Preventing Musculoskeletal Injury

(MSI) for Musicians and Dancers

A Resource Guide
June 6, 2002
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers� � � 1
About SHAPE
SHAPE (Safety and Health in Arts Production and Entertainment) is an industry association
dedicated to promoting health and safety in film and television production, theatre, dance,
music, and other performing arts industries in British Columbia. SHAPE provides
information, education, and other services that help make arts production and entertainment
workplaces healthier and safer.
For more information, contact:
SHAPE (Safety and Health in Arts Production and Entertainment)
Suite 280–1385 West 8th Avenue
Vancouver, BC V6H 3V9
Phone: 604 733-4682 in the Lower Mainland
1 888 229-1455 toll-free
Fax: 604 733-4692
E-mail: info@shape.bc.ca
Web site: www.shape.bc.ca
© 2002 Safety and Health in Arts Production and Entertainment (SHAPE). All rights
reserved.
SHAPE encourages the copying, reproduction, and distribution of this document to promote
health and safety in the workplace, provided that SHAPE is acknowledged. However, no part
of this publication may be copied, reproduced, or distributed for profit or other commercial
enterprise, nor may any part be incorporated into any other publication, without written
permission of SHAPE.

National Library of Canada Cataloguing in Publication Data

Robinson, Dan.
Preventing musculoskeletal injury (MSI) for musicians and dancers : a resource guide
Writers: Dan Robinson, Joanna Zander and B.C. Research. Cf. Acknowledgments.
Includes bibliographical references: p.
ISBN 0-7726-4801-8
1. Musculoskeletal system - Wounds and injuries - Prevention. 2. Entertainers - Wounds
and injuries - Prevention. 3. Musicians - Wounds and injuries - Prevention. 4. Dancing
injuries - Prevention. I. Zander, Joanna. II. Safety and Health in Arts Production and
Entertainment (Organization). III. B.C. Research. III. Title.
1
RD97.8.A77R62 2002 617.4'704452 C2002-960144-4
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers� � � 2
Acknowledgments
Thanks to the members of SHAPE’s Special Committee on Musculoskeletal Injury for
helping
develop and review this resource guide and to the organizations they represent:
• Burt Harris, Pacific Music Industry Association
• Day Helesic, Canadian Alliance of Dance Artists, BC Chapter
• Jennifer Mascall, The Dance Centre
• Gene Ramsbottom, Vancouver Musicians’ Association, Local 145, American Federation of
Musicians of the United States and Canada
Thanks also to:
• Dan Robinson, Joanna Zander, and BC Research (researching and writing)
• Rob Jackes, Linda Kinney, and Robyn Carrigan of SHAPE (coordinating and reviewing)
• Kevin Sallows (coordinating and editing)
• David Harrington of the Lynn Valley Orthopaedic and Sports Physiotherapy Centre
(reviewing)
• Workers’ Compensation Board (WCB) of British Columbia (reviewing)
Thanks to the WCB for their permission to use source material from WCB health and safety
publications, including the lifting illustration on page 29.
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers� � � 3
Contents
About this resource
guide...................................................................................................3
Who should read this resource
guide...................................................................................4
Background………………………………………………………………………5
What is musculoskeletal injury (MSI)?
Risk factors
General prevention and treatment
References
Dancers and musculoskeletal injury (MSI)…………………………………….9
Overview
Preventing musculoskeletal injury for dancers
Treating musculoskeletal injury for dancers
Nutrition
Bone injuries
References
Musculoskeletal injuries (MSIs) prevalent in performers………………………
24
Overview
Jaw and head injuries: Temporomandibular joint (TMJ) dysfunction.
2
Shoulder injuries (rotator cuff injuries)
Shoulder injuries: Rotator cuff tears
Shoulder injuries: Shoulder impingement syndrome
