Injuries in Dancers and Performance Enhancing Choreography

“I really enjoyed the way it was taught and it most definitely had a positive impact on the rest of the dance classes for the day!! We had a jazz class straight after and the improvement in our pirouettes was genuinely noticeable and that was only after one session 🙂“

Testimonial from a student at The MTA.

What is Performance Enhancing Choreography?

Dance-centred routines, using exercises derived from evidence-based practice to improve performance and reduce incidence of injury.

Why do we need it?

Dancers come from a background where ‘patching up’ is common. Most dancers I see expect a lot of hands-on treatment, and many endure the affliction of the more painful treatments (not from me) like a rite of passage. My favourite example is when the male dancers of a big West End production I was working on started a competition to see who could give themselves the biggest bruise down their ITB. One guy rolled it out on a metal cylinder! All this in the belief that they were actually helping their bodies heal and preventing further injuries… The mind boggles.

I want to help change all that. I did very little to reduce my injury rate when I was performing and I paid the price. I often danced in pain and I’m sure never performed to the level I was capable of. On the odd occasion I did cross-train with a bit of yoga, I noticed that I felt better, but even that wasn’t enough to convince me that my daily classes and rehearsal weren’t enough to keep me fit for the job. I often felt tired, so wanted to rest in my spare time. If only I’d trained a bit, I’d likely have had more energy, less muscle pain, higher jumps, better control… Ah, hindsight.

What should dancers be doing?

There’s evidence to show that engaging in a strength and conditioning programme does indeed reduce injury rates in dancers. One great example is work done in 2016 by Nico Kolokythas, the performance enhancement coach at Elmhurst Ballet School. He used an adapted version of the FIFA 11+ with young ballet students. After the programme was implemented, reports of injury decreased by 40%. Research is not yet published, but see this link for more details.

Why choreography?

I wanted to find a way to make strength and conditioning more accessible to performers and also make it engaging enough that they would enjoy doing it. Choreography is a dancer’s life. It’s a great way to set performers up with something comprehensive that can be easily added onto the end of a warm-up, or beginning of a rehearsal session. The teaching process then becomes a mini lesson in anatomy and physiology, which is a great way to spark people’s interest in how their bodies work.

Learning choreography aids recall: the routine can be broken down into sections and repeated, like performing reps. Dancers would have a repertoire to choose from, where they could select the parts they struggle with and practise those in order to master the technique.

First on the list: The Ankle

Ankle sprains are common in sporting populations, see here. People with chronic ankle instability (CAI) suffer from impaired neuromuscular control, strength, and functional movement in comparison to individuals with no such a history, see here.

Evidence for treatment and reduction of ankle injuries:

A critical review of 24 studies, with two independent reviewers checking for quality methodology, found that a combination of taping/bracing and neuromuscular exercise gave the best protective outcomes for reducing lateral ankle sprain. This 2017 systematic review of 46 papers found strong evidence for bracing and moderate evidence for neuromuscular training in prevention of reoccurring sprains. Further support for rigid bracing and proprioceptive training can be found here. NICE does not add much to these findings, simply recommending very general cardiovascular exercise, strength, and flexibility training.

In summary, the prevention of sprains in the athletic population is most effective with rigid bracing and neuromuscular training. Generally, it’s not possible to brace a dancer without severely limiting their function, so the evidence is clear that neuromuscular training is the best chance we have! Of course, flexible tapes such as Kinesiology tape could be a useful adjunct to training in performers.

Dance-specific literature and applying what we know to the dance population:

Mirroring other sporting areas, foot and ankle injuries are unsurprisingly a very common problem in the dance world, as discussed here and here.

CAI is often seen as part of the presentation of hypermobility. So in a population where over 40% are hypermobile, getting dancers to engage in some form of protective exercise is surely advisable. Research shows that (non-dance) subjects with Benign joint hypermobility syndrome (BHJS) have reduced knee proprioception. Exercises to address this deficit resulted in lower rates of pain (VAS) and better function (AIMS2) in 15 patients with BHJS who were prescribed proprioceptive exercise as part of the experimental group vs. 25 matched controls. For dancers with a history of lateral ankle sprain, this is associated with increased risk of injury on the contralateral side, as this prospective cohort study demonstrates.

Destabilising equipment:

Neuromuscular exercise and proprioceptive training often involve the use of wobble boards and other destabilising equipment. Most dance studios/stages are (on the whole) flat and stable, which (some would argue) might make the use of this equipment less valid. However, some stages have all sorts of trap doors, taped-up cables, grates, and ridges in them, so there’s still a place for a bit of wobble-time when training proprioception in dancers. It’s worth noting there is evidence to suggest that traditional foam-surface rehabilitation exercises are just as effective in improving impairments associated with CAI as the more complex kit such as this:

Anecdotally, in cheerleading there are ‘flyers’ who are lifted in the air, and ‘bases’ who physically support the flyers during their stunts.

