Stress fractures occur in up to 46% of dancers during their career (Delegete, A). Over 60% of these fractures occur during puberty. Decreased strength, proprioception, and balance control, as well as poor technique can lead to increased stress to the bones and thus increased risk for stress fracture. Females are twice as likely than males to have a stress fracture secondary to caloric restriction, reduced bone mineral density, and menstrual irregularities (Delegete, A).

RISK FACTORS

• Delayed period
• Decreased bone mineral density
• Reduced caloric intake
• Vitamin D deficiency
• Muscular weakness
• Dancing on dead pointe shoes
• Dancing on hard flooring
• Increased dance intensity (Weiss, D)

COMMON FRACTURE SITES IN DANCERS

• Lumbar spine (pars interarticularis)
• Anterior tibia
• Distal fibula
• Forefoot (2nd metatarsal and cuneiforms) (Weiss, D)

POSSIBLE SIGNS/SYMPTOMS:

• Persistent pain
• Aching at night
• Bony tenderness
• Warmth
• Redness
• Swelling  
• Positive on imaging (MRI and/or bone scan) (Weiss, D)

​An acute fracture is typically not detected on x-ray. MRI and/or bone scan are preferred for detecting acute stress fractures.

REDUCING RISK
Rehabbing a stress fracture can involve complete rest for 6 to 10 weeks. It is important to recognize possible signs and risk factors to avoid bone damage.

• Avoid rapid increase in dance intensity
• Regulate pointe work and jumping intensity
• Avoid dancing on hard flooring
• Wear protective shoes inside and outside of dance
• Refer suspected dancers for nutritional consult to address restricted eating and vitamin deficiencies
• Work in correct alignment
• Improve flexibility, endurance, balance control, and strength (Delegate, A; Weiss, D)

References:
1) Delegete, A. Health Considerations for the Adolescent Dancer. A webinar through the Harkness Center for Dance Injuries. Accessed September 23, 2018.    
2)Weiss, David S. Stress Fractures in Dancers: Evaluation and Treatment. A webinar through the Harkness Center for Dance Injuries. Accessed November 11, 2018.    

Strength, precision, and artistry set you apart at an audition. Optimal nourishment and rest is important. Audition at your best by staying in peak shape with these helpful tips.

Before audition day:

1. Narrow down your list: Make an audition list based on your goals. Are you looking to participate in a summer program, improve your audition skills, or gain acceptance into a dance company?  
2. Address prior/current injuries: Don’t audition with an injury! This can lead to further injury and hinder your chances of being accepted.
3. Get adequate sleep: Sufficient sleep will allow you to focus during the audition and learn combinations quickly. Meal preparation: Bring adequate snacks to help fuel you before your audition.
4. Check audition day requirements: Be prepared with your resume, headshot, proper attire, and audition fee.
5. Arrive early: This will allow you to mentally prepare yourself and warm up properly.  
6. Refine your technique: Avoid skipping technique classes. Take daily technique classes to prepare. Focus on your alignment and stability to avoid overuse injury.
7. Increase your strength/endurance: Technique classes don’t always prepare you for dancing for extended periods. It is important to supplement with cardiovascular exercise and strength training to prepare for audition days (Koutedakis 2000).

Skills to focus on during your audition:

• Good technique (correct alignment, core stability)
• Musicality
• Ability to pick up combinations and understand corrections
• Artistry
• Positive attitude
• Avoiding injury during the audition season:
• Avoid more than one audition per day
• Plan local auditions if possible
• Don’t work through fatigue, illness, or injury; seek help if an injury occurs.
• REST! Muscle requires 12-24 hours of rest following intense levels of physical activity in order to heal and repair damaged tissue prior to additional workouts (Koutedakis 2000 & 2004).
• If possible, allow for full rest days in between auditions to avoid overuse injury.

References: 
Koutedakis, Y. (2000). " Burnout” in Dance: the physiological viewpoint.
Koutedakis, Y., & Jamurtas, A. (2004). The dancer as a performing athlete. Sports Medicine, 34(10), 651-661.

A dancer’s progression to pointe work is a much anticipated moment. It is completely normal to be excited about this milestone, but it is extremely important not to rush into pointe work. There are a variety of factors that need to be considered to ensure that a dancer is ready to sufficiently meet the demands of pointe work.

