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Muscular Strength: Applications for Dancers

Yiannis Koutedakis, PhD, Frances Clarke, BA, Matt Wyon, PhD, Danielle Aways, MSc,
Emmanuel O. Owolabi, PhD
Muscle fibers can generally be divided into slow and fast twitch
according to their contraction speed. Even though an individual
normally has the same ratio of slow/fast muscle fibers throughout
his or her body, the lower-limb muscles are predominantly designed
to provide the maximum dynamic output in rapid movements (e.g.,
jumping). The limited data on dancers muscle profiles have shown
that (ballet) dancers have predominately slow fibers. Muscular
strength, together with aerobic and anaerobic capacity, joint mobility and muscle flexibility, and body composition form the continuum of physical fitness. Strength is defined as the maximum force
that a muscle group can generate at a specified velocity; its levels can
be affected by several factors. which include age, gender, type of
muscle fiber, nutrition, and body temperature. There is no scientific
evidence suggesting that different strength training regimens should
be employed for the different styles of dance. However, reduced
muscular strength has been associated with greater severity of injury
in dancers. Poor aerobic capabilities, high ectomorphy ratings with
low percent body fat values, and the biomechanics of different
dance techniques have also been identified as underlying sources of
injury in dancers. The most common location for injury in ballet
dancers is the foot and the ankle, while in contemporary dancers it
is the low back and knee. Little information is available with respect
to other dance styles. Med Probl Perform Art 2009; 24:157165.

ancewith its three main genres classical, modern/contemporary, and folkmay be defined as a cognizant
effort to create visual designs in space by using the endless
movement capabilities of the human body in synchrony to a
particular rhythm. Given the complexity of the mental, physical, and artistic abilities needed, only a small number of
aspiring dancers eventually meet the strict requirements of
established selection procedures to reach the level of professional dancer.
Muscular strength, along with aerobic and anaerobic
capacity, power, joint mobilitymuscle flexibility, body composition, and body balance, mainly constitute what we understand as physical fitness. Without adequate physical fitness,

Prof. Koutedakis is at the School of Sport, Performing Arts and Leisure,

Wolverhampton University, UK, and the Department of Sport & Exercise
Sciences, Thessaly University, Greece; Ms. Clark, Dr. Wyon, and Ms.
Aways are at the School of Sport, Performing Arts and Leisure, Wolverhampton University, UK; and Prof. Owolabi is at the Department of Physical Education, Health & Recreation, University of Botswana, Gaborone,
Address correspondence to: Prof. Yiannis Koutedakis, Department of Sport
and Exercise Science, Thessaly University, 42100 Trikala, Greece. Tel/fax
+30-2431-047056; email

most humans would be unable to properly work, study, participate in sports, and, of course, dance.1
Since the centuries of classical Greece, muscular strength
has been perhaps the most desired body characteristic and the
epitome of the healthy bodyhealthy mind philosophical
approach. This has been depicted by many artists in a number
of the worlds greatest statues (Discobolos by Myron, Hermes by
Praxitelis), poems (the description of Achilles and Patroclus in
Homers the Iliad), and paintings (The Creation of Adam or
David and Goliath, by Michelangelo, in the Sistine Chapel,
Rome), to mention just a few examples. Strength training in
particular was the first known exercise regime that was used
for preparing athletes for the ancient Olympic Games, while
Hippocrates, the father of medicine, explained the main principle behind strength training when he wrote that what is
used develops, and that what is not used wastes away, referring to muscular hypertrophy and atrophy, respectively.
The arrival of Christianity and the Dark Ages which followed resulted in a dramatic change of this ancient tradition,
where the body suddenly became the souls poor carrier.
Strength and strength training as a practice were resurrected
only in the middle last century by practitioners who advocated
that exercise resistance must be periodically increased in order
to achieve performance-related bodily improvements.
Most movements of the human body and inside it are the
results of a remarkable contraction-relaxation cycle executed
by muscle fibers. From laughing and swallowing to playing
music, lifting weights, jumping, and dancing, these are all carried out by such muscle action. This article will cover elements of muscle strength in relation to dance.