When performed correctly, it is the bases who should maintain the flyers’ balance. Competitive cheerleaders I’ve spoken to, have reported that flyers who practise their poses on an unstable surface like a bosu ball, tend to be less stable in the air with a partner. This is likely because they have trained to rectify their own balance, as opposed to maintaining one stable position and allowing the base to move and adapt as necessary. A nice example of the importance of specificity in training.

Visual input, changing proprioceptive demands, and touring:

Sensory input is completely different during performance:

Imagine rehearsing in a well lit studio with floor to ceiling mirrors and a lovely smooth dance floor. Then try performing that same dance on a raked stage, with house lights down, a spotlight in your face, and a huge costume/headpiece to contend with. I’ve had personal experience of losing my balance because I was at the very front of the stage, with a spot in my face and couldn’t see the floor level. It was quite unnerving and I nearly fell over in my double pirouette – mortifying. I also had a similar experience during an important exam where I performed a tilt and immediately fell over.

I realise now that it was because I’d never done it without the mirror for reference. I was using my visual input over my proprioception for balance. Moral of the story is of course that once mirrors have served their purpose (to help with placement, lines, and aesthetics), they should be taken away. Dancers should rehearse as much as possible in an environment similar to the one they’re going to perform in. But, it’s no wonder that injuries are so prevalent in touring companies, when they go from stage to stage – some raked, some not, with different dimensions, with various floor surfaces; some sprung and some made of solid concrete. There’s a distinct lack of RCTs in this area and the samples are small, but this and this study shed some light on the difficulties dancers face.

Which exercises are best?

As we have seen, the literature is consistently in favour of neuromuscular, proprioceptive training to reduce and rehabilitate ankle injuries. This particular study is prescriptive about exactly which exercises are effective, as well as how to progress them. For this reason, I used the ‘Neuromuscular Control’ section as the foundation for this choreography.

In this study, they used the Star Excursion Balance Test (SEBT) as a functional measure, which was found to be responsive to changes in improvement in postural control as a result of these exercises. Unfortunately, I wasn’t forward-thinking enough to get SEBT results from the students before teaching the choreography, but I do have single leg knee bend (SLKB) measures (rated subjectively by me out of 5), so we’ll see if they improve. This involves a certain amount of extrapolation, but then, this is a work in progress…

The Choreography:

I deliberately kept it simple in terms of equipment. We could have used balls, steps, and wobble boards, but I didn’t for the following reasons:

• Dancers do not usually work on unstable surfaces, except in particular circumstances as previously discussed.
• So that dancers would never find themselves without the necessary equipment. Therefore, this would not form a barrier to their adherence. By using just a music track, it should help to make it more accessible.

I taught it in three groups:

• Basic – for those who were currently injured (These students had various stages of MTSS/ankle sprains/knee pain).
• Intermediate – with reduced impact and demi-pointe work.
• Advanced – with more changes of direction, elevation, and single leg work – there is still room for further progressions and complexity.

Participation in the advanced group required full strength, ROM and a limb symmetry index >80%.

Coincidentally enough, one of the students – hypermobile with history of ankle sprains (of course) – had rolled her ankle the day before I taught this. When I saw her later that day, I was able to say that once she could weight-bear pain-free, she could do the basic version of the choreography, which we both found really useful. 

How to use the choreography:

The plan is for dancers to try this around three times in a row, so there’s an element of fatigue. A difference in muscle activation, pre and post fatigue in the lower limb, between control and CAI groups has been shown here.

Dance teachers can use it in their warm ups three/four times a week. Further simple progressions would be performing it in bare feet, facing away from the mirror, and definitely trying it on a raked stage.

Feedback from this group of students:

My response was that if they felt it was easy in parts, they must be able to do it perfectly with good technique! There is plenty of scope for progressing, and as this was very much an experiment, I really appreciated their commitment and comments 🙂

It’s not just about the ankle…

A bonus is of course that you can’t really exercise the ankle in isolation at this level, so there are widespread kinetic chain benefits as shown in this study looking at increased hip-strength following ankle exercises. The hip (possibly combined with the core) is my next project. There’s less evidence as far as injury reduction in this area, but there are plenty of EMG studies showing which exercises target certain muscles most specifically. This seems like a good place to start, so watch this space…