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Competitive Sports: Section Articles

Athletes Doing Arabesques

Important Considerations in the Care of Young Dancers

Wilson, Julie C. MD1; Quinn, Bridget J. MD2; Stratton, Corinne W. PA-C3; Southwick, Heather MSPT4; MacDonald, James P. MD, MPH5

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doi: 10.1249/JSR.0000000000000208
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Abstract

Introduction

Dance, a combination of art and athleticism, is physically demanding and involves many different styles of movement. Rigorous dance training often begins at a young age, and young dancers are not immune to injury. This article will discuss dance terminology, epidemiology, as well as injury rehabilitation and prevention, with a focus on the young dancer.

Dance Genres

Health care practitioners caring for dancers must have some fundamental knowledge of different dance genres. Each discipline has a unique vocabulary, type of shoe and/or costuming, and potential for placing distinct demands on the body. The following is a brief overview of the various types of dance that are popular in the United States.

Ballet

Ballet is a traditional and highly technical form of dance that dates back to the Renaissance and the imperial courts of Italy, France, and Russia (17). Ballet serves as the foundation for many forms of dance, and its vocabulary is primarily built on the French language. The American Ballet Theatre’s online dictionary (www.abt.org/education/dictionary) is a useful reference for clinicians unfamiliar with ballet terminology. Ballet technique focuses on alignment, turnout, the five positions of the feet, and the appearance of weightlessness and strength. Ballet movements are often performed at the extremes of joint motion, particularly in the spine, hips, and ankles. Steps may be performed with the foot and toes pointed (plantarflexed) or flat on the ground, on demi pointe with the dancer on the balls of her feet, or en pointe in maximal plantarflexion with the dancer on her toes.

Ballet is danced in soft, flat ballet slippers or when en pointe, in specially designed pointe shoes with a firm box encasing the forefoot that positions the dancer directly on extended toes (Figs. 1 and 2). Dancing en pointe is typically reserved for female dancers, and training begins at the discretion of the instructor. Ideal criteria for starting pointe include the dancer’s physical development, core stability, leg alignment, strength and flexibility of the foot and ankle, and years of consistent ballet training (47). Turnout, one of the fundamentals of ballet technique, refers to the outward rotation of the legs, predominantly from the hips. This technique allows for clean lines, complex movement, and greater extension. Dancers are generally encouraged to achieve specific ideals such as 180° of turnout, extreme flexibility, and highly arched feet. Partner dancing in ballet, termed pas de deux, typically involves a duet between a male and female dancer and involves the man supporting and lifting the woman.

Figure 1
Figure 1:
Dance footwear — ballet slippers.
Figure 2
Figure 2:
Dance footwear — pointe shoes.

Tap

Tap is a rhythm and percussion style of dance where the lower extremity is the instrument (25). The percussive sound is created via metal plates under the toes and heels of the dance shoe. Tap stems from the African tradition of communicating via drum beats and was transferred to the feet as a physical code during the American slave era. It evolved with the incorporation of Irish and British clogging styles and the Jazz movement. There are a variety of tap styles such as classical, hoofing, and clogging. Common tap steps include the brush, flap, shuffle, and ball change (15).

Jazz

Jazz dance is a broad term for a variety of dance styles that evolved from traditional African dances and grew alongside the Jazz movement in the early 20th century (2). Jazz dance can be varied and complex and incorporates elements of ballet. Common steps include the jazz square, jazz walk, and jazz layout. Jazz shoes come in a variety of styles; most have a thin, flexible sole and are close fitting.

Modern/Contemporary/Lyrical

Modern and contemporary are terms often used interchangeably. Historically, the modern tradition was born during the late 19th and early 20th centuries. Changing artistic mores, both in the United States and Europe, produced a new form of dance that rejected social strictures and the rigid formality of ballet (12). “Modern dance” quickly became an umbrella term for the unique styles of training and performing created by such pioneers as Wigman, Graham, Horton, Humphrey-Weidman, and Cunningham, each of whom spawned a plethora of disciples that established their own companies and styles. In the modern form, gravity and the dancer’s body weight are used to enhance movement, often performed in bare feet. Pioneers of modern dance worked to develop their own techniques and styles, such as the Graham technique, where the dancer curves the pelvis under and hollows the chest during a forceful contraction (40). Contemporary dance emerged in the latter half of the 20th century as a style that incorporates a variety of dance forms such as ballet, jazz, and modern. Lyrical dance also borrows elements from ballet, modern, and jazz. It utilizes balletic lines and rhythmic whole body “lyrical” style movements to express emotional sentiment (30).

