And the Dance Goes On: Psychological Impact of Injury
Lynda M. Mainwaring, Ph.D., C.Psych., Donna Krasnow, M.S., and Gretchen Kerr, Ph.D.
Journal of Dance Medicine & Science, Volume 5, Number 4, 2001.
This review provides a glimpse into the
dancer’s psychological reaction to physical
injury. Based on the current evidence, dancers’
reactions to injury involve initial negative
affects that may become more positive
as the injury heals. Dancers with chronic
or overuse injuries are more likely to ignore
the injury, sometimes to the point of more
severe damage and psychological distress.
There is evidence that the impact of injury
may vary across different types of
injury (acute, chronic, overuse, recurrent),
individual differences in personality,
levels of knowledge and available information
about injury and recovery, and
styles of coping and social support. Dancers
continue to dance with injury, pain
and discomfort, perhaps to avoid the “disruption
of self ” that emanates from injury,
and perhaps because of the embedded
subculture in dance that embraces
injury, pain, and tolerance. Some implications
of these findings for future research,
teaching, and clinical practice are
Since approximately 1975,
information on the nature,
incidence, prevalence, and risk
factors of dance injuries has
multiplied. Even though dance is not
a high-risk activity, research shows
that most dancers have experienced
injury during their careers.[2-5]
Different dance forms seem to
promote different patterns of injury.
For example, injuries to the foot,
ankle, knee, and back are common in
ballet,[1,5-7,9] knee and back injuries are
more frequently reported by modern
dancers,[1,6,8,10] and sesamoiditis is
common in flamenco. Whatever the
dance form, there is risk of injury,
depending on extrinsic factors (e.g.,
training environment, floor surface,
shoe condition, and performance and
rehearsal schedule) and intrinsic
factors (e.g., age, personality, fatigue,
psychological stress, and social
support). Dance medicine, and the
budding field of dance psychology,
have only recently begun to address
the psychological precursors and
sequelae of injuries in dance. A few
empirical studies have examined
psychological factors that may be
associated with injury
occurrence;[7,12,13] however, very little
research exists regarding the
psychological impact of injury on the
dancer. Despite this current gap, it is
evident from existing studies,[4,13-16]
clinical observation, and anecdotal
accounts that physical injury
concurrently affects a dancer’s
psychological and social health and
Only in the last few years has
dance psychology emerged as an
area of scholarly activity. It follows
the lead of sport psychology, yet has
distinct issues for examination.
Dancers face unique challenges in
terms of the injury and rehabilitation
experiences. To begin with,
dancers are reluctant to acknowledge
being injured for fear of being
replaced in a performance and losing
potential income. There is pressure
from choreographers, peers,
and the dancers themselves to continue
to rehearse and perform despite
pain and injury, simply because
the show must go on. When
dancers do seek treatment for their
injuries they tend to pursue nontraditional
modalities. They too often
feel misunderstood and inadequately
treated by medical professionals, who they believe lack an
appreciation of the dance world.
Thus, dancers have quite different
values and priorities from people in
mainstream careers. In what other
profession does one train for 10
years or more, investing time,
money and energy, with the knowledge
that gainful employment is
uncertain and that even success may
involve living at poverty levels?
Recently researchers have begun
to investigate these matters. This
special issue of this journal is evidence
of the topic’s importance, and
the dance medicine and science
community’s commitment to understanding
and advancing matters
germane to the psyche of dancers in
relation to injury prevention, education,
and treatment. This study
will provide an overview of the current
state of knowledge regarding
the psychological and psychosocial
impact of injury on the dancer. Existing
scientific information is reviewed,
followed by an overview of
implications for research and practice.
Psychological Reactions to Athletic Injury
We can look to sport psychology to
begin to understand the psychological
consequences of injury for the
dancer. In the 1980s investigators
began to explore athletes’ reactions
to injury and rehabilitation.[17-21]
They started by examining the postulate
that the reaction to sport injury
is the same as the grief reaction
associated with death and dying.
Elizabeth Kubler-Ross’ five-stage
theory (shock/denial, anger, bargaining,
depression, and acceptance)
was presumed to describe an
athlete’s psychological experience
following injury. However, this presumption
proved not to be supported
by empirical evidence; it was
based solely on anecdotal evidence
and speculation. Over the past 12
years research has flourished concerning
the psychology of athletic
injury. Numerous studies have investigated
the impact of injury,[20-25]
and theory development is well underway.
[22-26] Evidence strongly suggests
that Kubler-Ross’ theory does
not explain an athlete’s reaction to
physical injury; however, one still
may stumble upon written and verbal
discussions that endorse a similarity.[27,28]
Empirical studies, both quantitative
and qualitative, suggest that
there are cognitive, emotional, and
social consequences of sport injury.
[22,24,29-31] Injured athletes experience
a variety of emotions that are
initially, and primarily, negative,
followed by moments of optimism.
 Andersen and Williams
proposed a stress response model
that hypothesizes the following factors
as influences on injury occurrence:
personality (e.g., competitive
trait anxiety, locus of control, hardiness,
history of stressors (previous injuries,
life events), and coping resources
(social support, coping behaviors).
A number of studies have
supported their model. Wiese-
Bjornstal and colleagues developed
an integrated model of response to
sport injury that builds on Andersen
and Williams’ pre-injury model.[26,22]
This model depicts factors hypothesized
to influence athletes’ response
to injury (person factors such as injury
experience, and individual difference
factors such as psychological,
demographic, and physical
factors), as well as features of the
actual response (cognitive, emotional,
and behavioral). Brewer developed
a cognitive appraisal model
of psychological adjustment to athletic
injury. It suggests that personal
and situational factors lead
first to a cognitive appraisal of the
injury, which in turn leads to an
emotional response, and then a behavioral
response to injury and rehabilitation.
According to Brewer,
cognitive appraisal models account
for individual differences in response
to injury, whereas grief models
do not. Consistent with stress
and coping models, cognitive appraisal
models focus on the cognitive
interpretation of injury. Data
driven models that describe the experience
of injury from the athletes’
perspective have been offered by
Rose and Jevne and by
Mainwaring. Rose and Jevne proposed
four phases in the impact of
injury: getting injured, acknowledging
the injury, dealing with the impact
of the injury, and achieving a
physical and social outcome.
