Perspectives and Experiences of Dance-Related Injuries: A Qualitative Survey of Adolescent Pre-Professional Ballet Dancers in Australia

Abstract

Objective: To explore perspectives and experiences of adolescent ballet dancers in Australia in relation to dance-related injuries and their impact, injury risk factors, prevention, and treatment. Design: Adolescent ballet dancers aged from 12 to 19 years in Australia were invited to participate in an online qualitative survey. Methods: Responses to open-ended questions were analyzed thematically using grounded theory while quantitative information was summarized with descriptive statistics and triangulated with qualitative data. Results: Nineteen adolescent dancers reported experiencing pain and multiple injuries but hiding or ignoring injuries due to fear. Dancers recognized the significant physical and psycho-social impact of dance-related injuries on themselves and others. Several risks and injury prevention strategies were identified by dancers. Dancers perceived that treatments were not always informed or effective. Conclusion: Findings suggest that adolescent ballet dancers experience multiple dance-related injuries but require support to disclose injuries, participate in injury prevention, and access treatment. Health professionals may improve quality of care by increasing their understanding of ballet and providing specific management advice. Dance teachers may benefit from further education to support their students. Clinical trials are required to confirm or negate the validity of proposed injury risks and the effectiveness of injury prevention strategies and treatments.

Keywords

ballet dance adolescent/children/pediatrics injury survey qualitative social identity theory injury impact injury prevention injury management

Key Points

Adolescent ballet dancers require additional support to report, prevent, and manage their dance-related injuries.

Health professionals should increase their dance literacy to improve quality of care and enhance rehabilitation.

High-quality clinical trials are necessary to confirm or negate the validity of proposed injury risks, prevention and management in adolescent ballet dancers.

Introduction

Ballet is a popular dance genre requiring significant physicality and artistry.^1-3 An emphasis is placed on “perfection” in movement, timing, and technique.^4-6 Ballet dancers subsequently need to be fit, strong, and flexible and have finely-tuned motor control, balance and coordination.^3-7 Ballet is undeniably a physically and technically challenging pursuit, with a unique social paradigm that only ballet dancers themselves can fully comprehend.^1-7 Dancers typically commence ballet at a young age and increase their training volume and intensity in adolescence as they compete for professional ballet positions.^1,8 Adolescents, regardless of their skill level or future ballet aspirations, must commence their ballet training within a pre-professional setting, either within a vocational or recreational ballet program.^1,2

Adolescent ballet dancers, however, frequently experience dance-related injuries.^2,9 A dance-related injury can be defined as any physical complaint leading to difficulties participating in normal dance class rehearsal or performance.¹⁰ Adolescent pre-professional ballet dancers may experience between 0.76 and 2.73 injuries per 1000 dance hours each year.⁹ The higher injury rate represents “all complaints” injuries where the dancer may continue dancing despite injury, whereas the lower rate represents a “time loss” injury where the dancer must cease dancing.^9,10 Most dance-related injuries in professional and pre-professional ballet dancers affect the lower limb and/or spine, involve strains, sprains, and inflammation.^1-2,9,11

Adolescent ballet dancers may be particularly vulnerable to dance-related injuries because they are still developing physically and psychologically.^1,6 Adolescent ballet dancers, for example, may be at increased injury risk with high training loads or when they push past the safe loads of stretching to demonstrate “perfect” technique.^1,12 Adolescent ballet dancers also may be at risk of injuries when transitioning to full time training and learning to dance en-pointe.^13,14 Adolescents also may be vulnerable to psycho-social pressures to continue dancing when injured which can lead to further injuries and ongoing symptoms.^6,8,15

Being unable to dance due to injury can cause considerable distress for professional dancers as dancing is intertwined with their identity and source of income.^4-5,16-18 There is also an attached stigma to injuries in dance circles and under-reporting due to fear of judgment and reduced career opportunities.^8,15,16 Treatment and support for dance-related injuries may subsequently be insufficient or delayed and dancers may experience worsening injuries and chronic disability.¹⁶ Currently little is known regarding the personal impact of injuries on adolescent ballet dancers who are yet to transition to professional roles.

Several individual risk factors predisposing professional ballet dancers to injury have been reported in the literature—such as being young, hypermobile, having poor psychological coping skills and insufficient fitness, strength, and motor control.^18,19 Other risk factors include high dance training loads, undertaking new or difficult choreography, dancing with incorrect technique, wearing ill-fitting pointe shoes, and dancing on inappropriate dance floors.^20-23 Currently there are few studies that have proposed and/or rigorously tested injury prevention strategies. One randomized controlled trial, however, has reported an 82% reduction in injury rates with targeted strengthening of abdominal, back, and hip muscles in professional ballet dancers.²⁴

Treatment of injured ballet dancers is minimally described and evaluated in the literature. Systematic review findings suggest that a range of physiotherapy treatments (eg, manual therapy, exercise, dry needling) may reduce pain, increase range of movement, and physical function following injury.²⁵ However, additional research is required as primary studies have significant methodological limitations which can influence the credibility of findings.²⁵ Also, given ballet dancers may try to self-manage injuries before seeking health professional input, future research should explore what therapies dancers find beneficial and barriers and enablers to seeking treatment and support.²⁶

Currently there is no known qualitative research that has explored the perspectives and experiences of Australian adolescent novice and pre-professional ballet dancers regarding dance-related injuries. Previous qualitative research focused on professional ballet dancers from other countries and/or those aged over 18 years who may have different perceptions and feelings compared to younger pre-professional ballet dancers in Australia.^8,17 Hence, this research aimed to explore the perspectives and experiences of Australian adolescent ballet dancers regarding dance-related injuries, their impact, risk factors, prevention, and management. Findings may inform efforts to understand and prevent injuries, and support and treat injured adolescent ballet dancers.

