Epidemiological Characteristics of Foot and Ankle Injuries in 2 Professional Ballet Companies: A 3-Season Cohort Study of 588 Medical Attention Injuries and 255 Time-Loss Injuries

Differences in the Size of Individual Plantar Intrinsic Foot Muscles Between Ballet Dancers and Non-Dancers

INTRODUCTION

In classic ballet, choreography often involves tiptoe standing. Tiptoe standing requires a high and stable foot arch structure, which is achieved by contraction of the plantar intrinsic foot muscles (PIFMs). Long-term repetitive loading with a specific movement can induce hypertrophic adaptation of the associated muscles. For dancers, however, limited information on the size of individual PIFMs is available from previous studies. The purpose of this study was to determine the differences in the sizes of 10 individual PIFMs between dancers and non-dancers.

METHODS

Muscle volumes (MVs) of 10 individual PIFMs were measured using magnetic resonance imaging in 15 female dancers and 15 female non-dancers. Muscles analyzed included abductor hallucis, flexor digitorum brevis, abductor digiti minimi, quadratus plantae, lumbricals, flexor hallucis brevis, adductor hallucis oblique head, adductor hallucis transverse head, flexor digiti minimi, plantar/dorsal interossei. In addition to absolute MVs, relative MVs normalized to body mass (rMVBM) and the percentage of individual MVs relative to the sum of 10 individual PIFM MVs (%MVWHOLE) were calculated.

RESULTS

The absolute MVs of 6 individual PIFMs, including the flexor digitorum brevis and lumbricals, were +16% to 59% larger in dancers than in non-dancers (P ≤ .048). The rMVBM of all individual PIFMs were +35% to 95% larger in dancers than in non-dancers (P ≤ .019). The %MVWHOLE of the flexor digitorum brevis and lumbricals were +10% to 36% higher (P ≤ .014) and those of the abductor digiti minimi and adductor hallucis oblique head were +8% to 11% lower (P ≤ .037) in dancers than in non-dancers.

CONCLUSIONS

For all 3 MV measures, only the flexor digitorum brevis and lumbricals, which are functionally specialized for flexion of the second to fifth metatarsophalangeal joints, were consistently larger in dancers than in non-dancers. This may be due to long-term repetitive loading on these PIFMs during ballet training involving tiptoe standing.

Epidemiology of ankle sprain and chronic ankle instability in elite adolescent dancesport athletes

BACKGROUND

Dancesport is performed in high-heeled shoes. Dancesport athletes may have a higher prevalence and incidence of ankle sprains, which can affect their performance. However, the occurrence of ankle sprains among dancesport athletes remains unclear. This study aimed to determine the prevalence and incidence of ankle sprains among elite dancesport athletes and to investigate the related information.

METHOD

We conducted a mixed descriptive epidemiological study (cross-sectional and longitudinal) involving 198 elite adolescent dancesport athletes, using past medical records and questionnaires administered to the participants. Data on the occurrence of ankle sprains among all participants were compiled using medical records and information on injury mechanisms, missed days, severity types, and countermeasures for ankle sprains were collected. The prevalence of chronic ankle instability (CAI) among the participants was assessed using a questionnaire. Following the initial survey, we conducted a one-year follow-up study to investigate the incidence of ankle sprains, incidence rate per 1000 exposure hours, and recurrence of ankle sprains.

RESULT

The cross-sectional study and longitudinal study included 198 participants and 92 elite dancesport athletes, respectively. The prevalence of ankle sprains and CAI was 49.5% and 45.1%, respectively. Of all ankle sprains, 88% were medial injuries. The most common injury mechanisms were turning (46.9%) and jumping (46.9%). The average number of missed days due to ankle sprains was 11.2 days. Most injuries were managed with rest, and only one male athlete underwent surgery due to an ankle sprain sustained during dancing. During the one-year follow-up, the incidence of ankle sprains, incidence rate per 1000 exposure hours, and recurrence rate of ankle sprains were 46.6% (male, 41.2%; female, 48.8%), 0.65 ankle sprains/1000 h, and 35.3%, respectively. No sex-related differences were observed.

CONCLUSION

It is crucial to focus on the occurrence of ankle sprains and CAI in dancesport athletes with high heels. Future research should clarify the impact of ankle sprains on dancesport performance and develop preventive measures to reduce the incidence and recurrence of these associated injuries.

