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Abstract

Dancers need their feet to be healthy and pain-free; therefore, the footwear they use is of great importance. Footwear has the potential to enhance or restrict movement and impact the dancer's body in various ways. To evaluate the effects of footwear on dancers, in particular the effects on foot motion and injury during dance movements, we undertook a systematic review of the literature. The major databases were searched for articles on theatrical dance styles and dance footwear. Sixteen articles were selected for inclusion in this study, ten on ballet and the remainder covering a variety of other genres. The contribution of dance shoes to the quality of dance movement is a relatively unexplored subject; little experimental research has been done. Prospective scientific evidence is needed to support or disprove traditional beliefs regarding the effects of footwear on dance performance and dancers' health.

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... HH shoes are also worn during many kinds of dance (ballroom, flamenco, jazz, etc.), an activity midway between sport and art [8][9][10]. ...
... Future studies may include also assessments of muscular activity via surface electromyography, as well as evaluations of the actual forces and moments at the single joints via force platforms [1-5, 7, 11-14, 16, 17, 21, 22, 33]. Additionally, the assessment of HH gait should also be performed during activities such as flamenco and ballroom dance, where a natural action is modified to serve artistic and sports purposes [8][9][10]. ...
... Body landmarks: right and left tragus (1, 2), acromion(3,4), olecranon (5, 6), ulnar styloid process(7,8), anterior superior iliac spine (9, 10), greater trochanter(12,13), femoral lateral epicondyle(14,15), fibular malleolus(16,17); on the midline, sacrum(11). Markers no. ...
Article
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Purpose The purpose of this study was to assess the modifications in body center of mass (CoM), total mechanical work and walking characteristics during low-heeled and high-heeled gait performed in ecological conditions. Methods The 3D coordinates of 19 body landmarks were recorded by an optoelectronic motion analyzer in 13 women while walking overground at self-selected speed with either low-heeled or high-heeled shoes (minimum height, 70 mm). Using mean anthropometric data, the CoM was estimated, and its position evaluated during normalized gait cycles. Shoulders, pelvic and knee orientations were also assessed together with estimates of total mechanical work. Results High-heeled walking was performed with significantly lower horizontal speed (p < 0.05) but with the same cadence than low-heeled walking. During the whole gait cycle, the CoM (calculated from the malleolus landmarks) was 3 % lower during high-heeled walking (p < 0.05), had higher vertical displacements and vertical velocity modifications (p < 0.001), and it was significantly more anterior (p < 0.01). On average, walking with high heels at self-selected speed required a 16 % higher total mechanical work, but the difference was not significant. At heel strike with high heels, the shoulders were more inclined (p < 0.05), the support limb knee was significantly more flexed (p < 0.05), with a 12 % reduced total range of motion (p < 0.001), while the back limb knee was less flexed (p < 0.05). Conclusions Wearing high-heeled shoes significantly alters the normal displacement of human CoM; high-heeled gait exaggerated female walking characteristics with a more anterior CoM position, a wider vertical movement and a slower velocity.
... In a recent systematic review on the effects of footwear on dance, only 16 out of 242 articles met the inclusion requirements (experimental methodology, referred to theatrical dance styles, and examined the role of footwear). 3 Injuries to the foot and ankle account for 9% in males and 10% in females of all injuries, 4 and self-report causes of injury suggest that 12% of all injures are caused by dance shoes, 5 and landing from a jump onto one leg accounted for 92% of the recorded injuries. 6 Dance shoe designs have benefitted from the material developments within the sports industry, though the aesthetic requirements have often taken precedence over functuality. ...
... 6 Dance shoe designs have benefitted from the material developments within the sports industry, though the aesthetic requirements have often taken precedence over functuality. 3 The material development and sole design to improve cushioning, support, and guidance 2 through increased midsole thickness has been negatively associated with stability during locomotion. 7 Robbins and Waked 8 noted that participants wearing thick-soled shoes implement unconscious movement strategies, such as reducing joint flexion angles, in an attempt to compress the midsole material and increase stability. ...
... In their review, Fong Yan et al. 3 commented that dance shoe selection for dance class, rehearsals, and performances is mainly based on aesthetic attributes rather than mechanical performance capabilities. Time motion analysis of dance has shown that during performances, there are approximately 5 jumps and 3 changes in direction per minute, 17 though this is comparatively low compared to field and court sports. ...
Article
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Landing from jumps is one of the main causes of injury within dance. A number of studies have reported a negative effect of shoe midsole thickness on lower limb kinematics during running due to the reduction in afferent sensory outputs from the foot's epithelium. The purpose of this study was to examine the influence of varying midsole thicknesses in dance shoes on dynamic postural stability during a single-leg landing. Twenty-eight female undergraduate dance participants volunteered for the study. They carried out three trials under four conditions: barefoot and in ballet flats (2 mm midsole thickness), jazz shoes (7 mm), and dance sneakers (30 mm). The task consisted of a single-leg forward jump over a hurdle at 50% of their maximal vertical jump height, landing on a force platform, and balancing for 3 seconds. The stability indices for vertical stability (VSI), anterior-posterior stability (APSI), medial-lateral stability (MLSI), and dynamic postural stability (DPSI) were calculated using Wikstrom's revised method. Significant differences were reported between the midsole thicknesses for both DPSI and VSI (p<0.01). No statistical differences were noted for the indices SPSI or MLSI. The present data agree with the running studies in that increased midsole thickness has a negative influence on landing stability.
... Classical ballet is an exceptionally physical performing art form. While audiences may enjoy the grace and artistic merit of ballet, this demanding activity requires repetitious, rigorous training and performance schedules (Yan, Hiller, Smith, & Vanwanseele, 2011), which may contribute to a high annual incidence of injuries (67%-95%) in this group (Byhring & Bo, 2002). In female dancers, overuse injuries to the lower extremities are the most prevalent (Allen, Nevill, Brooks, Koutedakis, & Wyon, 2016). ...
... The toe box of the pointe shoe is constructed from layers of hessian, glue and fabric (Kadel, 2006), which must be strong enough to support the dancer en pointe, but be malleable enough to allow articulation of the joints of the foot and ankle. However, in several cases, professional dancers are required to change their pointe shoes once or twice per performance, due to rapid deterioration of the shoe's integrity (Cunningham, DiStefano, Kirjanov, Levine, & Schon, 1998;Yan et al., 2011). With this deterioration comes a softening of the shank and the satin outer-lining, which causes reduced rigidity of the pointe shoe. ...
... Previous dance studies have found injuries can be caused predominantly by inadequate stabilisation of the foot and ankle (Yan et al., 2011). A worn pointe shoe with reduced structural integrity may reduce the ability of a dancer to correct postural sway, resulting in accelerated rates of muscle fatigue, ankle sprains or falls (Beynnon, Murphy, & Alosa, 2002). ...
Article
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Dancing en pointe significantly increases the risk of lower limb injuries by placing the foot and ankle joint in unfavorable positions. The pointe shoe, worn predominantly by female ballet dancers may aid movement and acts as a major stabilizer of the foot. The deterioration in pointe shoe structure with excessive wear may increase a dancer's risk of ankle and foot related injuries by placing excessive load on the joints when the foot is poorly aligned. The purpose of this study was to investigate differences in foot and ankle kinetics and kinematics between new and worn pointe shoes. Fifteen professional ballet dancers completed a series of bourreés (walking en pointe) in both new and worn pointe shoes (>20 h wear). Force and pressure analyses determined peak ground reaction force and centre of pressure velocity. A 2D kinematic analysis determined the magnitude of mid-foot flexion and ankle plantarflexion. The worn pointe shoe caused significantly greater mid-foot flexion (P < 0.01) and ankle plantarflexion (P < 0.01) en pointe compared to the new pointe shoe. No significant changes in peak force (P = 0.855) or centre of pressure velocity (P = 0.297) were observed between conditions. The reduced structural integrity of the worn pointe shoe may be a causal factor for kinematic changes and subsequent pain and lower limb injuries in professional dancers.
... Various studies have related foot problems to flamenco dancing 5,18,19 and other forms of dance. [20][21][22][23][24][25] Indeed, in 2008 the Spanish National Institute of Health and Safety at Work declared flamenco art performers to be a high-risk group, 26 noting their mostly poor working conditions and their lack of appropriate education, information, and awareness concerning health issues in general and the prevention and avoidance of occupational hazards in particular. Given the overriding importance of the lower limbs in flamenco, one has to consider flamenco dancers as an at-risk group highly susceptible to foot lesions. ...
... The literature in general shows dancing to be a factor that increases the prevalence of hallux abducto valgus. [23][24][25][26][27] The present result is similar to that reported for a group of ten flamenco dancers by Bejjani et al, 3 although in a study of retired ballet dancers, Einarsdó ttir et al 28 found no increase in the hallux abducto valgus angle compared with a population that did not practice this activity. The percentage obtained in this present study was greater than the 40% obtained in a previous study performed by the same research group but on a smaller sample. ...
... Claw toe was present in 43.2% of the study population, and fifth toe abducto varus in 6.8%. In their systematic literature review of dance shoes, 23 two articles on flamenco were considered, concluding that the footwear was, indeed, a risk factor for claw toe, a conclusion that reflected the findings of other authors. 20 In the present study, however, the presence of hallux valgus or claw toe was unrelated to the height of the heels, with no significant differences in heel height of individuals who had hallux valgus and those who did not or between those who had claw toe and those who did not (P ¼ .621 ...
Article
Background: The foot is the main element of artistic creation in flamenco dancing. At the professional level, the foot undergoes high musculoskeletal demands, predisposing the development of podiatric pathologic disorders in this group. The principal objective of this study was to determine the most common foot lesions in professional female flamenco dancers. Methods: In a cross-sectional observational study of 44 female professional flamenco dancers, the participants completed a short questionnaire about their demographic features, number of hours danced per week, and years of professional activity. Any foot lesions presented by the participant were also recorded. Results: Some type of pathologic foot condition was noted in 75% of the women, with a particularly high prevalence of hallux abducto valgus (61.4%), hypermobility of the first ray (43.2%), claw toe (40.9%), and varus fifth toe (37.5%) compared with the general population. No significant differences in the presence of pathologic disorders of the foot were found according to the time dedicated to dance or the years of professional activity. Conclusions: Female flamenco dancers in this study had a high prevalence of podiatric medical problems: some kind of pathologic abnormality of the foot was present in 75% of the participants. Hallux abducto valgus, claw toe, and hypermobility of the first ray were the most common pathologic disorders observed.
... Proper selection of footwear has the potential to attenuate impact forces transmitted into the body 4 Despite dancers performing approximately 200 jumps per 1.5 hour class each day 5 , the impact attenuation properties of dance shoes have not been quantified. 6 The relationship between the impact attenuating characteristics of shoes and injury risk is not yet fully understood, however, several studies have shown that shoe design has the potential to reduce impactrelated injury risk. [7][8][9][10] Athletic shoe testing has shown that various midsole materials are capable of attenuating impact. ...
... Research exploring the effect of dance footwear is sparse in comparison to athletic footwear. 6 The primary aim of this study was, therefore, to quantify the impact attenuation characteristics of different designs of jazz shoes using a mechanical testing rig. We hypothesised that the jazz sneaker, with more cushioning and a thicker outsole, would have greater impact attenuation capacity. ...
