









































ANNALES KINESIOLOGIAE • 13 • 2022 • 2

93

INJURY PREVENTION AND PHYSIOTHERAPY 
PROCEDURES FOR ANKLE INJURIES IN BALLET 

DANCERS: A LITERATURE REVIEW

Pia Lina VILAR1, Tine KOVAČIČ1, Mitja GERŽEVIČ1,2

1Alma Mater Europaea – ECM, Department of Physiotherapy 
2MILLEO, Sports, Tourism and Education, Mitja Gerževič s.p. 

Corresponding author: 
Mitja GERŽEVIČ

Department of Physiotherapy, Alma Mater Europaea – ECM,
Slovenska ulica 15, 2000 Maribor, Slovenia

e-mail: mitja.gerzevic@almamater.si

ABSTRACT

The aim of this study was to investigate the most frequent, effective and up-to-date 
injury prevention and physiotherapy procedures used in relation to ballet dancers’ 
ankle injuries. A literature review with a qualitative analysis was performed using 
the following databases: PubMed, SAGE, ScienceDirect, PlosOne and Cochrane Li-
brary. The inclusion criteria were: both genders, age > 18, journal impact factor > 0, 
age of study ≤ 10 years and the following search keywords were used: “ankle”, “in-
jury”, “ballet”, “dancers”, “physiotherapy”, “physical therapy” and “prevention”. 
A total of 520 articles were found, out of which six were determined to be appropriate 
according to the inclusion and exclusion criteria. They dealt with the prevention/
rehabilitation of ankle sprains (N=2), tendinopathy of the Achilles tendon (N=2), 
tendinitis of the m. hallucis longus (N=4), rupture of the Achilles tendon (N=2), and 
anterior (N=3) and posterior (N=4) impingement syndrome. It was found that for 
injury prevention in ballet, strengthening and stretching exercises are the most often 
used methods, while rest, ice therapy, muscle strengthening exercises, foot braces and 
dance technique optimisation are the most frequently used methods in injury manage-
ment. These seem to also be the most up-to-date injury prevention and physiotherapy 
procedures, while the most effective procedures could not be retrieved due to a lack of 
relevant studies, which prevented the quantitative comparison of their effectiveness. 
The published clinical evidence endorses physiotherapy/kinesiotherapy as an effec-

Review article                                        DOI: https://doi.org/10.35469/ak.2022.349
received: 2022-10-14                UDC: 792.82:615.8

mailto:mitja.gerzevic@almamater.si


94

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

tive ankle injury prevention and management modality in ballet dancers, although 
additional studies with a better quality of methodology are required. 

Keywords: rehabilitation, ballet, ankle, injury, physiotherapy, prevention

PREVENTIVNA VADBA IN FIZIOTERAPEVTSKI POSTOPKI PRI 
POŠKODBAH GLEŽNJA BALETNIH PLESALCEV: PREGLED 

LITERATURE

IZVLEČEK

Cilj študije je bil raziskati najpogostejše, najučinkovitejše in najsodobnejše preven-
tivne in fizioterapevtske postopke pri poškodbah gležnja baletnih plesalcev. Pregled 
literature s kvalitativno analizo je bil opravljen s pomočjo naslednjih podatkovnih baz: 
PubMed, SAGE, ScienceDirect, PlosOne in Cochrane Library. Pri tem smo uporabili 
naslednje vključitvene kriterije: oba spola, starost > 18 let, faktor vpliva publikaci-
je > 0, starost študije ≤ 10 let ter naslednje iskalne ključne besede: »ankle«, »injury«, 
»ballet«, »dancers«, »physiotherapy«, »physical therapy« in »prevention«. Skupno 
smo našli 520 člankov, izmed katerih je bilo glede na vključitvene in izključitvene kri-
terije primernih 6 člankov. Ti so obravnavali preventivo/rehabilitacijo zvina gležnja 
(N=2), tendinopatijo Ahilove tetive (N=2), tendinitis m. hallucis longus (N=4), rupturo 
Ahilove tetive (N=2) ter anteriorni (N=3) in posteriorni (N=4) utesnitveni sindrom. 
Ugotovili smo, da se v preventivne namene najpogosteje uporabljajo krepilne in raz-
tezne vaje, za fizioterapevtsko obravnavo poškodb pa počitek, terapija z ledom, vaje 
za krepitev mišic, nožne opornice in optimiziranje plesne tehnike. Slednji so kot kaže 
tudi najsodobnejši preventivni in fizioterapevtski postopki, medtem ko najučinkovitejših 
preventivnih in fizioterapevtskih postopkov ni bilo mogoče izluščiti, saj je bilo premalo 
študij za kvantitativno primerjavo učinkovitosti med postopki, kar nakazuje potrebo 
in možnosti za nadaljnje raziskovanje. Objavljeni klinični dokazi potrjujejo, da je fi-
zioterapija/kinezioterapija učinkovito preventivo in kurativno sredstvo pri poškodbah 
gležnja baletnih plesalce, čeprav so potrebne dodatne študije z bolj kakovostno meto-
dologijo. 

