Perspectives and Experiences of Dance-Related Injuries: A Qualitative Survey of Adolescent Pre-Professional Ballet Dancers in Australia

Objective: To explore perspectives and experiences of adolescent ballet dancers in Australia in relation to dance-related injuries and their impact, injury risk factors, prevention, and treatment. Design: Adolescent ballet dancers aged from 12 to 19 years in Australia were invited to participate in an online qualitative survey. Methods: Responses to open-ended questions were analyzed thematically using grounded theory while quantitative information was summarized with descriptive statistics and triangulated with qualitative data. Results: Nineteen adolescent dancers reported experiencing pain and multiple injuries but hiding or ignoring injuries due to fear. Dancers recognized the significant physical and psycho-social impact of dance-related injuries on themselves and others. Several risks and injury prevention strategies were identified by dancers. Dancers perceived that treatments were not always informed or effective. Conclusion: Findings suggest that adolescent ballet dancers experience multiple dance-related injuries but require support to disclose injuries, participate in injury prevention, and access treatment. Health professionals may improve quality of care by increasing their understanding of ballet and providing specific management advice. Dance teachers may benefit from further education to support their students. Clinical trials are required to confirm or negate the validity of proposed injury risks and the effectiveness of injury prevention strategies and treatments.


Introduction
2][3][4][5][6][7] Dancers typically commence ballet at a young age and increase their training volume and intensity in adolescence as they compete for professional ballet positions. 1,8Adolescents, regardless of their skill level or future ballet aspirations, must commence their ballet training within a pre-professional setting, either within a vocational or recreational ballet program. 1,2dolescent ballet dancers, however, frequently experience dance-related injuries. 2,9A dance-related injury can be defined as any physical complaint leading to difficulties participating in normal dance class rehearsal or performance. 10dolescent pre-professional ballet dancers may experience between 0.76 and 2.73 injuries per 1000 dance hours each year. 9The higher injury rate represents "all complaints" injuries where the dancer may continue dancing despite injury, whereas the lower rate represents a "time loss" injury where the dancer must cease dancing. 9,10 Adolescent ballet dancers may be particularly vulnerable to dance-related injuries because they are still developing physically and psychologically. 1,6Adolescent ballet dancers, for example, may be at increased injury risk with high training loads or when they push past the safe loads of stretching to demonstrate "perfect" technique. 1,12dolescent ballet dancers also may be at risk of injuries when transitioning to full time training and learning to dance en-pointe. 13,14Adolescents also may be vulnerable to psycho-social pressures to continue dancing when injured which can lead to further injuries and ongoing symptoms. 6,8,1517][18] There is also an attached stigma to injuries in dance circles and under-reporting due to fear of judgment and reduced career opportunities. 8,15,16Treatment and support for dancerelated injuries may subsequently be insufficient or delayed and dancers may experience worsening injuries and chronic disability. 16Currently little is known regarding the personal impact of injuries on adolescent ballet dancers who are yet to transition to professional roles.
Several individual risk factors predisposing professional ballet dancers to injury have been reported in the literature-such as being young, hypermobile, having poor psychological coping skills and insufficient fitness, strength, and motor control. 18,19][22][23] Currently there are few studies that have proposed and/or rigorously tested injury prevention strategies.One randomized controlled trial, however, has reported an 82% reduction in injury rates with targeted strengthening of abdominal, back, and hip muscles in professional ballet dancers. 24reatment of injured ballet dancers is minimally described and evaluated in the literature.Systematic review findings suggest that a range of physiotherapy treatments (eg, manual therapy, exercise, dry needling) may reduce pain, increase range of movement, and physical function following injury. 25However, additional research is required as primary studies have significant methodological limitations which can influence the credibility of findings. 25Also, given ballet dancers may try to self-manage injuries before seeking health professional input, future research should explore what therapies dancers find beneficial and barriers and enablers to seeking treatment and support. 26urrently there is no known qualitative research that has explored the perspectives and experiences of Australian adolescent novice and pre-professional ballet dancers regarding dance-related injuries.Previous qualitative research focused on professional ballet dancers from other countries and/or those aged over 18 years who may have different perceptions and feelings compared to younger preprofessional ballet dancers in Australia. 8,17Hence, this research aimed to explore the perspectives and experiences of Australian adolescent ballet dancers regarding dancerelated injuries, their impact, risk factors, prevention, and management.Findings may inform efforts to understand and prevent injuries, and support and treat injured adolescent ballet dancers.

