Preventing Dance Injuries

The purpose of this article is to discuss what we know about injury prevention in dancers, help you understand how to receive the best care from health care professionals and to motivate you to take care of yourself as a dancer. 

Section 1: Dance injury research

Section 2: Injury prevention factors

Section 3: Access to health care for dancers

Section 4: Conclusion

Section 1: Dance injury research

One of the things we need to establish is the definition of a “dancer”. It appears that dance can encompass a wide variety of styles (ballet, jazz, modern, break), avenues for performing (theatre, stage, cruises, or the street) and groups (university students, professional artists). Very often dancers engage in multiple forms of dance. This often makes dance research difficult to study. Ballet has been the most researched genre, with break dancing coming in second. 

Different groups also have different definitions of what constitutes an “injury”. Does it mean you experience pain? Is it having to take time off and resting completely? Is it modifying all or part of a dance routine? Injuries can be influenced by a dancers prior experience of pain; communication with a choreographer, director, peers or family; current circumstances within the dance community such as employment or a scholarship at university. 

Across genres, a range of 42-97% of dancers were “injured”. This suggests that nearly all dancers will experience at least one injury in their career. The lower extremities (hips, knees and foot/ankle) were the most commonly reported to be injured. This is not surprising, given that dancers are required to perform leaps, floor work and wear different footwear. Footwear plays a greater role if multiple genres are required for a single contract (as is the case with performers on cruise ships). 

For every 1000 hours of dance, 4.4 injuries occurred. Overuse injuries were the most commonly reported. Females lost an average of 4 days, males an average of 9 days. 

In conclusion, due to high injury rates and the near certainty that most, if not all, dancers will experience at least one injury in their career, an injury prevention program is warranted.

Dancers are a unique domain of athletes in that the pursuit of perfection in technique is multifaceted. Technique training and rehearsals comprise a large portion of a dancers time. This places a high volume of work on the athlete and creates a deep emotional connection to the performance itself. This means that dancers are often very emotionally invested. Understandably, suffering from an injury can invoke both physical and emotional pain. 

Several studies demonstrate that dancers exhibit a higher pain threshold and higher pain tolerance. This means that they typically acknowledge pain when it is very high and tend to disregard the pain in order to continue to participate in dance. Ballet dancers have a difficult time distinguishing between “customary” dance pain and “pathological” pain. Coping skills (perception and reaction to pain) also tend to be poor in ballet dancers. 

Several factors may contribute to dance injuries (see Table). Some of these factors are modifiable, meaning you have control over them. Communication with health care professionals also plays a role in a dancers understanding of their injury. A provider that understands the nature of dance, rehearsals and performing can provide the psychological support necessary for a dancer to feel comfortable sharing their pain experience. This often results in improved outcomes for the dancer. 

Studies demonstrate that female dancers are more disciplined than male counterparts. Their more resilient outlook on dance performance often results in more success but consequentially greater risk of injury. 

Poor training technique or coaching, especially with a skillset such as turnout, may increase the likelihood of a dancer suffering from back, hip, knee and/or foot and ankle pain. Younger dancers are more susceptible because dance technique is a requisite for an aesthetically pleasing performance. 

 

Section 2: Injury prevention factors in dance

So now that we spoke about dance injury research, lets see what we can do to prevent injuries from happening in the first place. 

Several authors identify a proper warm up, strength training, knowledge on footwear and self-care as the cornerstone for injury prevention. We know that dance rehearsals alone does not adequately prepare a dancer for performance. This “gap” needs to be addressed in order to reduce the risk of injury while performing a show. 

Strength training:

Other authors demonstrate that implementing a strength training program to dance rehearsals cut injury rates in half (from 4.76 per 1,000 hours to 2.2 per 1,000 hours in males and 4.14 per 1,000 hours to 1.81 per 1,000 hours in females). 

