in training and strength and conditioning. Because if they are returning the following year, you'll see those athletes who have been working with us and our programming come in much stronger. Their energy levels are elevated, their instance of injury is reduced, and they're able to get through these seasons almost pain-free.
[33:33] Recovery is involved for every single athlete. We have ice baths at all of the locations, making sure they're utilizing all the recovery protocols that we have in place. But no one really understands how intense the Radio City Christmas Spectacular is when it comes to the performing athlete.
[33:51] They are fortunate enough to have a full gym on the ninth floor of the Music Hall, right off of our athletic training room. Performers can come in and utilize that space, and they luckily have us to advise them on how to properly care for their bodies throughout their season so that they're not predisposed to injury. Whereas if they were left without any care whatsoever, they may be pushing themselves beyond their limits, and that's where injury would occur.

[34:17] Dr. Linda Bluestein: And I'm curious — you mentioned that muscle hypertrophy is so important. We've talked to a lot of different dancers and some have so much difficulty building any muscle. Have you noticed that hypermobile dancers sometimes have more difficulty building muscle? And if so, how do you handle that?

Monica Lorenzo, MS, ATC: Absolutely. And that goes for your traditional dancer as well, especially through these intense seasons where they lose so much weight because it is a really difficult intensity protocol. So nutrition is going to be our biggest base. We'll refer out — I work with sports nutritionists — and the majority of the time, implementing proper nutrition and supplementation has always allowed for better hypertrophy when it came to strength and conditioning. That was the missing piece: nutrition and sleep.
[35:19] When those two things were addressed, and I have to say mindfulness and meditation has been something that I have noticed benefiting all of my performing athletes when it comes to any positive changes they want to make for themselves. I haven't specifically tested this in an athlete I felt was unable to sustain hypertrophy of their musculoskeletal system, but I will be a little bit more aware in the future. But I can say that those three things — nutrition, sleep, and mindfulness — are how we have addressed any issues. Working on that and then strength and conditioning afterwards has always been beneficial.

[36:00] Jennifer Milner: Excellent. And we will have your contact information and your website in our show notes. So that'll be easy for people to find. Well, it really is individualized. And I think something that can be difficult is looking at every single individual athlete as their own unique person.

[36:07] Dr. Linda Bluestein: Yes, and I sometimes feel like I may be reinventing the wheel when it comes to working with each individual. I think that's just something as a practitioner — I don't know if you feel this, but sometimes I feel almost drained in the sense that I want to make sure each person is receiving the exact prescription and protocol they need. And I find that that is really what works. But as a practitioner, if you're dealing with a large population or a large company and giving each individual athlete their own prescription, it can be a little bit draining.

[36:55] Monica Lorenzo, MS, ATC: What I would recommend as a practitioner is it's really important to regulate. What I've now transitioned into is having my little offsets — my pillars that I build upon. So I have my hypermobile athlete, then I have athletes that don't have mobility at all, then I have your athletes in a traditional range, and then a stylistic pillar. Those pillars are what I build off of. Once I place each performer in one of those pillars, then it makes it a little bit easier to now transition into their personalized training protocols. Because I think as practitioners we want to give everything we possibly can, but we may have leaky energy when we feel like we're either prescribing the same thing over and over again that's not working, or we're overthinking and starting from the very beginning every time we evaluate an individual athlete.

[37:56] Jennifer Milner: That makes sense. And another thing we've really wondered about is when dancers are asked to work on less than ideal surfaces — if they're doing guest performances on concrete, on grass, AstroTurf, things like that — how do you strengthen and prepare dancers for jumping, turning, et cetera, on those surfaces?

[38:19] Monica Lorenzo, MS, ATC: Oh, I love this question. Number one is the shoe. The shoe format is something I work on with all of my individual performers. And at times we have actually purchased different flooring so that we can train on that different flooring. For the Rockettes, we actually had flooring that was placed for the Thanksgiving Day Parade — we had patches of that flooring available to us so that we could train on what that would feel like.
[38:56] They will not perform on wet floors. If there's any type of wet flooring and we can't control the amount of moisture, there have been times those performances have been canceled. And so on the opposite side, working with my dance teams, their flooring in rehearsal space is always different from the court performance floor. Two ways that I train for that — obviously I always start with a lower load. And then eccentric training is where I've found the secret sauce to make sure we can transition easily from, say, a sprung floor to a flooring that has ice underneath it. A lot of these arenas will have ice space for their hockey rinks underneath the hardwood basketball floor. So a lot of times what I'll do is work on eccentric loading and eccentric training, and then build into plyometrics. So we'll work on our plyometrics finally and then transition to the floor space so that they now understand how to reduce their load when it comes to decelerating off of any jump, move, turn, et cetera. Really retraining their deceleration phase with all of their plyometrics has been huge.

[40:12] Jennifer Milner: That is really scientific. And I hope people understand that there's just so much more that goes into this than simply jumping higher or jumping less and hoping you don't get hurt. So thank you.