Criteria for pointe readiness based on expert recommendation:

1. Appropriate age  (at least 11 years old)
2. Minimum of 3 to 4 years of ballet training
3. Full plantar flexion range at the ankle (>90 degrees)
4. Adequate balance control
5. Good core stability and strength of the lower quarter  (Richardson 2017)                   

It is important to note that core strength and proximal hip control are better indicators of ankle stability than isolated foot/ankle strength. If a dancer has poor turnout control from the hip and inadequate core stability, the ankle is less stable en pointe,  thus placing the dancer at increased risk for injury (Bullock-Saxton 1994). According to research, the tests most predictive of readiness for pointe* are the airplane test, topple test, and saute test (Richardson 2010). These tests are an indication of the dancer’s neuromuscular control and skill set, which are more significant factors than isolated muscle strength (Richardson 2017).

What are the risks if I start too early? If the dancer begins pointe work without adequate range of motion and/or neuromuscular control, they can hinder proper technique development, foster bad habits, and potentially increase the amount of stress on the developing bones as well as the surrounding musculature. There is rapid bone growth and remodeling between the ages of 9-15 years old. During this time, growth plates are weaker than the surrounding bone, making them less resistant to different forces and more susceptible to injury. In addition, there are neuromuscular changes that occur as the dancer accommodates to rapid growth. The dancer takes time to adapt to changes in strength, flexibility, and proprioception, which ultimately influences motor control and performance en pointe. Therefore, chronological age cannot be a sole marker for pointe readiness (Richardson 2017, Shah 2009).
It is important to communicate with your ballet teacher regarding the progress of your technique and whether you meet the criteria to initiate pointe work. Health care professionals (MD, PTs) with a background in dance can assist in conducting pointe readiness screens.

​*Description of pointe readiness tests:

1. Airplane test: the body is pitched forward into a flat back arabesque with the leg at 90 degrees and the pelvis square to the ground. The dancer must bring the fingertips to the ground while performing a plie with the supporting leg. The dancer returns to the starting position and performs five plies total. The knee must track over the center of the foot, the pelvis must remain in neutral, the head/trunk remains stable, the foot does not pronate, and the dancer does not lose balance for four out of five attempts.
2. Topple test: pirouette en dehors from fourth position. Look for full releve, full passe height, straight supporting leg, vertical alignment, and controlled landing. The dancer must complete one successful turn out of two attempts.
3. Saute test: 16 single leg saute jumps without support. The dancer must keep the pelvis in neutral, keep the trunk upright, fully straighten the supporting leg, roll through the foot on the landing, and point the foot in the air for eight out of 16 repetitions (Richardson 2010).

References:
1) Richardson, M. Principles of Dance Medicine, Functional Tests to Assess Pointe Readiness. A webinar through the Harkness Center for Dance Injuries. Accessed Feb 23, 2017.
2)Bullock-Saxton, J. E., Janda, V., & Bullock, M. I. (1994). The influence of ankle sprain injury on muscle activation during hip extension. International journal of sports medicine, 15(06), 330-334.
3) Richardson, M., Liederbach, M., & Sandow, E. (2010). Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science, 14(3), 82-88.
4) Shah, S. (2009). Determining a young dancer's readiness for dancing on pointe. Current sports medicine reports, 8(6), 295-299.

Rest is essential for recovery and healing. It is a recommended to take a couple weeks off after a summer intensive. Adjustments in food intake should be made during these rest periods.  Typically, one week is not enough time for your metabolic rate to decrease or for lean mass to dissipate significantly. However, durations longer than one week can result in loss of muscle mass and fat gain if you're not supplementing with resistance training and/or adjusting calorie intake. Plan to make small, simple changes to account for the reduced calorie expenditure when you're not dancing. Be careful not to overcompensate with extreme calorie restriction.This is counterproductive and can cause muscle loss, illness, and injury when you begin training again.

What adjustments should be made to diet during the off-season?

• Continue to practice healthy nutrition habits as recommended during training.
• Slightly reduce portions of meals and snack sizes. Approximately 250 fewer calories per day are needed if your goal is to maintain your weight during your break. A larger reduction in calorie intake can lead to loss of muscle mass and should be avoided.
• Be aware of hidden and unhealthy fat in foods like salami, biscuits, pastries, sausage, and other processed meats. Some of these convenience foods that you might eat while training for hours a day become a serious problem when you are sedentary.
• Increase the proportion of vegetables in your meal and slightly reduce the starch or protein portions. Do NOT cut out entire food groups.
• Consume at least 2 cups of fruits and 2½ cups of vegetables a day.
• Don't skip meals and avoid fad diets (e.g., Paleo, detoxes, juicing).
• ​Drink at least 6 to 8 glasses of water each day. Have no more than 2 to 3 cups of caffeinated drinks a day. Be aware of calories from alcoholic beverages.

