Common Injuries in the Performing Arts

When injuries arise, many artists are often unsure what to do. Important steps to follow when injury occurs include injury recognition, proper treatment, understanding what factors led to injury, and a progressive return to training.

  • Not every ache is an injury. Minor aches and pains  are normal and usually lessen once the muscles are warm. Pain that persists or becomes more intense as you practice and is localized to a particular area is a warning sign to stop. If pain continues after practicing and for the remainder of the day, be cautious and initiate treatment phases. 
  • Overall, always remember that pain is your body’s way of warning you that something may be wrong. It is normal to feel an occasional ache or pain while performing, however, if the pain does not resolve and becomes progressively worse, stop before you cause greater injury.
  • Once you recognize that you have an injury or dysfunction, make an appointment to see one of our Sports Medicine Providers. While you are recovering, analyze the reasons why you may have become injured. Causes of injuries can include abnormal anatomic alignment, poor training and technical errors.

*Please bring instrument, shoes, etc to your appointment if possible.*

Ankle Impingement

Anterior impingement may develop when the tibia (shinbone) and the talus (main ankle bone) do not properly glide over one another, pinching the tissues on the front of your ankle. Over time this can cause biomechanical changes in the ankle that can be more difficult to overcome.

Posterior impingement may be cause by inflamed soft tissue or bony compression in the back of the ankle. The muscles of the calf can become inflamed around and just above their attachment at the heel. Variations in bony anatomy can cause continued compression due to the amount of time the foot is in a pointed position with dance. These issues can cause a restriction in the pointing movement.

Symptoms

  • Anterior (front): Sharp, grabbing pain in the front of the ankle with plié and jumping
  • Posterior (back): Pain with jumping
  • Restriction with relevé (unable to rise en pointe)
  • Pain with taking off or landing from jumps
  • Pain with pointing, as in tendu

Treatment

  • Rest and ice the injured area.
  • Examine your technique to ensure you are working in proper alignment.
  • Consult a healthcare provider to rule out any other overuse injury.
  • Joint mobilizations performed by a healthcare professional may give you more motion. Manual therapy may release any soft tissue restrictions.
  • A kinetic chain examination is highly recommended.

Source: OSU Wexner Medical Center-Performing Art Medicine

Ankle Sprain

An ankle sprain is an acute injury that is common in all types of physical activity. It is the most common dance-related sprain/strain. The typical mechanism is “rolling over” the outside of the ankle (lateral sprain). In dance, this is usually caused by landing a jump, turning or coming off your toe en pointe. The severity of an ankle sprain is graded first, second or third (mild, moderate or severe), depending on the extent of ligament injury.

Causes

  • Muscle fatigue
  • Poor motor control and/or balance
  • Lapse in concentration

Symptoms

  • You may hear and/or feel a “pop” in your ankle. This may be quite painful and you will have some immediate swelling in your ankle joint.
  • You may develop ecchymosis (discoloration) or bruising into the foot or up the lateral (outside) side of your leg.

Treatment

  • Follow PRICE:
  • Protect the injured area with compression wraps or braces. Compress the area with an elastic bandage if available. Start at toes with the most compression and gradually reduce the pressure as you wrap up the ankle.
  • Rest the injured area. Do not attempt to continue to dance or be active. Sit down!
  • Ice the injured area 15-20 minutes every hour.
  • Elevate the injured area; this prevents the swelling from settling in the ankle joint.
  • Seek medical attention. Your physician may order X-rays to rule out a fracture.
  • Depending on the severity, you may need rehabilitation to regain your range of motion and strength and retrain your balance. Manual therapies are also recommended to promote and re-establish proper mechanics and prevent the formation of scar tissue.

Source: OSU Wexner Medical Center-Performing Art Medicine

Ankle Tendinitis

Tendonitis is inflammation of a tendon, an overuse injury usually due to repetitive stress activities such as running and jumping. In chronic cases, the tendon composition changes over time, causing a thickening known as tendinosis. In severe/chronic cases, microtearing can occur and increase the risk of tendon rupture.

