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).

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.

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:

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.

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.

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!