DISLOCATED shoulders, ruptured tendons, torn ligaments, foot fissures, fractures ... sprains, strains, bruises, bunions.
In the world of professional dance, potential disaster lurks in every picture-perfect pose and plie.
The required aesthetic of line and the illusion of absolute corporeal control that define this visual art form come about through passion fueled by muscle, buckets of sweat and bullheaded determination.
In real life, studies show, the otherworldly beings who beautify the world's stages with seemingly effortless stretches, extreme turnouts, leaps and lifts are engaging in an activity as challenging as any high-level contact sport.
As a result, dance medicine has steadily outgrown its sports medicine niche identity in recent years, due to increasing awareness of ballet's hard-core physical and mental challenges. The first study of its kind, published in the Journal of Sports Medicine in 1975, ranked the demands of ballet ahead of 60 other physical activities, including football.
Professional ballet artists -- and modern, stage musical and folk dancers too -- learn that injuries, be they career blips or career blasters, come with the territory.
Here's Alvin Ailey American Dance Theater veteran Matthew Rushing, 32, ticking off a litany of past woes:
"I started off with a hip injury. After that, I had a back injury, back spasms, then a herniated disk, a minor sprain on my ankle, then a tear in my calf."
Or consider the "compounded frustrations" of American Ballet Theatre luminary Ethan Stiefel, 33, who recently resigned as Irvine-based Ballet Pacifica's artistic director because of the company's funding difficulties.
A week after Stiefel returned to the stage in 2005 following arthroscopic surgery on one knee, his other knee required more-invasive surgery. Less than two months into full recovery, bone spurs in both knees fragmented.
After six months of "eating anti-inflammatories and hoping things would settle," Stiefel had to pull out of this year's world premiere of Benjamin Millepied's "Closer" at New York's Joyce Theater as well as his spring performances at the Metropolitan Opera House.
"They have to basically open up the knees and cut into the patella tendons and remove these fractured pieces of bone," Stiefel said by phone from New York a day before undergoing his latest surgery April 5. Yet he hopes to return to the stage in six months or less.
Classical ballet companies, weighing injury totals against the number of dancers who perform each year, report a 67% to 95% annual injury rate -- some unfortunates account for multiple hurts, while others escape relatively unscathed. That's according to statistics documented in "Injuries in a Modern Dance Company," a five-year study published in the American Journal of Sports Medicine in 2003. It was co-written by Alvin Ailey staff physical therapist Shaw Bronner, director of research at the Long Island University-based ADAM (Analysis of Dance and Movement) Center.
Some typical causes: grueling contemporary choreography, the vagaries of stage surfaces (mitigated by portable flooring), toe shoes, bare feet (stubbed toes, split soles), hyperextensions and turnouts, stumbles, falls, bad catches, smack-down collisions and, No. 1 on the list, overuse.
"We estimate that most professional dancers and students on a professional track probably do over 2 million little jumps a year," says Richard Gibbs, San Francisco Ballet's staff supervising physician, who works with a team of orthopedic surgeons, therapists and physical trainers to keep his company healthy. "That's a lot of wear and tear."
A more diversified workout
THE good news is that many serious injuries are no longer the career death knell that they were only a few decades ago.
The landscape has altered with a shift in focus to dance medicine as a field related to but apart from sports medicine. Along with new research and advances in medical treatment and technologies, that shift has led to an emphasis on preventive therapies, some as basic as cross-training, once a ballet no-no.
Traditional thinking held that exercise outside dance class was harmful. Gibbs, a general practitioner and former ballet dancer who left ballet for medical school in his 30s, offers an example: He was taught that dancers should never get on a bicycle.
"We now know that it doesn't hurt you at all to do light weight training, a lot of Pilates," he says.
At the Ailey, cardiovascular conditioning, general strengthening and stretching have become the norm. Bronner, who is looking toward industrywide injury surveillance as a follow-up to the 2003 study, helped Rushing recover from his most serious injury, an ankle sprain, with a regimen of weight lifting, swimming, Pilates, floor exercises and yoga.
"It was key in my healing," Rushing says. "The more I did cross-training, the easier dance became. Even cooling down after you dance -- we've all known about that, but we haven't always done it. I didn't start doing it till I actually got injured."
The Ailey reflects a growing trend toward in-house health management. In their study, Bronner and her colleagues showed that the Ailey's institution of a comprehensive management program of daily physical therapy, early medical intervention and varied exercise over a three-year period reduced injury rates and significantly decreased workers' compensation claims. Days lost from work dropped 60%.
Similar results have been reported by New York City Ballet. Veteran dance orthopedist William Hamilton and his wife, clinical psychologist Linda Hamilton, a former City Ballet dancer and longtime advice columnist for Dance Magazine, were instrumental in the creation of the company's multitiered wellness program.
Launched in 2001, it has measurably reduced dancers' downtime using a combination of physical screening, stress management and nutritional counseling.
"Muscle pulls and ruptured Achilles' tendons are the same whether in a football player or a dancer," says Hamilton, whose orthopedic practice encompasses the New York City Ballet and its School of American Ballet, as well as American Ballet Theatre and pro sports teams. "What has changed is our understanding.
"You really can't think of dancers as athletes. They're more athletic artists than they are artistic athletes," he says, adding firmly that professional ballet, with its relatively young, healthy population, shouldn't be defined by its risks.
Still, even as new thinking makes inroads in injury prevention and treatment, old thinking may be a thornier challenge: A culture of stoicism -- imposed from within and without -- often persuades dancers to tough it out.