Physical fitness may be defined as the individuals ability to
meet the demands of a specific physical task. Its components
include aerobic and anaerobic capacity, muscular strength/
power, joint mobility and muscle flexibility, and body composition.1 Although poor levels of physical fitness, particularly low aerobic7 and strength8 levels, have been generally
associated with injuries in dancers, available data indicate
that certain forms of dance elicit only limited stimuli for fitness enhancement911 and that dancers in general are not as
well conditioned as equivalent athletes.1214 Published data
have repeatedly indicated lower strength values in dancers
than other athletes15,16 and even untrained individuals.1 No
December 2009 157


Human muscle consists of many hundreds, thousands, or millions of muscle cells. Because in skeletal muscle these cells are
very long and thin, muscle cells are often referred to as muscle
fibers. They are capable of causing large variations in force
(defined as an influence that operates on the body in such a
manner as to produce an alteration in its state of rest or
motion), speed, power (defined as the rate at which work is performed or the amount of energy required or expended for a
given unit of time), and range of movement. In dancers, skeletal
muscle accounts for 38 to 45% of body weight.
The French physician Louis-Antoine Ranvier (1835-1922) in
1873 was the first to recognize that skeletal muscles not only
differ in color but also have different contractile properties.
Muscle fibers can generally be divided into slow and fast twitch
according to their contraction speed. Slow twitch fibers are
fatigue resistant and can produce relatively low-level, long-lasting
force; they are used in everyday activities and during activities
requiring low power outputs. In contrast, fast twitch fibers are
fatigue sensitive and are suited for intermittent and high force
productions, such as lifting and jumping. It should be noted
that when a muscle is used, it is always a mixture of fast and slow
twitch fibers that is involved.
Men and women have genetically determined mixtures of fast
and slow fibers determined. Most people have around a 50:50
ratio of fast to slow. However, gifted individuals may have a
muscle profile that is significantly different. For example, great
sprinters have up to 90% of their muscle cells fast, while successful marathon runners may have over 90% of their muscle cells
slow. The limited data on dancers muscle profiles have shown
that (ballet) dancers have predominately slow fibers.2 No training
or teaching method can alter the genetically determined mixtures
of fast and slow fibers, although some metabolic change may be
possible (e.g., making fast fibers more fatigue resistance).
In general, about 3 kg of force are produced per cm2 of
muscle area in both men and women. This implies that the gastrocnemius muscle can exert a tension of over 250 kg, and the
gluteus maximus can develop up to 1200 kg. All the skeletal
muscles together could, in theory, produce a tension of around
20,000 kg.1
Body skeletal muscle is under the voluntary control of motor
nerves from the spinal cord, which in turn is an extension from
the brain. As a result, skeletal muscle fibers are organized into

significant differences have been detected in the quadriceps

and hamstring peak torque between ballet and contemporary
dance students and professional dancers.17 Ballerinas have
the least muscular strength, demonstrating only 77% of the
weight-predicted strength-norms.18
The fact that strength has not generally been considered
as a necessary part in dance may partly reflect the subjective
view that strength and strength training would harm dancers
aesthetic appearance. Contrary to this view, available data on
male19 and female20 ballet dancers have revealed that supplemental resistance training can demonstrate muscular
strength enhancements without interfering with key appearance requirements. This notion has been supported by more
recent data, which showed that an 8-week strength training

Medical Problems of Performing Artists

motor units, which are varying sized groups of muscle fibers all
supplied with electrical impulses from a single motor neuron. A
single impulse originating in a motor neuron passes down the
axonal branches and stimulates all of the muscle fibers at virtually the same moment, generating a synchronous action potential in all the fibers.3
The number of muscle fibers in a motor unit may be as low
as 10 in a small muscle in the finger, to several thousand in a
large muscle such as the hamstrings. Motor units can be large,
fast, and fatigable at one end of a spectrum, and small, slow, and
endurant at the other. Slow fibers are organized into relatively
small motor units, which provide a better measure of fine control. So, if accuracy in a dance movement is required, it should
be executed as slowly as reasonably possible, particularly during
the initial learning stages.
However, what primarily makes a motor unit fast or slow is
not the genetic coding of the muscle fibers themselves but their
capacity to process electrical impulses. Fast nerves tend to transmit their impulses at a rate of about 40 Hz (i.e., 40
impulses/sec), while slow nerves operate at a rate of around 10
Hz. Aging causes fast fibers to lose their nerve connections and
subsequently re-innervated with slow nerve from neighboring
slow fibers. As a result, during aging muscle loses power more
quickly than force, at a rate of 3.5% compared to 1.8% per year,
Speed in muscle movements is probably based on much
more than simply having a fairly high proportion of fast fibers
and fast motor units. For a successful jump, for example, virtually all fibers must be recruited in the smallest window of time
and the closest possible synchrony of contraction. This has
implications for strength training; loading needs to be heavy in
order to enable recruitment through the entire fiber bed.
Even though an individual normally has the same slow/fast
muscle fiber ratio throughout his or her body, it has been
hypothesized that the lower-limb muscles of physically active
individuals are predominantly designed to provide the maximum dynamic output in rapid movements (e.g., jumping)
against the load imposed by the weight and the inertia of their
own body.5 This supports earlier data demonstrating that the
performance of rapid movements (such as vertical jumps)
assesses the same physical ability as properly normalized tests of
muscle power.6