Back pain in particular can lead to upper and lower extremity injuries due to its ability to control movement while moving across the stage. Ballet dancers in particular demonstrate smaller muscle size of the back muscles after suffering from a low back pain injury. This may increase the risk for further back injuries as well as of the extremities due to poor timing mechanics. 

Poor leg strength, as measured by jump height, is a predictor for taking more time off from dance as a result of an injury. In other words, weak legs = less dancing. Luckily, one study was able to demonstrate that a 6 week training program could significantly increase muscle strength, power and endurance in addition to improved aesthetics (you look better). 

Nutrition & Rest

Disordered eating is a common problem in the dance population. Maintaining a certain “look”, by managing food, and thus weight, is a practically obligation of dancers. Unfortunately, dancers often receive poor counseling on effective strategies to supply their bodies with the necessary nutrients. Thus, it is very important for dancers, especially young dancers, to seek nutrition counseling if they feel the need to do so. 

Fatigue, due to overtraining form multiple classes, rehearsals and performances (or even holding down a job to make ends meet), is a common occurrence within the dance community. Scheduling of “down-time” where dancers take a physical & psychological break is warranted to allow the body to rest and digest. This provides adequate “space” for dancers to solidify their performance. 

Flooring

Due to the variety of dance genres, many floor types may be used. Modern and ballet dancers often train on “sprung” floors whereas break dancers may perform on a piece of cardboard thrown on the concrete sidewalk. Schools that cannot afford material that is more agreeable to dancers feet might see an increase in lower extremity dance injuries. 

Jumping and landing mechanics change on “marley floors” compared to concrete or wood that is unsprung. One study suggests that some 12.7% of accidents may be attributed to faulty flooring. 

Footwear

As mentioned above, the variety of dance genres require different footwear. A jazz shoe is different than a ballet slipper which is worlds away from a tap dancing shoe. Poorly fitting footwear, or inadequate support may result in foot and ankle injuries. 

Lack of training, a wearing schedule (breaking in the shoe) or premature adoption of footwear also plays a role. In young dancers learning pointe, this is especially important. 

Section 3: Access to health care for dancers

Dancers often receive sub-par care due to a lack of understanding on the health care practitioners part. An inability to conceive dance schedules, requirements for aesthetics, and other psychosocial factors limits a provides ability to provide proper care. Some 80% of dancers at one university felt their doctors did not understand dancers and 43% believed they gave unhelpful advice. 

I can personally attest to this with patients I have treated at Royal Caribbean and Celebrity studios over the past years. Performers have told me the medical doctors said “just google it”. Thats definitely NOT helpful…

Many medical doctors tell dancers to just “stop dancing”, which is often not an effective strategy and may alienate a dancer from continuing care under their guidance. Many dancers do not have the opportunity to “just stop dancing” due to career or academic pressure. 

Research performed by Bronner et al demonstrated a substantial decrease in time-loss from injury and decrease in medical expenditures after implementation of a health care program. Across the implementation time, workers compensation injury rates declined 80% across the first 3 years of study to 24% in the fourth year and 17% in the fifth year. 

A follow up study of the same dance company showed a 34% decrease in injury incidence, 66% fewer workers compensation claims, and 56% decline in days lost from dance. 

Section 4: Conclusion

1. Screening of dancers’ physical and psychological attri- butes, prior injuries, and current and planned dance activity can identify areas that should be addressed to minimize the likelihood of injury. 

2. Physical training of dancers, apart from their technical training in dance, should be encouraged, with special attention to the core and to the musculature specific to the demands of their genre(s). 

3. Proper nutrition and rest (reduction of fatigue) are essential factors in maintaining a dancer’s body that is as resistant to injury as possible. 

4. The provision of specialized health care services to danc- ers is important to risk assessment, injury management, and injury reduction. 

5. Health care practitioners not conversant with dance or the psyche of performing artists will become more appreciative of dance’s physically rigorous nature, be better equipped to care for dance injuries, and gain favor with dancers by observing different varieties of dance and interacting with dancers about their art form.