A Comparison of Injury History Versus a Functional One Legged Squat and One Legged Hop

and Their Ability to Predict Injuries Over the Course of a Competitive Dance Season

Anastasia Engelsman

Doctor Leigh A. Roberts

Mary Jane Sasser

River Hill High School

 In the dance world, there is a major controversy of the most efficient way to predict

injury. Injuries can be predicted by observing flaws in the dancers alignment and proposing the

repetitive technique as a major cause of injury, or one can review the dancers past injury history

to then cite the injury as recurring due to improper rehabilitation. To narrow down these

predictive techniques, a screening and a past medical history will be analyzed to compare which

will be a better predictor.

A screening of a one legged squat and one legged hop will be a better predictor of injury

over the course of a competitive dance season than a past medical history. The one leg squat and

one leg hop can be analyzed to reveal patterns of weakness and improper neuromuscular control

that predispose the dancer to injury.

Injury rates among dancers are inordinately high. The mean amount of injuries in a

professional ballet company is 4.5 injuries for every 1,000 hours of dance (Allen 781). Even in

a high level company, data results expose just how common and prevalent injuries are in dancers.

From another experiment, Four fifths of the dancers reported having had at least one injury at

some time that had affected their dancing, and almost half reported that they were currently

suffering from at least one chronic injury that gave them continuing problems (Bowling 732).

As shown, chronic injuries may continue to plague the dancer throughout his or her career.

An injury for a dancer can be defined as any physical ailment causing loss of

performance or rehearsal time.

These ailments cannot only be costly to the dancer, but to the companies as well. An

injury may lead to a permanent disability and could possibly force the dancer to retire from his or

her career. Injuries also force professional companies to change their choreography due to the

constant change of availability of dancers. Despite the overwhelming consequences of an injury,

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dancers do not always listen to their health advisors. While most dancers realize it is not healthy

to push past their limits, expectations in the dance world runs high and many dancers do not heed

reason when roles are at stake (Rivera 12). This blindness towards serious matters only

increases the urgency and probability of receiving an injury.

Similar to other rigorous physical activities, there are certain factors that can produce injury.

Specific movements and alignments may expose the body to ailments while certain body regions

may be more susceptible to injury than others. Ailments can occur for a number of reasons,

ranging from self-inflicted to environmentally produced. These injuries inflicted on dancers are

typically intrinsic and overuse. The most common site of trauma is found in the lower

extremities.

Characteristics of injuries can be grouped into a few categories. One of these categories is

intrinsic and extrinsic factories. Intrinsic factors are a property of the individual human body

(Butulis 2). Intrinsic factors take into account bone density, skeletal alignment, flexibility,

muscular endurance, bone turnover rate, hormonal balance, and nutrition. Extrinsic factors are

the environment surrounding the individual (Butulis 1). This includes everything in the

surrounding environment except the individuals body. This encompasses dance surfaces,

footwear, training schedules, and load. The nature of extrinsic factors are crucial to a dancers

career. This is because the great number of repetitions found in dance can result in a tremendous

amount of strain on the body. Despite this, intrinsic factors account for the majority of factors

causing injuries. The reasoning for this is because outside forces are not typically strong enough

to inflict a career threatening injury.

The next classification of ailments are described as overuse and traumatic injuries. Overuse

injuries are much more common in dancers than traumatic injuries. This is because of the

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requirement for similar movement patterns and the repetition of those movements required to

perfect sequences for performance. Traumatic injuries from falls and collisions are rarely found

in dancers. In comparison to other rigorous activities, this minimal amount of traumatic injuries

may be because dance is not a contact sport. The strict, choreographed nature of dance leaves

little room for collisions to occur.

The last grouping of injury is the body region it is located. Due to the amount of force going

through the lower extremities, pressure is significantly higher here than anywhere else in the

body when performing dance movements. The result is a majority of injuries in the lumbar

region, knee, foot, and ankle. Another reason for this grouping of injuries is once again, because

of the recurrent motions in dance. Load and repetition can account for most dancer injuries and is

a recurrent theme when assessing the source of the injury.