Mainwaring’s model suggests an interaction
between the injured athlete’s experience of injury (the
person) and the environment (the
situation), and depicts a holistic reaction
that is multidimensional
rather than linear. It outlines psychological,
physical, and social consequences
and experiences of injury.
All of the models cited are based on
empirical and clinical evidence, and
none support Kubler-Ross’ grief
theory as relevant for injured athletes.
In essence, the current empirical
work on the impact of athletic injury
reveals that athletes view injury
as stressful, and its consequence may
disrupt an athlete’s sense of identity.
 For first-time serious injuries,
athletes experience shock, frustration,
depression, anxiety, fear, and
anger in the first few weeks post injury.
[4,24,25,31,34,35] Fluctuations in
negative and positive emotion occur
in relation to daily events and
progress in rehabilitation. Optimism
and happiness are often associated
with perceived gains in rehabilitation,
[24,36,37] whereas the
corollary – greater pain, frustration,
fear, and pessimism – may be experienced
in relation to decreases in
range of motion. Athletes seem to
cope differently with second-time or
third-time injuries than they do
with first-time injuries, and differently
with chronic and acute injuries.
 Johnson reported that multiply-
injured athletes had greater
capacity to accept injury, higher levels
of social orientation and activity,
and less anxiety about subsequent
injuries than did first-time
injured athletes. In addition, they
experienced injuries as less stressful
and threatening. Johnson suggests
that experience with severe injury facilitates certain psychological and
psychosocial qualities: belief in one’s
own inherent capacity to proceed
through rehabilitation, the power to
cope actively with and master the
stressful injury experience, and the
ability to maintain contact with
friends and family. Smith found that
seriously injured athletes had significantly
more tension, depression,
and anger, and lower vigor, than
those with less serious injuries. In
general, the emotional reaction to
severe athletic injury involves increased
depression, anger, frustration,
[31,41] shock,[24,27] fear,[24,29,35,37] and
The methodologies used to examine
athletes’ reactions to injury
have varied in type and quality.
Most of the early research involved
case studies and retrospective selfreport
studies. More recently, strong
research designs have provided a
clearer understanding. Large-scale
prospective control group studies
have shown a change in emotional
profiles pre-injury and post-injury.
For example, Leddy and associates
showed that when compared to preinjury
measures, injured athletes
were more fatigued and depressed,
and less vigorous. In addition,
there have been prospective studies
that examined the injured athlete’s
personal struggle, particularly with
anterior cruciate ligament injuries.
[24,29,37] For the most part, the research
on impact of injury in the
sport psychology literature has been
conducted with methodological
rigor, and reveals a general picture
of how athletes respond to injury.
The details of that picture are being
explored through continued inquiry.
The field of sport psychology has
also examined the role psychology
can play in injury rehabilitation.
Numerous suggestions for psychological
intervention have emerged
from clinical experience,[7,19,21] current
empirical research, and studies
that specifically examine rehabilitation
issues.[42-46,48] In general, the
guidelines to facilitate recovery are
a blend of sound clinical psychology
practice and sport psychology
strategies that have been used for
performance enhancement (goal
setting, relaxation, positive self-talk,
and so forth).[49,50]
Psychological Impact of Dance Injury
The psychological impact of injury
on the dancer involves a number of
personal and situational factors. As
a point of reference for the following
discussion these factors are represented
schematically in Figure 1.
Recent research in dance medicine
and science provides evidence
that a variety of injuries in dance
are common, if not inevitable.[1,13,51]
Often injuries are ignored by the
dancer and frequently not reported
to a physician.[53,54] Research
that explores psychological and psychosocial
sequelae of dance injury
may uncover a rationale for such
behavior. A high prevalence of
dance injuries has been revealed in
studies that used self-report, rather
than medical diagnosis, to identify
injury. One prospective study reported
that 38 of the 39 dancers in
the subject base (97%) were injured
during the course of the investigation,
with a mean of 2.4 injuries per
dancer.54 Macchi and Crossman
found that all 26 of the dancers they
interviewed had been injured at
least once during their career, with
a mean injury rate per dancer of 2.7
(range: 1 to 5 injuries). In a similar
age group, Krasnow and coworkers
reported that 15 of 16 ballet
dancers (94%) and 15 of 19 modern
dancers (79%) were injured.
Type and incidence of injuries
vary across dance forms and age.
Schafle and colleagues reported that
of 3,251 dance-related injuries,
55% were seen in ballet, 15% in
modern, and 30% in aerobic dancers.
The greatest proportion of ballet
injuries was found in 13 to 18
year olds. The authors reported that
43% of the ballet injuries occurred
in dancers younger than 16 years of
age. A closer inspection of the intrinsic
factors associated with injuries
across genre and age may provide
insight into injury patterns and
the barriers to reporting and treatment.
We know that the great majority
of injuries in dance are overuse injuries,
[1,56] which tend to be accompanied
by pain and discomfort, a
lack of understanding for the injury,
and psychological sequelae that
typically are unrecognized or ignored.
 Theatrical dance has
evolved a “culture of tolerance” concerning
injury and pain that encourages
dancers to dance through,
around, and in spite of injury. If the
physical injury is ignored, the psychological
impact of injury clearly
has not been, and probably will not
be, addressed. With the increased
attention to the nature and prevalence
of dance injuries, along with
the research on psychological aspects
of athletic injury emanating
from sport psychology, an appreciation
for the emotional side of injury
has evolved in the dance science
The emotional reaction to injuries
sustained by dancers has been investigated
in three studies to date.[4,7,14]
Similar to the findings in sport psychology,
dancers’ emotions immediately
post-injury are negative and
progress to more positive feelings
with recovery. Macchi and
Crossman examined the impact of
injury on 26 professional ballet
dancers between the ages of 12 and
21. Retrospective accounts of injuries
were collected through semistructured
interviews, and revealed
that the predominant emotions recalled
for the initial period after injury
(typically ankle and back
sprains) included frustration, fear,
distress, anger, and depression. Several
dancers indicated that they were
initially afraid of the reaction of others
(teachers, staff, parents, and
other dancers), and what impact the
injury would have on their career.
