Lisa Howell- Dance Physiotherapist

This interview bursts with helpful tips and knowledge to assist you be a strong and informed artist. We dive into the details of ice baths, calf rises, cupping, as well as your mindsets role in injury rehab (spoiler, experiencing depression is normal, you are not alone in this), and so much more.  Lisa is a leading mind in injury prevention and caring for dancers bodies, with so much wisdom to share. She is also a genuinely amazing person and it was a pleasure to sit down and grow in her knowledge about art and life in general.  

Disclaimer* all of Lisa’s amazing insights could not be put into a blog post word for word. Hence, some of her answers have been condensed with her approval. 

What is your current profession?  

I am a dance physiotherapist, creator of The Ballet Blog, and also run dance teacher and  therapist training courses around the world.  

What has your career path been, including your background in dance?  Many people are surprised that I was never a professional dancer, however dance has always  been a big part of my life. I danced recreationally through my school years, and started my  university training for Physiotherapy at 18 years old. I began with classical ballet and flamenco  early in my childhood, however didn’t really get exposed to contemporary till I was at university.  Dance has always held a special place in my heart, and I wish I was able to do more of it. Upon  completing my degree and moving to Australia I seemingly ‘fell’ into a job as a dance  physiotherapist, and have continued on that trajectory ever since. Beginning that job felt like my  life had aligned, it was the perfect blend of my fascination with the human body and my absolute  love of the arts. Unfortunately, several years later, that clinic went bankrupt and we learned that our jobs were gone the day of closing. I quickly got a locum job at the Navy, but was still  privately treating my old clients. I noticed how many of those clients’ injuries were occurring  from poor and mis-informed training, so I decided to open my own practice. One of the first  things I did after opening Perfect Form Physiotherapy was write ‘The Perfect Pointe Book’, which is a guide to help prepare young dancers safely transition to pointe work. Over time I have continued developing resources to make dancers less dependent on acute care from therapists. The development of The Ballet Blog was just another way for me to share those  resources with as broad of a community as possible.  

How have you continued to explore movement and art in your life?  

I feel it’s a shame that many people get locked into a particular style of movement. Throughout  my entire life I have tried to explore as many kinds of movement as possible and have brought  that knowledge back to my work. As well as exploring Classical Ballet, Contemporary and Latin Styles more deeply than I was ever able to as a teen, I have studied Aikido and other martial  arts, many forms of yoga, different forms of functional training, and various philosophies about  movement. I then tried to make a cohesive movement practice, using learnings from each style  of training to inform the others; rather than just doing things the way we’ve always done them.  

Do you have a favourite quote/poem/piece of art?  

“The more injured you get, the smarter you get”- Mickhail Baryshnikov  

I love being a part of the process of people learning more about their bodies and helping them  see injuries or challenges as blessings rather than curses.  

Do you have a specific morning routine? 

I see all these successful people with amazing routines, and though I’ve tried, I’ve never stuck  to one diligently. I let my intuition guide what I need to do in the morning. This morning I knew I  needed to move, so I went for a power walk in the sunshine, and did some work outside. Other  days, I don’t feel like doing any physical activity so I begin my online work straight away. I will  also jump straight online if I have nearing deadlines and need to prioritise that. I’m not a  structured morning person, and don’t get attached to routines. I try to mix things up in  accordance with what’s happening in my life at the time. This has certainly been a mentality shift  from when I was running the clinic. In those days it was very structured and repetitive. Since not  having the clinic I’ve allowed myself more scope to do what needs to be done and it feels really  nice!  

Was there a particular circumstance that showed you the need for a more dance specific  physio clinic?  