Methods

Study Design

An online survey was undertaken to facilitate ease of distribution and data collection and to reduce geographical barriers to participation.²⁷ The survey consisted of mainly open questions to allow exploration of participant views and experiences in their own words.²⁷ Survey design and questions were developed by literature review and identification of evidence gaps, but also by cross-checking design options and topic areas with existing surveys and ensuring it was appropriate for an adolescent population.^1,12,13,27 A qualitative survey design was chosen over other qualitative methods (eg, focus group, interview) as participants could answer questions confidentially without external pressure, which was considered important due to the social stigma surrounding injury reporting and the young age of participants.^16,27 Quantitative data was also collected to provide context to qualitative responses, and was used in data triangulation in development of themes.^1,7,11

Ethics and Consent

Ethical approval to conduct this study was obtained from the Human Research Ethics Committee (H20342). Participants needed to email a completed consent form to researchers to access the survey. For dancers aged under 18 years, consent forms were also obtained from a parent and/or guardian.²⁸ Participation was voluntary and consent could be withdrawn at any time. Identifying information regarding participants was only used for survey administration. Pseudonyms were used to protect participant identity during data analyses and reporting.

Participant Recruitment

Convenience and snowball sampling were used to recruit participants via email and social media.²⁸ Australian recreational dance schools who teach a ballet syllabus, and health professionals with expertise in treating dancers, were emailed by the research team and asked to forward study information to relevant dance students/patients and parents/guardians. Contact details for ballet schools and health professionals in each Australian state and territory were sourced from online publicly available directories. National and state dance organizations and dance schools also assisted recruitment by posting study information on their Facebook and Instagram pages.

Selection Criteria

To participate in the survey, participants needed to meet the following criteria:

Be aged between 12 and 19 years (inclusive) to meet the definition of “adolescent” described in the literature.²⁹

Study ballet at an Australian recreational dance school and have experienced at least one dance-related injury.

Dance ballet more than 50% of the time. Dancers who danced other genres could be included but they needed to predominantly dance ballet.

Participants were also required to be proficient in English language, and have adequate access to an email server and internet to provide consent and access to the survey.

Survey

The online survey was distributed using SurveyMonkey and was estimated to take 45 minutes to complete.³⁰ Participants could complete the 53-question survey (Appendix A) in a single sitting or multiple sittings within 2 weeks and participants were encouraged to complete the online survey individually, in their own time, to prevent external influence on injury reporting. The survey consisted primarily of open-ended questions to explore dancers’ perspectives and experiences using their own words. Participants were asked to report on self-reported injuries, as well as those diagnosed by licensed health professionals. Multiple choice and closed questions were utilized to collect demographics and quantitative information. Pilot testing using an adolescent population was conducted to reduce design flaws, identify any ambiguity in questioning, and address any issues with survey access and flow. Participants were instructed to contact the primary researcher via email for question clarification if required.

Key terms and definitions were provided at the beginning of the survey. This included the study’s definition of dance-related injuries: Any physical complaint leading to difficulties participating in normal dance class rehearsal or performance.¹⁰ Participants were encouraged to cease the survey if recalling personal injury experiences caused emotional distress, and were asked to confide in their parent/guardian, general practitioner, or other trusted health professional. Crisis support contact details were also supplied to participants.

Data Analysis

Participant demographics and quantitative data were summarized using descriptive statistics. Responses to open-ended survey questions were coded using NVivo 12 software.³¹ Qualitative data was analyzed thematically using grounded theory and the step-wise approach described by Braun and Clark.³² Initial data familiarization and coding was conducted by 2 physiotherapy researchers working on the same survey response, whereas the remaining responses were coded separately and findings compared. Once data saturation was achieved and no new codes were identified, codes were reviewed by both researchers in real-time to identify patterns and generate themes. Any disagreements between researchers were resolved by discussion and reexamination of participant responses.

The rigor of qualitative analyses was facilitated by triangulation of qualitative data with quantitative statistics, and consideration of social identity theory.^33,34 Social identity theory proposes that people categorize each other into social groups, identify with and join a social group, and then compare groups—favoring their group (the “in-group”) over others (the “out-group”).³⁵ This model seemed appropriate to use given ballet dancers have linked dancing to their personal identity (Wainwright et al.¹⁷) and adolescents are at an age where they are developing their sense of identity and strongly influenced by social interactions.^17,36,37

Results

Participants

Nineteen out of 21 participants completed the survey representing a participation rate of 90.5% (19/21). The 2 participants who did not complete the survey did not respond to reminders. Participant demographics are summarized in Table 1.

Table 1.

Participant Demographics (n = 19).

Demographic information	Mean (standard deviation)	Number and percentage of participants (n [%])
Age (years)	16.5 (1.7)	—
Number of injuries	6.3 (4.3)	—
Dance hours per week	8.8 (5.0)	—
Years of ballet training and experience	9.5 (3.3)	—
Age when started to dance en pointe (years)	12.4 (1.0)^a	—
Gender
Female	—	18 (94.7)
Male	—	1 (5.3)
State of residence
New South Wales	—	12 (63.2)
Queensland	—	3 (15.8)
South Australia	—	2 (10.5)
Western Australia	—	2 (10.5)
Dance participation^b
Ballet	—	19 (100.0)
Contemporary	—	13 (43.3)
Modern	—	5 (16.7)
Jazz	—	5 (16.7)
Hip hop	—	3 (10.0)
Tap	—	1 (3.3)
Other (ie, Bollywood, Acrodance)	—	3 (10.0)
Dance en pointe	—	18 (94.7)
Syllabus type being studied
Royal Academy of Dance	—	16 (84.2)
Vaganova method	—	3 (15.8)
Ballet grading
Intermediate	—	7 (36.8)
Advanced	—	12 (63.2)

All except one participant did not dance en-pointe (18/19).