Measuring Foot Pressure in Pointe Shoes of Ballet Dancers Using a Modified Foot Pressure Sensor: A Brief Study

Introduction: The mechanism of foot injury in ballet dancers can be understood by measuring the forces exerted on the foot in pointe shoes. In this study, we aimed to reveal the vertical forces applied to the toes in a pointe shoe during ballet movements in a time series using a modified foot pressure sensor. Methods: Three dancers wore their pointe shoes equipped with sensors to replace their usual toe pads. They performed 2 tasks: (1) holding a pointe posture on the right leg for 5 seconds and (2) jumping 5 times on the right leg while on pointe, on a force platform. Their movements were captured using a 10-camera motion-capture system synchronized with the force platform and pressure sensor. Results: The force data for the bottom of the toe box, calculated by multiplying the pressure by the area, showed a correlation with the vertical ground reaction force measured using the force platform. Our results revealed that, during the jumping task, the highest forces were applied to the toe box, whereas in the standing task, the metatarsal area experienced greater forces than the toe box did. Significant individual variability was observed in other areas. Conclusion: This study demonstrates that the modified sensor effectively captures pressure variations with different movements, offering valuable insights for injury prevention and optimizing ballet techniques.

Validated Tools Used to Assess Musculoskeletal Injuries in Dancers: A Systematic Review

Introduction: Dance is a physically demanding art form that often results in musculoskeletal injuries. To effectively treat these injuries, standardized and reliable assessment tools designed to the dancer's needs are required. Thus, the aim of this review is to identify studies that have employed validated tools to assess musculoskeletal injuries in ballet, modern, and contemporary dancers, focusing on describing the content and psychometric quality of the tools used. Methods: This systematic review is registered at PROSPERO (CRD42022306755). PubMed, Cochrane, LILACS, Web of Science and SPORTDiscus databases were searched by two independent reviewers. Articles assessing musculoskeletal injuries with validated tools in ballet, modern and/or contemporary dancers and written in English, Portuguese, or Spanish were included. Non-peer reviewed articles, books, conference abstracts, thesis/review articles, or case design studies were excluded. The original validation studies were compiled when necessary. Two independent reviewers conducted a standardized data extraction and evaluated the methodological quality using an adapted Downs and Black checklist. Results: From the 3933 studies screened, 172 were read to verify if they met the inclusion criteria, resulting in 37 studies included accounting for 16 unique validated tools. Two were imaging exams, one was an injury classification system, and 13 were self-reported injury questionnaires. Only four injury assessment tools were validated for dancers, emphasizing the need for further validation studies for the dance population. Most of the articles (57%) achieved high-quality methodological scores and the remaining (43%) reported medium-quality scores. Conclusions: Valid, reliable, and specific tools to assess dance injuries are lacking in general. For enhanced methodological rigor in future studies, the incorporation of validated tools is recommended to improve methodological quality and facilitate cross-study comparisons. Researchers may consider conducting validation studies, involving processes such as translation into another language, validation of modifications to the original tool, or reporting reliability within the article itself.

Epidemiology of Musculoskeletal Injuries in Professional Ballet Dancers at the Opéra de Paris

OBJECTIVE

To describe the incidence, location, and type of musculoskeletal injuries in ballet dancers at the Opéra de Paris from 2018 to 2023 and to evaluate the effect of COVID-19 on injury incidence.

DESIGN

Descriptive Retrospective Study.

SETTING

Primary.

PATIENTS

Professional ballet dancers registered at the Opéra de Paris across 5 seasons (September 1, 2018-June 30, 2023).

INDEPENDENT VARIABLES

Demographics (age, body mass index, sex, rank).

MAIN OUTCOME MEASURES

Injury data (duration, mechanism, location, and type).

RESULTS

The incidence proportion of musculoskeletal injuries ranged from 47.1% to 72.6% per season between 2018 and 2023. Dancers most commonly sustained foot (49.3%) and ankle (45.1%) injuries, with 75.6% of dancers sustaining a lower limb injury. Compared with the 2018 to 2019 season, the risk of a dancer sustaining an injury was significantly lower in the COVID-19 season (2019-2020) (OR, 0.34; 95% CI, 0.21-0.53; P < 0.001), while the risk of an injury resulting in time loss was significantly lower in the 2022 to 2023 season (OR, 0.42; 95% CI, 0.27-0.64; P < 0.001).

