Longer careers for dancers

~ By Janet Lawrence ~

Patrick Lynch lies on an examining table, squirming in pain. Kunal Kalra, a doctor at the Harkness Center for Dance Injuries, has just plunged a 4-inch-long needle into Lynch’s swollen left quadriceps.

Moments before, Kalra had examined the partly-healed incisions on Lynch’s knee. The marks were caused by an operation Lynch, a professional dancer for the last 20 years, underwent 10 days earlier to repair a torn anterior cruciate ligament, or ACL. Today he has come to Harkness’ weekly Dance Clinic on East 18th Street for his first post-op visit.

Lynch’s surgeon, Dr. Donald Rose, who is the center’s director, and Kalra, an intern observing Dr. Rose, want to relieve the swelling in the thigh muscle above the incisions.

“Taking out the fluid will make a difference in the pain,” Kalra said. “We’re gonna have to drain the blood out.”

“That sounds like fun,” Lynch mutters as he lies on his back on the table. Then he laughs out loud.

Lynch stands 6-feet-4 inches, and has long legs and a barrel chest. His brown hair, blue eyes and quick wit were endowed by his Irish immigrant parents. When Lynch is not auditioning for or performing in operettas as a dancer and singer, he teaches yoga at Bikram NYC. He is 45 years old and still dancing. Or was before he snapped his ACL doing the limbo at a wedding.

Kalra probes the dancer’s thigh with the long needle. Lynch arches his back and grimaces as the intern draws back the plunger. The barrel remains empty.

Dr. Rose, the city’s premier ACL surgeon and a leading champion of dancer orthopedics, steps in to demonstrate as the intern looks on.

“Small prick,” Rose advises as he expertly inserts a larger syringe with a 60-ml barrel to hold the built-up fluid.

“What?” Lynch’s eyes widen in mock horror. This time, the vial fills immediately with bright red fluid. “Ohhh, it’s better,” Lynch says, relieved. Kalra nods.

Unlike a painter or a musician, who generally can produce paintings or compose music into old age, a dancer’s ability to create art depends almost entirely on keeping his or her body healthy and fit.

Until recently, dancers’ fitness was determined by their youth. Dance careers used to end around the ages of 30 or 35, if they were lucky. Dancers’ hips, knees and backs were worn out by strenuous overuse and dancing on too-hard floors. Injuries, often misdiagnosed or improperly cared for, also cut careers short.

But today, improved specialized care for dancers, more complete education and a holistic approach to dance training is helping dancers continue into their 40s and beyond.

EDUCATION AND TRAINING

In 1941, Nora Shattuck dropped out of high school in Ottawa to move to New York City where she joined the School of American Ballet. A year later, at age 17, she was accepted into the Ballets Russes. For six years, Shattuck toured with the itinerant company eight months a year, performing eight shows a week.

At the time, ballet dancers practiced a prescribed set of movements that originated from a centuries-long tradition of French ballet later refined in Russia. Exercises at the ballet barre remained relatively unchanged from those ballerinas had done centuries before, exercises developed to be aesthetically, rather than ergonomically, pleasing.

“We had no anatomy and no kinesiology,” Shattuck said of her dance training. “You didn’t learn much about your body.”

Although she was never injured herself, Shattuck saw numerous friends and colleagues drop out in their prime because of injuries. Shattuck, who was lucky enough to work with famed choreographers George Balanchine, Alwin Nikolais, and Martha Graham, said she envies dancers today who have greater opportunity to study dance at academic institutions where anatomy is part of the curriculum.

Dancers today know more about anatomy and the physiology of exercise than ever before because more of them are pursuing college degrees. About 5 percent of American university students obtained performing arts degrees in 2008, compared to 3 percent in 1970, according to the National Center for Education Statistics. And anatomy classes are a regular part of the curriculum for most university dance departments.

The Juilliard School requires all students in the Dance Division to take a six- credit anatomy course, which examines movement strategies to enhance stability, control and develop musculo-skeletal problem-solving skills applicable to dance. Irene Dowd, who teaches the course, explained that when dancers without anatomical awareness experience discomfort or pain, it can be difficult for them to know whether to push through it, change technique, or stop dancing entirely.

“Familiarity with anatomy makes dancers more likely to listen to their bodies,” Dowd said.

Medical practitioners agree—one recent study shows that 74 percent of dance specialists think that it is important for dancers to understand human anatomy to avoid injury and to know when to report injuries to medical professionals.

Alison Deleget, a Harkness clinician, said the dancers she sees who are aware of how their bodies work tend to have fewer or less severe injuries. These dancers are better able to manage overuse syndromes, such as heel, knee and back injuries.