Common Sites

  • Achilles tendon (back of the heel)
  • Flexor hallucis longus (medial ankle/arch into the big toe)
  • Posterior tibialis (medial ankle into the arch)
  • Peroneals (lateral leg into the lateral ankle/foot)

Causes

  • Environment – footwear, floor surfaces and choreography
  • Muscle weakness and lack of flexibility
  • Alignment/technique – lack of heel contact with landing, rolling in during plié or landing from jumps

Symptoms

  • You will experience a gradual increase in pain in the affected area. Pain is typically felt at the beginning of practice or rehearsal.
  • You may also experience pain with stretching.

Treatment

  • Ice after activity and lightly stretch to maintain flexibility.
  • Avoid jumps and any other activities that elicit pain (pliés, relevés, running).
  • Utilize manual therapy, including self-massage and cross-friction massage at the insertion of the tendon to release the muscles.
  • Find the source of what is causing the pain (poor technique, overtraining).
  • Participate in an eccentric (contracting the muscle as it lengthens) exercise program.
  • A kinetic chain examination is advised.

Source: OSU Wexner Medical Center-Performing Art Medicine

Focal Dystonia

Focal or task-specific dystonia is defined as an abnormal movement disorder that develops when a person is attempting to perform a specific task such as playing piano or putting in golf (yips). In the performing arts, focal dysonia is instrument related; artists that play strings or piano tend to develop dystonias of the hand, while those who play reed or brass tend to develop  dystonias of the facial musculature. Singers can develop dystonias of the vocal cords and drummers can develop dystonias of the upper extremities. 

Treatment

  • Medication
  • Biofeedback
  • Manipulative and movement therapies
  • Relaxation techniques
  • Stretching and strengthening programs
  • Changes in equipment and/or technique
  • Splinting

Source:Athletes and the Arts-The Role of Sports Medicine in the Performing Arts (PDF)

Hallax Valgus (Bunion)

This is an overuse injury that occurs when the big toe starts to deviate at an angle toward the second toe. As the angle of the deviation increases, a bump may begin to form at the joint; this bump is called a bunion. Bunions are more common in feet that overpronate (roll in).

Causes

  • Bunions develop over time and can be caused by wearing shoes that are too tight or narrow
  • Improper pointe technique
  • Heredity

Symptoms

  • A bunion is not always painful, however, if pain develops, you typically experience a gradual onset of pain.
  • You may notice your big toe is swollen and painful to the touch after technique or rehearsal.
  • Pain when going up onto demi-pointe may also be an indicator that you are developing a bunion as the inflammation may limit the range of motion in your toe.

Treatment

  • Toe spacers help keep space between the toes and assist the big toe in staying straight so that it tracks properly.
  • Silicone gel or felt pads may help cushion the area taking pressure off the bunion.
  • Strengthening of the intrinsic muscles of the foot may also help keep the toe in better alignment and prevent larger deviations, leading to correcting improper foot structure.
  • Icing after activity helps limit the amount of inflammation.
  • Gentle manipulation and myofascial release techniques by a medical professional are recommended.
  • If your pointe shoes are too small for your feet, you may need a bigger pair or a different style.
  • Have your teacher assess your ballet technique. If you are working through your foot improperly or excessively pronating, this can cause your injury to get worse.

Source: OSU Wexner Medical Center-Performing Art Medicine

Hearing Loss

Noised induced hearing loss (NIHL) is hearing loss that is associated with continuous or intermittent noise exposure.  Occupational NIHL is always sensorineural and affects the cochlear hear cells in the inner ear.

Causes

  • Musical behaviors in various occupational settings, including music schools, concert venues, and nightclubs are capable of generating sound levels that exceed recommended exposure does prescribed by the National Institute for Occupational Safety and Health. 
  • 50% of musicians may have problems with hearing loss. 

Treatment

  • Permanent NIHL is irreversible.
  • Temporary NIHL is reversible with adequate rest and recovery.