Watching class provoked feelings of
guilt and anger. During rehabilitation,
reactions varied from optimism
about resuming their careers
to pessimism about the severity of
the injury and time needed to recover.
Macchi and Crossman’s qualitative
study provided information
regarding dancers’ recollections of
reactions to injuries incurred over
their careers. The authors emphasized
that one of the main limitations
to their research is the bias
inherent in retrospective self-reports.
Another limitation is the heterogeneity
of the type and severity
of injuries. Consequently, we cannot
discern from this research
whether the reactions noted are to
mild, moderate, severe, overuse,
acute, chronic, or recurrent injuries,
nor whether reactions to a severe
back strain, for example, are commensurate
with those to an ankle
Mainwaring and Krasnow interviewed
two young injured dancers (16
and 18 years of age) whose retrospective
accounts of their chronic debilitating
hip injuries revealed a preponderance
of negative emotions throughout the injury period. For
both, there was a mix of anger, uncertainty,
jealousy, frustration, anxiety,
feelings of alienation, depression,
guilt, self-doubt, disappointment, and
fear. In these cases the dancers also
experienced anger, guilt, and distress
about watching others dance. In addition,
they continued to perform
movements that evoked pain that was
recognized as a sign that something
was wrong. Both dancers experienced
coping difficulties that resulted in
psychotraumatic distress, manifested
by an attempted suicide in one case
and depressive episodes and disordered
eating in the other. One of the
dancers also went through bouts of
self-mutilation, in the form of selfcutting,
and used clothing to hide the
symptoms. The severity of the negative
psychological impact on the lives
and experience of these two young
aspiring dancers is obvious, but one
must be cautious in attributing these
traumatic experiences to the injury
occurrence alone. The dancers’ recollections
and perceptions were made
available because of their willingness
to share their experiences of injury in
an interview; it was not a psychological
Liederbach and colleagues followed
12 professional ballet dancers
(6 female and 6 male, with mean
ages of 24 and 26, respectively) for
5 weeks of an intensive season.7 At
injury onset they found increased
fatigue and inertia, decreased vigor
and energy, and increased secretion
of urinary catecholamines, a measure
of sympathoadrenal activity,
and thus stress. The majority of the
injuries (75%) were categorized as
“overuse injuries.” The authors concluded
1. The increase in catecholamine
“may be a reaction to performance-
and/or physiological stress,”
2. Injury trends in their study appeared
to be closely tied to
time-specific onset of performance-
and physical stress.
We cannot determine cause and effect
from this study, but it certainly
points to some interesting associations
between the physical and psychological
precursors and reactions
to injury. The study of psychophysiological
indicators of the stress response
associated with injury is an
area that sport psychology is pursuing
currently, and dance science has
Pain is an obvious psychosociophysiological
reaction to injury. What is familiar to the dancer and
clinician is finally gaining the respect
of scientific investigation. Tajet-Foxell and Rose found that
dancers, like athletes, exhibited
higher pain thresholds and tolerance
than non-dancers. These investigators
suggested that the “mostlikely”
explanation is the higher exposure
to fitness and training, and
thus higher circulating endogenous
opioids, for elite performers compared
with a control population.
However, they cautioned that one
should not overlook a possible psychological
explanation that attributes
higher pain thresholds in
dancers and athletes to their familiarity
with the interface between
physical activity and pain. They suggested
that the multidimensional
study of pain in dancers and athletes
has received insufficient attention,
and that studies using threshold
measures only may not reveal a
complete picture, nor lend themselves
to correct interpretation.
They concluded that “the meaning
of pain, the importance of acknowledging
pain and of learning how to
respond to it, should be targeted as
early as possible in a dancer’s training.”
Ramel and associates reported
that older ballet dancers, despite an
increase in age and workload, do not
report more incapacitating pain
than their younger colleagues.59
Similarly, Encarnacion and coworkers
found no difference in pain coping
styles among groups of 135 ballet
dancers of varied skill levels.
Again, this research suggests that
dancers, regardless of skill or age, are
trained to cope with pain and injuries
in a particular way. The authors
also noted that ballet performers
exhibited lower coping and cognitive
skills and higher catastrophising
responses than recreational runners,
high school and collegiate intramural
athletes, rodeo performers, and
elite equestrians. In short,
Encarnacion and coworkers suggested
that ballet dancers do not
exhibit pain coping styles similar to
those of other sport performers.
However, it needs to be acknowledged
that the assessment of pain
and coping styles is not uniform
across studies: there are numerous
measures of pain and coping. In
addition, the study by Encarnacion
and coworkers did not account for
current injuries, time of season, history
of injuries, or type and severity
of injury – all issues that have
impact on the injury experience and
its evaluation. Moreover, the instrument
used in this case was the Sports
Inventory for Pain (The SIP), which
“measures 5 sub-scales relevant to
competition” (not aesthetic activity),
and may not be a valid measure
of pain and coping issues in
dance. For example, the authors
state that the coping sub-scale
“seems to measure the extent to
which an athlete utilizes ‘direct’ coping
strategies. High scorers tend to
ignore pain, realize that pain is part
of competition, and in general tend
to ‘tough it out.’” Furthermore,
this questionnaire does not differentiate
between first-time or subsequent
injuries, or chronic or acute
It seems reasonable, given that
dancers suffer more overuse injuries
than athletes, to postulate that dancers,
or those who suffer overuse injuries
in general, cope quite differently
than those who suffer
traumatic injuries. Living day to day
with pain and discomfort wears on
the body and psyche such that it is
likely that different coping styles or
strategies are developed (it has been
suggested previously that persistent
daily hassles are much more detrimental
to the body’s immune system
than are acute bouts of stress).