[40:24] Monica Lorenzo, MS, ATC: Right. The deceleration is what's more important when it comes to injury prevention. And a lot of performers don't realize that when they have control over their deceleration, their acceleration and their height and their capacity in jumps and turns increases. I like to say that stability allows for more mobility. I know that may be the antithesis for our hypermobile athlete, but it truly is. Stability allows for more mobility because it allows them to actually reach these controlled edges that will elongate their careers, will reduce their injury rates, and will allow them to perform at a grander capacity without that looming fear of injury.

[41:07] Jennifer Milner: So do you encourage young dancers — and we're going to kind of segue away from working with dancers who are currently on the team professionally — if there are dancers who know that they want to do precision dance or dance for a sports team, do you encourage the younger dancers to focus on their favorite dance style and be really good at it and hope that gets them hired? Or encourage them to try a variety of dance styles, maybe even some other sports when they're at a younger age? We'd love to hear what you have to say on that.

[41:40] Monica Lorenzo, MS, ATC: Absolutely. I encourage youth dancers to do everything. I also encourage them to try traditional sports — soccer, track, volleyball, et cetera. It makes them a much more well-rounded performer and a well-rounded athlete.
If performers want to be on a dance team, obviously precision style dance is something that they should train in. Jazz is usually the base of that style of performance, but ballet is always the structure of all performance as well. So making sure that you are a well-rounded performer is important. As a youth athlete, I want them doing all different things. I don't want them to overtrain. I don't want them to work into sports specialization. I want them to avoid sports specialization because that's what's going to predispose them to injury. That's where poor biomechanical patterning forms.
[42:31] If these youth athletes can transition their bodies from all different types of surfaces, all different types of strength training, all different types of endurance training — stressors against the body in different aspects — I mean, we all know this is something that I obviously advise. I can't tell you how many times I still attend a competitive circuit and talk about injury prevention and sadly still get resistance or a lack of education on what strength training or cross-training for the performing athlete consists of. And the misnomer that taking a jazz class or a ballet class or a tap class — still staying in the realm of dance — constitutes cross-training. That education piece is still the hard part for me. I always think we're a little further along, and I get surprised when I receive raised eyebrows from either a parent or an instructor who doesn't understand this, who doesn't understand the necessity of transitioning the body through all different aspects of resistance and training cycling.
[43:50] Also, we have breakdancing that's going to be in the 2024 Paris Olympics, which is so exciting. These youth athletes are now looking at these older athletes and saying, now they have something new to aspire to. Your breakdancers who have always thought of themselves more as street performers are now going to be Olympic athletes. The level of training and consistency is going to change at the youth level. I'm hoping these youth athletes understand that they have to cross-train in order to have long careers.

[44:22] Dr. Linda Bluestein: That definitely makes sense. Early sports specialization can be so problematic. I really appreciate you sharing that.

[44:38] Monica Lorenzo, MS, ATC: Not at all.

[44:40] Jennifer Milner: Super important. And we've touched on a lot of different areas today, but I'm sure there's so much more that you do that we didn't discuss. Are there any things we didn't talk about that you'd like to include?

[44:59] Monica Lorenzo, MS, ATC: Yeah, one last thing that I've implemented over the last few years as well. I work with predominantly female athletes. My male athletes have come a little bit later in my career, and they are the majority of my breakers, and they're hypermobile and immobile in many aspects. So that's been really fun to now utilize a new part of my brain to work with breakdancers who perform these crazy tricks and move their bodies in these amazing ways, similar to the way that our Cirque du Soleil athletes work.
[45:31] But breakers in particular, because the majority of the time they are self-trained and not working in a traditional training style — they're just taught to get their body to do whatever it can do — can't even perform a basic squat. So now working through biomechanical retraining with these artists while also maintaining their level of performance and helping them work on stability around their mobility has been really exciting for us as athletic trainers.
[45:56] And then the last thing that I've implemented over the last few years for the female athletes is cycling their training around their hormone patterning, around their menstrual cycle. And that for me was a personal journey that I've now been able to implement with a lot of my performers. It is something that's really important with your female hypermobile athletes as well.
Looking at their menstrual cycle and their training cycle and understanding how to work through that — you have your easy phases to break it down. Obviously you have your early follicular phase during your menses, and you want to make sure that that's more of a yin style of training — more restorative. Obviously they can't change their performance level around their hormone cycling. So what I do is just take their cross-training into account, and that is where I'll prescribe more restorative practices.
[46:47] And then we move up — you start to ramp up after menses into your early, mid-follicular, and late follicular phases right before ovulation, where you want to increase training a little bit more. So we can move into full bodyweight exercises or low-level intensity exercises, elevating your strength training.
[47:09] Then we move into ovulation, and we can really fire things up and start to transition into maybe a HIIT style, where you'll elevate your cardiovascular output and strength training output as well. And that'll transition after ovulation into your early luteal. And then you want to start to scale down towards your end luteal phase, right before menses again, where you decrease your intensity so that we can prepare for your menses. Just a day or two before your menses cycle is supposed to initiate is where we scale back down.

