Demi-plié in first position demonstrating challenges to proper alignment. a Knee slightly forward of foot in lieu of optimal position with knee centered over second toe. b Further compensation with excessive hip flexion. Photographs courtesy of James Koepfler
Anatomical limitations are another risk factor for injury in all dancers, but young dancers can be educated on how to work with their body as their artistic instrument and learn what they can improve. Truly understanding their own body and their own strengths and limitations can be paramount to avoiding injury. No one has a perfect body, and every dancer’s body is different. Dancers and their teachers need to understand an individual student’s unique anatomical advantages and limitations and how to work within those physical capabilities. For example, dancers who are very flexible tend to have to work harder to build strength and those who are very strong generally need constantly to address flexibility issues. Given the nature of dance and the need to execute gestures in extreme ranges of motion, it is important for the rehabilitation professional to have knowledge of the dancer’s bony architecture if imaging has been done or is advised. For example, it is important to know if any hip dysplasia is present, as it has been demonstrated in the literature that those with dysplastic hips have labrum that supports more of the total load across the hip joint (4–11%) than those with normal hips (1–2%) , thus increasing the risk of labral injury . These measures reflect components of the normal gait cycle and ascending and descending stairs, so it is likely the force transmissions are substantially greater with dance .
Understanding hypermobility and the presence of benign or more serious heritable connective tissue disorders (HCTD) is important, as ligamentous laxity can lead to injury. An easy and basic test for assessing joint hypermobility is the Beighton Scale, which while widely used has only recently been tested for validity . More and more dancers are being selected into different forms of dance due to their hypermobility. The laxity of their ligaments can make it harder to control the end range of movement in a joint, so there is often a presentation of instability around the joint with the paradox of tight muscles because they are working harder than non-hypermobile individuals to keep the joint stable. Addressing core and pelvic stability and teaching how properly to stretch without compromising ligaments is extremely important for the hypermobile dancer.
Reviewing and correcting muscle imbalances can be critical to preventing injuries in young dancers. In order to avoid injury the muscles surrounding a joint should be relatively equal in strength and flexibility. This helps prevent one side of the joint, for example, the plantar flexors at the ankle, from being more stressed and over used than the dorsiflexors. This is a typical imbalance seen in ballet because of the emphasis on demi-pointe and pointe work. An imbalance like this can make a dancer more susceptible to shin pain and tibial stress, as when jumping she or he does not have the posterior chain flexibility to land with a deep plié and then enough eccentric strength in the dorsiflexors to control the landing motion.
Encouraging proper technique and facilitating optimal muscle strength and use are extremely important. The deep outward rotators of the hip should be trained for turnout. Healthy length and strength of the iliopsoas is necessary for its role as both a trunk stabilizer and hip flexor. The often weak gluteus maximus needs to be recruited and contracted before the hamstrings for safer movement of the femoral head in gestures such as arabesque.
Fatigue is another well known and documented precursor of injuries seen in practice and supported in the literature . In students pursuing intense dance training there is often little to no periodization provided for minimal rest time. Generally with dance students injuries are more likely to occur at the beginning of a season when they return to a demanding schedule after having time off from dance, which in itself is becoming a shorter period of time. Injuries are also becoming more common mid-year, as many young dancers are performing in “Nutcracker” or other seasonal productions while also auditioning for summer dance intensives. Following this, many multidiscipline dancers move on to competitions and then right on to their year-end training with added rehearsals and final performances. While periodization has traditionally been reserved for training at the elite level, as just illustrated the young dancers of today are now keeping schedules that are similar to those of their professional adult counterparts. Guidelines are needed to promote schedules that offer the required time for musculoskeletal repair and recovery between intense periods of dance.
Lack of Warm Up
Lack of a proper warm up before class or rehearsal is another potential risk factor for injury. As every dancer has different needs, warming up should be individualized, but must include movement and exercises that will help increase body temperature and heart rate, and lubricate the joints . Static stretching in a split is commonly misconceived by younger dancers as warming up. While research is ongoing as to what methods of stretching are best, it is generally agreed that before dancing a combination of controlled warm-up exercises followed by dynamic stretching is beneficial for addressing both the need for increased muscle flexibility and joint range of motion. Long periods of static stretching are best reserved for after dancing, and more advanced forms of stretching, such as contract-and-release techniques, are for the more mature dancer. Dancers should be encouraged to keep themselves warm during rehearsals and breaks in performances when they are not dancing for extended periods of time.