Consequently, research into pain
and coping of dancers needs to address
the unique issues and circumstances
of dancers. Stating that
dancers have lower coping and cognitive
skills and higher
catastrophising scores than athletes
probably promotes an inaccurate
idea that dancers do not cope with
injuries as well as athletes do. The
truth of the matter lies in the assessment
of pain and coping in relation
to all the important moderator
variables (type and severity of
injury, history of injury, and so
forth), and to what is known of the
dance population itself, especially if
the personality of a dancer varies
from that of an athlete. As an example
of this approach, Pedersen
and Wilmerding suggested that flamenco
dancers are not well apprised
of injury prevention and rehabilitation
techniques, and consequently
continue to dance despite painful
injuries. Sesamoiditis is such a
common problem for this population,
the authors reported, that
many dancers do not consider it an
injury. Hence, the habit of ignoring
pain may simply be a by-product
of the dance form.
With the adolescent dance population
specifically, there is risk of the
1. Young dancers having insufficient
knowledge of injuries,
anatomy, and the injury-andrecovery
process to manage their
injuries themselves, and
2. Students hiding pain in their attempt
to please or gain the approval
of their teachers, and
thereby exposing themselves to
Consequently, research into the pain
and coping experiences of dancers
across age groups would be useful.
The Role of Person Factors
The role that person factors, such
as personality, motivation, identity,
and injury history, play in recovery
from dance injury has not been well
established. Few studies have examined
the relationship between personality
and injury. Krasnow and
colleagues explored the relationships
among perfectionism, stress, and
injury. They found differences
among sub-scales of perfectionism,
negative and positive stress, and injury.
The authors recommended further
research of psychological correlates
of the stress-injury
It is clear from the literature on
illness and health that a person’s disposition
plays a major role in rehabilitation.
For example, optimists
tend to cope more effectively after surgery[63-69] and after athletic injury.
 Similarly, hardiness has been
found to be negatively associated
with total mood disturbance in relation
to athletic injury. Observation
reveals that dancers exhibit hardiness
in relation to overuse injuries
in that they often endure pain and
discomfort in order to rehearse and
perform. The following quotation
from two experts in dance medicine
and science (one a former dancer)
alludes to this personality trait:
To survive and ascend, a dancer
must be self-analytical and selfcritical
virtually to a fault. For
dancers, dance is more than an
art; it is an all-consuming
lifestyle. The aesthetic, the technique,
the teachers, and perhaps
most importantly, the dancer
must constantly push to exceed,
to overcome, to persist and to
persevere. The love of dance and
desire to dance are intrinsic to
dancers of all levels and talent.
Many have sacrificed so much
just to have those few moments
of pure movement where the
physical price was no measure of
the artistic reward.
The image one has of oneself, or
identity, is often defined by one’s
work. For dancers, their work is their
dancing: it is a way of life that defines
who the dancer is. Therefore, any barrier
to self-expression and movement
may be a threat to a dancer’s identity.
Identity is the most examined person
factor in recovery from athletic
injury. The research suggests that the
more narrowly defined the sense of
self, the more threatened the athlete
will be by any challenge to identity.
In the case of injury, the more an
athlete’s self-identity is linked to his
or her role as athlete, the more likely
reactions to injury will be negative
(e.g., feelings of anxiety, depression,
or hopelessness).[31,33] The fundamental
loss of self that accompanies
chronic illness or injury[69,70] or athletic
injury,[24,71] and the context within
which this happens, has been well established
in the sport sociology research.
[71,72] Moreover, the concept “restoring
the self ” after injury is an
emergent theme in the psychology
and sociology literatures[24,71] that has
implications for rehabilitation and
treatment. These implications will be
discussed in a later section.
Shaffer found that prior experience
with successful rehabilitation
had a positive impact on assessments
of ability to manage subsequent
injury. This is consistent
with social learning theory and research,
which indicates that self-efficacy
(the belief that one can accomplish
a particular task) is an
important mediator of behavior.
A few trends have been identified
with respect to the medical and psychosocial
issues of injury reporting
and treatment. Pedersen and
Wilmerding suggested that most
foot injuries were not reported to
or treated by a physician. Similarly,
Kerr and associates found that only
20% of the injuries identified by
university dancers were reported to
a physician. In the latter study, the
dancers indicated that they did not
feel comfortable seeing a physician
because they perceived that their
situations and injuries would not be
understood, and that they would be
told to stop dancing regardless of
the severity of the injury. In general,
there was a lack of confidence in
Ryan and Stephens in their 1988
book wrote that:
until very recently there was
little information about the
causes, nature and appropriate
treatment of dancers’ injuries
available to physicians. As a consequence,
dancers may have had
difficulty in finding physicians
who had good understanding of
their situation and their particular
They indicate that the same was true
years ago of athletes and physicians.
“Both have learned from cultivating
these relationships, and the same
thing is possible for dancers.”68
Clearly, the lack of information and
understanding about the nature of
both the physical and psychosocial
impact of dance injuries has affected
the treatment available to dancers.
Most dancers have not been afforded
the luxury of a practitioner
who once danced or who specializes
in dance injuries. Consequently, the
field of dance medicine and science
serves a vital educational function
in the lives of dancers and those who
treat them. As Trepman points out,
“the primary goal of the emerging
field of dance medicine and science
is improved prevention, diagnosis,
treatment, and rehabilitation of
From a psychological perspective,
it is important for dancers to be understood
by their practitioners, as
dancers want to feel comfortable
knowing that their medical personnel
and teachers understand their
injury, lifestyle, and the implications
of the injury for their participation
in dance. They do not want
to be told to stop dancing, and they
want the practitioner to understand
that, unlike some athletes, dancers
do not have an “off season.” Dancers
often rehearse for large shows or
a series of shows in a concentrated
period, so that a two-week break
from practice, which may seem negligible
to the medical person, may
well seem catastrophic to the dancer.