Study Design
An online survey was undertaken to facilitate ease of distribution and data collection and to reduce geographical barriers to participation. 27The survey consisted of mainly open questions to allow exploration of participant views and experiences in their own words. 27Survey design and questions were developed by literature review and identification of evidence gaps, but also by cross-checking design options and topic areas with existing surveys and ensuring it was appropriate for an adolescent population. 1,12,13,27A qualitative survey design was chosen over other qualitative methods (eg, focus group, interview) as participants could answer questions confidentially without external pressure, which was considered important due to the social stigma surrounding injury reporting and the young age of participants. 16,27uantitative data was also collected to provide context to qualitative responses, and was used in data triangulation in development of themes. 1,7,11dministration.Pseudonyms were used to protect participant identity during data analyses and reporting.

Participant Recruitment
Convenience and snowball sampling were used to recruit participants via email and social media. 28Australian recreational dance schools who teach a ballet syllabus, and health professionals with expertise in treating dancers, were emailed by the research team and asked to forward study information to relevant dance students/patients and parents/ guardians.Contact details for ballet schools and health professionals in each Australian state and territory were sourced from online publicly available directories.National and state dance organizations and dance schools also assisted recruitment by posting study information on their Facebook and Instagram pages.

Selection Criteria
To participate in the survey, participants needed to meet the following criteria: 1. Be aged between 12 and 19 years (inclusive) to meet the definition of "adolescent" described in the literature. 29

Study ballet at an Australian recreational dance
school and have experienced at least one dancerelated injury.3. Dance ballet more than 50% of the time.Dancers who danced other genres could be included but they needed to predominantly dance ballet.
Participants were also required to be proficient in English language, and have adequate access to an email server and internet to provide consent and access to the survey.

Survey
The online survey was distributed using SurveyMonkey and was estimated to take 45 minutes to complete. 30articipants could complete the 53-question survey (Appendix A) in a single sitting or multiple sittings within 2 weeks and participants were encouraged to complete the online survey individually, in their own time, to prevent external influence on injury reporting.The survey consisted primarily of open-ended questions to explore dancers' perspectives and experiences using their own words.
Participants were asked to report on self-reported injuries, as well as those diagnosed by licensed health professionals.Multiple choice and closed questions were utilized to collect demographics and quantitative information.Pilot testing using an adolescent population was conducted to reduce design flaws, identify any ambiguity in questioning, and address any issues with survey access and flow.Participants were instructed to contact the primary researcher via email for question clarification if required.Key terms and definitions were provided at the beginning of the survey.This included the study's definition of dance-related injuries: Any physical complaint leading to difficulties participating in normal dance class rehearsal or performance. 10Participants were encouraged to cease the survey if recalling personal injury experiences caused emotional distress, and were asked to confide in their parent/ guardian, general practitioner, or other trusted health professional.Crisis support contact details were also supplied to participants.

Data Analysis
Participant demographics and quantitative data were summarized using descriptive statistics.Responses to open-ended survey questions were coded using NVivo 12 software. 31ualitative data was analyzed thematically using grounded theory and the step-wise approach described by Braun and Clark. 32Initial data familiarization and coding was conducted by 2 physiotherapy researchers working on the same survey response, whereas the remaining responses were coded separately and findings compared.Once data saturation was achieved and no new codes were identified, codes were reviewed by both researchers in real-time to identify patterns and generate themes.Any disagreements between researchers were resolved by discussion and reexamination of participant responses.
The rigor of qualitative analyses was facilitated by triangulation of qualitative data with quantitative statistics, and consideration of social identity theory. 33,34Social identity theory proposes that people categorize each other into social groups, identify with and join a social group, and then compare groups-favoring their group (the "in-group") over others (the "out-group"). 35This model seemed appropriate to use given ballet dancers have linked dancing to their personal identity (Wainwright et al. 17 ) and adolescents are at an age where they are developing their sense of identity and strongly influenced by social interactions. 17,36,37

Participants
Nineteen out of 21 participants completed the survey representing a participation rate of 90.5% (19/21).The 2 participants who did not complete the survey did not respond to reminders.Participant demographics are summarized in Table 1.