The percentage is >100% as participants were able to select multiple dance forms for this question.

Themes

Four themes were identified: (1) Sustaining multiple injuries but hiding or ignoring symptoms; (2) Experiencing the widespread and potentially significant impact of injuries; (3) Identifying risks and injury prevention strategies but not always following advice; (4) Seeking informed and effective treatments focused on return to dance. Themes and subthemes with supportive participant quotes are detailed in Table 2, while complementary quantitative statistics referred to in themes is provided in Table 3.

Table 2.

Qualitative Data.

Primary theme	Subtheme	Supportive participant quotes
(1) Experiencing pain and multiple injuries but hiding or ignoring them	(i) Dance-related injuries are musculoskeletal and typically affect the lower limb and back	“I’ve unfortunately had many injuries during my time dancing. My injuries have been mainly to my back and knees but I’ve also had trouble with my ankles as well. All my injuries have been caused by ballet” (Casey, 15 years)
	(ii) Dancers expect pain and injury and continue dancing despite symptoms	“As a dancer you always experience sore muscles or minor injuries all the time so you just treat them and move and keep dancing” (Alex, 15 years)
	(iii) Dancers hide their injuries from others and ignore pain to avoid stopping dancing	“Hiding dance-related pain was a norm for me because I knew that injuries cost a lot of money and time. Ironically I thought I was doing my family a favor by hiding my pains, but after experiencing the full consequence of rehab and time off dancing, I now know that this isn’t the case” (Lee, 18 years)
	(iv) Dance teachers may not always support dancers resting from injury and reinforce dancing through pain	“My dance teacher overlooked my injury. She didn’t seem to be too concerned, actually encouraging me to continue performing even after telling her it hurt” (Gene, 16 years)
	(v) Some dance teachers are more supportive when dancers reported their injuries and needed to rest from dancing	“My dance teacher was fine with it and told me (that) I need to have a break because she knew I would be able to catch up” (Oakley, 18 years)
	(vi) Younger dancers require encouragement and support to report injuries due to lower self-confidence and fear of judgment from others	“Giving students the affirmation and confidence to confront their teachers and parents about their pains or niggles without fear of being called ‘lazy’ will be a benefit to many” (Lee, 18 years)
(2) Experiencing the widespread and potentially significant impact of dance-related injuries	(vii) Dance-related injuries result in pain, reduced mobility, and reduced strength	“I had pain when I moved and walked and an overall weak(ness) in the ankle” (Billie, 16 years) “When I injured my back and hip the pain was quite severe. I wasn’t able to twist from side to side or move to(o) quickly” (Ellis, 15 years)
	(viii) Dance-related injuries may mean resting from dance or adjusting dance routines and choreography	“It’s stopped me from dancing when it’s a really bad injury but when it’s only minor then you just need to change the way you do things or the amount of time you dance” (Sam, 17 years)
	(ix) Dance-related injuries can take a long term to recover from	“I’m on month 4 and half of my 6-month recovery. I haven’t been able to do everything that I usually can. I’ve only recently been able to bend down to tie my shoes again and at ballet I am only really allowed to (do) barre” (Gene, 16 years)
	(x) Dance-related injuries can affect everyday activities outside of dance	“I wasn’t able to walk without crutches” (Frankie, 17 years) “I can’t sit for very long periods of time and I can’t lay on my belly” (Oakley, 18 years) “I couldn’t play sport during PE classes because of the pain” (Jackie, 15 years)
	(xi) Dancers become angry, frustrated, distressed, and anxious following injury	“I constantly felt frustrated and angry, wondering ‘why me?’ and ‘why now?’ The fact that I had no control over the speed of my recovery made me feel upset and anxious. I worried a lot about how far behind I would be, compared to all my classmates who were healthy and continuing classes” (Gene, 16 years)
	(xii) Returning to dance post injury is difficult and painful	“It’s difficult to continue dancing after an injury. You have to catch up on choreography, you might still be dancing with pain and it’s hard to get back to where you initially were before you got injured” (Indi, 19 years)
	(xiii) Dancers fear re-injury, and being unable to dance after injuries	“The fear of never being able to dance again was very depressing for me, I’ve been dancing for most of my life and it was a huge part of my identity and still is” (Hadley, 18 years)“Having an injury makes you a bit paranoid about recurrence and sustaining injuries that will prevent dancing longer term” (Indi, 19 years)
	(xiv) Some families expect dancers to be injured while others are initially more distressed	“My family was worried obviously but once I got back home from the hospital it was back to normal” (Hadley, 18 years)“I think they [family] expect me to get injured now so they are always happy to take me to appointments, drive me places if I can’t and they’re pretty supportive” (Indi, 19 years)
	(xv) Dance teachers and peers can be inconvenienced by a dancer’s injuries	“My teacher had to take more time with me during class to teach me the choreography” (Kennedy, 18 years)“My class mates had to change their positions so that my spot was covered in the routine” (Frankie, 17 years)
	(xvi) The impact of injuries on dance schools may be minimal	“I don’t feel like it impacts the dance school that much because I still pay my fees and go to watch classes so I don’t fall too far behind” (Nic, 14 years)
(3) Identifying several risks and injury prevention strategies but not always following advice	(xvii) Acute injuries can result from accidents or technical errors, especially when dancing en-pointe or leaping or twisting	“My last injury was to my ankle. I landed a leap but my ankle was in the wrong position. At the time there was a crunch sound and it was very painful” (Billie, 16 years)“I was completing a routine in class with lots of spins and turns. I wasn’t spotting like I should have and rolled my ankle and tore the ligaments” (Frankie, 17 years)
	(xviii) Overuse injuries can result from insufficient rest, intense dance scheduling, and inadequate strength and control	“Some of my injuries occurred due to (being) overworked, overuse(d) and not enough strength training” (Alex, 15 years)“I think I was overtraining and doing too much dance and exercise” (Sam, 17 years)
