Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Luke Abnett @balletphysio

Observing dancers

Ballet is an interesting and challenging field of sports medicine, and to be optimally able to manage injury rehabilitation it is important to know your sport. In this case it is important to know your art, because ballet doesn’t see itself as a sport at all. In fact, the entry level position in the Corps de Ballet of the Royal Ballet company carries the title of ‘Artist’. However, these athletic artists require just as coordinated a sports medicine approach to perform at their peak as any other sport.

In this blog I will share my experience of working for six years in ballet medicine to demystify some of the quirks of this population. I will explore some basic principles of ballet, the habits of its artists, the specialised equipment they use, and a typical balletic body.

Basic Principles

Classical ballet is an aesthetic art form and the most important outcome is how a performer subjectively looks whilst performing, rather than any objectively measurable physical achievement such as speed or strength. By way of example, the dancer who jumps higher may be overlooked in favour of the dancer whose technique and alignment is more visually appealing. Ballet aims to please the eye of the observer by creating the illusion of weightlessness in making seemingly effortless shapes with dancers’ bodies. Additionally groups of dancers coordinate their movements to make patterns and lines on the stage. To achieve this precision of movement, and precision of prescribed balletic positions.

There are two features of classical ballet which distinguish it from other forms of dance. Firstly dancers dance in a ‘turned out’ position, that is the lower limb is externally rotated (with maximal contribution from the hip joint but additionally from joints at the knee and foot). This allows the audience to see the line of the leg as it is either bent, extended or in some cases hyperextended more clearly than if the leg is viewed in the anatomical position. Secondly female dancers frequently dance on pointe, or on the tips of the toes, to add to the impression of weightlessness and to lengthen the leg line.

Habits

Dancers’ technical practice involves a high degree of repetition of set positions in various sequences, with the intention of maximising precision and efficiency of movement and therefore minimising risk of injury. However, the extreme nature of some ballet positions at the end of a joint’s available range of motion increases this risk, and the low variability of very repetitive movements may increase this risk further.

There is also a relatively limited capacity for practising ballet technique whilst resting one body part. Dancers commonly report feeling the technique of ballet as a whole-body position or movement, with part-practice of these positions feeling confusing and counterproductive. For example if a dancer was avoiding end range ankle plantarflexion to rest a posterior ankle impingement injury, it would be difficult to practise a high leg extension (which demands hip abduction/external rotation, knee extension and ankle plantarflexion). Changing the ankle position would change the overall feeling of ‘stretch’ in the leg as a whole and, even though the knee and hip ranges would not be limited by the ankle injury, the whole manoeuvre would tend to be avoided.

This ‘all or nothing’ approach is culturally embedded within ballet and also tends to affect training as a whole. In fact this makes sense when considering that, during a performance, a dancer must perform every step of their role to the full, otherwise they would not be permitted on stage. The unfortunate side-effect of this approach is that ballet training periodisation historically lags behind that of other athletic pursuits.

Equipment

Ballet generally uses little equipment. Footwear is designed either for flexibility, to enable the dancer full freedom of movement of all foot and ankle joints, or rigidity, to enable the dancer to maintain neutral metatarsophalangeal joints when dancing on pointe.

Dance floors are sometimes sprung to reduce the shock of impact of jumping on the feet, legs and lumbar spines of dancers, though some theatre floors may be concrete. Most studios have floors that are flat, but some older theatres’ stages may be ‘raked’ – meaning sloping up towards the rear of the stage to give the audience a better view of the performance. This angulation adds the additional challenge of trying to avoid ending up in the orchestra pit when dancing pirouettes!

Ballet Physique

Ballet favours aesthetically pleasing lines, so hyperextended knees, excessive hip external rotation, excessive lumbar extension and excessive ankle plantarflexion with a high medial longitudinal arch are all favoured characteristics. A significant proportion of ballet dancers is hypermobile¹, though this brings its own challenge of having sufficient strength to control excessive movement at the end of joint range. Ballet dancers (especially females) also tend towards low BMI and other female athlete triad risk factors, which could partially explain risk of bone stress injury^2,3.

If a healthcare practitioner working in sports medicine considers that the typical ballet dancer is naturally hypermobile, regularly practises positions of extreme flexibility, uses unsupportive footwear and trains with a high degree of repetition, it is unsurprising that overuse injuries form the majority of those sustained by professional dancers. In part two of this blog I will explore some of the more common ballet injuries and discuss their mechanisms.

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Luke Abnett has specialised in ballet physiotherapy for six years, having managed healthcare provision at the Royal Ballet School and now working in private practice in central London and leading a Dance Medicine Clinic in Surrey.

Email: balletphysiotherapist@gmail.com

Facebook: BalletPhysio

Twitter: @balletphysio

Instagram: balletphysiolondon

References

1. J Rheumatol. 2004 Jan;31(1):173-8.

Joint laxity and the benign joint hypermobility syndrome in student and professional ballet dancers.

McCormack M¹, Briggs J, Hakim A, Grahame R.

2. Am J Sports Med. 2014 Apr;42(4):949-58. doi: 10.1177/0363546513520295. Epub 2014 Feb 24.

Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women.

Barrack MT¹, Gibbs JC, De Souza MJ, Williams NI, Nichols JF, Rauh MJ, Nattiv A.

3. J Sci Med Sport. 2014 May;17(3):271-5. doi: 10.1016/j.jsams.2013.07.013. Epub 2013 Aug 8.

Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences.

Ekegren CL, Quested R, Brodrick A.