Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers

A Resource Guide

June 6, 2002

Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers

About SHAPE

SHAPE (Safety and Health in Arts Production and Entertainment) is an industry association dedicated to promoting health and safety in film and television production, theatre, dance, music, and other performing arts industries in British Columbia. SHAPE provides information, education, and other services that help make arts production and entertainment workplaces healthier and safer.

For more information, contact:

SHAPE (Safety and Health in Arts Production and Entertainment)

Suite 280–1385 West 8th Avenue

Vancouver, BC V6H 3V9

Phone: 604 733-4682 in the Lower Mainland

 1 888 229-1455 toll-free

Fax: 604 733-4692

E-mail: info@shape.bc.ca

Web site: www.shape.bc.ca

© 2002 Safety and Health in Arts Production and Entertainment (SHAPE). All rights reserved.

SHAPE encourages the copying, reproduction, and distribution of this document to promote health and safety in the workplace, provided that SHAPE is acknowledged. However, no part of this publication may be copied, reproduced, or distributed for profit or other commercial enterprise, nor may any part be incorporated into any other publication, without written permission of SHAPE.

National Library of Canada Cataloguing in Publication Data

Robinson, Dan.

Preventing musculoskeletal injury (MSI) for musicians and dancers : a resource guide

Writers: Dan Robinson, Joanna Zander and B.C. Research. Cf. Acknowledgments.

Includes bibliographical references: p.

ISBN 0-7726-4801-8

1. Musculoskeletal system - Wounds and injuries - Prevention. 2. Entertainers - Wounds

and injuries - Prevention. 3. Musicians - Wounds and injuries - Prevention. 4. Dancing

injuries - Prevention. I. Zander, Joanna. II. Safety and Health in Arts Production and

Entertainment (Organization). III. B.C. Research. III. Title.

RD97.8.A77R62 2002 617.4'704452 C2002-960144-4

Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers

Acknowledgments

Thanks to the members of SHAPE’s Special Committee on Musculoskeletal Injury for helping

develop and review this resource guide and to the organizations they represent:

• Burt Harris, Pacific Music Industry Association

• Day Helesic, Canadian Alliance of Dance Artists, BC Chapter

• Jennifer Mascall, The Dance Centre

• Gene Ramsbottom, Vancouver Musicians’ Association, Local 145, American Federation of

Musicians of the United States and Canada

Thanks also to:

• Dan Robinson, Joanna Zander, and BC Research (researching and writing)

• Rob Jackes, Linda Kinney, and Robyn Carrigan of SHAPE (coordinating and reviewing)

• Kevin Sallows (coordinating and editing)

• David Harrington of the Lynn Valley Orthopaedic and Sports Physiotherapy Centre

(reviewing)

• Workers’ Compensation Board (WCB) of British Columbia (reviewing)

Thanks to the WCB for their permission to use source material from WCB health and safety

publications, including the lifting illustration on page 29.

Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers �� 3

Contents

About this resource guide...................................................................................................3

Who should read this resource guide...................................................................................4

Background………………………………………………………………………5

What is musculoskeletal injury (MSI)?

Risk factors

General prevention and treatment

References

Dancers and musculoskeletal injury (MSI)…………………………………….9

Overview

Preventing musculoskeletal injury for dancers

Treating musculoskeletal injury for dancers

Nutrition

Bone injuries

References

Musculoskeletal injuries (MSIs) prevalent in performers………………………24

Overview

Jaw and head injuries: Temporomandibular joint (TMJ) dysfunction.

Shoulder injuries (rotator cuff injuries)

Shoulder injuries: Rotator cuff tears

Shoulder injuries: Shoulder impingement syndrome

Hand and arm injuries: Carpal tunnel syndrome

Hand and arm injuries: Cubital tunnel syndrome

Hand and arm injuries: Thoracic outlet syndrome

Hand and arm injuries: De Quervain’s syndrome

Hand and arm injuries: Lateral epicondylitis (tennis elbow)

Hand and arm injuries: Medial epicondylitis (golfer’s elbow)

Hand and arm injuries: Focal dystonia

Joint injuries: Arthritis

Hip injuries: Snapping hip syndrome (tight iliotibial band)

Knee injuries

Knee injuries: Patellofemoral pain

Knee injuries: Knee sprains and strains

Knee injuries: Meniscus tears

Back and neck injuries

Back and neck injuries: Spondylolysis

Back and neck injuries: Back and neck pain

Lower leg and ankle injuries

Lower leg and ankle injuries: Shin splints, stress fractures, and stress reactions

Lower leg and ankle injuries: Ankle sprains

Lower leg and ankle injuries: Posterior impingement syndrome (dancer’s heel).