Reporting and treatment of injuries,
or lack thereof, is very much tied to
psychological and psychosocial issues
such as personal beliefs, perceived
risks, available social support,
and the culture of tolerance. Assessment
and treatment of injuries
should include a careful history and
consideration of intrinsic factors,
such as “associated illness, nutrition,
cultural de-conditioning, and psychosocial
Stress, Injury, and Social Support
A relationship has been demonstrated
between increased stress and
injury in sport[19,76-79] and dance.[7,13]
Evidence from research on dance
injury suggests that negative life
stress (events such as a difficult relationship with a peer or teacher that
are interpreted by the individual as
negative) is related to duration of
injury, maladaptive sub-scales of
perfectionism, injury onset, and
the number and severity of injuries
in dance. Garrick and Requa
found that 23% of the dancers in
their study accounted for 52% of all
injuries and hypothesized that there
may be potential injury vulnerability
factors with respect to injuries
sustained. They suggested a need
for more research into the risk factors
associated with injuries to dancers.
To answer this call, Patterson and
colleagues investigated, prospectively,
the relationships among stress, injury, and social support.
Consistent with the research showing
that social support has a buffering
effect on stress, their results suggested
that high negative life stress
and low social support may place
dancers at increased risk for injury.
[82-84] Their finding that negative
life stressors (also defined as
“microstressors” or “daily hassles”)
are related to injuries only in dancers
who report low levels of social
support speaks to the importance of
promoting supportive environments
in order to buffer the impact
of stress. It follows that social support
is an important ingredient in
the management of dance injuries.
Research and related dancers’ experiences
indicate that dancers often
do not receive sufficient social support
once injured.[13,14] Injury is a
disruptive life event for most and,
for some dancers, a traumatic life
event. Logically, if negative life
events contribute to the onset of
injury (as research indicates), an
injury would, in turn, compound
the negative stress. Therefore, it is
not surprising that dancers experience
negative mood states after an
Given what we know about
stress, injury, and reactions to injury,
it is critical that injured dancers
perceive that they are getting
adequate social support. Peers,
dance educators, dance companies,
friends, choreographers, medical
personnel, and loved ones can facilitate
injury recovery by supporting
the injured dancer. What, then,
constitutes appropriate social support
for the injured dancer?
Mainwaring found that a group of
athletes with severe knee injuries did
not appreciate certain kinds of
help. For example, most did not
like sympathy or being viewed as
“disabled,” and they especially abhorred
having doors held open for
them when they were on crutches.
It may be that, for injured dancers,
appropriate social support means
helping them to rest or modify their
training according to sound medical
advice. Time spent with peers
may also be crucial, especially when
that involves events other than
merely observing classes and rehearsals.
As we have acknowledged, most
dancers continue to dance despite
injuries, or hasten their return to rehearsal
or performance to their own
detriment, because they perceive
that “others” expect them to continue
to work through the injury.
Appropriate social support and understanding
is critical. It may well
be the friend, the artistic director,
or the practitioner who validates the
emotional upheaval and the “disrupted
sense of self ” that accompany
injury. Giving the dancer assurance
that there will not be
negative judgments surrounding
time off or work modifications may
be an essential element of support.
Culture of Injury, Pain, and Tolerance
The dance community subscribes to
a subculture that reinforces certain
beliefs and values about pain, tolerance,
perseverance, and accepting and ignoring injury. This systemic
“culture of injury, pain, and tolerance”
encourages behavior that predisposes
the dancer to risk of injury
(primarily overuse) and chronic
pain. A similar subculture has been
well documented recently in
sport.[71,72,85] Nixon suggested that
injuries and pain are normal in sport
and that athletes are exposed to a:
set of beliefs about structural
constraints, structural inducements,
general cultural values and processes of institutional
rationalization and athletic socialization
that collectively convey the message that they
ought to accept the risks, pain
and injuries of sport.
The culture of dance, like sport,
also encourages dancers to be constantly
aware of their body image,
weight, and food intake. Hence,
when injury requires a dancer to
reduce or modify training, weight
gain is often a concern. Dancers frequently
will equate the loss of
muscle tone that may accompany
injury with “getting fat.” Consequently,
caloric intake may be reduced
to dangerous levels. The relationship
between eating disorders
and injury onset has been established,
[88-90] but disordered eating as
a consequence of injury has not yet
Implications for Research, Teaching, and Clinical Practice
It is evident from this review that the
psychological impact of physical injury
on dancers is not well understood,
and is only just beginning to
be addressed in current research. This
has broad implications for the dancer,
the educator, the clinician, and the
scientist. First, we need to understand
the reaction to injury from a dancer’s
perspective. There are issues unique
to dancers that may influence psychological
reactions, and thus physical
Directions for research are multifaceted
and include the identification
of the following:
• Subjective experiences of dance
• Personality correlates of stress
• Psychophysiological markers of
stress throughout the injury
• Coping styles and strategies;
• Moderator variables for pain experiences in dance (e.g., the
meaning of pain to the individual);
• Differences in emotional reactions
to acute and overuse injuries;
• Appropriate and accepted forms
of social support following
• Systemic factors that contribute
to a subculture of injury, pain,
• Issues of eating behaviors after
• Education and intervention
strategies for psychological
management of dance injuries.
These are exciting opportunities for
From an educational perspective,
recommendations and materials from
research, experience, and clinical expertise
should be developed to help
the dancer manage the psychological
reaction to injury. For example,
Mainwaring and Krasnow suggested
a variety of approaches for the dance
teacher or choreographer dealing with
an injured dancer, including educating
and assisting the dancer to better
understand how to modify dance activities
during the rehabilitation period
in a manner that still allows for
improvement, and continuing verbal
support and correction. Giving the
dancer more say about the use of a
temporary understudy replacement,
thereby reducing the fear that his or
her part will be permanently lost, may
be important. If the dancer is totally
unable to participate, the teacher can
ask her or him to assist in classes,
coach other students outside class
time, and assist in rehearsals (taking
and giving notes, coaching other
dancers who are struggling with sections
of the work, and similar roles).