Article
Objectives: To quantify the impact attenuation properties of the jazz shoes, and to investigate the in-vivo effect of four jazz shoe designs on lower limb joint stiffness during a dance-specific jump. Design: Repeated measures. Methods: A custom-built mechanical shoe tester similar to that used by athletic shoe companies was used to vertically impact the forefoot and heel region of four different jazz shoe designs. Additionally, dancers performed eight sautés in second position in bare feet and the shoe conditions. Force platforms and 3D-motion capture were used to analyse the joint stiffness of the midfoot, ankle, knee and hip during the jump landings. Results: Mechanical testing of the jazz shoes revealed significant differences in impact attenuation characteristics among each of the jazz shoe designs. Gross knee and midfoot joint stiffness were significantly affected by the jazz shoe designs in the dancers' jump landings. Conclusions: The tested jazz shoe designs altered the impact attenuating capacity of jump landing technique in dancers. The cushioned jazz shoes are recommended particularly for injured dancers to reduce impact on the lower limb. Jazz shoe design should consider the impact attenuation properties of the forefoot region, due to the toe-strike landing technique in dance movement.
... Dancers are on their feet most of the time, and healthy, pain-free feet are imperative for dancers regardless of age or level of accomplishment (Fong Yan, Hiller, Smith, & Vanwanseele, 2011). Whereas in most other sports the shoes have improved considerably in recent decades in terms of reducing shock, supporting the leg and improving stability during locomotion, the standard ballet shoe has remained quite similar over time (Pearson & Whitaker, 2012;Wyon, Cloak, Lucas, & Clarke, 2013). ...
... Dance shoe design driven by aesthetic requirements has often taken precedence over functionality. It has been noted that there is a trade-off between the "feel of the floor" provided by the soft ballet shoes when executing the fine movements required in dance, and cushioning and shock absorption, such that increasing the latter reduces the former (Fong Yan et al., 2011;Pearson & Whitaker, 2012;Wyon et al., 2013). Thus, new designs for ballet shoes with inserted proprioception-enhancing insoles (e.g., slightly spiky insoles) might improve dancer's abilities in terms of balance and stability, and confer reduced risk for injuries. ...
Article
With the aim of determining both the acute and the chronic effects of textured insoles on the ankle discrimination and performance ability of dancers, 60 ballet dancers from the Australian Ballet School, aged 14-19 years, were divided into three groups (two intervention groups and a control group), age- and level-matched. In the first 5 weeks (weeks 1 to 5), the first intervention group (GRP1) was asked to wear textured insoles in their ballet shoes and the second intervention group (GRP2) was not given textured insoles to wear. In the next 5 weeks (weeks 6 to 10), GRP2 was asked to wear the same type of textured insoles and GRP1 did not wear the textured insoles. The control group (CTRL) did not wear textured insoles during the whole 10 weeks. All participants were tested preintervention, after 5 weeks and after 10 weeks for ankle discrimination score (AUC scores). Dance performance was assessed by 5-7 dance teachers. Pre-to-post change in AUC scores was significantly greater for the groups wearing insoles than for the controls (P = .046) and the size of pre-to-post changes did not differ between the two intervention groups (P = .834). Significant correlation was found between ankle discrimination score and performance scores, using the textured insoles (r = .412; P = .024). In conclusion, the stimulation to the proprioceptive system arising from textured insoles worn for five weeks was sufficient to improve the proprioceptive ability and performance ability of ballet dancers.
... They used different methods, and a consensus emerged that a worn pointe shoe in a dance movement resulted in a significantly increased swing area, especially in the forefoot and mid-foot. Previous studies have found that injuries in ballet dancers can result from inadequate stabilization of the foot and ankle [39]. Pointe shoes are supportive of the foot, which provide stiffness with the compromise of the midfoot ligaments. ...
... The footwear that is needed for each type of dance must also be determined, especially in ballet. It has been suggested that ballet dance footwear manufacturers should consider biomechanical design features in shoe manufacturing, as opposed to just focusing on the aesthetics of the shoes themselves [39]. In support of this, ground reaction force analysis has been seen as a variable of interest because of its potential correlation with increased injury rates. ...
Article
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Professional ballet dancers can be classified as dance artists and sports performers. This systematic review aims to consider the biomechanical risk factors for foot and ankle injuries in ballet dancers, as this could potentially reduce the impact that ‘cost of injury’ may have on ballet companies. An additional outcome was to examine the effects of injury on the career of ballet dancers. This study searched articles in four electronic databases for information in peer-reviewed journals. The included articles examined the relationships between biomechanical factors and the relationship between ballet shoes and foot performance. There were 9 articles included in this review. Among these articles, two focused on the peak force of the foot using two types of pointe shoes, three focused on overuse injuries of the ballet dancer’s foot, one article focused on the loading of the foot of a dancer, and three articles focused on the function and biomechanics of the foot in dancers. This review also found that the pointe shoe condition was the most important factor contributing to a foot injury; overuse injury related to high-intensity training and affected both the ankle and the foot; and metatarsophalangeal joint injury related to the function and structure of the foot. Finally, strengthening the lower extremity muscle is also a recommendation to improve muscle coordination and reduce injuries.
... Studies have suggested that ballet injuries are associated with intrinsic factors such as female gender, age, reduced functional turnout, pronated foot, insufficient ankle plantar flexion range of motion, and previous contralateral inversion ankle sprain (Kenny et al., 2016;Campbell et al., 2019). The extrinsic risk factors among female dancers proposed to increase ballet injury were training errors (Kaufmann et al., 2021), inappropriate training methods (Kaufmann et al., 2021), technique demands and style of dance (Yin et al., 2019), shoes, environmental temperature (Fong Yan et al., 2011), floors and costumes (Barringer and Schlesinger, 2004), and psychosocial factors (Byhring and Bø, 2002). Although ballet shoes are an important consideration, their role is rarely discussed in the current literature. ...
Article
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Ballet dancers are thought to be at higher risk of lower extremity injury. This objective of this study was to describe the self-reported incidence, location, and factors associated with lower extremity injury in collegiate ballet dancers. Two hundred and forty-nine female ballet dancers responded to a questionnaire that addressed their injury event/location, dance behavior over the past 2 years, and overall dance history. Behaviors assessed included the following: types and number of shoes worn (pointé shoes/ballet slippers), wear time, training time (session frequency and duration), use of warm-up/cool-down, and use of a strengthening program and lower extremity accessory. Overall dance history included age of the onset of training, total years of experience, and number of dance styles. Backward multivariable logistic regression analysis was used to determine the extent to which variables measured were associated with injury. Ankle injury was the most prevalent injury. Years of wearing pointé shoes (adjusted odds ratio = 1.21, p = 0.01) and days/weeks in pointé shoes (adjusted odds ratio = 1.26, p = 0.04) were associated with an increased risk of injury; while additional strengthening (adjusted odds ratio = 0.39, p = 0.02) and use of lower extremity accessories during classes/rehearsals (adjusted odds ratio = 0.64, p = 0.01) were protective associations. These findings suggested that the use of pointé shoes, lower extremity accessories, and additional exercise should specifically be recorded during evaluation of injured ballet dancers; and must be considered potential factors to modify during rehabilitation.
... The proprioceptive function of ballet dancers may be altered by injuries [6] and footwear has the potential effect of restricting foot motion, leading to loss of stability and injuries [7]. Thus we can suppose that the use of ballet shoes may also play a role in postural stability, by affecting foot motion to control body oscillations. ...
Article
The purpose of this study was to describe the effects of lower limb positioning and shoe conditions on stability levels of selected single leg ballet poses performed in demi-pointe position. Fourteen female non-professional ballet dancers (mean age of 18.4±2.8 years and mean body mass index of 21.5±2.8kg/m(2)) who had practiced ballet for at least seven years, without any musculoskeletal impairment volunteered to participate in this study. A capacitive pressure platform allowed for the assessment of center of pressure variables related to the execution of three single leg ballet poses in demi pointé position: attitude devant, attitude derriére, and attitude a la second. Peak pressures, contact areas, COP oscillation areas, anterior-posterior and medio-lateral COP oscillations and velocities were compared between two shoe conditions (barefoot versus slippers) and among the different poses. Barefoot performances produced more stable poses with significantly higher plantar contact areas, smaller COP oscillation areas and smaller anterior-posterior COP oscillations. COP oscillation areas, anterior-posterior COP oscillations and medio-lateral COP velocities indicated that attitude a la second is the least challenging and attitude derriére the most challenging pose.
... 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. ...
Article
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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.
... 14 Según una revisión sistemática reciente, falta evidencia para determinar si el calzado tiene algún efecto en la movilidad del pie y en las lesiones en bailarines de ballet. 26 ...
Article
Full-text available
Ballet is a sport that is being practiced frequently. Dancers are exposed to sport injuries and have predisposing factors for them. For that reason, we made a literature review to show a general approach of risk factors, incidence of injuries and their distribution in ballet dancers. There are several risk factors for injuries such as arch movement, anatomic anomalies, dancing techniques, dancing discipline and postural stability. About the 50 % of dancers present injuries each year and the majority of them are adolescents. The most frequent ones occur as a result of overuse and are mainly located in the lower extremities. We conclude that they need a special attention as occupational group, more information about risk factors and that there should be more possibilities to design prevention programs on this respect.
... A key milestone for all aspiring young female dancers is starting pointe work 1 . It is well-known that pointe shoes place an increased demand on the joints of the feet [4][5][6] . The body must be gradually prepared to control the foot during pointe work if it is to accept this demand and therefore allow the dancer to improve her technique en pointe. ...
Data
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... These include heterogeneous populations of both ballet and nonballet dancers. 3,13,17,18,28,35,38,39 The majority of ballet injury investigations predominantly report lower extremity injuries. 4,16,24,26,[31][32][33][34] Less frequently reported injuries include back and upper extremity injuries. ...
Article
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Background: Most published studies on injuries in the ballet dancer focus on the lower extremity. The rigors of this activity require special training and care. By understanding prevalence and injury pattern to the musculoskeletal system, targeted prevention and treatment for this population can be developed. Purpose: To determine the incidence and prevalence of musculoskeletal injuries in ballet. Study design: Systematic review; Level of evidence, 4. Methods: A systematic review registered with PROSPERO was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Level 1 through 4 evidence studies reporting incidence of musculoskeletal injuries in male and female ballet dancers were included, with the numbers and types of injuries extracted from each. Injury rates were recorded and calculated based on professional status, sex, and nature of injury. Incidence was defined as number of injuries sustained over a specific time. Prevalence was defined as proportion of subjects with an injury at a given point in time. Results: The studies analyzed reported injury incidence or prevalence in more than 1365 amateur and 900 professional dancers. The mean age was 16.2 years among amateur and 27.0 years among professional dancers. The incidence of injury among amateur dancers was 0.99 and 1.09 injuries per 1000 dance hours in males and females, respectively; 75% of injuries were overuse, with similar rates among males and females. In professional dancers, the incidence of injury was 1.06 and 1.46 injuries per 1000 dance hours in males and females, respectively, and 64% of female injuries were overuse, compared with 50% in males (P < .001). Only 3 studies provided prevalence data, including 62% prevalence of lumbosacral pain, 58% painful snapping hip, and 29% patellofemoral pain. Lower extremity injuries comprised 66% to 91% of all injuries, with the foot and ankle accounting for 14% to 57%. Conclusion: The overall incidence of injury among amateur and professional ballet dancers is 0.97 and 1.24 injuries per 1000 dance hours, respectively. The majority are overuse in both amateur and professional dancers, with amateur ballet dancers showing a higher proportion of overuse injuries than professionals (P < .001). Male professional dancers show a higher proportion of traumatic injuries, accounting for half of their injuries (P < .001).