program for female college-age dancers was found to be effective in improving overall muscular strength and decreasing
circumference in the waist-hip region but elicited no significant changes in body composition.21 An elevated neural
involvement may account for some of the increases in muscular strength,22 suggesting that hypertrophy is not a prerequisite for strength gains. Nevertheless, many authors note
that conventional dance-studio exercise alone confers little
strength benefits.2325
The most consistent finding of available meta-analyses is
that strength training can be successfully used in patients
with different chronic diseases without having detrimental
effects on disease progression.26 These authors also suggest
that, in patients with chronic disease, exercise training is

FIGURE 1. Maximum voluntary static strength in healthy elderly

men (white bars) and women (black bars). (Adapted from Skelton et
al.: Age Ageing 1994; 23(5):371-377; with permission of the British
Geriatric Society.38

effective in improving the prognostic risk factor profile and,

in certain diseases, in delaying mortality. This includes
chronic diseases such as osteoporosis, frequently found even
in young dancers,27 and rheumatoid arthritis,28 common in
former dancers. It might be interesting to note here that as
both osteoporosis29,30 and rheumatoid arthritis31,32 have been
linked to tobacco smoking, that dancers exhibit relatively
high rates of smoking prevalence,33 and that because exercise/strength training is effective in improving the prognostic
risk factor profile in certain chronic diseases, it makes
strength training as important for these individuals and their
future health status as skill acquisition. Muscular strength
and strength training are also necessary for maintaining functional reliability of the older individual,34,35 including older
or former dancers.1

linearly up to age 15 but with no evidence of an adolescent

strength spurt. At the age of 11, boys and girls exhibit equal
anthropometric measures and strength performance.37 In
both genders, muscle strength increases significantly during
ages 12 to 16, with larger increases being recorded for the
boys. In inactive individuals, strength increases stop at about
age 18 and 20 for women and men, respectively. This is followed by a plateau up to the age of 40, with a steady decline
afterward. This decline becomes more prominent in later
stages of life (Figure 1).
In prepubescent children, gains in muscular strength
appear to be due to enhancement of neuromuscular activation of muscle units, improvement in the firing rate of activated muscle units or alterations of EMG firing patterns, and
changes in motor skill coordination (synchronization of
muscle action) rather than muscle hypertrophy. In pubescent
children, hormone levels and activity account for much of
the differences in muscular development between girls and
boys.39 Testosterone appears to be the most acute stimulator
of muscle development.40
Dance training at a young age does appear to affect muscular function and related parameters. For example, young
male ballet dancers have relatively good leg muscle explosive
strength and mechanical power.41 Nevertheless, dance programs for prepubescent children, while teaching the skills
and proper technique, should also accentuate general fitness
and include conditioning and strength elements.42
People of all ages can increase their muscular strength as a
result of a safe and effective strength training program (Figure
2). However, these increases appear to be greater from age 15
to 25, after which they steadily decline; contrary to common
belief, whereby different types of fitness training should be
kept separate within preparation cycles, a synergy rather than
interference between concurrent strength and aerobic
endurance training has been found in young individuals,43


Strength is simply the ability to exert force, and the weight
that a person can lift is probably the oldest quantitative measure of strength. Given the individual differences in the ability to exert force at different speeds, perhaps a more inclusive
definition of strength is: the maximum force that a muscle group
can generate at a specified velocity.36 However, several factors can
affect strength levels. These include:
Prior to puberty, strength development progresses steadily.
Specifically, muscular strength increases linearly up to about
age 13 or 14 years in boys, followed by an accelerated increase
through the late adolescent period. Girls strength improves

