Preventing dance injuries: current perspectives

Abstract

Dancers are clearly athletes in the degree to which sophisticated physical capacities are required to perform at a high level. The standard complement of athletic attributes – muscular strength and endurance, anaerobic and aerobic energy utilization, speed, agility, coordination, motor control, and psychological readiness – all are essential to dance performance. In dance, as in any athletic activity, injuries are prevalent. This paper presents the research background of dance injuries, characteristics that distinguish dance and dancers from traditional sports and athletes, and research-based perspectives into how dance injuries can be reduced or prevented, including the factors of physical training, nutrition and rest, flooring, dancing en pointe, and specialized health care access for dancers. The review concludes by offering five essential components for those involved with caring for dancers that, when properly applied, will assist them in decreasing the likelihood of dance-related injury and ensuring that dancers receive optimum attention from the health care profession: (1) screening; (2) physical training; (3) nutrition and rest; (4) specialized dance health care; and (5) becoming acquainted with the nature of dance and dancers.

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Preventing dance injuries: current perspectives
Jeffrey A Russell
Division of Athletic Training, School
of Applied Health Sciences and
Wellness, Ohio University, Athens,
OH, USA
Correspondence: Jeffrey A Russell
Ohio University, School of Applied
Health Sciences and Wellness, Grover
Center E335, Athens, OH 45701, USA
Tel +1 740 593 4648
Fax +1 740 593 0289
Email jeff.russell@ohio.edu
Abstract: Dancers are clearly athletes in the degree to which sophisticated physical capacities
are required to perform at a high level. The standard complement of athletic attributes – muscular
strength and endurance, anaerobic and aerobic energy utilization, speed, agility, coordination,
motor control, and psychological readiness – all are essential to dance performance. In dance,
as in any athletic activity, injuries are prevalent. This paper presents the research background
of dance injuries, characteristics that distinguish dance and dancers from traditional sports and
athletes, and research-based perspectives into how dance injuries can be reduced or prevented,
including the factors of physical training, nutrition and rest, flooring, dancing en pointe, and
specialized health care access for dancers. The review concludes by offering five essential
components for those involved with caring for dancers that, when properly applied, will assist
them in decreasing the likelihood of dance-related injury and ensuring that dancers receive
optimum attention from the health care profession: (1) screening; (2) physical training; (3)
nutrition and rest; (4) specialized dance health care; and (5) becoming acquainted with the
nature of dance and dancers.
Keywords: dance, injuries, injury prevention, fitness, wellness, health
Introduction
Among activities in the realm of sports, dance is typically not included. Nonetheless,
dancers are clearly athletes in the degree to which they require sophisticated
physical capacities to perform at a high level. The standard complement of athletic
attributes – muscular strength and endurance, anaerobic and aerobic energy utilization,
speed, agility, coordination, motor control, and psychological readiness – are all
essential for dance performance. In dance, as in any athletic activity, injuries are
prevalent. However, as is also true in traditional sports, the prevention of injury is
preferable to the management of injury; ie, maximizing a participant’s ability to engage
in his or her chosen pursuit without injury is the ultimate goal.
In light of these assertions, the purposes of this review are: (1) to highlight the cur-
rent state of knowledge about injuries in dance with a view toward injury prevention;
(2) to equip clinicians, researchers, and others who work with dancers with informa-
tion that will assist them in providing optimum care; and (3) to offer motivation for
additional health, wellness, and health care personnel to embrace the practice of caring
for dancers. The main approach taken herein is to elucidate many of the idiosyncra-
sies and challenges inherent in dance medicine that are typically not seen in sports
medicine. This will serve as a means to provide the reader with an appreciation for
how to approach dance injury prevention and management.
