INJURIES IN CLASSICAL BALLET Injuries IN CLASSICAL BALLET Adriana Coutinho de Azevedo Guimarães * Joseane Paulini Neves Simas ** SUMMARY

This study aimed to elucidate the possible injuries that can occur depending on the practice of classical ballet. The study was literature, with bibliographies and foreign. The literature review indicated that the technical and aesthetic ch aracteristics lead to a practice with no anatomical movements, leading to classi cal dancer with a group of associated injuries, most injuries are due to errors and technical training, problems in children are due to attempts to force the ex ternal rotation at the hips and misuse of the pointe shoe, the most common injur ies are foot and ankle, followed by knee and hip, and those that happen are the least of the upper limb. These injuries occur due to excessive exercise and repe titions, always using the same hand, and misuse and early pointe shoe. It is con cluded that the technique of ballet, when misapplied, predisposes its practition ers to characteristic lesions. Keywords: dance, ballet, injuries. INTRODUCTION In its elemental form, dance is a natural and instinctive man exhausted by the d rive, its latent state. The classic ballet is the development and transformation of primitive dance to a dance formed by different steps, links, gestures and fi gures previously developed (DI DONATO, 1994). Historically, classical ballet was born with the Renaissance in the sixteenth century, the Medici Court in Paris, initially reflecting gestures, movements and patterns typical of the time (BAMBI RRA, 1993). Since then, Malanga (1985) highlights that the evolution of classica l technique was guided by the quest for lightness and agility in which the dance r seeks total mastery of the body, their muscles and their movements, so you can use it so expressive without being tied to natural limitations. The author emph asizes that the classical technique has certain principles of * posture - an upright, elongated - and placing the body, which must be kept in ev ery movement, bringing the full potential of balance, agility and harmonic motio n of the human body, and hence its value and permanence in time. Moreover, Bambi rra (1993) cites that the ballet can not be seen only under an ethereal vision, he is a complex whole in which the principal is the artist's talent and mastery of technique. Complementing, Lima (1995) points out that classical ballet is the involvement in the artistic world through a highly technical and complex practi ce, which requires of its practitioner performance athlete. Among the studies th at emphasize the risks caused by physical activity the body, found Watson (1983) , Juli (1983), Gonçalves et al. (1989) and Mota and Maia (1992), which stressed that the structures of the body are affected by the shape of Professor of Rhythmic and Dance at the University of Santa Catarina (UDESC / CEF ID), Master in Physical Education from Universidade Federal de Santa Catarina / CDS. Collaborative teacher at the University of Santa Catarina (UDESC / CEFID), post-graduate degree in Physical Rehabilitation and Prevention. ** Journal of Physical Education / EMU Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 90

Guimaraes and Simas implementation, the amount and specificity of the movement. Juli (1983) adds tha t when physical activity is carried to certain limitations, requiring the most m uscles and tendons, bones and joints can act as a pathological agent on the loco motor system. In this sense, Schafle (1996) mentions that the high range of moti on of hip and knee, and the repeatability of these movements may be unbalanced m uscle groups, thus altering the biomechanics of the body and compromising the fu nction, increasing the body structure, which may increase the susceptibility the characteristic lesions in ballet dancers. This review study aims to elucidate t he possible injuries that can occur depending on the practice of classical balle t, but also characterize the technique and practice of classical ballet. CLASSICAL BALLET TECHNIQUE OF CLASSICAL BALLET The dance was born with humanity itself and, second Bambirra (1993), the oldest documents prepared by the men, found in caves, show dance steps, whether in pain tings or drawings carved on the stone itself. The classic ballet is the developm ent and transformation of primitive dance, which was based on instinct, to a dan ce formed by different steps, links, gestures and figures previously developed f or one or more participants (DI DONATO, 1994). To Malanga (1985), classical ball et works essentially the amplitude of joint movements,€the accuracy of their tur ns on or off the body axis and the field of emotional balance, generates confide nce and overcomes the limitations of body, and enhances the personality, leads t o self-esteem and self-esteem, which consequently leads to the mastery