Previous damage, a major issue, is one of the leading causes of injury. Once a trauma has

occurred, the injury site will be much more susceptible to future injury if proper rehabilitation

steps have not been taken. A relapse of injury may occur if the treatment was not finished or the

area was not given enough time to heal. Recovery time typically exceeds the dancers prediction

which may lead them to return to their normal activities before the injury is fully healed.

One reason for this may be because of avascular tissue. Tendons and ligaments lack an

efficient blood supply and can take a long time to recover versus a bone which will take a

quicker time to heal because of the good blood supply. As said by Mrs. Christin Lauer Good

blood supply allows bone to heal when injured as opposed to avascular tissue like cartilage

(PPT Lauer). This poses as a major issue in dancers as soft tissue damage accounts for the

majority of dancer injuries. For example, the some of the most common ailments include rotator

cuff tendinitis, low-back strain, snapping hip syndrome, achilles tendinitis, and ankle sprains

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(Wozny 1). All of these injuries pertain to the damage of soft tissues. Due to the long

rehabilitation period of soft tissues, a relapse of injury is fairly high.

Another important factor to keep in mind while assessing the cause of injury is if the site

is completely healed. A prior injury that was not completely healed may inflict stress on other

tissues due to compensation, causing injury. Until the ailment is fully healed, the tissue does not

have the same extensibility. The lack of extensibility in this context means that the site of injury

does not have the same degree of extension as it did prior to the injury. This lessened degree of

extension may then cause the area to be reinjured.

This review of re-injury is one way of predicting a future one. By making the health advisor

aware of any previous injury, he or she is able to take this into account when creating a program

for the patient. Even if the previous injury site is not the one causing pain, it is crucial to

maintain treatment to the area. Due to the inevitable atrophy as a result of injury, programs

designed to strengthen the injury site should be sustained. This continuation of treatment may

fully heal the area and could even prevent future injury.

Another tactic used to predict a future injury is a screening. A screening can be defined as

a series of tests designed to assess the overall well-being and functional capacity of dancers

(Potter 14). By evaluating a screening, the clinician can evaluate the malalignment and make

inferences from there. A screening of a functional squat and hop test have been shown to be

indicative of strength and neuromuscular control deficits and is the most efficient predictive

mechanism as it can expose malalignment in a dancers position ("Screening in a Dance Wellness

Program." 1). A dancers technique is crucial when evaluating for malalignment. Malalignment

exposed during the screening can be measured by the angles at the hip and knee during a

functional activity when comparing them to normal.

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 The presence of minimal malalignment is not threatening since the body is made to

withstand the wear and tear or daily activities. However, any malalignment can lead to a higher

potential of injury. Incorrect positioning can cause a cascade of problems for the body. When a

part of the body is misaligned, it can create an uneven distribution of stress on the joints.

Because everything in the body is connected, this can result in a dangerous rippling effect. For

example, malalignment at the knee joint can have an effect on the hip and foot while

malalignment at the hip can have an effect on the knee and the lumbar spine. These

misalignments can be easily shown once a dancer performs even the simplest movements. In the

case of the screenings being done on the Studio Dans Dance Company, the primary focus is the

alignment between the hips, knees, and feet. As stated by Bohdanna Zazulak, Proprioceptive

deficits in control of the bodys core may affect dynamic stability of the knee (Zazulak). By

identifying the incorrect placements of the body, one can then infer the end consequences.

Torsion, the twisting of a body part, is also an

indicator of malalignment. For example, If

abnormal limb torsion is also present, then the

lateral displacement force acting on the patella is

increased, and the ligament is more likely to fail

and allow lateral patellar instability (Alfonso). In

summary, a compensation in one area will create an array of similar issues to occur

throughout the body. Screenings will help to reveal any misalignments that could cause

an injury in the future.