	(xix) Some injuries cannot be avoided (eg, accidents, genetics) and injuries are an inherent part of dance	“My broken back was a fluke 100% genetics I just inherited my dad(‘)s spine shape, in fact even though he wasn’t a dancer he got the same injury as me at about the same age” (Hadley, 18 years)“I feel like sometimes they [injuries] can’t be prevented like when you trip or accidentally fall during dance” (Lee, 18 years)“I don’t think it [injuries] can be [avoided], getting hurt is a just part of dance” (Hadley, 18 years)
	(xx) Dancing with correct technique, alignment, control, and attention can reduce the risk of injury	“My ankle injury occurred due to wrong use of muscles and using certain muscles in the foot at the wrong time” (Alex, 15 years)“Because of my injury I now realise the significance of correct alignment in dancing. Small adjustments can make a huge difference in the long run!” (Lee, 18 years)“I aim to arrive at the studio an hour before class, to prepare my mind and body” (Gene, 16 years)
	(xxi) Dance injuries may be prevented by managing dance loads, and incorporating rest, warm up, stretching and strengthening exercises	“[Injuries can be prevented] by taking lots of rest breaks and limiting the amount of activity I do as well as dance” (Jackie, 15 years)“Injuries can be prevented by warming up and stretching regularly” (Lee, 18 years)“Every morning before class, I incorporate strengthening exercises into my warm-up regime, specifically for areas I personally know to be weaker, like my feet and lower legs to avoid injury” (Gene, 16 years)
	(xxii) Injuries may be prevented by dancers ensuring appropriate nutrition, sleep, clothing, pointe shoes, and flooring	“Eating smaller portions instead of a large lunch helps me distribute the energy and fuel I need for classes. . .I aim for at least 8 hours of sleep” (Quin, 15 years)“You need to wear warm clothes and stay warm before you start” (Ellis, 15 years)“I regularly check that my pointe shoes are in dance condition and not worn” (Parker, 14 years)“You should always practice on performance floors” (Darcy, 13 years)
	(xxiii) Dancers do not always follow injury prevention advice provided by dance teachers and/or feel additional education of dance teachers as well as students is necessary	“I think that dance teachers work to educate you on how to prevent injuries as much as they can. I do feel that sometimes this advice isn’t really listened to by dancers” (Riley, 16 years)“I believe that by educating not just students but also dance teachers and coaches about the importance of correct alignment, strength, nutrition and resting time will have a great influence and prevent many dance injuries in students” (Gene, 16 years)
	(xxiv) Dancers acknowledge the importance of being aware of limitations and resting when experiencing pain or injury but do not always follow their own advice	“For me I think that I need to be more aware of my limitations and when I need to rest and allow my body time to heal from minor injuries and muscle pain” (Nic, 14 years)“I should have stopped but I continued to dance even though it was clear that something was wrong” (Riley, 16 years)
(4) Seeking effective and informed treatments focused on return to dance	(xxv) Health professional input is commonly sought for injury treatment	“The physio(therapist) that I have seen was really good and helped me to get back to dance quicker. The doctor that I saw was also helpful but only helped with pain medication rather than the injury” (Lee, 18 years)
	(xxvi) Positive outcomes were reported for resting from dancing, surgery, electrophysical agents, taping/bracing, massage, exercise, and mobility equipment (when required)	“It is very important that when you are injured you rest” (Casey, 15 years)“Surgery was the most effective obviously for my back but for small things, heat and ultrasound seems to work the best for me” (Hadley, 18 years)“Taping and bracing helped my foot when I had a fracture, and the ice helped my tendons. Massages almost always help any tightness or stiffness I have in muscles and correct Pilates, strengthening and stretching have all been a huge part of my recovery” (Gene, 16 years)
	(xxvii) Treatments are not always effective and can make injuries worse if inappropriately applied without a diagnosis	“I don’t think that medication is the best option. It doesn’t always work” (Sam, 17 years)“Before being diagnosed with a stress fracture, I tried to massage my foot. However, this didn’t help at all, if anything it actually worsened the condition” (Kennedy, 18 years)
	(xxviii) Dancers report ongoing pain related to dance-related injuries despite treatment	“I still have pain when I dance or do any other physical activity from injury” (Quin, 15 years)“I can now dance again but I will never be the same” (Hadley, 18 years)
	(xxix) Few health professionals understand the demands of ballet dancing—health professionals who are familiar with dance requirements can provide increased quality of care	“They [health professionals] need to understand the dance world better and what we go through and how our bodies work” (Alex, 15 years)“They [health professionals] should know more about pointe shoes for when ballet dancers have ankle and toe injuries” (Nic, 14 years)“I’ve got an excellent physio(therapist) that I see and have seen for a few years now. She’s really good and has some dance knowledge which is great” (Riley, 16 years)
	(xxx) Dancers seek specific advice from health professionals on when they can return to ballet dancing and how to manage their injuries apart from pain relief	“The doctor at the hospital didn’t tell me how long to have off dancing so I think I went back too soon” (Riley, 16 years)“Doctors need to give better advice on how to manage injuries. Don’t just tell me to have Panadol” (Darcy, 13 years)
	(xxxi) There are different opinions of when health professional treatment should be sought—some dancers advocate early intervention, others suggest waiting to see if health professional treatment is necessary	“It’s better to have it checked by a professional than just think you can manage it yourself” (Indi, 19 years)“It is best to catch injuries early before they become a bigger problem and prevent you fr(om) dancing for months” (Sam, 17 years)“Help from health professionals should be sought if pain becomes unmanageable or serious injury occurs” (Morgan, 18 years)“[Consult a health professional] if the pain gets worse, if the minor injury hasn’t gone away after self treatment and rest” (Alex, 15 years)

Table 3.