CONCLUSIONS

The incidence of musculoskeletal injuries in professional ballet dancers was as high as 72.6% per season between 2018 and 2023, with the most common injury location being the foot and ankle. Compared with that in the 2018 to 2019 season, the risk of a dancer sustaining an injury was significantly lower in the COVID-19 season (2019-2020). These findings can help anticipate musculoskeletal injuries in professional ballet dancers and improve injury prevention programs, by developing targeted training schemes.

Self-reported Health Problems of Professional Dancers from Five German Opera Houses or State Theatres: A Prospective Study with Weekly Follow-ups during One Season

BACKGROUND

Most studies on injuries of professional dancers used a medical-attention and/or time-loss definition and did not analyse all health problems. Further, almost all studies included just one company. The aim was to analyse all self-reported health problems of professional ballet and contemporary dancers during one season and compare sexes and five companies in Germany.

METHODS

Dancers of five professional companies completed weekly health questionnaires during the season (September 2022 to June 2023). Numerical rating scales were used for severity of all health problems, musculoskeletal pain, impairment of the ability to dance at full potential, physical and mental workload in the previous seven days. If the severity of all health problems were rated greater than "0", the dancers were asked to report the type and consequences of their most severe health problem.

RESULTS

During 43 weeks, 98 dancers (39.8% male) completed 3123 weekly reports (response rate 74.1%). The season prevalence of any health problem was 100% and of time-loss health problems 74.5%. The average weekly prevalence of any health problem was 62.7%, of musculoskeletal pain 83.4% and of impaired ability to dance at full potential, due to health problem 48.6%. While the season prevalence and type of health problems was similar between sexes, the average weekly prevalence of severe health problems was higher in female than in male dancers (Chi2 = 23.2; p < .001), and female dancers saw a qualified health professional more often than male dancers (Chi2 = 19.5; p < .001). Companies differed in almost all investigated variables, with more health problems in companies where more dancers rated their workload higher than "ideal".

CONCLUSION

Health problems are frequent in professional dancers and affect their ability to dance. Future studies should analyse the impact of physical and mental workload on health problems.

An Update on the Six Recommendations from the 2012 IADMS Standard Measures Initiative: Assessing and Reporting Dancer Capacities, Risk Factors, and Injuries

INTRODUCTION

In 2012, the Standard Measures Consensus Initiative (SMCI) of the International Association for Dance Medicine and Science (IADMS) presented 6 recommendations regarding dance injury surveillance, definitions of injury and exposure, dance-specific screening, risk reduction strategies, and collaborative data management. The aim was to standardize risk factor measurement and injury reporting by researchers in dance medicine and science. Since then, numerous reports on the recording and reporting of injury data in sport and performing arts have been published.

METHODS

IADMS commissioned SMCI to update the 2012 recommendations, a process that involved 3 stages: (1) current field experts were invited to join SMCI, (2) SMCI members reviewed recent and relevant sport and performing arts literature, then drafted, discussed, and revised section updates, (3) IADMS invited individuals representing diverse backgrounds in the IADMS community to critically review drafted updates. The final update serves as a bridge from the 6 recommendations in the 2012 report to the current state of evidence.

RESULTS

We continue to encourage use of dance injury surveillance systems and support that surveillance protocols be fit-for-purpose, and that failure to use clear and consistent injury definitions perpetuates a lack of rigor in dance injury research. Based on new evidence, we recommend that some aspects of injury surveillance be self-reported, that the choice of dance exposure measures be dependent on the research question, contextual factors, and type of injury/health problem(s) of interest, and that studies using dance-specific screening articulate specific objectives, validity, and reliability of each protocol.

CONCLUSIONS

Future studies should focus on the development, implementation, and evaluation of strategies to minimize injury risk to improve consistency and rigor in data collection and research reporting on the health and wellness of dancer populations, thus facilitating a future dance injury consensus statement similar to recent statements published for sports and circus arts.

Foot and Ankle MRI Findings in Asymptomatic Professional Ballet Dancers

Background

Previous research in sport populations has demonstrated that abnormal magnetic resonance imaging (MRI) findings may be present in individuals without symptoms or known pathology. Extending this understanding to ballet, particularly in relation to the foot and ankle, is important to guide medical advice given to dancers.

