To get an insider's view of dance-related injuries, some leading dancers talked to Gramilano about their experiences – how they coped both physically and mentally – and gave advice to help keep a dancer injury-free.
Principal dancers from the world's top companies took time out to share some unpleasant memories in the hope that their misfortunes may serve as cautionary tales for others:
Cynthia Harvey (American Ballet Theatre, The Royal Ballet), Greta Hodgkinson (National Ballet of Canada), Daria Klimentová (English National Ballet), Agnes Oaks (English National Ballet, Birmingham Royal Ballet), Julio Bocca (American Ballet Theatre), Steven McRae (The Royal Ballet), Vito Mazzeo (San Francisco Ballet, Dutch National Ballet), Marijn Rademaker (Stuttgart Ballet, Dutch National Ballet) and James Whiteside (American Ballet Theatre).
NO PAIN, NO GAIN
“No pain, no gain…” blah, blah, blah.
Many athletes, dancers included, have such words hardwired in their brain and it can lead to unhealthy attitudes and dangerous practices.
Gesley Kirland once wrote,
I have suffered from tendinitis since I was 13, and it flared up again until the pain was paralyzing. There were times I prayed I'd be sick so I wouldn't have to go on.
Interestingly, the tendinitis that gives her extreme pain doesn't stop her from going onstage yet a bout of ‘flu does. “Push through the pain…”
It is obvious that a dancer can't stop at the first hint of pain otherwise most dancers would be more off than on. But as Tamara Rojo told the Guardian,
We're not masochists. We don't enjoy the pain. It's not some kind of religious ritual. You do not and should not think you have to suffer for the art.
The problem is, where do you draw the line? A line that will be in a different place for different people and for different injuries. Being over careful can also be damaging; too much time away from training can disturb muscle equilibrity, reduce stamina, and generally make it more difficult to return to previous form. An impossible balance to find?
Dutch National Ballet's Marijn Rademaker says,
A colleague in Stuttgart once said to me, ‘If you can still walk, you can dance!'.
Probably disastrous advice for many, but he adds,
She is the living proof of that… but I don't know if it's healthy!
So horses for courses… what works for one person may not be the solution for someone else. When the colleague or fellow student at the barre gives you advice, be wary. Listen and nod but don't necessarily follow it. Ask experts, and even then, as Rademaker will attest, there is no guarantee of finding the right answers.
It is natural that dancers are injured. As American Ballet Theatre and Royal Ballet Principal Cynthia Harvey says,
Dancers have what you would call, occupational hazards: being dropped, running off stage and tripping on wires, hitting a leg on a lighting boom, or being hit during a particularly crowded mise en scene!
Some get struck down more frequently than others. Rademaker says,
When I was 19, I had five knee operations in one year.
Julio Bocca had his fair share too,
I had nine operations during my career and all of them were after mishaps on stage. I think that nowadays the special flooring allows jumps to be more comfortable and also there is less risk of slipping, which lets dancers suffer less.
Yet The National Ballet of Canada's Greta Hodgkinson says,
I've been so very fortunate to not have had a major injury in my career.
Physical predisposition may explain these differing experiences, as can a lack of a full understanding of your own body, incorrect training, workload, tiredness, diet… the causes are many, but there is a unifying attitude after injury:
A dancer's initial reaction – says The Royal Ballet's Steven McRae – is usually anger, frustration and sadness. We dedicate our lives to our profession, so to have it taken away from you is not only physically debilitating but mentally too.
“The show must go on” mentality, coupled with a higher than normal pain threshold1, can lead to dancing with an injury and aggravating it. Harvey recalls a period when she was at ABT:
I had pins and needles in my arms and fingers and even then I tried to keep going. At one point I could not lift my arm but was still going to dance Swan Lake.
She had a herniated disc in her neck and eventually had to have traction and wear a brace.
That was the most frightening one because I didn't realise the potential for nerve damage I nearly caused.
She was fortunate to receive the right advice at the right time.
American Ballet Theatre had, and still has, Peter Marshall as its physiotherapist and he was alarmed at my description of symptoms enough to send me to get an x-ray. Between Peter and Marika Molnar, I had some of the best physical therapy and never had to undergo an operation.