Lower leg and ankle injuries: Anterior impingement syndrome

Lower leg and ankle injuries: Achilles tendinitis

Lower leg and ankle injuries: Subtalar subluxation

Foot and toe injuries

Foot and toe injuries: Stress fractures of the second metatarsal

Foot and toe injuries: Fractures of the fifth metatarsal (dancer’s fracture)

Foot and toe injuries: Cuboid subluxation

Foot and toe injuries: Flexor hallucis longus tendinitis

Foot and toe injuries: Blisters

Foot and toe injuries: Bunions

Foot and toe injuries: Toenail injuries

Index

About this resource guide

Performers such as musicians and dancers are at risk of occupational health problems that can significantly interfere with their ability to perform. If not recognized and properly treated, many of these health problems can limit, interrupt, or even end an individual’s performing career.

This resource guide provides information and resources for the prevention of musculoskeletal injury (MSI) in performers. Other terms used to describe MSI include:

• overuse problems

• repetitive strain injury

• cumulative trauma disorder

• work-related musculoskeletal disorder

• activity-related soft tissue disorder

Generally, this guide will use the term musculoskeletal injury or MSI to describe an

injury or disorder of the muscles, bones, joints, tendons, ligaments, nerves, blood vessels,

or related soft tissues that may be caused or aggravated by activities related to

performing, rehearsing, practising, or taking classes in music or dance.

Performers can and should prepare themselves for a long and healthy career by learning

to recognize:

• early signs and symptoms of MSI

• occupational factors that cause or aggravate MSI

• practical strategies to reduce the risk and impact of MSI

This resource guide has four parts.

Background, defines musculoskeletal injury and provides basic information on pain, risk factors, and general prevention and treatment. Parts 2 and 3 will be easier to understand if you read Part 1 first.

Dancers and Musculoskeletal Injury (MSI), discusses common symptoms and types of injuries; strategies for preventing and treating MSI; nutrition; and bone injuries.

Musculoskeletal Injuries (MSIs) Prevalent in Performers, summarizes MSIs that occur in musicians and dancers. These MSI summaries provide a brief description of the injury as well as information on signs and symptoms; the causes of the injury; and treatment and prevention strategies. These summaries are not intended to replace the services of trained medical practitioners. Performers who recognize their own experience within an injury summary are strongly urged to seek a professional medical opinion.

Who should read this resource guide

If you participate in any aspect of the performing arts industry, this resource guide may help you prevent MSI in performers. A holistic approach to injury prevention includes consideration of personal, administrative, technical, and artistic issues, and recognizes that risk of injury can be significantly influenced by various factors (for example, parents, training at an early age, and facility and equipment design).

Background

What is musculoskeletal injury (MSI)?

Musculoskeletal injury (MSI) is any injury or disorder of the muscles, bones, joints,

tendons, ligaments, nerves, blood vessels, or related soft tissues. This includes a strain,

sprain, or inflammation that is caused or aggravated by activity.

Daily activities place demands on the body that may contribute to the development or

occurrence of MSI. Most performers spend a large part of each day on practice, rehearsal,

or performance. The physical, professional, and artistic demands of these activities can be

stressful on the body and may eventually result in MSI-related signs or symptoms.

Signs and symptoms

Signs that may indicate MSI include:

• swelling

• redness

• difficulty moving a particular joint

Symptoms that may indicate MSI include:

• numbness

• tingling

• pain

These signs and symptoms may appear suddenly or they may develop gradually over a

period of months or years. Signs and symptoms may or may not occur during the activity

that is causing or aggravating the condition. Some conditions result in signs and

symptoms that occur after the activity and may even occur during sleep.

Health professionals classify the severity of signs and symptoms using a graded scale that

represents the progression of a typical overuse injury. This scale, adapted for performers,

is illustrated in Figure 2, page 9. The severity of an injury and the need to establish a

treatment plan increase as an individual progresses from Level I to Level V.

Health effects

Early signs or symptoms are indicators of various health effects that may develop if the

signs or symptoms are allowed to progress. The specific health effects that are likely to

develop depend on the specific activities. MSI-related health effects include:

• strains

• sprains

• disc herniation

• tendinitis

• tenosynovitis

• bursitis

• nerve compression

• nerve degeneration

• bone degeneration or malformation

Early recognition of signs and symptoms and appropriate responses are critical in

minimizing the severity of health effects and maintaining an individual’s ability to

practise, rehearse, and perform.

Level I

Pain occurs after class, practice, rehearsal, or

performance, but the individual is able to

perform normally.

Level II

Pain occurs during class, practice, rehearsal,

or performance, but the individual is not

restricted in performing.

Level III

Pain occurs during class, practice, rehearsal,

or performance, and begins to affect some

aspects of daily life. The individual must alter

technique or reduce the duration of activity.

Level IV

Pain occurs as soon as the individual attempts

to participate in class, practice, rehearsal, or

performance, and is too severe to continue.

Many aspects of daily life are affected.

