Educating the Dance Community with Lisa Howell

[00:35] Jennifer Milner: Welcome to Bendy Bodies with the Hypermobility MD. This is your guest co-host Jennifer Milner here with Dr. Linda Bluestein for another episode of this dance-specific series. Today we have a very special treat in store for you as we are speaking with Australian physiotherapist Lisa Howell. In addition to being a physiotherapist, Lisa is an author, speaker, and creator of The Ballet Blog, which has revolutionized how dancers think about their bodies, injuries, and performance enhancement. She works closely with some of Australia's top dance medicine specialists and has lectured through Europe, the United Kingdom, the United States, and Australasia on dance anatomy, injury prevention, recovery, and performance enhancement. She's also been a guest speaker at the IADAMS Conference, which is an international group of dance professionals aiming to enhance the health, well-being, training, and performance of dancers by cultivating educational, medical, and scientific excellence. Lisa is well respected both nationally and internationally for her work with young dancers, professional dancers, and dance teachers. So, hi Lisa, and welcome to Bendy Bodies.

[01:44] Lisa Howell: Hi, thank you for having me.

[01:57] Jennifer Milner: Can you start out just by telling us about your background?

[02:00] Lisa Howell: Well, I grew up in New Zealand. A lot of people think I'm Australian, but I'm actually a Kiwi. I grew up in a very small town dancing the whole way through my adolescence, but went straight to university to do physio and did my training in New Zealand. After I graduated, I moved to Australia and thankfully fell right into a job with a dance physio. Before then, I never realized that dance physio was even a thing. It wasn't really at the time, definitely not in New Zealand, but I had some amazing mentors very early on and learned a huge amount. I started seeing that a lot of the issues that we were seeing in clinic could have been prevented. So I wanted to move on and do a lot more educational work out in the community to actually stop a lot of the issues that we were seeing. I started doing that in 2005 when I started my own clinic. In the last 15 years, I've just constantly been trying to get more education out into the community so that we can prevent a lot of the really common injuries that a lot of people think are just par for the course. Because there is so much that can be prevented rather than dealing with it once it becomes a problem.

[03:14] Jennifer Milner: Absolutely. I know that is a passion of yours — trying to prevent them before they happen. What made you interested in hypermobility specifically?

[03:25] Lisa Howell: Well, I'm hypermobile myself, and I never understood it when I was dancing. I was actually very inflexible when I was young, which a lot of people find surprising. They think if you're hypermobile, you're super bendy and super flexible. A lot of hypermobile people are inflexible until they learn how to stabilize, or they may be inflexible in certain areas. Once I understood how much my own back pain — I had severe back pain from about 18 to 26, when I worked out how much my hypermobility was influencing it and mastered control. Now I'm great, touch wood. That's been a real driver to help teach people about the many, many factors that affect you when you're hypermobile, and really practical ways of actually dealing with it rather than just accepting it as a diagnosis and suffering. There is so much that you can do. But it's purely from personal experience — myself not having that information, and seeing so many clients come in who don't realize how their hypermobility is actually affecting the conditions that they're working with.

[04:32] Jennifer Milner: Absolutely. And I'm glad you mentioned that — you can be inflexible and still be hypermobile.

[04:37] Lisa Howell: I couldn't touch my toes as a kid.

[04:39] Jennifer Milner: Right, and I will have so many dancers come to me and I'll say, I think you're hypermobile, and they'll say, no, no, I can't touch my toes, and I'm like, your shoulders dislocate three times a year — let's dig deeper. So knowing that inflexibility — and this is something that Linda talks about as well — knowing that inflexibility can go hand in hand with hypermobility.

[05:00] Lisa Howell: 100%.

[05:01] Jennifer Milner: It's so important to know when you're working with hypermobile people. So you owned a physio clinic for several years. You teach workshops across the world. You post videos. You write books. You do blogs. You are so passionate about working with dancers and educating them, especially pre-professionals and people with hypermobility. So how has your work as a physio and what you've seen during it shaped your approach and your focus on what you do?

[05:30] Lisa Howell: Yeah, I think the constant frustration that I had was seeing the same injuries over and over again, and often seeing injuries at pretty pivotal points. So being in Australia, there's not a great professional dance world. A lot of students have to go overseas to continue their training. Often just before they'd go overseas, something would come up that could have been intervened or could have been prevented 6 to 12 months before. Or we'd constantly see the same issues over and over again in pre-pointe students — kids coming in for their pre-pointe assessment and being totally unprepared. They would feel devastated because we'd have to say no, whereas the training should have been happening 2 years before so that they're actually prepared at the right time. So it was this constant frustration and feeling like a stuck record of saying the same things over and over.
[06:20] That's originally what drove me to start condensing things into manageable programs that could be brought in at different stages during their career. Also, I remember having a conversation with my mom after a couple of years into running my practice, and she said, "Lisa, even if you had existed when you were dancing, I wouldn't have been able to afford to take you to you." So a driver for me has always been to make the information accessible and affordable. In Sydney, I had a very high socioeconomic bracket — everyone has private health cover, physio is very widely used preventatively as well as responsively. But as I've traveled, I've seen that so many different countries don't have a health system that actually supports preemptive training. So it's trying to get that preemptive training out of the clinic and into Pilates with Pilates instructors, into high-level dance teachers, into the studio so that they don't have to wait till somebody gets injured and then spend a fortune trying to learn this after the fact. So it was really trying to make sure that what I see as so simple is not being done globally at all in many, many studios. Trying to get that out as much as possible.

[07:35] Jennifer Milner: That makes a lot of sense. And in terms of the biggest recurring themes — you covered some of this already, but could you go into a little bit more depth about what the big recurring themes are that you see in working with hypermobile dancers?

[07:52] Lisa Howell: Yeah. Initially, 20 years ago when I started practicing, we saw so many foot and ankle injuries, and that was by far the biggest thing that I saw, which is why I did the Perfect Pointe book and the Advanced Foot Control. A lot of my early work was about foot control. What I noticed is that as the studios around us learned this work and started integrating it, we had far fewer issues in this area. But in the last especially 5 to 10 years, with the rise of social media — Instagram, YouTube, Facebook — we're seeing a huge amount more hip injuries and back injuries, especially in the hypermobile kids.
[08:32] There is this idolization of extreme mobility, and my real concern is that some of these students, who often have an undiagnosed hypermobility disorder of some kind, are being used as the little show ponies in the advertising for studios. The kids don't feel it yet, so everyone thinks it's okay, including their parents and including some of the teachers. But seeing those kids long term, and also seeing the kids who aren't hypermobile trying to copy the kids with excessive mobility and trying to push themselves into things in their bedrooms, in their lounge rooms, when they're fooling around in the playground — this is really concerning me.
[09:14] So the more information that we can get about the differences in body types and what's appropriate at certain points of training, I think the better. Because we're seeing injuries in 11 and 12-year-olds which we only used to see in professional classical dancers or contortionists in their 20s or late teens. And trying to rehab an 11-year-old with a labral tear is really, really hard, because they just don't have the body awareness or the mastery of their body to do the detailed rehab that is required.

