Injury Reduction for Dancers
As an avid theatre-goer, cinephile, and sports enthusiast, there is nothing like watching people come together to produce something special. You know these artists and athletes spend years, if not decades, honing their craft and skills to deliver what you see. In dance, the craft of the artist and athlete come together uniquely. However, depending on whom you ask, you seldom hear a dancer called an athlete. Like any artistic athlete, the dancer may spend their entire career striving for aesthetic perfection and will do what it takes to achieve it.
In pursuing perfection, a pesky thing can hinder progress and potentially end careers, injury. The injury rates for pre-professional dancers are comparable to professional ballet and contemporary dancers (0.77 to 4.70 vs 0.56 to 4.45 per 1000 hours; Mendes-Cunha et al. (2022). Smith et al. (2016) performed a meta-analysis investigating the prevalence of musculoskeletal disorders in ballet dancers. In the 19 studies they reviewed, 7332 injuries in 2617 ballet dancers were found, and the most prevalent conditions included: hamstring strain (51%), ankle tendinopathy (19%), and generalised low back pain (14%). Interestingly, for professional dancers, toe stress fractures (63%), tibial stress fractures (22%), and glute/hip muscle spasms (13%) were notably high.
Mendes-Cunha et al. (2022) studied dance-related musculoskeletal injuries that lead to forced time loss in elite pre-professional dancers and found differences between males and females for anatomical location and incidence. For female dancers, injuries that lead to forced time loss were Medial Tibial Stress Syndrome (14.3%) and Posterior Ankle Impingement Syndrome (7.1%). Hallux Sprain (17.5%) and Lumbar Spine Joint Injuries (7.1%) were most prevalent for males. The study broke down the experience level from 1 to 3. 72.2% of the chronic injuries and 50% of the acute injuries occurred in level 3 dancers. These findings suggest a tendency for males to suffer more acute traumatic injuries whilst females suffer from more overuse injuries.
Beyond ballet, Ojofeitimi et al. (2010) looked at hip-hop dancers and their subsets (Breakers, Poppers/Lockers, New Schoolers). Out of 232 dancers that reported 738 injuries, 506 were time-loss injuries. Hip-hop dancers experienced more injuries in the upper body than ballet and contemporary dancers. Breakers incurred more injuries in the hand and forearm/wrists than non-Breakers. Injuries in the lower body are similar to ballet and contemporary dancers.
Fatigue
Interestingly, compared to other intermittent athletes, such as football (soccer) players, ballet dancers tend to have lower aerobic fitness and higher injury rates (Koutedakis & Jamurtas, 2004), possibly due to cumulative muscle fatigue produced by the various jumping, leaping and bounding movements associated with dance (Westblad et al., 1995; Rodrigues-Krause et al., 2013).
Twitchett et al. (2010) studied the exercise intensity of a typical workday (9.30 am to 6.30 pm) of female professional ballet dancers. They found that the exercise’s intensity depended on the dancers’ ranking (principals, soloists, first artists, and corps de ballet). Although the average exercise intensity for all the dancers was fairly low, soloists reached the highest intensities and the least rest. For every minute of work, principals and soloists were found to have less than half a minute of rest. However, principal dancers would spend more time in moderate to high intensity during performances than the other groups.
The cumulative muscle fatigue and the long workdays with little rest increase the likelihood of an overuse injury. Compensatory and incorrect movement patterns due to motor control fatigue may also result in acute and traumatic bone injuries (Prus et al., 2022).
Relative Energy Deficiency in Sport
Relative Energy Deficiency in Sport (RED-S) syndrome is characterised by low energy availability (LEA; disordered eating is not a prerequisite), menstrual irregularity, decreased bone mineral density, and impaired physiological function (Brown et al., 2020).
Low energy availability can be defined as an imbalance between energy intake and energy expenditure due to exercise and affects males and females. It is a chronic state with long-term effects, such as menstrual cycle disorders, bone and muscle health issues, metabolic issues, immune resistance, and mental health problems (Prus et al., 2022).
In aesthetic sports, such as dancing, gymnastics, etc., it is a logical assumption that to maintain a particular body type; these athletes may not provide themselves with optimal nutrition. If an athlete does not consume enough food, i.e., a negative energy balance is achieved, the ability of muscles to recover from the high demands is hindered. Over time, this may cause muscle-related problems resulting in soft tissue injuries and forced time loss.
As previously mentioned, the short rest breaks and long work hours may not allow the athlete enough time to fuel their performance and recovery.
Bone Health
We have a finite amount of time to develop bone mineral density (BMD) during childhood and adolescence, which peaks at around 25 years old (Nayak et al., 2016). For this reason, low BMD is a concern, especially in young female dancers.