Hip-Hop

The origins of hip-hop can be traced back to the 1970s in The Bronx, NY, as a form of street-style dancing among African-American and Latino youth. There are two main categories in hip-hop: old school and new school. Old school is characterized by breaking, popping, and locking. New school styles, developed in the 1980s and 1990s, include house, krumping, jookin, and street jazz. These styles can range from gymnastic-like acrobatics to isolated jerking of joint(s) (32). Hip-hop is performed both in the dance studio and on the street, and dancers often wear sneakers. There is a strong tradition of improvisation, and hip-hop’s increasing popularity has brought it to dance schools throughout the country.

Irish Step Dance

Irish step dance hails from the traditional dance forms of Ireland and has become popular as a competitive form of dance in recent years. The dancer’s upper body is kept stationary with the arms held at the side, while the lower body executes quick, precise foot and leg movements (41). There are two forms of shoes: hard shoes and soft shoes. Hard shoes, similar to tap shoes, but without the metal plates, have a fiber-glass tip and heel. Soft shoes, or ghillies, are black lace-up soft slippers similar to ballet shoes. Boys typically dance in a black, hard-heeled reel shoe. Irish step dancers spend a great deal of time on the balls of their feet similar to the demi pointe position in ballet, and there has been a trend toward going up on the toes in hard shoes. Dances are performed either solo or in groups of two or more to a particular time signature (e.g., 2/4 time, 4/4 time, etc.). Ceilis are group dances performed socially and at competitions (49).

Ballroom

Ballroom dance is an umbrella term for a number of different partner dances. These can be social or competitive. There are a variety of styles including, but not limited to, waltz, tango, foxtrot, samba, cha-cha, rumba, jive, swing, and mambo. The focus is on poise, posture, alignment, emotional expression, foot action and steps, and overall presentation. Costumes and footwear can vary depending on the style of dance but often involve a heeled shoe for women.

Competitive Dance

In recent years, dance activity has grown into a competitive sport. Dancers perform solo or in duos, trios, or groups in a variety of dance styles such as ballet, jazz, hip-hop, lyrical, modern, tap, and acro (a combination of dance and acrobatics). The competition season is year-round. Individual production companies currently organize competitions and dancers can compete at the local, regional, or national level. Competitive dance can be challenging due to short rehearsal time for new choreography and a large number of performances (46).

Dancers are unique athletes that begin intensive training at a young age, combining the elements of both art and physical skill. Having a basic understanding of the demands of different dance forms allows the health care practitioner to more fully understand the nature of dance injuries and to communicate effectively with the dancer.

Injury Epidemiology in Young Dancers

While dance participation statistics are not readily available, it is reasonable to expect that enrollment has been increasing, similar to that of other youth sports and activities (33). In addition, there has been an increase in the overall number of reported dance injuries. Dance injuries presenting for evaluation in an emergency department setting increased 37.2% from 1991 to 2007, according to a study published by Roberts et al. (36) in 2013. Age-adjusted injury rate increased from 10.2 to 12.1 per 100,000 children and adolescents during the study period, with higher numbers of injuries occurring in older adolescents (15 to 19 years of age) and girls. Lower extremity injuries accounted for the majority of dance-related injuries (58.1%), especially in children older than age 11. Falls and noncontact injuries accounted for nearly 70% of injuries, and 55% of injuries were sustained in classical dance, 11.7% specifically in ballet (36).

The dance medicine community has published guidelines for injury reporting in dance, as a method of standardizing injury reports to promote research in the field and develop injury prediction and prevention strategies. Recommendations from the International Association for Dance Medicine and Science published in 2012 include mandatory injury surveillance, reporting injury per exposure data, and use of a licensed health care professional for evaluation and diagnosis of injuries. An injury is defined as an event resulting in at least 1 d of time loss from dance participation. Injury rates are typically reported as injuries per 1,000 dance exposures (DE), but some studies also report injuries per 1,000 h of dance participation. One dance exposure is defined as a class, rehearsal, or performance (22).