of techni que . The practice of classical ballet can develop and enrich the qualities of m an and in this context Achcar (1998) says that the physical beauty, vision, prec ision, coordination, flexibility, tenacity, imagination and expression are the e ssence teaching ballet. The classical technique has certain principles of posture and body placement tha t must be maintained in all movements (Malange, 1985). According to Malanga (198 5), Bambirra (1993), Di Donato (1994) and Achcar (1998), was the end of the seve nteenth century that Pierre Beauchamps defined the basic positions of classical ballet, describing the beginning or the end of compulsory all steps. To obtain a good placement posture, Sampaio (1996) suggests some basic principles: (a) feet must bear the weight of the dancer's body and the arch of the foot should be en couraged upward to avoid overloading the joint of hallux (b) the hip is the basi s for a perfect placement posture, so it is essential to strengthen the abdomina l and gluteal muscles, and promote the elongation of the quadriceps, (c) bringin g the shoulder blades down, lift your chest, take out the ribs and oblique muscl es of abdomen to maintain posture, (d) the arms are always rounded, and the elbo w is the most important point, it suspends the arm and it is he who lead the mov ement. The "en dehors" principle is more important in the ballet, which, accordi ng Achcar (1998), is learning to turn the legs out with their toes out, heels in , knees and thighs following the toes. To Sampaio (1996), the degree of external rotation on femoral joint is determined primarily by the bone structure and cha racteristics of articular ligaments. Its normal level, for individuals in genera l is 40-50 degrees in each joint, making a angle of 80 to 100 degrees. In the fi rst position, a dancer it reaches 180 degrees. PRACTICE OF CLASSICAL BALLET A class always begins with ballet barre exercises. According to Cosentino (1985) , the bar serves to support the execution of exercises that will give dancers se curity, support, lightness, proper muscle and knowledge of the other steps and m ovements Journal of Physical Education / EMU

Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 Injuries in classical ballet 91 technicians. After the exercises the bar, get the center exercises, in which the y perform movements based on activities already carried out at the bar, but with out the aid of this, seeking a better balance of the dancer. At the end of class , come the port de bras, which are combined with arm movements and head movement back, not forgetting of the breath, which must be worked in harmony and awarene ss. And like a farewell, it is a series of movements called reverence. Most part icipants ballet, according Schafle (1996), consists of beginners. In general, th ey attend classes once or twice per week and the average level of intensity vari es by school. The student receives lessons at beginner shoes soft leather or can vas. Classes for beginners concentrate on basic positions of the legs and arms c ontrol in the trunk and external rotation properly. It emphasized the developmen t of strength, coordination and grace. According to Hill (1989), the practice of ballet is recommended after six years, the fact that, at this age the child alr eady has motor coordination and muscular system developed further as to maintain balance and posture , ie assimilate the technique and have better technical res ults faster. For Bambirra (1993), the age to start ballet should be around 4-6 y ears of age, but the work to be developed should be fun. Agreeing, Lima (1995) m entions that one should avoid the application of pure classical ballet technique in childhood, but exalt the taste stimulus and the musicality and natural movem ent. In the intermediate levels, according Schafle (1996), ballet classes, there are fewer participants. The classes are attended 3-5 times per week and intensi ty levels are increased. The girls begin to work on tiptoe and both sexes begin to increase the height and complexity of the jumps and spins, and to pursue more advanced attitudes or positions of equilibrium. As the skill level increases,€t he frequency of classes also increases and may now include summer sessions with teachers and strangers dancing days longer than usual. Therefore, attempts to increase the external rotation (en dehors) and flexibilit y can increase disproportionately to the skill level of the student. According t o Lima (1995), the ballet teacher must verify individual maturation to capture t he movements considered faster or slower absorption. Each individual has their o wn reaction rate, which will be adapted according to the choreography required. Not require advance quickly from those who have slower reaction time absorbing a nd understanding of movement. At advanced levels, according to Schafle (1996), t he