During adolescence psychological factors can be more of a risk for injury than at any other age in a dancer. Pressure and expectations from parents, peers, and teachers can all lead to increased stress. Stress and anxiety can affect concentration, making injury more likely. Fear of injury, not achieving goals or being picked for a role, letting down your competition team due to inability to perform, or teacher criticism are all examples of potential stressors in the dancer’s life. As a practitioner, attending to who is answering intake questions, whether it is the young dancer or his/her parent or guardian, and how the questions are answered can be revealing. It is important for the healthcare provider to educate and offer objective criteria for safe return to dance. Having some resources to help address psychological factors, and when needed referring to a dance/sports psychologist, can facilitate the healthiest return to dancing.
Finally, nutrition is an enormous component of injury prevention and rehabilitation. As young dancers mature, concerns about their changing bodies and maintaining the thin aesthetic characteristic of most dancers can lead to poor nutritional practices and eating habits. In the USA there is also a tendency for young dancers just not having enough time to eat well due to their demanding schedules, and processed food becoming the easy mainstay. Teaching dancers about proper nutrition and that at such a high level of peak performance our bodies need fuel can be paramount to preventing and treating injury. In particular, understanding adequate vitamin D and calcium intake in the adolescent years is a significant component for good bone health, not only while training but also in a dancer’s adult life . In areas where there are four seasons of climate change, often the dancer experiences little to no natural sunlight during a day filled with academic and dance study. Educating young female dancers on how poor nutrition can affect their menstrual cycles and lead to hormone imbalances that can then cause lower bone density and reproductive issues is vital to preventing and treating injuries when they are young, and has significance for when they are older. While this may be taken for granted by healthcare providers and well-informed dancers/dance educators, in practice many dancers and their parents receive such information as new and surprising.
Components of Rehabilitation
Many of the risk factors for injury are common to all young athletes and are not unique to dancers. In rehabilitating an injury in a young dancer, the initial treatment and education may therefore be very similar to that of any young athlete. A comprehensive rehabilitation program should include incorporation of the young dancer’s goals; emphasis on education and communication with the dancer, parent, and dance teacher to help ensure a safe and successful return to dancing ; use of objective and functional protocols to determine readiness to progress in rehab; cross training; relative rest; task-specific rehab while addressing motor learning and motor control to change long-standing habitual ways of moving: and review of dance technique that might contribute to injury. The overall goal should always be to return the dancer to optimal performance, and more confidence than prior to the injury. Dancers are generally anxious to return to classes, rehearsal, and performance too quickly following an injury . Premature return not only increases the risk of reinjury, but also places the dancer at risk for a new injury as compensatory movement patterns emerge.
Rehabilitation should begin immediately following an injury and should not end until the dancer has returned safely to full activity. Initially, any rehabilitation program should focus on how to maximize the dancer’s abilities while protecting the existing injury. It is important to educate healthcare providers, dance teachers, and parents on the importance of an immediate referral to therapy, especially for dancers who will need to significantly limit or refrain from dance activity. Having a few early visits to establish a comprehensive home program that can also be done at the dance studio will allow the dancer to maintain or improve optimal condition and can help prevent depression and other issues due to the injury. It also allows the later phases of rehab to be focused on the area of specific injury without concern that the rest of the body is conditioned well enough to initiate the return to dance. Dancers with injuries that require limited weight bearing or more gradual progression of therapeutic exercise may benefit from water or floor barre exercise therapy. The buoyancy of water allows the dancer to replicate dance movements typically done at the barre with much greater ease and less impact as compared with on-land training. The hydrostatic benefits of water include reduction in pain and edema, which can facilitate an increase in joint range of motion . Depending on the exercise, water can provide assistance or resistance to muscles. It is effective in challenging the cardiorespiratory system to maintain aerobic capacity, and there is research to support that it does not increase risk of infection postsurgically . Without access to a pool, or in addition to water therapy, floor barre exercises allow the dancer to avoid weight bearing positions by lying on all sides of their body (injury permitting) to replicate many of the dance movements they perform in standing, such as passé or développé. Pilates matwork serves as a wonderful compliment to floor barre work, especially since entry-level Pilates matwork teaches the young dancer how properly to engage their local core stabilizers: the pelvic floor, transversus abdominus, and multifidi . Use of equipment-based Pilates such as a reformer or cadillac also serves to reduce weight bearing impact (Fig. 4.2a, b, c). Similar to Pilates is the Gyrotonic method of exercise, which also offers a beneficial method to improve pelvic and core stability. The primary difference between the two is that in Gyrotonic the equipment offers more diagonal and rotational movement as opposed to Pilates equipment, which is more linear in nature.