[09:47] Jennifer Milner: Wow. And like you were alluding to, you wonder how that person is going to feel 10 years from now, 20 years from now.

[09:54] Lisa Howell: Yeah, 40 years from now — think about 60. If they're having their first arthroscopy and their first resurfacing at 14, where are they going to be by the time they're 45?

[10:06] Jennifer Milner: Right.

[10:06] Lisa Howell: So this is a massive concern, and from the surgeon's point of view, they don't have data on what happens in this age group because it's happened so quickly. A lot of them are doing procedures on adolescents who haven't even gone through puberty yet that they would normally be doing on adults — it's a very big difference. A lot of them are in a "we'll try this and see what goes" mindset, but there's no history of it. So I think it's a very serious issue, and a lot of people don't realize how dire it is if they're not seeing the long-term injury side of it.

[10:41] Jennifer Milner: Right. We did an episode with Dr. Wells — he's a hip preservationist, Dr. Joel Wells — which was really great because I totally agree with everything that you're saying. And surgeons understandably are going to be optimistic about the outcome of the surgery, and maybe it is going to be a great outcome. But what if it's not? And when they're that young, even if they have a great outcome, what's the long range?

[11:09] Lisa Howell: What if you've got 10 to 15 years on each partial one?

[11:13] Jennifer Milner: Right.

[11:14] Lisa Howell: If you have your first at 45, then you've got a couple of revisions into your later years. If you're having your first at 13, you're running out of options for revision by the time you're 50. And hopefully the tech will be better by then, but it's not a great time to start broaching the hip capsule because once you go in, it's never the same again afterwards.

[11:35] Jennifer Milner: Right.

[11:36] Lisa Howell: And I think also the kids seem to have this mentality — oh well, if something happens, I'll just have an operation and it will be fine — which I think is a very scary attitude to have in preteens.

[11:49] Jennifer Milner: Yes, very much so.

[11:53] Lisa Howell: And no, that was exactly what he was saying. He was saying if you start to go into the hip and they're 13 and 14, where do you go from there? And it seems with this group of dancers, with this generation, like you said, it's happened so fast. We have no data behind it to say, hey, here's what's going to happen in 10 years if your first hip replacement is when you're 15. And so we don't have anything to help put the brakes on it yet at the studio level. I think that's starting to change. I'm wondering if you're seeing that too, but I am seeing it start to slow down some — teachers at the more regional level wanting to bring the dance science into the classrooms, as evidenced by the fact that people are coming to your workshops.

[12:45] Lisa Howell: I have a feeling that it's going like this.

[12:48] Jennifer Milner: Okay.

[12:49] Lisa Howell: So the good side is getting great. I always introduce my workshops by saying, look, I am already preaching to the converted. The teachers who come to the workshops are the ones who are already trying to do it safely. They're the ones who've already looked at and studied anatomy. They're trying to find ways of doing it better. The ones who need it most are not there. So it's a divergence, I think — the great teachers are getting greater and getting far more education behind them. But unfortunately, parents don't know to ask their dance teacher what their qualifications are and what their continuing education process is.
[13:28] Even in my own family, I asked my brother whether the dance teacher that my beautiful little niece was going to had any qualifications, and he said, "Oh, I'm sure she does, she's got a dance school." I said, "You could own a dance school." And he was like, "I never thought to ask if she has qualifications. It's her business, so surely she's qualified to do what she's saying she's doing." And I realized — he's a scientist, his wife is an accountant and a lawyer. They wouldn't dream of doing something they're not qualified to do. Yet because there is no restriction on opening a dance school, your local 17-year-old can decide to start running classes with zero training. So I think this is something that we need to educate parents on: how are you choosing the school that you are trusting with your child? How are you going through that process? Because they don't understand the risks and they don't understand that there are a lot of very unskilled people doing what is a highly, highly technical and extremely important role. A lot of the education needs to be focused at the parents so they can screen where they're even taking their kid, because they'll often just take them to the closest one that fits in with the schedule. Without realizing the potential dangers.

[14:43] Jennifer Milner: Or like you said, the child is looking on social media and sees these people doing things and thinks, oh, I want to be able to do that, and if I go to that school, then I will be able to do that. And I agree with you — educating the parents is critically important so that they know. Yeah, definitely.

Lisa Howell: Yeah.

[14:56] Jennifer Milner: Do you have a go-to shortlist of concepts to tackle in most hypermobile dancers? For example, proprioception, strength building, things like that.

[15:16] Lisa Howell: Yeah. The first thing — it depends on the student. I treat human beings, not human bodies, is usually what I say. So it depends on what that person needs. One of the things that I actually focus on first is creating some taping techniques or offloading strategies to show that person what it's going to be like when they have some stability.
[15:36] So one example I had was an excessively hypermobile 14-year-old who came to see me. Her dad's best friend's family I had seen. He said, "You must take her to see Lisa." She had been to a sports physician who told her she was excessively hypermobile, she was going to be in pain for the rest of her life, and she shouldn't do any exercise.

[15:58] Jennifer Milner: Oh no.

[16:00] Lisa Howell: At that stage, I quelled myself, walked out, threw a tantrum, walked back into the room. Let's start again. But basically, she had been in pain for 18 months everywhere. She was having headaches, neck pain, her shoulders were dislocating, knee pain, back pain, pelvic pain, and she had recurrent stress fractures in her feet. And I thought, what is the best thing that I can do for you right now? I used dynamic tape a lot, and I dynamic taped her with about 6 different techniques to basically suspend her body. And she just looked at me and there were little tears in her eyes. She said, "I don't have any pain." I said, "Darling, that's what you're going to feel like when we can get you stable." And she was crying, her mum was crying, everyone was crying. But she said, "I thought I was going to be in pain forever because that's what the specialist told me." And I said, "You need to feel what it's going to be like when you don't have it so that you can feel that this is achievable. The work is slow and laborious and boring, telling you that now, but if you can experience what it's like when all of your superficial muscles are not working so damn hard, then you've got an insight into it."
[17:10] And I often use those taping strategies to help suspend them in the right position as we learn how to stabilize underneath. So the first thing I do is offloading and trying to reduce their pain levels. If they are in pain, they are not going to be able to find the deep stabilizers. Then we work to create first conscious, but then building towards subconscious stability in the joints. And stability is not strength. We need to get appropriate timing. It's a very detailed process, but trying to create the muscles that are closest to the joints to become basically dynamic ligaments, because their ligaments aren't able to do that job. And then we aim to look at the reasons driving their poor patterns. By examining their day-to-day life, we can often pull out certain things that they do during the day that are setting them back. For me, I worked out my worst position was actually brushing my teeth — I'd hyperextend one knee, lock into one hip and brush my teeth. So by having the taping on, it also gives them a little bit more awareness of when they're coming out of their positions and brings them back in.
[18:20] But our ultimate aim is to have them moving with control rather than bracing in one position. And I think this is where a lot of people attempt stability exercises but they're actually overtraining the already overused global muscles rather than finding deep dynamic subconscious control around the joints.
[18:33] The beautiful thing was — within 6 weeks she was pain-free. She walked in and I said, how are you going? And she said, I have no pain. She had been given basically a life sentence from the sports physician. So the mom was just beside herself, and she actually burst into tears. She said, "This is the first time I've seen my daughter smile in 18 months."