introduction of work on tiptoe is the first step towards separating the serio us from those dancers who wish or who may be able to dance only with recreationa l purpose. From the first class, the bar and center in the ballet exercises desi gned to strengthen the foot and lower extremity in preparation for work on tipto e. The strength and level of technique should be the criteria for deciding when it is possible to dance on tiptoe. Teaching the technique of using the pointe sh oe is very important and the teacher ought to know when children should start us ing the pad, not just the right age, but also observe the child's maturation (Ha nkin, 1997). Lima (1995) reports the importance of using strategies to introduce the tip shoes at the right time. He considers it important to start after puber ty, and even then, checking the actual physical conditions and preparatory indiv idual to receive such an effort and burden of joint exercises in the region requ ested more toes, metatarsal and toes. You must also pay attention to the type of material that the student has, for a sneaker that lets your foot is broken or i rregular too much could lead to a fracture or injury, because, according to Sean and Gallagher (1996), is of fundamental importance that the teacher guide the s tudents regarding the material it uses, since the protection of fingers with adh esive tape to buying the shoes that fit your body type. Journal of Physical Education / EMU

Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 92 Guimaraes and Simas Schafle (1990) states that some children are ready to work on tiptoe to 9 years old and others never will. Already Bambirra (1993), save the child, to 11 or 12 years is ready to receive the effort to work on tiptoe. The work begins when the tip of the bottom end is strong enough to maintain balance and correct alignmen t without the help provided by the contact of the entire foot. The stand on the tips is not only a technical change, but also an adaptation of the body to a new form of equilibrium with the fortification of bones, tendons, ligaments and mus cles. POSSIBLE INJURIES RELATED TO CLASSICAL BALLET The ballet is characterized by the constant search for aesthetic patterns of mov ements, ie movements of large amplitude coordinate that go beyond the anatomical limits. According to Hamilton et al. (1992), Wiesler et al. (1996) and Khan et al. (1997), muscular strength and high range of motion in the joints of the hips (maintenance of external rotation of 90 degrees) and knee (hyperextension), far beyond the control of the ankle joint are some of the characteristics that lead to the dancers no anatomical movements. These patterns of movement does not ana tomical characteristics associated with musculoskeletal and physiological charac teristics varied, the distinguished classical ballet sporting activities, thereb y, the ballerina peculiar to a group of associated injuries (Klemp, 1984; Kadel et al., 1992 ). The use of tip shoes, according Achcar (1998), when started too early, force the bone structure muscle, tendons and ligaments, leading to seriou s orthopedic problems in children, such as flatfoot, in which the curvature does not develop, leaving loose ligaments, creating hernias capsular ligaments of th e joints and bone callus. To Sampaio (1996), certain trends and strain may worse n initially imperceptible, like back problems, observed in positions almost always wrong. There are several dancers with bunion s, corns and knee problems. May arise elastic knee or back, as a result of sprai ned ligaments. Other strains may still come from the early use of tips, with cla w feet, or with the fingers curled, as its name suggests. According Schafle (199 6),€work on the tip causes the first two metatarsals bear most of the weight. Co nsequently, when children learn to dance on tiptoe, the bones begin to suffer th ese processes of remodeling, so the cortical of the first and second radius beco mes much thicker than in children who do not dance. During training and even thr ough his career, these bones, particularly the second radius, are at risk of suf fering a stress fracture. The same author considers that the usual manifestation is that of gradual onset of pain at the base of the second metatarsal, which at first increases with the work on tiptoe, and is usually followed by pain in ado pting the position of middle point. If untreated, pain can manifest itself even in the floor. If dietary deficiencies are excluded and if the body fat seems to be within the limits of good health, treatment consists of rest with respect to aggravating activities, while the force is maintained with exercises that do not produce pain. Of course, citing Schafle (1996), dance on tiptoes is associated with a set of problems and injuries from overuse. As shoes for work are much mor e rigid tip and narrower than the half tip shoes, to perform traction on the flo or is even more difficult when the feet are fully in contact with the surface. T he lack of strength in the foot and ankle can result in acute ankle sprains or o veruse injuries such as peroneal tendinitis, Achilles tendinitis and posterior t ibial tendinitis. According Kadel et al. (1992), the formation of a classical da ncer starts early, as it is necessary to fully develop physical skills such as s trength, range of motion, flexibility, endurance, coordination,