Level V

Pain is continuous during all activities of daily

life, and the individual is unable to participate

in class, practice, rehearsal, or performance.

Figure 2

Progression of MSI signs and symptoms in performers. Where are you on this

scale? If you are at Level I or II, modify your activities to prevent further

progression of symptoms. If you are at Level III or higher, seek professional

assistance.

Pain

Pain is a unique experience for each individual. The pain threshold of performers tends to

be very high, partly because pain is a common experience in this physically demanding

industry. Performers normalize pain and are less likely to fear it than the average person.

Yet pain is a defence mechanism that is intended to protect and preserve our bodies. If

you experience pain, it is important to pay attention to:

• when the pain occurs

• how long it lasts

• how it influences your ability to perform

• how it influences your other daily activities

Knowing where you are on the signs and symptoms scale (see Figure 2, page 9) may help

you distinguish between pain that is due to intense or unaccustomed physical activity and

pain that indicates a progressing injury.

Risk factors

Medical and scientific research has identified several risk factors that are widely believed

to increase the likelihood of MSI (for more information, see “References,” page 14).

Understanding these risk factors and looking for practical ways to minimize their

influences are important for maintaining your health and desired activity levels, as well as

for preventing the frustrating and potentially career-ending effects of MSI.

Risk factors include environmental aspects, physical demands of activities, and personal

characteristics. Figure 3 illustrates the primary risk factors associated with these three

categories.

Risk factors

Physical demands

Awkward postures

Forceful exertion

Repetition

Long-duration activities

(inadequate rest)

Contact stress

(sharp edges)

Vibration

Personal characteristics

Age and gender

Physical fitness

(strength, flexibility, endurance)

Nutrition

Posture

Addictive substances

(tobacco, alcohol, narcotics)

Psychological stress

Diseases or health conditions

(pregnancy, diabetes, osteoporosis)

Musculoskeletal injury

Environmental aspects

Temperature

Confined space

Layout of space

Equipment

Layout or configuration

of equipment

Surfaces (floors)

Lighting

Figure 3

A non-exhaustive list of MSI risk factors

In general, the strongest relationship between risk factors and incidence of MSI is

associated with extreme levels of any single risk factor or the occurrence of multiple risk

factors simultaneously.

For performers, the greatest risk of MSI is associated with situations that involve:

• a change in technique or instrument

• intense preparation for performance

• preparation of a new and difficult piece

• prolonged performance without adequate rest

These situations are common for performers, but they could lead to a worst-case scenario.

Over time, repetitive and sustained postures may result in stress to tendons, muscles, and

nerves. Psychological stress and poor diet — which often accompany a challenging

schedule, pressure to perfect, and performance anxiety — may also contribute to the

negative effects of physical demands on performers.

General prevention and treatment

Prevention

MSI prevention is based on two levels of approach: (1) Control the risk factors and (2)

Recognize and respond to early signs and symptoms.

Controlling risk factors

Controlling risk factors requires an awareness that they exist and the creative use of

strategies to reduce their effects. In the performing arts, as in other occupations, control

strategies are based on a combination of the following philosophies:

• Balance physical and psychological demands with the characteristics of the individual

(know your personal limits).

• Maintain a high level of well-being, health, fitness, and nutrition.

Recognizing and responding to early signs and symptoms

Early recognition of signs and symptoms allows performers to:

• seek professional medical assistance

• get referrals to appropriate specialists

• take preventive action before pain starts to affect their daily lives (Figure 2, Levels I

and II, page 9)

Unfortunately, it is more common for performers to work through pain until they can no

longer perform. At later stages of injury (Levels III–V), the likelihood of full recovery

diminishes, and the treatment process is more complex and disruptive to daily life.

Treatment

Medical management of signs and symptoms is best performed by medical practitioners

who are sensitive to the professional and artistic demands placed upon performers.

Musicians and dancers should seek the services of known medical professionals who

have demonstrated an understanding of the performing arts.

Performers commonly combine complementary approaches with traditional medical

management of MSI. There are many complementary approaches spanning a range of

philosophies and practices, including:

• body-awareness training (for example, the Alexander Technique, Feldenkrais Method,

Pilates Method, yoga, and Tai Chi)

• acupuncture

• massage therapy

• herbal medicine

While anecdotal evidence supports the effectiveness of complementary approaches, it is recommended that they be implemented in conjunction with the approach of traditional western medicine.

For a list of health-care professionals who have experience treating MSI for musicians and dancers, contact SHAPE.

References

Bernard, B., and L. Fine, eds. 1997. Musculoskeletal disorders and workplace factors: A

critical review of epidemiological evidence for work-related musculoskeletal

disorders of the neck, upper extremity and low back. Publication No. DHHS (NIOSH).

Cincinatti: U.S. Department of Health and Human Services, National Institute for

Occupational Safety and Health: 97–141.