[19:03] Jennifer Milner: But don't you find that when you tell them upfront — this is going to be tedious and boring — just so they know what to expect and they know the parameters? I do have a lot of hypermobile clients, and I do a lot of the tucks and tilts that you do at the start of the sessions, just deep pelvic spinal stabilizers, and they will say, "I feel nothing," and I say, "Good." They'll do it every day for 2 weeks and I'll say, "Let's check back in on that," and they're like, "Oh, my back doesn't bother me anymore." Is there a correlation there? It takes them a while to see that the boring work sometimes equals nothing — no pain. And it's the absence of something that says that it's actually working.

[19:47] Lisa Howell: 100%. And this is something — it's hilarious in the workshops because it always comes up, a teacher going, "Oh, I'm not sure I'm doing it right, I'm not feeling anything." And I say, if you are creating that movement and you're not feeling it, you're using the right thing. It's such a foreign concept for most dancers especially, because we've been taught that we have to work hard. If you are generating the correct movement with no activity on the surface, then we're actually accessing some of those deeper layers. This is the mastery component — you will get awareness of those eventually. But in the beginning, a lot of people feel like they're doing nothing. Understanding — I do a lot of explanation of the anatomy behind it, what they will and won't feel, to try and normalize that. But it's often such a different style of training than they're used to. So there's less feedback. When you've got a super floppy joint, if you're not at the end of it, you're not going to feel anything. So I think that's a really important thing for people to realize. If you're not feeling it, it's probably a good sign.

[20:55] Jennifer Milner: Yes, absolutely. And "no pain, no gain" tends to be something that dancers are kind of used to, especially once they've gone on pointe and things like that. I love the way that you approach that. When I attended your workshop a couple of years ago and went through those exercises, it was eye-opening to me even as a mid-adult — to realize that you could do the same motion but using different muscles. That was really fascinating.

Lisa Howell: Yeah.

[21:24] Jennifer Milner: So, well, good. You've gone into dance studios all over the world — what are one or two takeaways that you wish every dance teacher knew about working with hypermobile dancers?

[21:39] Lisa Howell: Yeah. I think one of the biggest ones is how changeable we are. So watching fatigue levels on dancers is super, super important, especially when they're hypermobile. You may find that one piece of choreography or one exercise, if they're fresh in the morning, they're totally fine. If they are at the end of a long Saturday or a long competition day or a long season, they're not going to have that same performance. As we get tired, our endurance disappears. So even something that at one point in the day they can do extremely well, they may start to fail at. So looking at fatigue levels of both training load, time of day, but also their nutritional profile, their sleep patterns, their gut biome — all of those other things are hugely important to make sure that they're actually being able to sustain their energy. Because I find when they get tired is when they get sloppy. When they get sloppy is when they start going into that risk of injury. So just because they can do it once doesn't mean they can do it all the time.
[22:43] The other one that I bring up — and everyone is so surprised but then they understand straight away — is checking to see whether your dancers have any abdominal pain. This can be period pain, it can be any gastrointestinal discomfort, either acutely because they got food poisoning, or whether they have any allergies or things like that, or whether they just have an appalling diet, which some do. If you have any abdominal pain or back pain, it will actually switch off the deep stabilizers that you need. So if they are just about to get their period and they've got really deep cramping or a lot of pain, those stabilizers are not going to kick in as much. It's not a good time to be trying to crank an arabesque or bust out 6 turns. And once the dancers understand this, they're a bit more gentle on themselves — because if they can normally do 6 and suddenly they can't, they beat themselves up. But if you're not actually in an appropriate stabilizing state, there is no way you're going to be able to bust out the turns that you normally do.
[23:47] So especially if we're going into any extension-based positions — whether it's an arabesque, whether it's a layback in jazz, whether it's a pressage position in a contemporary piece — if they've currently got abdominal pain, their deep stabilizers are not going to be kicking in like they normally do, and they're at a higher risk of injury.
[24:07] This is also super important for physios to understand. I had a couple of male physios in one of the courses in Australia, and we went through the risk factors for not having an optimal stabilizing core. We had one woman in the room who had 17 risk factors. We had one physio who had zero, and he had this amazing realization. He said, "Oh my goodness, I just thought people weren't doing the work. They weren't getting stronger, or they'd keep getting set back, and I just assumed they weren't doing their exercises. I totally did not think of how set up the system is to even have that training, and the fact that a lot of women get scheduled to zero every single month."
[24:50] Whereas a lot of males, if they are not hypermobile, they have never had any issues in their gut, they crawled well when they were young, they've had a very physically active lifestyle, they don't spend much time sitting — their core is going to naturally spontaneously fire and any training they do will build on top of itself. A huge number of people have a dysfunctional system from very early on, and then it's being reset to zero or negatives every month. So we have to understand that some people are more at risk and the same training won't work the same for all people.

[25:26] Jennifer Milner: Can you just elaborate slightly on when you're talking about each month going back to zero? There's going to be a whole range of people listening to this, and that's such a great point and really important concept.

[25:47] Lisa Howell: So if you have either cramping, discomfort, or strong pain with your menstrual cycle — a lot of people have already associated it that their back gets sore at that time of the month, and it's not necessarily that there's something going wrong in your back, but often the pain in the abdomen will switch off all of the deep back stabilizers. Often the pelvic floor is not as responsive. You may even get some cramping. You may find that you get a stitch more often because the diaphragm is trying to stabilize. So if every month your deep stabilizers are getting wiped out, if you don't know how to specifically retrain them — and these are those very, very tiny little baby exercises — we need to specifically attend to them to get them back online. If you don't know how to do that, or if you miss doing that, then when you go back to your normal activities you won't have the pre-stabilization of all these deep muscles that really help support your spine, and the big muscles will tend to grip on. That's even for a normal person, let alone somebody who has a super hypermobile back.
[26:58] The more hypermobile you are, the more we need very detailed control of the deep back muscles to actually help create that stability through the spine. If somebody is very stiff and has really tight ligaments, they can sit unsupported without even thinking about it. Anyone who has any degree of hypermobility in their spine will usually hate sitting unsupported because it's a very conscious process to try and hold position. And if you're not doing it exactly right, your big back muscles will get fatigued very quickly. So it is a big difference between people who have tightly bound ligaments and people who have sloppy ligaments in their spine. Does that explain it?

[27:37] Jennifer Milner: Yes. Yes, thank you. That's very, very helpful.

