The Artist as an Athlete: Injuries in Dancers

Professional dancers are both artists and athletes—not only performing incredible feats of athletic prowess, muscular strength, and flexibility— but doing so in an aesthetically pleasing and seemingly effortless way. The thousands of hours which are devoted to perfecting each individual component of a routine require dedication and commitment akin to any other professional sport—and similarly place these artistic athletes at risk for certain injuries.

The rising incidence of dance-related injuries may be a product of the physical demands of newer dance moves, combined with the earlier starting age of aspiring dancers and higher cumulative number of hours of practice and performance. Multiple studies have documented the rates of injury in dancers, which are overwhelmingly related to overuse and the repetitive actions associated with frequent jumping and landing maneuvers. Most injuries occur in the lower extremity and can lead to significant absences from both rehearsals and performances. The most frequently injured body parts are the foot (24%), lumbar spine (23%), and ankle (13%). This experience is comparable to that of a collegiate athletic department or professional sports team.1

Interestingly, when evaluating risk factors for injury, age, years in training, body mass index (BMI), gender, and ankle range of motion, all showed no predictive value for identifying those at risk for injury. A history of previous injury and dance discipline (ballet) both correlated with risk of injury.2 The “dancer’s fracture,” is a common injury among ballet dancers and usually occurs when the dancer rolls over the outer border of the foot while in the demi pointe position on the ball of the foot with the ankle flexed. Non-operative management has been shown to be incredibly successful for these injuries, even in the face of displacement, and almost universally results in return to pre-injury level of dance performance. Dancers, on average, return to barre exercise around 11 weeks and performance by 19 weeks.3

Stress fractures are also a concern for many female athletes, including dancers. Data suggest that prolonged periods of amenorrhea and heavy training schedules (more than 5 hours per day) are risk factors for developing stress fractures. Thirty-one percent of dancers in professional ballet companies have sustained stress fractures, most commonly of the metatarsal (63%), tibia (22%), and spine (7%).4

Somewhat surprisingly, despite the high volume of jumping and landing performed during dance routines, dancers have been shown to have a much lower incidence of ACL injuries (0.009 ACL injuries per 1000 exposures) than athletes competing in team sports (0.07 to 0.31 ACL injuries per 1000 exposures).5 Also interesting to note is that there is no clear gender difference in the incidence of ACL injuries in dancers. Investigation into the jump landing biomechanics of dancers has revealed that both male and female dancers, who universally have received jump- and balance-specific training since an early age, avoid landing patterns that have been associated with increased ACL injury rates.6

In summary, dancers are similar to other elite athletes in the ways they approach training, and in many ways, surpass many team sport athletes in the volume of training that they perform. This can put dancers at risk for a variety of unique acute and chronic overuse injuries. Vigilant attention to modifiable risk factors and early education can potentially help minimize these injuries and keep these artistic athletes at peak performance levels.

References 1. Garrick JG, Requa RK. Ballet injuries: An analysis of epidemiology and financial outcome. Am J Sports Med. 1993.21:586-90. 2. Wiesler ER, Hunter DM, Martin DF, Curl WW, Hoen H. Ankle flexibility and injury patterns in dancers. Am J Sports Med. 1996.24:754-7. 3. O’Malley MJ, Hamilton WG, Munyak J. Fracture of the distal shaft of the fifth metatarsal: dancer’s fracture. Am J Sports Med. 1996.24:240-3. 4. Kadel NJ, Teitz CC, Kronmal RA. Stress fractures in ballet dancers. Am J Sports Med. 1992.20:445-9. 5. Liederbach M, Dilgen FE, Rose DJ. Incidence of anterior cruciate ligament injuries among elite ballet and modern dancers: a 5-year prospective study. Am J Sports Med. 2008.36:1779-88. 6. Orishimo KF, Kremenic IJ, Pappas E, Hagins M, Liederbach M. Comparison of landing biomechanics between male and female professional dancers. Am J Sports Med. 2009.37:2187-93. 7. Harris JD, Gerrie BJ, Varner KE, Lintner DM, McCulloch PC. Radiographic prevalence of dysplasia, cam, and pincer deformities in elite ballet. Am J Sports Med. 2016.44:20-27. 8. Winston P, Awan R, Cassidy JD, Bleakney RK. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007.35:118-26. 9. O’Neill JR, Pate RR, Liese AD. Descriptive epidemiology of dance participation in adolescents. Res Q Exerc Sport. 2011.82:373-80.