Reactions to watching class vary in
each individual, and the teacher
should allow the dancer to use class
time for activities such as physiotherapy
or personal work if she or he
is one who finds passive observation
depressing and frustrating rather than
useful. Further suggestions include
giving the dancer readings and film/
video viewing to sustain interest and
motivation, encouraging imagery
work, engaging in discussions with
medical personnel and family (making
sure to include the dancer in these
exchanges), and establishing realistic
goals with the dancer, in concert with
the medical personnel.
Clinical management of injuries
could be facilitated with a greater appreciation
of the psychological sequelae
of injury. For example, dancers
want to feel that their practitioner
understands that refraining from
dance is not the best option for them
and their lifestyle. The dancer-practitioner
relationship is an important
element in adherence to rehabilitation;
an understanding of the psychological
context of injury can facilitate
that relationship. The following excerpt
from Ryan and Stephen’s book
promotes the whole person and
multidisciplinary approach to rehabilitation
that incorporates many of
the psychological concepts considered
in this paper:
Whether an illness or injury has
caused a dancer to stop dancing
entirely for a short or long time or
has simply forced him or her to
reduce the workload, his or her
mind should be set on getting back
to normal activity as soon as possible.
Rehabilitation describes that
process in brief, but doesn’t specify
what it means in terms of objectives,
methods and goals and the
persons who must necessarily be
Each step should be in a logical
progression so that it builds on the
preceding steps to move smoothly
towards the stated goal. If surgical
treatment is part of the program
physical therapy may be appropriate
before as well as after surgery.
Psychological counseling for adapting
to the particular surgery should
begin before the surgery. Improvement
of nutritional practices, if
necessary, should not have to wait
until the treatment…has finished.
Contemporary research on dance
injuries is helping to address
longstanding psychological issues and
to improve the multidisciplinary
management of dance injuries. For
example, the book by Solomon and
colleagues expresses the importance of
both the “psyche” and the body in
preventing dance injuries.8 The book’s
dedication is poignant: “To Jean
Erdman, who taught me to teach so
that the individual artist in each of us
could emerge without damage to the
body or psyche. R.S.”8 Appreciating
the impact and sequelae of dance injuries
from a psychological perspective
not only provides us with information
about recovery, but also points
to issues (such as being understood
by practitioners, the reporting of injuries,
and sound teaching practices)
that can be addressed and may facilitate
In general, the information reviewed
here emphasizes that dance
medicine, dance science, and dance
psychology are contributing to a pool
of knowledge regarding injury prevention
and management which endorses
the view that…
the ovation, and…
the dance goes on!
The authors would like to thank Enid K.
Headley, Christine Provvidenza, Jennifer
Jones, and the editors for their comments
and suggestions for earlier drafts of the
paper and the model.
1. Caine C, Garrick J: Dance. In: Caine D, Caine C, Lindner K (eds): Epidemiology of Sports Injuries. Champaign, IL: Human Kinetics, 1996, pp.124-160.
2. Krasnow D, Mainwaring L, Kerr G: Injury, stress, and perfectionism in young dancers and gymnasts. J Dance Med Sci 3(2):51-58,1999.
3. Lewis R, Dickerson J, Davies G: Lifestyle and injuries of professional ballet dancers: reflections in retirement. J Royal Society of Health 117(1):23-31, 1997.
4. Macchi R, Crossman J: After the fall: Reflections of injured classical ballet dancers. J Sport Behav 19(3):221-234, 1996.
5. Macintyre J, Joy E: Foot and ankle injuries in dance. Clinics in Sport Med 2:351-368, 2000.
6. Krasnow D, Kerr G, Mainwaring L: Psychology of dealing with the injured dancer. Med Probl of Perform Art 9:7-9, 1994.
7. Liederbach M, Gleim G, Nicholas, J: Physiologic and psychological measurements of performance stress and onset of injuries in professional ballet dancers. Med Probl of Perform Art 9:10-14, 1994.
8. Solomon R, Minton S, Solomon J: Preventing Dance Injuries: An Interdisciplinary Perspective. Reston, VA: American Alliance for Physical Education, Recreation and Dance, 1990.
9. Solomon, R, Micheli, LJ: Concepts in the prevention of dance injuries: A survey and analysis. In: Shell, CG (ed), The Dancer as Athlete: The 1984 Olympic Scientific Congress Proceedings, 8. Champaign, IL: Human Kinetics Publishers, Inc., 1986 pp. 201-212, 1986.
10. Solomon, R, Micheli, LJ: Technique as a consideration in treating modern dance injuries. Physician and Sportsmedicine 14(8):83-92, Aug. 1986.
11. Pedersen M, Wilmerding V: Injury profiles of student and professional flamenco dancers. J Dance Med Sci 3:108-114, 1998.
12. Hamilton LH, Hamilton WG, Meltzer JD, Marshall P, Molnar M: Personality, stress, and injuries in professional ballet dancers. Am J Sports Med 17:263-267, 1989.
13. Mainwaring L, Kerr G, Krasnow D: Psychological correlates of dance injuries. Med Probl Perform Art 8:3-6, 1993.
14. Mainwaring L, Krasnow D: Psychological response to hip injuries in the young elite dancer. Presented at the International Association for Dance Medicine and Science Conference, Tring, England, October 1999.
15. Hamilton L: A psychological approach to the rehabilitation of injured performers. Orthopaedic Physical Therapy Clinics of North America 6(2):131-143, 1997.
16. Hamilton L, Hamilton W, Warren M: Injury prevention in ballet: Physical, nutritional and psychological considerations. Presented at the Annual APA Convention, Toronto, 1993.
17. Gordon S: Sport psychology and the injured athlete: A cognitive-behavioural approach to injury response and injury rehabilitation. Science Periodical on Research and Technology in Sport, pp.1-10, 1986.
18. Mainwaring L, Galway R: Psychological factors of athletic injury rehabilitation. In: Giam CK, Chook KK, The KC (eds): Conference Proceedings for the 7th World Congress of the International Society for Sport Psychology. Singapore, 1989.
19. May J, Sieb G. Athletic injuries: Psychosocial factors in the onset, sequelae, rehabilitation and prevention. In: May JR, Asken MJ (eds): Sport Psychology: The Psychological Health of the Athlete. New York: PMA Publishing, 1987, pp.157-185.