... Strategies to improve proprioceptive feedback from the plantar sole of the foot were related mainly to the use of different types of shoes, different types of insoles, and a different type of surface contact. 17,[26][27][28] It was suggested that insoles provide the sensory feedback needed for accurate foot positioning and decrease some biomechanical variables (such as ankle dorsiflexion at foot-strike and maximum ankle eversion). The main outcome of the insoles was to reduce the risk of injury in athletes using those insoles. ...
Article
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Methods: Forty-four dancers from the Australian Ballet School, ages 14-19 yrs, were tested for static and dynamic PB and AIMD under two conditions: in ballet shoes, and in ballet shoes with textured insoles inserted. Results: Female dancers demonstrated a significant inverse relationship between AIMD and static PB in the medio-lateral direction when wearing ballet shoes, but not when wearing textured insoles. Male dancers showed a non-monotonic relationship when tested with ballet shoes only, but a significant inverse relationship between AIMD and dynamic PB in the vertical direction and with the waist/head cross-correlation acceleration in the three movement directions when they were tested with textured insoles. Conclusions: Male dancers demonstrated an improved association between dynamic PB and proprioception ability when using textured insoles, suggesting that the increased afferent information from the plantar surface had a beneficial effect on proprioception feedback about their PB. Conversely, for female dancers, that association was present when wearing ballet shoes, but not when using textured insoles, suggesting that the increased afferent information for female dancers who already had high proprioception ability was "overloaded" by wearing the textured insoles.
... Whilst supported by many authors as important to promote superior performance and prevent injury [33,34], stretching during warm-up and cool-down has not always been found to prevent injury [35,36]. Finally, a systematic review on the impact on footwear in dance injury reported a relationship between pointe shoes and foot and nail trauma, but reported a lack of good experimental research in the area [37]. ...
Article
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Background: The popularity of Irish dancing has increased enormously since the success of 'Riverdance, The Show'. The evolution of Irish dance to professional status has placed increased demands on dancers, yet scant investigation of musculoskeletal pain and injury among Irish dancers has been undertaken. This review examined the evidence regarding the rate of injury among Irish dancers, and the factors associated with injury risk. Methods: Electronic databases were searched by two independent assessors. Studies were included if they examined the rate of musculoskeletal pain or injury among Irish dancers, and/or the factors associated with musculoskeletal pain or injury among Irish dancers. Study quality was assessed using the Oxford levels of evidence scale. Results: Only two retrospective studies met the eligibility criteria, with no prospective studies on injury rate having been published. These studies indicate that lower limb injuries, especially in the foot and ankle, are most common in Irish dancers. There is preliminary evidence that dancers who did not complete a warm-up and cool-down, who did not use split-shoe sneakers while training, and who perform at higher levels of competition may be at greater risk of injury. Conclusions: No high quality prospective studies of injury have been completed in Irish dance. The existing retrospective studies demonstrate that foot and ankle injuries are the most common, and some potential contributing factors to injury have been identified. However, prospective studies which evaluate these risk factors for injury, as well as common injury risk factors identified in other forms of dance, are required.
... 14 Según una revisión sistemática reciente, falta evidencia para determinar si el calzado tiene algún efecto en la movilidad del pie y en las lesiones en bailarines de ballet. 26 ...
Article
Full-text available
Ballet is a sport that is being practiced frequently. Dancers are exposed to sport injuries and have predisposing factors for them. For that reason, we made a literature review to show a general approach of risk factors, incidence of injuries and their distribution in ballet dancers. There are several risk factors for injuries such as arch movement, anatomic anomalies, dancing techniques, dancing discipline and postural stability. About the 50 % of dancers present injuries each year and the majority of them are adolescents. The most frequent ones occur as a result of overuse and are mainly located in the lower extremities. We conclude that they need a special attention as occupational group, more information about risk factors and that there should be more possibilities to design prevention programs on this respect.
... These include heterogeneous populations of both ballet and nonballet dancers. 3,13,17,18,28,35,38,39 The majority of ballet injury investigations predominantly report lower extremity injuries. 4,16,24,26,[31][32][33][34] Less frequently reported injuries include back and upper extremity injuries. ...
... Die größte Belastung entsteht beim Übergang vom flachenFuß(normaler Stand mit Sohlenvollbelastung) oder der halben Spitze (Zehenstand) in die Position auf der Spitze im Zehengliedbereich. Die Standfläche des gesamten Körpers verringert sich dabei auf einen Bruchteil [12] (vgl. Aufbau). ...
Article
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Zusammenfassung Der Spitzenschuh zählt zu den charakteristischen Arbeitsschuhen im professionellen Bühnentanz. Als Arbeitsmittel dient er v. a. im klassischen Tanz der Umsetzung charakteristischer technischer Anforderungen. Vor deutlich über 100 Jahren entwickelt, stellt er in seiner seitdem nahezu unveränderten Form einen Kompromiss zwischen Ästhetik, Funktion, Sicherheit und Gesundheit dar. Aufgrund der hohen Spezifik dieses Schuhs sind Besonderheiten zu berücksichtigen, die von arbeitsmedizinischer Relevanz sind. Der Beitrag thematisiert ausgewählte Aspekte.
... Similarly, the wearing of high heel shoes by female dancers exacerbates weight transfer forces [45]. which can subsequently increase foot, knee and back injuries [46]. ...
Article
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In spite of the extensive research on incidence site and type of injury in ballet and modern dancers, limited studies on injury in DanceSport have been reported. Therefore, this study determined retrospectively (within last 12 months) incidence, severity, site and type of injury, between gender and age-class in DanceSport. Participants were 97 international sport-dancers (female, 41; male, 56). Sixty-six (69%) dancers reported 96 injuries (1.00 (range = 4)) injuries per dancer) and an injury incidence of 1.7 (range = 14) per 1000 h. Females revealed significantly higher median injury incidence (females, 2.6 (range = 14); males, 1.9 (range = 9), p < 0.05) than males. A total of 61.5% of all injuries recorded were traumatic with a significant gender difference (Wald chi-square = 11.616, df = 1, p < 0.01). Injury severity was 3 (range 240) days with an interaction effect between gender and age-class (Wald chi-square = 251.374, df = 3, p < 0.001). Meanwhile, 72.3% of the dancers reported not including sport specific exercises besides dancing. These findings show gender and age-class differences in injury incidence, type and severity. Therefore, to reduce the likelihood of injuries, the implementation of supplemental DanceSport specific exercises that also considers the gender and age-class anatomical, functional, and choreographic demand differences in the training program should be recognized.
... For additional context, several literatures and systematic reviews have been published in the past decade on the topic of classical ballet, but mostly addressing issues such as injuries and rehabilitation processes [3][4][5][6], finding and compiling techniques that may help dancers to prevent injuries or to recover from them. However, four systematic reviews were found regarding motor behavior and biomechanics analysis associated with dance [2,[7][8][9]. By studying isolated parts of the body or analyzing a specific movement, researchers reviewed studies in order to understand what has been explored in the dance field and what is still to be discovered. ...
Article
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Background Human performance in classical ballet is a research field of growing interest in the past decades. Technology used to acquire data in human movement sciences has evolved, and is specifically being applied to evaluate ballet movements to better understand dancers’ profiles. We aimed to systematically review sensing technologies that were used to extract data from dancers, in order to improve knowledge regarding the performance of ballet movements through quantification. Methods PubMed, MEDLINE, EMBASE, and Web of Science databases were accessed through 2020. All studies that used motor control tools to evaluate classical ballet movements, and possible comparisons to other types of dance and sports movements were selected. Pertinent data were filled into a customized table, and risk of bias was carefully analyzed. Results Eighty studies were included. The majority were regarding classical ballet and with pre-professional dancers. Forty-four studies (55%) used two or more types of technology to collect data, showing that motion capture technique, force plates, electromyography, and inertial sensors are the most frequent ways to evaluate ballet movements. Discussion Research to evaluate ballet movements varies greatly considering study design and specific intervention characteristics. Combining two or more types of technology may increase data reliability and optimize the characterization of ballet movements. A lack of studies addressing muscle–brain interaction in dancers were observed, and given the potential of novel insights, further studies in this field are warranted. Finally, using quantitative tools opens the perspective of defining what is considered an elite dancer.
... Though an understudied area, both shoe types could increase the risk of ankle and foot injuries. 7,30 Males presented with a greater proportion of shoulder sprains and facial lacerations. Traditional partnering styles of dance often require males to lift partners above their heads, a potential cause of shoulder injuries 23,26 and a risk for facial injury. ...
Article
Methods: Data were obtained from the nationally representative National Electronic Injury Surveillance System from 2000-2013. National estimates of injuries were determined using complex sample design. Trends using 2-year intervals were calculated using linear regression and injury proportion ratios using Pearson's X2. Results: The average annual incidence of dance-related injuries requiring emergency medical attention was 17,145 per year. The number of injuries grew from 14,204 in 2000/1 to 21,356 in 2012/3, a change of 33.4% after accounting for population growth. Lower limb injuries were most common, particularly ankle and knee sprains. Females presented with a greater proportion of ankle (injury proportion ratio [IPR]=1.34, p=0.029) and foot sprains (IPR=2.11, p<0.001) but a lower proportion of shoulder sprains (IPR=0.41, p<0.001) and face lacerations (IPR=0.13, p<0.001). Younger dancers presented with a lower proportion of knee (IPR=0.79, p=0.006) and low back sprains (IPR=0.68, p=0.019). Conclusions: The average annual incidence of dance-related injuries of a serious enough nature to require presentation to the emergency department in the United States was 17,145 per year, with ankle and knee sprains being the most common. Injury numbers have increased in recent years.
... However, injury outcomes were not evaluated at the review level as the methodological shortcomings of assessing and reporting footwear may affect the injury data at the study level. We used a modified version of the Downs and Black quality assessment tool, which is intended to assess public health studies of randomised and non-randomised design (Downs & Black, 1998 Perkins, Hanney, & Rothschild, 2014, Radzimski et al., 2012Yan et al., 2011). However, the modified tool can no longer be considered valid and reliable under a modified version, unless the properties of the modified version are tested for validity and reliability (Streiner & R, 2004). ...
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Background: Many footwear characteristics are argued as risk factors for running related injuries (RRI). Several footwear assessment tools are available; however, their use in studies of RRI is unknown. Objective: This systematic review evaluated the characteristics and methods of assessing footwear in studies of RRI. Results: Twenty-five articles were included in the review. Low risk of bias was determined for 11 (44%) of the included studies. Twenty-nine different footwear characteristics were grouped into four categories: nomenclature, measurements, qualitative features, and subjective features. Fifteen different methods for assessing the 29 footwear characteristics were reported among the included studies. Only three methods were described previously, as valid and reliable. Conclusion: Differences in assessing footwear may lead to incomplete data and systematic bias between studies of footwear characteristics. Systematic footwear assessments and nomenclature are needed to evaluate the effects of footwear characteristics on RRI.
