March 2020

Unique partnership between University Hospitals’ Sports Medicine Team and the Cleveland Ballet focuses on performer preparation to avoid long-term problems.

By Douglas J. Guth

Efficient movement in ballet is easy to recognize, as every step the dancer takes flows seamlessly into the next, representing a perfect balance of muscular engagement and release.

Anyone around ballet, however, knows the art form’s outward beauty can overshadow the stress it puts on the body, particularly the lower extremities. Just utilizing a common en pointe technique–where a performer’s feet are completely extended and supporting her body weight–can cause foot, shin, and ankle pain, leading to injury and even long-term damage.

A recently inked partnership in Cleveland, Ohio, between the University Hospitals’ (UH) Sports Medicine team and the Cleveland Ballet provides an innovative approach to reduce injury and drive peak performance in dancers. Launched in the summer of 2019, the endeavor focuses on long-term injury prevention to make foot stress fractures, hip arthroscopies, and other conditions related to dance less of a common occurrence.

“It was so important for us to create a program that takes care of the body as a tool,” said Gladisa Guadalupe, artistic director of the Cleveland Ballet. “It’s about preventing injuries in an art form we need to think about as a sport because of the wear and tear and all the repetitive movements dancers are doing.”

Led by James Voos, MD, an orthopedic surgeon and head of the Sports Medicine team, the project presents the same preventative services to dancers the hospital system already offers as medical provider for 2 of the city’s professional sports teams, the Cleveland Browns (National Football League) and Cleveland Monsters (American Hockey League). To that end, the partnership takes a 3-pronged approach to dancer care, integrating performer evaluations, wellness initiatives, and injury prevention techniques.

“We want to keep all of our athletes healthy for the length of their careers and beyond,” said Voss. “Most ballerinas are done professionally in their 30s, so we look at them the same as gymnasts and others whose careers peak at a young age. The challenge is to keep them dancing not only as professionals, but as something they can enjoy for the rest of their lives.”

The Rigors of Training

2019–2020 marks the first season the ballet is working with UH, with an understanding from both sides that while it takes months to rehearse for a production, it takes years for dancers to train their bodies for ballet. UH clinicians caring for the Cleveland Ballet’s dancers bring expertise in a spectrum of specialties, including sports health, nutrition, foot and ankle care, and hip arthroscopy and cartilage restoration. Although it may not be obvious to most observers, ballet dancers suffer the same musculoskeletal, hip, patella, and ankle injuries that sideline other athletes.

“Ballet requires a significant amount of physical prowess and athleticism that delivers the same acrobatics and agility displayed by other professional athletes. Their preparation is really quite similar in intensity and difficulty,” said Michael Krasnyansky, president and CEO of the Cleveland Ballet, when announcing the partnership. “Professional dancers put in just as many hours training and practicing.”

As an ex-performer herself, UH dance rehabilitation specialist Anna Cerveny PT, DPT, understands the rigors of daily ballet training, when a typical dancer might execute 200 jumps per class. Repetitive movements can result in chronic overuse injuries, typically tendonitis of the Achilles or flexor hallucis longus (FHL), which effects the FHL tendon originating from the calf muscle and coursing along the instep of the ankle and foot.

“Those tendons are used in pointing the foot over and over again,” said Cerveny. “Plus you’re using the same muscles when you go to jump.”

Shana Miskovsky , MD, a UH orthopedic sports medicine and foot and ankle specialist, said cumulative stress from constant pushing off and landing often leads to tendonitis among performers. Continued loading of the tendon above what it can sustain may then result in tendinopathy, where scar tissue and bone deposits form in the tendon. With tendinopathy, the tendon loses flexibility, putting dancers at risk of recurrent tendonitis, partial tearing, and even rupture. Damage over time can also lead to muscle weakness, affecting foot balance, pushoff strength, and leg endurance.

“The tendons involved particularly in dance injuries are the Achilles tendon, posterior tibial tendon, and flexor hallucis longus,” said Miskovsky. “We would like to catch tendonitis early with treatment and activity modification to allow tendons to heal properly before onset of tendinopathy.”