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Russell
The nature of dance, injury,
and dance injury research
The prevention of dance injuries hinges in part on an
adequate research foundation about the incidence of these
injuries, yet there are several aspects of such research that
present obstacles. Dance as an art form is a collective of a
variety of genres, some of which are becoming increasingly
difficult to categorize because they are influenced by two or
more styles. Thus, the term “dancer” is often troublesome
to delineate secondary to participants commonly possess-
ing skills in multiple genres or to the differences in skills
required among genres. For example, “dancer” may be
applied to anyone who participates in genres such as ballet,
modern, contemporary, jazz, tap, hip-hop, ballroom, musical
theater, and a variety of ethnic forms like flamenco, Irish,
African, and countless other versions subscribed to virtually
every nation. Nonetheless, it is tenuous at best to imply that
research on “ballet dancers” generalizes across all “dancers.”
Furthermore, particularly in dance practice outside of profes-
sional, pre-professional, and ethnic groups (eg, individuals
in university dance training), it is common for dancers to
regularly engage in several genres.
A simple, cursory search of the Medline database easily
indicates that, to date, ballet has received the greatest scien-
tific research focus; just the article title search term “ballet”
generates more than 350 articles since 1952. This is followed
in level of attention in the literature, perhaps surprisingly,
by break dance1–21 (usually referred to as breaking by its
participants, who are called “b-boys” and “b-girls”), and
modern/contemporary dance.22–40 Other dance genres that
have received research consideration, though comparatively
not as much, include hip-hop,41 flamenco,42–44 ballroom,45–51
Highland,52,53 and Irish.54–60 Investigation of some of these is
becoming more frequent.
One of the difficulties with the current dance injury litera-
ture is its history of multiple definitions for what constitutes
an injury and the lack of a standard injury reporting system,
problems addressed in detail by the Standard Measures
Consensus Initiative of the International Association for
Dance Medicine and Science.61 This group of researchers
offers three primary purposes of its work:
1. Establish uniform methodology for tests and measures
used to assess dancer capacities and intrinsic and
extrinsic risk factors for injury;
2. Establish common protocols for reporting injuries;
3. Assist the dance medicine community in apply-
ing these recommendations [via] all applicable
technologies.61
Noting that identification of an occurrence as an “injury”
only if it results in time lost from an individual’s activity is
the typical model for epidemiological reporting, the consen-
sus statement also specifies several caveats that may affect
injury reporting data, such as a participant’s motivation, pain
tolerance, and peer influence, as well as a team’s coaching
philosophy (or, in the case of dance, teaching philosophy).61
Access to proper medical care and a facility’s or practitioner’s
relative attentiveness to recordkeeping also may affect both
the quality and quantity of injury data collection.
While ideal data may not be available, dance is undoubtedly
associated with numerous injuries.23,24,39,41,60,62–84 In research
reporting the percentage of dancers injured out of a studied
sample, the range was 42%−97% across a variety of genres
and skill proficiencies.63,64,66,68,69,71,73,85–88 The lower extremi-
ties have been shown repeatedly to be the most commonly
injured region of the body in dancers.63,64,67,68,71,75,76,79,80,82,83,85,88–90
Nonetheless, the physical requirements of specific genres may
dictate injury location, such as a higher proportion of injuries
occurring in the upper extremity29,75 and back40,75 in modern
or contemporary dance compared to ballet as a result of the
former’s dependence on floor-based and partner maneuvers
that require substantial weightbearing involvement by the
upper extremities. For dance injuries occurring in children
and adolescents aged 19 years and younger, increasing age
has been associated with increasing likelihood of injury to the
lower extremity versus the upper extremity.82
Roberts et al82 reviewed 17 years of National Electronic
Injury Surveillance System (United States) data for individu-
als aged 3 to 19. They identified a total of 113,084 dance-
related injuries in this age group during the span of the study,
with the number of cases and the annual age-adjusted rate
of injury both increasing substantially during the span of
years studied. Investigations that include injuries to dancers
across their careers report that 84% to 95% of dancers are
affected.68,87,91
In a 1-year prospective study of professional ballet
dancers, Allen et al83 tabulated 355 injuries in 52 dancers,
or a mean of nearly seven injuries per dancer in that single
year. The researchers’ injury definition was any condition
that prevented a dancer from participating fully in normally
scheduled dance activities for at least 24 hours from the
time the injury occurred. The incidence was 4.4 injuries per
1,000 hours of dance exposure, and overuse injuries were
the most commonly reported type in this sample (64% of
injuries in females and 68% in males). Females had a mean
time-loss from dance due to injury of 4 days, while males’
mean time-loss was 9 days. This study is exemplary in that

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Preventing dance injuries
the high injury rate spurred the authors to implement an injury
reduction program in their ballet company.