When I was 13 there was a girl in my pointe class who struggled to get over her pointe shoe  box. The teacher would constantly yell at her to get over her box, and when she bent her knees  to do so the teacher would yell at her for doing that too. I remember being struck by how silly the  whole situation seemed and thinking there must be some kind of assessment to see if your  body was capable of or ready for pointe work. Once I became a physio and had the opportunity  to work in a clinic that specialised in dancers, that need for more thorough screening was  something I particularly focused on. I noticed that by working on people’s strength and mobility  before they got en pointe there were far fewer injuries occurring down the track. Another  realization about the need for a dance based clinic was when I initially went out on my own and  tried employing some amazing physios who had no knowledge of dance. Whilst understanding  the body is important, I learnt to effectively work with dancers you have to understand the whole  psychological and societal situation dancers are in. I came to learn that having a dance focused  clinic is great for the therapists, but even better for the client. They know when they say, “I  injured my hip doing a grand battement”, their therapist will understand what they’re talking  about. So many clients have been grateful for that; not having to explain themselves, not being  told that they need to stop dancing completely, and actually having somebody understand how  much dance means to them. Hence, I feel it’s really important for the therapists to understand  dancers inside and out in order to be able to treat them well and I wanted to provide a space for  that to happen.  

What values did pursuing physiotherapy speak to in yourself?  

I have always loved caring for others. As a kid I would go to aged care homes with my Nanna and sing for the residents, and nurse the weak, neglected lambs on the farm back to health. I  was always trying to fix things and make them better, so this job just felt like a natural flow on. I  didn’t know much about physiotherapy, but my high school PE teacher suggested it.  Interestingly, I wasn’t convinced physiotherapy was for me throughout my degree. It wasn’t until  I began working with dancers that it truly felt right.  

Injuries are a massive hurdle and no doubt one of dancers biggest fears. Have you ever  experienced someone’s mindset/mental health affecting the quality of their rehab? If so,  do you feel there needs to be more conversations on this topic? 

Yes, yes, and yes! I feel EVERYONE’S rehab is affected by mindset in one way or another.  Mindset impacting the healing processes is an area that I believe will have a lot more research  done over the next 20 years. Think about how your mindset influences how you fuel your body,  how focused you are, your excitement around creating movement, and so on. If you go into a  downward spiral you will often start self sabotaging behaviours that impair your healing; I have  seen numerous people turn to drugs and alcohol when they can’t experience the adrenaline  rush from dancing. Something I always discuss with my clients are ways to get endorphin hits if  we have to pull back their dance load during recovery. I will be frank and if it’s a serious injury  that will require a long time off I will say “you’re likely going to feel like you’re getting depression,  you may get really upset and cranky at people for absolutely no reason. That is totally normal”.  By normalizing it, it opens the conversation so we can actually talk about it and get the right help  when needed.  

Why do you believe dancers feel the desire to stretch in extreme ways? Is this a bad  thing? If so, what is a different mindset you’d suggest?  

I feel dancers are passionate people who love intensity. I think dancers enjoy the ‘feeling’ of  stretching. This loving relationship with pain is also why I feel dancers are so aggressive with  devices such as foam rollers, yet that love of pain is something I believe needs further  discussion. The mentality of ‘no pain, no grain’ has been so ingrained that it takes a long time to  unravel. Is extreme stretching a bad thing? I don’t like to say everything in one genre is bad, so  for me the most important thing when stretching is focusing on what the dancer feels. Five  people in the same position may feel five completely different things. For example, one person  in over splits may be feeling compression in the front of their hip (which isn’t a good thing),  whilst another may have a slight muscular hamstring stretch which is ok. I feel there needs to be  more education and awareness on what safe feelings in the body are when stretching, and the  best times to do certain stretches. Generally, stretching in the direction you’re trying to improve  is the slowest and most dangerous way of getting there. Use traditional stretches as tests not  exercises, get information about what you feel in the position then do other exercises to target those specific restrictions. The mindset I try to encourage is being aware of what you’re feeling  and respecting your body.  

What is the most common injury you see? Do you feel anything in today’s society has  contributed to this?  

