Research: Hallux Valgus in Dancers

This review article discusses the relevant anatomy and clinical presentation of hallux valgus with a specific focus on the condition in dancers. There are many intrinsic and extrinsic risk factors for hallux valgus in the current literature, including age, gender, genetics, race, first ray hypermobility, foot architecture, tight Achilles tendon complex, first metatarsal length, footwear, technique, and workload/stresses on the MTP joint.

Research: A Preseason Cardiorespiratory Profile of Professional Dancers

Nine professional dance companies which regularly perform the post-hire, pre-season health screen for professional dancers (developed by the Dance/USA Task Force on Dancer Health) were examined for this study. Examining several indicators of physical fitness, the researchers sought to identify a cardiorespiratory fitness profile of professional dancers, look for differences in heart rate of modern and ballet dancers during and after a fitness test, and identify any genre- or company-specific variables that may be related to level of fitness among professional dancers.

Research: Dance-related Concussion: A Case Series

While concussions have been a focus for sports medicine literature and the sports media, they have received very little attention in the dance and dance medicine communities. This case series retrospectively reviewed the medical charts of 11 dancers who suffered a concussion during dance activities over the course of 5.5 years. The cases presented here are similar to sports-related concussion cases in mechanism of injury and presentation of symptoms. Perhaps unsurprisingly, nearly all of the dancers examined here continued dancing on the day of their injury despite experiencing symptoms. The researchers theorized that many dancers, like athletes, may be suffering concussions without recognizing or reporting them. Additionally, dancers are known to attempt to dance through pain, which means that some dancers may also be intentionally continuing to dance despite concussion symptoms. Since many dance-related concussions occur through accidents like collisions and falls, standard safety measures can and should be taken at dance studios and performance venues. The researchers finish up by proposing dance-specific adaptations to the guidelines for concussion management from the 4th International Conference on Concussion in Sport.

Stein CJ, Kinney SA, McCrystal T, et al. Dance-related concussion: A case series. J Dance Med Sci. 2014:18(2):53-61

Research: Trunk Muscle Endurance and Low Back Pain in Female Dance Students

Previous research has suggested that trunk muscles with lowered levels of muscular endurance can predispose an athlete to low back pain. This study sought to examine the exact role that trunk muscle endurance plays in the development of low back pain among female dance students. To achieve this, the researchers had all study participants perform four isometric trunk muscle endurance tests: right side plank, left side plank, double straight leg raise, and the Sorensen test. The study’s participants were female dance students; 11 of the 17 participants had low back pain while the remaining 6 did not. The study found significant differences between groups for both side planks and the double straight leg raise, with the low back pain group recording significantly shorter times on these tests (a shorter time indicated lower levels of muscle endurance). Therefore, it appears that, among female dance students, those with low back pain have lower levels of trunk muscle endurance than those who do not. These findings are consistent with previous literature that identified good isometric endurance of the trunk muscles as a protective mechanism against the development of low back pain. However, the results of this study can only demonstrate association, not causation with respect to lower levels of trunk muscle endurance and the development of low back pain.  It is possible that the dancers' low back pain limited their ability to effectively perform the trunk muscle endurance tests.

Swain C, Redding E. Trunk muscle endurance and low back pain in female dance students. J Dance Med Sci. 2014;18(2):62-66

Research: EMG Comparison of Grand Battement Devant at the Barre, in the Center, and Traveling

In examining trunk and lower extremity muscle usage during a functional dance motion, the researchers used surface EMG electrodes and force plates to study beginner, intermediate-level, and advanced dancers as they performed a grand battement devant at the barre, in center, and while traveling. The researchers had two hypotheses: (1) that trunk and lower extremity muscle use would differ between the 3 conditions (stationary with support, stationary without support, and while moving), and (2) that muscle activation levels would differ by training/experience level of dancers. The movement of the grand battement devant was broken down into 4 distinct phases (or “events”): stance, initiation of movement, peak of movement, and end of motion.

Foot, Ankle, and Lower Leg Pain in Dancers: FHL Tendinopathy

The Flexor Hallucis Longus (FHL) tendon is Harry in the “Tom, Dick, and Harry” grouping of extrinsic foot muscle tendons that pass through the tarsal tunnel. The FHL is responsible for great toe flexion and it assists with plantar flexion of the ankle. While not often inflamed in isolation in the general population or in the athletic population at large, the FHL can very easily become injured in dancers. Most frequently, FHL tendinopathy is caused by repetitive strain, but indirect or direct injury and irritation can result from acute trauma.