Dance-Related Injury Characteristics, Impact, Perceived Risk Factor, and Prevention and Treatment Strategies Reported by Participants (n = 19).

	Number (n)	Percentage (%)
Location of injuries
Foot/toes	17	89.5
Ankle/calf	19	100.0
Knee/thigh	14	73.7
Hip/buttock	11	57.9
Lower back	13	68.4
Mid back/chest	4	21.1
Neck/head	5	26.3
Shoulder	2	10.5
Elbow/forearm	1	5.3
Wrist/hand	1	5.3
Injured structures
Muscle	17	89.5
Joint	17	89.5
Tendon	13	68.4
Fracture	10	52.6
Ligament	9	47.4
Nerve	4	21.1
Other (eg, skin damage/blisters)	2	10.5
Mechanism of injury
Jumping/leaping	18	94.7
Twisting/turning	11	57.9
Stretching	8	42.1
Dancing en pointe	7	36.8
Overuse	5	26.3
Kicking	3	15.8
Running	2	10.5
Unsure/unable to recall	1	5.3
Impact of injury (for recent injury)
Time-loss from dance:
Mild (no time off dance)	3	15.8
Moderate (1-7 days off dance)	11	57.9
Severe (>7 days off dance)	5	26.3
Pain intensity (/10):
0-3	1	5.3
4-7	9	47.4
8-10	9	47.4
Impact of injury (for worst injury)
Time loss from dance:
Mild (no time off dance)	0	0.0
Moderate (1-7 days off dance)	2	10.5
Severe (>7 days off dance)	17	89.5
Pain intensity (/10):
0-3	0	0.0
4-7	2	10.5
8-10	17	89.5
Number of health professional treatment sessions required:
0-3	2	10.5
4-6	3	15.8
7-10	3	15.8
11+	11	57.9
Perceived injury risk factors
Dancing en pointe	12	18.8
No rest breaks	11	17.2
Difficult choreography	10	15.6
Not warming up/stretching	9	14.1
Pointe shoes	8	12.5
Flooring	8	12.5
New choreography	3	4.7
Costumes	2	3.1
Partner work	1	1.6
Injury prevention strategies
Regularly practice and attend dance classes	19	100.0
Incorporate warm up and cool down exercise	15	78.9
Maintain and update ballet shoes	15	78.9
Ensure healthy lifestyle (eg, nutrition, sleep)	15	78.9
Undertake regular stretching	14	73.7
Seek further technical training	13	68.4
Undertake strength training or other forms of exercise	12	63.2
Only dance on sprung performance floors	12	63.2
Limit dance hours and schedule rest breaks	8	42.1

Participants could select more than one option for selected questions (Appendix A).

Theme 1: “I’ve Had So Many Injuries”: Sustaining Multiple Injuries But Hiding or Ignoring Symptoms

Participants reported experiencing multiple injuries (Table 2; i) with most involving moderate to severe lower limb strains, sprains, or fractures (Table 3). Participants reported continuing to dance despite injury as they perceived this to be expected as a ballet dancer (Table 2; ii). Participants also reported hiding injuries as they wanted to continue dancing and not miss out on dance opportunities (Table 2; iii). Some participants did recognize, however, that failing to rest when injured could prolong their recovery (Table 2; xxiv). Most participants did not feel confident in reporting injuries to their dance teacher and felt pressured to continue dancing following injury (Table 2; iii). Other participants reported their dance teacher supported them to rest when injured (Table 2; iv). Several participants suggested that adolescent dancers needed specific encouragement and support to report injuries and rest when indicated so that injuries may be more effectively managed (Table 2; vi).

Theme 2: “It’s Difficult to Continue Dancing After an Injury”: Experiencing the Widespread and Potentially Significant Impact of Injuries

Participants described how injuries resulted in pain and reduced mobility, strength, and function, which affected their ability to dance (Table 3; vii). Some participants also reported difficulties sitting, walking, or bathing, and attending and participating in school due to injury (Table 3; x). If injuries were mild or less painful, participants continued to dance with modifications to scheduling, load, or choreography (Table 3; viii) but if pain and injuries were severe, dancers had to cease dancing (Table 3; viii). Some participants reported being unable to dance for days or weeks due to an injury, while others reported months (Table 3; ix). Participants felt frustrated, angry, and anxious when injuries prevented or restricted their dancing ability (Table 3; xi). Participants described intense fear of being unable to dance again, and depression when they were unable to dance as they felt dancing was part of their identity (Table 3; xiii). Participants also described how returning to dance after injury was painful and how it was difficult to return to their previous performance level (Table 3; xii). Participants also feared re-injury, and felt their dancing was affected by this fear (Table 3; xiii).

Some participants felt their parents were distressed when they were injured, while others felt their parents expected their injuries and had little concern (Table 3; xiv). Participants did recognize, however, that they relied on psychological, physical, and financial support from their family to cope and recover from injuries (Table 3; xiv). Some participants recognized the inconvenience and extra workload for dance teachers who needed to help them catch up and/or change choreography, as well as the need for peers to cover them in rehearsals and performances (Table 3; xv). Other participants felt, however, that the impact of injuries on others was minimal in contrast to the personal ramifications (Table 3; xvi).

Theme 3: “I Overworked Myself and Wasn’t Letting My Body Rest”: Identifying Injury Risks and Injury Prevention Strategies But Not Always Following Advice

Participants perceived most of their dance-related injuries to be caused by accidents or technical errors associated with jumping/leaping, twisting/turning, and dancing en pointe (Tables 2 and 3; xvii). Some participants also described overuse injuries due to insufficient rest breaks, intense dance scheduling, rigorous choreography, and insufficient strength (Tables 2 and 3; xviii). Some participants also perceived that genetics may have predisposed them to injury (Table 3; xix). Several participants felt that not all injuries could be prevented as they were accidental or that injuries were unavoidable due to ballet’s technical requirements (Table 3; xix). However, participants felt injury risk could be reduced by focusing on and improving technique, control, and alignment when dancing (Table 3; xx). Participants did note, though, that “perfect” technique was difficult to achieve as a novice (Table 3; xxii).

