Returning to Dance Performance After Injury Part One: The Subjective Assessment

What This Blog Is About

  • Subjective (Part One) and objective (Part Two) measures, looking at readiness to return to sport. Specifically dance performance, although a lot of the information will apply to many different athletic populations.
  • Stages of rehabilitation, using a real-life case study (which was extremely time dependent) as an example.
  • Evidence for return to sport protocols.

Note that this discussion will not consider return to pointe work in ballet and will focus on lower limb injuries.

Case Study: Harry

Harry was a 20-year-old performing arts student who came to see me after landing badly from a turning jump. I diagnosed a grade 1 lateral sprain of the right ankle before sending him off for an X-ray to confirm my suspicions of a bony forefoot injury. We found out the next day that he had sustained a fracture to the neck of his fifth metatarsal (MT).

Harry’s X-ray

Most acute, non-displaced fractures of the fifth MT heal with conservative management within six to eight weeks. We had JUST NINE WEEKS to get Harry back to full performance capacity for his final show, where he’d be looking for agent representation. If I’m honest, I wasn’t at all sure we would manage it and at our second session, Harry and I had a discussion about the possibility of his not being able to perform everything for the showcase. But, we were determined to try, so I put together a rehab plan with targets to meet in order to be fully functional by week nine and we pushed ahead (spoiler: we did it and Harry landed one of the best agents in town).

Harry’s injury was different from the classic ‘dancer’s fracture’, which has a spiral pattern and runs from distal-lateral to proximal-medial.

Image taken from footEducation.com
Note the first MTPJ OA, which is a common finding on dancers’ X-rays.

A dancer’s fracture can require longer healing times. These injuries are more likely to require surgical intervention and have more complications compared with fractures at the neck of the MT, though conservative management is recommended in most cases. There can also be vascular and thus nonunion issues with fifth MT injuries. These tend to be at the base of the MT in zone two, where you would find the notorious Jones fracture:

Image taken from UpSwing Health.com

So, as fifth MT fractures go, we were quite lucky considering the time frame we had to work with. Harry was issued with a hard-soled shoe, which was removed at the beginning of week five by the fracture clinic.

Mental Health and Mental Readiness

Injury can remove the one coping strategy people have — their sport. The best example I can think of is runners, who are renowned for their reluctance to stop doing what they love. However, dancers would feature high up on the list of people who use their sport to manage mental health. Performing is part of a dancer’s identity and the threat of losing that can be devastating. There is a very real risk that negative emotions may spiral out of control after an injury, or at the very least impact recovery, especially return to high-level performance. For this reason, assessment of emotional and resulting behavioural factors should be considered in the treatment plan. There are two subtly different areas that we need to address in the subjective assessment: is the performer’s mental health likely to negatively affect their recovery, and are they mentally ready to perform?

There is certainly no homogeneity between clinicians when it comes to looking at Health Related Quality of Life (HRQoL) in dancers, as this 2020 systematic review has shown. Over the years, I have worked closely with a range of dancers and therefore assess their readiness to return based on personal experience and academic knowledge. I explore how they’re doing by simply talking to them, rather than using a validated patient reported outcome measure (PROM). My confidence to do this comes from my years of experience working among dancers in a personal and professional capacity. If you wanted a more standardised way to assess this, there are some good options: no matter how well they perform on objective tests, if patients are lacking in confidence or motivation, they are less likely to do well. There is also evidence that dancers have better outcomes when their recovery is not limited by fear. This review is extremely comprehensive. It’s a good read if you’re interested in psychological assessment and how it relates to sports injury outcomes.

Subjective PROMs

Mental Health, Function, and QoL

12-Item Short Form Survey

The SF-12 has been utilised by some researchers to assess wellbeing in dancers following injury. While this questionnaire goes into some detail about physical and mental health, it’s not very specific for higher level sports.