These screenings can be multi purposed for revealing malalignment, patterns, and a

baseline. Exposing specific weaknesses and strengths during screening can allow quick

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identification of propensities. Screenings might indicate tendencies in a group (Potter 1). By

identifying regular patterns in a dance company, the clinician may be able to quickly design a

program to target the overall weaknesses and lessen the focus on the strengths. As a result,

design and treatment time is shortened. In addition to locating the technique flaws of a company,

screenings help in creating a starting point. When assessing a groups technique, it is important to

know the level in which they train. Screenings Provide a starting profile of the dancers baseline

physical, medical, and psychological status ("Screening in a Dance Wellness Program." 2). The

advantage of having a baseline better ables the evaluator to critic the dancers alignment and

propose an individualized program.

To thoroughly decide which tactic is best for predicting injury, an experimental study will be

conducted. The first step is to study dancer specific injuries. This will include what

characteristics are causing injuries, what are the best treatments for these injuries, and how we

can prevent them in the first place. The true focus is on a comparison between malalignment,

past medical history and their ability to predict injury. To start the experiment, permission slips

are developed, sent out and received to utilize the Studio Dans Dance Company as the subjects

for the experiment. This includes an overview of the experiment, permission slip, and past

medical injury history to the parents of the Studio Dans Dance Company. The next step is

receiving and reviewing the permission slips and medical histories of those given permission to

participate in the study. For the most important part, screenings are to be recorded of the dancers

performing 5 one legged squats and 5 one legged hops on both the right and left legs and to later

analyze for improper alignment during either of the tasks. Following this, will be the tracking

portion. Dancers injuries will be tracked over the course of the competitive dance season

(January - March). This will be done by sending a questionnaire to the teachers, parents, and

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students at the end of January. To determine if incorrect alignment or the dancers past medical

history is a better predictor of injury, the compiled data will be analyzed. The last step is to

propose an answer and present any findings and conclusions. This will be presented to the

dancers and director(s) of the Studio Dans Dance Company and River Hill Dance Company.

For the future, more research should be conducted on the consequences of malalignment in a

dancer's technique. Research on this topic will better help examiners to locate the source of an

injury and in turn, correct it for the future. Hopefully the dance medicine community will

establish a standardized method for recording technique. A personalized measurement for

technique, including turnout factors, will greatly help researchers as there will be a standardized

injury reporting to construct conclusions from. Advancements in this field of data collection may

decrease the rehabilitation time period and as a result, lessen the amount of lost performance and

rehearsal time. Although injuries will never cease to occur, a decrease in frequency and severity

will allow these artistic athletes to return to the stage.

Experiment Results

Key:
< = Angle

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Pelvis = Pelvis to Femur
Knee = Knee valgus

Screening Data

Screening Data of Active Angles - Original Resting Angle

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 Screenings revealed that the largest deviations occurred in the knee valgus angle rather

than the hip angle. It can also be observed that there was no significant difference between the

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right and left leg deviations. All resting pelvis to femur angles maintained scores within the

upper 70s to low 90s. The largest deviation was from the change in pelvis angle on the right leg

from resting to hop as it had an average of 11.03 degrees. The smallest deviation overall was the

change in knee angle on the right leg from resting to squat for it had an average of -0.9 degrees.

Injuries

During the course of the competition there was 9 total injuries. These included: osteitis

pubis, strain of the peroneus longus, unknown lumbar back pain, hip flexor tendinitis, unknown

ankle pain, pulled groin, strained lumbar spine, patellar tendinitis, and a strained left hamstring.

Three of these injuries were recurrent and or caused due to deficits from a previous

injury. These would be classified as re injury. The remaining 6 were newly created injuries not

caused by the dancers past medical history.

Discussion

Some of the patterns found from the screening were an increased valgus angle from

resting to hop, compensatory elevation or depression in the contralateral side of the pelvis,

flexion of the lumbar spine, and an internal tibia rotation which leads to a pronation of the foot.