... In addition, it is worth emphasizing that the shape the spinal curvatures and motor control of the lumbarpelvic complex in women practicing dance can be influenced by high-heeled shoes, which amateur and professional dancers wear during training and performances. Also, Fong Yan et al. [7] claim that the characteristic dance position adopted by the dancers and the movement in dance shoes are associated with significant changes in the spinal curvatures. In turn, Gottschlich et al. [10] and Ball et al. [2] stressed that wrong dance technique is the cause of muscular imbalances of the spine, which may lead to hyperlordosis. ...
Article
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Purpose: The study aimed to assess the formation of the spinal anteroposterior curvatures in people practicing ballroom dancing. Methods: The study group comprised 98 people practicing ballroom dancing (58 W, 40 M; aged 35–45 years). Digital inclinometer “Baseline” was used as primary research tool. The data were analyzed based on Student’s t-test, Mann–Whitney U-test and Pearson Chi-square test. Results: Statistically significant inter-gender differences were in the values of angles determining inclination of lumbosacral section of the spine ( p < 0.001), the lumbar lordosis curvature ( p < 0.001) as well as the compensation ratio ( p = 0.002). Statistically significant dependences between the types body posture and gender ( p = 0.005) were noted. Conclusions: Women practicing ballroom dancing are distinguished with increased inclination of lumbosacral section of the spine and deeper lumbar lordosis, while men are characterized with shallowed lumbar lordosis. Women are more likely to have lordotic body posture while men are characterized by balanced body posture. The prevalence of body posture subtypes is not dependent on gender. Key words: lumbosacral inclination, thoracic kyphosis, lumbar lordosis, dance
... These dance shoes are minimally force dispersive by nature of their construction -having a layer or two of leather/microfiber material. However, footwear like pointe shoes, have been associated with foot pain and injuries as it usually compromises the midfoot ligaments 2,7,8,12 . Overuse of the tap shoes too may lead to common injuries such as tendonitis (inflammation of a tendon) as well as ankle and toe fractures. ...
Article
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Dance training is characterised by a systematic progression of repeated motions while biomechanics observe forces acting on the body, which contributes to an understanding of the technical demands and the artistry of dance. This article will explore the kinematics (the study of motion) of jumps and its correlation with dance floor and shoes. (Published on: scape.sg/venue/dance-science-articles)
... 14,15,19 Perhaps most significantly, no study has evaluated within-shoe specifications of the pointe shoe, such as "breaking in" treatments applied, shoe age, shank length, or any added padding. 14,15,19,25 Dancers wear out pointe shoes quickly (sometimes even multiple pairs in a single performance), and are known to spend extensive amounts of time modifying shoes before wearing them. 26 Despite little overall change in pointe shoe design historically, 27 there is a multitude of brands, shanks, and padding options available today. ...
Article
In the research devoted to ballet, ground reaction force (GRF) and shoe condition have been identified as possible risk factors for injury. Shoe conditions vary immensely between dancers and could indeed have significant impact on biomechanics and injury rates. Therefore, the objectives of this study were: 1. to investigate the maximal ground reaction force (GRF max) when ballet dancers land from two jump conditions in pointe shoes, in flat technique shoes, and barefoot; and 2. to explore the effects that specific pointe shoe characteristics (shoe age, shank style) have on GRF max. Twenty-one healthy female ballet majors in an elite college program volunteered for the study. All participants had similar years of classical ballet training (12.85 ± 2.37). For the study, they performed two ballet jumps, assemblé and grand jeté. Each jump was performed in the three shoe conditions mentioned previously. A total of 18 trials per subject were completed, with the order of jump type and shoe condition random-ized. Each jump was landed on a force plate, and maximal GRFs were recorded. A repeated measures analysis of variance was calculated with two within subject factors, shoe type at three levels and jump type at two levels. Tukey's post hoc test was applied to significant findings. Alpha level was set a priori at p = 0.05. Results demonstrated no significant differences in GRF max between the three shoe conditions; however, significant differences in GRF max between the jump types were identified. Post-hoc testing revealed that when dancers performed the grand jeté jump, higher GRF max was obtained compared to the assemblé jump. In conclusion, results of this study indicate that GRF max varies between ballet jumps; however, it does not appear that shoe condition significantly affects GRF max .
... However, injury outcomes were not evaluated at the review level as the methodological shortcomings of assessing and reporting footwear may affect the injury data at the study level. We used a modified version of the Downs and Black quality assessment tool, which is intended to assess public health studies of randomised and non-randomised design (Downs & Black, 1998 Perkins, Hanney, & Rothschild, 2014, Radzimski et al., 2012Yan et al., 2011). However, the modified tool can no longer be considered valid and reliable under a modified version, unless the properties of the modified version are tested for validity and reliability (Streiner & R, 2004). ...
Article
Full-text available
Background: Many footwear characteristics are argued as risk factors for running related injuries (RRI). Several footwear assessment tools are available; however, their use in studies of RRI is unknown. Objective: This systematic review evaluated the characteristics and methods of assessing footwear in studies of RRI. Design: Five online databases were searched for studies on adult runners, in running style footwear, who experienced running-related pain or injury. The methodological quality of included articles was independently assessed by two raters using a modified Downs and Black checklist. Study and participant characteristics, footwear assessment tools used, and footwear characteristics reported were extracted for qualitative synthesis. Results: Twenty-four articles were included in the review. Low risk of bias was determined for 11 (44%) of the included studies. Twenty-eight different footwear characteristics were grouped into four categories: nomenclature, measurements, qualitative features, and subjective features. Fifteen different methods for assessing the 28 footwear characteristics were reported among the included studies. Only three methods were described previously, as valid and reliable. Conclusion: Differences in assessing footwear may mask the link between footwear characteristics and injury risk. Systematic footwear assessments and nomenclature are needed to evaluate the effects of footwear characteristics on RRI.
... With dancers on their feet most of the time, the type of footwear and the floor construction are important considerations. Although the structure of the foot has an influence on functionality and flexibility of the feet (Jankowicz-Szymanska, Mikolajczyk, & Wardzala, 2015), the stiffness and thickness of materials used in both their footwear and in the studio floor have a major contributing role as well (Fong Yan, Hiller, Smith, & Vanwanseele, 2011). The supportive effects of different types of footwear on balance control have been demonstrated in the general population (Kilby & Newell, 2012), among athletes (Percy & Menz, 2001), and among dancers (Lobo da Costa, Azevedo Nora, Vieira, Bosch, & Rosenbaum, 2013), suggesting that different footwear materials can result in increased plantar surface contact area and decreased postural sway, which may improve dance performance (Pearson & Whitaker, 2012). ...
Article
Background: Postural balance (PB) is an important component skill for professional dancers. However, the effects of different types of postures and different underfoot surfaces on PB have not been adequately addressed. Purpose: The main aim of the present study was to investigate the effect of different conditions of footwear, surfaces, and standing positions on static and dynamic PB ability of young ballet dancers. Method: Thirty-six male and female young professional ballet dancers (aged 14-19) completed static and dynamic balance testing, measured by head and lumbar accelerometers, while standing on one leg in the turn-out position, under six different conditions: 1. "relaxed" posture; 2. "ballet" posture; 3. barefoot; 4. ballet shoes with textured insoles; 5. barefoot on a textured mat; 6. barefoot on a spiky mat. Results: A condition effect was found for static and dynamic PB. Static PB was reduced when dancers stood in the "ballet" posture compared with standing in the "relaxed" posture, and when standing on a textured mat and on a spiky mat (p<.05); and, Static PB in the "relaxed" posture was significantly better than PB in all the other five conditions tested. Dynamic PB was significantly better while standing in ballet shoes with textured insoles and when standing on a spiky mat, compared with all other conditions (p<.05). Conclusions: The practical implications derived from the present study are that both male and female dancers should try to be "relaxed" in their postural muscles when practicing a "ballet" aligned position; including dance practice on different types of floors and on different types of textured/spiky materials may result in skill transfer to practice on normal floor surfaces; and, both static and dynamic PB exercises should be assessed and generalized into practical dance routines.
Article
Performing artists are athletes. Like athletes, performing artists practice and/or perform most days with little off season, play through pain, "compete" in challenging environments, and risk career-threatening injury. Athletes and the Arts is a multiorganizational initiative linking the sport athlete and musician/performing artist communities. Performing artists of all ages and genre are an underserved population related to medical coverage, care, injury prevention, performance enhancement, and wellness. Sports medicine professionals are a valuable resource for filling this gap by applying existing knowledge of treating sport athletes (nutrition, injury prevention) while gaining a better understanding of performers' unique needs (hearing loss, focal dystonia) and environment. These applications can occur in the clinical setting and through developing organizational policies. By better understanding the needs of the performing arts population and applying existing concepts and knowledge, sports medicine professionals can expand their impact to a new patient base that desperately needs support.
Article
Over the past 35 years the dance domain has adopted sports medicine as a key driver of professional practice. However, similar to limitations identified within sport, research is yet to achieve its full translational potential within applied settings. This Viewpoints paper begins to identify and unpick key philosophical and methodological aspects, with the view to stimulate discussion in this rapidly growing and developing domain. Firstly, we outline a pragmatic philosophy that underpins expert professional practice as a basis to evaluate research. Secondly, we critically appraise study design characteristics to exemplify a gap between accepted scientific research protocols and professional needs within applied settings. Thirdly, we comment on recommendations/insights made within the literature against the requirements and practices of professionals. Finally, based on this appraisal we suggest an exemplar new line of research that draws upon a pragmatic philosophy; namely, motor skill refinement. In enacting these ‘new moves’, we look forward to increased collaboration between practitioners and academics to fully realise a strong applied evidence-base. This task will not be easy, as with any interdisciplinary research, and should draw upon interdisciplinary expertise to do so. Hopefully our brief comments will provide a stimulus for further discussion, planning and future action.
Article
Background: Impaired ankle inversion movement discrimination (AIMD) can lead to ankle sprain injuries. The aim of this study was to explore whether wearing textured insoles improved AIMD compared with barefoot, ballet shoes and smooth insoles, among dancers. Methods: Forty-four adolescent male and female dancers, aged 13-19, from The Australian Ballet School were tested for AIMD while barefoot, wearing ballet shoes, smooth insoles, and textured insoles. Results: No interaction was found between the four different footwear conditions, the two genders, or the two levels of dancers in AIMD (p > .05). An interaction was found between the four different footwear conditions and the three tertiles when tested in ballet shoes (p = .006). Although significant differences were found between the upper tertiles and the lower tertiles when tested with ballet shoes, barefoot and with smooth insoles (p < .001; p < .001; p = .047, respectively), when testing with textured insoles dancers in the lower tertile obtained similar scores to those obtained by dancers in the upper tertile (p = .911). Conclusion: Textured insoles improved the discrimination scores of dancers with low AIMD, suggesting that textured insoles may trigger the cutaneous receptors in the plantar surface, increasing the awareness of ankle positioning, which in turn might decrease the chance of ankle injury.