Purpose

To assess foot and ankle MRI scans in asymptomatic ballet dancers focusing on bone marrow edema and the posterior ankle and to investigate whether these MRI findings would become symptomatic within 1 year.

Study Design

Case series; Level of evidence, 4.

Methods

In total, 31 healthy dancers (62 feet/ankles; 15 male and 16 female; age, 26.5 ± 4.3 years) who were dancing in full capacity were recruited from an elite professional ballet company. Orthogonal 3-plane short tau inversion recovery imaging of both feet and ankles was obtained using 3T MRI and the images were reviewed using a standardized evaluation form by 2 musculoskeletal radiologists. Injuries in the company were recorded and positive MRI findings were assessed for correlation with any injuries requiring medical attention during the subsequent 12 months.

Results

A total of 51 (82%) of the 62 feet and ankles had ≥1 area of bone marrow edema. The most common locations of bone marrow edema were the talus (n = 41; 66%), followed by first metatarsal (n = 14; 23%). Os trigonum and Stieda process were seen in 5 (8%) and 8 (13%) ankles, respectively. Among them, 2 os trigona showed bone marrow edema. Fluid in the anterior and posterior talocrural joints and the subtalar joint was observed in 48%, 63%, and 63% of these joints, respectively. Fluid around foot and ankle tendons was observed, with the most prevalent being the flexor hallucis longus tendon (n = 13; 21%). Two dancers who had positive findings on their MRI subsequently developed symptoms during the next 12 months.

Conclusion

Positive MRI findings are commonplace in the foot and ankle of asymptomatic professional ballet dancers. The majority do not result in the development of symptoms requiring medical attention within 12 months. Careful interpretation of MRI findings with the dancer's clinical picture is required before recommending activity modification or further intervention.

Health Problems of Professional Ballet Dancers: an Analysis of 1627 Weekly Self-Reports on Injuries, Illnesses and Mental Health Problems During One Season

BACKGROUND

Several studies have investigated injuries of (pre-)professional ballet dancers, however most used a medical-attention and/or time-loss definition and did not analyse the prevalence of all health problems. The aim was to analyse the frequency and characteristics of all self-reported physical and mental health complaints (i.e. injuries, illnesses and mental health problems) of professional ballet dancers during one season.

METHODS

Three professional ballet companies were prospectively monitored weekly during one season with the Performing artist and Athlete Health Monitor (PAHM). Numerical rating scales (ranging 0-10) were used for severity of musculoskeletal pain, all health problems and impairment of the ability to dance at full potential in the previous seven days. If dancers rated the severity of their health problems or their impairment greater than 0, they were asked to answer specific questions on the characteristics of each health problem.

RESULTS

Over a period of 44 weeks, 57 dancers (57.9% female) filled in 1627 weekly reports (response rate of 64.9%), in which 1020 (62.7%) health problem were registered. The dancers reported musculoskeletal pain in 82.2% of the weeks. They felt that their ability to dance at their full potential was affected due to a health problem in about every second week (52.6%) or on at least 29.1% of the days documented in the weekly reports. Almost all dancers (96.5%) reported at least one injury, almost two thirds (64.9%) an illness and more than a quarter (28.1%) a mental health problem. On average, every dancer reported 5.6 health problems during the season. Most of the 320 health problems were injuries (73.1%), 16.9% illnesses and 10.0% mental health problems. Injuries affected mainly ankle, thigh, foot, and lower back and were mostly incurred during rehearsal (41.6%) or training (26.1%). The most frequent subjective reasons of injury were "too much workload" (35.3%), "tiredness/exhaustion" (n = 22.4%) and "stress/overload/insufficient regeneration" (n = 21.6%).

CONCLUSION

Preventive interventions are urgently required to reduce the prevalence of health problems and especially injuries of professional dancers. Injury prevention measures should regard the balance of the load capacity of professional dancers and the workload in training, rehearsals and performances.

Single-Leg Heel Raise Capacity is Lower, and Perceived Ankle Instability is Greater, in Dancers and Athletes With Posterior Ankle Impingement Syndrome

OBJECTIVE

To compare clinical assessment findings between elite athletic populations with and without a clinical diagnosis of posterior ankle impingement syndrome (PAIS).