FIGURE 2. Knee extensor strength levels in healthy young men (28

yrs), healthy but inactive older men (68 yrs), and healthy older men
(68 yrs) who had strength training over a number of years prior to
data collection. No differences were found between the young and
the older active group. (Adapted from Klitgaard et al.: Acta Physiol
Scand 1990;140(1):41-54; with permission. 45
December 2009 159

while long-term training counteracts the age-related decline

in muscle strength and power.44
Sarcopenia is a progressive loss of skeletal muscle mass
and strength associated with aging. This is accelerated by the
presence of myostatin, a negative regulator of myogenesis,
which inhibits satellite cell activation and the muscles regenerative capacity. In contrast, lack of myostatin may result in
increased satellite cell number and activation, suggesting a
greater tendency to undergo myogenesis and reduction of
age-related sarcopenia.46
Women are approximately 50% and 70% as strong as men
in the upper and lower body, respectively. The greater
gender difference in upper body strength can probably be
attributed to the fact that women tend to have a lower proportion of their lean tissue distributed in the upper body.
Men are also stronger relative to lean body mass, probably
due to their larger fibers.47 The presence of testosterone, the
male sex hormone, may account for this difference; moderate exercise training can significantly increase testosterone
concentrations in men.48 In contrast, women have only low
levels of testosterone, making muscle fiber diameter growth
harder to achieve.
Muscle Cross-sectional Area
In addition to age, gender, recruitment of motor units, and
synchrony of contraction, the force a muscle generates is proportional to its cross-sectional area (rather than its length).
However, speed of shortening is dependent on length. A
short thick muscle will produce high force at low speed, and
a long thin muscle will produce low force at higher speed. In
both cases, the power may be the same.
The relationship between strength levels and cross-sectional area has also been confirmed in dancers. For example,
Japanese ballerinas, with no exercise other than ballet classes
and performances, revealed significantly greater cross-sectional muscle area and leg muscle strength than ordinary
Type of Muscle Fiber
Although the slowfast muscle fiber profile appears not to be
altered in number (except possibly in aging), the area of both
slow and fast muscle fibers may be altered in response to
strength training, particularly that of the fast fibers. Following a similar strength training regimen, muscular individuals (who probably have a higher percentage of fast fibers to
begin with) will have more hypertrophy of their muscle than
slimmer men or women. Fast twitch muscle fibers experience greater increases in muscle size and strength and thus
may demonstrate greater and/or faster results following a
strength training program compared to those classified as
slow twitch. An aesthetic problem often encountered by
dancers is that soon after the start of a strength-training pro160

Medical Problems of Performing Artists

gram, dancers may demonstrate body fat decreases,9 which

cause muscles to appear larger than they actually are.
Dance Type and Seniority
Dance can be generally classified as classical ballet (typified
by the turnout of the hip, rising up on toes, elevation, beats,
turns, and toe dancing), modern dance (characterized by
barefoot dancing, asymmetry, and personal choreographic or
dance styles), and folk dance (characterized by folk rhythms
and traditional dance steps from a particular area or ethnic
origin). The latter includes jazz dance. Dance type and different seniority levels within a dance company seem to affect
muscular strength parameters, in line with other forms of
physical activity50 and normal individuals.51 For example,
EMG activity of the vastus lateralis and medialis at the midcycle valley in grand-pli has been found to be significantly less
in ballet dancers than in contemporary dancers, despite similar degree of knee flexion, suggesting that ballet dancers may
have lower patellofemoral joint reaction force and strength
levels than contemporary dancers.52
At the professional level, classical ballet soloists demonstrate significantly greater power capacities compared to principals and corps, who in turn have significantly greater aerobic capabilities.53 Soloist ballerinas are also characterized by
higher muscular strength.54 Such information can help guide
strength and conditioning intervention strategies for optimal
results, as aspects of muscular strength can be successfully
trained in female dancers as young as 8 to 11 years of age.55
In general, key physical fitness parameters, such as muscular
strength, seem to demonstrate greater values in high-level
dancers compared to their less capable counterparts. This
indicates that to achieve the highest possible level of dance
profession, skill mastery is not enough.
Nutritional Factors
Protein forms the structural basis of muscle tissue, which is
the largest protein pool within the body. Protein is also one
of the most essential and multipurpose nutrients, as it has a
wide variety of physiological functions associated with optimal physical performance and health, including strength
levels.56,57 Therefore, optimal levels of protein should be
maintained in the dancers body.
The average person needs 0.8 g of protein per kg of body
weight per day, which provides 10 to 15% of the total daily
energy intake. However, individuals who engage in highintensity physical activities of up to several hours, or who
desire to build muscle bulk, would probably benefit from an
increased protein intake of 1 to 2 g and up to 4 g of his/her
body weight, respectively.58,59 Most conventional diets provide more than 4 g of protein/kg body weight/day, hence
protein supplements are not required. However, this may not
be applicable to individuals who consume low calorie diets or
to those who have relatively low daily protein intakes, because
of the reduced protein density in their diets (e.g., vegetarians). Vegetarians should consume approximately 10 to 20%