Book
The book will provide historical context for the growth and development of Irish dancing, insights into the etiology and epidemiology of Irish dance injury, and provide information and advice on appropriate preparation and environmental considerations for healthy Irish dancers. Chapters to enhance physical and psychological resilience and preparedness for the very specific demands of Irish dancing are presented. These include bespoke strength, conditioning and flexibility programs, goal-setting, managing competition anxiety, mental imagery and mindfulness, and sleep optimization. Appropriate training load prescription, tapering and the balance between rest and rehearsal will be explored, as will the most suitable diet to support the Irish dancer. Injury prevention, risk minimization and management are additionally discussed in the book. There is consideration given to the specific needs of certain dancer groups, such as the elite adolescent Irish dancer, the professional touring dancer, and the older dancer. The pivotal role of the parent in impacting the health and performance of the younger dancer is also explored.
Article
Dancers are exposed to many landings from jumps during class and performance, and repetitive loading has been linked with an increased risk of injury. Little is known about the effect of different dance shoe types on jump landings, and with so many dance shoe designs available to choose from, a thorough exploration is warranted. Dance technique dictates that jump landings be “rolled through the foot,” with a toe strike followed by controlled lowering of the ball of the foot and heel. For this study, 3D motion analysis was used to capture the movement of 16 female dancers performing sautés in second position. Lower limb joint kinematics were examined during the landings, both barefoot and in different jazz shoe designs. The results showed that all dancers executed the technique of “rolling through the foot.” All jazz shoe designs increased knee and ankle sagittal ROM (p < 0.05) but reduced ankle frontal plane ROM and midfoot ROM in all three planes (p < 0.05). Chorus shoes increased maximum knee flexion by more than 5° during the plié. Jazz shoes restricted midfoot sagittal and transverse plane motion and MPJ sagittal motion compared to barefoot throughout stance phase (p < 0.05). These changes may translate to a reduced capacity to absorb impact or decreased propulsion. Dance jump landings in the jazz shoe designs tested may appear to be heavier due to the greater reliance on knee flexion to absorb impact and less push-off for subsequent jumps.
Article
Epidemiological studies in the performing arts are scarce, and only one such study in the last 20 years directly examines West End productions. Therefore, the aim of this study was to analyse the epidemiology of injuries sustained by West End performers over a 12-month period (2016-2017). Injury data were self-reported retrospectively by West End performers using an online injury surveillance questionnaire. Information collected covered: participant characteristics, injury location, diagnosis, severity, mechanism of injury, and external risk factors. Simple proportions were calculated for injury location and type. Categorical data were assessed using Chi-squared (p = 0.05) and magnitude-based inferences described as between-group differences. Forty-seven performers responded (26 male, 21 female), with 65% suffering at least one injury in the previous year. The lower limb accounted for 50% of injuries, with muscle strains being the diagnosis in 37% of cases. Males sustained 53% of all injuries, but no differences were found between sexes in locations injured (χ2 = 2.296, p = 0.513). Seventy-two percent of injuries were said to have occurred during performance, with one-third of the total injuries having a gradual onset. Little or no time was lost in the majority of cases.
Article
Musical theater is a unique genre within the field of the performing arts. Research of injury epidemiology and treatment efficacy is growing in the field of dance, but little is published specific to the field of musical theater. One study has reported that injury rates in musical theater are high and that injuries occur often to the foot and ankle. Unfortunately, it appears that in many settings, particularly in university settings, musical theater performers may have little access to healthcare to prevent and treat injuries. A foot-screening and education pilot program was implemented in a university musical theater program to fulfill a curriculum requirement with the goals of: (1) giving the performers basic background knowledge on common injuries related to feet, (2) teaching the performers how to identify what type of arch and foot they have, (3) disseminating information on treatment strategies and injury prevention both during performance and in everyday life, and (4) providing an interprofessional education learning experience for the students involved. This article explains the implementation of this program, why programs like this are needed, and improvements that could be made in the future.
Article
Aims: Dancers have high injury rates of the lower extremity. External factors such as footwear likely alter the work demands placed on the lower extremity joints when performing dance-style movements. Research on pedestrians shows an increase in knee work demand when wearing heels, which may occur in dancers as well. The purpose of this study was to assess the effect of heeled shoes on lower extremity joint work demand during a basic dance-specific jump (sauté) in dancers when compared to barefoot. Methods: Ten healthy, female dancers (age 25.6±4.7 yrs; height 1.7±0.1 m; weight 64.9±9.2 kg; mean years of dance training 17.6±6.4) performed repetitive vertical bipedal dance jumps (sautés) barefoot as well as wearing heeled dance shoes. Sagittal plane hip, knee, and ankle kinetics were calculated. Percentages of work done by these joints were calculated in comparison to the work done by the leg as a whole and compared between the two conditions. Results: During a dance-specific jump, the percent contribution of energy absorption was significantly different at the ankle and knee between the two conditions. The ankle contribution decreased from 50.7±6.1% in the bare condition to 34.9±5.3% in the shod condition (p=0.002), and the knee contribution increased from 38.6±3.9% barefoot to 55.1±2.8% shod (p=0.002). The same pattern was seen for energy generation, with the ankle contribution decreasing from 48.1±7.3% to 35.6±6.9% and the knee contribution increasing from 43.3±5.6% to 56.4±6.1% in the bare vs shod condition (both p=0.002). There was no significant difference in the percent contribution from the hip. Conclusion: With heeled shoes, there is a shift in work demand from the ankle to the knee with no change at the hip as compared to barefoot.
Chapter
Hip problems are common in young dancers and often preventable. The extreme ranges of motion demanded of the dancer’s hip without the necessary strength and flexibility to accommodate them create the potential for injury. Additionally, some dancers may have an anatomic makeup that predisposes them to injury, and those with developing musculoskeletal systems may be particularly vulnerable. Pathology about the hip ranges from intra-articular to extra-articular, as well as referred pain from adjacent structures. Diagnosis begins with a history and physical examination to formulate a differential diagnosis, and imaging can be used as an adjunct. Treatment of injuries relies on an understanding of the mechanics of dance, especially as they apply to the dance discipline in question, the associated hip anatomy, and the specific etiology of the injury. When rehabilitation and physical therapy fail, additional interventions such as targeted steroid injections or surgery may be beneficial.
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There has been little scientific investigation of the impact of dance shoes on foot motion or dance injuries. The pointed (plantar-flexed) foot is a fundamental component of both the technical requirements and the traditional aesthetic of ballet and jazz dancing. The aims of this study were to quantify the externally observed angle of plantar flexion in various jazz shoes compared with barefoot and to compare the sagittal plane bending stiffness of the various jazz shoes. Sixteen female recreational child dancers were recruited for 3D motion analysis of active plantar flexion. The jazz shoes tested were a split-sole jazz shoe, full-sole jazz shoe, and jazz sneaker. A shoe dynamometer measured the stiffness of the jazz shoes. The shoes had a significant effect on ankle plantar flexion. All jazz shoes significantly restricted the midfoot plantar flexion angle compared with the barefoot condition. The split-sole jazz shoe demonstrated the least restriction, whereas the full-sole jazz shoe the most midfoot restriction. A small restriction in metartarsophalangeal plantar flexion and a greater restriction at the midfoot joint were demonstrated when wearing stiff jazz shoes. These restrictions will decrease the aesthetic of the pointed foot, may encourage incorrect muscle activation, and have an impact on dance performance.
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A literature search revealed no information on the prevalence of tap dance injuries, one of several dance styles involving percussive footwork. We conducted a retrospective survey to determine the rates and patterns of injury among a cohort of experienced tap dancers enrolled in "advanced" or "master" classes at the New York City Tap Festival. Demographic factors, dance/performance, exercise, and injury histories were recorded and analyzed and the injury rate per 1000 dance exposures calculated. Calculated injury rates among the tap dancers were substantially lower than those previously reported for other dance and athlete populations. We conclude that kinetic and kinematic analysis is required to explain the apparent decreased risk of injury among tap dancers. Comparison data may lead to improved strategies for injury prevention in these other areas.
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Modern dancers are a unique group of artists, performing a diverse repertoire in dance companies of various sizes. In this study, 184 professional modern dancers in the United States (males N=49, females N=135), including members of large and small companies as well as freelance dancers, were surveyed regarding their demographics and training characteristics. The mean age of the dancers was 30.1 +/- 7.3 years, and they had danced professionally for 8.9 +/- 7.2 years. The average Body Mass Index (BMI) was 23.6 +/- 2.4 for males and 20.5 +/- 1.7 for females. Females had started taking dance class earlier (age 6.5 +/- 4.2 years) as compared to males (age 15.6 +/- 6.2 years). Females were more likely to have begun their training in ballet, while males more often began with modern classes (55% and 51% respectively, p < 0.0001). The professional modern dancers surveyed spent 8.3 +/- 6.0 hours in class and 17.2 +/- 12.6 hours in rehearsal each week. Eighty percent took modern technique class and 67% reported that they took ballet technique class. The dancers who specified what modern technique they studied (N=84) reported between two and four different techniques. The dancers also participated in a multitude of additional exercise regimens for a total of 8.2 +/- 6.6 hours per week, with the most common types being Pilates, yoga, and upper body weightlifting. The dancers wore many different types of footwear, depending on the style of dance being performed. For modern dance alone, dancers wore 12 different types of footwear. Reflecting the diversity of the dancers and companies surveyed, females reported performing for 23.3 +/- 14.0 weeks (range: 2-52 weeks) per year; males reported performing 20.4 +/- 13.9 weeks (range: 1-40) per year. Only 18% of the dancers did not have any health insurance, with 54% having some type of insurance provided by their employer. However, 23% of the dancers purchased their own insurance, and 22% had insurance provided by their families. Only 16% of dancers reported that they had Workers' Compensation coverage, despite the fact that they were all professionals, including many employed by major modern dance companies across the United States. It is concluded that understanding the training profile of the professional modern dancer should assist healthcare providers in supplying appropriate medical care for these performers.
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The flamenco dancer acts on the floor like a drummer. The percussive footwork and vibration patterns created during dancing impose unusual demands on the musculoskeletal system. This study investigated the clinical and biomechanical aspects of this task. Using the electrodynogram and skin-mounted accelerometers, foot pressures as well as hip and knee vibrations were recorded in 10 female dancers after a thorough clinical evaluation. A health questionnaire was also distributed to 29 dancers. Foot pressures and acceleration data reveal the percussive nature of the dance. Some clinical findings, like calluses, are related to pressure distribution. Urogenital disorders, as well as back and neck pain, may be related to the vibrations generated by the flamenco dance form. The hip joint seems to absorb most of the impacts. “Vibration-pressure” diagrams are suggested as a useful tool for evaluating a dancer's biomechanical behavior, as well as the effect of floors and footwear on this behavior.