Chong, J., M. Lynden, D. Harvey, and M. Peebles. 1989. Occupational health problems

of musicians. Canadian Family Physician 35:2341–2348.

National Institute of Health. 1998. Acupuncture — National Institute of Health consensus

conference. Journal of the American Medical Association 280 (17): 1518–1524.

Paull, B., and C. Harrison. 1997. The athletic musician: A guide to playing without pain.

Lanham, Md.: The Scarecrow Press, Inc.

Zaza, C. 1998. Play it safe: A health resource manual for musicians and health

professionals. London, Ont.: Canadian Network for Health in the Arts.

Dancers and musculoskeletal

injury (MSI)

Overview

Musculoskeletal injury (MSI) is the most frequently reported medical problem among

classical and modern dancers. The majority (60–80%) of dancers have reported at least

one injury that has affected their dancing or kept them from dancing (Bowling 1989;

Hamilton et al. 1992; Milan 1994; Guierre 2000), and approximately half of dancers

report at least one chronic injury (Bowling 1989).

Note: This part includes lists of selected references at the end of each section as well as a

full reference list at the end of the part (page 50).

Long-term and chronic injuries

In 1989, Bowling surveyed the injury incidence in 141 professional ballet and modern

dancers in the United Kingdom, including representation from the Royal Ballet, London

Contemporary Dance Theatre, Sadler’s Wells Royal Ballet, Diversions Dance Company,

English Dance Theatre, and many smaller dance companies. The majority of dancers

surveyed had experienced multiple injuries and injuries that were either recurring or not

resolving (chronic).

Many dancers report long-term and chronic injuries because minor injuries go unreported

and untreated for long periods. By the time these dancers finally report an injury or seek

treatment, the damage has intensified to a level that requires major rehabilitation. Many

dancers report self-treating injuries rather than seeking systematic professional medical

treatment. Dancers self-treat and delay medical intervention for various reasons. They are

often required to juggle a demanding schedule and lack the financial resources necessary

to subsidize preventive or early treatments. In a 1992 study, Hamilton et al. found that the

personality traits that characterize people with a high pain threshold also distinguish most

of the injured dancers. As a result of a high pain tolerance, a dancer may delay medical

intervention (Hamilton et al. 1992; Tajet-Foxell and Rose 1995).

Delayed-onset muscle soreness versus injury

Through their careers, dancers learn to recognize the difference between the delayed-

onset muscle soreness that normally accompanies a physically demanding workout and

the pain or symptoms that indicate injury. Delayed-onset muscle soreness is muscle

stiffness that may develop 24 to 36 hours after intense or unaccustomed physical activity.

Delayed-onset muscle soreness is a normal part of a physically challenging training

program. It does not usually limit further activity and subsides within a few days. Muscle,

tendon, or ligament injuries typically have a more rapid and localized onset of pain and

require much longer (weeks or months) for full recovery. Because dancers commonly

experience delayed-onset muscle soreness, there is a danger that they may not recognize

pain caused by injury as such. Therefore, dancers are at risk of further aggravating

injuries by continuing to train or rehearse in the same way.

Factors contributing to injury

The high incidence of injury in dancers has been attributed to:

• excessive dance training at an early age (before puberty)

Part 3: Dancers and musculoskeletal injury (MSI)

Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers �� 37

• extensive and intense rehearsal

• the physical characteristics of footwear

• dancing on pointe

• the dietary habits common to dancers

(Reid 1988)

The effects of excessive and intense rehearsal are compounded by:

• overtired or overworked dancers

• inadequate warm-up

• unstable or unsuitable flooring

• cold environments

(Bowling 1989)

Faulty technique has been implicated as a major problem and contributor to injury

(Maran 1997; Guierre 2000). Injuries because of faulty technique tend to recur even when

rest and rehabilitation are successful in treatment of the initial injury. Each time a dancer

resumes dancing with incorrect technique, the dancer may be reinjured. This scenario

illustrates the importance of long-term dance training that includes a focus on correcting

faulty technique.

The combination of high physical, mental, and environmental demands is thought to

contribute to the high incidence of injury in dance (Smith, Ptacek, and Patterson 2000).

The mental demands of dance can manifest as both physical stress (for example, muscle

tightness or hyperventilation) and mental anxiety. Both of these factors are known

contributors to injury (Smith, Ptacek, and Patterson 2000; Hamilton et al. 1992). Treating

stress disorders in dancers has been shown to reduce the incidence of injury (Maran

1997). The dancer’s stress level may also be influenced by interpersonal conflicts among

individuals in the dance environment.

Rest and proprioception

Rest after injury, particularly lower limb injury, plays an important role in maintaining or

restoring proprioception. Proprioception relies on sense organs in the joints to provide

awareness of the joint’s position, which is critical for posture, balance, and coordinated

movements. Proprioception is important for dancers who are trying to coordinate difficult

choreography and to balance in difficult positions. Postural stability requires adequate

proprioception from the ankle joint. Proprioception is decreased for several weeks in

dancers who have sprained their ankle, but will gradually improve as the injury heals.