more protein due to differences in digestibility between vegetable and animal protein sources. In such cases, protein supplementation may be necessary for maintaining the bodys
optimal protein levels. In general, animal protein sources
such as meat, fish, eggs, and/or dairy products are referred to
as complete protein foods, whereas vegetable sources are
described as incomplete.
Body Temperature
It has been found that different body temperatures can affect
levels of muscular strength. Following warm-up, for example,
increased temperature (up to about 39oC) could lead to a
considerable performance increase in muscle power, which is
the explosive aspect of strength (often called fast
strength).60 This finding may be of particular relevance to
dance, which involves similar powerful muscular action.
However, a 45-min hot water immersion prior to exercise produced no significant changes in selected isokinetic or isometric parameters such as knee extension peak torque, angle of
peak torque, time to peak torque, and isometric force.61
In general, body temperatures greater than 39oC affect
muscle function by limiting the ability to maximally activate
a muscle and by changing muscle contractile characteristics.
Such changes are progressive in nature; with increases in core
temperature, there are concomitant decreases in muscle function, which gradually come back to normal as core temperature returns to thermoneutral levels. These phenomena are
due to a centrally induced muscle activation failure, demonstrating the primary role of core temperature afferents in
mediating responses to the muscle,62 regardless of training
status.63 In particular, elevated core body temperatures
reduce voluntary activation during isometric maximal voluntary contraction, and neither skin temperature nor cardiovascular levels can modulate this response.64
Much of the literature investigating cooling on human
performance involves cooling of the core, though many performance effects relate to cooling of the periphery. Nevertheless, there is general agreement that rate properties are
slowed with almost any level of cooling, thereby most substantially reducing muscle power. It is the slowed enzymatic
processes and slowed nerve conduction that impair rate of
force development,65 which can demonstrate reductions of
approximately 10 to 30%.66
Seasons of Year
In line with other fitness parameters, muscular strength
demonstrates noticeable seasonal variations.67 Aspects related
to exercise training or even overtraining may account for these
variations. Indeed, after 3 to 5 weeks of summer holiday in
elite dancers, during which very little physical work was
reported, strength measurements revealed unexpected
increases.68 It was argued that the demanding physical work
and performance schedules prior to holiday triggered an overtraining effect which negatively affected muscular strength
levels; however, this overtraining effect can be lessened with

some rest from dance commitments, thus supporting the

notion that physical rest should be part of the dancers lifestyle.