But there are physios and physios. Dutch Ballet's Vito Mazzeo says,
In the ballet world we're years behind that of sport and, even if we don't like being called sportsmen, we are, 100%. I have watched work done on the Italian Basketball Team for the prevention of injury and the improvement of physical capacity, not only with physiotherapy and rehabilitation, but also diet which is extremely important.
Having worked with companies in both America and Europe I can say that there is an abyss between the two. In America there is much greater attention with a team working together to make recovery the most efficient possible. In Europe this is more rare: 15 minutes of physiotherapy isn't much use without other related therapies.
Sometimes, the offered treatment is just wrong. Rademaker again:
I went to ‘one of the best' clinics in Germany… they always say one of the best. That doctor advised me to sew my meniscus together because I was still so young and it meant not dancing for 6 months. It didn't grow together. The thread was loose and floating around in my knee. I went back and they decided to cut a part of the meniscus out. I was compensating, of course, by not putting weight on my operated leg which automatically increased the pressure on the other knee. Again a meniscus tear and the same clinic sewed it together. Again the meniscus didn't grow together.
I decided to look for another clinic and went to the Schelztor Clinic in Esslingen with Dr Degenhardt, a doc who took his time and really listened. He said they should never have tried to sew those menisci back together. He cut a piece out and finally I could start back.
Sometimes, the offered treatment goes wrong, as English National Ballet and Birmingham Royal Ballet Principal Agnes Oaks attests.
I had one unsuccessful cortisone injection to my ankle. The doctor did not admit that the injection had gone into my vein. I was very confused about what to do until I found another doctor who had seen a similar case. In the end, I had to have surgery on my ankle. Although it was successful, my ankle never felt the same again.
Horror stories abound and, let's face it, those are the ones that are remembered and passed around. But here are some success stories.
WHAT HAPPENED AND WHAT I DID ABOUT IT
American Ballet Theatre Principal James Whiteside has been mostly fortunate.
The only long-lasting injury I've had is patellar tendinitis. It's a real pest that not only limits one's dancing ability, but makes its victim miserable every time he or she is sitting down for more than 10 minutes.
I've had tendinitis for about six years. It makes going to the movies pretty unbearable, unless I can sit with my feet up on the seat in front of me. If my knees are bent in a seated position for too long, my patellar tendons begin to ache like the devil! Yes, it sucks at movies, but it also limits my demi plié, making jumps difficult and dangerous. At this point, I've basically conquered my tendinitis. I stretch regularly… as all humans should! I get massages, I don't drink (too much), and I do a boatload of squats. They have really strengthened the area around my knee, and have made my jumps higher. It's a good thing too, because I adore jumping!
Ever since I told my tendinitis to “sashay away”, I'm less irritable, more fun at long group dinners, and amenable to most seating situations at a movie. Success!
A seemingly invincible Steven McRae was still a soloist at The Royal Ballet when he was brought down by Paris's arrow: he ruptured his Achilles' heel.
In 2007, I entered the stage as Romeo and I honestly thought that I was living the dream. I was on the Royal Opera House stage dancing alongside one of the world's greatest ballerinas, Alina Cojocaru.
I had been in the company for two years at this point and I was trying to learn as much as I could that was physically possible. My workload suddenly multiplied and my body didn't accept it. After performing a number of Principal roles relatively quickly, my Achilles' tendon partially ruptured.
He was forced to cancel performances from January until December 2008.
Being forced to step off stage gave me time to learn more about the profession. I watched so many performances, rehearsals, classes as well as taught a number of classes myself. This gave me a moment to genuinely slow down and take everything back to basics.
As I started my rehabilitation classes with my coach, Leslie Collier, I realised that I was being given a second start. A chance to come back stronger, with a newfound knowledge that would help prolong my career.
When I first asked Vito Mazzeo about his experience with injury he said,
You're talking to the type of dancer who's never had an injury, except for the normal ones that go away in a couple of days.
But a month or so later…
For twenty years I had not had anything, but an accident with my knee happened after an intense year of work during which I visited all five continents in less than five months. Tiredness!