Ključne besede: rehabilitacija, balet, gleženj, poškodba, fizioterapija, preventiva 
poškodb



95

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

INTRODUCTION

Classical ballet is considered a high-performance dance art form that requires an ad-
vanced level of technical skills (Campbell, Lehr, Livingston, McCurdy, & Ware, 2019). 
It demands from the dancer a similar level of development of motor and functional abil-
ities and physiological characteristics as some top athletes have. Due to strict schedules 
and repetitive movements during exercise, training sessions and performances, where 
specific ballet movements are often performed with large amplitudes and in extreme 
positions at the limits of the range of motion, where muscles, tendons and other pas-
sive structures are weaker and thus more prone to injuries, ballet dancers experience 
relatively large loads on joints, muscles, tendons and ligaments. Therefore, they have 
an increased chance of acute and chronic injuries (Bickle, Deighan, & Theis, 2018; 
Leanderson et al., 2011; Nunes et al., 2019). Ballet dancers can jump up to 200 times 
in an hour and a half. The force acting on the lower limbs during jumps can represent 
up to 12 times their body weight, which increases the risk of injury to the lower limbs, 
especially the ankle (Steinberg et al., 2018).

Previous research has shown that the lower extremities account for the largest share 
(77%) of ballet dancer injuries (Bickle et al., 2018; Leanderson et al., 2011; Rietveld, 
2013; Nunes et al., 2019). More specifically, ankle injuries account for up to 33% of 
all injuries (Ekegren, Quested, & Brodrick, 2014) in ballet, which, according to most 
authors, is also the most frequently injured body part in rhythmic gymnastics (Meeu-
sen & Borms, 1992). In ballet, the most common of these injuries is the lateral sprain, 
which most often occurs during the landing phase or when rising to the tips of the toes, 
when the foot is less stable (Morton, 2013). In addition to ankle sprains, the following 
are common ankle injuries: fractures, Achilles tendinopathy, Achilles tendon ruptures, 
posterior and anterior impingement syndromes, and m. flexor halluces longus tendinitis 
(Kadel, 2014; Morton, 2013). A meta-analysis by Doherty et al. (2014) found that the 
female gender is a risk factor for lateral ankle sprain (LAS), with a cumulative inci-
dence rate for females of 13.6 per 1000 exposures (95% CI: 13.25, 13.94). Conflicting 
evidence exists that previous LAS elevates risk for a subsequent LAS (Vuurberg et al. 
2018). There is also conflicting evidence on the role of injury severity in the clinical 
course after a LAS, as well as weak evidence for primary injury prevention regarding 
the use of prophylactic balance training exercises in individuals who have not expe-
rienced a first-time LAS (Martin et al. 2021). Regarding the secondary prevention of 
recurrent LAS following an initial sprain, there is strong evidence that physiothera-
pists should use proprioceptive and balance-focused therapeutic exercise training pro-
grammes to address impairments identified during physical examination to reduce the 
risk of a subsequent injury in patients with a first-time LAS (Martin et al. 2021), yet 
there is a lack of evidence for the use of these interventions for ballet dancers. Vuur-
berg and colleagues (2018) reported that while there is evidence to support the use of 
exercises to prevent recurrent sprains, there is a lack of evidence to support the use 
of prophylactic exercises to prevent first-time ankle sprains and a lack of evidence to 
support the use of these interventions in professional ballet dancers. According to Vera 



96

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

and colleagues (2020), their randomised controlled investigation of an injury preven-
tion programme was the first of its kind for professional ballet dancers. Due to the high 
incidence of ankle injuries (Bickle et al., 2018; Ekegren et al., 2014; Leanderson et 
al., 2011; Rietveld, 2013; Nunes et al., 2019) and based on current Clinical Practice 
Guidelines (CPG) (Martin et al., 2021) there is conflicting evidence as to the best way 
to augment the components of rehabilitation programmes (e.g. by written instructions, 
exercise-based videos or app-based instruction) in patients with acute and post-acute 
ankle sprains and other injuries. The physiotherapist should determine what actions to 
take according to the individual’s specific motor and functional abilities, learning needs 
and access to relevant treatment options such as proprioceptive and neuromuscular 
therapeutic exercises in order to improve dynamic ankle stability and patient-perceived 
stability during function (ballet training sessions and performances) in individuals with 
chronic ankle instability (CAI) in order to prevent further injuries. Although the CPG 
describe evidence-based physiotherapy practice, including diagnosis, prognosis, in-
tervention, and assessment of the outcome of patients with ankle injuries commonly 
managed by orthopaedic or sports physiotherapists, there is a lack of evidence for the 
use of these approaches for professional ballet dancers due to extremely high demands 
on dynamic ankle stability. As Biernacki, Stracciolini, Fraser, Micheli, & Sugimoto 
(2018) established, there is no consensus in the literature regarding risk factors for bal-
let-related injury in females, despite the high prevalence of dance injuries among this 
group. This may stem from methodological inconsistencies including a lack of standard 
definition of injury, time loss and medical attention, and limited high-quality original 
studies.  In the previous systematic reviews of studies which assessed the effects of the 
therapeutic alliance on the effectiveness of primary and secondary prevention strate-
gies for ankle injuries there is a lack of evidence pertaining to the therapeutic alliance 
in rehabilitation of musculoskeletal conditions (Doherty et al., 2014; Vuurberg et al., 
2018). Due to the heterogeneity of impairments and activity limitation experienced by 
individuals with LAS and CAI, methods should be tailored to the specific needs of the 
patient. Furthermore, intrinsic and environmental factors that mediate outcomes should 
also be addressed when prescribing treatments for individuals with LAS and CAI (Mar-
tin et al., 2021).