To our knowledge, there is no scientific evidence suggesting
that different strength training regimens should be employed
for the different styles of dance. However, exercise selection
should be similar to the selection of warm-up activities.60
General conditioning activities are initiated at the beginning
of a yearly training schedule, much as general warm-up activities are utilized at the start of a warm-up period.
The main aim of strength training is to train the nervous
system, not the muscle. By training the appropriate neural
pathways, dancers will be able to activate a larger percentage
of their musculature during a particular action. Muscle fiber
hypertrophy normally comes much later. It should be noted
that 1 month of detraining (i.e., inactivity) results in minimal
muscle fiber atrophy and strength loss; after that, decreases in
strength occur at a greater rate than decreases in fiber size.
Prolonged inactivity normally represents a persistent catabolic stimulus that exacerbates strength and lean muscle loss
via a chronic reduction in muscle protein synthesis.69
Some misconceptions associated with strength training
are that women will produce hypertrophic muscles. It is
rather difficult for a woman to produce such muscles due to
the fact that women generally have high levels of the hormone estrogen, which, unlike the predominately male hormone testosterone, is not associated with muscle bulge.
Strength improvements in women can be accomplished in
muscle tone, strength, and endurance and not necessarily in
size. Strength exercises also have been recommended as a
means of preventing osteoporosis in dancers.24 This claim is
supported by an earlier set of data on ballerinas, in whom
bone density was found to be normal or elevated at weightbearing sites whereas deficits were observed at non-weightbearing sites.70
Resistance Training
A muscle will only strengthen when forced to operate beyond
its customary intensity. This may be achieved by increasing:
1) resistance, 2) the number of repetitions with a particular
weight, or 3) the number of sets per exercise. Beginning
trainees are often introduced to resistance training with
machines and/or simple free weights. Free weights can be utilized to more closely approximate certain dance movements,
while the application of machines may allow isolating certain
muscle groups for physical development and injury prevention. Apart from developing strength, the use of free weights
or machines can lead to improvements of different fitness
parameters, as illustrated in Table 1.
A typical strength training program, already used in male19
and female71 dancers, lasts for approximately 12 weeks with
up to three 50-min sessions/wk using free weight exercises.
During the first 2 weeks, exercises are of low resistance lifts
(<70% of one-repetition maximum [1-RM]) but with high
December 2009 161

TABLE 1. Different Training Goals Can Be Achieved by Changing the Components of Strength Training

Load (% of 1-RM)
Reps per exercise
No. of exercises
Exercise sets
Rest between sets (mins)
Training sessions per week

Training Goal
Muscle Hypertrophy

repetitions. The principle of high resistance (>75% of 1-RM)

with a low number of repetitions can be adopted for the
remaining period during which resistance increases by about
15 to 20%. A rest period of about 4 min was allowed between
exercises in each test and between sets.
Weak muscle groups need priority, more sets and exercises, whereas strong areas just require maintenance. The
more difficult exercises should be performed when the
dancer is fresh. During a strength training session, multiplejoint, large-muscle-mass exercises precede single-joint, smallmuscle-mass exercises. Relatively heavy resistance that allows
only slow movements should be part of strength training, as
this may allow for more motor units to be recruited during
the action.72 Aerobic exercise and stretching should be performed first followed by resistance training participation.
Dancers should demonstrate proper technique of each
strength-exercise before participation is encouraged.
Vibration Training
In recent years, vibration training has been added to the
dancers training armory. However, despite the expanding use
of this whole-body vibration training, it is not entirely clear
whether adding such a regimen to the conventional preparation methods will improve performance in selected fitnessrelated elements.73 There is some evidence to suggest that
vibration may provide a small benefit to maximal strength and
power of trained individuals, while speed does not seem to be
enhanced.74 In general, given that whole-body vibration does
not seem to be detrimental to performance when used in a
controlled manner, it could provide an additional training
stimulus for dancers. This notion is supported by Delecluse et
al.75 who reported strength gains in knee extensors in previously untrained females to the same extent as resistance training at moderate intensity. Whole-body vibration also seems to
be as efficient as conventional resistance training to improve
strength in older women.76 However, more research is
required to establish appropriate training protocols using
vibration training for the different disciplines.
Genes and Strength
Emerging molecular techniques have made it possible to gain
a better understanding of the genes involved and how they
activate muscle progenitor cells that provide the extra nuclei
required for muscle hypertrophy, repair, and maintenance.77

Medical Problems of Performing Artists




It has been found that many small contributing genes are

involved in causing variation in the torque-velocity relationship of leg muscles.78 By using gene microarray analysis to
compare the global expression profile of genes involved in
adaptation to strength training in skeletal muscle, Stepto et
al.79 found that chronic training subtly co-regulates numerous
genes from important functional groups that may be part of
the long-term adaptive process to repeated training stimuli.
Nevertheless, several inflammatory genes are transcriptionally
upregulated after a repeated strength exercise bout, potentially
indicating a role for these genes in the adaptation process.80