Additionally, while female ballet dancers who dance on tiptoes (en pointe) have an extreme range of motion in their plantar flexors, constantly putting weight on the toes can contribute to a variety of ankle impingements. Repetitive plantarflexion movements–specifically the en pointe and ankle plantarflexed position–may cause pinching of the talus between the tibia and calcaneus.

Dancers with an os trigonum–an extra bone attached by partial bone bridging or fibrous tissue to the talus–face their own unique problems, noted Miskovsky. With repetitive plantarflexion, the connecting bone or tissue is disrupted, causing impingement due to abnormal motion of the extra bone fragment.

Pointe shoes worn by classical ballet dancers don’t provide the necessary cushion for powerful dance movements, Miskovsky said. The tips of the shoes are made from layers of densely packed fabric supported by cardboard or hardened paper. Dancers sometimes place lamb’s wool or other soft material in the shoe, increasing comfort ideally bolstered by the strength they’ve developed in their legs, feet, and ankles from years of training.

“Ballet dancers go barefoot or have footwear with minimal shock absorption,” said Miskovsky. “In some ways they’re more challenging to take care of than traditional athletes, because performances, aesthetics, and routines all can vary. The public doesn’t see dancers struggle because they’re so good. It’s the strength in their core, body control, and posture.”

Offer Preventative Measures

As official medical provider for the Cleveland Ballet, Voos and his team put together a preventative program that begins with a comprehensive screening of each performer. The Cleveland Ballet consists of 25 dancers–as well as 4 artists-in-residence and 7 trainees–hailing from the U.S., Cuba, Puerto Rico, Japan, Columbia, Brazil, China, Belgium, France, and Italy. Per partnership parameters, UH clinicians evaluated the movement and flexibility of every performer at the start of the 2019–2020 season.

During her first days on site, UH’s Cerveny observed dancer movement patterns for the kind of overuse injuries she’d seen as a physical therapist working with Broadway shows in New York. Cerveny and her colleagues assessed the strength of the dancers’ muscle groups in plié, an essential dance technique that acts as a springboard for many jumps and turns. A correct and functional plié is also necessary for smooth transitions between movements, helping provide proper cushioning for dancers when landing from jumps.

As ballet places high stress on the dancer’s body and influences mobility of the lower limb joints, UH therapists concentrate on gait patterns, Cerveny noted.

In plié, a performer bends at the knees, with the movement often seen before and after more advanced steps to help load the muscles or absorb the shock. Dancers in the Cleveland Ballet are tested for this movement alongside takeoffs and landings on jumps. UH also analyzes trunk control and lower extremity alignment in the airplane position, where a dancer stands on one leg with their arms in a horizontal position. Participants who demonstrate, for example, a pelvic drop or foot pronation may receive additional training that counterbalances what they’re learning in rehearsal.

“If someone’s hip is clicking, that’s not an injury, but we’ll evaluate what we think is going on, as it might just be an imbalance where they’re not rotating their hips enough,” said Cerveny. “Often dancers are running the same pieces over and over, and so they’re working the same muscles on one side and not the other. We’ll send them home with an exercise that uses opposing muscles to give overused muscles a break.”

The program works with younger trainees who may not be as mindful of body upkeep as their older colleagues. Therapists use injury prevention modalities–from deep-tissue manual therapies to various stretching techniques–and monitor menstruation cycles among the female dancers for signs of early bone loss. Though UH doesn’t have an official gait-testing lab, program officials do look closely at balance and flexibility.

“We were seeing a void in the care of these athletes,” said Voos. “It’s about raising awareness for preventative care, and ballet is a great place to start. For a dancer’s balance and flexibility, we want to find out if one leg is stronger than the other. We’ll look at asymmetries from side-to-side. Then if someone has chronic ankle sprains or other problems, we’ll see what we can do to prevent those imbalances.”

Heat of the Moment

The truly unique aspect of the partnership is that while an ounce of injury prevention may be worth a pound of cure, Voos’ team is ready to treat performers “in the moment” should the need arise.