Journal of Physical Education / EMU Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 Injuries in classical ballet 93 speed and balance for an adequate performance. Besides the factors mentioned abo ve, the repetitiveness characteristic of classical dance leads to too much burde n on the lower limbs, causing imbalances between muscle groups, altering the bio mechanics of the musculoskeletal system ligament thereby undermine its function, and increasing their susceptibility to injury. In dance, most injuries are due to errors and technical training. Schafle (1996) states that the most frequent e rror is the forced turnover. Forcing the foot rotated out into the soil at the e xpense of the knees, hips and back, causing a predictable pattern of injuries, i ncluding tendonitis hip flexor, irritation of facet joints, stress fractures of the portions interarticularis, chronic inflammation of the collateral ligament m edial and medial tibial stress syndrome. The same author adds that the strength of external rotators to maintain the rotation en dehors - during the motion is t herefore of paramount importance. Insufficient development of the external rotat ors produce a medial inclination of the knee during the plie and heels. This can cause problems patelllofemoral, patellar subluxation and tendonitis by overuse of the hip adductors and the patellar tendon. According Schafle (1996), the prob lems that often occur in children are due to attempts to force the movement en d ehors, which is the ballet term for external rotation of the hips. However, the dancers usually measure their external rotation by observing the position of the feet. Children understand very early, during the ballet classes, the external r otation at the hip is extremely important, and often they will try to increase t hat speed, carrying out some fairly draconian forms of stretching. A practice of young dancers is to sleep in the butterfly position, ie face down with hips fle xed and externally rotated as much as possible, and if this is not enough, the c hild may ask a partner to stand on buttocks to increase the stretch in the hips. Alternatively, the young dancer can stay in the supine throttle position as a partner is standing, leaning on the medial aspect of her knees. The training performed by dancers, according Coltro and Campello (1987), very little or almost nothing specifically refers to the abdominal muscles, so w hile it works fully the extent of the lumbar spine (paravertebral muscle strengt hening and stretching the abdominals ), strengthening the abdominal muscles is t he charge of "hip socket, pelvic retroversion, ie isometric contraction of muscl es. What is insufficient for maintaining the balance between these two major mus cle groups,€maintainers of the posture of the lumbar spine. Thus, the lumbar spi ne is exposed to injury by not building and care of this area. Another frequent error, according Schafle (1996), both young and advanced dancers, is the repetit ion of a certain part of the choreography. Unfortunately, the repetitions contin ue even after the fatigue of the tip due to the determination of the dancers in attaining perfection. Most injuries occurred with the increase in class time, si nce according to the same author, tests or a sudden change of technique, either in advance of class or level of choreography, for which no classical ballet bar prepares the dancer. The inequality of the partners is also a source of injuries , particularly the introduction of pairing classes at the intermediate level. Of ten, the dancers were not prepared to raise with special exercises or not well l earned the technique of lifting weights before the first attempt to lift the bal lerina. Moreover, the dancers to be raised may be inexperienced and unprepared t o participate actively in surveys. According to Gantz (1989), the work incorrect ly demi-plie, relevé passé and can lead to back problems, knees, feet and ankles . In demi-plie, is due to hyperextension or flexion resulting from excessive ant erior or posterior pelvic movement. The joints are affected by the force placed on the feet, ankles and knees. In the past, and the column