DESIGN

Cross-sectional case-control study.

SETTING

Elite ballet and sport.

PARTICIPANTS

Ten male and female professional ballet dancers and athletes with a clinical diagnosis of PAIS and were matched for age, sex, and activity to 10 professional ballet dancers and athletes without PAIS.

INDEPENDENT VARIABLES

Posterior ankle pain on body chart and a positive ankle plantarflexion pain provocation test.

MAIN OUTCOME MEASURES

Single-leg heel raise (SLHR) endurance test, range of motion testing for weight-bearing ankle dorsiflexion, passive ankle plantarflexion, and first metatarsophalangeal joint dorsiflexion, and Beighton score for generalized joint hypermobility. Participants also completed the Cumberland Ankle Instability Tool (CAIT) questionnaire.

RESULTS

The group with PAIS achieved significantly fewer repetitions on SLHR capacity testing ( P = 0.02) and were more symptomatic for perceived ankle instability according to CAIT scores ( P = 0.004).

CONCLUSIONS

Single-leg heel raise endurance capacity was lower, and perceived ankle instability was greater in participants with PAIS. The management of this presentation in elite dancers and athletes should include the assessment and management of functional deficits.

Health consultations at a performing arts health centre among classical music students based on electronic health record data: a cross-sectional study

Physical and mental health problems in music students are usually identified using self-reported data. The use of an Electronic Health Record database can avoid biases to give an overview of the extent of health problems in this population. Therefore, the aim of this study is to gain insight into both physical and mental health related issues in classical music students using this type of data collection. An Electronic Health Record database including five years of data from a Performing Arts Health Centre (PAHC) of a university or the arts, was used to analyze the number and characteristics of health consultations in music students. The total number of students, health consultations and the average number of visits per health consultation were calculated over five years. Furthermore, numbers and percentages of both physical and mental health consultations were registered. Also, the number and percentage of health consultations per instrument group were compared to the proportion of each instrument group within the specific sample. Over a period of five years, 230 students visited the PAHC and 417 health consultations were reported. 43.5% of the students who visited a health professional indicated at least one physical health consultation, 29.1% at least one mental health consultation and 27.4% at least one in both categories. An injury was the most frequently registered physical health consultation (40.2%), followed by performance improvement (9.8%) and stress (9.6%). Voice students registered relatively most health consultations. As far as we know, this is the first cross-sectional study using Electronic Health Record data from a PAHC to gain insight into both physical and mental health related issues in a population of classical music students. Looking at the variety of health consultations registered in the database, a multidisciplinary team and multidisciplinary approach are necessary to meet the needs of the students in terms of physical and mental health support and performance improvement.

Surgical management of spiral oblique fractures of the fifth metatarsal leads to faster return to play in athletes: A systematic review

PURPOSE

The purpose of this systematic review was to evaluate outcomes following both operative and nonoperative management of spiral oblique fractures of the fifth metatarsal.

METHODS

During November 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following operative and nonoperative management of dancer's fractures. Data regarding subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed.

RESULTS

Ten studies were included in this review. In total, 125 patients underwent operative treatment for dancer's fractures and 365 patients underwent nonoperative treatment for dancer's fractures. The weighted mean follow-up in the operative cohort was 15.3 ± 32.7 months and the weighted mean follow-up in the nonoperative cohort was 30.6 ± 24.3 months. The overall union rate in the operative cohort was 99.2% and the overall union rate in the nonoperative cohort was 98.6%. The weighted mean time to return to sport was 15.4 ± 6.7 and 22.4 ± 4.4 weeks in the operative cohort and nonoperative cohort, respectively. The complication rate in the operative cohort and nonoperative cohort was 12.0% and 15.1%, respectively.

CONCLUSION

This current systematic review demonstrated comparable radiographic outcomes together with low failure rate and low complication rate following both operative and nonoperative management of dancer's fracture at short-term follow-up. However, faster return to sport rates was observed in the operative cohort, suggesting that surgical management of displaced spiral oblique fractures of the fifth metatarsal should be the mainstay treatment option. However, the under-reporting of data, marked heterogeneity between studies and paucity of comparative studies limits the generation of any robust conclusions; thus, further high-quality comparative studies are warranted.

LEVEL OF EVIDENCE

Level IV.