Injury rates among elite preprofessional ballet students range from 1.09 to 1.87 injuries per 1,000 DE (0.77 to 1.38 injuries per 1,000 h of dance), with 32% to 76% of preprofessional dancers sustaining a time loss injury each year (13,1413,14). This wide range is reflective of differences in injury definition and reporting criteria between studies and emphasizes the need for standardized injury reporting. Steinberg et al. (42) published data regarding injury rates in young, recreational, multidisciplinary dancers (jazz, modern, and ballet) and demonstrated a positive linear relationship between increasing age and injury prevalence with an overall injury incidence of 0.84 per 1,000 h of dance participation. For comparison, dancers appear to have lower rates of injury relative to high school athletes participating in girls’ and boys’ soccer and basketball (34).

A 5-year retrospective study of dancers at a preprofessional ballet boarding school reported a predominance of lower extremity injuries (91.1% of all injuries) as well as overuse injuries (55% to 88% of all injuries) (14). In another study, overuse injuries accounted for 72% of all time loss injuries, with 77% of injuries involving the lower extremity. Of the lower extremity, the ankle, lower leg, and foot were most commonly involved in preprofessional ballet students (13) whereas the knee was more frequently injured in recreational, multidisciplinary dancers (42). Trunk/back injuries account for the majority of dance injuries not confined to the lower extremity (13,4213,42).

Hip-hop appears to carry an increased risk for injury, with one study reporting an incidence of 2.5 time loss injuries per dancer, which is considerably higher than that in other dance forms, such as ballet, tap, and modern. Lower extremity injuries still account for the majority of injuries; however, “breakers” who perform more acrobatic movements demonstrate a higher proportion of upper extremity injuries as well as the highest overall injury rates of the hip-hop subtypes (32).

In general, the vast majority of the dance injury literature focuses on ballet, and there is little written about other dance disciplines, especially with regard to the young dancer. However, as other disciplines grow in popularity, the knowledge gap in injury epidemiology will hopefully be addressed. Common ankle/foot injuries occurring in all dance forms include ankle inversion sprains, peroneal tendinopathy, fifth metatarsal fractures, metatarsalgia, and Achilles tendinopathy. Specific conditions fairly unique to ballet include stress fractures of the second and third metatarsals, cuboid syndrome, posterior ankle impingement syndrome (often related to a prominent Stieda process or os trigonum), and flexor hallucis longus tendinopathy (1,23,481,23,481,23,48). Other conditions occurring more commonly in dancers compared with those in other athletes include sesamoiditis, sesamoid stress fracture, Freiberg necrosis, peroneal tendon subluxation, and posterior talus osteochondritis dissecans (23,4823,48).

Irish step dance injuries demonstrate a tendency toward lower extremity injuries, similar to ballet, with the ankle, foot, and knee being the most common injury sites (31). A study of Irish dancers aged 8 to 23 years found that stress fractures were the most common injury type, with the sesamoids, metatarsals, navicular, and first proximal phalanx being the most common locations of stress injury. This unique injury pattern is likely related to the extreme and repetitive impact stress placed on the foot during Irish dance (31). Overuse injuries accounted for 90% of knee pain diagnoses in young Irish dancers, of which 64.2% were characterized as patellar tracking disorders, including patellofemoral syndrome and patellar subluxation (5). Health care providers caring for dancers should feel comfortable in the diagnosis and treatment of these conditions, especially given the potential impact of these injuries on a dancer’s training and future in performing arts.

Rehabilitation Considerations for the Young Dancer

While sports medicine clinicians are observing an increase in training intensity across all youth sports (11), dancers have historically been encouraged to adhere to a disciplined and rigorous training schedule from a very young age. Early training of young dancers allows for the progressive development of flexibility and strength required to excel in all forms of dance. However, intense early training in dance can also create opportunities for injury (26). Preventing injuries in young dancers requires increased attention to early warning signs, an understanding of the intrinsic and extrinsic factors that can lead to injuries, and attention to some basic principles to ensure that rehabilitation is effective and long-lasting, reducing the risk of injury recurrence.