Hand and arm injuries: Carpal tunnel syndrome
Hand and arm injuries: Cubital tunnel syndrome
Hand and arm injuries: Thoracic outlet syndrome
Hand and arm injuries: De Quervain’s syndrome
Hand and arm injuries: Lateral epicondylitis (tennis elbow)
Hand and arm injuries: Medial epicondylitis (golfer’s elbow)
Hand and arm injuries: Focal dystonia
Joint injuries: Arthritis
Hip injuries: Snapping hip syndrome (tight iliotibial band)
Knee injuries
Knee injuries: Patellofemoral pain
Knee injuries: Knee sprains and strains
Knee injuries: Meniscus tears
Back and neck injuries
Back and neck injuries: Spondylolysis
Back and neck injuries: Back and neck pain
Lower leg and ankle injuries
Lower leg and ankle injuries: Shin splints, stress fractures, and stress reactions
Lower leg and ankle injuries: Ankle sprains
Lower leg and ankle injuries: Posterior impingement syndrome (dancer’s heel).
Lower leg and ankle injuries: Anterior impingement syndrome
Lower leg and ankle injuries: Achilles tendinitis
Lower leg and ankle injuries: Subtalar subluxation
Foot and toe injuries
Foot and toe injuries: Stress fractures of the second metatarsal
Foot and toe injuries: Fractures of the fifth metatarsal (dancer’s fracture)
Foot and toe injuries: Cuboid subluxation
Foot and toe injuries: Flexor hallucis longus tendinitis
Foot and toe injuries: Blisters
Foot and toe injuries: Bunions
Foot and toe injuries: Toenail injuries
Index
About this resource guide
Performers such as musicians and dancers are at risk of occupational health problems that can
significantly interfere with their ability to perform. If not recognized and properly treated,
many of these health problems can limit, interrupt, or even end an individual’s performing
career.
This resource guide provides information and resources for the prevention of musculoskeletal
injury (MSI) in performers. Other terms used to describe MSI include:
• overuse problems
• repetitive strain injury
• cumulative trauma disorder
• work-related musculoskeletal disorder
• activity-related soft tissue disorder
Generally, this guide will use the term musculoskeletal injury orMSI to describe an
injury or disorder of the muscles, bones, joints, tendons, ligaments, nerves, blood vessels,
or related soft tissues that may be caused or aggravated by activities related to
performing, rehearsing, practising, or taking classes in music or dance.
Performers can and should prepare themselves for a long and healthy career by learning
to recognize:
• early signs and symptoms of MSI
• occupational factors that cause or aggravate MSI
• practical strategies to reduce the risk and impact of MSI
This resource guide has four parts.
Background, defines musculoskeletal injury and provides basic information on pain,
risk
factors, and general prevention and treatment. Parts 2 and 3 will be easier to
understand if you
read Part 1 first.
Dancers and Musculoskeletal Injury (MSI), discusses common symptoms and
types of
injuries; strategies for preventing and treating MSI; nutrition; and bone injuries.
4
Musculoskeletal Injuries (MSIs) Prevalent in Performers, summarizes MSIs that
occur in
musicians and dancers. These MSI summaries provide a brief description of the injury as well
as information on signs and symptoms; the causes of the injury; and treatment and prevention
strategies. These summaries are not intended to replace the services of trained medical
practitioners. Performers who recognize their own experience within an injury summary are
strongly urged to seek a professional medical opinion.
Who should read this resource guide
If you participate in any aspect of the performing arts industry, this resource guide may help
you prevent MSI in performers. A holistic approach to injury prevention includes
consideration of personal, administrative, technical, and artistic issues, and recognizes that
risk of injury can be significantly influenced by various factors (for example, parents, training
at an early age, and facility and equipment design).