Still, knowledge about the body would not increase dance longevity without a complementary change in dance training. Nowadays, dancers and teachers incorporate anatomical awareness into what they do in the dance studio. They are adjusting traditional dance positions to place less stress on the joints and build strength for specific dance shoes.

Shattuck said when she toured with the Ballets Russes, she moved from one classic ballet to another, switching from ballet shoes to character shoes without proper training. The muscles she had developed in pointe shoes did not translate to the strength necessary to dance in high-heeled character shoes.

“It’s a wonder we ever got out of this without killing ourselves,” she said.

In those days, ballet teachers used to tug their students’ feet into first position, so that their heels and toes were forced into a perfect, if unnatural, 180-degree turnout. This placed a great deal of torque on the knees. In the past decade, teachers have begun to teach turnout from the hip down, so that knees and feet are aligned, alleviating stress and preventing common knee injuries.

Another development in training is combining exercises from different movement traditions. Rather than learning only the dance vocabulary particular to one technique, like Graham, Horton, or Limon, now dancers cross-train. A modern dancer may complement 15 hours a week of dance classes and rehearsals with five hours of yoga or Pilates. These alternative movement practices are popular among dancers because they focus on proper alignment and strengthening, but lack the jumps and other rigorous movements that can lead to stress fractures and broken bones.

As a yoga teacher, Patrick Lynch is hyper-aware of his body. During his doctor’s visit he describes his aches and pains in detailed anatomical terms, mentioning “meniscus,” “tibia,” and “quadriceps,” at various moments.

“My yoga has made me in tune with what was happening in the body at the point of injury, surgery, and then recovery,” he says after his visit with Dr. Rose.

“I can put my faith in it.”

Lynch’s friend Catherine Thibault, 54, danced professionally in France for 15 years before moving to the United States to dance for Alwin Nikolais in the 1980s and ‘90s. She has retired from a performance career, but still takes ballet class every day and performs in a folk dance company—her life as a dancer is hardly over.

Thibault credits cross training as the thing that has allowed her to dance into her 50s.

“I stretched like any dancer would as a young girl, but 14 years ago I started doing Pilates,” she says. “That’s where you really improve preparation for the body to dance. Now I always do yoga after ballet class to relax my hips and knees and rebalance both sides of the body.”

IMPROVED CARE

Like most dancers, Thibault is no stranger to dance-related injuries and the doctors who treat them. Dancers have one of the highest rates of nonfatal on-the-job injury, as high as 97 percent according to one study by the Bureau of Labor Statistics. Thibault has broken four toes and, like Lynch, torn her ACL. In 1996, she broke her big toe and was disappointed by the care she received from dance specialists. She said her doctor, whose name she requested not be mentioned, had been running a dance clinic for a half dozen years but still misdiagnosed arthritis in her feet and legs and set her toe improperly. It is now crooked.

But dance medicine has improved dramatically since the 1990s and many injuries that were once career ending have become manageable. This past October, Thibault slipped as she pirouetted in a class at the Ballet Arts studio in New York and broke her right arm. She found herself being cared for by the very same dance specialist who had treated her 14 years before. This time, the doctor knew more about scar tissue and set her bone more efficiently than he had 14 years ago.

“The years of experience made him better,” she said. “Now they can help dancers heal faster.”

Thibault now plans to get back into the studio within two months of the injury— one that, years before, might have barred her from ballet because it demands full range of motion in both arms.

Wendy Whelan’s experience with scoliosis offers another example of how advancements in medical treatment have lengthened dancers’ careers . A principal dancer for New York City Ballet, Whelan still performs with the company at 43, an age that few professional ballet dancers reach as performers. (Notable exceptions include British prima ballerina Margot Fonteyn, who danced into her 50s.) As a girl, Whelan was diagnosed with scoliosis, a curvature in the spine. At the time, she was treated with stretching machines and plastic braces. Now, acupuncture and massage help Whelan manage the disease between performances.

The quality of care has improved as more doctors have entered the field. The Harkness Center, which has provided dancers of all ages with specialized care since 1989, is a teaching hospital. Over the years it has trained hundreds of residents about the unique orthopedic issues dancers face and published more than 25 research studies on dance-related injury in journals like American Journal of Sports Medicine and Journal of Dance Medicine and Science to reach thousands more doctors.

Since the 1980s, dance medicine also has expanded to include physical therapists and athletic trainers, in addition to orthopedic surgeons. Today it is common for companies like New York City Ballet or Alvin Ailey American Dance Theater to have dance athletic trainers as on-site consultants.

Physical therapists, or PTs as they’re known, work with dancers long after the surgeon has said “you’re O.K.,” and signed off. They help dancers recover from injuries and prevent future ones.