All of the literature taken together indicates, then, that
the reduction of injury incidence in dancers is a worthwhile,
if elusive, target. The task is multi-faceted, and certainly
replete with opportunities for additional high-quality research
engagement. For further insight into systematically approach-
ing dance injury research, the reader is referred to Liederbach
et al’s technical report.61
Challenges in caring for dancers
versus traditional athletes
While highly tuned physical capacities are as important for
dancers as they are for athletes, there are important differ-
ences between these two types of participants and between
their activities. These factors impact the application of
both preventive and treatment measures within the dance
community.
Sports, in most cultures, are widely played, as well as
followed by an enormous fan base. Interest extends from
the highest professional ranks to the remotest of children’s
playgrounds. Dance, on the other hand, does not enjoy such
cultural pervasiveness (nor do any of the performing or
visual arts, for that matter) even though the art form is taught
in many schools and universities, and worldwide there are
immensely talented and popular dance companies. Overall,
most dancers, dance teachers, choreographers, and dance
funding patrons describe feeling a lack of appreciation and
respect by society at large for their extraordinarily physical
and aesthetic craft. Despite this, they are never dissuaded
from pursuing its creation, rehearsal, and performance, as
the very nature of dance as athletic artistry engenders a
high degree of dedication in its participants. This motiva-
tion informs virtually every aspect of their participation and
presents some unique challenges to clinicians.
In contrast to most athletes who engage in daily practice
sessions that are of comparatively short duration, dancers
may routinely participate in technique classes during most
of any given day, followed by rehearsals through the late
afternoons and evenings. Weekends may be similarly filled.
They feel an obligation to participate in and perfect their
art, and conversations with and observations of dancers
corroborate for the health care professional the intense
psyche these athletic artists possess. Ballet dancers, in
particular, exhibit a consuming passion for dance that
makes a decision to stop dancing for injury or other reasons
exceedingly difficult, a frame of mind Wainwright et al92
liken to an addiction.
One difficulty in assessing and monitoring dance injuries
is dancers’ extraordinary processing of pain. They exhibit
both a higher pain threshold (the amount of pain required for
them to acknowledge it) and a higher pain tolerance (their
ability to disregard pain while participating in physical activ-
ity) than non-dancers.93 This also may play a role in dancers’
minimalist reports of pain that do not seem to correlate with
the presence of imaging findings.94,95 In addition, Anderson
and Hanrahan96 noted that ballet dancers tended to distinguish
poorly between pain that is customary in dance performance
and pain associated with injury. Pain is typically seen by
dancers as an accompanying facet of dance practice, and
dancers are prone to “dance through” pain, even when doing
so may be detrimental.97 Moreover, their pain coping skills
are not as developed as those seen in many types of sports
participants.98 These points should be helpful to anyone car-
ing for injured dancers.
Psychosocial and technical factors
related to dance injuries
Injuries are considered by dancers to be a natural, even neces-
sary, part of participating in dance.92 Toledo et al99 suggest
several contributors to dance injuries (Table 1). These should
serve only as a general baseline, however, as research into
dance injuries becomes more sophisticated with concomitant
access to an ever wider cross-section of dancers, including
increasingly popular genres like hip-hop41 and breaking,2,4 as
well as young dancers.82,89,100 Note that most of the factors in
Table 1 are modifiable or treatable, thus making prevention
more realistic. This and other references101,102 suggest that
improved health care for dancers may result from a psy-
chosocial approach wherein health care providers become
conversant with the nature of dance practice and performance
in order to effectively assist dancers in preventing and recov-
ering from injuries.