​Cross-Training During Off-Season
Rather than restricting calories during vacation or off-season, consider cross-training with cardio and resistance training. Low-impact, moderate-intensity cardio such as swimming or fast walking are excellent options to allow for extra calorie burning and promote muscle retention. Walking at ~3.8 to 4 miles per hour (3 to 4 miles/day) or swimming for 30 minutes at a moderate intensity are good options. Add light resistance training with weights, Pilates, or yoga while on a break from dance in order to maintain flexibility and promote muscle gain.
Enjoy your summer and remember that you deserve a break!

Dance is highly demanding and requires exceptional flexibility, balance, power, agility, coordination, and endurance. To properly execute movements, a dancer assumes positions that place excess stress on bones, muscles, tendons, and ligaments, thus leading to high injury rates. The injury incidence is reported to be as high as 5.6 per 1,000 dancing hours for pre-professional dancers, and 4.44 per 1,000 hours in a company of professional dancers (Allen et al, 2012). In comparison, the injury rate for elite gymnasts is 2.86 per 1,000 hours and 0.69 for novice gymnasts (Saluan et al, 2015).  Gymnasts have a higher percentage of traumatic injuries, whereas 75% of the injuries sustained in dance are related to overuse. Overuse injuries are caused by repetitive movements/stress which can lead to micro-injury of the tissue that is being loaded. If the injury rate exceeds the rate of healing/repair, the tissue can become damaged (Sephton, 1998).   

The majority of dancers are fatigued at the time an  injury occurs. This is because fatigue compromises muscle performance, coordination, joint stability, and neural feedback (Liederbach 2012). Overuse injuries tend to be more severe in nature and result in more dance time lost. Lower leg injuries are reported to be between 66 and 78% of the injuries, whereas foot/ankle injury comprises 14 to 57% of all injuries among dancers. Injuries sustained during class and performances are more severe than injuries that occur during rehearsals (Allen 2012).

Common risk factors for injury include:

• Delay of recognition
• Prior history of injury
• Premature return to dance before full recovery
• Lack of proper training
• High number of dance hours
• Insufficient warm-up prior to dancing
• Lack of shock absorption from improper shoe wear and hard flooring
• Nutritional deficiencies
• Biomechanical imbalances such as inadequate turnout, lack of core control, or weak lower body strength (Russell, 2013)

General principles for avoiding injury include:

• Increase aerobic capacity
• Plan for adequate warm-up and avoid over-stretching
• Improve technique
• Cross-train to help with muscle imbalance
• Know the signs of a potential injury and don’t resume dance until the injury is resolved
• Wear protective and adequate fitting shoe wear
• Establish rest periods
• Hydrate and eat a balanced diet (Allen, 2014)

The injury rate has been significantly reduced with medical management. Therefore it is essential to seek a healthcare professional with experience in dance if pain persists. Dr. Chris Koutures (http://www.dockoutures.com) provides very useful insight on signs that an injury may be developing in "Dance Discomfort: Deciding to Dial Up a Dance Medicine Specialist" (http://www.activekidmd.com/dancersdiscomfort/). Koutures has extensive experience in treating dancers and is an excellent resource for all dance-related injuries. ​

References:
1.Allen, N. Nevill, A. Ballet Injuries: Injury Incidence and Severity over 1 Year. Journal of Orthopaedic and Sports Physical Therapy. Vol 42, number 9, September 2012. 781-790.
2.Saluan, Paul et al. “Injury Types and Incidence Rates in Precollegiate Female Gymnasts: A 21-Year Experience at a Single Training Facility.” Orthopaedic Journal of Sports Medicine 3.4 (2015): 2325967115577596. PMC. Web. 4 Feb. 2018.
3.Sephton, Sharlene. "Foot Injuries in Dancers." ADVANCE for Physical Therapy and Rehab Medicine (1998) Web. 4 Feb. 2018.
4.Liederbach, Marijeanne. "Epidemiology of Injuries in Dance: Biopsychosocial Considerations." Principles of Dance Medicine: Clinical Management of the Dancer Patient. July 12, 2012, New York University Langone Medical Center. 2012. Print.
5. Russell, J. A. (2013). Preventing dance injuries: current perspectives. Open access journal of sports medicine, 4, 199.
6. Allen, N., Ribbans, W. J., Nevill, A. M., & Wyon, M. A. (2014). Musculoskeletal injuries in dance: a systematic review. Int J Phys Med Rehabil, 3(252), 2