[27:41] Lisa Howell: Yeah. So the biggest thing is whenever that pain comes — yes, we need to deal with the pain. Is there anything that we can do with that? I personally used to get ridiculous period pain, and traditional Chinese medicine acupuncture resolved a lot of it. So is there something else that we can look at to help reduce the pain that you're having? But also, every time you have that pain, we have to go back to the drawing board and reprogram before we start doing your normal higher-level stability work or dancing.

[28:14] Jennifer Milner: That makes sense. And speaking of working with dancers in the therapist setting — we've talked about you reaching out to studios and working with them on that level, but you've spent a long time working one-on-one with dancers in the therapy setting.

[28:30] Lisa Howell: Yes.

[28:31] Jennifer Milner: And they are all so grateful to you for that. But what are some of the unique challenges that face a therapist who is trying to work with a hypermobile dancer, or what are the challenges facing a hypermobile dancer who's really just trying to get back into the studio?

[28:47] Lisa Howell: Yeah, that's a very two-sided question. I am now so appreciative of the amount of pain that I had and my hypermobility, because it's taught me to be so much more sympathetic, empathetic, and patient when working with this. I see sometimes, if there are therapists who are not hypermobile themselves, they really struggle to understand the complexity and the subtlety that is needed because they've never had to do that themselves. So I think there's that issue.
[29:17] From the client side, I think the hardest thing for them is that it is a very detailed and laborious process. I've gotten better and better at doing it, so now I have a few more hacks. The way I get people out of pain now is about 10 times faster than how I got myself out, which was a very long, slow process because nobody was teaching me and I had to work it out for myself. I've now got ways of making it a little bit more subconscious, because also when you're dealing with very young students or people who are not aware of their body, it becomes much harder. So I think having the patience to go through the layers that are needed is super important.
But one thing I think is really interesting is that often people who are super hypermobile have kind of merged it with their identity as a dancer. All the people who dance with them say, "Oh yeah, they've got an amazing back, it's so flexy." And so often if we're trying to back them away from their extreme injurious positions, they have a bit of an identity crisis, because it's almost like, well, who am I without my amazing back? And it's not that they're not going to have an amazing back long term — I am not against extreme mobility. I am about doing it safely. But often they really struggle. They may be super attentive in the clinic and do everything right, and then you catch them on Instagram cranking their leg up and whacking into a backbend.
[30:48] We need to spend a lot of time with them looking at the identity that they've created of themselves as a dancer and what they associate with their kind of superpowers — the things that they're great at. If you're trying to take away the thing that has always set them apart, there's going to be a dissonance there. So that's something that we have to approach and build back over time, because if they have amazing range, we want them to be able to use their amazing range, but we don't want them hinging into it and getting recurrent stress fractures in their spine. And I don't think a lot of people think about this when they're wondering why the client won't be patient or won't progress. It's often the stuff that they're doing outside. They're trying to maintain their persona as a dancer, and they're not wanting to give up that special thing that they've always had.

[31:37] Jennifer Milner: And it is partly compartmentalizing. As you had mentioned earlier, you hyperextend when you're standing to brush your teeth. And dancers will do everything perfectly for me — they will never lock their knee and they will do their single leg work beautifully. And then their mom comes in to pick them up, and I'll stand and talk with her, and 60 seconds later I'll look over and they're slumped and their legs are locked. In certain settings they have the correct posture, but they compartmentalize it. So when they're working with you, they're going to say, "I have that lumbar stress fracture, I'm going to do all these things perfectly," and then they're going to leave and go, "I've done my exercises, so now I can go do the things that my teacher wants me to do" — or that will keep them in the front row doing the scorpion while everybody else does fancy stuff around them. So yes, helping them have it permeate their whole life and also seeing that that's not all that they are — yes, I think really important.

[31:41] Lisa Howell: 100%.

[32:43] Jennifer Milner: Well, so looking at the young hypermobile dancer — your Perfect Pointe book I think should be required reading for every dance teacher and every dancer who wants to go on pointe. I hand it out by the dozens, and every time I go in and speak to a different dance studio, I say, "Now get this book, all the teachers should be using this." But hypermobility has its own issues obviously with going on pointe. So do you have advice for the young hypermobile dancer who really wants that first pair of pointe shoes?

[33:14] Lisa Howell: Yeah. The stages that we go through in the book — the first one is looking at range. Often they have no issues with the range. However, building the fine control is something, and the deep stability is something that they usually struggle with, because also the makeup of their tissues and even their muscular structure — sometimes they actually don't have the same range of muscle fibers available to be used as some of the others. So they will find the strengthening takes a little bit longer. We need to be very, very patient and make sure that they are listening to the people who say they are not yet ready, even if they think that they are ready. If your dance teacher and your therapist are saying "not quite yet," please don't go and grab your friend's pointe shoes and try them, because that often happens.
[34:00] And then once they do get cleared and they've done all the work and they get on pointe, the biggest thing is to not stop all of that deep conditioning. The thing that comes up most for them is pain at the back of the ankle — a posterior impingement. If they're sinking into their range, they'll often get a compression of the soft tissues at the back of the ankle. And this does not get better by working into it. It won't get better by continuing to press into it. Some of them think, I'll just stretch it by pressing into it more. If something's getting squashed and you squash it more, it gets more inflamed, takes up more space, and will get more squashed. So the big one for them is watching out for pain at the back of the ankle and reporting it to their teacher and/or their therapist as quickly as possible, because if left unchecked, it can become a problem long term. So I'd definitely be flagging that one to keep an eye on when they start and as they get older and attempt more and more challenging things on pointe.

[35:03] Jennifer Milner: Absolutely. And also for them to know that they should never stop their foot strengthening exercises.

[35:11] Lisa Howell: Yeah.

[35:12] Jennifer Milner: And their ankle strengthening exercises.

[35:12] Lisa Howell: And they will evolve and get more complex.

[35:14] Jennifer Milner: Absolutely.

[35:17] Lisa Howell: It's interesting because some of them do so well to actually get their sign-off, and then they just totally stop doing them.

[35:23] Jennifer Milner: Right, right.

[35:24] Lisa Howell: Because I wouldn't see them every week — I'd see them 6 months later and they would have done nothing and they'd be back to before. I said, "Honey, you have to keep going with these so that you are continually reinforcing those good patterns." So it is very, very important that they continue with all of their little itty-bitty baby foot stuff and are conditioning to the level that they need to support the dancing at the level they're doing. So the exercises that were fine when they were 11 are not going to be fine when they're 16 and dancing double the amount of hours each week. We need to make sure that their conditioning program evolves as their training does.

[36:01] Jennifer Milner: Absolutely.

[36:03] Lisa Howell: Yeah.

[36:04] Jennifer Milner: And what advice would you give to students and their parents who have been put on pointe — and we know this happens sometimes — they're put on pointe at 8 or something. I know I've spoken with teachers who then the student comes to their studio and they say, "I'm sorry, but we are going to actually hold off. You're too young." And of course the child wants the pointe shoes, and the parents don't necessarily know. So it kind of comes back to what we were talking about before. But do you have any specific suggestions when it comes to pointe work and parents and how to navigate that with their child?