Background
What is musculoskeletal injury (MSI)?
Musculoskeletal injury (MSI) is any injury or disorder of the muscles, bones, joints,
tendons, ligaments, nerves, blood vessels, or related soft tissues. This includes a strain,
sprain, or inflammation that is caused or aggravated by activity.
Daily activities place demands on the body that may contribute to the development or
occurrence of MSI. Most performers spend a large part of each day on practice, rehearsal,
or performance. The physical, professional, and artistic demands of these activities can be
stressful on the body and may eventually result in MSI-related signs or symptoms.
Signs and symptoms
Signs that may indicate MSI include:
• swelling
• redness
• difficulty moving a particular joint
Symptoms that may indicate MSI include:
• numbness
• tingling
• pain
5
These signs and symptoms may appear suddenly or they may develop gradually over a
period of months or years. Signs and symptoms may or may not occur during the activity
that is causing or aggravating the condition. Some conditions result in signs and
symptoms that occur after the activity and may even occur during sleep.
Health professionals classify the severity of signs and symptoms using a graded scale that
represents the progression of a typical overuse injury. This scale, adapted for performers,
is illustrated in Figure 2, page 9. The severity of an injury and the need to establish a
treatment plan increase as an individual progresses from Level I to Level V.
Health effects
Early signs or symptoms are indicators of various health effects that may develop if the
signs or symptoms are allowed to progress. The specific health effects that are likely to
develop depend on the specific activities. MSI-related health effects include:
• strains
• sprains
• disc herniation
• tendinitis
• tenosynovitis
• bursitis
• nerve compression
• nerve degeneration
• bone degeneration or malformation
Early recognition of signs and symptoms and appropriate responses are critical in
minimizing the severity of health effects and maintaining an individual’s ability to
practise, rehearse, and perform.
Level I
Pain occurs after class, practice, rehearsal, or
performance, but the individual is able to
perform normally.
Level II
Pain occurs during class, practice, rehearsal,
or performance, but the individual is not
restricted in performing.
Level III
Pain occurs during class, practice, rehearsal,
or performance, and begins to affect some
aspects of daily life. The individual must alter
technique or reduce the duration of activity.
Level IV
Pain occurs as soon as the individual attempts
6
to participate in class, practice, rehearsal, or
performance, and is too severe to continue.
Many aspects of daily life are affected.
Level V
Pain is continuous during all activities of daily life, and the individual is unable to participate in
class, practice, rehearsal, or performance.
Figure 2

Progression of MSI signs and symptoms in performers. Where are you on this

scale? If you are at Level I or II, modify your activities to prevent further

progression of symptoms. If you are at Level III or higher, seek professional

assistance.
Pain
Pain is a unique experience for each individual. The pain threshold of performers tends to
be very high, partly because pain is a common experience in this physically demanding
industry. Performers normalize pain and are less likely to fear it than the average person.
Yet pain is a defence mechanism that is intended to protect and preserve our bodies. If
you experience pain, it is important to pay attention to:
• when the pain occurs
• how long it lasts
• how it influences your ability to perform
• how it influences your other daily activities
Knowing where you are on the signs and symptoms scale (see Figure 2, page 9) may help
you distinguish between pain that is due to intense or unaccustomed physical activity and
pain that indicates a progressing injury.
Risk factors
Medical and scientific research has identified several risk factors that are widely believed
to increase the likelihood of MSI (for more information, see “References,” page 14).
Understanding these risk factors and looking for practical ways to minimize their
influences are important for maintaining your health and desired activity levels, as well as
for preventing the frustrating and potentially career-ending effects of MSI.
Risk factors include environmental aspects, physical demands of activities, and personal
characteristics. Figure 3 illustrates the primary risk factors associated with these three
categories.
Risk factors
Physical demands

Awkward postures

Forceful exertion

Repetition
Long-duration activities

(inadequate rest)
7
Contact stress

(sharp edges)

Vibration
Personal characteristics

Age and gender

Physical fitness

(strength, flexibility, endurance)

Nutrition

Posture

Addictive substances

(tobacco, alcohol, narcotics)

Psychological stress

Diseases or health conditions

(pregnancy, diabetes, osteoporosis)

Musculoskeletal injury
Environmental aspects

Temperature

Confined space

Layout of space

Equipment

Layout or configuration

of equipment

Surfaces (floors)