“Physical therapists are the heroes of the dance field,” says Lynn Garafola, Professor of Dance at Barnard College. “Now physical therapists really help people get through injuries that once would have been career ending.”

Physical therapists and trainers who specialize in dance are often former dancers. Like nearly all of the certified athletic trainers (ATCs) at Harkness, Megan Richardson, was a dancer before she became a trainer. She attended George Washington University on a dance scholarship and graduated with a Bachelor of Athletic Training and later earned a master’s in kinesiology at Indiana University.

On a practical level, ATCs’ familiarity with dance allows them to communicate better with dancers.

“We speak their language,” Richardson explained. And it’s not simply knowing basic dance terminology like releve or plie, but jargony, unofficial phrases that have never been written down.

In one consult at the Harkness Center, a doctor asked a 16-year-old girl what she was doing in her Graham technique class when she hurt her knee. The girl mumbled, “Tumble on down.”

Richardson, who accompanies the doctor on all consults, responded, “You mean, go down to the floor?”

The ATC twirled as she dropped her body to the floor. The girl nodded. Knowing this, helped Richardson and the physician diagnose the specific nature of the injury. Richardson recommended that while she healed, the girl modify her Graham floor exercises by doing them in a chair.

Harkness’ Alison Deleget recalled how chronic tendonitis in her left ankle caused by hours of ballet was treated without success for nearly a decade until, during college, she saw an athletic trainer who specialized in dance. Deleget was finally able to manage her injury after the ATC took her pointe shoes apart and spotted the problem. The revelation re-routed her into a career as a dance-specialized ATC.

As communication among doctors, PTs, ATCs and dancers has improved, dancers have started trusting medical professionals more.

A study published in 1994, found that just 20 percent of dance injuries were reported to doctors. Only 43 percent of dancers who did seek medical treatment would stop dancing to recuperate and follow through with physical therapy prescriptions. With the dawn of dance specialized trainers and PTs, Barnard’s Garafola said, dancers are much more likely to follow through with treatment.

Lynch walks into the Orthopaedic and Sports Physical Therapy Center on a Thursday in late October, three weeks after his surgery and one week after his post-op visit with Dr. Rose. Harkness patients like Lynch receive physical therapy at the center, located on the fourth floor of NYU Langone Medical Center’s Hospital for Joint Diseases. Lynch limps slightly, wearing shorts that reveal his muscle loss. Compared to his right calf muscle, which bulges like a balled fist under his skin, the flesh on Lynch’s injured leg is slack where the muscle has melted away.

First stop is an exam bed, where therapist Sally Donaubauer massages around the incisions on Lynch’s left thigh to prevent the scar tissue from adhering to surrounding muscles. Then he moves to the center of the room to do exercises designed to strengthen his quad. Lynch turns toward a mirror with an attached ballet barre to practice balance. Stepping with his injured leg onto a squishy foam square, he wobbles, then stabilizes. In the mirror, Lynch checks to see Donaubauer is not watching and then pulls his healthy leg into a ballet attitude and rounds his arms above his head, a classic ballet silhouette.

“I get bored easily,” he says as explanation.

Lynch may be bored, but he follows Donaubauer’s prescribed exercises carefully. He credits the speed of his recovery to Donaubauer’s exercises before and after the surgery—and his own willingness to listen to his doctors and PT.

During his massage, Donaubauer urged him not to push his body too much, because at six weeks the repair is at its most vulnerable.

Recalling that moment, Lynch said, “Having such a fast recovery, it’s having the intelligence to really hear that. I would have pushed myself. I would totally have gone back to class,” he says as he completes his reps.

“She’s a life-saver.”

Still, Lynch can’t resist pushing just a little. His eyes dart to the mirror to make sure Donaubauer isn’t watching and then he strikes another off-limits pose.

ACCESSIBILITY

Without the surgery Lynch would most likely have had to retire from his life as a professional performer, which for him was not an option. “I don’t want to give up dance,” he says. “I want to do it as long as I can.” Although 10 percent of dancers who experience torn ACLs can return to dance without surgery, Dr. Rose felt that Lynch’s age made surgery the best option.

Lynch is uninsured. So the operation’s $24,000 price tag—nearly his entire annual income—might have made that option out of the question. That figure does not include the additional tens of thousands of dollars in physical therapy costs that are so essential to recovery.

Lynch had the good luck to be referred by a friend to the Harkness Center. His income, around $30,000, qualified him for Charity Care. The NYU Langone Medical Center’s Hospital for Joint Diseases absorbed the cost of surgery and physical therapy, which should then be reimbursed by the state.