Source: Athletes and the Arts-The Role of Sports Medicine in the Performing Arts (PDF)

Inadequate Nutrition

Rehearsing or performing in a fasted state or going for long periods without eating due to demanding practice and performance schedules reduces the availability of energy and nutrients to active muscles and has been shown to impair performance. Several sports nutrition guidelines can apply to performing artists to improve performance and reduce the risk of injury. 

Pre-Performance Guidelines

  • Fuel for performance; never show up for a performance in a fasted state. Artists should eat at least two meals before an evening performance as well as a small snack before performing. 
  • Pre-event meals should consist of mostly carbohydrate (i.e. whole grains, pasta, rice, potatoes, energy bars, vegetables, and fruit), moderate protein, and low fat. The pre-event meal should be consumed three to four hours prior to performance. 
  • The closer to the start of the performance, the smaller the meal should be. 
  • Stay hydrated. Performers are advised to drink 12 to 20 ounces of water or a sports drink at least two to three hours before a performance. This will optimize hydration and allow time for excretion of any excess fluid. 

It is important to avoid overeating late at night by spreading meals throughout the day, a real challenge to performing artists. Performing artists can ward off hunger during performances and avoid being extremely hungry afterwards by eating small bites and drinking fluids between acts or during intermissions.  

Post-event eating can impact fuel availability for the next day's performance. Artists often have little time to recover between performances. The window for optimal post-exercise recovery spans several hours. The earlier food is ingested within this window, the faster energy stores are replenished. This is especially important for multiple performances per day or for those who practice/perform everyday. 

Post-Performance Guidelines

  • Carbohydrate consumption within 30 minutes after a practice/performance replaces energy in the muscle and decreases recovery time compared to eating later. 
  • Protein should be added to a post-event recovery snack to support muscle repair and growth. 
  • Optimal rehydration post-activity includes consuming 1.5 times more fluid than was lost during the performance. Generally this means consuming three cups of fluid for each pound lost during the performance. 

For more resources, check out our Sports Nutrition page.

Source: Athletes and the Arts-The Role of Sports Medicine in the Performing Arts (PDF)

Knee Pain

Knee pain can be from a few different causes. The most common knee injury in performing arts is patellofemoral pain syndrome, which is usually due to the patella (kneecap) not gliding smoothly along the femur (thigh bone). Pain is usually felt anywhere around the kneecap.

Over time, the cartilage beneath the patella can soften and wear away. This softening or wearing away of cartilage and the pain and inflammation associated with it are referred to as chondromalacia.

Causes

  • Tight iliotibial band may pull the kneecap laterally (to the outside)
  • Tight gastrocnemius/soleus (calf) muscles
  • Weak hip muscles, especially the gluteus medius and hip external rotators
  • Weak medial quadriceps (inner thigh) muscle
  • Poor hip-knee-ankle alignment with plié and jump tasks
  • Poor core stability

Symptoms

  • Dull aching pain
  • Sharp pain with dance moves such as pliés, especially grand plié
  • Pain with jumping
  • Pain after sitting for a long time
  • Swelling around the kneecap
  • Crepitus (snapping or crunching sounds) with knee flexion/extension

Treatment

  • Icing after activity will help limit pain and inflammation.
  • Reduction in training time.
  • Cross-friction massage at the kneecap tender points.
  • Strengthening program for the core, hip, and thigh.
  • Stretching of calf, quadriceps and iliotibial band.
  • Avoidance of grand plié and jumps until pain symptoms diminish.
  • A kinetic chain examination is advised.

Source: OSU Wexner Medical Center-Performing Art Medicine

Lateral Hip or Knee Pain

Lateral knee or hip pain, known as iliotibial band syndrome or ITBS, occurs when the iliotibial band, which runs from the lateral hip down to the knee, becomes tight. This tightness can cause the tendon to “flip” over the outside bony prominence of the knee (lateral tibial tubercle) as the knee flexes. The “flip” can cause an audible “pop,” which causes discomfort and pain. The tightness can also pull on the knee, affecting its mechanics.