Adam et al,103 Patterson et al,104 and Hamilton et al105 all
found that negative stressors in ballet dancers’ lives predicted
an increased injury rate. However, they also found that this
effect could be mediated by the presence of positive social
support in the dancers’ lives. Two examples of stressors
suggested by Noh et al106 that are associated with a height-
ened risk of injury in ballet dancers are worry and negative
confidence in one’s dance abilities. In another study, these
researchers determined that ballet dancers who are taught
general psychological coping skills experienced fewer inju-
ries and less time injured.107 Among professional ballet danc-
ers, females tend to be more disciplined than males. Women
portray a tougher personality than their male colleagues in

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Russell
the face of the demands of a professional dance career, along
with generally having fewer negative psychological traits.105
In addition, data from this study present a difficult enigma
in suggesting that the same personality characteristics that
promote success in ballet also place a dancer at increased
risk of injury.
Technical intricacies required for success in particular
dance genres may predispose dancers to injury. That is, aes-
thetic demands that are part of any given style of dance are
typically not alterable. For example, “turnout” – externally
rotating the hips and lower extremities to place the feet as
close as possible to an ideal angle of 180° with each other – is
a fundamental component of ballet. But, many dancers force
this position beyond their normal limits, a practice that may
result in conditions such as foot pronation,35 low back pain
associated with anterior pelvic tilt,108,109 and pain and injury in
joints of the lower extremity.35,109 Younger dancers or dancers
who are less well trained are especially susceptible because
they strive for a technical performance level for which their
bodies may not be suited or properly instructed.110
In keeping the technical demands of dance from increas-
ing the chance of injury, ensuring that dancers receive appro-
priately qualified instruction is paramount. However, poor
teaching may be a difficult factor for health care providers
to assuage unless they have both a dance background and
unusually good access to the teachers of dancers under their
care or in their community. Organizations such as the Interna-
tional Association for Dance Medicine and Science (IADMS,
www.iadms.org) are important assets; IADMS holds a yearly
educational day for dance teachers in conjunction with its
annual conference, as well as produces resources designed
specifically to foster healthy dance instruction.
Injury prevention factors in dance
Physical training
As previously described in light of a substantial body of
research, dancers sustain many injuries. Research about
preventive strategies to mitigate the incidence of dance
injuries is less voluminous. Malkogeorgos et al111 offer
five main areas of attention for preventing dance injuries:
warm-up, training (including muscular strength, power, and
endurance; plyometrics; agility; balance; joint stability; and
dance-specific technique), equipment (including footwear
and surfaces); regulatory aspects (rules and regulations
governing dance); and self-care prevention and treatment
methods. Of these, training is the most expansive area, and
one that perhaps holds the most promise for success in reduc-
ing the incidence of dance injuries.
Participation in dance is not sufficiently intense across long
durations to substantially improve aerobic capacity,31,112,113
and low cardiorespiratory endurance has been associated
with dance injuries.114 In adolescent female dance students,
O’Neill et al115 found that moderate-to-vigorous physical
activity was lowest in the highest level dance classes, though
students with more dance training generally tended to be
more active in their classes than students with less training.
Further, they noted that ballet classes offered less time for
physical activity than did jazz and tap classes. Overall, the
dance students they studied were moderately to vigorously
active for only 10 minutes per hour of dance classes. In a
study of modern dancers, Wyon et al31 found, not surpris-
ingly, that participating in dance performances resulted in
significantly higher heart rates and greater mean oxygen
Table 1 Contributors to dance injury
General
cause
Specic cause Alterable with
conservative
management?
Improper
training
Lack of warm-up exercise
routine
Yes
Repetitive jumping Yes
Poor alignment of body weight Yes
Disregarded overuse/fatigue Yes
Faulty
technique
“Sickling” (forefoot/hindfoot
varus in demi-pointe or en pointe)
Yes
“Winging” (forefoot/hindfoot
valgus in demi-pointe or en pointe)
Yes
“Rolling in”
(foot hyperpronation)
Yes
Poor turnout (inadequate
hip external rotation)
Somewhat
Anterior pelvic tilt Yes
Environmental
hazard
Hard oors Depends on facility
Ill-tting shoes Yes
Barefoot dancing Depends on genre*
and instructor
Structural
deformity
of the foot
Hallux rigidus Somewhat
Hallux valgus Somewhat
Pes cavus (high arch) No, but treatable
Pes planus (at foot) No, but treatable
Biomechanical
imbalance
Poor core strength Yes
Weak eccentric strength
of leg muscles
Yes
Pelvic muscle imbalance
or inexibility
Yes
Tight Achilles’ tendon Somewhat
Hypermobility syndrome
(Beighton score $4)
No, but
manageable
Notes: *Barefoot dancing is integral (and, thus, unmodiable) to many dance forms;
eg, modern/contemporary and several ethnic genres.