Young dancers are not simply miniature professional dancers but instead are growing and developing children. As young dancers aspire to mimic the abilities of adult professional dancers, compensations in technique and alignment may occur when their bodies are not ready for the challenges of moving and holding positions in the end ranges of motion. Growth spurts in the adolescent dancer also can cause issues with training and contribute to injury (26). Rapidly elongating bones may exceed muscular growth, which can lead to muscle tightness. Muscle strength also can become inadequate during rapid growth, particularly in the hip, a joint whose full function is critical for classical ballet and other dance genres (10). Young dancers also may experience decreased coordination and balance during a growth spurt, making turns and balancing on one leg more difficult (7). Rehabilitation programs should address changes in flexibility, strength, balance, and coordination for young dancers. Deficits of strength and endurance at the hip and core muscles can lead to injuries at the foot, ankle, and knee, so the whole dancer should be assessed when addressing any distal injury (10).

The young dancer may receive appropriate initial treatment for an injury, but subsequent rehabilitation can be inadequate. Dancers are often anxious to return to rehearsal or performance quickly following an injury (21). Premature return to dance not only increases the risk of injury recurrence but also places the young dancer at risk of developing a new injury. A comprehensive rehabilitation program must be dance specific, include the young dancer’s goals, and emphasize education and communication between the dancer, parents, and dance teachers to ensure a safe and effective return to dance (37). A plan of treatment should include education on conservative and realistic expectations for return to dance, incorporate “relative rest,” identify individual intrinsic risk factors such as muscle weakness or imbalance, and address any errors in technique that may contribute to injury. Tools to help accomplish treatment goals should include a mirror to help a dancer understand issues of alignment, a ballet barre to allow for progression of exercises that are specific to dancing, and incorporation of Pilates equipment such as a reformer for jumping or Gyrotonics® equipment for enhanced treatment of issues around the spine and with core stability (Figs. 3 and 4).

Figure 3
Figure 3:
Ballet barre and mirror setup for use in dance rehabilitation.
Figure 4
Figure 4:
Reformer (foreground) used in dance rehabilitation setting.

Initially, the focus of a rehabilitation program should be to maximize the dancer’s abilities while protecting the existing injury. All rehabilitation programs should incorporate cross-training to maintain physical fitness during healing, as decreased aerobic fitness can contribute to injury risk (21,4421,44). For example, swimming, water-based dance warm-up activities, and ballet barre in the water may be very beneficial activities in the treatment of a number of injuries, notably stress injuries to bones in the feet or lower legs (27). Young dancers should always be given a home exercise program to address areas contributing to the injury and to supplement dance class activity (6).

For certain injuries, young dancers may be able to continue to participate in dance, with modifications until proper strength and control are demonstrated in physical therapy (6). Educating the young dancer and dance teachers on the concept of “relative rest” can help keep a dancer training safely while allowing an injury time to heal. Dance activity can be modified to accommodate pain or injury restrictions by avoiding specific exercises like grande plié or jumps or by limiting the range of movements (8). For example, decreasing the amount of external rotation (or turnout) at the hips can offload stress from a number of joints and lowering the height of the gesture leg (elevated leg performing movement) can reduce stress on the iliopsoas muscle and help promote control of the standing leg and improve hip and lumbopelvic alignment.

Dance-specific exercises should be incorporated into the rehabilitation program as the dancer demonstrates adequate healing, range of motion, flexibility, strength, and balance. Evaluation of dance technique should address alignment, quality of movement, proper recruitment of muscles, and prevention of compensation habits. Often, dancers need to relearn movement strategies as their motor memory is very well developed. This is much easier to accomplish in the young dancer who is consistently striving for proper technique than in the adult professional with years of potentially dangerous movement patterns and habits. Due to the unique terminology, mechanics, and demands of dance, working with a physical therapist with expertise in dance rehabilitation is highly desirable.

Holistic Care of the Dancer

The clinician caring for a dancer must be attuned to the total health of the athlete. There are several issues that go beyond the purely musculoskeletal for which vigilance should be kept.

Female Athlete Triad/Relative Energy Deficiency in Sport

The “Female Athlete Triad,” which consists of three interrelated but distinct clinical conditions, is commonly seen in dance. The triad includes energy deficiency due to a relative mismatch of dietary energy intake and energy expenditure, menstrual irregularity, and impaired bone health (9,289,28). Approximately 90% of a woman’s bone mass is accrued by the age of 18; thus, factors that inhibit optimal bone development can have lifelong implications on bone health such as osteopenia, osteoporosis, and increased fracture risk (4). The resulting impaired physiologic function from energy deficiency can influence multiple systems beyond the triad and can affect men as well as women; therefore, the International Olympic Committee developed the term “relative energy deficiency in sport” (RED-S) to reflect and define these broad systemic implications in both sexes (28).