Themes
Four themes were identified: (1) Sustaining multiple injuries but hiding or ignoring symptoms; (2) Experiencing the widespread and potentially significant impact of injuries; (3) Identifying risks and injury prevention strategies but not always following advice; (4) Seeking informed and effective treatments focused on return to dance.Themes and subthemes with supportive participant quotes are detailed in Table 2, while complementary quantitative statistics referred to in themes is provided in Table 3.

Theme 1: "I've Had So Many Injuries": Sustaining Multiple Injuries But Hiding or Ignoring Symptoms
Participants reported experiencing multiple injuries (Table 2; i) with most involving moderate to severe lower limb strains, sprains, or fractures (Table 3).Participants reported continuing to dance despite injury as they perceived this to be expected as a ballet dancer (Table 2; ii).Participants also reported hiding injuries as they wanted to continue dancing and not miss out on dance opportunities (Table 2; iii).Some participants did recognize, however, that failing to rest when injured could prolong their recovery (Table 2; xxiv).Most participants did not feel confident in reporting injuries to their dance teacher and felt pressured to continue dancing following injury (Table 2; iii).Other participants reported their dance teacher supported them to rest when injured (Table 2; iv).Several participants suggested that adolescent dancers needed specific encouragement and support to report injuries and rest when indicated so that injuries may be more effectively managed (Table 2; vi).

Theme 2: "It's Difficult to Continue Dancing After an Injury": Experiencing the Widespread and Potentially Significant Impact of Injuries
Participants described how injuries resulted in pain and reduced mobility, strength, and function, which affected their ability to dance (Table 3; vii).Some participants also  "As a dancer you always experience sore muscles or minor injuries all the time so you just treat them and move and keep dancing" (Alex, 15 years) (iii) Dancers hide their injuries from others and ignore pain to avoid stopping dancing "Hiding dance-related pain was a norm for me because I knew that injuries cost a lot of money and time.
Ironically I thought I was doing my family a favor by hiding my pains, but after experiencing the full consequence of rehab and time off dancing, I now know that this isn't the case" (Lee, 18 years) (iv) Dance teachers may not always support dancers resting from injury and reinforce dancing through pain "My dance teacher overlooked my injury.She didn't seem to be too concerned, actually encouraging me to continue performing even after telling her it hurt" (Gene, 16 years) (v) Some dance teachers are more supportive when dancers reported their injuries and needed to rest from dancing "My dance teacher was fine with it and told me (that) I need to have a break because she knew I would be able to catch up" (Oakley, 18 years) (vi) Younger dancers require encouragement and support to report injuries due to lower self-confidence and fear of judgment from others "Giving students the affirmation and confidence to confront their teachers and parents about their pains or niggles without fear of being called 'lazy' will be a benefit to many" (Lee, 18 years) (2) Experiencing the widespread and potentially significant impact of dance-related injuries (vii) Dance-related injuries result in pain, reduced mobility, and reduced strength "I had pain when I moved and walked and an overall weak(ness) in the ankle" (Billie, 16 years) "When I injured my back and hip the pain was quite severe.I wasn't able to twist from side to side or move to(o) quickly" (Ellis, 15 years) (viii) Dance-related injuries may mean resting from dance or adjusting dance routines and choreography   reported difficulties sitting, walking, or bathing, and attending and participating in school due to injury (Table 3; x).If injuries were mild or less painful, participants continued to dance with modifications to scheduling, load, or choreography (Table 3; viii) but if pain and injuries were severe, dancers had to cease dancing (Table 3; viii).Some participants reported being unable to dance for days or weeks due to an injury, while others reported months (Table 3; ix).Participants felt frustrated, angry, and anxious when injuries prevented or restricted their dancing ability (Table 3; xi).Participants described intense fear of being unable to dance again, and depression when they were unable to dance as they felt dancing was part of their identity (Table 3; xiii).Participants also described how returning to dance after injury was painful and how it was difficult to return to their previous performance level (Table 3; xii).Participants also feared re-injury, and felt their dancing was affected by this fear (Table 3; xiii).Some participants felt their parents were distressed when they were injured, while others felt their parents expected their injuries and had little concern (Table 3; xiv).Participants did recognize, however, that they relied on psychological, physical, and financial support from their family to cope and recover from injuries (Table 3; xiv).Some participants recognized the inconvenience and extra workload for dance teachers who needed to help them catch up and/or change choreography, as well as the need for peers to cover them in rehearsals and performances (Table 3; xv).Participants could select more than one option for selected questions (Appendix A).