Symptoms

  • Pain and or swelling on outside of the knee
  • Tight hip flexors
  • Outside hip pain in your stance leg
  • Painful “pop” when you plié, jump or developpé

Treatment

  • Rest.
  • Ice the insertion point at the knee.
  • Use a foam roller: manual therapy can assist in releasing tight tissues.
  • Avoid grand plié and fifth position.
  • Evaluate training schedule to determine if you are overtraining.
  • A kinetic chain examination is advised.

Source: OSU Wexner Medical Center-Performing Art Medicine

Low Back Strain

A low back sprain may involve injury to the joints of the back called the facet joints. The spinal muscles can be strained from overuse or being overstretched. In either case, protective muscle spasm, guarding and limited range of movement typically occurs.

Causes

  • Choreographic demands, especially partnering and extreme spinal movements
  • An unsupported fall to the floor
  • A sudden movement the body is not prepared for
  • Poor lumbo-pelvic stability

Treatment

  • Rest, ice and anti-inflammatory medicine.
  • Use of a back brace.
  • Manual therapy by a medical professional to restore proper myofascial and/or joint mobility.
  • Correcting postural and/or lifting technique.

Source: OSU Wexner Medical Center-Performing Art Medicine

Plantar Fasciitis

Heel or arch pain is known as plantar fasciitis. It is an inflammation of the plantar fascia or irritation at its attachment on the medial (big toe side) aspect of the calcaneus (heel) often related to excessive weight-bearing.

Causes

  • Excessive jumping
  • Poor mechanics such as overpronation with plié, jumps or excessive turnout in gait

Symptoms

  • The pain can be aggravated by dancing on hard surfaces and is typically worse in the morning or when standing after prolonged sitting.

Treatment

  • Roll arch on frozen water bottle during acute (new injury) phase.
  • Apply cross-friction massage at the site of attachment to reduce soft tissue restrictions.
  • Perform hip, gastrocnemius/soleus (calf) and foot intrinsic muscle stretching and strengthening maneuvers.
  • Modify activities by reducing aggravating movements.
  • Cross-train with floor barre, cycling, Pilates or swimming until inflammation subsides.
  • Address technique and alignment dysfunction.

Source: OSU Wexner Medical Center-Performing Art Medicine

Shin Pain

Shin splints involve pain and inflammation in the lower leg due to repetitive stresses. Pain is usually on the medial (inside) border of tibia due to irritation of the muscle attachments and/or periosteum (outside layer of bone) along the lower leg. If treatment or rest is not initiated, this can progress to a stress fracture.

Causes/Training Factors

  • Increased volume of dancing compared to regular schedule, such as rehearsals or summer intensives
  • Tight gastrocnemius/soleus complex (calf muscles)
  • Training on an unsprung floor
  • Frequently changing dance style/choreography
  • Footwear

Biomechanical Factors

  • Flat feet/collapsed arch
  • Improper body alignment

Symptoms

Your symptoms will develop over time rather than all at once

If untreated, this pain can become more frequent/constant and intense. Your shin may become tender to the touch. You may notice:

  • Pain that becomes worse with prolonged dancing
  • Rest relieves pain
  • Soreness so bad that pain is experienced when walking
  • Limitations with pliés, frappés (gesture leg) and jumps
  • If you are able to pinpoint with a fingertip exactly where you have pain on your shin, the injury may have progressed to a stress fracture and you should see your sports medicine physician as soon as possible.

Treatment

  • Rest and ice will help with your pain symptoms.
  • Ice massage is the best way to ice for shin splints. Take a paper or foam cup, fill it with water and freeze it. Peel the cup down to the ice and massage it along the painful area for five minutes.
  • Restrict activities until symptoms improve.
  • A kinetic chain examination can help find the cause of your injury.
  • Arch supports in your shoes and arch support tape during activity may alleviate some of your pain.
  • Manual therapy is very effective in releasing muscles and fascia in the lower leg.

