Dance is a constantly evolving sport and art form, with hundreds of different styles of dance around the world. With the prevalence of shows like ‘World of Dance,’ ‘Dancing with the Stars,’ ‘So you think you can Dance,’ ‘Dance Moms,’ among others, the popularity of dance as a sport continues to grow. Inevitably, there is also an increase in dance-related injuries that accompanies an increasing population of dancing athletes. In one study conducted by the Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital, 23 children or teens are treated in U.S. emergency departments for dance-related injuries each day. Many other dance injuries are seen in other settings, such as urgent care or with one’s primary care clinic.
To date, ballet has been the highest focus of scientific research, however, research on “ballet dancers” cannot necessarily be generalized across all “dancers.” Injury locations may correlate with the physical requirements of specific genres of dance. For example, modern or contemporary dancers experience a higher proportion of upper extremity injuries when compared to ballet dancers. One reason for this is the predominance of floor-based and partner movements that involve extensive upper extremity weight bearing. Taking a look at hip hop dancer injury patterns, reported injury rates exceed other dance forms but are similar to gymnastics. The majority of these injuries involved the lower extremities and torso.
Within hip hop, it is notable that breaking largely incorporates aerobatic skills, popping/locking utilizes quick contraction and relaxation of muscle groups, and house dancing integrates rapid, complex steps with fluid torso movements. Among ballet dancers, the highest percentage of injuries occur in the foot/ankle (53.4%), followed by the hip (21.6%), knee (16.1%), and back (9.4%). Similarly, jazz and tap dancers experience a higher frequency of distal to proximal joint injuries. With the unique demands posed by each distinctive dance style, there are variations in specific injury patterns and risk factors.
Fundamental technique plays a significant role in predisposing ballet dancers to injury. Take for example, “turnout” – in which the hips and lower extremities externally rotate such that the feet can obtain a 180-degree angle with each other (Figure 1). Pushing beyond normal limits in attempt to achieve maximal turnout, called “sickling”, many dancers develop excessive foot pronation, excessive forces on the hips, knees and ankles (Figures 2 and 3). Additionally, in order to achieve maximal turnout, many dancers overcompensate with anterior pelvic tilt or by rolling of the feet forward. This overcompensation can lead to back pain, snapping hip syndrome, sprained ligaments and strained muscles and tendons. Not only does improper posture and positioning lead to injury, but it also prevents appropriate lower extremity strengthening and is less aesthetically pleasing to the eye.
Another reason for the frequency of foot and ankle injuries in ballet is the extreme positioning of the foot into demi pointe – body weight concentrated on the ball of the foot (Figure 4), or en pointe – dancer on tips of toes with body weight distributed through the ankle joint (Figure 5). When a dancer rises into such a position, misalignment and improper training or technique can be the root of foot and ankle injuries. Such injuries may include Achilles tendonitis, flexor hallucis longus tendinitis, ankle sprain, trigger toe, ankle impingement, sesamoiditis and stress fracture. Some dancers may further exacerbate the matter by inverting or everting the foot while stretching or by crunching their toes for an appearance of a higher arch.
Another common injury seen in ballet dancers is lumbar stress injury or fracture, called “spondylolysis.” Spondylolisthesis is a more severe stress fracture where one vertebra slides anteriorly over the vertebra below, and often results in chronic low back pain. (Figure 6) These injuries are often associated with recurrent hyperextension of the spine, which is quite prevalent among not only ballet and modern dancers, but other sports and activities involving trunk flexibility, such as gymnastics and cheer.
The distinctive movements that make-up modern or contemporary dance are important considerations for the types of injuries these dancers may present with. Modern dancers have a higher variability in style, body shape and size, and strength and flexibility in comparison to ballet dancers. There are several conglomerations of techniques that are incorporated into modern dance. One such technique, referred to as the “cornerstone” of American modern dance, is the Graham technique. The basis of the Graham technique is contraction and release, in which muscles work in opposition to represent and exaggerate the normal breathing cycle. This technique also involves spiraling of the torso and hip around the vertical axis of the spine as well as controlled falls i.e. standing falls directed forward, backward, or into a split. Understanding the methods and skills utilized in modern and contemporary dance can better aid health care providers in determining patterns of injury unique to this population of dancers. The use of pelvic and abdominal muscles and pulling of the spine into a contracted position may explain why the lower back is a common location for injury in contemporary dancers. Similarly, taking into consideration biomechanics and landings of choreographed falls can be helpful in recognizing mechanisms of knee injuries that are prevalent in these dancers.
Tap Dancing considerations
Tap dancers have a unique ability to turn their feet into percussive instruments. In order to achieve this, tap dancers need loose ankles and increased range of supination motion. The balls of the feet are the bearers of weight in landing jumps and the entire foot – toe to heel – is used for shuffling, pounding, tapping, and clicking movements. Typical injuries seen in tap dancers include high incidence of tendonitis due to overuse, ankle and toe fractures stemming from tap shoes that don’t absorb the shock of pounding movements well, and blisters and ingrown toe-nails related to ill-fitting shoes, moisture, and friction.
Hip Hop considerations
Hip hop dancing has a distinctive culture and involves a diverse range of styles including but not limited to breaking, locking, popping, and krumping. Compared to other dance genres, hip hop dancers may frequently practice and perform in gymnasiums, sidewalks, and maybe even at bus or subway stations with little protective equipment or supervision. A study looking at three groups of hip hop dancers: Breakers, Popper/Lockers, and New Schoolers found that tibial stress injuries, thoracolumbar sprains, and neck and shoulder injuries were more common in Breakers than the other two groups. This may be related to repetitive impact with the hard ground surfaces as well as moves that involve weight bearing on their head or shoulders. Foot/ankle, knee, and hip injuries were commonly reported among all of the groups. Poppers use joint hyperextension and isometric muscle contractions; Lockers incorporate deep squatting and valgus motions; New Schoolers like Krumpers perform quick, powerful whole body movements; Breakers execute spins and freezing while weight bearing on shoulders, head, wrists, or hands. With the high level of aerobatic movements in hip hop dancing, the annual injury rate for this dance genre is in the same range reported in gymnastics. Interestingly, hip hop dancers have 2 times the rate of injury for tappers, 3.4 times the rate for modern dancers, and 8 times the rate for time loss injuries in ballet dancers.
To better understand injury mechanisms in dancing athletes, it is critical for the dancer, instructor and medical provider to recognize the distinctive elements present in various dance genres. Additionally, proper training and strengthening of muscles specific to the demands of the genre of dance can improve targeted prevention of injury and rehabilitation of dancers.
By Sameeha Khalid and Jonathan Minor, MD
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