"I have many injuries," legendary prima ballerina Natalia Makarova informed a reporter for the Sydney Morning Herald in 1998. "It is better not to talk about them."
Companion to that deeply engrained mind-set is the fear of enforced downtime, says Ogulcan Borova, who was a principal with the now-defunct Indiana-based Ballet Internationale and a gold medalist at the 2003 New York and 2005 Seoul international ballet competitions.
Last summer, during a phone call from Indianapolis, Borova's philosophical shrug was all but audible through the receiver. "Injuries will always be a part of life," he said.
A few months later, the financially strapped Ballet Internationale folded and Borova signed on with the Tulsa (Okla.) Ballet as a guest principal. But during a rehearsal for his first production there, he tore the anterior cruciate ligament in one knee, a major injury for dancers and athletes alike.
Facing surgery this month and several months' recovery time, Borova withdrew from Tulsa, canceled an engagement with the Cincinnati Ballet and put in abeyance offers from the Boston Ballet and the Royal Swedish Ballet.
"You try to think of other things, but every time it's 'Oh, my God, how did this happen to me?' " he mourns now. "It was my turn, I guess. But as soon as I'm past it, I want to be even better."
Only 24, Borova is aware of the clock ticking. In ballet, at an age when other artists are reaching artistic maturity -- singers in their 30s, for instance, are just coming into their voices -- a dancer's instrument is starting to wear out. But quitting comes hard, even for someone such as Ballet Argentino and American Ballet Theatre superstar Julio Bocca, 39, who has a 25-year stellar career behind him.
He's in psychotherapy to cope with his decision to retire later this year, he said in a call from Buenos Aires. And that's after chalking up more injuries over the years than even his seven surgeries would indicate.
"Sometimes it's more in your head than your body," he said. "I've been on with my ribs broken, my ankle twisted. I did all the shows anyway with all the pain." One of his ribs still sticks out noticeably. "It looks kind of weird. If I want to look pretty, I could have aesthetic surgery, but forget it."
"It's like a pro quarterback who wants to keep going," says Gibbs. "I don't blame the dancers, but we do try to combat that."
Not surprisingly, the mantra on the medical and preventive side -- "If it hurts, don't do it" -- is routinely ignored.
"I think we're used to pain," muses New York City Ballet star Jennie Somogyi, 28. "Maybe our tolerance level is a bit off from the normal person."
Getting help early and often
A shut-up-and-dance attitude isn't confined to ballet. "Riverdance" medical officer Scott Lamb, an athletic trainer with a background in professional soccer and baseball, is the first line of defense for the core Irish troupe and for the other artists in the show: Russian dancers from the Moscow Folk Ballet, American tap dancers and a Spanish flamenco dancer.
The most common injuries Lamb sees are calf and Achilles pulls, shin splints, foot fractures, abdominal strains, sprains and neck injuries from whiplash-inducing head turns.
"These people are very tough, and they work through a lot of pain," Lamb observes. "I'd rather they come see me at the first sign of something bothering them. If I can catch it early, then it may not turn into a stress fracture. If it's gotten to that level, and we rest them early, it'll be better sooner."
A codified shift toward prevention may be the next step. Evidence that a significant number of injuries can be reduced or forestalled has led to a recent push for universal oversight standards.
For several months, Gibbs, who like Bronner and the Hamiltons is a member of dance medicine's vanguard, has chaired a task force on dancers' health that was convened last year by the national service organization Dance/USA.
In February, the task force introduced recommendations for a standard health assessment for ballet, contemporary and show (musical stage) artists.
A prevention-intervention approach, it was shaped with input from the heads of major professional companies, athletic trainers, doctors and physical therapists in the U.S. and Canada, as well as the American Guild of Musical Artists, the dancers union.
"Radio City Music Hall was at the table," Gibbs says. "Alvin Ailey, Hubbard Street, the New York City Ballet, American Ballet Theatre, the San Francisco Ballet -- it was a real mix."
The assessment would emphasize issues of functional movement common to all dance forms, as well as the basics of "just plain good health," Gibbs says. It would be done after a dancer was hired to identify risk areas and offer personalized guidance for therapies, medical treatment and nutrition. Privacy would be key, he stresses.
Before the program moves forward, data will be gathered from a pilot program, now in the planning stages, that is expected to involve several larger companies. Gibbs acknowledges that smaller companies may not have the staff and budget to implement such an extensive screening and follow-up, but he points to an economic upside.
"If it benefits the dancer, it's going to benefit companies artistically because they're going to have more people available to them more of the time," he says. "It benefits the budget because we're not spending so much on healthcare after illness and injury arise."
And dancers need and deserve safeguards, Gibbs says. Living and breathing their passion, they'll keep doing what they do regardless of the pitfalls.
Just ask Somogyi.
During a 2004 performance of "Tchaikovsky Piano Concerto No. 2," she ripped the posterior tibial tendon in one foot, a crippling disaster. Fueled by adrenaline, she refused to bail out of the show until, she says, her concerned stage manager, Perry Silvey, snipped the ribbons of her toe shoes.
It was a near-career-ending injury. But after what Somogyi describes as Hamilton's unusual surgical approach -- "they ended up having to remove almost half of my tendon" -- and a year-and-a-half recovery period, she was back onstage, on pointe, nearly full time as of December.
"I'm taking it day by day, and I still can't do everything I did," she says. "But I'm so happy that I'm doing what I love to do and that I got a second chance."