Managing a dance injury: Do no H.A.R.M

In addition to being the founder and director of Greenstone Belly Dance, Siobhan is a Rehabilitative Exercise Specialist and Strength & Conditioning Coach. This blog post was originally written by Siobhan for her Safe Dance Column in the Middle Eastern Dance Association of New Zealand Newsletter. You can join MEDANZ to access their newsletters and find out more about MEDANZ here.  Photo by Theuns Verwoerd.

As dancers, you’re probably familiar with the acronym R.I.C.E.D for injury management (and if you’re not, you will be!). But injury and exercise science progresses every year, and there are now reasons to examine whether or not the R.I.C.E.D method is right for your injury, and to consider using the more up to date “No H.A.R.M” method. What do each of these entail? Read on to find out!

Managing A Dance Injury_ A Blog Post by Siobhan Camille of Greenstone Belly Dance.png

R.I.C.E.D (Or R.I.C.E.R) and what we know now

R is for Rest: Previous wisdom suggested that if we had an injury in a certain area, we should rest that area. Think of how bed rest used to be prescribed for back pain.

What we know now: Complete rest of an injured site can actually delay recovery time and make it much harder to regain strength when you do return to activity.[1][2] This doesn’t mean dancing on a foot with a stress fracture, mind you! But is aqua jogging or swimming an option that doesn’t cause pain? We recommend keeping injured areas active, but modifying the movement. There is almost always an option to keep moving, so consult a specialist if you’re not sure how.

I is for Ice: We used to advise that injury sites should be iced in 20 minute intervals, making sure that direct contact wasn’t made with the skin.

What we know now: Ice is great for stopping pain, but if you ice too frequently, or for more than 10 minutes at a time, you may actually increase swelling, and therefore pain. Ice is not likely to “burn” if it is in direct contact with the skin (it’s in the process of melting, not freezing), and icing through a towel may not provide enough cooling to dull the pain. If you want to help reduce your pain, you can apply ice directly on the skin for a maximum of 10 minutes every hour during the first 24-48 hours after injury. There doesn’t seem to be enough evidence to say that ice has an impact on healing,[3],[4],[5] but regardless of this, it is a cheap, safe way to deal with most types of pain. So don’t suffer if you’re hurting, get out the ice if you want it!

C is for Compression: It was common to advise bandaging an injury to prevent further swelling, bleeding or damage.

What we know now: We still recommend compression to an injured site to limit the amount of bleeding.[6] This applies to sprains and some bad bruises. However, just make sure your bandage isn’t so tight that it cuts off circulation! Moving as soon as you are able still applies. For lower limb injuries, for example, you can also walk (or even point and flex the toes) as soon as possible to use the calf muscle “pump” to help reduce swelling.[7]

E is for Elevation: We used to recommend elevating an injured site to help prevent gravity adding to any swelling.[8]

What we know now: We still recommend this – gravity can be a powerful thing! For best results, elevate the injured site above the heart.

D is for Diagnosis/R is for Referral: We used to recommend seeking a diagnosis and/or assistance from a medical professional for your injury.

What we know now: ….And we still do! Sometimes just knowing exactly what the problem is can help a lot with management (I’ve seen several cases where an individual has thought they’ve just sprained something, which has turned out to be a fracture – the two need to be handled quite differently!). I generally recommend seeing some sort of musculoskeletal specialist, such as a physiotherapist (especially in countries like Canada or New Zealand where physiotherapists undergo university-level training), rather than your home doctor or GP when it comes to sports or dance injuries.

So what now? Do no H.A.R.M: An update to our recommendations

The “Do no H.A.R.M” acronym was created to address some of the gaps missing in R.I.C.E.D, and provides important updates for us as we look after our bodies as dancers.

This means, in the 48-72 hours following an injury, there should be:

No Heat: Sometimes it can be tempting to take a warm bath or hot shower after hurting yourself at dance practice. However, if you heat up your injured site, you can increase blood flow to the area, thereby increasing swelling and pain.

No Alcohol: Alcohol also increases swelling and bleeding at injury sites which can delay healing. It can of course also inhibit perception of pain, so you may make your injury worse.[9]

No Re-injury: Sounds simple, right? But there is where you need to be careful regarding movement. Don’t put the injured area under too much stress; find how to keep it active safely, but don’t jump right back into everything you were doing at full force. It might be tempting to dance “just at half-effort” on your sprained ankle, but it’s not worth it if you want to recover well.

No Massage: Massage can also increase bleeding and swelling to an area by stimulating blood flow, thereby making pain worse. This applies mainly to injuries where swelling is present or possible, such as sprained ankles, fractures, etc. For something like low back pain? Probably not such an issue. (Refer to my last article on the tweaky low back to get some ideas on how to address this for dancers!).

A final note on swelling….

Swelling is not actually a bad thing when we are initially injured. When an injured site is swollen, this is an immune response from the body to start the healing process. It allows white blood cells to come along and clean up the injured area and clear away dead cells. However, this should generally only last for a few days. When we’re applying ice (not too frequently; see above again if you’re unsure) or avoiding heat, we’re not doing this to help with swelling, we’re doing it to help with the pain cycle. Because inflammation is actually helpful in the initial phases of injury,[10] we don’t recommend the use of anti-inflammatory medication (such as ibuprofen) in the first 48-72 hours of an injury.

After that, if swelling still persists, it can be wise to take a dose of ibuprofen for 2-3 days to knock the swelling on the head so it does not develop into chronic inflammation. Unlike the swelling that occurs right at the beginning of an injury, chronic inflammation is actually associated with slower healing. Bottom line: We need a bit of swelling when we’re first injured, but we don’t want to let it stick around too long!

[1] Buckwater & Grodzinsky (1999). Loading of healing bone, fibrous tissue, and muscle: implications for orthopaedic practice. https://www.ncbi.nlm.nih.gov/pubmed/10504356

[2] Bayer (2017). Early versus Delayed Rehabilitation after Acute Muscle Injury: https://www.nejm.org/doi/pdf/10.1056/NEJMc1708134

[3] Collins (2008). Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? https://www.ncbi.nlm.nih.gov/pubmed/18212134

[4] Van de Bekerom et al. (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?https://www.ncbi.nlm.nih.gov/pubmed/?term=22889660

[5] Malanga et al. (2015). https://www.ncbi.nlm.nih.gov/pubmed/25526231

[6] Bleakley (2013). Acute soft tissue injury management: past, present, and future. Physical Therapy in Sport; 14: 73-74.

[7] Goddard, Pierce, & McLeod (2008). Reversal of Lower Limb Edema by Calf Muscle Pump Stimulation.  Cardiopulm. Rehabil. Prev., 28:174-179.

[8] Järvinen et al. (2007). Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol;21(2):317-31.

[9] Suter & Schutz (2008). The effect of exercise, alcohol or both combined on health and physical performance. International Journal of Obesity, 32(6): 48-52.

[10] Stovitz & Johnson (2003). NSAIDs and musculoskeletal treatment: what is the clinical evidence? Phys Sportsmed., 31(1):35-52.

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