[36:42] Lisa Howell: 100%. With the Perfect Pointe System and my whole process of pre-pointe assessment, I say if you've got that situation, it's really good to get the parent in the room and go through the assessment so they can see where they are passing and failing. Having them actually in the room is super important. You can give them a report afterwards — parents don't read anything — but having them in the room and seeing their child unable to do 8 rises, that's kind of important.
[37:10] I do also have a very practical suggestion for if they are in pointe shoes and a teacher thinks this kid shouldn't be in them, but this is going to cause World War III if we take them off: in my Beginner Pointe program, we have a preparatory exercises stage where they're in the shoes but they're not on the shoes. So it's all about building stability. There's a lot of standing flat balance exercises. They're doing seated rises, they're doing tendus in the shoe. I've crafted a stage of exercises where if they are in shoes and they're not quite ready to be doing classwork, it will highlight their weaknesses and help them build the required strength to actually do the classwork. So it's a nice kind of in-between stage, because I've talked to many teachers who have this situation. They're like, "This kid has been working so hard, I know she's not ready, but she's getting really depressed about it, and the parents want us to put her up, and I kind of want to keep her with this group."
[38:08] So this preparatory exercises stage is really handy because even when anyone gets their first shoes, they should go through it before they do their classwork. But it's a great way to kind of hold them — they're still in their shoes, but they're actually being shown how unprepared they are for the next stage, and it will help stall them a little while you build the strength for them to be actually able to do classwork safely.

[38:35] Jennifer Milner: And I think the assessment is such an important tool because parents — so much of ballet is subjective. You know, that girl is better than this girl, and it's so hard to put your finger on why. But to give a parent a checklist and say, if your child meets these, we can go on pointe, and if not, we can't — they understand that, they can help explain that to the child, and everybody comes out of it a little bit happier. And then they have measurable goals that they can try to reach.

[39:02] Lisa Howell: Yeah, that's fabulous. And especially if it's built in during the couple of years before it even happens — so it's harder when you inherit somebody from another studio. But if you have it within your own studio and you're building them up, it can start 2 years before. They know what the requirements are to hit before they go on pointe. So it's not that you like little Sophie better than you like little Charlotte. Or if you have guys who are wanting to go on pointe, they have exactly the same requirements that they have to check off. So it's not playing favorites, and it's a really nice way of honing in on the elements that are needed. It really helps support all of their other training as well.
[39:41] I'm actually planning to redo, refilm, and reorganize the entire pointe training work because we've revised it repeatedly over the last 15 years. Talking with a lot of teachers and looking at how things are implemented in studios, and also understanding that the kids I work with in Sydney are often very well trained — they've got amazing teachers who are already integrating a lot of the work. I've seen in other areas that some of what I see as the most simple things just aren't even being done. So breaking it apart even a little bit more to allow it to be built into at least a year of training before they're even thinking of starting on pointe, in a very easy-to-access way.
[40:30] There's a studio in Melbourne, and she's brilliant. She had had a 1-year program. She now has a 2-year program. She sends a PDF out to all of the parents and organizes a meeting for them to come in. They get a hard copy and a soft copy of her document, which explains the process they are going to go through if they're going to go on pointe, the cost of pointe shoes, the requirement for extra training. "This is what's involved. If you want to be a part of it, great. If you don't want this as part of your training, let us know now." And she said her compliance has been amazing and her kids are gorgeous because they've been working on it for 2 years before they even had their first official pointe assessment.
[41:07] So I think it's really important for the studio to be integrating it into their processes and building communication with the parents so that they know why there's so much more work being done on this and they have the big picture view. Because most parents haven't done it themselves — they go, "Oh, little Sophie's friend goes to another school and they just put them up. Why is this even necessary?" And the parents who really care will be absolutely delighted that you are jumping through hoops to make sure they are safe.
[41:42] However, it is absolutely gobsmacking to me that you will have some parents — the therapist is saying this child is not strong enough for pointe, the teacher is saying you're not strong enough for pointe — and they remove the student and take them to another studio where they're allowed on pointe. I see this as very dangerous parenting. I will always stand by my guns. Studio owners, unfortunately, if the parent is willing to put their child at risk in that way after they've been given all the information, we also have to go — this is now not my problem. If they are making that decision against the advice of two professionals, you kind of have to let them go and wish them well. It's something that the ones who care struggle so much with, because they know the long-term effect of it and they know how dangerous it can be. But if that parent is going to make that decision for their child, we have to love them and let them go, unfortunately.

[42:45] Jennifer Milner: Right. Which is hard, but there's a point at which you can't be responsible. You've given the information and you do the best that you can, and they'll accept it or they won't.

[42:53] Lisa Howell: And you will either be super grateful for it or push back.

[43:01] Jennifer Milner: Right, right.

[43:04] Lisa Howell: And I think there's a very big difference between the parents who have no information making that decision versus when the information is there and they're choosing to ignore it — that is now on them.

Jennifer Milner: Right.

Lisa Howell: Yeah.

Jennifer Milner: Yeah.

[43:14] Lisa Howell: And super hard, but I've had to learn to do this.

[43:18] Jennifer Milner: Yeah, to just let go. Well, I've told dancers so many times that no one has regretted waiting to go on pointe. They may regret not getting to do that year's competition on pointe as a 10-year-old, but as a professional dancer, no one has regretted waiting a year to go on pointe. I had a friend who was a professional dancer. She danced with Hubbard Street, and so she was a jazz dancer. She got a part with a show that did pointe work. She went on pointe when she was 25, and it took her a week because she already had solid technique and solid strength, and she was able to go on pointe and she looked fantastic. And the difference between putting a 13-year-old on pointe who's had that much time with great training and technique versus putting a 10-year-old on pointe can be quite significant.

[44:07] Lisa Howell: And they'll just progress faster once they go on. The thing I bring up — if I had a kid who just looks like a principal dancer, this one's actually going to go the distance, I would pull them aside and say, "Honey, I'm going to be even harder on you than I am on your friends. You want to be a principal dancer? Great, you've got all the goods for it. I'm going to keep you off 6 months longer than any one of your friends. Why? Because you're going to be on pointe for the next 30 years. That kid next to you is going to be on pointe maximum 2 years. They're going to stop by the time they're 14. However, you, my darling, are super talented. I do believe in you, and I do think you can go the whole way. 6 months now is probably going to add about 10 years to the rest of your career. Do you think that's a good trade-off?"
[44:59] And when you explain it like that, the parents are like, thank you so much. Some of them not so much, but most of them go, wow, that's a totally different way of looking at it. I'm not going to put you up because you are so good — I'm going to make sure that you have every single thing ticked off. If I've got a recreational kid who is going to do it for a couple of years, I'm going to be a little bit looser on them. But if I have that kid who I think is going to be the next Sylvie Guillem, I'm going to be way, way harder on you because you are doing more training, you're going to be doing it for longer, and I want you to stop dancing because you are tired of it, bored of it artistically, rather than because you can't because your feet are destroyed. And I find once they realize that they're special in being kept back, it's a totally different ballgame.