Adapted from Arch Phys Med Rehabil, 85(3 Suppl 1), Sports and performing arts
medicine. 6. Issues relating to dancers, S75–S78, Copyright 2004, with permission
from Elsevier.99 The table has been recongured for clarity. Items in italics are
additions to Toledo et al’s list, as are the commentaries in the rightmost column.

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Preventing dance injuries
uptakes than either dance classes or rehearsals. Activity heart
rates in their cohort of dancers were only rarely at a level
consistent with that needed for aerobic improvement.
An investigation of ballet dancers suggested that
inadequate physical training was a primary contributor to
dance injuries.78 However, a 6-year follow-up of the same
dancers revealed that, while they still were frequently
injured, their increased age and dance workload did not
result in more pain or injuries; rather, improved physical
training facilities were identified as a helpful adjunct to
their dance activity.116 Furthermore, professional ballet
dancers who participated in a fitness program apart from
their dance technical training showed an increase in maxi-
mum oxygen uptake, as well as decreased psychological
stress, in comparison to a control group of dancers who
did not pursue a fitness program.117
A study suggesting that decreased injury incidence in
professional ballet dancers results from implementing physi-
cal training was performed by Allen et al.84 Over 3 years of
prospective injury recording, male dancers’ injury incidence
dropped from 4.76 per 1,000 hours of dance exposure to
2.22 per 1,000 hours. Injury incidence for females declined
from 4.14 to 1.81 per 1,000 hours in the same 3-year period.
Based on their first year’s data, these researchers incorporated
individualized conditioning programs based on each dancer’s
injury history and physical screening data and subsequently
showed the value of such programs in reducing ballet injuries.
As one possibility, physical regimens already popular with
dancers, such as Pilates,30 should be encouraged and greater
intensity and training volume across a general fitness program
are advisable.
Whereas poor core stability has been identified as a
risk factor for upper118 and lower119 extremity injury, and
inadequate neuromuscular control in the trunk has been
specifically associated with increased athletic knee injuries
in females,120 dancers’ attention to these components of fit-
ness is warranted. In elite professional ballet dancers, smaller
cross-sectional area of the multifidus muscles have been cor-
related with lower back pain.121 The trunk muscles appear to
fire in anticipation of lower extremity muscle contraction;122
this suggests the importance of optimal core function as the
aesthetics of dance are intimately dependent on precise con-
trol of both the trunk and extremities. Therefore, attention to
core stability and strength should be considered foundational
to the remainder of a dancer’s training with the caveat that
further research on core function in dancers is needed in light
of Rickman et al’s123 findings that the research literature on
this topic is relatively scant.
Low levels of muscular strength and power also have been
suggested as predictive of dance injuries.22,124,125 Specifically,
thigh torque in a cohort of male and female ballet and con-
temporary dancers was correlated with severity of injury as
measured in days lost from dancing.124 Angioi et al22 similarly
found leg power measured by vertical jump height to be
positively correlated with days lost from dancing. In sup-
port of the need for physical training by dancers, a 6-week
program of circuit and vibration training of contemporary
dancers led to improvement in lower body muscular power,
upper body muscular endurance, aerobic fitness, and aesthetic
competence.34
Ambegaonkar et al33 studied upper body muscular
endurance in university modern dancers, finding no differ-
ence between dancers and non-dancers in spite of modern
dance requiring more consistent work with the upper body
than ballet, especially in females. They surmised that their
dancers’ lack of engagement in upper body physical training
outside of dance classes, rehearsals, and performances was
the primary contributor, thereby suggesting that participation
in modern dance, in and of itself, does not lead to upper body
muscular training effects.