Dancers with ankle injuries have decreased postural stability and are more likely to suffer

reinjury if they return to dancing before regaining full proprioception (Leanderson et al.

1996).

Types of MSI

The most common dance MSIs are strains, sprains, and bone disorders affecting the back

or lower extremities (Bowling 1989; Kadel, Teitz, and Kronmal 1992; Khan et al. 1995).

The majority of dance injuries are to the hip, knee, ankle, and foot. The lower limb is

particularly vulnerable to injury for dancers because of the stress and strain that dance

requires of this area (Milan 1994; Khan et al. 1995). The high incidence of lower

Part 3: Dancers and musculoskeletal injury (MSI)

Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers �� 38

extremity injury has been attributed to forcing turnout and dancing on pointe in classical

ballet dancers (Khan et al. 1995).

Approximately two-thirds of dance injuries are overuse and misuse injuries to the soft

tissue (Bowling 1989; Milan 1994). Although soft tissue injuries are generally associated

with full recovery within six to eight weeks, this is not typically the case for dancers,

whose injuries often become chronic (47–60% of injuries) (Bowling 1989; Milan 1994).

Chronic injuries are most likely to affect the back, neck, and lower extremities of dancers

(see Table 2).

Table 2

Body parts affected by chronic injuries in dancers

Body part injured Percentage of chronically

injured dancers

Back or neck 29

Ankle 20

Knee 17

Thigh or leg 16

Hip, groin, or rib 6

Foot or toes 6

Upper extremities 6

(Adapted from Bowling 1989)

The majority of soft tissue dance injuries occur at performances or rehearsals (see Table

3). This suggests that the environmental, psychological, and physical factors affecting the

dancer during performance or rehearsal increase the risk and incidence of injury. Dancers

are more likely to push their physical limits during performance or rehearsal. Dancers

may also experience high levels of physical and mental anxiety that result in tight

muscles. Inadequate warm-up contributes to an increased risk of injury. Environmental

factors that may affect dancers are the types of floors and temperatures in theatres.

Table 3

Location of injury occurrence

Location Percentage of dancer injuries

Performance 32

Rehearsal 28

Class 16

Slow onset — multiple locations 7

Unknown 17

(Adapted from Bowling 1989)

Part 3: Dancers and musculoskeletal injury (MSI)

References

Bowling, A. 1989. Injuries to dancers: Prevalence, treatment and perceptions of causes.

British Medical Journal 298 (6675): 731–734.

Guierre, A. Ballet dancers’ injuries: A review of literature.

 (October 1, 2000).

Hamilton, W., L. Hamilton, P. Marshall, and M. Molnar. 1992. A profile of the

musculoskeletal characteristics of elite dancers. American Journal of Sports Medicine

20:267–273.

Kadel, N., C. Teitz, and R. Kronmal. 1992. Stress fractures in ballet dancers. American

Journal of Sports Medicine 20 (4): 445–449.

Khan K., J. Brown, S. Way, N. Vass, K. Crichton, R. Alexander, A. Baxter, M. Butler,

and J. Wark. 1995. Overuse injuries in classical ballet. Sports Medicine 19 (5): 341–

57.

Leanderson, J., E. Eriksson, C. Nilsson, and A. Wykman. 1996. Proprioception in

classical ballet dancers. American Journal of Sports Medicine 24 (3): 370–373.

Maran, A. 1997. Performing arts medicine. Royal College of Surgeons of Edinburgh.

Milan, K. 1994. Injury in ballet: A review of relevant topics for the physical therapist.

Journal of Orthopaedic Sports Physical Therapy 19 (2): 121–129.

O’Malley, M., W. Hamilton, J. Munyak, and J. DeFranco. 1996. Stress fractures at the

base of the second metatarsal in ballet dancers. Foot and Ankle International 16 (3):

89–146.

Smith, R., J. T. Ptacek, and E. Patterson. 2000. Moderator effects of cognitive and

somatic trait anxiety on the relation between life stress and physical injuries. Anxiety,

Stress and Coping 13:269–288.

Tajet-Foxell, B., and F. Rose. 1995. Pain and pain tolerance in professional ballet

dancers. British Journal of Sports Medicine 29 (1): 31–34.

Whitting, W., and R. Zermick. 1998. Biomechanics of musculoskeletal injury. Windsor,

Ont.: Human Kinetics Publishing.

Preventing musculoskeletal injury for dancers

When preventing and treating dance MSIs, it is important to understand the mechanism

of injury, the multifactorial causes of injury, and the professional and artistic demands on

dancers. This section provides general suggestions and considerations to help prevent

MSIs in dancers.