It is thought that dancers are at high risk for the aforementioned issues due to the aesthetic nature of the discipline and the contemporary emphasis on leanness in many dance forms (16). In one study, the majority of ballerinas were found to consume only 70% to 80% of the recommended daily energy intake (19). In another study, one-third of the dancers surveyed had abnormal responses to a validated eating disorder questionnaire (16). Consequently, clinicians who care for dancers should be vigilant for the female athlete triad and RED-S. A multidisciplinary team involving the primary care physician, sports medicine physician, physical therapist, sports dietician, and psychologist should be part of the total care of a dancer.

Treatment of the female athlete triad and RED-S is beyond the scope of this article but is discussed in the references.

Psychological Health of the Dancer

Disordered eating is only one of the mental health concerns that may affect the dancer. There is growing recognition of the prevalence and burden of mental health concerns in sports in general (29), and dance is no different in this regard.

One aspect that deserves particular attention is the relationship between a dancer’s mental health and injury occurrence and recovery. Dancers cope with injury in a fashion similar to other athletes and go through similar reactions to injury, such as denial, grief, and acceptance (24). That said, typical interventions used in sports medicine, such as rest and activity modification, may provoke strong psychological reactions from the dancer. Given the demands of dance — such as practicing for months in preparation for a very concentrated period of performance (a show) — a prescribed period of rest for an overuse injury may seem catastrophic to the dancer (24). As with treating the most motivated football player, clinicians will need their most advanced skills in tailoring an appropriate and acceptable treatment program with which their patient will comply. They also must be attuned to the psychological well-being of their dancer and intervene or refer appropriately.

Primary Prevention of Injury

Primary prevention of injury is at the heart of sports medicine. Here, too, dance medicine is no different. Functional performance tests are used frequently in dance programs to assess the preparticipation readiness of dancers and identify impairment before it leads to injury. Many dance forms place dancers at a high risk of hip, ankle, and foot injuries, so it is not surprising that many functional movement screens relate to hip function (18) or pointe readiness (35,3835,38). Addressing deficiencies identified in preseason functional movement screens may help prevent injury.

The value of preseason conditioning has recently become better appreciated by the dance community. Increased levels of aerobic fitness have been found to be inversely correlated with risk of injury in dancers (44). Historically, dancers performing in different forms have been found in studies to have differing baseline aerobic capacities. Ballet dancers have been found to have low V˙O2max relative to other athletes, despite the fact that active dance such as hip-hop or center work in ballet can require 80% V˙O2max (19). Conversely, contemporary dancers were found in this same study to have a higher baseline aerobic capacity. This physiologic difference is likely reflective of intrinsic differences between the dance forms, with contemporary dance emphasizing more continuous, moderately active movement while ballet emphasizes periods of rest punctuated by intervals of very high exercise intensity (50). However, in both dance forms, it appears that executing proper movement and avoiding injury when fatigued depends, at least in part, on fitness levels (3,453,45). There is, consequently, increasing emphasis on cross-training and conditioning in dance companies as a means to both prevent injury and improve performance.

Barriers to Care

The potential barriers to a dancer seeking medical care should not be underestimated. Dancers, like other athletes, may have difficulty differentiating pain from injury, so initiation of medical evaluation and treatment may be delayed (43). As previously discussed, the unique pressures of preparing for a performance may make a dancer psychologically reluctant to present for care. A dancer may likewise fear that in seeking care and following prescribed advice such as activity modification or rest, a role may be lost to an understudy (20).

Preprofessional and even professional dancers are frequently underinsured or even uninsured, and so presenting for medical care or following prescribed advice may be difficult (39). Furthermore, there is evidence that dancers are more likely to seek out nontraditional healers and often feel misunderstood by the mainstream medical community (24). The clinician caring for a dancer must be proactive in dealing with these challenges.

Conclusions

Dancers are unique athletes, whose artistry and athleticism place intense demands on the body. Health care providers should have a good understanding of the dance forms, unique injury patterns, the complexities of rehabilitation, and the impact of injury on a dancer’s psychological health in order to provide appropriate care.

 The following authors declare no conflicts of interest and do not have any financial disclosures: Julie Wilson, Bridget Quinn, Corinne Stratton, Heather Southwick, and James MacDonald.

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