1. Conditioning protocols based on injury types in a professional ballet company: a case study and workshop
David Outevsky MSc, PhD (candidate)
Tanya Berg MA, PhD.

2. Background Research on injuries in professional ballet dancers
Research on conditioning for DanceSport
Work as part of the health team for a professional ballet company
Dancers asked for a remedial program inspired by dance science

3. Procedures Screening: Dancer Wellness Project (DWP).
In section 1, we took participants health history and demographic information.
In section 2, we conducted a physical assessment of aerobic capacity, hypermobility, ROM, strength, functional movement, balance, and alignment
We thank the Dance/USA Task force on Dancer Health for the development of the Annual Post-Hire Health Screen for Professional Dancers and/or the standardized system for reporting injury.

4. Conditioning Program Remedial program:
Based on analysis of each dancer’s weaknesses and injuries and relevant research, each dancer was provided with an individualized remedial conditioning program to be followed during the performance season.
The use of C-I Training was instrumental in the development of the conditioning protocols as David is a certified trainer.

5. Summary of Results Common issues: Remedial exercises:
Alignment and balance issues, especially in tests done in parallel (6th pos.). Several have also exhibited symptoms of hypermobility, spinal misalignments, as well as low strength and proprioception capabilities.
Remedial exercises:
Rooted in endurance, aerobic, and alignment conditioning for dance and athletics. See following chart.

6. Pre-Season Screening (weakest results)
Name
Step
0=ex.
Beighton
Adams
PROM
Strength
Balance
Step Down
Sara
Score 4
L Thoracic
Dec IR hips
feet 3/5
R/L 9
F/F
Holly 5 -
hips, FHL
5/5
L 12; R 13
Emma
L hip;
R hip IR; FHL
GM 3/5;
L Foot
L 29; R41
P/P
Sally
1-good
L lumbar
(pain w ext)
L IR
w pain in supine lie
Abd 4
GM 3 or 4
feet3L; 4R
L 5; R 10
Ken 9
L 110; R 120
Abd 3
GM 3
L ER 3
foot L4;
R 3
L 60;
R 60
Leo
3- average 3
L/R hip IR
L/R HS
GM 4/3
R weaker
L 60; R 9

7. Remedial exercises chart *discussed during workshop
TEST
WEAKEST RESULT
EXERCISES FOR WEAKEST RESULT
*3 Minutes Step Test
Score: 3 (average)
Cardiovascular conditioning
*Beighton Hypermobility Test
Score: 9
Specific strengthening/alignment
Adams
L Lumbar (pain with extension)
Turned out alternating leg lifts
Arabesque exercise prone
Sitting with folded leg stretch
Progress to second position
PROM
R/L Hip IR
R/L HS
Pretzel
Over-crossed passé
Hamstrings with legs across
*Strength: Gluteus Medius
Score: 3/5
Outer leg lifts
Sitting or lying double leg hip abduction (snow angels)
*Strength: Intrinsic Foot
Points and Squeezy Flexes
U shapes for ankles
Balance
L 5; R10
Proprioception exercises
*Step Down
F/F
Parallel pliés

8. Discussion
The reason for screening (potential injury prevention, systematic/accessible knowledge base for institutions)
The values of conditioning (potential preventative measures, easily applied and understood, shown to improve performance)
Value to the teacher, more informed student (teacher can structure lessons based on results, use conditioning tools in the classroom/ student can be more mindful about his/her limitations and better prepared for dance)

9. Tests For Practical Demonstration
Step Down Test
Beighton Hypermobility Test
Strength
a) Gluteus Medius
b) Intrinsic Foot Strength
3 Minute Step Test

10. 1) Step Down Test

11. 1) Step Down: Exercises for Dynamic Hip Alignment
Basic Exercise for “Fail”:
Plié in parallel (paying attention to alignment of knees), progress to one leg
add relevé.
Can be done lying down
Barre maybe used but gradually eliminated.
Progressions:
Leg can be extended to a tendu en croix during each plié.
If bossu half ball is available, repeat the above on the middle of the ball, then turn the ball over and do the same.

12. 1) Step Down: Result in relation to ballet specific training
The turnout required in ballet results in imbalances between in/out rotators and medial vs lateral flexors /extensors.
Tightness in outward rotators is a potential cause of sciatica
Lack of alignment during jump landings has potential to cause injuries
Balancing both groups by conditioning can improve these parameters
If trunk or pelvis misalignments are observed, core support issues might be present

13. 2) Beighton Hypermobility Test

14. 2) Beighton Hypermobility Test
Advice for weakest result:
control hyperextend knees/elbows (esp. weight bearing)
Strengthen supporting musculature
Do not work in ‘overstretch’ during flexibility training

15. 2) Beighton Hypermobility Test
Ballet specific training:
Hypermobility is a common selective characteristic for ballet, often resulting in a need for more strength conditioning rather than stretching, as well as a comprehensive understanding of proper alignment to avoid injury
The hyperextended knee position has the potential to create further postural misalignment that can be problematic for the dancer (e.g. lordosis)
If choosing to use hyperextension while weight-bearing, the dancers must be aware of the risks
Hyperextended position of the knees requires a flexion action to ‘unlock’ which slows down the reaction during landing from jumps and can potentially cause injury