[45:52] Jennifer Milner: Absolutely. That's a fascinating way of looking at it. I love that.

[45:57] Lisa Howell: The more talented, the more strict I'm going to be on them.

[46:00] Jennifer Milner: Mm-hmm. Yes, for sure. Yeah, definitely. And it's hard because at that age, convincing them that we want to be looking at the long haul — I mean, we know that it's a particular challenge for kids that age for anything, whether it's learning to drive a car or playing any athletic sport.

[46:19] Lisa Howell: But this is where parents need to be parents.

[46:22] Jennifer Milner: Right.

[46:23] Lisa Howell: My mum was not my best friend, but she was an amazing parent.

[46:27] Jennifer Milner: Right.

[46:28] Lisa Howell: And I think some parents blur that line a little bit too much. I think parents need to take the responsibility to make the decisions until that child has the acumen to be able to predict long-term consequence, which usually doesn't happen until at least after 16. So we need to be able to make those decisions and guide them towards having involvement in the decisions themselves — yes — but at the end of the day, you actually need to parent. And if something is going to be dangerous for your child, if they wanted to sit there and light their hand on fire, would you let them? No, you wouldn't. So we actually need to encourage parents, and sometimes I have to put it that bluntly: "Actually, I know she wants to, but this is not what's best for her. Can you please stand up and be a parent and help me on this, rather than trying to appease your child and be their best friend?" And I usually have the kid out of the room when I have that conversation, but it's important for them to hear it, and I don't actually think some of them have that said to them enough.

[47:35] Jennifer Milner: Yes, that is the most perfect lead-in to our next topic. As you're saying about lighting your hand on fire, I'm so excited that this is our next planned question about stretching, because — again, getting back to the whole social media thing and people doing the oversplits — your book, where your dad did the illustrations — oh my gosh, that is such a fantastic book, everyone should have that book. And you teach workshops for teachers and physios on flexibility, and I would love to hear what you think about stretching for everybody, whether they're hypermobile, hypomobile, or a mix of both in different joints. I feel like stretching is kind of the hot topic these days.

[48:25] Lisa Howell: Yeah. My flexibility course is not about stretching. It's about understanding flexibility and the multitude of factors that come into it. I very, very rarely — I can't think of any time in the last 5 years where I've given somebody a static stretch. So it's about understanding where flexibility comes from, why it's different in different people, the priority of restrictions that we're going through.
[48:54] First we have to respect bone on bone — if something is pressing bone on bone, I don't want to push into it. Then looking at the importance of the breath, because if you are not breathing, you won't actually have the appropriate mobility in your upper back, the relationship of your diaphragm and pelvic floor, or deep stabilization of your deep core. Most restrictions in flexibility actually come because they're hiding an instability or they're being overused due to something underneath not working quite so well. And then we look at neural restrictions, fascial restrictions, and muscular restrictions. But I very, very rarely give a muscle stretch. If it is a muscular issue, we're often looking at retraining that muscle so it's not being overused all the time. So it is extremely appropriate for hypermobile people.
[49:49] I think we need to be careful because some people say hypermobile people shouldn't stretch. You do need to understand your own body, and if you are doing an art form that requires mobility, you need to know how to be able to achieve what you want to achieve safely. Not stretching will actually make you feel much worse. However, building the stability and learning how to manage any restrictions that do pop up — and they may change, it may be neural one day, fascial the next — so you need to be able to read the differences between those and know super safe ways of modifying that feeling of resistance without overstretching your joints. So I think it's essential for anyone who's hypermobile or anyone who's not — it's the same process, but you're just not as much at risk of injury if you do it wrong.
[50:39] I think it's very important for people to realize that flexibility is not about stretching. And this is where the magic happens, because some people have been restricted for years. Even at this last workshop in Calgary, one of the ladies — she was halfway down her shins when we started; by the end of the day, palms flat, nose to her knees. And she said, "I haven't been here in decades." No stretching, no pain — and she woke up the next day feeling totally fine. She came in and said, "I thought I was going to be so sore this morning, but I'm totally fine." I said, "Yes, that's because we did it with respect for your body rather than pushing it to do something that it is so scared to do." So I think understanding the way your body puts the brakes on is extremely important in managing flexibility long term. But we definitely need to get away from the linking of flexibility and stretching.

[51:32] Jennifer Milner: Well, and it's so ingrained in the ballet world and the larger dance world too that when something gets tight, you stretch it. I have dancers come in to me and say, "I worked a lot yesterday, so my calves are really tight," and they'll start to get into a runner's stretch to release their calves. I'll say, "If your calves are tight, let's do some heel raises." They say, "No, no, they're tight." And I say, "I know, let's work them through a full range of motion." Training and reeducating them — just because something's tight, you're not necessarily going to go into that full range stretch and stand there and hold it. Actually working that muscle through a full range of motion, all the way down, all the way up, is going to be more effective. And once they see the results, like you said — that woman felt such a difference. But getting them to that point where they can see it and accept it and go, "Yes, what's next?" — that's the hard part.

[52:27] Lisa Howell: Yeah. But also looking at the multitude of different things — if they do have a fascial restriction, dealing with it as a muscular restriction isn't going to work. If they have a neural restriction and you're trying to stretch the muscle, it won't work. So the number of kids who go into a roll down or a forward bend and say, "Oh yeah, my hamstrings are just tight" — you ask them where it is and they indicate their calves. Honey, those aren't your hamstrings. If it's a neural or fascial restriction, it won't respond to your traditional stretches, and those traditional stretches will often make it worse. So we really need to be screening what that restriction is, how do we judge the difference between these types of restrictions, and what is the appropriate response when we feel it.
[53:14] They are amazing then at working themselves out because they actually have the understanding and the awareness to be able to unravel themselves no matter what they've done the day before — whether they have been lounging around on the sofa on a Sunday, or sitting in a bus, or at a competition doing some crazy things they don't normally do. Being able to assess their own body and go, "What does my body need now?" I think is one of the most important things we can give them as a dancer and as a human being, because whether or not they dance professionally, they're going to be a human and they're going to need that body. If they understand how their body works, I think that is one of the most amazing things we can give them.

[54:00] Jennifer Milner: Absolutely. And when you were talking about stretching and being able to find what it feels like neuromuscularly or fascially — your other book that I hand out a lot is the Front Splits Fast book. So many dancers will come to me and say, "I want to get my splits, what stretches can I do?" And I can say, "You can buy this book, and you have to do the things in this book and not look at it and go, there's no stretches, and put it aside." But when they work through those different release points like you talked about, and just troubleshooting all the different things it could be — they release their thorax and all of a sudden they drop deeper into their splits. And seeing those things again makes them believers. It's just changing the information that's handed out and the expectations that they have as a younger population.