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Objective: Athletic shoes and mats are support surface interfaces composed of relatively soft compressible materials designed to protect against injuries occurring in sports through force of vertical impact. Impact remains high with their use because humans land harder with them. We hypothesize that this hard-landing strategy is an attempt by the user to improve stability, by compressing the material to a less destabilizing thinner-stiff variety. We tested this hypothesis by comparing impact and balance on materials consisting of ethyl-vinyl acetate (EVA) foams of varying stiffness, identical to that found in soles of athletic footwear. Design: Randomized-order, crossover trial, controlled comparison, blinded. Setting: Volunteers were selected from the general community. Participants: A random sample of 12 healthy men from the general population (mean age 30 years, SD +/- 6). Additional selection criteria were absence of disabilities influencing ability to walk, run, and balance, and no history of frequent falls. Methods: Impact testing and stability measures were performed on the same test day. Ground reaction forces were measured for ten barefoot footfalls. The protocol required stepping forward from perch to surface 4.5 cm below. Stability testing was performed with one-legged standing consisting of placing left foot on top of right for 30 sec, barefoot, eyes open, and gaze straight, with arms to side. Subjects confronted four surface conditions presented in random order: a bare rigid platform, and the platform covered with one of three 2.5-cm-thick materials. Results: Steady state vertical impact was a negative function of interface stiffness, with the softest interface producing the greatest vertical impact, and the stiffest interface the least vertical impact. Vertical impact and stability measures were also negatively related, with the strongest correlation obtained with the softest interface (r = -.87, p < .001). No relation between these variables was obtained for the rigid surface. Conclusion: Balance and vertical impact are closely related. This supports the hypothesis that landing hard on soft surfaces is an attempt to transform the interface into a form associated with improved stability. According to these findings, currently available sports shoes and mats are too soft and thick, and should be redesigned to protect the persons using them.
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Dancing en pointe requires the ballerina to stand on her toes, which are protected only by the pointe shoe toe box. This protection diminishes when the toe box loses its structural integrity. The objectives of this study were 1) to quantify the comparative structural static and fatigue properties of the pointe shoe toe box, and 2) to evaluate the preferred shoe characteristics as determined by a survey of local dancers. Five different pointe shoes (Capezio, Freed, Gaynor Minden, Leo's, and Grishko) were evaluated to quantify the static stiffness, static strength, and fatigue properties (cycles to failure) of the shoes. Under axial loading conditions, the Leo's shoe demonstrated the highest stiffness level, and the Freed shoe exhibited the least strength. Under vertical loading conditions, the Leo's and Freed shoes demonstrated the highest stiffness levels, and the Gaynor Minden and Freed shoes exhibited the highest strength. Fatigue testing highlighted the greatest differences among the five shoes, with the Gaynor Minden demonstrating the highest fatigue life. Dancers rated the top five shoe characteristics, in order of importance, as fit, comfort, box/platform shape, vamp shape, and durability and indicated that the "best" shoe is one that "feels right" and permits artistic maneuvers, not necessarily the strongest or most durable shoe.
Article
Specialised shoes for various types of dance - such as ballet, ballroom dancing, flamenco and tap - are designed with both biomechanics and pathomechanics in mind. The first is concerned with movements of the body and the second with injuries associated with athletic movement. Manufacturers are now much more concerned to prevent foot and ankle injuries - the example of Pointe ballet shoes is illustrated.
Article
Flamenco is a dance tradition that arose from the Spanish gypsies at the end of the eighteenth century. Originally an improvised art form created to express emotions, flamenco today is a popular dance style that can be seen and learned in many countries around the world. The injuries of flamenco dancers are made unique through the percussive nature of the dance steps and through the use of high-heeled shoes. The purpose of this study was to examine the self-reported injuries of professional and student flamenco dancers in order to understand better the impact of high-heeled shoes and rhythmic stamping patterns. Injuries sustained by student flamenco dancers were compared to the injuries sustained by professional flamenco dancers to see how these injuries are linked to training practices. The number of injuries sustained by professional flamenco dancers (30) was greater than the number of injuries sustained by student flamenco dancers (20). Consideration of each injury site was made to see how it is affected by footwear and rehearsal practices.
Article
No analysis of the relative contribution of the ankle extensors (primarily soleus and gastrocnemius) and the m-p flexors (flexor digitorum longus, flexor hallucis longus and the intrinsic lumbricals) has been done. With inverse dynamic modelling of the foot as two segments, the ankle and m-p joint powers as well as foot and phalangeal segmental energies were calculated. Of the estimated 60 J of energy required to raise the centre of mass of the body 11 cm vertically upward, the model predicted 26.2 J generated from the m-p crossing muscles while 33.8 J came from the ankle plantarflexors. Considering the relative physiological cross-sectional areas of the relevant muscles at the ankle joint versus the m-p joints and the ratio to be about 10:1, it is understandable that the m-p joint injuries are so prevalent. Such evidence demonstrates the need for a major redesign of pointe shoes.
Article
In the range of specialized work equipment, pointe shoes occupy a special place.The design of these essential tools for dancers has remained essentially unchanged for 200 years. In an age of high-tech sneakers, pointe shoes are made of cardboard, newspaper, fabric, and glue and cause countless injuries and tremendous pain to ballerinas. In this project, we consider them in an ergonomic and usability context and explore design changes to improve their safety, comfort, usability, and durability. Copyright 2008 by Human Factors and Ergonomics Society, Inc. All rights reserved.
Article
This review introduces different tech­ niques used in biomechanics that have been used in analyzing dance movement. Biomechanics provides information not only for analysis of motion, but for un­ derstanding muscle use, forces acting on the body, issues ofmotor co ntrol , and the interaction between anyone body part and the body as a whole. The goal of this review is to highlight the role that bi ome­ chanical analysis plays in understanding dance movement, with ap pli ca ti ons for teaching, skill enhancement, and in jury preve ntion. movement . JGn em atics p rovides a description of motion: h ow far, how fast , how much change, and what type of motion is involved. It describes a dancer's motions and allows the re­ searcher to identifY key events in the performance ofa skill. In kinematics, quantification of component jo int motions and identificati on of the ranges of motion of indivi dual joints provides a foundation for understand­ ing how these elements contribute to the dancer's total motion. Kinetics, on the other hand , focuses on the cause-and-effec t relationship see n in movement: the force involved and the resultant motion. The primary mechanical quantities in kinetics are forces and moments (torques) ac ti ng within the body (i mernal) and those that originate in the environment (external). A dancer's environm ent includes anything that is in contact wic h the body: other dancers, train­ ing spaces, performance sp aces, and
Article
Flamenco dance requires male and female dancers to wear heeled shoes and learn to employ a stylized posture. Injury patterns of the adult flamenco dancer reveal that low back pain and self-reported injury is substantial. It is unclear what compensations are made in the normal spine to overcome the effects of acquiring this posture while standing in a heeled shoe. To prepare the beginning child dancer well for the rigors of this art form, it would be appropriate to know if the young performer exhibits the same postural strategies to compensate for the change in position of the foot in a heeled shoe. This study attempts to determine the degree and magnitude of changes of angulation in pelvic tilt in young dancers who were accustomed to standing in forced plantar flexion. Suggestions could then be made to teachers to prepare the body for the stresses that accompany training in flamenco dance. Sixteen children (10 girls, 6 boys) between the ages of 4 and 12 participated in this study. A Vicon 250 Motion Analysis System (Tustin, CA) was used to evaluate postural alignment by measuring the change angles of the joints of the lower body. No significant differences between the barefoot and heeled stance were revealed at the pelvis, hip, or knee. As expected, a paired t-test revealed that there was a significant change in the degree of plantar flexion of the ankle in the children when standing on a 2 inch platform (p = 0.001). The standard deviations of each site were quite large, which might account for the lack of a statistically significant difference between the two conditions. The children compensated in different, and opposite ways from each other. Children who dance in a heeled shoe might be at greater risk for injury because of the postural changes that accompany the chronic plantar flexed position. Although it must be recognized that there are many potential factors influencing back pain in the flamenco dancer, the reduction or change in the pelvic and lumbar region is a component. Teachers should make an effort to prepare students by increasing core strength and lower extremity flexibility as well as developing postural awareness and proprioception before the child engages in long and arduous flamenco training.
Article
Objectives: The purpose of this study was to determine the rate and types of injury in competitive dancers of Irish Dance, establish the injury prevention measures used by dancers, and investigate any relationships between prevention measures and incidence of injury. There are no in depth published studies on injury rates or injury prevention strategies for Irish dance. Methods: One hundred and fifty nine Irish dancers who were participants at the North American Irish Dance Championships (July 2-7, 2004) took part in this descriptive epidemiology study. Each participant completed a self administered questionnaire. The subjects were aged from 15 to 24 years (mean: 17.8; SD: 2.9). The number of years dancing ranged from 1 to 20 years (mean: 10.8; SD: 3.8). Results: The results showed 79% (n = 125) of dancers had one or more injuries. The ankle (31%, n = 60) and foot (25%, n = 48) were the most frequently injured. Sixty-three percent (n = 121) of the dancers took over 21 days to recover from their injuries. Use of shock absorbent dance shoes significantly reduced the incidence of ankle injury (p < 0.0001). In addition warm up and cool down were associated with a decreased incidence of ankle injury (p < 0.0001 and p < 0.0001 respectively). Conclusions: A variety of lower limb and in particular ankle injuries was reported by the competitive Irish dancers in this study. Injury prevention methods for ankle injury such as warm up, cool down, and use of shock absorbing dance shoes were associated with a decreased incidence of injury and warrant further investigation.
Article
The child's foot is clearly distinct from the adult foot in its functional anatomy and ability to cope with pressure. This requires special considerations in the development of a children's sport shoe. Medical and sport science databases were thoroughly searched for studies pertaining to the anatomy and biomechanics of children's feet during their development. With the data found, a list of requirements for the children's shoe was compiled. Small children should have a sports shoe, which is as flexible as their own foot. The small impact forces during their sports activities make extra cushioning superfluous. During school age the connective tissue gains stability. The growing amount of sports activities, much of which is performed on hard indoor surfaces, enhances the need for cushioning. At the same time there is a growing necessity for adequate mechanical stimuli to help the muscles and bones develop. The strength of the connective tissue and the flexibility of the joints reach adult levels by the age of 15. In small shoes, the displacement of proportions can lead to improper positioning of the flex zone and thereby causing harmful stress on the foot. Cushioning elements are often oversized. Considering the wide range of anatomy in the child's foot, it is advisable to produce children's shoes in different widths. The child's foot differs in anatomy and function from the adult foot. Children sport shoes should meet the child specific requirement.
Article
The forefoot positions of nine ballet dancers standing on pointe were determined using a mold technique. These molds revealed three positions of the toes: (1) no crossing of the three medial toes; (2) crossing of the third toe behind the second; and (3) crossing of the hallux partially in front of the second. Almost half of all the toes seen on the molds had some deformation of the toenails. These molds also indicated a wide variability in the amount and location of contact between the shoes and toes.
Article
Ballet dancers are vulnerable to various stress-related injuries; foot and ankle injuries are the most common. This study determined if the pressure across the foot could be more evenly distributed by wearing various modified technique shoes padded with PPT, Spenco, or Sorbathane, alone or in combinations. A professional ballet dancer performed a jump by taking a single step on his left foot, jumping and landing with his right foot on the force and pressure plates with each modified shoe plus one unmodified shoe. The results of this study revealed: (1) total force cannot be reduced, (2) center of gravity and the majority of the pressure is maintained over the first and second metatarsal heads, and (3) the modified technique shoe can more evenly distribute pressure to the medial arch and away from the toes, metatarsal heads, and heel.