Lighting
Figure 3
A non-exhaustive list of MSI risk factors
In general, the strongest relationship between risk factors and incidence of MSI is
associated with extreme levels of any single risk factor or the occurrence of multiple risk
factors simultaneously.
For performers, the greatest risk of MSI is associated with situations that involve:
• a change in technique or instrument
• intense preparation for performance
• preparation of a new and difficult piece
• prolonged performance without adequate rest
These situations are common for performers, but they could lead to a worst-case scenario.
Over time, repetitive and sustained postures may result in stress to tendons, muscles, and
nerves. Psychological stress and poor diet — which often accompany a challenging
schedule, pressure to perfect, and performance anxiety — may also contribute to the
negative effects of physical demands on performers.
General prevention and treatment
8
Prevention
MSI prevention is based on two levels of approach: (1) Control the risk factors and (2)
Recognize and respond to early signs and symptoms.
Controlling risk factors
Controlling risk factors requires an awareness that they exist and the creative use of
strategies to reduce their effects. In the performing arts, as in other occupations, control
strategies are based on a combination of the following philosophies:
• Balance physical and psychological demands with the characteristics of the individual
(know your personal limits).
• Maintain a high level of well-being, health, fitness, and nutrition.
Recognizing and responding to early signs and symptoms
Early recognition of signs and symptoms allows performers to:
• seek professional medical assistance
• get referrals to appropriate specialists
• take preventive action before pain starts to affect their daily lives (Figure 2, Levels I
and II, page 9)
Unfortunately, it is more common for performers to work through pain until they can no
longer perform. At later stages of injury (Levels III–V), the likelihood of full recovery
diminishes, and the treatment process is more complex and disruptive to daily life.
Treatment
Medical management of signs and symptoms is best performed by medical practitioners
who are sensitive to the professional and artistic demands placed upon performers.
Musicians and dancers should seek the services of known medical professionals who
have demonstrated an understanding of the performing arts.
Performers commonly combine complementary approaches with traditional medical
management of MSI. There are many complementary approaches spanning a range of
philosophies and practices, including:
• body-awareness training (for example, the Alexander Technique, Feldenkrais Method,
Pilates Method, yoga, and Tai Chi)
• acupuncture
• massage therapy
• herbal medicine
While anecdotal evidence supports the effectiveness of complementary approaches, it is
recommended that they be implemented in conjunction with the approach of traditional
western medicine.
For a list of health-care professionals who have experience treating MSI for musicians and dancers,
contact SHAPE.
9
References
Bernard, B., and L. Fine, eds. 1997. Musculoskeletal disorders and workplace factors:
A
critical review of epidemiological evidence for work-related musculoskeletal
disorders of the neck, upper extremity and low back. Publication No. DHHS (NIOSH).
Cincinatti: U.S. Department of Health and Human Services, National Institute for
Occupational Safety and Health: 97–141.
Chong, J., M. Lynden, D. Harvey, and M. Peebles. 1989. Occupational health problems
of musicians. Canadian Family Physician 35:2341–2348.
National Institute of Health. 1998. Acupuncture — National Institute of Health consensus
conference. Journal of the American Medical Association 280 (17): 1518–1524.
Paull, B., and C. Harrison. 1997. The athletic musician: A guide to playing without pain.
Lanham, Md.: The Scarecrow Press, Inc.
Zaza, C. 1998. Play it safe: A health resource manual for musicians and health
professionals. London, Ont.: Canadian Network for Health in the Arts.
10
Dancers and
musculoskeletal
injury (MSI)
Overview
Musculoskeletal injury (MSI) is the most frequently reported medical problem among classical and
modern dancers. The majority (60–80%) of dancers have reported at least one injury that has
affected their dancing or kept them from dancing (Bowling 1989; Hamilton et al. 1992; Milan 1994;
Guierre 2000), and approximately half of dancers report at least one chronic injury (Bowling 1989).
Note: This part includes lists of selected references at the end of each section as well
as a
full reference list at the end of the part (page 50).
Long-term and chronic injuries
In 1989, Bowling surveyed the injury incidence in 141 professional ballet and modern
dancers in the United Kingdom, including representation from the Royal Ballet, London
Contemporary Dance Theatre, Sadler’s Wells Royal Ballet, Diversions Dance Company,
English Dance Theatre, and many smaller dance companies. The majority of dancers
surveyed had experienced multiple injuries and injuries that were either recurring or not
resolving (chronic).
Many dancers report long-term and chronic injuries because minor injuries go unreported
and untreated for long periods. By the time these dancers finally report an injury or seek
treatment, the damage has intensified to a level that requires major rehabilitation. Many
dancers report self-treating injuries rather than seeking systematic professional medical
treatment. Dancers self-treat and delay medical intervention for various reasons. They are
often required to juggle a demanding schedule and lack the financial resources necessary
to subsidize preventive or early treatments. In a 1992 study, Hamilton et al. found that the
personality traits that characterize people with a high pain threshold also distinguish most
of the injured dancers. As a result of a high pain tolerance, a dancer may delay medical
intervention (Hamilton et al. 1992; Tajet-Foxell and Rose 1995).
Delayed-onset muscle soreness versus injury
Through their careers, dancers learn to recognize the difference between the delayed-
onset muscle soreness that normally accompanies a physically demanding workout and
the pain or symptoms that indicate injury. Delayed-onset muscle soreness is muscle
stiffness that may develop 24 to 36 hours after intense or unaccustomed physical activity.
11
Delayed-onset muscle soreness is a normal part of a physically challenging training
program. It does not usually limit further activity and subsides within a few days. Muscle,
tendon, or ligament injuries typically have a more rapid and localized onset of pain and
require much longer (weeks or months) for full recovery. Because dancers commonly
experience delayed-onset muscle soreness, there is a danger that they may not recognize
pain caused by injury as such. Therefore, dancers are at risk of further aggravating
injuries by continuing to train or rehearse in the same way.
Factors contributing to injury
The high incidence of injury in dancers has been attributed to:
• excessive dance training at an early age (before puberty)
Part 3: Dancers and musculoskeletal injury (MSI)
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers� � � 37