The Disablement in the Physically Active Scale (DPA)

The DPA was discussed in the systematic review (mentioned previously), which looked at HRQoL in dance. It was described as the most adequate tool in measuring HRQoL in dancers of the eight measures they reviewed. While not specifically for dancers, it was designed to assess impairments, functional limitations, disability, and QoL in more athletic populations.

This path analysis shows the structure model created for the DPA. (Vela and Denegar, 2010)

It has been shown to be a reliable, valid, and responsive instrument, although the sample size was small in this study.

Mental Readiness to Return to Full Performance

Injury-Psychological Readiness to Return to Sport Scale

Another alternative is to ask patients about their confidence on a scale of 0-100, where 0 is no confidence at all, and 100 is complete confidence.

The Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale is both reliable and valid in assessing an athlete’s psychological readiness to return to sport participation after injury. It does not specifically address HRQoL or mental health.

The Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale

You take the sum of scores from questions 1-6 and divide it by 10 to give a final score. Scores between 50 and 60 indicate the patient is feeling mentally ready to return to sport; scores below 50 suggest that they may need more time to recover.

Dance Specific

The Dance Functional Outcome Survey

The Dance Functional Outcome Survey (DFOS) was developed as a self-report questionnaire for ballet and modern dancers. The survey helps to pinpoint areas of weakness in everyday movement, as well as in specific dance technique, for example pliés, arabesques, and turns. It is reliable, valid, and responsive to change. Like the I-PRRS, it does not address HRQoL or emotional effects of injury.

I only came across this questionnaire in researching this blog! I asked colleagues who work with dancers if they had ever used the DFOS and the answer was ‘no’ across the board, not only because they were unaware of it, but also because they deemed it unnecessary. Usually, clinicians who work with dancers are proficient in their knowledge of terminology and technique. As a result, they are able to discuss limitations owing to injury, and devise treatment plans with confidence. However, my colleagues and I agreed that the DFOS might be useful for anyone who was less familiar with dance, as it would help guide rehabilitation in quite a specific manner. It was used in this case study with a dancer in 2016, for instance.

Onward Referral and Management

There were no risk factors or significant medical history to account for the fracture Harry sustained. However, in cases of bony injury it is important to screen for potential underlying causes that may need to be addressed by the wider MDT. Relative energy deficiency in sport (RED-S) is the result of insufficient caloric intake and/or excessive energy expenditure. It can affect many physiological systems, one of which being bone health. As aesthetic athletes, dancers are at higher risk of suffering the effects of low energy availability. The website Health For Performance by Dr Nicky Keay is an excellent resource if you are unsure about how to identify and manage RED-S.

If you are concerned about a patient’s mental health or their subjective readiness to perform, you should consider onward referral. Recognising your scope of practice is paramount, and being part of a multi-disciplinary team (MDT) invaluable, when working with high-level athletes. I am lucky enough to work alongside a counsellor who is experienced in treating people in the arts. I have also referred dancers to their GP for advice about medication and/or further psychological therapies. Knowing a trusted clinical sports psychologist is also essential for patients who require higher level input. If you do not know practitioners directly, the following organisational directories are a good place to search for the appropriate professional: The British Psychological Society (BPS), The British Association of Sport and Exercise Sciences (BASES), and The British Association for Counselling and Psychotherapy (BACP).

With Harry, there was never any concern about emotional negativity. I actually suspect that his positivity and motivation facilitated such a fast, successful return to full dance. However, we did address his confidence in his performance, with exercises in visual imagery during the week of the showcase. This will be discussed further in part two.

Returning to Dance Performance After Injury Part Two: The Objective Assessment

  • Objective measures
  • Functional tests
  • Periodisation in exercise prescription
  • How to clinically reason progression
  • Return to sport protocols
  • Dance specific progressions/regressions

Coming soon!

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:

A. Myolux Athletik and B. Myolux II – destabilisation devices used in the above study

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.

Beautiful e.g. of a ’tilt’ found on Pinterest and definitely better than mine!

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.

Table 1 from Hale et al 2007

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:

The routine starts around 20 seconds in if you want to skip the intro

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…