20 years ago the majority of injuries I saw were foot and ankle related, now they are mainly hip  and back. There has been a rise in awareness for foot and ankle care, and educating  dancers/teachers around this matter has proven very effective. Unfortunately, I feel the rise of  Instagram has majorly contributed to the accumulation of hip and back injuries. I’m noticing  many issues related to spinal instability (such as spinal stress fracture, disc injury and spondylolisthesis) from people emulating poses they see on social media. I also think part of  the issue is the number of hours students are doing at a younger age, which has also been  influenced by social media. In the past, you would do the hours that were set by your dance  school. Now, based on what people see others doing, people are asking the schools to deliver  more classes and they want to be doing more and more and more. They’re often doing these  extra hours before they have the base technique to support it, hence we’re seeing labral tears  and hip impingements in 11 year olds. We never used to see those injuries until people were 18 or 19 and in full time  training. I don’t see this desire for extreme flexibility going away on its own so we need to  combat it with education. I focus on teaching young kids on ‘how to see’, rather than ‘what they  are seeing’. Instead of seeing the leg behind the head, they are able to look at how much the foot is pronating, how much the knee is hyperextending, or the lack of turnout control. This  allows them to be more observant and aspire to positive things rather than being swayed by  dramatic poses.  

Are ice baths the most efficient recovery tool? If not, why and what is?  There are multiple sides to this conversation. Health professionals used to be taught aggressive  icing was good for acute injuries, however this is being questioned recently and I prefer to use  the BE CALM* protocol. Aggressive icing stops the inflammatory process, but inflammation is  actually part of healing. I think we have to think physiologically, rather than having a blanket rule  that goes for every situation. Icing can be a great tool after you’ve worked hard, but only if you’re  not injured. If you have done a big performance and you want to stop swelling, it’s fine to do an  ice bath. Whereas if you’ve just injured yourself we don’t want to stop the inflammatory process  because that’s how you get all the body’s tools you need to heal the injury. In that case we want  to think of allowing some inflammation, but not letting it get stuck in the injured area. Once you’re  through the first 24-48 hours, then you need to look at what’s really going on, see if relative rest  is needed, and deal with any contributing factors. Don’t heat an acute injury straight away either  as this will dilate the blood vessels. If we’ve got long term injuries, I like to use contrast baths,  especially in stress fractures or if there hasn’t been enough blood flow.  

*BE CALM= breathe, evaluation, compression, able actions, lift (elevation), minimal ice (5 mins on, 20 mins off) 

*Contrast Bath= alternating between ice water and hot water (warm spa temperature not boiling). 2 minutes in each alternating, 5 times in cold, 4 times in hot, then elevate your feet up the wall for 2 minutes. 

What is the science behind the benefits of calf rises and when is the most optimal time to  do them?  

It all depends on the person and situation. If you’re a pre-pointe student the aim of your rises is to develop the strength, control, and range to support yourself when you get your pointe shoes.  In this case, alignment and technique of the rise is very important so I would prefer 15 double leg  rises than 30 dodgy single leg ones. The aim for a professional dancer is to load the tendons  and the tissues in a safe repetitive way to get really good lay down tissue. These rises are used  to develop resilient tissue, that’s going to help guard against injury when you’re actually dancing.  That’s why we like doing them in parallel, making sure they’re super slow, the toes are nicely  aligned, and the dancer is not snapping into end-range. A pre-pointe dancer needs to be going  into end-range with their rises to practice that position, whereas a professional already goes into  end-range multiple times a day with pointe work so they don’t need to use their training rises to  do so. Hence, professional dancers will often only go to ⅞ height. Again, we need to think about  the aim of that person’s rises rather than having a blanket rule. Company level dancers often do  their rises between barre and center, this way they are already a bit warm but can condition their  calves for the allegro to come. Younger students can do them at this time, but I often include it in their conditioning program instead. That way their rise program can be more  focused and personalised. If a teacher is including calf rises in their class, I would recommend  them be at the end of barre. The dancers should do less rises at the end of barre than they can  achieve outside of class, otherwise they will be too fatigued in center.  