Table 3. (continued) (continued)
Other participants felt, however, that the impact of injuries on others was minimal in contrast to the personal ramifications (Table 3; xvi).

Theme 3: "I Overworked Myself and Wasn't Letting My Body Rest": Identifying Injury Risks and Injury Prevention Strategies But Not Always Following Advice
Participants perceived most of their dance-related injuries to be caused by accidents or technical errors associated with jumping/leaping, twisting/turning, and dancing en pointe (Tables 2 and 3; xvii).Some participants also described overuse injuries due to insufficient rest breaks, intense dance scheduling, rigorous choreography, and insufficient strength (Tables 2 and 3; xviii).Some participants also perceived that genetics may have predisposed them to injury (Table 3; xix).Several participants felt that not all injuries could be prevented as they were accidental or that injuries were unavoidable due to ballet's technical requirements (Table 3; xix).However, participants felt injury risk could be reduced by focusing on and improving technique, control, and alignment when dancing (Table 3; xx).Participants did note, though, that "perfect" technique was difficult to achieve as a novice (Table 3; xxii).
To prevent injuries participants recommended incorporating warm up and cool down exercise, stretching, and rest (Tables 2 and 3; xxi).Participants also perceived that a healthy lifestyle (including a balanced diet and quality sleep) and physical conditioning and exercise outside of dance were helpful (Tables 2 and 3; xxii).Other reported injury prevention strategies included arriving early to class to prepare, staying warm with appropriate clothing, maintaining pointe shoes, and dancing on sprung performance floors (Tables 2 and 3; xxii).Participants also suggested that by respecting their physical and mental limitations, injuries may also be prevented or better managed (Table 3; xxiv).Despite this, nearly all participants reported continuing to dance through pain and injury (Table 3; ii-iii).Some participants indicated the dance teacher integrated injury prevention strategies into classes although most participants felt dance teachers had limited understanding regarding injury prevention and/or students did not take injury prevention seriously (Table 3; xxiii).

Theme 4: "Don't Just Tell Me to Have Panadol": Seeking Effective and Informed Treatment Focused on Return to Dance
Participants sought injury treatment from a range of health professionals and reported variable outcomes and experiences (Table 3; Theme 4).Positive outcomes were reported in response to ice, heat, ultrasound, massage, joint mobilization, exercise (eg, stretching, strengthening, Pilates), taping, bracing, surgery, and use of crutches (Tables 2 and 3; xxvi).Not all participants, however, found treatments effective (eg, medication, massage, taping) and sometimes treatments made their condition worse (Table 3; xxvii).Several participants also reported ongoing pain related to previous injuries, even though they sought health professional treatment (Table 3; xxviii).
Participants felt their treatment would have been more effective if health professionals had a greater understanding of ballet and associated demands (ie, dancing en pointe, dance loads, psycho-social pressures) (Table 3; xxix).Participants also suggested that having access to dancespecific health professionals may reduce their stress and anxiety related to seeking treatment (Table 3; xxix).Dancers sought specific advice on when to return to dancing and not just symptom management (Table 3; xxx).While some participants suggested seeking health professional treatment as soon as possible to prevent an injury from worsening (Table 3; xxxi), others suggested health professional treatment should be sought only if symptoms are worsening and long-lasting, and the injury does not improve with self-management and rest (Table 3; xxxi).