Certainly what they can do surgically nowadays is miraculous. They cleaned up part of my meniscus without removing all of it, and just a month after the operation I felt stronger than ever. This was thanks to the period of rehabilitation and returning to dance basics after the injury. I worked on those small defects that had become habits. It all helps you to become stronger. Even though I'm back dancing again I am continuing with the rehabilitation exercises to improve my physique.
Marijn Rademaker had a rather unusual problem with an Achilles' tendon:
I had to stop dancing because I couldn't go on relevé anymore. It was hard for me to stop that time because I was preparing for Béjart's Song of a Wayfarer, a piece that I'd always wanted dance. I heard of Prof. van Dijk, a Dutch ankle specialist with a very good reputation. So I went there with my MRI and in two minutes he said, ‘Oh, it's your plantaris tendon that is bothering your Achilles' tendon.' Not many people have this tendon. Evolution is leaving it out most of the time. Monkeys used it to grab tree branches. I guess I can't climb a tree like I used too because he had to cut it out.
And another problem that he resolved by finding the right specialist was a recurring twisted ankle.
I did that like five or six times. It became a problem. So Reid Anderson – Artistic Director of the Stuttgart Ballet – said that he wanted me to go to this special dance physiotherapist in New York. I was there for four days. The therapist looked at me walking, we did class together and she tried to find the deficit in my body, to discover the root of the problem.
She found out that my turnout muscles were way too weak and I had no centre, which makes everything weak anyway and puts more pressure on the joints. So she gave me exercises to do at home. Well, I did those everyday and I never twisted my ankle again. I learned a lot about my own body and started to change the way I work.
Learning from the recovery process and being able to return stronger, and wiser, than before compensates for the disappointment that comes with being forced to stop dancing. However, not all problems can be completely overcome, and to continue dancing sometimes means learning to live with them. Here's Agnes Oaks.
Already early in my career arthritis developed in my big toe joint and that was quite difficult to cope with as there is no real cure for arthritis. It was suggested that I have a joint replacement but there was a big risk that I would never be able to dance again. I decided to not to do it and for many years I used to take anti-inflammatory tablets which really helped me to not to feel pain. It was not good for my stomach but I had no choice. I also had shaving of the bone done and that helped a little too.
It was too painful to do high demi-pointe work and to work in soft shoes, therefore I started to mostly work in pointe shoes. Somehow over the years it settled down a bit and I got used to living and working with it.
A condition that she couldn't just grin and bear were shin splints, which are pains in the tibia, or shin bone. The Mayo Clinic says that shin splints are “common in runners, dancers and military recruits”… Military recruits! Isn't that what you become if you're not tough enough to get into a corps de ballet?
For two years I struggled with recurring shin splints. That was most difficult time in my career as I had to give up many opportunities and it took such a long time to cure. I found it mentally very, very hard to cope. With this injury you just have to take enough time off and how fast bone heals depends on the individual. The first time it happened I did not get the best advice and kept coming back to training too early only then to realise that it had not healed. So I took some more time to rest and managed to come back to dancing for a couple of months when it happened a second time.
I was extremely frustrated as I just had joined my new company – the Birmingham Royal Ballet – at that time. Doctors there advised me to rest for almost 6 months and that was what I did. It was a very slow recovery and it took me years to overcome the fear that it could happen again.
And this is maybe the crux of the matter, that although the body is injured, the mind takes a while to heal too. A young, seemingly invincible twenty-something changes mentally after his body fails him for the first time.
Steven McRae says,
I did not deal with the realisation of my injury very well at first. I was borderline depressed and didn't quite know how to cope. However, when a surgeon said that I may not ever dance again unless I listen and do exactly as he prescribed, I quickly toughened up, switched my head into recovery mode and said to myself, this is a new challenge and it's up to me to tackle it.
An attitude that Agnes Oaks echoes:
I think the hardest thing with injuries was to be away from dancing and the time it takes to get back into shape and on stage. Every time it takes real willpower and determination to prove to yourself that you can do it. Hard work mentally and physically!