At showings of holiday favorite The Nutcracker at Cleveland’s historic Hanna Theatre, UH therapists were on-site to assess and treat any untimely sprain or strain. Stretching, icing, and various muscle activation techniques are all in play mid-performance, just as if a member of the Browns came to the sideline with a rolled ankle or sore hamstring during a game.

Miskovsky, the UH foot and ankle specialist, said a simple resistance band can be utilized between numbers to work out muscle tightness.

“Dancers can wrap a band on their foot and do controlled high kick movement, which is just like dynamic stretching, but they’re also working out the muscle,” Miskovsky said. “They can bend their knee slightly and increase stress by pulling the band tighter, and use controlled up-and-down movements.”

On-site tweaks may require soft-tissue mobilization via an intervention like the Graston Technique, a form of manual therapy harnessing stainless steel tools to find and release adhesions in the muscles.

UH does not recommend orthotics for performances. While the device can assist in creating a more optimal loading pattern for the foot during a dance routine, it’s not going to fit in a pointe shoe or ballet slipper. Braces are a no-go, too, as they impractically limit motion in performers. But dancers who require them for everyday use are actively encouraged to use them accordingly.

Taping an affected area has its own limits, given that a swatch of tape on an ankle is going to stand out at showtime. Leukotape is discreetly skin toned, but may be too constrictive for use on a regular basis.

“Instead of a knee brace, we’ll use different modalities to see if it’s safe for a dancer to perform, or if they need to get an injury treated,” said Voos. “Our artists are tough; they have a desire to perform through significant injuries. Our job is to make sure the dancers are able to perform at a level they’re safe and comfortable with.”

Toward a Healthy Future

UH’s partnership with the Cleveland Ballet continues to flourish, with easy access to treatment the most notable outcome so far, observed Voos.

“For me, that’s the No. 1 item that shows we’re doing the right thing,” he said. “The dancers love having a therapist here [at rehearsals and performances]. If they have an injury, they know it’s going to be acknowledged and addressed.”

Having a team of experts on call motivates dancers to speak up about potential problems early on, rather than riding out discomfort that might later turn into a serious injury. The expense of outside physical therapy is another deterrent performers no longer have to worry about.

“There’s a stigma to being injured; it’s not something dancers want to admit because they might lose their role,” said Cerveny. “Our program is giving them peace of mind.”

Elias Re, who performed during the recent run of The Nutcracker, has changed his pre-show routine thanks to UH interventions. With help from a backstage physical therapist, Re stretches his ankle with a resistance band, or gets a muscle-activating massage.

“It helped me when I was having a problem with my shin,” Re said of the program. “I was taking Advil all the time. Now I’m doing these exercises regularly.”

The collaboration’s strong start doesn’t exclude it from ongoing improvement. Voos said an examination of the internal and external forces, aka the biomechanics, affecting a dancer could play a future role in the program. Using special software, UH therapists could study symmetry and range of motion, ostensibly giving dancers more opportunities to receive preventative care.

Nutrition and sleep management are growing facets of the UH screening process. According to Miskovsky, a key to dancer self-care is taking time out to eat, be it small snacks or regular meals in the “golden hour” after training when muscles absorb nutrients and glycogen is replaced most efficiently.

“We’ll identify any issues and have performers follow up with an x-ray, a nutritionist, or our sleep medicine department,” said Miskovsky. “If pain starts to develop, the dancer can contact one of our care coordinators to get them to the right person for evaluation and treatment.”

Ultimately, treating dancers as athletes will change the paradigm within dance culture where injury prevention has a real chance to lengthen careers, said the Cleveland Ballet director Guadalupe.

“Our measure of success is providing artists the tools to understand their limitations and assets, and prolong their time in this art form,” Guadalupe said. “We’re in the baby steps right now, but we’ve hit the ground running because of the knowledge Dr. Voos and his staff have brought to us.”

Douglas Guth is a freelance writer in Cleveland, Ohio.