In a sample of female professional ballet dancers com-
pared to a control group, Koutedakis and Sharp126 reported
significant improvements in quadriceps and hamstring torque
output, as well as improvement in thigh muscle fatigability
during dance, as a result of 12 weeks of strength training for
these muscles. The improvements were particularly note-
worthy in dancers who were weaker at the beginning of the
study. As the control group dancers did not exhibit strength
increases, the authors suggested that dance technical training
alone is incapable of eliciting strength gains. Undesirable
increases in muscle bulk are a concern for many female
dancers because of the importance of anatomical aesthetic
contours in dance. However, importantly for females, the
increases in thigh strength seen in this study occurred without
a concomitant alteration of thigh circumference, a finding the
researchers offer as an indicator that the aesthetic character-
istics of the lower extremities can be preserved when female
ballet dancers participate in weight training.126
In view of the research evidence, it seems wise to recom-
mend that dancers take part in general fitness training, not only
as a helpful supplement to their technical training and perfor-
mance, but as a means to reduce their chance of injury.
Nutrition and rest
Suboptimal nutrition has been associated with injury in danc-
ers.127,128 Disordered eating and eating disorders – a discussion

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Russell
of which is beyond the scope of this review – are well known
to affect many dancers.129–132 In addition, physiques generally
associated with female ballet dancers, ie, high ectomorphy,
low mesomorphy, and low percent body fat, have been linked
to increased injury.133 Ballet dancers are particularly prone
to control their physiques, especially via restricted dietary
practices, because of the aesthetic requirements of their genre,
as well as the related issue of the pressure to manage every
detail of their existence as a means to maintain their place
in a dance company. Many dancers may not follow sound
research-based nutritional practices; thus, health care practi-
tioners should utilize well-documented advice in encouraging
dancers toward a healthy energy and fluid intake. Excellent
resources for this purpose include the joint position state-
ment on nutrition for sports performance developed by the
American Dietetic Association, Dietitians of Canada, and
the American College of Sports Medicine.134
Fatigue has been proposed as a risk factor for injuries in
physical activity.135–139 In addition, fatigue manifest as “burn-
out” was shown to have a negative effect on several physical
performance variables in professional female classical ballet
dancers.140,141 Typical schedules of dancers that include dance
classes and rehearsals throughout much of any given day may
not be conducive to rest unless dancers purposely ensure they
find time for adequate breaks and leisure. Also, dance seasons
may not incorporate as much off-season recovery time as
most sports seasons do. University dance students especially
might be at risk of not receiving necessary rest because of the
combination of their dance practice, the requirements of their
non-dance academic work, and, often, their need to maintain
employment to cover their personal expenses.
While research about fatigue and rest in dancers appears
scarce, Twitchett et al142 mapped female professional ballet
dancers’ activity across a typical workday. Ninety percent of
the dancers took less than 60 consecutive minutes of rest, and
one-third took less than 20 minutes rest during the day. In a
5-year prospective study of both ballet and modern dancers,
more injuries tended to occur in the evening, toward the end
of the season, and during performances; these all suggest
fatigue as a contributing factor.75 Thus, dancers must be
encouraged to schedule appropriate “down time” in support
of both their physical and emotional health.
Flooring
Most dancers prefer to dance on a “sprung” floor rather than
on an unyielding surface such as concrete. Sprung floors are
typically manufactured from wood and are set on a subfloor
by means of a framework of dense foam blocks or other
resilient material that effectively suspends the wood floor
above the hard subfloor. In many genres of dance that utilize
studios and stages, the wood is covered with a 1−2 mm thick
vinyl sheet called “marley” in the dance vernacular. The
suspended, or sprung, nature of the floor allows it to disperse
some of the forces associated with dance, particularly in
jumping and landing.143,144 Unfortunately, in many instances
dancer preference must give way to the necessity of dancing
on whatever surface is installed in a given school, studio, or
theater. Hopper et al145 found great variability in force reduc-
tion capability amongst different professional ballet venues,
concluding that none of the floors met suggested standards
for force reduction and that the floor with the greatest intra-
surface variability in force reduction was the floor on which
the most injuries occurred.