Journal of Physical Education / EMU Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 94 Guimaraes and Simas pelvis are supported by one leg, in which the entire body weight is placed, and yet it is swings and turns, leaving the spine in hyperextension. The repetition and excess can lead to fractures and knee injuries, spine, ankle and foot. In re levé, instability and misalignment of the spine in line with the pelvis, the wei ght of the body is all about the toes can lead to spinal injuries, ankle, feet a nd knees. The orthopedic problem in the feet can cause, citing Solomon (1991), m ore serious problems in the ballet. The position of gripper in order to settle t o the floor with his feet inside causes rotation or pronation, causing internal rotation and eversion of the first ray, biomechanical setting the stage for the formation of the bunion. The concern with their feet, pronation and external rot ation insufficient level of the hips combine to impose an external sprain on the tibia. This can cause pain in the medial compartment of the knee, stretch the m edial collateral ligament and result in problems of patellofemoral dysfunction, patellar tendinitis and chondromalacia patella. According Schafle (1996), is obs erved in the dancers, stress fractures of the second metatarsal, tibia, fibula a nd portions interarticularis. The pain of these areas, nãoexplicadas other diagn oses should be attributed to stress fractures until proven otherwise by the squa dron bone. The treatment of stress fractures depends on the level of skill or pr ofessional goals of the dancer. For example, the novice dancer who has hopes of being recruited by a professional company will not accept a treatment of rest, i t is likely that should receive support in the rest of learning, resting, when p ossible, during the summer. Participates in performance that is more important t o her, next month and then do the rest for his stress fracture. A study by Palaz zi et al. (1992) showed that injuries are the most common foot and ankle, follow ed by knee and hip, and those that happen are the least of the upper limb. The a uthors argue that these injuries occur due to excess exercises and repetitions, always the same side, and also the early and incorrec t use of pointe shoe. Miller et al. (1992) also indicate that injuries are the m ost common foot and ankle for the same reasons cited above, and also add that ma ny of these injuries occur in the wrong direction on the part of instructors. Th ordason (1996) cautioned that the majority of injuries occur from stress, and al most always happens at the same location, especially foot and ankle. The author notes that it is an injury that can lead to fractures typically result from inco rrect and that training will increase as it continues to train. The incorrect te chnique and early results in lesions that often end up with the career of the da ncer. This can occur when working excessively one motion, mainly in the pointe s hoe, in which all the body's weight is being supported by the feet and sometimes by only one foot, and these excessive movements, done incorrectly, in a inadequ ate floor, with a poor technique and always using the same leg,€can lead to inju ries in the foot and ankle (and SEAN GALLAGHER, 1996). CONCLUSION Through theoretical analysis and consultation respecting the limitations of the study, concluded that: - the ballet, like any physical activity that requires re peated contractions of certain muscle groups, has its own set of associated inju ries, in which more common are the foot and ankle, followed by knee and hip, and finally, the upper limb - if parents and doctors are careful in order to mainta in a good working relationship with the dance instructor, some problems associat ed with the training of ballet can be eliminated. Parents should seek competent professional and specialized schools for their children and monitor classes, avo

iding in this way, future problems. - Lesions of young dancers in general are se lf-induced, with the pursuit of extreme Journal of Physical Education / EMU Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 Injuries in classical ballet 95 external rotation, as most likely culprit. The explanation of the effects in the long term, technique incorrect, will help the young dancer to improve technique and strength, and have faith that these efforts, over time, will produce the de sired external rotation - the also important is to insert the technique of class ical ballet at the appropriate time, avoiding to apply the pure technique of bal let as a child, but exalt the taste stimulus and the musicality and natural move ment. Use strategy for the introduction of shoes tip at the right time after puberty, and even then, checking the actual physical conditions and preparatory to receive su ch individual effort and overhead exercises in the region sought to articulate m ore toes, metatarsal and toes. Taking these precautions, the dancer's career wil l probably happen with fewer injuries and disappointments. Injuries IN CLASSICAL BALLET ABSTRACT This study Aimed to elucidate