Article
Muscle strains represent more than a third of all injuries in both dancers and athletes. Although often overlooked, anatomic variations play an important role in the etiology of these injuries, as does strength imbalance between agonists and antagonists. The incidence of spondylolysis is unusually high in ballet dancers and certain athletic groups, such as gymnasts, javelin throwers, and weight-lifters. Mechanical factors play a major role and can be exacerbated by congenital abnormalities. Various permanent adaptive musculoskeletal changes have been described both in dancers and athletes, especially those that start at a very young age. Task-related adaptive changes can also be seen in isokinetic strength measurements of various muscle groups, such as the spine muscles of Flamenco dancers. Shoes and floor surfaces can be directly responsible in part or in whole for many sports and dance injuries. "Vibration-pressure" diagrams are suggested as an objective way to document their effect on biomechanical behavior.
Article
Dancers are an interesting and exciting group of patients. Those clinicians interested in treating their musculoskeletal disorders should, among other things, be familiar with the construction and function of the pointe shoe and have an understanding of what a dancer does with that shoe.
Article
In this paper a review of the epidemiology of both traumatic and overuse injuries is presented with special emphasis on the role of biomechanics. Biomechanical analysis of injuries and the specific sports has increased in sophistication to such a degree we have a much better understanding of both aetiology and management. Particularly in the area of overuse injuries this biomechanical data can also be utilised in prevention. This paper discusses acute traumatic injuries with emphasis on knee injuries. A de-tailed examination of knee injuries during skiing is explored. In addition, cervical injuries in gridiron football and rugby are outlined. Overuse injuries occurring during running are next discussed. Aetiological factors including training errors, muscular dysfunction and inflexibility, footwear, running gait and lower extremity malalignment are considered. Overuse injuries in swimming, dance, gymnastics and throwing sports are briefly dis-cussed. Biochemical analysis is felt to be important in developing strategies that lead to rule changes, alteration of training techniques and improvement in equipment and footwear.
Article
Hip problems form about 10% (7.0 to 14.2%) of most published series of ballet injuries. The abnormally large range of external rotation needed for a perfect turnout is primarily due to soft tissue adaptation, more readily achieved in the young dancer. Insufficient range of motion at the hip throws considerable stress on the other lower limb segments. The snapping hip syndrome is common (43.8% of hip problems), with about one-third associated with pain. A tight iliotibial band may contribute to this, and balanced flexibility requires special attention to abductor stretching. The external clicking hip must be distinguished from the internal clicking hip, which is associated with the joint and psoas tendon. Stress fractures of the hip are easily overlooked and, if undetected, they may progress to a complete fracture. Knee problems account for 14.0 to 20% of complaints, and over 50% of these are perior retropatellar problems. This includes synovial plica, medial chondromalacia, lateral patella facet syndrome, subluxing patella and the fat pad syndrome. Specific diagnosis leads to specific treatment and the best chance of cure. Mild hyperextension of the knee may be aesthetically desirable, but excessive range leads to symptoms in the posterior capsule and poor control. Young dancers with a tendency to very lax joint structures should be identified early and protected from overstretching. In the author’s series, meniscal lesions did not appear to be as big a problem as reported elsewhere in the literature. Ballerinas appear to have less leg strength than other groups of athletes, having only 77% of the weight-predicted norms. The introduction of strength training for male and female dancers may reduce injuries and improve balance, but it requires an intensive educational programme to dispense with the many myths. There are several references to the development of early arthritis but, while relatively common in the foot, symptomatic arthrosis in ballet dancers’ hips and knees is not more prevalent than in the general population. The young age at which serious dance training begins, the long and rigorous hours of practice, the thin ballet slipper, dancing en pointe and unusual dietary regimens may all contribute to injury patterns in varying degrees.
Article
Back injuries may occur at any age or level of skill and are slightly more prevalent in male dancers. The risk factors that may be involved in a given injury include training errors, musculotendinous imbalance, anatomic malalignment of the lower extremity, shoe wear, and floor surface. Assessment of these risk factors provides guides for management and prevention.
Article
A biomechanical model of the ankle joint was developed and was used to predict the forces at the ankle during the stance phase of running. Measurements from five cadavers were averaged to obtain insertion points and directions of pull of equivalent tendons with respect to the assumed center of the ankle joint. A minimum joint force solution was obtained by assuming that only two equivalent muscle groups could exert force at one time. Three subjects ran at 4.47 m/s across a force platform that recorded the external forces and moments acting on the foot. Cinematography was used to measure the foot and leg positions during stance. Peak resultant joint forces ranging from 9.0 to 13.3 times body weight and peak Achilles tendon forces ranging from 5.3 to 10.0 times body weight were predicted. Small variations in some cases resulted in large differences in predicted forces. The highest tendon forces predicted exceeded those reported to cause damage to cadaver tendons in other studies.
Article
Classical ballet is a popular but physically demanding activity. Minor injuries become increasingly common as the dancer encounters the greater workload of professional dancing. The doctor must have a basic knowledge of ballet technique and an understanding of the mental approach of dancers to accurately diagnose and effectively treat their injuries. The practice of dancing on the toes, the exaggerated turn out of the feet, and the extreme flexibility of the hips and spine all lead to unusual injuries. With informed conservative treatment, most ballet injuries will heal, but surgery is occasionally required.
We have reviewed the frequency and variety of rheumatic problems among performing artists. For instrumentalists, injuries are related to the type of instrument played, the technique used and the effort expended in the quest for excellence. For dancers, musculoskeletal problems too reflect technique and effort. We should not be surprised at the frequency of these problems. Rheumatologists, as well as orthopaedic surgeons, physiotherapists, neurologists and other physicians, encounter performing artists as patients. We should be familiar with their problems and be able to knowledgeably diagnose and manage them. This may include observing the artist during actual performances. How is the instrument being held? What is the posture of the artist? What are the comments of the coach or teacher. What type of shoes does the ballerina wear? What movements in particular cause discomfort? These and similar observations will have direct bearing on the musculoskeletal problems of these artists. Published studies have related the variety, frequency and disabling nature of performance-related musculoskeletal problems. Unfortunately few if any of these are controlled, blinded or prospective. We need more and better information. We will want clear information about prevalence of problems, better definition of the musculoskeletal ailments, classification of the relationship of problems with performance and individual biomechanical features, information about response of specific problems to interventions, and data about the long-term consequences, if any, of these rheumatic problems to the musculoskeletal system. Artists as patients are unique. Minor problems can become potentially career-ending disabilities. Making music or performing dance may provide us with delightful entertainment but represents a source of livelihood to artists. Understanding their medical needs and enabling them to continue to perform is the challenge before us.
Article
Currently, there is a need for a review of the literature on ballet injury as it pertains to the physical therapist. Relatively few articles have reviewed ballet injury prevalence and mechanisms of injury. The purpose of this paper was to provide a thorough literature review of the prevalence of ballet injury and mechanisms of injury. Environmental factors and footwear relating to ballet injury were also reviewed. The literature indicated that 65-80% of ballet injuries are in the lower extremity, 10-17% occur in the vertebral column, and most of the remaining percentage are upper limb injuries (5-15%). The etiology of common lower limb conditions included an incorrect turnout; soft tissue imbalances; reduced quadriceps performance; "rolling in of the foot;" inversion sprains; and frequent pliés, pointé, and demipointé work. Spinal conditions were reported to result from hyperextension and hyperlordosis of the lumbar spine as well as the psoas insufficiency syndrome. It was revealed that inappropriately fitting footwear lead to various foot conditions and abnormal lower kinetic chain biomechanics. Environmental factors, such as the dance surface, also have implications in ballet injury. The author concluded that ballet injuries have a multifactorial etiology that primarily involves the interplay of compensatory biomechanics in the spine and lower extremity, environmental factors, and footwear. In addition, some clinical recommendations have been made regarding the physical therapy management of ballet injuries.
Article
Incorrect techniques repeated daily by a dancer can lead to overuse injuries. This article discusses the causes and treatment of foot and ankle injuries in the ballet dancer. The author also addresses skin lesions that are common in dancers who wear pointe shoes.
Article
To test the feasibility of creating a valid and reliable checklist with the following features: appropriate for assessing both randomised and non-randomised studies; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting, internal validity (bias and confounding) and power, but also for external validity. A pilot version was first developed, based on epidemiological principles, reviews, and existing checklists for randomised studies. Face and content validity were assessed by three experienced reviewers and reliability was determined using two raters assessing 10 randomised and 10 non-randomised studies. Using different raters, the checklist was revised and tested for internal consistency (Kuder-Richardson 20), test-retest and inter-rater reliability (Spearman correlation coefficient and sign rank test; kappa statistics), criterion validity, and respondent burden. The performance of the checklist improved considerably after revision of a pilot version. The Quality Index had high internal consistency (KR-20: 0.89) as did the subscales apart from external validity (KR-20: 0.54). Test-retest (r 0.88) and inter-rater (r 0.75) reliability of the Quality Index were good. Reliability of the subscales varied from good (bias) to poor (external validity). The Quality Index correlated highly with an existing, established instrument for assessing randomised studies (r 0.90). There was little difference between its performance with non-randomised and with randomised studies. Raters took about 20 minutes to assess each paper (range 10 to 45 minutes). This study has shown that it is feasible to develop a checklist that can be used to assess the methodological quality not only of randomised controlled trials but also non-randomised studies. It has also shown that it is possible to produce a checklist that provides a profile of the paper, alerting reviewers to its particular methodological strengths and weaknesses. Further work is required to improve the checklist and the training of raters in the assessment of external validity.
Article
Full body gait analysis was used to determine if differences exist in kinematic, kinetic, and temporal-spatial data with and without shoes in able-bodied children. The greatest difference noted between conditions was an increase in stride length with shoes. Minimal changes were seen in kinematics and kinetics with the addition of shoes. Due to the very tight standard deviations of the data, these minimal changes in the magnitude of the curves resulted in statistically significant differences, yet these changes do not appear to be clinically significant. It is believed that this study establishes that barefoot gait analysis is sufficient for most clinical studies, and an additional assessment undertaken while wearing shoes is not necessary.
Article
Acute traumatic injuries are common in ballet dancers. A careful history, thorough examination, and appropriate imaging should allow for the diagnosis of most problems. The clinician must have a high index of suspicion for occult bony injuries, especially if the patient fails to recover as expected. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries. Kinetic chain dysfunctions are common in ballet dancers with overuse injuries and commonly follow ankle sprains. They may represent a secondary phenomenon that developed in response to the compensatory movement changes caused by the initial injury. It is important to remember, however, that these dysfunctions may have been long standing and a causative factor in the injury. Regardless of the time of onset of the dysfunction, residual kinetic chain dysfunction associated with incomplete rehabilitation of an injury may predispose the dancer to further injuries. Untreated dysfunctions at one site in the kinetic chain may predispose to compensatory dysfunction at other sites in the chain. Accordingly, it is essential to thoroughly examine the entire chain for functional movements when dealing with an injury, because identification and treatment of the kinetic chain dysfunction is important in the rehabilitation of the dancing athlete. Kinetic chain dysfunctions are common in injured ballet dancers and may be a cause of repeated injury. Why then are these dysfunctions left untreated? Medical personnel caring for dancers are sometimes guilty of tunnel vision, and focus solely on the injured site without considering what is happening at other sites in the kinetic chain. This oversight is compounded when the physicians or therapists are satisfied with discovering simply what injury has occurred rather than asking why the injury has occurred. The significance of kinetic chain dysfunctions is only just beginning to be recognized, and many examiners are not aware of the relationship between abnormal motion and injury. Generally, people see only what they look for, and they look only for what they know. Kinetic chain dysfunctions can easily be detected with simple tests of functional movement if the examiners include these tests in their assessment of the injured dancer. As long as clinicians are either unaware of or unwilling to perform these tests, these dysfunctions will remain untreated and may put the dancer at risk of failed rehabilitation or predispose them to further injury.