The shock absorptive quality of the surface may not be
the only floor-related hazard associated with dance injuries,
however. Wanke et al146 attributed 12.7% of all accidents (291
of 2,281 reported injuries spanning 17 years) in professional
and student dancers to a fault with flooring. The most com-
mon complaint from the injured dancers was a slippery floor,
with the second most common being too much friction in the
interface between the foot/shoe and the floor. The majority of
the injuries to the professionals occurred on a stage surface,
and about half of the professionals’ injuries occurred during
performances. In response to these data, optimal maintenance
practices are essential to ensuring a surface properly prepared
for the type of dance to be performed on the floor and the
footwear to be worn (or the lack of footwear for some genres).
However, this responsibility rests with the dance facility and,
therefore, hazardous conditions may be outside the influence
of a health care provider unless he or she is employed by the
responsible dance company or university.
Footwear
Most genres of dance employ specific types of shoes,
although modern/contemporary dancers and certain eth-
nic style dancers do not wear shoes. Unshod dancers are
especially challenging when foot orthotics are indicated for
treatment or prevention of injury. Dance shoes in genres
that require them (eg, ballet, jazz, tap, flamenco, Irish) are
minimally force dispersive by nature of their construction.
Ballet slippers, jazz shoes, and Irish dance shoes are little
more than a layer or two of leather or microfiber material.
Flamenco shoes have high heels suggested to be a cause of
injuries to the feet and lower back.42,43 Despite the possibil-
ity that cushioned shoes help dissipate energy when landing
on a floor57,147 and provide shock absorption to reduce the

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Preventing dance injuries
chance of lower limb pathology,148 dancers are unlikely to
incorporate these into their rehearsals because they need to
precisely replicate their performance conditions and because
the specific “feel” of the floor by their feet is essential to their
success in dancing.
Pointe shoes in ballet are supportive of the foot, having
been shown to provide stiffness with compromise of the
midfoot ligaments.149 They are a necessity for en pointe
technique, but have been associated with foot pain and
injuries.150,151 Their ability to dissipate force through the sole
appears to be better than ballet slippers.152 Some evidence
suggests that a soft, partial pointe (ie, demi-pointe) shoe is
helpful in reducing leg, ankle, and foot injuries in adolescent
dancers when these shoes are worn as a prelude to initiating
pointe training.153
Certainly, research on footwear in dance is insufficient at
present.154 In short, health care providers must work within the
constraints of the footwear – or lack of footwear – customary
within the dance genres practiced by their dancer-patients.
Dancing en pointe
Dancing en pointe is a specific type of ballet that can give
rise to numerous injuries in young dancers if proper care is
not exercised in deciding when a dancer is ready to begin
pointe training.155,156 It requires an extreme amount of plantar
flexion157–159 that includes motion among the bones of the
feet160 in order to stand on the toe tips in pointe shoes (Figure 1).
The physical test – among several evaluated – found to be most
associated with appropriate readiness for pointe work is the
“Airplane test,”161 an assessment substantially related to core
stability. The dancer stands on one leg while bending over at
the waist and extending the other leg backward such that it
and the trunk are parallel to the floor. In this position, then, the
dancer is facing downward at the floor. The upper extremities
are extended outward from the shoulders, also parallel to the
floor. The dancer then lowers herself by flexing the knee of
the support leg, simultaneously keeping the trunk and non-
support leg parallel to the floor and bringing the fingertips of
both hands downward, while maintaining extended elbows, to
touch the floor in front of the face. The dancer then extends the
knee and upper extremities to return to the starting position.
Four out of five consecutive trials performed with good bal-
ance and without valgus or varus motion of the support knee
are required to pass the test.161
Other factors related to success in moving to ballet en
pointe include foot strength, ankle range of motion, stabil-
ity and control during rising to the toes and lowering, and
seriousness of ballet training as evidenced by the number
of days and hours per week the student attends ballet
classes.155,156 Implementing solely an age-based criterion for
advancement to pointe is not appropriate.88,156 Health care
providers who have occasion to consult with young dancers
and their parents about dancing en pointe should become
conversant with the demands of this activity.