[47:41] Dr. Linda Bluestein: I really love that. I hear from so many dancers that they feel even more joint instability shortly before the onset of their menses. So I think it's really great that you are working so intentionally through those different phases. And of course you're working with a lot of dancers, so I'm sure you're educating them so that they can also be adjusting what they're doing at home. That's really fabulous.
[48:10] And as you were talking, I was remembering that if someone has less than normal mobility, we would call that hypomobility. There is research showing that if someone is hypomobile or hypermobile, they have higher injury risk. But the interesting thing is a person can have some joints that are hypermobile and some that are hypomobile, or some that are normal mobility. So when we were talking earlier about what's the right word for normal mobility — in medicine, I believe the term would be "eu-" as a prefix, but that would be hard to pronounce.

[48:51] Monica Lorenzo, MS, ATC: Absolutely. Taking all this into account is necessary. And educating the performer on understanding — this area of your body or this joint is hypermobile, this area is hypomobile — is huge for them. Because then they realize, oh, I actually have to work through a little bit more mobility here. Oh, I didn't understand that my hip couldn't externally rotate this far. So I've been hyperextending my back in order to make this position happen or make a picture happen. And that education for them is huge.
[49:20] Education is freedom. Allowing these performers to take autonomy of their own bodies — I personally, as a performer, felt that my autonomy was me being able to execute choreography. It was still at the expense of how I was being viewed by my choreographer. Whereas I think now we are able to transition to where performers feel autonomy in their own bodies, and they are able to communicate that well with choreographers.
[49:52] I've actually noticed a transition in culture, if that makes sense, where they feel that they can now express their limitations or express their desires or express where their bodies are at at that current moment in time. And it's respected now by choreographers and directors, especially during a rehearsal phase or a creative building phase. They're able to show up the way that they need to at that time, and they don't have to push themselves into an injury phase because the choreographer and director understands that they're doing the work that will get them to that level of performance.
[50:34] And it also helps to have healthcare professionals, which is why it's really great to have athletic trainers available in programming like we have provided for the Knicks and in programming provided for the Rockettes. Because now not only can the performer advocate for themselves, but the healthcare practitioner can also advocate. We're right there on the sidelines, able to discuss with my directors and choreographers — so-and-so is experiencing this limitation today. They either have this injury or they are feeling X, Y, and Z that may predispose them to injury. So we're going to scale back their output in accordance with whatever prescription we have for that day.
[51:10] And that's respected, and it only makes the choreographer and director's life so much easier. They don't have to worry about having to transition this performer out if they're injured, and it allows for a swing to come in and work that day so that the performer can return to their show much faster than they would have if they were suffering from a long-term injury.

[51:31] Jennifer Milner: I 100% agree. I think that communication and education are what's going to change the dance world and the arts world beyond it. Every way that I'm working with a dancer, whether as a ballet teacher or a coach or a trainer, my whole goal is body autonomy. We want them to have autonomy over their bodies. And for any artistic athlete to have that autonomy — to be able to do the things they want to do, to be able to recognize what's going on so they can speak up about it — that's a really important part.
[52:02] Thank you so much. I know a lot of people are going to want to find out more about you and to be able to reach out to you. How would they be able to find out more? Where can people find you?

[52:14] Monica Lorenzo, MS, ATC: I am @romofit — R-O-M-O-F-I-T — on all social media platforms, and that's the best way to reach out to me. Shoot me a message and I will get back to you.

[52:25] Jennifer Milner: Excellent. Well, you have been listening to Bendy Bodies with the Hypermobility MD, and our guest today has been Monica Lorenzo. Monica, thank you so much for being here. We have learned so much from you.

[52:32] Monica Lorenzo, MS, ATC: Thank you, my pleasure. I learned from you guys as well.

[52:40] Jennifer Milner: Yeah, we love this conversation.

[52:42] Dr. Linda Bluestein: Super helpful.

[52:43] Jennifer Milner: And I know we're going to get a lot of people who are really going to gain a lot of benefit from hearing this conversation. So thank you.

[52:52] Monica Lorenzo, MS, ATC: I hope so. My pleasure. Thank you so much.

[52:56] Jennifer Milner: If you love what you learned, follow the Bendy Bodies Podcast to avoid missing future episodes. Screenshot this episode, tagging us in your story so we can connect. Our website is www.bendybodies.org and follow us on Instagram @bendy_bodies. We love seeing your posts and stories, so please tag us using #BendyBuddy. Please leave a review and share the podcast to help us spread the word about hypermobility and associated conditions. This information is not intended to diagnose, treat, cure, or prevent any disease. The information shared is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for all medical concerns. We will catch you next time on the Bendy Bodies Podcast.