Relevance of Social Identity Theory
Figure 1 summarizes how themes intersect with social identity theory, whereby participants define the "in-group" as those who dance ballet and the "out-group" as those who do not dance ballet.Participants described hiding and ignoring injuries so they could continue dancing (Theme 1) and prioritized dancing over injury prevention (Theme 3) to stay in the "in-group."Injuries, meanwhile, that stopped participants from dancing (Theme 2) led to them being categorized as the "out-group" and participants therefore sought treatment to help them to return to dance as soon as possible so they could rejoin the "in-group."

Discussion
This survey provides the first known qualitative evidence to explore perspectives and experiences of Australian adolescent ballet dancers in relation to injuries, their impact, risk factors, prevention, and management.Findings suggest adolescent ballet dancers experience multiple musculoskeletal injuries but may ignore or hide injuries to continue dancing.Adolescent ballet dancers are aware of potential injury risks, but do not always engage in injury prevention strategies preferring to focus on their dancing.Adolescent ballet dancers may access treatment from health professionals with support from others, however, their goal is to focus on return to dance and not just symptomatic management of injuries.
Participants reported experiencing multiple dancerelated injuries related to ballet (Theme 1, Table 3).The injury rate can be estimated at 0.7 injuries per year using the mean number of injuries and years of experience reported by participants (Table 1) (6.3/9.5).This injury rate is lower than those reported by professional ballet dancers (1.61-6.8injuries per dancer per year). 13The injury rate could also be estimated at 1.5 injuries per 1000 dance hours (ie, 0.7 × 1000/(8.8× 52)) using the mean number of hours per week reported by participants (8.8 hours).This injury rate is similar to that of pre-professional ballet dancers (0.77-3.06 injuries per 1000 dance hours) and suggests that ballet dancers are experiencing injuries even when not undertaking high training loads. 1,2Although the location and type of injuries reported by participants (Table 2) was similar to previous studies, participants reported more injuries to be caused by accidents and technical errors as opposed to overuse and high dance loads. 7,11,21This finding may relate to the small sample size, however, and so findings require confirmation in future research studies.
Participants were reluctant to disclose injuries to others due to fear of judgment or impact on their ability to continue dancing (Theme 1).This finding has also been reported in professional dancers. 16The reluctance of dancers, then, to report injuries likely relates to the "culture of risk" in ballet whereby pain is normalized and injuries are trivialized. 5here is therefore an urgent need to correct misunderstandings regarding pain and injury prevention and management in adolescent ballet dancers to ensure timely treatment and support to prevent injury chronicity. 25,38Dance schools, teachers and professional dancers may have the most success in challenging group norms and maladaptive responses to pain and injury in adolescent ballet dancers as they may also be seen as part of the "in-group" (Figure 1).
Participants described anxiety and distress when they were injured as "it was difficult to continue dancing" (Theme 2).Being unable to dance meant participants were demoted to the "out-group" and were therefore dissatisfied with their social identity (Figure 1).Similar feelings have been reported by professional ballet dancers who are unable to dance. 16It therefore seems vitally important that injured dancers remain connected with their dance colleagues and are supported in dance participation and associated activities as soon as possible.This study also highlights the widespread impact of injuries on an adolescent dancer outside of dancing (eg, school, work, activities of daily living) and their reliance on family, friends, and dance teachers/peers.These aspects therefore need to be considered when supporting adolescent ballet dancers throughout their recovery.
Several injury risk factors identified by participants (Theme 3, Table 2) appear consistent with previous research findings regarding dance-related injuries. 7Some risks though require further assessment in research studies with a wider age range of adolescent ballet dancers.Prospective longitudinal studies, for example, that track dance injuries as dancers progress to dancing en pointe (between 11 and 13 years of age), and progress to more advanced grades and technical training may be particularly insightful. 7,20It also may be relevant to compare the support and resources of adolescent dancers with that of professional dancers regarding factors that influence injury rates and management (eg, access to health professionals, sprung dance floors, replacement pointe shoes). 1,7indings also reinforce the importance of progressing from understanding risks to implementing effective injury prevention strategies.For example, participants identified continuing to dance through pain as an injury risk factor, yet they still regularly danced through pain and injury (Theme 3). 16Adolescent dancers, then, who strongly link their identity to dancing (Figure 1), and who may be particularly susceptible to psycho-social influences are likely to need strong advocacy and support from others to rest from dancing when injured. 1,6Dance teachers, as part of the "in-group" may be in the best position to provide this