Research: A Yoga Intervention for Music Performance Anxiety in Conservatory Students

This pilot study sought to determine the effectiveness of a 9-week yoga program with respect to reducing music performance anxiety among undergraduate and graduate music conservatory students. The 17 subjects who completed the entire study demonstrated decreases in performance anxiety (especially associated with solo performance) and in trait anxiety. Follow up at 7-14 months indicated that the improvements experienced by the program completers were sustained. The positive feedback received from the participants about the program and its effects on general well-being and performance anxiety were encouraging to the authors.

Research: Survey of Health Problems in Musical Theater Students, A Pilot Study

Musical theater performers face a wide variety of injury risk factors as they dance, sing, and act and perform a wide variety of repertoire both musically and physically. To obtain a clearer picture of the health problems faced by musical theater students, the authors surveyed the 37 students attending one musical theater school in Germany. Of all of the students, nearly half reported suffering an orthopedic or internal illness up to twice per year. The students cited the pressure of expectation and performance from their peers, family members, and school administrators and fears regarding casting or exams as the highest-rated problems that may contribute to the onset of illness or injury. In this cohort, the lower extremity was the most common site of injury, with nearly two-thirds of the students reporting acute injuries there and almost as many students reporting a chronic injury to the lower extremity. Strains, sprains, and contusions were the most commonly reported injuries. Interestingly, 76% of the injuries reported in this cohort occurred during well-known movement sequences.

Research: Fatigue Effects on Quadriceps and Hamstrings Activation in Dancers Performing Drop Landings

To examine fatigue’s effects on the quadriceps and hamstrings in dancers, this study had subjects perform single-leg drop landings before and after a dance-specific fatigue protocol. The authors examined the co-contraction ratios using EMG electrodes placed on the vastus medialis, vastus lateralis, and biceps femoris muscles. This study only examined 7 female dancers, but they found that dancers use a quadriceps-dominant landing strategy both before and after a landing protocol. They also found an increase in the quadriceps-hamstring contraction ratios following the fatigue protocol. The authors felt that this change could be explained by an increase in quadriceps activity with no associated change in hamstrings activity. The authors theorized that the reason dancers demonstrated a quadriceps-dominant landing strategy during this single-leg drop landing task both before and after a fatigue protocol is related to the way dancers are taught to land in dance. Dance technique dictates that the dancer lands with an upright trunk and minimal hip flexion. Landing with these mechanics reduces the ability of the hamstrings to activate and absorb landing forces.


McEldowney KM, Hopper LS, Etlin-Stein H, and Redding E. Fatigue effects on quadriceps and hamstrings activation in dancers performing drop landings. J Dance Med Sci. 2013;17(3):109-114.

Research: What is Known About the Effect of Fatigue on Injury Occurrence Among Dancers?

This review article discusses and compares the injury incidence in dance, the relationships between fatigue and dance injuries (as has been studied so far), and the inter-play between fatigue, diet, and menstrual status. Reporting an injury incidence as high as 75%-97%, the authors point out that dance injuries are activity-specific (much like sports injuries). While some studies have found that the highest rate of injury among dancers occurs during performance seasons, others have discovered that the greatest number of injuries occurred during the rehearsal stages of a season, when the amount of repetitive activity was the highest. One study, examining female professional ballet dancers, found that subjects who danced more than 5 hours per day were significantly more likely to suffer a stress fracture than those who danced less. Another study found that the incidence of ACL injuries in dancers was higher late in the day and late in the season, indicating fatigue as a possible cause of injury. Like a previous review article examining fatigue and dance injuries, this article also examines the diet with respect to injury incidence. All of the information presented in this review article can lead to important educational content for dancers and, more importantly, dance administrators.

Liederbach M, Schanfein L, and Kremenic, IJ. What is known about the effect of fatigue on injury occurrence among dancers? J Dance Med Sci. 2013;17(3):101-108.

Guide: String Instruments, Part 1

There are several instruments that fall into the category of “string instrument.” To keep from presenting an overwhelming amount of information, this installment of a guide to string instruments focuses on the four most common string instruments encountered when treating classical musicians: violin, viola, cello, and (upright/acoustic) bass. Additional instruments will be discussed in later articles.