Source: OSU Wexner Medical Center-Performing Art Medicine

Snapping Hip

Snapping hip may not cause pain when it occurs, but the tendon can become irritated if not addressed. It may be considered an injury if it occurs more frequently or becomes painful. It is very common among dancers and commonly occurs during grand battement developpé – especially à la seconde and rond de jambe en l’air.

Common Sites

  • The snap typically occurs in the gesture leg; in ponche, the snap usually occurs in the stance leg but can occur in the gesture leg as well
  • Lateral snapping involves the iliotibial band snapping over the greater trochanter (outside of hip)
  • Anterior snapping involves the psoas (hip flexor) tendon snapping over a bony prominence or another (iliacus) tendon in the hip, causing groin pain
  • Deeper snapping or snapping in the lumbar spine (low back) may indicate sacroiliac joint dysfunction or lumbar spine instability

Causes

  • Poor lumbo-pelvic core control
  • Weak hip flexors and/or external rotators
  • Tight hip flexors and/or iliotibial band

Symptoms

  • Sharp pain in the groin/lateral hip region

Treatment

  • Apply self-massage techniques for the hip region.
  • Modify dance schedule by keeping your leg lower or using less turnout.
  • Initiate a core stability program and regain flexibility.
  • Address postural dysfunction, especially with movement.
  • A kinetic chain examination is advised
  • Manual therapy techniques by a medical professional.

Source: OSU Wexner Medical Center-Performing Art Medicine

Spondylolysis or Spondylolisthesis

Spondylolysis is a stress fracture to the vertebra in the lower back known as pars interarticularis. Spondylolisthesis is a stress fracture to the pars interarticularis, which includes anterior slippage of the vertebrae.

Causes

  • Repeated stress in lumbar spine, particularly hyperextension movements
  • Poor lumbo-pelvic stability
  • Overly tight hip flexors

Symptoms

  • Restricted extension in the thoracic spine (mid-back)
  • Hyperextension in lower back
  • Movements, such as port de bras, cambre (especially back) and arabesque, are painful.
  • Can progress to pain in everyday tasks and may affect sleep

Treatment

  • Seek medical attention, especially with chronic back pain. Early recognition of stress fracture will help in your recovery process.
  • Rest from dance and hyperextension activities.
  • Start a local and global core stability program.
  • Relearn movement and dance technique to use the entire spine.
  • Seek manual therapy by a medical professional to restore any postural faults or myofascial restrictions throughout the body.

Source: OSU Wexner Medical Center-Performing Art Medicine

Stress Fracture

Stress fracture is a chronic injury that is caused when a specific part of a bone experiences more repetitive load than it can tolerate. Although stress fractures can occur in any bone that bears repeated stresses, there are three common places where dancers and other performers experience a stress fracture:

  • Base of the second metatarsal (foot bone)
  • Along the fifth metatarsal (foot bone along little toe side)
  • Around the femoral neck (hip)
  • Tibia (shin)

Causes

  • Low to normal load activities performed without enough rest
  • Muscle fatigue
  • Low-energy availability
  • Faulty mechanics
  • Intrinsic and extrinsic biomechanical factors
  • Amenorrhea, low bone density/osteoporosis and inadequate nutritional status – the female athlete triad

Symptoms

  • Pain during and sustained after activity
  • Pain that does not go away with rest
  • Pain at night
  • Ability to pinpoint the exact spot along the bone where the pain is
  • In some cases, persistent focal swelling at the site of pain

Treatment

  • Adequate rest is the best treatment strategy for a stress fracture.
  • Your physician may require that you immobilize the injured area to allow proper healing through rest.
  • If you have a longer second toe, padding the adjacent toes may help distribute forces evenly when en pointe.
  • Modify your dance-training schedule to reduce repetitive loads.
  • Seek consultation with your healthcare provider if you suspect the female athlete triad.
  • A kinetic chain examination is also advised.

Source: OSU Wexner Medical Center-Performing Art Medicine