• extensive and intense rehearsal

• the physical characteristics of footwear
• dancing on pointe
• the dietary habits common to dancers
(Reid 1988)
The effects of excessive and intense rehearsal are compounded by:
• overtired or overworked dancers
• inadequate warm-up
• unstable or unsuitable flooring
• cold environments
(Bowling 1989)
Faulty technique has been implicated as a major problem and contributor to injury
(Maran 1997; Guierre 2000). Injuries because of faulty technique tend to recur even when
rest and rehabilitation are successful in treatment of the initial injury. Each time a dancer
resumes dancing with incorrect technique, the dancer may be reinjured. This scenario
illustrates the importance of long-term dance training that includes a focus on correcting
faulty technique.
The combination of high physical, mental, and environmental demands is thought to
contribute to the high incidence of injury in dance (Smith, Ptacek, and Patterson 2000).
The mental demands of dance can manifest as both physical stress (for example, muscle
tightness or hyperventilation) and mental anxiety. Both of these factors are known
contributors to injury (Smith, Ptacek, and Patterson 2000; Hamilton et al. 1992). Treating
stress disorders in dancers has been shown to reduce the incidence of injury (Maran
1997). The dancer’s stress level may also be influenced by interpersonal conflicts among
individuals in the dance environment.
Rest and proprioception
Rest after injury, particularly lower limb injury, plays an important role in maintaining or
restoring proprioception.Pr opri ocepti on relies on sense organs in the joints to provide
awareness of the joint’s position, which is critical for posture, balance, and coordinated
movements. Proprioception is important for dancers who are trying to coordinate difficult
choreography and to balance in difficult positions. Postural stability requires adequate
proprioception from the ankle joint. Proprioception is decreased for several weeks in
dancers who have sprained their ankle, but will gradually improve as the injury heals.
12
Dancers with ankle injuries have decreased postural stability and are more likely to suffer reinjury if
they return to dancing before regaining full proprioception (Leanderson et al. 1996).
Types of MSI
The most common dance MSIs are strains, sprains, and bone disorders affecting the back
or lower extremities (Bowling 1989; Kadel, Teitz, and Kronmal 1992; Khan et al. 1995).
The majority of dance injuries are to the hip, knee, ankle, and foot. The lower limb is
particularly vulnerable to injury for dancers because of the stress and strain that dance
requires of this area (Milan 1994; Khan et al. 1995). The high incidence of lower
Part 3: Dancers and musculoskeletal injury (MSI)
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers� � � 38