[54:48] Lisa Howell: And if you think about it, the thing that's so exciting for me now is that the kids I worked with 15 years ago are in their late 20s, early 30s, and some of them are starting dance schools, and their knowledge is massive. One of them in particular who I worked with a lot — she has a beautiful little dance school. Her students are immaculate, and they do half the training of some of the other schools. They have way better technique, and she is sculpting them so beautifully. I sat and watched one of her classes and said, "Oh my God, your kids are gorgeous." And she said, "I just do everything that you taught me."
[55:28] And that, for me, is the most exciting thing — to see what happens the next generation when we do have people who have grown up with this. It's all they know, doing it well. That's going to be an amazing generation to step into. And that's why I say I think we're diverging — or the bell curve is getting bigger. The amazing ones are getting more amazing, and the ones who don't look at things are passing it on with zero education, and it's getting worse and worse, with a lot in the middle. So I'm trying to focus on the people who want to accelerate.
[56:10] You can lead a horse to water, you can't make it drink. If you have people who are wanting this information, passing on as much as humanly possible to this next generation — they are going to be the dance teachers, the Pilates instructors, the physios, the health professionals, the doctors, the architects of the next generation. The more that they have experienced it themselves, they are going to be the ones to actually change the industry long-term.

[56:36] Jennifer Milner: And their bodies will feel better in adulthood than the people who have been exposed to the other end, as you said. I think that's so true. And what advice would you give to young pre-professional hypermobile dancers?

[56:55] Lisa Howell: Learn about your body. It's one thing to learn about the human body — studying anatomy is great — but you have to learn the nuances of yours. For instance, I had my appendix taken out when I was 16. The pain that I ended up getting in my back was due to one band directly in line with my appendix scar and 2 levels of multifidus in my back being totally wiped out after that surgery. Everything else around was working totally fine, but because I had hypermobile ligaments and this one band wasn't firing, I had immense amounts of pain. What was needed for me was very different than what my sister needs, what my best friend needs.
[57:37] So learning the nuances of your own body — working with somebody like Jennifer, where they can come in and explore their body long-term, finding someone who you can work with closely, who is going to be patient and work through at the pace that you need to unravel your own body. If at all possible, doing one-on-one or small group work is so important. If a teacher is trying to deal with 25 people in a class, they cannot be that specific. I think we need to use the private lessons that people are having to look at re-educating their basic classical technique rather than just running their routine over and over again. And seeking out people who understand hypermobility — whether or not they're hypermobile themselves, there are some amazing clinicians who are great at dealing with it — but I find the ones who are hypermobile usually have a more in-depth view on just how intricate it is.
[58:38] But the biggest thing to keep in mind is: if you have been in pain, do not think you're going to be in pain forever. You just need to learn more. Because this is the most devastating thing for me to hear — that people have been told, "Well, you're hypermobile, you're going to be in pain." That is not correct. I am perfect living proof of it, from having years of extreme chronic back pain to being totally fine. So I think we need to be very, very careful with the messages.
[59:05] If you are a young dancer and you are hypermobile, it's harder. You need to learn more. But you will get so much smarter, so much more intelligent as a dancer, and have a much longer career by understanding the nuances of your own body — the nuances between your right hip and your left hip. They may be totally different hips. So learning your own body inside out, upside down is the most empowering thing.

[59:32] Jennifer Milner: Amen. Excellent. And that's true for dancers, non-dancers, everybody. 100% work with the body that you have and not the body that somebody else has.

[59:46] Lisa Howell: Or the body that's in an anatomy book.

[59:48] Jennifer Milner: Right.

[59:50] Lisa Howell: A lot of people's anatomy is different from what is put on those little plates in an anatomy book. When I was a student, we were doing anatomy and we'd often have different cadavers and different dissections, and I would make a point of going around and looking at the differences between them. Because they'd all had different histories, they'd all have had different lives, they're all different heights and weights and races and nationalities and everything. And it was fascinating — the differences even in their muscle attachment points, some were vastly different to others.

[59:56] Jennifer Milner: Right.

[1:00:17] Lisa Howell: To learn, we need to know that anatomy can be different. The version in the book is kind of an approximation and a summation of what it generally is, but it can be so different. So learning what works for you is the most important thing rather than having one generic program that works for everyone. Any program, I think, must involve some assessment and training and reassessment to actually check that you're working on the right things.

[1:00:45] Jennifer Milner: Sure. And for older hypermobile dancers who've been doing this for several years, what advice would you give them?

[1:00:53] Lisa Howell: Same deal. Keep learning. Just because it's been one way for the last 20 years doesn't mean it's going to be that way. And also don't let your ego get in the way — "No, no, I've reached this point of training, I must not go back." Going back to the drawing board is one of the most important things for everyone. And especially if you're one of those people who every month you get back to zero, or if you have gut issues — they may be affecting things way more than you think.
[1:01:24] Again, just learn your own body. Seek out people who can help you learn your own body, because doing it on your own is possible, but it's way slower and way more painful than finding somebody who's been doing it for years and will have 10 different techniques for facilitating each thing that you're missing. Hunt down somebody to work with and expect yourself to continue to improve. Your body is in a constant state of reformation. Give it different instructions, you get a different result.
[1:01:58] And the thing that just warms my heart so much is the number of teachers after the Level 1 training course who contact me 3, 6, 9 months later going, "Oh my goodness, thank you so much. I am so much better because I've been doing these two simple little things." It's different things for everyone, but: "I've actually been doing these and I feel like I did 10 years ago," or "I haven't had back pain, and I've had back pain for 12 years." So for me, it's just that constant state of learning, exploring more, understanding as much as we humanly can, and just being gentle on yourself. Not trying to achieve a certain level every day during the months — be aware that it'll wax and wane.

[1:02:43] Jennifer Milner: Very good. And in terms of switching gears just a little bit to future research — there's obviously a lot that we still would like to know, but is there any particular research that you're hoping to see happen in the next few years?