Article
Classical ballet is a demanding professional occupation, with participants who are often underserved in terms of accurate diagnosis and appropriate comprehensive medical care. The view that follows is designed to be as global and insightful as published to date. Specific rehabilitation considerations, dance mechanics, idiosyncratic differential diagnosis, and personality and equipment issues are discussed, and a rational view of dogma is presented.
Article
To provide evidence that lower-extremity muscle activity during running is tuned in response to the loading rate of the impact forces at heel-strike. Six runners ran two 30-min trials per week for 4 wk. The trials tested two shoes which differed only in the material hardness of the midsole. The shoes were tested in a randomized sequence. Bipolar surface EMG was recorded from the muscles of the rectus femoris, biceps femoris, medial gastrocnemius, and tibialis anterior. EMG was resolved into time-frequency space using wavelet techniques. EMG was analyzed for the 150 ms time window immediately before heel-strike. The intensity of the EMG and the ratio of the EMG intensity between high and low frequency components both showed significant changes between shoes, subjects, and muscles. Additionally, the intensity ratio showed a significant change over the course of each 30-min run. Lower-extremity muscle activity used to tune the muscles for the impact task can be altered by changing the material hardness of the shoe. The changes in the EMG frequency ratio suggest that muscle fiber-type recruitment patterns can also be altered by the choice of midsole material.
Article
The purposes of this study were (a) to determine group and individual differences in oxygen consumption during heel-toe running and (b) to quantify the differences in EMG activity for selected muscle groups of the lower extremities when running in shoes with different mechanical heel characteristics. Twenty male runners performed heel-toe running using two shoe conditions, one with a mainly elastic and a visco-elastic heel. Oxygen consumption was quantified during steady state runs of 6 min duration, running slightly above the aerobic threshold providing four pairs of oxygen consumption results for comparison. Muscle activity was quantified using bipolar surface EMG measurements from the tibialis anterior, medial gastrocnemius, vastus medialis and the hamstrings muscle groups. EMG data were sampled for 5 s every minute for the 6 min providing 30 trials. EMG data were compared for the different conditions using an ANOVA (alpha=0.05). The findings of this study showed that changes in the heel material characteristics of running shoes were associated with (a) subject specific changes in oxygen consumption and (b) subject and muscle specific changes in the intensities of muscle activation before heel strike in the lower extremities. It is suggested that further study of these phenomena will help understand many aspects of human locomotion, including work, performance, fatigue and possible injuries.
Article
The purpose of this project was to study the EMG pattern of the tibialis anterior muscle in heel-toe running. Specifically, EMG changes in time, intensity and frequency shortly before and after heel-strike were addressed using an EMG-specific non-linearly scaled wavelets analysis. This method allowed extracting the time, intensity and frequency information inherent in the EMG signal at any time. The EMG signals of 40 male subjects were recorded for running barefoot and with shoes. The results confirmed that the pre-heel-strike EMG activities were typically seen at higher EMG frequencies (60-270Hz) while the post-heel-strike EMG activities resulted in lower frequency signals (10-90Hz). The timing of the pre-heel-strike EMG activities was not influenced by the used shoe conditions. The timing of the post-heel-strike EMG activities was significantly delayed when wearing shoes. The intensity of the pre-heel-strike muscle activity increased compared to the post-heel-strike one when wearing shoes. One can conclude that the activity of the tibialis anterior adjusts specifically to exterior conditions. The frequency shift between pre- and post heel-strike muscle activity were discussed with respect to activation of different motor units.
Article
Ballerinas develop stress fractures at the second metatarsal base associated with dancing en pointe. The purpose of this study was to evaluate the relative importance of the pointe shoe and the tarsometatarsal ligaments in Lisfranc joint stability en pointe. Eleven cadaver feet were dressed with pointe shoes, loaded in foot flat with ligaments intact, and loaded en pointe before and after sequential sectioning of the dorsal, interosseous, and plantar ligaments between the first and second metatarsals and cuneiforms. Relative motion between the first and second metatarsals and cuneiforms was determined radiographically. No significant displacement of the Lisfranc joints occurred when the shod foot with intact ligaments was loaded in the foot flat or en pointe positions. Serial sectioning of the ligaments from dorsal to plantar in the shod foot en pointe demonstrated no change in alignment after the dorsal and interosseous ligaments were cut, but a significant change in alignment between the second metatarsal and second cuneiform was noted after the plantar ligament was cut (p < 0.0001). Removal of the pointe shoe after cutting the ligaments and applying a minimal (1 to 2 kg) load resulted in complete subluxation and diastasis through the first-second intermetatarsal and intercuneiform region. Replacing the shoe improved alignment en pointe with similar loading. Both the pointe shoe and Lisfranc ligaments are important for Lisfranc region stability in feet en pointe. The plantar ligaments are major stabilizers of the Lisfranc region in the loaded, shod foot en pointe. Selection of a pointe shoe with adequate support may limit susceptibility to stress fracture of the second metatarsal base in ballerinas.
Article
This study characterizes the stiffness of the human forefoot during running. The forefoot stiffness, defined as the ratio of ground reaction moment to angular deflection of the metatarsophalangeal joint, is measured for subjects running barefoot. The joint deflection is obtained from video data, while the ground reaction moment is obtained from force plate and video data. The experiments show that during push-off, the forefoot stiffness rises sharply and then decreases steadily, showing that the forefoot behaves not as a simple spring, but rather as an active mechanism that exhibits a highly time-dependent stiffness. The forefoot stiffness is compared with the bending stiffness of running shoes. For each of four shoes tested, the shoe stiffness is relatively constant and generally much lower than the mean human forefoot stiffness. Since forefoot stiffness and shoe bending stiffness act in parallel (i.e., are additive), the total forefoot stiffness of the shod foot is dominated by that of the human foot.
Article
The purpose of this study was to determine the prevalence, number, and distribution of musculoskeletal injuries among young, recreational, female dancers before and after dancing in pointe shoes and to explore possible risk factors. Thirty-one female, nonprofessional ballet dancers, eight to 20 years of age, were recruited from two dance studios in London, Ontario. Participants completed a descriptive questionnaire and reliable examiners performed stress, stability, and laxity tests. The prevalence of instability for nonpointe and pointe groups was 0% and 8% for the knee and 17% and 3% for the ankle, respectively (a nonsignificant difference). The mean number of painful sites was 1.3 (SD = 1.9) and 2.9 (SD = 2.1) for nonpointe and pointe groups, respectively (p = 0.04). The only variable that, in part, predicted the number of painful sites was the number of years of having danced ballet. The generalizability of these results is limited by the small sample size. Additional prospective research with larger samples, inclusion of dancers who are just beginning to dance in pointe shoes, and consideration of level of exposure and the intensity of both dancing and other physical activity is indicated before prevention programs can be planned and tested.
Article
Although dancers develop overuse injuries common in other athletes, they are also susceptible to unique injuries. This article reviews common foot and ankle problems seen in dancers and provides some basic diagnosis and treatment strategies.
Article
The increased prevalence for flatfoot and hallux valgus in modern societies may be the consequence of inadequate footwear in childhood. Based on the assumption that barefoot walking represents the best condition for the development of a healthy foot the objective of this study was to monitor the influence of commercial footwear on children's foot motion during walking. Furthermore, an attempt was made to reduce this influence by changing the physical properties of standard footwear. Children's barefoot motion pattern was monitored by a marker-based optical 3D-tracking method using a multi-segment foot model. In the study's first stage, barefoot walking was compared to walking with a commercial product. In the second stage it was compared to both, the pattern with the commercial product and with the shoe modified on the basis of the findings of the first stage of the study. Eighteen children (8.2+/-0.7 years old) with no foot deformity and with the same shoe size were recruited for this study. It was found that tibio-talar ROM increased in the commercial shoe (26.6 degrees ) compared to the barefoot condition (22.5 degrees , p=0.001) whereas the medial arch changes for push-off were diminished since the variation in arch length was reduced from 9.9% (barefoot) to 5.9% (shoe, p<0.001). Further, ROM in foot torsion along the long foot axis was reduced from 9.8 degrees (bare) to 4.7 degrees (shoe, p<0.001). These parameters could be improved with more flexible footwear. The present study shows that slimmer and more flexible children's shoes do not change foot motion as much as conventional shoes and therefore should be recommended not only for children in this age but for healthy children in general.
Article
Dancers are required to perform at the extreme of physiologic and functional limits. Under such conditions, peripheral nerves are prone to compression. Entrapment neuropathies in dance can be related to the sciatic nerve or from a radiculopathy related to posture or a hyperlordosis. The most reproducible and reliable method of diagnosis is a careful history and clinical examination. This article reviews several nerve disorders encountered in dancers, including interdigital neuromas, tarsal tunnel syndrome, medial hallucal nerve compression, anterior tarsal tunnel syndrome, superficial and deep peroneal nerve entrapment, and sural nerve entrapment.
Bunion deformity and the forces generated around the great toe: a biomechanical approach to analysis of pointe dance, classical ballet
  • S R Kravitz
  • C J Murgia
  • S Huber
Kravitz SR, Murgia CJ, Huber S, et al. Bunion deformity and the forces generated around the great toe: a biomechanical approach to analysis of pointe dance, classical ballet. In: Shell CG (ed): The Dancer as Athlete: The 1984 Olympic Scientific Congress Proceedings, Vol. 8. Champaign, IL: Human Kinetics Publishers, Inc., 1986, pp. 43-51.
The pathogenesis of dance injury
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Hardaker Jr WT, Erickson L. The pathogenesis of dance injury. In: Shell CG (ed): Dancer as Athlete 1984 Olympic Congress Proceedings. Champaign, IL: Human Kinetics Publishers, 1984, pp. 11 -29.
Foot and ankle injuries in dance and athletics: Similarities and differences
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Hardaker Jr WT, Moorman CT. Foot and ankle injuries in dance and athletics: Similarities and differences. In: Shell CG (ed): The Dancer as Athlete The 1984 Olympic Scientific Congress Proceedings. Champaign, IL: Human Kinetics Publishers, 1986. pp. 31-41.
Young dancers and their feet. Podiatry Management
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Spilken T. Young dancers and their feet. Podiatry Management. 2007;26(3):133-5.
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Atwells RL, Smith RM. Shoe control of foot motion during walking and running. XVIII International Symposium of Biomechanics in Sports. The Chinese University of Hong Kong Department of Sports Science and Physical Education: The Chinese University of Hong Kong, 2000.
Ground reaction and lower extremity joint forces produced during tap dance
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Mayers L, Agraharasamakulam S, Ojofeitimi S, Bronner S. Ground reaction and lower extremity joint forces produced during tap dance. Proceedings of the 16th Annual Meeting of the International Association for Dance Medicine and Science 2005.