With over 600 muscles, 206 bones, and countless ligaments
and tendons in the body, it is almost impossible for dancers
not to develop an injury (dance injury is defined here as the
result of acute trauma or repetitive stress associated with
dance activities). Acute injuries, such as muscle pulls, can
happen at any time during a class, rehearsal, or stage performance. Chronic (or overuse) injuries, such as tendinitis,
develop over longer periods of time. The nature of dance as
a yearly activity should also be considered. Unlike athletes,
dancers do not have predictable annual seasons during which
a regular training schedule can be periodized to include regular resting periods following increased volumes of work.81
As a result, many dancers submit to problems such as overtraining (or burnout), where their ability to adapt successfully
to physical conditioning ceases.82 This may partly explain the
high injury rates found in dance.83,84
Professional dancers have a 90% risk of injury during
their careers.85 As shown in Figure 3, the lower extremity is
involved in approximately 75% of the injuries sustained by
dancers.86 The lower back, ankle, and knee are the most commonly injured body regions in dancers.87 Yet, these anatomical sites coordinate with the leg and foot and provide a significant contribution to the dancers ability to perform.
Therefore, a good understanding of their anatomy and biomechanics is important for those working with dancers, and
for dancers themselves.88 It is noteworthy that while sprinters, for instance, sustain their injuries during high-speed
sprinting, dancers can be injured by just performing slow
stretching-type exercises.89
Significant differences between injured and uninjured
dancers are related to, among other things, a history of low

FIGURE 3. The most commonly injured body regions in dance. The figure shows the number of injuries recorded in a 2-year period preceding data collection in 608 professional dancers and dance students in the UK. (Koutedakis, unpublished study.)

back pain and lower extremity strength.90 Indeed, in line with

the relatively low muscle strength levels displayed by dancers
in relation to other athletes,1,23,91 it has been confirmed that
reduced thigh muscle strength is associated with a greater
severity of injury in dancers.8 Poor aerobic capabilities,92 high
ectomorphy ratings with low percent body fat values,93 the
biomechanics of different dance techniques,94 and reduced
levels of lower body muscular power95 also have been identified as underlying sources of injury in dancers.
It is worth mentioning that all three aforementioned physical fitness parameters (i.e., muscular strength, aerobic capacity,
and body composition) have been linked with poor technique
or alignment, which can cause abnormal loading on joints and
surrounding tissues and, therefore, injury.7 For instance, while
the aesthetically ideal body type in many professional ballet
companies is a mesomorphic-ectomorph profile96 with low
waist-to-hip and waist-to-thigh circumference ratios,97 it is not
entirely clear whether this is also the most anatomically resilient
body type for dance. Nevertheless, strength improvements are
part of the rehabilitation process following a dance injury. This
is at least the case with hallux musculature, which is necessary
to attain and maintain balance, push-off in multiple turns, and
decelerate in jumps and hops.98 The use of advanced biomechanical techniques, such as motion-capture videography, can
provide useful information about which part of the dancers
body requires special attention.99
Although stress fractures and overuse seem to be the main
types of injury in both contemporary and ballet dancers,100
differences do exist between these two dance styles in injury
site and severity. The most common location for injury in
ballet dancers is the foot and ankle,101 while in contemporary
dancers it is the low back and knee.87,102 Little information is
available with respect to other dance styles.
Stress fractures, in particular, seem to result from the
unsuccessful adaptation of bone to a change in its mechanical environment caused by repetitive loading.103 Lack of mus-

cular strength in conjunction with increased exercise volumes and reduced recovery periods may significantly add to
such injuries.104 In contrast, overuse (or nontraumatic) dance
injuries are often attributed to faults in technique, partly due
to insufficient muscular strength levels, with poor turnout
and inappropriate compensatory strategies.105 The process
starts when repetitive activity fatigues a structure such as
tendon or bone.

Skeletal muscle differs not only in color but also in contractile properties.
Muscle fibers can generally be divided into slow and fast
twitch according to their contraction speed. The limited
data on dancers muscle profiles have shown that ballet
dancers have predominately slow fibers.
Strength levels can be affected by several factors, which
include age, gender, type of muscle fiber, nutrition, and
body temperature.
There is no scientific evidence suggesting that different
strength training regimens should be employed for the different styles of dance. However, reduced muscular
strength has been associated with greater severity of injury
in dancers.
The most common location for injury in ballet dancers is
the foot and ankle, while in contemporary dancers is the
low back and knee. Little information is available with
respect to other dance styles.
More multidisciplinary scientific research is needed on
the different forms of dance and dance training.


Koutedakis Y, Sharp NCC: The Fit and Healthy Dancer. Chichester:

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