Dance on sprung floors

According to Newton’s third law, for every action there is an equal and opposite reaction.

When jumping and completing high-impact manoeuvres, a dancer exerts a force on the

floor and the floor exerts an equal force on the dancer. These forces have a large impact

on the dancer’s feet and joints. A sprung floor absorbs some of the force, decreasing the

acute impact on the body.

Dance in warmer studios

Cold environments are associated with decreased blood flow to the extremities. When

blood flow is decreased, the affected body parts are more prone to injury.

Warm up before dancing

Warming up accomplishes three important changes in the body that help reduce the risk

of injury:

1.Exercise increases the temperature of the muscle and connective tissue. This is

associated with a decreased risk of soft tissue injury.

2.Exercise provides the stimulus and time needed for the cardiovascular system to adjust

blood flow from the body’s core to the active muscles, where the need for oxygen

increases in response to the exercise.

3.Exercise stimulates joint lubrication and prepares the joints for full range of movement.

An adequate warm-up should accomplish each of these three goals.

Remain aware of dancers’ limitations

When teachers and choreographers are aware of dancers’ physical and mental limitations

and requirements, dancers are not likely to feel pressure (whether real or interpreted) to

push themselves beyond their capabilities. Dancers who are fatigued and pushing

themselves beyond their physical capacity are more likely to adopt sloppy technique or

make unsafe movements, increasing their risk of injury.

Rest between workouts

Any type of fitness training, including dancing, is based on the overload principle. To see

an improvement in fitness, the body must work harder than it is accustomed to working.

This principle works well as long as the muscles get adequate rest between workouts.

Without rest, muscles become fatigued and can no longer do the same amount of work.

The stress of the work (i.e., dance) then shifts from the muscles to other soft tissue such

as tendons and ligaments. Most soft tissue injuries occur when the muscles are fatigued.

With adequate rest between workouts, muscles become increasingly strong and able to

sustain more force, and thus do more work. Adequate rest breaks between workouts

allow dancers to feel refreshed and ready to continue working near their physical

limitations without progressively increasing their level of pain, discomfort, or fatigue.

Without adequate rest between workouts, cumulative fatigue reduces muscle strength and

endurance, and the level of pain or discomfort associated with activity progresses.

Maintain communication

Communication between dancers and artistic directors, teachers, and choreographers is

important to maintain dancers’ health. Brief conversations in class or rehearsal can help

monitor dancers’ physical and mental status. Early identification of problems can help

reduce the likelihood of injury. Open communication provides both an opportunity and

permission to identify signs and symptoms of developing soft tissue injuries before they

become problematic. In addition, showing a genuine interest in dancers’ well-being can

have a positive effect on their level of stress and state of mind. A dancer’s status can

provide valuable information regarding the balance between the intensity of the workout

and the adequacy of rest and recovery.

Rest when injured

Immediate management of acute MSIs is important. Care administered within the first 72

hours of an acute injury is critical to the injury’s outcome. The RICE treatment protocol

(rest, ice, compression, and elevation) is an effective measure in dealing with an acute

soft tissue injury (see page 44). Knowing the difference between delayed-onset muscle

soreness and pain due to injury is important for determining when to rest an injury and

when to continue physical activity.

Delayed-onset muscle soreness peaks 24 to 36 hours after intense or unaccustomed

activity. It is a normal response to such activity and subsides within a few days. Most

dancers will recognize this soreness as muscle stiffness that is common during training.

No restriction of activity is required for recovery from delayed-onset muscle soreness,

and the individual may benefit from active use of the sore muscles.

Pain due to more serious soft tissue injury usually has a more rapid or acute onset and

more localized symptoms, and is recognized as having different characteristics from the

usual muscle soreness. Most soft tissue injuries require rest in the form of modified

activity to allow the damaged tissue to heal. Modified activity may range from reduced

intensity of activities that stress the damaged tissue to complete removal of all activity

that affects the injured region. Guidance is best provided on a case-by-case basis by a

medical professional who is familiar with sports or occupational injuries and the dance

industry.

Get proper nutrition

Maintaining the body in a strong, resilient state requires enough balanced nourishment to

support the caloric and metabolic demands of high-level physical activity and to develop

a strong structural foundation in the musculoskeletal system. Bone density and muscle

mass depend on an adequate supply of nutrients to support constant tissue remodelling.

For more information, see “Nutrition,”

Avoid strain when carrying equipment

For most dancers, carrying equipment, clothing, costumes, and other items is a reality

that can place a significant amount of stress on the neck, shoulders, arms, and hands.

Minimize the effects of carrying by selecting appropriate containers for your gear.

Ideally, containers should be lightweight, with padded handles or shoulder straps. Avoid

carrying gear in bags with narrow straps or handles because these increase the effects of

contact stress. Where possible, use wheeled carts or bags (such as overnight travel

suitcases) with handles that allow you to pull them while in a full standing posture.