To prevent injuries participants recommended incorporating warm up and cool down exercise, stretching, and rest (Tables 2 and 3; xxi). Participants also perceived that a healthy lifestyle (including a balanced diet and quality sleep) and physical conditioning and exercise outside of dance were helpful (Tables 2 and 3; xxii). Other reported injury prevention strategies included arriving early to class to prepare, staying warm with appropriate clothing, maintaining pointe shoes, and dancing on sprung performance floors (Tables 2 and 3; xxii). Participants also suggested that by respecting their physical and mental limitations, injuries may also be prevented or better managed (Table 3; xxiv). Despite this, nearly all participants reported continuing to dance through pain and injury (Table 3; ii-iii). Some participants indicated the dance teacher integrated injury prevention strategies into classes although most participants felt dance teachers had limited understanding regarding injury prevention and/or students did not take injury prevention seriously (Table 3; xxiii).

Theme 4: “Don’t Just Tell Me to Have Panadol”: Seeking Effective and Informed Treatment Focused on Return to Dance

Participants sought injury treatment from a range of health professionals and reported variable outcomes and experiences (Table 3; Theme 4). Positive outcomes were reported in response to ice, heat, ultrasound, massage, joint mobilization, exercise (eg, stretching, strengthening, Pilates), taping, bracing, surgery, and use of crutches (Tables 2 and 3; xxvi). Not all participants, however, found treatments effective (eg, medication, massage, taping) and sometimes treatments made their condition worse (Table 3; xxvii). Several participants also reported ongoing pain related to previous injuries, even though they sought health professional treatment (Table 3; xxviii).

Participants felt their treatment would have been more effective if health professionals had a greater understanding of ballet and associated demands (ie, dancing en pointe, dance loads, psycho-social pressures) (Table 3; xxix). Participants also suggested that having access to dance-specific health professionals may reduce their stress and anxiety related to seeking treatment (Table 3; xxix). Dancers sought specific advice on when to return to dancing and not just symptom management (Table 3; xxx). While some participants suggested seeking health professional treatment as soon as possible to prevent an injury from worsening (Table 3; xxxi), others suggested health professional treatment should be sought only if symptoms are worsening and long-lasting, and the injury does not improve with self-management and rest (Table 3; xxxi).

Relevance of Social Identity Theory

Figure 1 summarizes how themes intersect with social identity theory, whereby participants define the “in-group” as those who dance ballet and the “out-group” as those who do not dance ballet. Participants described hiding and ignoring injuries so they could continue dancing (Theme 1) and prioritized dancing over injury prevention (Theme 3) to stay in the “in-group.” Injuries, meanwhile, that stopped participants from dancing (Theme 2) led to them being categorized as the “out-group” and participants therefore sought treatment to help them to return to dance as soon as possible so they could rejoin the “in-group.”

Figure 1.

Understanding the social identity of adolescent ballet dancers and impact of injuries*.

Discussion

This survey provides the first known qualitative evidence to explore perspectives and experiences of Australian adolescent ballet dancers in relation to injuries, their impact, risk factors, prevention, and management. Findings suggest adolescent ballet dancers experience multiple musculoskeletal injuries but may ignore or hide injuries to continue dancing. Adolescent ballet dancers are aware of potential injury risks, but do not always engage in injury prevention strategies preferring to focus on their dancing. Adolescent ballet dancers may access treatment from health professionals with support from others, however, their goal is to focus on return to dance and not just symptomatic management of injuries.

Participants reported experiencing multiple dance-related injuries related to ballet (Theme 1, Table 3). The injury rate can be estimated at 0.7 injuries per year using the mean number of injuries and years of experience reported by participants (Table 1) (6.3/9.5). This injury rate is lower than those reported by professional ballet dancers (1.61-6.8 injuries per dancer per year).¹³ The injury rate could also be estimated at 1.5 injuries per 1000 dance hours (ie, 0.7 × 1000/(8.8 × 52)) using the mean number of hours per week reported by participants (8.8 hours). This injury rate is similar to that of pre-professional ballet dancers (0.77-3.06 injuries per 1000 dance hours) and suggests that ballet dancers are experiencing injuries even when not undertaking high training loads.^1,2 Although the location and type of injuries reported by participants (Table 2) was similar to previous studies, participants reported more injuries to be caused by accidents and technical errors as opposed to overuse and high dance loads.^7,11,21 This finding may relate to the small sample size, however, and so findings require confirmation in future research studies.

Participants were reluctant to disclose injuries to others due to fear of judgment or impact on their ability to continue dancing (Theme 1). This finding has also been reported in professional dancers.¹⁶ The reluctance of dancers, then, to report injuries likely relates to the “culture of risk” in ballet whereby pain is normalized and injuries are trivialized.⁵ There is therefore an urgent need to correct misunderstandings regarding pain and injury prevention and management in adolescent ballet dancers to ensure timely treatment and support to prevent injury chronicity.^25,38 Dance schools, teachers and professional dancers may have the most success in challenging group norms and maladaptive responses to pain and injury in adolescent ballet dancers as they may also be seen as part of the “in-group” (Figure 1).

Participants described anxiety and distress when they were injured as “it was difficult to continue dancing” (Theme 2). Being unable to dance meant participants were demoted to the “out-group” and were therefore dissatisfied with their social identity (Figure 1). Similar feelings have been reported by professional ballet dancers who are unable to dance.¹⁶ It therefore seems vitally important that injured dancers remain connected with their dance colleagues and are supported in dance participation and associated activities as soon as possible. This study also highlights the widespread impact of injuries on an adolescent dancer outside of dancing (eg, school, work, activities of daily living) and their reliance on family, friends, and dance teachers/peers. These aspects therefore need to be considered when supporting adolescent ballet dancers throughout their recovery.