[1:03:00] Lisa Howell: Yeah. I think the great research that has been done — and there's been a huge amount of work on diagnosing different connective tissue disorders — is absolutely fabulous. However, I would love to see more work on the practical strategies that we use. There are a lot of very good clinicians in the world doing amazing things with retraining, but it's very hard to research that. The problem is the way most research is structured: taking a big group of people, giving them a technique, and expecting to see a positive response. And I think the hardest part is that most good clinicians will look at the individual, figure out what that person needs, structure their retraining around exactly that, and adjust it in real time if they're coping or not coping. So it's very hard to do great research around this topic.
[1:03:52] If 5 girls came in to Jennifer, all extremely hypermobile, does she do the same thing with all of them? Not at all. It's so customized. I brought this up at university. We were looking at research and I was getting a little bit frustrated, and my tutor asked if there were any questions. I said, "So you're taking 200 people with chronic nonspecific low back pain, you're giving them the same program, and you expect a positive response?" He said, "Well, yes." I said, "Even if they are all 36-year-old women, you could have one who's an Olympic athlete, one who's had 6 children, one who had Harrington rods put in when she was 12, one who is morbidly obese, and one who is on the spectrum and cannot concentrate on the task at hand. How are you going to give them all the same program? Give me those 6 individuals and I will give you 6 different ones." And he looked at me and said, "Lisa, you're going to make a great clinician. Don't do research." I think this is the thing — we need to learn how to research what the clinicians are doing. There is so much richness in what the clinicians are doing, but unfortunately the research is often being done by people who are just coming out of their degree, doing their master's, studying something with no practical experience, and they're not looking at the things that we know work. The research is not necessarily reflective of what experienced clinicians are doing in the studio or in the clinic.
I would also love to see more research on the relationship between gut biome, diet, dietary support, and hypermobility and connective tissue disorders. I think there's a massive area that is about to be uncovered, hopefully. I do think that's going to have a massive impact on how we perceive fascia, also on the effect of our internal organs, because most hypermobile people have their little lazy eye and they have occasional heart flutters and they have a sluggish digestive system. There are so many other things that happen when your connective tissue system is a bit insufficient, not quite as robust as it should be.
[1:06:08] And the other side of that is: okay, so we know that your fascia isn't been put together very well — looking at the research on the most optimal ways of training fascia for resilience rather than unraveling. I had a chat with Tom Myers, I went and did one of his courses, and I said, "All of the course was on unsticking things. What are your strategies for training it when it's insufficient?" And he just looked at me and said, "Lisa, that's your area." And I went, "But you're Mr. Fascia." He said, "Well, the clients that I deal with are all stiff as a board, so all of my work has been on unraveling them." Whereas those of us who work with dancers are often dealing with the complete opposite end of the spectrum. Sometimes, yes, they may need fascial unloading, but a huge amount of the time they actually need to be training their fascia to be more resilient. This is something that I haven't seen much research on. It's something that I think would be very, very powerful. And I think we need to focus the research on things that are going to change how people are treated rather than things that will just sit in a textbook.

[1:07:20] Jennifer Milner: Well, absolutely. That's really fabulous, because of course now fascia — we're understanding a lot more about it, but it wasn't that long ago that we thought fascia was very unimportant, and now we know that fascia is so important when it comes to chronic pain. That is such a huge area that 100% needs to be explored. So what is going to be next for you then, Lisa? Where are you going to go with your work? Because wherever you go, I will go there with you.

[1:07:52] Lisa Howell: I think the coolest thing — I closed my clinic last year, July last year, and for me that has now opened up a whole lot more potential. I have been hands-on with people for 20 years, and I had always structured the clinic as an R&D facility. I had 1-hour one-on-one, or an hour and a half or 2 hours one-on-one appointments, and I used it to research as much as humanly possible about what dancers needed. Now the focus is on getting that condensed into ways that people can understand.
[1:08:30] Something that I'm working on a lot is a series of injury management guides, which basically takes each common injury — say, plantar fascia pain, posterior impingement, Osgood-Schlatters, spinal stress fractures — and looks at what it actually is, why it usually happens, and enough detail so that we can understand the nuances, because it's never the same. There is no one program, but looking at how we need to assess somebody who has that thing going on, and possible rollouts, taping strategies, offloading techniques, and retraining so that it doesn't happen again.
[1:09:08] Especially with the hypermobility, I have a YouTube playlist called Hypermobility Hacks. I do want to do a lot more on those — they are practical hacks that I have learned myself to get around not having great ligaments.
[1:09:18] I am putting a huge amount of effort into the teacher training, running the teacher training workshops all around the world — everywhere from Norway to the US to Asia to Germany, Spain, wherever. But even more than that, from running those over the last 5 years, I've worked out it's one thing getting that information, it's another integrating it into the classroom. So I've now filmed every element of the original teacher training workshop, and I'm also creating class plans to help integrate that work at lots of different ages. How do you start to teach 10-year-olds about their turnout? How is this different to how you approach a class of 16-year-olds? If you have a student who's rolled over on their ankle, how do you deal with this in class? You've got a bunch of 8-year-olds coming up with Sever's disease — what things can we pull from the program that are completely appropriate for them? What information does the parent need?
[1:10:26] So really trying to unpack it and make it easy for teachers to use every day without them having to go and do a physio degree to understand it — digesting it down and packaging it up so that it's much easier to understand. That's kind of my big push over the next 12 to 18 months.

[1:10:47] Jennifer Milner: That is going to revolutionize dance training. Absolutely. I think that is going to be such a huge help on such a widespread level, so I'm really looking forward to that. Is there anything else that you wanted to say or add that we haven't covered?

[1:11:02] Lisa Howell: No, I just — first of all, thanks for inviting me to be on here, and thank you for the work that both of you are doing to raise the awareness of this, because it is such a massive, massive issue globally. I think the more of us who are out there educating and empowering and being in contact with different people — Linda, the work you're doing with health professionals to even expose them to the challenges that come when you're dealing with this — I think there's a huge number of medicos who do not understand hypermobility at all. That's why we're struggling with what some people are getting told when they go and see their health professional. So the work that you're doing to try and educate that sphere, I thank you so much for. And we're all trying to do as much as we can to raise awareness to help people live better, whatever field they're in. So I just want to thank you guys for everything you do.

[1:12:01] Jennifer Milner: Well, now I know where to find all of you, but for our listeners — where can we read your blog and buy your books and sign up for your workshops? Where can we find all of that?

[1:12:12] Lisa Howell: So theballetblog.com is my main website, and all of the workshops are on there, thousands of free articles, the video courses for any of the paid programs. We also have the hard copies available through Amazon now, so you can order them and get them in a couple of days rather than us holding stock in Australia and having to send it across the world. And then I have my YouTube channel — we're going through and trying to reorganize that at the moment and make it a whole lot easier to find everything. But just trying to get as much content out into the world. We also have Facebook and Instagram. So whatever channel you like to operate on, we have one of those. I don't do Snapchat — never got on that.

[1:13:01] Jennifer Milner: We're good.

[1:13:02] Lisa Howell: No TikTok just yet.

[1:13:05] Jennifer Milner: So whatever our favorite social media is, just look for The Ballet Blog.

[1:13:08] Lisa Howell: The Ballet Blog, yeah. But for YouTube — there is a Ballet Blog channel, but we're actually migrating it all to be under Lisa Howell. Managing 3 YouTube channels is a little bit time-consuming, so all of the YouTube stuff is going to be under Lisa Howell. But everything else, just look for The Ballet Blog. We also have Pinterest. We discovered with The Ballet Blog that a huge amount of people were sharing things themselves, so we decided to make a core channel to make it easy for people to find the information they want.

[1:13:41] Jennifer Milner: Super smart, that's really fabulous. Well, we are so grateful for you being here. You have been listening to Bendy Bodies with the Hypermobility MD. Today our guest has been Lisa Howell, physiotherapist. And that is it for today, but we have lots more great guests coming up, so stay tuned.