Research: Overuse, Tissue Fatigue, and Injuries

This review article breaks down the inter-related factors of overuse, fatigue, and related injury-causing factors for bone, cartilage, tendon, ligament, muscle, and neural tissue and functioning. The author states that it is a widely accepted fact that rest and adequate nutrition are imperative for injury prevention, injury healing, and improving performance and conditioning, but there is a disconnect between understanding this concept and implementing it into practice for dancers. This lack of proper nutritional support, combined with the long hours of a dancer’s typical workday, are a recipe for injury. The concepts presented in this article are an excellent primer for examining the common overuse injuries suffered by dancers, addressing dance-specific mechanisms of injury including the increased torque caused by Graham spirals and the forces placed on the menisci by Horton hinges. Fatigue-related injuries are especially prevalent in dance due to unforgiving schedules (often dictated more by tradition or pursuit of perfection than by medical considerations), misinformed “health” decisions and practices, and the tendency for dancers to push-through an injury for fear of losing a role. 

Murgia C. Overuse, tissue fatigue, and injuries. J Dance Med Sci. 2013;17(3):92-100.

Injured Dancers and Modified Activity

Dancers traditionally do not have a great (psychological) relationship with medical professionals. There is an overabundance of avoidance behaviors and, to some extent, denial about the injury itself. Many of these behaviors and fears stem from the belief that going to see a medical professional – or simply admitting that an injury has occurred – will result in losing a role or being forced to stop dancing.

The concept of absolute rest is abhorrent to performing artists, especially dancers. More often than not, dancers will push through pain for a significantly longer time before seeking help than traditional athletes. Sometimes, “toughing it” without seeking medical help even goes to the point of allowing the injury to worsen so much that the dancer can’t walk without pain.

Research: Lower-Limb Proprioceptive Awareness in Professional Ballet Dancers

Balance and proprioception in dancers has frequently been studied. To add to the existing knowledge, this study set out to compare lower-limb proprioceptive awareness and postural control of professional ballet dancers to matched controls with no dance training. The researchers examined joint position reproduction at the ankle, knee, and hip in both groups and found that dancers demonstrated significantly better awareness of their joint positioning (and reproduction of this positioning) than the controls. Additionally, the dancers’ proprioceptive awareness of specific joint positioning was equal among all three joints whereas controls had significantly less awareness of their ankle position compared to their awareness of the hip and knee. In addition to examining joint reposition sense, the researchers also took center of pressure excursion and path measurements during an eyes-closed bipedal stance task. The results related to this portion of the examination did not indicate a difference between dancers and non-dancer controls. It is possible that this task, like other simple, non-specific tasks examined in previous studies, is not difficult enough to require the dancers to utilize any enhanced postural control mechanisms they may have as compared to the control group.

An Ounce of Prevention...

While it is common to think only of exercises and stretches when discussing injury prevention, there are actually several other factors, both intrinsic and extrinsic, that contribute to preventing injury.

Research: Musculoskeletal Pain and Injury in Professional Orchestral Musicians in Australia

A survey of the members of Australia’s eight fulltime professional orchestras examining performance-related musculoskeletal disorders found that 84% of the respondents had experienced pain or injuries that interfered with playing or with participating in normal rehearsals and performances. This number is slightly higher than the previously reported 70%-80% rate of performance-related injury. In this study, the most commonly injured sites were the back, right upper extremity and neck, left upper extremity and neck, and the neck alone. Perhaps the most important finding from this study was that less than half of the injured musicians reported recovering completely from their injuries. Additionally, half of the 377 respondents were experiencing an injury at the time of the survey and more than 50% of these performers reported that their current pain had been present for more than 12 weeks.

Guide: Dance Footwear

Dance footwear can facilitate the dancer’s performance, enhance aesthetics, and protect the dancer from injuries. However, dance shoes can potentially put the dancer at risk of developing an injury from the shoes themselves (blisters), from ground reaction forces applied to the body during jump landings, or from altered mechanics or gait due to the structure and nature of the shoe.

There is a wide variety of footwear in use in the dance world.  While many types of shoes are primarily used by one particular genre or style of dance (like pointe shoes in ballet), dance genres are not always clearly delineated, meaning that your patient may face many challenges from many different types of footwear (ballet companies will perform pieces in character shoes, sneakers, or even barefoot). In fact, some ballets will place some dancers in pointe shoes, others in ballet slippers, and still others in character shoes. Some dancers may even have to switch types of footwear during a show (sometimes even in the middle of a piece).