Treating musculoskeletal injury for dancers

Dancers’ injuries can be managed at two levels. The first level is recognition of early

signs and symptoms, and administration of simple self-help techniques. Ideally, dancers

should learn to identify early signs and symptoms and use self-help techniques at an early

age. The second level is recognizing signs and symptoms that are persistent or unusual

and seeking professional medical assistance.

The RICE treatment protocol (rest, ice, compression, and elevation) helps control the

initial stages of an injury during the first few days. Injury that persists or becomes worse

and begins to influence the dancer’s ability to continue dancing is initially addressed by

conservative treatment methods. Conservative treatment methods are non-surgical

interventions that may include the use of:

• medication

• activity modification

• physical therapies

• splints

• orthotics

• taping

• ultrasound

• acupuncture

When conservative treatment methods are ineffective or the initial injury is particularly

severe, more aggressive (surgical) approaches may be warranted.

Warning signs and symptoms

Learn to recognize MSI signs and symptoms. Early warning signs and symptoms include:

• discomfort, pain, tingling, or numbness while dancing

• weakness or difficulty with fine control of movement

• stiffness or limited range of motion

• postural changes (for example, shoulders elevated or rounded forward)

• local swelling or redness

If you notice discomfort or pain while dancing and circumstances allow it, take a break

until the symptom subsides.

Preventive measures

If you experience early signs and symptoms of MSI, try the following preventive

measures:

• Identify aspects of your training habits or dance technique that may be contributing to

the sign or symptom. Take appropriate actions to improve any shortcomings you may

notice.

• Increase the amount of rest and decrease the duration of continuous dance time until

you can dance without symptoms. This may mean allocating more rehearsal hours in

the day to obtain the same amount of dance time.

• Be extra-conscious of performing a thorough warm-up at the beginning of your

rehearsal or performance sessions.

• Be aware of which movements contribute to the signs and symptoms, and reduce your

intensity and level of repetition while rehearsing those movements. Alternate physical

rehearsal with mental rehearsal (visualization or imagery) to balance the physical

demand with adequate rest, while maintaining a focus on performance.

The RICE treatment protocol (rest, ice, compression, and elevation) is applied during the

immediate stages of injury to help reduce the amount of damage to the body. This

protocol will help manage the injury; however, guidance from a health-care professional

should be sought to manage persistent or worsening symptoms.

The immediate benefits of following the RICE protocol are that it:

• decreases swelling

• decreases discomfort

• decreases muscle spasm

• prevents further injury

Rest

The concept of rest in this treatment protocol is a relative term. The objective of rest is to

stop the exposure of the injured area to activities that aggravate the injury. The dancer

can continue with a normal workout routine, but should avoid the actions that result in

discomfort or stress to the injured tissue.

Ice

Applying ice or cold packs helps reduce swelling and manage pain by decreasing blood

flow to the injured area and numbing pain sensation. Apply ice to the injured area for

15–20 minutes. Never place ice directly on the skin as this can result in frostbite. Place

crushed or cubed ice in a wetted towel and then place the towel on the affected area. If

ice is not available, a pack of frozen vegetables works just as well. Alternative methods

of icing (creams, balms, or rubs) are not recommended because they only cool the first

layers of skin and not deeper into the injured area. Never use ice to numb an area so a

dancer can keep performing through pain. This is dangerous because it masks the

symptoms and has the potential to make the injury worse.

Compression

Apply external compression to the injured area by wrapping the injury in a tensor

bandage. Apply the wrapping in a criss-cross method — get directions for appropriate

wrapping techniques from a health-care professional. Compression reduces the swelling

of the injured body part by forcing fluid away from the injured tissue. Compression and

ice often can be used together by wrapping the ice in the tensor bandage.

Elevation

Elevation allows gravity to help move the fluid away from the injured site. Elevate the

injured area above the level of the heart.

When to seek medical assistance

If symptoms continue to occur each time you dance, continue to get worse, or are unusual

for you, seek medical assistance. If symptoms continue to persist after you have stopped

dancing or if they appear at times other than when you are dancing (for example, during

sleep), seek immediate help from a health-care professional who is experienced in

treating dancers’ injuries.

Refer to Figure 2, Progression of MSI Signs and

Symptoms in Performers, page 9. You may want to seek

assistance at any level along this scale. However, it is

recommended that you seek immediate help from a

health-care professional if you reach Level III or beyond.

Conservative medical treatments

Conservative medical treatments are non-surgical methods of addressing a condition. The

majority of dancers’ injuries will respond well to an aggressive but conservative medical

treatment program that is based on a team approach to case management. Several

treatment modalities must be coordinated to deal with the injury thoroughly and to

prevent recurrence, including:

• accurate diagnosis

• correction of dance technique (if necessary)

• manual therapies to promote joint and soft tissue healing

• nutrition advice

• a strength and fitness program (such as the Pilates Method) to maintain fitness levels

and rehabilitate injured tissues while the dancer is unable to dance

(Khan et al. 1995)

Involving sports-medicine specialists in the treatment program has been shown to result

in a high success rate (Bowling 1989).