Osteoporosis is a bone disorder characterised by low BMD, making the occurrence of fractures and breaks more frequent. The elderly and postmenopausal females are high-risk populations for low BMD. Amorim et al. (2017) found lower BMD at non-impact sites (forearms) in professional female ballet dancers, but their male counterparts demonstrated healthy BMD. Weight-bearing exercises like resistance training may help increase or maintain BMD and improve performance.
Oestrogen is not only the primary sex hormone in females, but it also plays an important role in bone development (NHS, 2022). The delayed onset or absence (more than six months) of the menstrual cycle may negatively impact the development of BMD and increase the risk of injury as the dancer ages.
Providing optimal nutrition for a dancer may be challenging, given the aesthetic standards and issues with nutrient timing during rehearsals. LEA has been discussed, but it is worth reiterating the importance of nutrition in performance, bone health, and the menstrual cycle.
Putting It All Together
When we gather all this information to reduce the risk of injury (we can never prevent injury), acute injuries seem to stem from fatigue. The cumulative effect of physical and mental fatigue can affect an individual’s ability to perform tasks safely. Regular breaks (especially in rehearsals) and optimal nutrition may help aid recovery.
RED-S syndrome is more likely to affect the dancer later in life. RED-S components (LEA, menstrual disorders, and low bone density) may not immediately affect the dancer. However, as the dancer ages, the consequences of not having a regular menstrual cycle due to excessive exercise and suboptimal nutrition may lead to bone disorders, such as osteoporosis.
Most of the research I came across was on ballet dancers. However, the many styles of dance may introduce different physiological and biomechanical challenges and should be investigated.
References
Brown, A. L., Brooks, S. J., Smith, S. R., Stephens, J. M., Lotstein, A. K., Skiles, C. M., Alfiero, C. J., & Meenan, M. J. (2020). Female Collegiate Dancers Body Composition, Macronutrient and Micronutrient Intake Over Two Academic Years: A Longitudinal Analysis. Journal of Functional Morphology and Kinesiology, 5(1), 17. https://doi.org/10.3390/jfmk5010017
Koutedakis, Y., & Jamurtas, A. Z. (2004). The dancer as a performing athlete. Sports Medicine, 34(10), 651–661. https://doi.org/10.2165/00007256-200434100-00003
(Low) Energy Availability and Its Association — ProQuest. (n.d.). https://www.proquest.com/docview/2694020032?accountid=12860&forcedol=true&pq-origsite=primo
Mendes-Cunha, S., Moita, J. P., Xarez, L., & Torres, J. (2022). Dance-related musculoskeletal injury leading to forced time-loss in elite pre-professional dancers — a retrospective study. The Physician and Sportsmedicine, 1–9. https://doi.org/10.1080/00913847.2022.2129503
Nayak, N., Khedkar, C., Khedkar, G., & Khedkar, C. (2016). Osteoporosis. In Elsevier eBooks (pp. 181–185). https://doi.org/10.1016/b978-0-12-384947-2.00507-9
NHS. (2022, October 14). Osteoporosis. nhs.uk. https://www.nhs.uk/conditions/osteoporosis/causes/
Ojofeitimi, S., Bronner, S., & Woo, H. (2010). Injury incidence in hip hop dance. Scandinavian Journal of Medicine & Science in Sports, 22(3), 347–355. https://doi.org/10.1111/j.1600-0838.2010.01173.x
Prus, D., Mijatovic, D., Hadžić, V., Ostojic, D., Veršić, Š., Zenic, N., Jezdimirovic, T., Drid, P., & Zaletel, P. (2022). (low) energy availability and its association with injury occurrence in competitive dance: Cross-Sectional analysis in female dancers. Medicina, 58(7), 853. https://doi.org/10.3390/medicina58070853
Rodrigues-Krause, J., Krause, M., Cunha, G. D. S., Perin, D., Martins, J. B., Alberton, C. L., Schaun, M. I., Bittencourt, P. R. S., & Reischak-Oliveira, A. (2013). Ballet dancers cardiorespiratory, oxidative and muscle damage responses to classes and rehearsals. European Journal of Sport Science, 14(3), 199–208. https://doi.org/10.1080/17461391.2013.777796
Smith, T. O., Davies, L., De Medici, A., Hakim, A., Haddad, F. S., & MacGregor, A. J. (2016). Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis. Physical Therapy in Sport, 19, 50–56. https://doi.org/10.1016/j.ptsp.2015.12.007
Twitchett, E., Angioi, M., Koutedakis, Y., & Wyon, M. A. (2010). The demands of a working day among female professional ballet dancers. Journal of Dance Medicine & Science: Official Publication of the International Association for Dance Medicine & Science, 14(4), 127–132. https://doi.org/10.1177/1089313x1001400401
Westblad, P., Tsai-Felländer, L., & Johansson, C. (1995). Eccentric and concentric knee extensor muscle performance in professional ballet dancers. Clinical Journal of Sport Medicine, 5(1), 48–52. https://doi.org/10.1097/00042752-199501000-00009