Specialized health care access for dancers
Most dancers do not enjoy access to specialized health care that
is equivalent to their counterparts in traditional sports.30,162–164
Moreover, when they do approach the health care profession,
the response they receive is often unconstructive or, even,
discouraging.40,165–167 Russell and Wang167 found that 80%
of university dancers surveyed reported that they felt their
health care providers did not understand dancers and 43%
Figure 1 A ballet dancer standing en pointe. Note the extreme talocrural plantar
exion and the architecture of the midfoot, the combination of which is required for
the dancer to attain this position.

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Russell
indicated that their health care providers gave unhelpful
advice. Empirically, most dancers will report at least one – and
often several – instances of being told by a practitioner to
“stop dancing” as a method to manage their injuries. While
this advice is sound under certain injury circumstances that
require complete rest (eg, a tibial stress fracture), dancers
loathe receiving it as a carelessly offered, supposed panacea.
From the perspective of artists, health care workers could
better serve them by purposefully learning about performing
arts medicine168 and by attending dance performances as a
method for understanding the physical demands of dance.165
If reduction or discontinuance of dancing is warranted for
an injury, one method of improving the relationship between
providers and dancers, and better serving the physical nature
of dance, is for those in health care to prescribe rehabilitative
regimens that either moderate dancers’ dancing or define suit-
able activity alternatives during recuperative periods (rather
than suggest they “stop dancing”).
Appropriate, specialized health care for dancers is nec-
essary not only for proper care of injuries, but for preven-
tion of new injuries or worsening of current injuries. For
example, anterior leg pain that a dancer considers as “shin
splints” – and a corollary of participating in dance – may
have disastrous sequelae. As one dramatic illustration of this,
Martinez and Murphy169 described their experience with a
male professional ballet dancer exhibiting a radiologically
confirmed tibial stress fracture in the anterior cortex that
did not respond to conventional treatment. To address this,
intramedullary nailing was performed. However, the dancer
did not seek consistent follow-up care, and 4 months post-
surgery he landed from a jump, re-fractured the tibia, and
bent the nail, thus necessitating revision surgery.
Notably, Bronner et al24 reported a substantial decrease
in time-loss injury incidence and a concomitant decrease
in medical expenditures following implementation of a
health care program in a professional modern dance com-
pany. They compared injury records for 2 years without
health care intervention against the records for 3 years with
provision of comprehensive care. Their definition of injury
was “any musculoskeletal complaint resulting in financial
outlay”. Injury rates, measured by the quantity of new work-
ers’ compensation claims amongst the company’s dancers,
dropped markedly, declining from about 80% across the first
3 years of the study to 24% in the fourth year and 17% in the
fifth year. The number of injuries per 1,000 hours of dance
exposure also fell.
In a follow-up study, Ojofeitimi and Bronner39 slightly
refined their injury definition: “a physical insult that
required financial outlay (WC [workers’ compensation] or
self insurance) or caused a dancer to cease dancing beyond
the day of injury (time-loss injury)”. They studied a further
3 years of data from their experience with the professional
modern dance company and found overall that the company
exhibited a 34% decrease in injury incidence, 66% fewer
workers’ compensation claims, and a 56% decline in days
lost from dance. These two studies are highlighted because
they imply that attentive health care for dancers, both pre-
ventive and restorative, is associated with amelioration of
injury rates.
Conclusion
Dance is a rigorous physical activity accompanied by a large
quantity of injuries in its participants. In spite of some simi-
larities dance shares with sports, a number of differences and
challenges present themselves to those charged with caring
for dancers. Several elements related to how dancers approach
their art form are worthy of consideration in determining
how best to reduce their injuries. In summary, and in light of
the literature review presented above, the following current
perspectives are offered to professionals in dance, health,
research, and health care to support reducing and preventing
dance-related injuries.
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.
Disclosure
The author reports no conflict of interest in this work.

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Preventing dance injuries
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