Several injury risk factors identified by participants (Theme 3, Table 2) appear consistent with previous research findings regarding dance-related injuries.⁷ Some risks though require further assessment in research studies with a wider age range of adolescent ballet dancers. Prospective longitudinal studies, for example, that track dance injuries as dancers progress to dancing en pointe (between 11 and 13 years of age), and progress to more advanced grades and technical training may be particularly insightful.^7,20 It also may be relevant to compare the support and resources of adolescent dancers with that of professional dancers regarding factors that influence injury rates and management (eg, access to health professionals, sprung dance floors, replacement pointe shoes).^1,7

Findings also reinforce the importance of progressing from understanding risks to implementing effective injury prevention strategies. For example, participants identified continuing to dance through pain as an injury risk factor, yet they still regularly danced through pain and injury (Theme 3).¹⁶ Adolescent dancers, then, who strongly link their identity to dancing (Figure 1), and who may be particularly susceptible to psycho-social influences are likely to need strong advocacy and support from others to rest from dancing when injured.^1,6 Dance teachers, as part of the “in-group” may be in the best position to provide this advice and encouragement to not “push through” pain and injury. This premise is supported by participant views that a supportive teacher can significantly influence their injury experience and recovery (Table 2; v).

Theme 4 highlights the participants’ desire for informed and effective health professional treatments that facilitate their return to dance and return to the “in group” (Figure 1). Health professionals with experience and understanding regarding ballet were perceived to provide a higher treatment quality which has also been reported by professional dancers.²⁶ Most participants consulted with physiotherapists (Table 2) and found them to provide effective treatment, which aligns with previous research findings.^1,24,25 Some participants, however, reported ongoing symptoms and/or mixed results with health professional treatment (Table 2). This study, then, provides further evidence of the need for research studies to identify effective treatment for dance-related injuries in ballet dancers.

Strengths and Limitations

Findings provide perspectives and experiences of adolescent ballet dancers across a large range of topics (eg, impact, prevention, management) and not just injury statistics. Participants were recruited from multiple Australian states and territories, however, there were no responses from Victoria, Tasmania, or Northern Territory. Factors contributing to low response rates may include indirect online recruitment methods, the 2-step process of gaining parent/guardian and participant consent, and the reluctance of dancers to report injuries.^16,39 There is potential for volunteer bias, or reporting by dancers who experienced more severe injuries, and potential inaccuracies associated with retrospective injury self-reporting. Limitations in data comparison between this study and prior studies should also be acknowledged; including the use of differing injury definitions, and self-reported injuries versus those diagnosed by licensed medical professionals. The rigor of qualitative analyses was enhanced by triangulation of data across two researchers, qualitative and quantitative data, and consideration of social identity theory.^33,34

Conclusion

Findings suggest that adolescent ballet dancers experience multiple dance-related injuries with a potentially significant impact on themselves and others. Adolescent ballet dancers are reluctant to report injuries and rest from injury as dancing is linked to their sense of identity. Adolescent ballet dancers therefore require support and encouragement to undertake injury prevention and seek treatment. Health professionals should increase their understanding of ballet so they can provide dance-specific advice and need to focus treatments on return to dance and not just symptomatic management. Additional research is required to confirm suggested injury patterns and risks and to identify effective injury prevention and treatment strategies.

Footnotes

Appendix

Appendix A.

Survey Questions.