20. Pedersen P: The grief response and injury: A special challenge for athletes and athletic trainers. Athletic Training 21(4):312-314, 1986.
21. Rotella RJ, Heyman SR: Stress, injury, and the psychological rehabilitation of athletes. In: Williams J (ed): Applied Sport Psychology: Personal Growth to Peak Performance. Palo Alto CA: Mayfield, 1986, pp.343-364.
22. Andersen M, Williams J: A model of stress and athletic injury: Prediction and prevention. J Sport Exer Psych 10:294-306, 1988.
23. Brewer BW: Review and critique of models of psychological adjustment to athletic injury. J Appl Sport Psych 6:87-100, 1994.
24. Mainwaring L: Restoration of self: A model for the psychological response of athletes to severe knee injuries. Canadian Journal of Rehabilitation 12(3):145-156,1999.
25. Rose J, Jevne R: Psychosocial processes associated with athletic injuries. Sport Psych 7:309-328, 1993.
26. Wiese-Bjornstal DM, Smith AM, Schaffer SM, Morrey MA: An integrated model of response to sport injury: Psychological and sociological dynamics. J Appl Sport Psych 10(1):46-69, 1998.
27. Eaton D: A study of the emotional responses and coping strategies of male and female athletes with moderate and severe injuries. Unpublished Doctoral Dissertation, Western Michigan University, 1996.
28. Heil J: Psychology of Sport Injury. Champaign, IL: Human Kinetics, 1993.
29. Granito V, Carroll, J: Psychological response to athletic injury: Themes from intercollegiate athletes. Presented at the Association for the Advancement of Applied Sport Psychology Conference, Nashville, TN, 2000.
30. Leddy MH, Lamber MJ, Ogles BM: Psychological consequences of athletic injury among high-level competitors. Res Quart Exer Sport 65(4):347-354, 1994.
31. Smith A, Scott S, O’Fallon M, Young M: Emotional responses of athletes to injury. Mayo Clinic Proceedings 65: 38-50, 1990.
32. Williams JM, Roepke N: Psychology of injury and injury rehabilitation. In: Singer RN, Murphey M, Tennant LK (eds): Handbook of Research on Sport Psychology. New York: MacMillian, 1993, pp. 815-39.
33. Brewer BW: Self-identity and specific vulnerability to depressed mood. Journal of Personality 61:343-364, 1993.
34. May J. Veach T, Reed M, Griffey M: A psychosocial study of health injury and performance in athletes on the U.S. Alpine ski team. Phys Sportsmed 13:111-115, 1985.
35. Quackenbush N, Crossman J: Injured athletes: A study of emotional responses. J Sport Behav 17:178-187, 1992.
36. McDonald S, Hardy J: Affective response patterns of the injured athlete: An exploratory analysis. Sport Psych 4:261-274, 1990.
37. LaMott, EE: The anterior cruciate ligament injured athlete: the psychological process. Unpublished Doctoral Dissertation, University of Minnesota, 1994.
38. Johnson U: The multiply injured versus the first-time-injured athlete during rehabilitation: A comparison of nonphysical characteristics. J Sport Rehab 5:293-304, 1996.
39. Wasley D, Lox CL: Self-esteem and coping responses of athletes with acute versus chronic injuries. Perceptual and Motor Skills 86:1402, 1998.
40. Smith A: Psychological impact of injuries in athletes. Sports Med 22(6):391-405, 1996.
41. Pearson L, Jones G: Emotional effects of sports injuries: Implications for physiotherapists. Physiotherapy 78:762-770, 1992.
42. Suinn RM: Psychological reactions to physical disability. Journal of the Association for Physical and Mental Rehabilitation 21(1):13-15, 1967.
43. Gordon S, Milios K, Grove R.J: Psychological aspects of the recovery process from sport injury: The perspective of sport physiotherapists. The Australian Journal of Science and Medicine in Sport 23(2):53-60, 1991.
44. Flint FA: The psychological effects of modeling in athletic injury rehabilitation. Doctoral Dissertation, University of Oregon, 1991.
45. Grove JR, Stewart RML, Gordon S: Emotional reactions of athletes to knee rehabilitation. Presented at the annual meeting of the Australian Sports Medicine Federation, Alice Springs, Australia, 1990.
46. Ford IW, Gordon, S: Perspectives of sport trainers and athletic therapists on the psychological content of their practice and training. J Sport Rehab 7:79-94, 1988.
47. Ahern D, Lohr B: Psychosocial factors in sports injury rehabilitation. Clin Sport Med 16(4):755-768, 1997.
48. Williams J, Rotella R, Heyman S: Stress, injury, and the psychological rehabilitation of athletes. In: Williams J (ed): Applied Sport Psychology: Personal Growth to Peak Performance. Palo Alto, CA: Mayfield Publishing Company, 1986, pp.409-428.
49. Wiese-Bjornstal K, Smith A: Counseling strategies for enhanced recovery of injured athletes within a team approach. In: D. Pargaman (ed): Psychological Bases of Sport Injuries. Morgantown, WV: Fitness Information Technology, 1993, pp.149-182.
50. Williams J, Roepke N: Psychology of injury and injury rehabilitation. In: Singer R, Murphey M, Tenant LK (eds): Handbook of Research on Sport Psychology. New York: Mac Milan, 1993, pp. 815-839.
51. Lundon K, Melcher L, Bray K: Stress fractures in ballet: A twenty-five year review. J Dance Med Sci 3:101-107, 1999.
52. Pedersen E, Wilmerding V: Injury profiles of student and professional flamenco dancers. J Dance Med Sci 2(3):108-114, 1998.
53. Bowling A: Injuries to dancers: Prevalence, treatment, and perceptions of causes. BMJ 298:731-734, 1989.
54. Kerr G, Krasnow D, Mainwaring L: The nature of dance injuries. Med Probl Perform Art 7:25-29, 1992.
55. Schafle M, Requa R, Garrick J: A comparison of patterns of injury in ballet, modern, and aerobic dance. In: Solomon R, Minton S, Solomon J (eds): Preventing Dance Injuries: An Interdisciplinary Perspective. Reston, VA: American Alliance for Health, Physical Education, Recreation and Dance, 1990, pp.1-14.