Dance injuries that do not respond to conservative treatment and require surgical

intervention are likely to benefit from dance-specific rehabilitation that includes a focus

on maintaining and re-establishing joint mobility, flexibility, and strength.

References

Bowling, A. 1989. Injuries to dancers: Prevalence, treatment and perceptions of causes.

British Medical Journal 298 (6675): 731–734.

Khan K., J. Brown, S. Way, N. Vass, K. Crichton, R. Alexander, A. Baxter, M. Butler,

and J. Wark. 1995. Overuse injuries in classical ballet. Sports Medicine 19 (5): 341–

57.

For a list of health-care professionals who have experience treating MSI for dancers, contact

SHAPE.

Nutrition

Nutrition influences the body’s ability to respond to the stress of physical activity,

injuries, and micro-traumas. Dancers who do not have adequate nutritional intake have a

higher incidence of injury (Maran 1997).

Maintaining adequate hydration is also vital to avoiding injury. Dehydration occurs when

the amount of water in the body decreases below normal levels. When the body is

dehydrated, the level of electrolytes (sugars and salts) becomes unbalanced, and the risk

of MSI and heat injury increases.

Eating disorders

Dancers as a group have been identified with a high incidence of eating disorders

(Disordered Eating and Eating Disorders Web site, November 2, 2000). Eating disorders

affect males and females. In this resource guide, the term eating disorder refers to

maintenance of a diet lower than 70% of the recommended daily allowance (RDA) and to

the disorders anorexia nervosa and bulimia nervosa.

Eating disorders are psychological disorders that have serious physical complications.

Anorexia nervosa is characterized by abnormally low body weight. Anorexics achieve

their low body weight by severely restricting the intake of food and possibly purging

even small amounts of food. Bulimia nervosa is characterized by the ingestion of large

quantities of food in short periods (binges), followed by attempts to purge the food.

Purging is accomplished by vomiting, using laxatives, or engaging in intense physical

exercise.

Eating disorders have been implicated in the high percentage of dancers who suffer from

injury, osteoporosis, and fertility problems (Maran 1997). Dancers who are suffering

from an eating disorder should seek professional help as soon as possible.

Body mass index (BMI)

The effects of poor nutrition have been shown to significantly increase the risk of injury

in dancers (Benson et al. 1989). Dancers with a lower than normal body mass index

(BMI) are more likely to become injured. BMI represents the relationship between

weight and height (weight in kilograms divided by height in metres squared). BMI is a

loose predictor of nutritional status. An acceptable BMI ranges between 20 and 25, with

18 to 20 defined as mild starvation, and below 16 indicating severe starvation. In 1989,

Benson et al. showed that dancers with BMIs below 19 spent more days off with injury

than dancers with BMIs above 19.

Menstrual dysfunction

Low BMI and eating disorders are also implicated in menstrual dysfunction. Menstrual

dysfunction is another risk factor for MSI (Benson et al. 1989). Menstrual dysfunction

refers to either delayed menarche (initiation of menstruation at puberty) or amenorrhea

(cessation of menstruation). Dancers with lower than normal BMIs are more likely to

suffer from delayed menarche or amenorrhea.

In a study involving 350 dancers at a national dance company school, dancers were

shown to have a significantly later age of menarche than a matched group of non-dancers

(Brooks-Gunn and Warren 1988). Leanness was the best predictor of menarcheal age in

dancers, with the leanest dancers experiencing delayed menarche. Amenorrhea in dancers

is caused by over-exercise and leanness, particularly low nutritional intake and low BMI.

Both delayed menarche and amenorrhea have severe implications for bone and joint

health (see “Bone Injuries,” page 48).

Web sites for eating disorders

The following is a brief list of Web sites that provide more information on eating

disorders for dancers:

• The Eating Disorders Site www.closetoyou.org/eatingdisorders/

• Edancing www.danceart.com/edancing/

• National Eating Disorders Association www.nationaleatingdisorders.org

• Web MD http://my.webmd.com/content/dmk/dmk_article_40031

References

Benson, J., C. Geiger, P. Eiserman, and G. Wardlaw. 1989. Relationship between nutrient

intake, body mass index, menstruation function and ballet injury. Journal of American

Dietetic Association 89 (1): 58–63.

Brooks-Gunn, J., and M. Warren. 1988. Mother-daughter differences in menarcheal age

in adolescent girls attending national dance company schools and non-dancers. Annals

of Human Biology 15 (1): 35–43.

Disordered eating and eating disorders. (November 2,