16. 3) a) Strength: Gluteus Medius

17. 3)a) Strength: Gluteus Medius
Exercises for weakest result:
Outer leg lifts
Sitting or Lying double leg hip abduction (snow angels)
Progressions:
Use elastics and/or low weight for resistance

18. 3)a) Strength: Gluteus Medius
Ballet specific training: Hip
Hip abductors help the dancer balance on one leg
Constant low grade contraction creates inelasticity
Dancers often have tightness and weakness in this muscle group
Can cause ‘lateral snapping hip’ and contribute to risk of arthritis in the aging dancer
Stretching and strengthening is recommended to remedy problems associated with the above issues

19. 3)b) Strength: Intrinsic foot

20. 3)b) Strength: Intrinsic foot
Exercises for weakest result:
Points and Squeezy Flexes
U shapes for ankles
Progressions:
Use of elastics/pushing against resistance

21. 3)b) Strength: Intrinsic foot
Ballet specific training:
Pointe work and constant plantar flexion with ‘gripping of toes’ causes tightness in foot intrinsics at the MTP joint inhibiting the range of IP extension (‘toe spreading’)
Weak/ tight foot intrinsic muscles can cause cramps especially after a break
Tightness in the foot intrinsics decreases balance on demi pointe and therefore increases potential for injury
Working in full ROM can help

22. 4) 3 Minute Step Test

23. 4) 3 Minute Step Test Recommendations for weakest result:
Sept. to Apr. Aerobic conditioning 30min 1-2 times a week, can be dance specific or cross training 60-85% HRmax or around on Borg scale (depending on her age). Begin with dancer almost unable to complete, then increase intensity as the cardiovascular capacities improve.
Progressions:
Apr. 21 – June 21 reduce training and conditioning: continue at own pace for maintenance.
June 21- Aug. 21 increase the volume to 3 times per week, keep increasing intensity with improvement in cardiovascular capacity.
Aug. 21 – Sept. 15, same as Apr. 21- June 21.

24. 4) 3 Minute Step Test Ballet specific training:
The interval based nature of traditional ballet training provides more anaerobic than aerobic conditioning
Longer performances and training hours can tax the cardiovascular system and fatigue the dancers, creating potential for injury
Regular aerobic training can improve the dancers’ cardiovascular capacities

25. Conclusion Purpose of Screening Benefits and logic of conditioning
The educators role in dancer health
Collaborating with health practitioners
Future directions in research: further screenings, dancers’ understanding of kinesiology, practical application

26. References
Bompa, T., and Haff, G. (2009). Periodisation: theory and methodology of training. Champaign (Ill), Human Kinetics.
Fitt, S. S. (1996). Dance kinesiology (2nd ed.). New York : London: Schirmer Books.
Gomboa, M., Roberts, L.A., Maring, J., and Ferus, A. (2008). Injury patterns in Elite Preprofessional Ballet Dancers and the utility of screening programs to identify risk characteristics. Journal of Orthopaedic & Sports Physical Therapy, 38(3),
Harrison C., and Ruddock Hudson M. (2017). Perceptions of pain, injury, and transition-retirement: The experiences of professional dancers. Journal of Dance Medicine and Science, 21(2),

27. Kotler et al. (2017). Dancers’ perceived and actual knowledge of anatomy. Journal of Dance Medicine and Science, 21(2),
Krasnow, D., and Deveau, J. (2011). Conditioning with imagery for dancers. Toronto: Thompson Educational Publishing.
Krasnow D.H., Chatfield S.J., Barr S., Jenson J.L., Dufek J.S. (1997). Imagery and Conditioning Practices for Dancers. Dance Research Journal, 29(1),
Negus, V., Hopper, D., and Briffa, N.K. (2005) Associations between turnout and lower extremity injuries in classical ballet dancers. Journal of Orthopaedic & Sports Physical Therapy, 35(5),

28. Outevsky D. , and Martin B. (Dec. 2015)
Outevsky D., and Martin B. (Dec. 2015). Conditioning for DanceSport: Lessons from Gymnastics, Figure Skating, and Concert Dance Literature. Medical Problems of Performing Artists, 30(4),
Rafferty S. (2010). Considerations for integrating fitness into dance training. Journal of Dance Medicine and Science. 14(2),
Smith T.O., Davis L., de Medici A., Hakim A., and Haddad F. (2016) Prevalence and profile of muscularskeletal injuries in ballet dancers: A systematic review and meta-analysis. Physical Therapy in Sport. 19,

29. Smol E., Fredyk A. (2012). Supplementary low- intensity aerobic training improves aerobic capacity and does not affect psychomotor performance in professional female ballet dancers. J Hum Kinet. 31,
Wyon M. (2010). Preparing to perform periodization and dance. Journal of Dance Medicine & Science. 14(2),
Yau R. et al. (2017) Potential predictors of injury among pre-professional ballet and contemporary dancers. Journal of Dance Medicine and Science, 21(2),