Part	Question	Response type	Response options
Part 1. About you and your dance history	What is your age in years?	Open response
	What is your gender?	Multiple choice	MaleFemaleNon-binaryOther (please specify)
	Where do you live in Australia?	Multiple choice	New South WalesSouth AustraliaAustralian Capital TerritoryNorthern TerritoryQueenslandVictoriaTasmania
	Do you currently study ballet at a dance school in Australia?	Multiple choice	YesNoOther (please specify)
	Have you ever sustained an injury due to ballet training?	Multiple choice	YesNoOther (please specify)
	How often do you dance ballet?	Multiple open response	Hours per dayHours per weekDays per week
	Do you dance ballet more than 50% of the time each week?	Multiple choice	YesNoOther (please specify)
	Which dance forums do you participate in apart from ballet (tick all that apply)?	Multiple choice	ContemporaryModernHip hopTapJazzNo other dance formsOther (please specify)
	How many years have you been dancing ballet?	Open response
	Does your dance school follow a specific ballet syllabus?	Multiple choice	YesNoUnsure
	What dance syllabus does your dance school follow (if known)?	Open response
	Please describe your current level or grading of ballet training:	Open response
	Do you dance en pointe (ie, on the tips of your toes)?	Multiple choice	YesNoOther (please specify)
	How old were you when you started dancing en pointe?	Open response
	Do you identify as a professional, pre-professional, or recreational ballet dancer?	Multiple choice	Professional (ie, paid to dance, train or perform, and/or are a member of a professional dance company)Pre-professional (ie, undertaking a year long ballet program which is similar in intensity to full time professional positions)Recreational (ie, currently train in an Australian ballet school and are not paid to dance)Other (please specify)
Part 2. Dance-related injuries	Do you currently have a dance-related injury related to ballet?	Multiple choice	YesNoOther (please specify)
	How many dance-related injuries have you experience related to ballet:	Multiple open responses	In the past 6 monthsIn the past 12 monthsIn total (since you have been dancing ballet)
	At what age did you sustain your first dance-related injury (that you remember)?	Open response
	What type of dance-related injury/injuries have you experienced (tick all that apply)?	Multiple choice	Fractures/stress fractures (ie, broken bone)Dislocation/subluxation (ie, joint is out of place)Joint pain/injury (ie, joint is sore to move or load)Ligament sprain (I,e, torn or stretched tissue connecting bones)Tendon pain or tendinopathy (ie, pain where muscle attaches to bone)Muscle pain/injury (ie, pain or injury of whole muscle)Nerve related damage (ie, tingling, numbness weakness)UnsureOther (please specify)
	What area of the body have you injured (tick all that apply)?	Multiple choice	Head/neckShoulderUpper armForearmHand/fingersChestBackHipThighKneeCalfAnkle/footOther (please specify)
	How would you describe your most recent dance-related injury?	Multiple choice	Mild: no days of rest from dancingModerate: less than 7 days rest from dancingSevere: more than 7 days rest from dancingOther (please specify)
	How much pain did you experience at its worst relating to your most recent dance-related injury?	Numerical rating scale	0 (no pain) − 10 (worst pain imaginable)
	How much pain did you experience at its worst relating to your most severe dance-related injury?	Numerical rating scale	0 (no pain) − 10 (worst pain imaginable)
	How would you describe your most severe dance-related injury?	Multiple choice	Mild: no days of rest from dancingModerate: less than 7 days rest from dancingSevere: more than 7 days rest from dancingOther (please specify)
Part 3. Injury experience and impact	Please describe your experience of dance-related injury/injuries (ie, describe what happened, why it happened, what it meant for you)	Open response
	How did you feel when you sustained a dance-related injury/injuries?	Open response
	What has been the impact of dance-related injury/injuries on:	Multiple open responses	You:Your dancing:Your everyday life:Your study/work:Your family:Other dance students/peers:Your dance teacher:Your dance school:
	Has a dance-related injury ever stopped you from dancing?	Multiple choice/open response	YesNoIf yes, what is the maximum time you have been unable to dance due to injury, and what was this injury?
	Have you ever continued dancing ballet despite an injury/injuries?	Multiple choice/open response	YesNoWhy or why not? Please explain your answer
	Do you ever worry that you might injure yourself while dancing?	Multiple choice/open response	YesNoWhy or why not? Please explain your answer
	Have you ever hidden a dance-related injury from others?	Multiple choice/open response	YesNoWhy or why not? Please explain your answer
Part 4. Injury risk factors and prevention	Why do you think you were injured when you were dancing ballet? Please describe in relation to:	Open response	Most recent injury:Most severe injury:
	What were you doing when you were injured dancing (tick all that apply)?	Multiple choice	JumpingTwistingTurningStretchingKickingRunningLeapingDancing en pointeLifting a partnerOther (please specify)
	Do you think any of these aspects contributed to you getting injured (tick all that apply)?	Multiple choice	New choreographyDifficult choreographyFlooringFootwearCostumesNot warming up/stretchingNo rest breaksPartner workDancing en pointeLifting a partnerOther (please specify)
	From your perspective, how can dance-related injuries be prevented in ballet dancers?	Open response
	What do you do to prevent yourself from getting injured when dancing?	Open response
	How do other people (eg, parents, teacher, dance school) try to reduce the risk of injury when you are dancing ballet?	Open response
	Which of the following injury prevention strategies do you use (tick all that apply)?	Multiple choice	Regularly practice and attend dance classesSeek further training and feedback on techniqueLimit dance hours and schedule rest breaksIncorporate warm up and cool down sessionsUndertake regular stretchingOnly dance on appropriate flooringMaintain and update ballet shoesEnsure a healthy lifestyle (eg, balanced diet, adequate sleep)Undertake other forms of exercise (eg, pilates, yoga, strength training, aerobic exercise)Other (please specify)
	Do you have any suggestions for how dance-related injuries can be prevented more effectively for:	Multiple open responses	You:Others:
Part 5. Treatment and management of dance-related injuries	Have you ever sought treatment from a health professional (eg, doctor, physiotherapist) regarding dance-related injuries?	Multiple choice/open response	YesNoWhy or why not? Please explain your answer
Part 5. Treatment and management of dance-related injuries	What type of health professional have you seen about dance-related injury/injuries (tick all that apply)?	Multiple choice	General practitionerSports doctorOrthopedic surgeonPhysiotherapistChiropractorMassage therapistNaturopathNo health professionalsOther (please specify)
	In relation to your worst dance-related injury, how many treatment sessions in total have you had with health professionals?	Multiple choice/open response	012-34-56-1010+Please list the health professional/s you consulted in relation to this injury:
	Have you ever tried to self-manage dance-related injuries without seeking health professional treatment?	Multiple choice/open response	YesNoWhy or why not? Please explain your answer
	Which of the following treatment or management approaches have you undertaken to manage dance-related injuries (tick all that apply)?	Multiple choice	MedicationsSurgeryRest from danceTaping/bracingMassageJoint mobilization (ie, moving the joint back and forth by a therapist)StretchingStrengthening exercisesPilatesHydrotherapy (ie, exercise in a pool)IceheatUltrasoundElectrical stimulationOther (please specify)
	What has worked well for you in regards to treatment/management of dance-related injuries? Please explain your answer	Open response
	What hasn’t worked well for you in relation to treatment/management of your dance-related injury/injuries?	Open response
	From your experience, how can health professionals provide more effective treatments for dance-related injuries?	Open response
	From your experience, what can dancers do to help in managing their own dance-related injuries?	Open response
	From your experience, when should dancers seek health professional treatments rather than self-manage their dance-related injury/injuries?	Open response
	Do you still have ongoing issues with your dance-related injury/injuries?	Multiple choice/open response	YesNoPlease explain your answer
	Do you have any final thoughts or experiences related to dance-related injuries you would like to share? Please provide these below	Open response

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Natalie Cheers

Cherie Wells

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