Physical therapists may be the lifesavers and the heroes for the dance world, but without access to these specialists the longevity of a dance career would remain unchanged. As medical insurance has been—and continues to be—unobtainable for most dancers, more dance specialists offer sliding scale fees and free clinics. Harkness’ Deleget says that the majority of dancers, those not employed by big companies, are functioning in an uninsured or underinsured state.

“Dancers for Paul Taylor, Alvin Ailey, or City Ballet are all insured through their companies and are well-compensated. But they are the minority of the dance population in New York,” Deleget said.

According to the Bureau of Labor Statistics, only 1,370 dancers were employed in the New York metropolitan area in 2009. The study acknowledges that the number does not include dancers between engagements or who make a living through another means entirely, like Lynch and Thibault. Still, the official number probably reflects the number of dancers employed by companies that can afford to provide health insurance. And that leaves thousands of others who are uncovered.

Now, those uncounted dancers in New York have more options in obtaining health care. The Actor’s Fund’s Al Hirschfeld free clinic, founded in 2003, offers subsidized health care services. Dancers must prove they earned at least $3,000 of income generated through dance to qualify for care.

Another invaluable resource is the Artists Health Insurance Resource Center. Created in 1998, it assists people in the arts to find affordable health care and coverage.

The Harkness Center, which offers a free orthopedic clinic and subsidized surgery remains one of the city’s most well known organizations committed to dance medicine. Unlike Al Hirschfeld, it waives an income requirement, because, as Deleget explained, most downtown modern dancers do not earn an income from dancing.

“If you say you’re a dancer, we believe you,” Harkness trainer Megan Richardson said.

Most Harkness patients earn more than $24,000, the cutoff to qualify for Medicaid in New York state, but not enough to afford private insurance. As of September, nearly one quarter of the 879 patients who visited the Center this year were uninsured. The majority of those with some kind of coverage were underinsured, or, covered only for catastrophic incidents like being hit by a bus and emergency room visits. The average deductible for dancers with this insurance is around $2,000, a hefty amount for a group whose income hovers in the low five-figure range.

“If they can’t afford us, we’re not doing any good,” Deleget said. “We want to subsidize dancers so they can get care and still make a living.”

Harkness Center considers it part of its mission to help dancers find financial assistance to pay for their care. The institution encourages New York residents to apply for Charity Care, or federally funded financial aid, through the NYU Center for Joint Diseases. The state reimburses the hospital for all incurred costs by Charity Care recipients. And for out-of-state dancers, Harkness offers the Special Assistance Fund. The Fund, supported by the LuEsther T. Mertz Advised Fund of the New York City Community Trust, covers “pretty much all costs” of surgery and physical therapy, according to Harkness administrator Leigh Heflin. And when all else fails, the Center offers a sliding fee scale for visits from $250 to $110.

An injury is difficult for any dancer to overcome, but the difficulties are acutely felt by dancers above 40. For young dancers, losing control of their bodies through injury can be dismaying, but they still have time to enter a new career. For older dancers, the thought of finding a new career can be disorienting.

“The visits can be emotional,” Richardson said. “This is their identity.” An identity that dancers intend to keep for as long as they can. Dancers ages 40 and above are clearing a new space for themselves in the world of dance. From 1991 to 2006, Nederlands Dans Theater III, a company for dancers over 40, proved that dancing was not the sole province of the young. It paved the way for other dance groups like PARADIGM. The New York-based company started by Gus Solomons, Jr. and Carmen de Lavallade is made up of dancers over 60. In non-performative settings even more older dancers can continue to practice their art. For example, the 92nd Street Y’s Dance for Life series offers Ballet for the Older Body to accommodate these dancers’ needs and limitations.

In describing Wendy Whelan’s value as a mature dancer, Barnard’s Garafola seemed to capture the importance of the entire population:

“There is a deep pleasure in her dancing. She’s happy, even joyous I would say, doing what she’s doing. And while her physicality is diminished, there is no question, there is not the same physical exuberance that one saw in her dancing 10 years ago, there is another quality that is deeply satisfying and rich.”

For Patrick Lynch, who, going into his sixth week post-op, is told by Dr. Rose he has made an above-average recovery, the experience of the injury has been transformative. It gave him a new level of caution as he has realized what dance means to him: “Dance is my life. I can’t live without it.”

Even so, he is realistic about what he can and cannot expect from his aging body. “At my age, I’m 45, it’s not like I want to go have some big solo career,” he says over coffee following his final check-up. What is comes down to, what these advancements in dance have given him, is the freedom to self-determine when and how he will see out his career. “I want to be able to do what I want to do with it. And I want to dance.”