You have an amazingly successful business that helps so many! Was there any fear  around beginning that journey? If so, what was greater than that fear?  I didn’t grow up in a business oriented family, and had zero confidence in my management  abilities, but just felt it was the right thing to do. I’ve always focused on doing what’s in front of  me. Seeing what people need, and how urgently they needed it was far more important than my  own fears. As soon as I’m with someone, all of my ‘stuff’ goes out the window and I focus on  helping them on their journey. Yes, there was fear around starting the business and plenty of  panic attacks along the way, but giving care to others and doing what needed to be done in that  moment always felt more important than the fear.  

I have been noticing a rise in the use of cupping as a recovery tool lately. Could you  speak to the different techniques of cupping and if you recommend one over the other?  There are multiple cupping techniques, however I don’t use the traditional one (as much as I  respect its role at the time) . Traditional cupping is based on the meridian system and looks at  stagnant chi/energy. The cups are often left in one point, made of glass, and a specific burnable  herb is lit inside them to create the suction. This usually leaves rings or bruising. Traditionally  that area was then lanced to let the old blood that had risen to the surface out, obviously, we’re  not allowed to slice people in treatments these days. The way I use cupping is quite different. I  aim to create space between the layers of fascia allowing further hydration. Often in the areas  that feel stuck or restricted there will be gluing of different facial layers, traction from cupping  helps create space between those layers allowing them to slide again. When I do it, I like to  have lots of cream, use a plastic cup or with a suction gun (or a silicon cup) to create a gentle  bit of traction, and keep the cup moving. Keeping the cups moving will also mean you don’t  have bruisers to cover up for the stage. It should only be done over big muscle areas that you’d  like to have massaged, not over any exposed veins or areas where you can feel a pulse. I find  cupping to be a great recovery tool. If you can’t afford a massage after a performance, turning to  cups is a fantastic option.  

What perceived ‘failure’ has turned into your most helpful lesson on your journey thus  far?  

Growing up I was taught ‘if you weren’t falling you weren’t challenging yourself enough’; this  lesson has seen me through many trials in life. A perceived ‘massive failure’ for me was the  closure of my clinic. I felt I had failed to keep doing everything, when in reality I was trying to trade full time, run a clinic, run international and national workshops, run online product  development, and run the blog, which are basically five full time jobs. Something had to give  eventually, and it ended up being the clinic. I thought I had failed my staff and clients, but by  focusing on one area (Teacher Training Workshops – now available online) I have been able to  develop things that will help many more people for years to come. I cut everything else out and  zoned in on the dance teacher education, as I realised that for every teacher I was able to  educate, that would reach anywhere from 100 to 1000 dancers that will be impacted. This  experience taught me to keep focusing on my main mission rather than spreading myself too thin. My mission has always been to help  prevent the preventable injuries, and get the physical body out of the way so we can focus on  the art. For me the best way of doing that is to empower dance teachers. I also work with  therapists to help them treat injuries, but I believe if there are educated dance teachers who can  nurture beautiful performers with less injuries, then that’s going to be a much happier dance  world.  

What is one integral thing for yourself when striving for a holistic lifestyle? 

Being able to say no, and not feel guilty for doing so. I always used to just say yes to everything, as I wanted to help everyone. I realised that by  doing that, I didn’t have enough in me to properly help anyone or be able to focus on my main  mission.  

They say the pen is mightier than the sword, if you could scribe one word to use as your  weapon in life what would it be?  

Compassion.  

I think the world could use a whole lot more compassion. Having the ability to see a situation  through someone else’s eyes is a really important life skill. Compassion helps me as a therapist,  but honestly as a person it helps me even more. If we can have a little bit more compassion for  each other, we can learn so much about ourselves and about life.  

In what ways would you like to see readers’ minds expand with this interview?  I’d love for people to continue being curious and understand there is never just one answer.  Look into things from as many different lenses and get input from as many different people as  you can. I also hope people are encouraged to learn about the ways their bodies and minds  work in greater detail, which will not only empower your dancing but teach you lessons for later  in life.  

You can find Lisa on IG @theballetblogofficial or her Facebook page @/LisaHowellPhysio/

Featured Pic Credit: Dan Gosse

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