what injuries are most Likely to Occur du e to classical ballet practice. The research Used national and international bib liography. The bibliography analysis Indicated That Demands esthetical and techn ical lead to the practice of non-anatomical movements, causing the ballet dancer to Suffer from a number of Associated lesions. Most of the injuries are Caused by technical mistakes and wrong training. Troubles in children are usually; Tryi ng to force due to external rotation at hip level and point to undue use of ball et slippers. The commonest lesions are in feet and ankles, knees and hips Follow ed by. The rarest ones are in the upper limbs. These injuries are Caused by exce ss exercise, by repetitions always in the Same Side and wrong and by early use o f point slippers. The study Reached the Conclusion That incorrect application of classical ballet technique predisposes the characteristic injuries to dancers. Key words: dance, classical ballet, injuries. REFERENCES Achcar, D. Ballet: an art. New York: Twelve Books, 1998. BAMBIRRA, W. Dancing & dreaming: teaching ballet to children. Belo Horizonte: Del Rey, 1993. COLTRO, A. P., and CAMPELO, R. A. Low back pain in classical dancer. In: Proceedings of th e IV Specialization Course in Sports Medicine and School Health, Porto Alegre. P orto Alegre, v. 4, p. 37-41, 1987. COSENTINO, E. Classical school of ballet. Por to Alegre: Globo 1985. DI DONATO, S. Dance history. Dance Magazine, Rio de Janei ro, v. 1, p. 10, 1994. GANTZ, J. Evaluation of faulty technique dance patterns: a working model. Kinesiology and Medicine for Dance, USA, v. 12, n. 1, p. 3-11, 1989. GONÇALVES, D. V. et al. Postural assessment in swimmers: a critical analys is. Journal of Movement Science, Sao Caetano do Sul, v. 3, n. 2, p. 16-23, 1989. HAMILTON, G.W. et al. A profile of the musculosketecal Characteristics of profe ssional ballet dancers. Amplied Journal of Sports Medicine, USA, v. 20, n. 3, p. 267-273, 1992. Hankin, T. Facilitating discovery: student-centered teaching Str ategies in the technique class. JOPERD, USA, v. 68, n. 1, p.36-38, 1997. JULI, R. B. Acción de la deportiva overload on locomotor el del niño y teen. Apu nts, Barcelona, v. 20, p. 85-95, 1983. Kadel, N. J. et al. Stress fractures in b allet dancers. Amplied Journal of Sports Medicine, USA, v. 20, n. 4, p. 445-449, 1992. KHAN, K. et al. Hip and ankle range of motion in elite classical ballet d

ancers and controls. Clinical Journal Sport Medicine, USA, v. 7, n. 3, p.174-179 , 1997. Klemp, P. L. Hipermobility and injuries in a professional ballet company . Bristish Journal of Sports Medicine, England, v. 18, n. 3, p. 143-148, 1984. L IMA, L. Dance basic activity: perspectives for a new era. Journal of Sports Medi cine, São Paulo, v. 1, n. 3, p. 94-96, 1995. Malange, E. B. Communication and ba llet. Edimo, 1985. São Paulo: MILLER, C. et al.€Lower extremity range of motion in advanced level ballet dance rs. Journal of Applied Biomechanics, USA, v. 15, n. January, p.59-68, 1992. HILL , J. J. O. Psychomotor, maturation and growth. Curitiba: Clineuro, 1989. MOTTA, J.A.; MAIA, J. A. R. Posture as a factor of observation school. Journal of Movem ent Sciences. Sao Caetano do Sul, v. 5, n. 2, p. 36-39, 1991. PALAZZI, F. F. et al. Lesions en classical ballet dancers: estudio estadístico cuatro años. Archiv os de Medicina del Sports, Barcelona, v. 9, n. 35, p. 309-313, 1992. Journal of Physical Education / EMU Maringá, v. 12, n. 2, p. 89-96, February. no. 2001 96 SAMPAIO, F. Ballet essential. Rio de Janeiro: Sprint, 1996. SCHAFLE, M. D. Pe diatric Clinics of North America. Rio de Janeiro: Interlivros, 1990. _____. Secr ets in sports medicine: the necessary responses to day-to-day training centers, the clinic in oral and written exams. Porto Alegre: Artes Médicas, 1996. SEAN, P ., GALLAGHER, P.T. Foot and ankle taping for dancers. Journal of Applied Biomech anics, USA, v. 3, n. 10, p. 33-35, 1996. SOLOMON, R. Foot morphology and injury patterns in ballet and modern dancers: some thoughts on doing research. Kinesiol y and medicine for dance, USA, v. 14, n. 1, p. 12-24, 1991. Guimaraes and Simas THORDASON, D. B. Detecting and treating common foot and ankl e. The Physician and Sports Medicine, USA, v. 24, n. 10, p. 58-64, 1996. WATSON, AW.S. Posture and participation in sport. Journal of Sports Medicine and Physic al Fitness, USA, v. 23, n. 3, p. 231-239, 1983. Wiesler, E. R. et al. Ankle Flex ibility and injury patterns in dancers. Amplied Journal of Sports Medicine, USA, v. 24, n. 6, p. 754-757, 1996. Received 24/07/2001 Revised 14/08/2001 Accepted 08/29/2001 Correspondence to: Joseane Paulini Neves Simas, Av Tromposky No 227, apto 1201, Centro, Florianopolis, Santa Catarina, Brazil, Cep. 88015-300. E-mail: fabguima@terra.co m.br or joseanisimas@yahoo.com Journal of Physical Education / EMU Maringá, v. 12, n. 2, p. 89-96, February. no. 2001