extremity injury has been attributed to forcing turnout and dancing on pointe in classical
ballet dancers (Khan et al. 1995).
Approximately two-thirds of dance injuries are overuse and misuse injuries to the soft
tissue (Bowling 1989; Milan 1994). Although soft tissue injuries are generally associated
with full recovery within six to eight weeks, this is not typically the case for dancers,
whose injuries often become chronic (47–60% of injuries) (Bowling 1989; Milan 1994).
Chronic injuries are most likely to affect the back, neck, and lower extremities of dancers
(see Table 2).

Table 2
Body parts affected by chronic injuries in dancers
Body part injured Percentage of chronically
injured dancers

Back or neck 29

Ankle 20

Knee 17

Thigh or leg 16

Hip, groin, or rib 6

Foot or toes 6

Upper extremities 6

(Adapted from Bowling 1989)

The majority of soft tissue dance injuries occur at performances or rehearsals (see Table
3). This suggests that the environmental, psychological, and physical factors affecting the
dancer during performance or rehearsal increase the risk and incidence of injury. Dancers
are more likely to push their physical limits during performance or rehearsal. Dancers
may also experience high levels of physical and mental anxiety that result in tight
13
muscles. Inadequate warm-up contributes to an increased risk of injury.
Environmental
factors that may affect dancers are the types of floors and temperatures in theatres.
Table 3
Location of injury occurrence
Location Percentage of dancer injuries

Performance 32

Rehearsal 28

Class 16

Slow onset — multiple locations 7

Unknown 17
(Adapted from Bowling 1989)
Part 3: Dancers and musculoskeletal injury (MSI)
References
Bowling, A. 1989. Injuries to dancers: Prevalence, treatment and perceptions of
causes.
British Medical Journal 298 (6675): 731–734.
Guierre, A. Ballet dancers’ injuries: A review of literature.
<www.home.worldnet.fr/~aguierre/> (October 1, 2000).
Hamilton, W., L. Hamilton, P. Marshall, and M. Molnar. 1992. A profile of the
musculoskeletal characteristics of elite dancers. American Journal of Sports Medicine
20:267–273.
Kadel, N., C. Teitz, and R. Kronmal. 1992. Stress fractures in ballet dancers.Amer ican
Journal of Sports Medicine 20 (4): 445–449.
Khan K., J. Brown, S. Way, N. Vass, K. Crichton, R. Alexander, A. Baxter, M. Butler,
and J. Wark. 1995. Overuse injuries in classical ballet. Sports Medicine 19 (5): 341–
57.
Leanderson, J., E. Eriksson, C. Nilsson, and A. Wykman. 1996. Proprioception in
classical ballet dancers. American Journal of Sports Medicine 24 (3): 370–373.
Maran, A. 1997. Performing arts medicine. Royal College of Surgeons of Edinburgh.
Milan, K. 1994. Injury in ballet: A review of relevant topics for the physical therapist.
Journal of Orthopaedic Sports Physical Therapy 19 (2): 121–129.
O’Malley, M., W. Hamilton, J. Munyak, and J. DeFranco. 1996. Stress fractures at the
base of the second metatarsal in ballet dancers. Foot and Ankle International 16 (3):
89–146.
Smith, R., J. T. Ptacek, and E. Patterson. 2000. Moderator effects of cognitive and
somatic trait anxiety on the relation between life stress and physical injuries.Anxi et y,
Stress and Coping13: 269–288.
Tajet-Foxell, B., and F. Rose. 1995. Pain and pain tolerance in professional ballet
dancers. British Journal of Sports Medicine 29 (1): 31–34.
Whitting, W., and R. Zermick. 1998. Biomechanics of musculoskeletal injury. Windsor,
Ont.: Human Kinetics Publishing.
14