As a clinician, it is important to understand the differences in dance footwear when evaluating a dancer’s injuries. This guide overviews the most common types of footwear in dance.

Research: Case Study of Spinous Process Apophysitis in an Adolescent Female Dancer

The case study presented in this article is of a 13 y/o female dancer c/o insidious onset and progressive pain at the thoracolumbar junction and upper lumbar region for approximately 4 months. Her pain progressively increased each week following hip-hop class when she had to practice choreography that included backbends and kip-ups (laying supine on the floor and quickly kicking up to a standing position). Her deep and achy pain that increased in intensity over several hours following training was also increased with trunk extension, but she denied radiating pain, difficulty breathing, or bowel/bladder problems. She received 10 weeks of treatment to alleviate symptoms, the patient had a 2-week break in her dance training. During this break, her symptoms did not improve. At this time, diagnostic imaging was performed to identify a more accurate diagnosis. The plain x-rays and MRI indicated inflammatory apophysitis of the L1-L3 spinous processes. The authors wrote this case study to identify delineations between spinous process apophysitis and the more common and debilitating diagnosis of spondylolysis. While specific symptom patterns and causes of pain will differ between the two conditions, the authors also recommend early x-rays and MRI with STIR sequencing to identify the exact location of the vertebral pathology causing low back pain.


Quinlan E, Reinke T, Bogar WC. Spinous process apophysitis: A cause of low back pain following repetitive hyperextension in an adolescent female dancer. J Dance Med Sci. 2013;17(4):170-4

Research: Injuries in Irish Dance

The authors of this study examined the medical charts of injured Irish dancers who visited their clinic over an 11-year period (from 2000-2010) and investigated common themes among those whose injuries were directly or indirectly related to Irish dance (if the injury was caused by something un-related to dance, the medical chart was not included in the study). Nearly 80% of the injuries found were due to overuse and 95% of all injuries involved the hip or lower extremity. Acute injuries were seen in the medical clinic after a shorter period of time following the injury than the overuse injuries were. One-third of the patients included in this study had only one office visit while just over one-third had four or more visits. No information was given as to whether the patients with only one visit were supposed to return for a follow-up appointment but never did. Interestingly, this study found that acute injuries were more likely to occur on the right side of the body. The most common injury treatment prescribed to these dancers was physical therapy or a home exercise program, with the next most common prescription for immobilization devices (boot, brace, cast, etc.). The patients included in this study were contacted and surveyed regarding the injury in question. Suggestions for injury prevention, as provided by the patients, emphasized stretching and also recommended strengthening or conditioning, the use of shoe support (orthotics, etc), and educating dance teachers.

Stein CJ, Tyson, KD, Johnson VM, et al. Injuries in Irish dance. J Dance Med Sci. 2013;17(4):159-64 

Research: Injury in Professional Irish Dancers

This article is part 2 of a 2-part comprehensive survey of professional Irish dancers, and it focuses on the incidence of injury during a performance tour’s schedule. Three-quarters of the dancers surveyed reported a previous injury. The foot and ankle were the most common sites of injury, consistent with other dance injury literature. In contrast with the timing of injuries in a ballet or modern dance season, this study found the highest rate of injuries to be in the middle of the tour. This difference may be due to the different styles of performance between Irish dance and ballet/modern dance, since Irish dance choreography often does not drastically change from year to year (or at all within a tour/season, like it does for ballet companies).

Research: Job Satisfaction of Professional Irish Dancers

Part 1 of a 2-part comprehensive survey of professional Irish dancers, this article reports results from an online survey of current and retired professional Irish dancers, specifically focusing on attitudes toward careers in dance. Ninety-four percent of those surveyed would recommend a career in Irish dance, praising the opportunity to travel and experience other cultures and the ability to be paid while doing something they love. These findings are encouraging in light of other studies that have found job satisfaction of orchestral musicians to be lower than that of federal prison guards. While touring schedules offer little respite from fellow dancers away from performances and interpersonal problems can arise, the dancers surveyed here reported developing close and long-lasting friendships with their fellow company members. The negative sides of pursuing a career in Irish dance, as identified by the dancers surveyed in this study, included a lack of job security and the risk of pain and injury related to dancing.

Cahalan R, O’Sullivan K. Job satisfaction of professional Irish dancers: Implications for performer health and well-being. J Dance Med Sci. 2013;17(4):139-49