Marijn Rademaker also told me of the guilt you feel because performances are cancelled and fans are disappointed.
I think it's wrong to feel those things. People are disappointed not to see you on stage, yes, but they are not disappointed in you as a person. Getting injured is not committing a crime. Most of the time it's not your own fault you get injured. As long as you take care of your body the best you can, you have no blame. Ok, if you go on stage without warming up properly and rip your calf, then you can be mad at yourself for a while… but then you know that won't happen again right?!
While out of action, there are also the career worries like those missed opportunities to dance a new role or, worse, create a role; having someone else take your place, maybe permanently; even worries about a possible loss of income. Then there are those lingering thoughts that remain after the dancer gets back to performing; the déjà vu feeling when a certain move is looming. Those dancers who have come a cropper with a foot injury after a Manon slide can't possibly eliminate the memory from their mind. Agnes again,
Once I fractured my foot during a Swan Lake performance… it happened in the very end of second act. Every performance of Swan Lake after that I would always remember the place when it happened.
So what recommendations do these dancers have to help lower the risk of injury?
SOME GOOD ADVICE
English National Ballet's Daria Klimentová, who has had three meniscus operations and an operation on her ankle, says
I just have to exercise my knees and back to keep my muscles there so they hold my spine. I do yoga, that's very good, and I do planks, all sorts of different planks, as well as ballet class. I make sure I have muscles around my knees, but running is not good for me, as it puts too much pressure on my knees; swimming is better or cycling.
All that we take in can help the efficiency of recovery. Certain foods help the muscles that help us to jump so these foods are a great help not only for a speedy and safe recovery, but also for helping our performance.
For many years now I have incorporated Fletcher Pilates and Gyrotonics into my weekly regimen of cross-training and that has helped me to stay strong and loose and avoid injury. Combined with physiotherapy, osteopathy and massage.
I think one of the most important things is to thoroughly warm up your body before dancing… it helps a lot. Certainly, that's what I always did before the many performances I did, travelling the world. At the time I wasn't conscious about this… I just wanted to use my body to do what I loved best, dance, and to create characters which allowed me to take the audience with me on a journey.
I think in my day we hurt ourselves because, crazily, we always wanted to always to do more; now, I think many dancers hurt themselves because they are not concentrating enough on what they are doing. Of course, this is just my opinion… maybe I'm right, maybe not!
In order to try to prevent or reduce the risk of injury, I try to maintain a healthy balance of work, rest and play. Recovery time is crucial, allowing your body to repair however this is not always possible as dancers usually work 6 days a week. In this case, I try to plan what days I need to really push & focus on the more physically demanding work. Stepping off an aeroplane and going straight into a day of rehearsals or even a performance is not smart but sometimes necessary. In these circumstances, my knowledge of dealing with an injury and rehabilitation is instrumental in keeping me safe.
Not sleeping enough, not eating enough, not drinking enough water – all can put the body into a stress mode that creates the perfect opportunity to succumb to injury. My feeling on how to avoid this is to take care and use moderation when eating, drinking and working. If you feel tired, pace your work. If you didn't sleep the night before, find time for a catnap. If you need to eat, carry snacks that are packed with nutrients.
I also believe in cross fitness training. Using the same muscle groups all day long doesn't provide balance to the body. By cross training you can become fit without over tiring muscles. Again, balance is the key.
All good, sound advice, but as François de La Rochefoucauld said,
We give advice, but we cannot give the wisdom to profit by it.
So here's to wisdom! And to quote Epictetus:
It's not what happens to you, but how you react to it that matters.
1 – Pain and pain tolerance in professional ballet dancers, by Tajet-Foxell and Rose, Department of Psychology, University of East London.
Graham Spicer is a writer, director and photographer in Milan, blogging (under the name ‘Gramilano') about dance, opera, music and photography for people “who are a bit like me and like some of the things I like”. He was a regular columnist for Opera Now magazine and wrote for the BBC until transferring to Italy.
His scribblings have appeared in various publications from Woman's Weekly to Gay Times, and he wrote the ‘Danza in Italia' column for Dancing Times magazine.