Compare "us" versus "them"
OUT-GROUP ("THEM"): They do not dance ballet  advice and encouragement to not "push through" pain and injury.This premise is supported by participant views that a supportive teacher can significantly influence their injury experience and recovery (Table 2; v).Theme 4 highlights the participants' desire for informed and effective health professional treatments that facilitate their return to dance and return to the "in group" (Figure 1).Health professionals with experience and understanding regarding ballet were perceived to provide a higher treatment quality which has also been reported by professional dancers. 26Most participants consulted with physiotherapists (Table 2) and found them to provide effective treatment, which aligns with previous research findings. 1,24,25ome participants, however, reported ongoing symptoms and/or mixed results with health professional treatment (Table 2).This study, then, provides further evidence of the need for research studies to identify effective treatment for dance-related injuries in ballet dancers.

Strengths and Limitations
Findings provide perspectives and experiences of adolescent ballet dancers across a large range of topics (eg, impact, prevention, management) and not just injury statistics.Participants were recruited from multiple Australian states and territories, however, there were no responses from Victoria, Tasmania, or Northern Territory.Factors contributing to low response rates may include indirect online recruitment methods, the 2-step process of gaining parent/ guardian and participant consent, and the reluctance of dancers to report injuries. 16,39There is potential for volunteer bias, or reporting by dancers who experienced more severe injuries, and potential inaccuracies associated with retrospective injury self-reporting.Limitations in data comparison between this study and prior studies should also be acknowledged; including the use of differing injury definitions, and self-reported injuries versus those diagnosed by licensed medical professionals.The rigor of qualitative analyses was enhanced by triangulation of data across two researchers, qualitative and quantitative data, and consideration of social identity theory. 33,34

Conclusion
Findings suggest that adolescent ballet dancers experience multiple dance-related injuries with a potentially significant impact on themselves and others.Adolescent ballet dancers are reluctant to report injuries and rest from injury as dancing is linked to their sense of identity.Adolescent ballet dancers therefore require support and encouragement to undertake injury prevention and seek treatment.Health professionals should increase their understanding of ballet so they can provide dance-specific advice and need to focus treatments on return to dance and not just symptomatic management.Additional research is required to confirm suggested injury patterns and risks and to identify effective injury prevention and treatment strategies.

Theme 2 :
"Difficult to continue ballet" I am "OUT" when I am injured and cannot keep dancing.Theme 4: "Don't just give me Panadol" I am "OUT" when I cannot return to dancing after being injured

Figure 1 .
Figure 1.Understanding the social identity of adolescent ballet dancers and impact of injuries*.*Frameworkadapted from Social Identity Theory (Tajfel and Turner34 ) and applied to adolescent ballet dancers with integration of research study themes.
a All except one participant did not dance en-pointe (18/19).bThepercentage is >100% as participants were able to select multiple dance forms for this question.

Table 2 .
Qualitative Data.ve unfortunately had many injuries during my time dancing.My injuries have been mainly to my back and knees but I've also had trouble with my ankles as well.

Table 3 .
Dance-Related Injury Characteristics, Impact, Perceived Risk Factor, and Prevention and Treatment Strategies Reported by Participants (n = 19).