By analyzing the updated medical history and the recorded screenings, it was found that those

receiving an injury did in fact have high angles of malalignment. However what made this

interesting is that dancers with the highest malalignment angles did not always result in an injury.

For example, a dancer presenting with the highest malalignment angle of -31 degrees has never

received an injury before.

After receiving all the updated medical histories and then comparing them to the past

medical histories, it was found that the past medical histories were a predictive tool. There was 3

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recorded cases of re-injury or related injury. This means that the injury either re occurred or was

caused due to deficits from a previous injury.

However, because the remaining 6 injuries were not caused by a past injury but instead

by repetitive incorrect technique, the screenings prove themselves to be a better predictor of

injury. Screenings show to the clinician any malalignments in a dancer's technique. These small

incorrect placements may cause an uneven distribution of stress on the joints. Due to the fact that

tissues can only work at certain lengths, straining the tissues may cause injury. As a result,

screenings expose malalignment and in a way, foreshadow injury.

Regarding this experiment, some issues to resolve in the future are those regarding the

video. There was numerous flaws with the videotaping. First, a dot on the ankle in addition to the

hip and patella would result in a more precise measurement. Next, another dot should be added

on the floor so that the dancers better maintain their positioning in front of the camera. Lastlty, a

more exact front view of the camera should be considered because if the viewing was from the

side, angles would result in a false valgus or varus measurement

Conclusion

In conclusion, it can be said that both a medical history and a screening are a better

predictor of injury. Because both were successful in predicting alignment, both should be

considered a reliable source for predicting injury. However, the screening proves itself to be a

more accurate and versatile data collection method as it predicted 6 cases of injury. The

screening should not only be used as a tool for predicting injury but as a way to locate

malalignment in a dancers technique.

With a career on the line, it is a necessity for a dancers body to be functioning correctly.

An injury restricts and may threaten a dancer's education career for the rest of their lives. More

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advancements regarding a standardized recording technique and tools for predicting injuries

should be taken in order to achieve progress in the dance medicine world. With the ever growing

field of dancer rehabilitation, it is possible to create a reliable and accurate method for predicting

injuries. Development within this field may decrease the amount of injuries occurring in dancers

and may reduce the rehabilitation time period.

Works Cited

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Alfonso, Vicente Sanchis, MD, PhD. "How to Deal With Chronic Patellar Instability: What does the
Literature Tell Us?" Sports Health, vol. 8, no. 1, Jan.-Feb. 2016.

Allen, Nick, PT, MSc, et al. "Ballet Injuries: Injury Incidence and Severity Over 1 Year." Journal of
Orthopedic & Sports Physical Therapy, vol. 42, no. 9, Sept. 2016.

Bowling, Ann, PHD. "Injuries to Dancers: Prevalence, Treatment, and Perceptions of Causes."
British Medicine Journal, vol. 298, 18 Mar. 1989.

Butulis, Meredith, DPT, ACSM HFS. "Caring for Bone Injury Demystified." Journal of Dance
Medicine and Science, 27 June 2016, www.iadms.org/ blogpost/1177934/250811/

Lauer, Christin. "Anatomy." River Hill High School, 7 Dec. 2016, Clarksville. Lecture.

Potter, Karen, et al. "Screening in a Dance Wellness Program." International Association of Dance
Medicine and Science, Nov. 2008.

Rivera, Debra C., et al. "Dancers' Perception of Injuries." Journal of Music and Dance, vol. 2, no. 1,
3 Nov. 2011, www.academicjournals.org/journal/JMD/ article-full-text-pdf/0C2FA987818.

"Screening in a Dance Wellness Program." International Association of Dance

Medicine and Science, Nov. 2008.

Zazulak, Bohdanna T. "The Effects of Core Proprioception on Knee Injury." The American Journal
of Sports Medicine, vol. 35, no. 3, Mar. 2007.

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