56. Liederbach M: General considerations for guiding dance injury rehabilitation. J Dance Med Sci 4(2):54-65, 2000.
57. Tajet-Foxell B. Rose F: Pain and pain tolerance in professional ballet dancers. British J Sport Med 29(1):31-34, 1995.
58. Melzack R: The short form McGill Pain Questionnaire. Pain 30:191-197, 1987.
59. Ramel E, Moritz U, Jarnlo G: Recurrent musculoskeletal pain in professional ballet dancers in Sweden: A six-year follow-up. J Dance Med Sci 3:93-100, 1999.
60. Encarnacion M, Meyers M, Ryan N, Pease D: Pain coping styles of ballet performers. J Sport Behav 23(1):20-32, 2000.
61. Meyers MC, Bourgeois AE: Predicting pain response in athletes: Development and assessment of the Sports Inventory for Pain. J Sport Exer Psych 14:249-261, 1992.
62. Checkley S: The neuroendocrinology of depression and chronic stress. British Medical Bulletin 52(3): 597-617, 1996.
63. Rietveld B: Dance injuries in the older dancer: Comparison with younger dancers. J Dance Med Sci 4(1):16-19, 2000.
64. Carver CS, Pozo-Kaderman C, Harris SD, et al: Optimism versus pessimism predicts the quality of women's adjustment to early stage breast cancer. Cancer 73:1213-1220, 1994.
65. Fischer CA, Domm MA, Wuest DA: Adherence to sports-related rehabilitation programs. Phys Sportsmed 16:47-52, 1988.
66. Scheier MF, Carver CS: Optimism, coping, and health: Assessment and implications of generalized outcome expectancies. Health Psych 4:219-247, 1985.
67. Scheier MF, Carver CS: Dispositional optimism and physical well-being: The influence of generalized outcome expectancies on health. J Pers 55:169-210, 1987.
68. Ryan AJ, Stephens, RE: Rehabilitation from dance injuries. In: Ryan AJ, Stephens, RE (eds): The Dancer’s Complete Guide to Healthcare and a Long Career. Chicago, IL: Bonus Books. 1988, pp. 160-164.
69. Charmaz K: Identity dilemmas of chronically ill men. Soc Quart 35(2):269-288, 1994.
70. Charmaz K: The body, identity, and self: Adapting to impairment. Soc Quart 36(4):657-680, 1995.
71. Sparkes A: Athletic injury: An Achilles' heel to the survival of self. Qualitative Health Research 8(5):644-664, 1998.
72. Nixon H: Accepting the risks of pain and injury in sport: Mediated cultural influences on playing hurt. Sociology of Sport Journal 10:183-196, 1993.
73. Shaffer, SM: Attributions and self-efficacy as predictors of rehabilitative success. Master's Thesis, University of Illinois, 1992.
74. Trepman E: The treatment and rehabilitation of dance injuries. J Dance Med Sci 4(1):5, 2000.
75. Luke A, Micheli LJ: Management of injuries in the young dancer. J Dance Med Sci 4(1):6-15, 2000.
76. Bramwell S, Masuda M, Wagner V, Homes T: Psychosocial factors in athletic injuries. J Hum Stress 1:6-20, 1975.
77. Cryan P, Alles W: The relationship between stress and college football injuries. J Sports Med 23: 52-58, 1983.
78. Passer, M, Seese M: Life stress and athletic injuries: Examination of positive versus negative events and three moderator variables. J Hum Stress 9: 11-16, 1983.
79. Smith R, Smoll F, Ptacek J: Conjunctive moderator variables in vulnerability and resiliency research: Life stress, social support and coping skills, and adolescent sport injuries. J Pers Soc Psych 58(2): 360-370, 1990.
80. Garrick J, Requa R: Ballet injuries: An analysis of epidemiology and financial outcome. Am J of Sports Med 21:586-590, 1993.
81. Patterson E, Smith R. Everett J, Ptacek J: Psychosocial factors as predictors of ballet injuries: Interactive effects of life stress and social support. J of Sport Behav 21(1):101-111, 1998.
82. Cohen S, Syme SL: Social Support and Health. New York: Academic Press, 1985.
83. Petrie TA: Psychosocial antecedents of athletic injury: the effects of life stress and social support on female collegiate gymnasts. Behav Med 18:127-138, 1992.
84. Sarason IG, Sarason BR, Pierce GR (eds): Social Support: An Interactional View. New York: Wiley, 1990.
85. Kotarba JA: Chronic Pain: Its Social Dimensions. Beverly Hills, CA: Sage, 1983.
86. Pierce E, Daleng M: Distortion of body image among elite female dancers. Percep Motor Skills 87:769-770, 1998.
87. Culnane C, Deutsch D: Dancer disordered eating: Comparison of disordered eating behaviour and nutritional status among female dancers. J Dance Med Sci 2(3):95-100,1998.
88. Hamilton L, Brooks-Gunn J, Warren M, Hamilton W: The impact of thinness and dieting on the professional dancer. CAPHER J 52(4):30-35, 1986.
89. Micheli LJ, Solomon R: Stress fractures in dancers. In: Solomon R, Minton SC, Solomon J (eds): Preventing Dance Injuries: An Interdisciplinary Perspective. Reston, VA: American Alliance for Health, Physical Education, Recreation and Dance, 1990, pp.133-153.
90. Kaufman B, Warren M, Hamilton L: Intervention in an elite ballet school: An attempt at decreasing eating disorders and injury. Women's Studies International Forum 19(5):545-549, 1996.
91. Hamilton L, Kella J, Hamilton W: Personality and occupational stress in elite performers. Med Probl Perform Art 10:86-89, 1995.
92. Taylor J, Taylor C: Psychology of Dance. Champaign, IL: Human Kinetics, 1995.