Therefore, it was the aim of this study to determine, through a literature review, 
the most up-to-date, most common and most effective prevention and physiotherapy 
procedures for ballet dancers’ ankle injuries. Based on this, the following two research 
questions were posed: i) “What are the state-of-the-art physiotherapy treatments for 
ankle injuries in ballet dancers?” and ii) “What are the most common and the most 
effective prevention procedures for ankle injuries in ballet dancers?”



97

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

METHODS

Procedures

In this literature review, a qualitative research method was used. A compilation me-
thod was used to collect the most relevant original scientific and review articles and to 
describe and summarise their findings. The method of analysis and synthesis was used 
to analyse and integrate the facts already known in order to deepen the knowledge of 
the problem we identified in this literature review. The method of comparison was used 
to compare the different findings and conclusions of the collected articles in an attempt 
to arrive at the most common, effective and up-to-date preventive and physiothera-
peutic procedures in the management of various ankle injuries in ballet dancers. The 
conclusion and findings were thus formulated using the method of deduction. 

In the introduction, the known facts were described and the key concepts, problem, 
aim and research questions were defined based on a review of domestic and internati-
onal literature as well as based on our professional experience in the field of classical 
ballet. The literature review was performed using the following specialised scientific 
databases: PubMed, SAGE, ScienceDirect, PlosOne and Cochrane Library, and the fol-
lowing keywords: “ankle”, “injury”, “ballet”, “dancers”, “physiotherapy”, “physical 
therapy” and “prevention”. 

The search syntax was performed in four stages, using four combinations of key-
words (search strings). The first search string was related to rehabilitation with the fol-
lowing combination of keywords used in all databases: “rehabilitation” AND “ballet” 
AND “dancers” AND “ankle” AND “injury”, while the second one was related to pre-
vention and was also used in all databases with the following keywords combination: 
“prevention” AND “ballet” AND “dancers” AND “ankle” AND “injury”. Since there 
were no hits in the Cochrane Library using the previous two search strings, the next two 
were used in the Cochrane Library only, first “ballet” AND “injury” AND “prevention” 
and then “ballet” AND “dancer” AND “ankle” (Table 1).

The literature review included articles that dealt with professional ballet dancers 
over the age of 18, to avoid the influence of growth and development on the results. 
The focus was on the most up-to-date, most common and most effective prevention 
and physiotherapy procedures for ballet dancers’ ankle injuries. All articles were first 
evaluated for adequacy based on title, then based on the abstract, then based on a quick 
full-text overview and finally based on the following specific inclusion and exclusion 
criteria. The inclusion criteria were: i) both genders, ii) age of dancers > 18 years, iii) 
professional ballet dancers with ankle injuries in rehabilitation, iv) prevention exercise 
for ankle injuries, v) age of the study ≤ 10 years, vi) publication impact factor > 0, and 
vii) articles accessible in full-text, while the exclusion criteria were other injuries of 
ballet dancers and/or no physiotherapy treatment and/or without ankle injury preven-
tion exercises.



98

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Data analysis

To facilitate editing and data collection, Microsoft Office Excel 2016 (Microsoft 
Corporation, New York, USA) was used and the results were presented with the help of 
tables and diagrams. The search process and the final selection of articles was perfor-
med and presented using the PRISMA diagram (Page et al. 2021). Also presented are all 
the physiotherapy procedures discussed in the studies. The content and characteristics 
of the studies found in the field of prevention exercises and physiotherapy for ankle 
injuries were qualitatively analysed and described in detail. On this basis, guidelines 
and practical examples of exercises and training methods for prevention of ankle inju-
ries in ballet dancers were prepared.

RESULTS

Results of the search and selection procedure of articles

Based on search keywords and their combinations (search strings) in connection 
with ballet and ankle injuries of ballet dancers, we found a total of 520 articles in the 
research databases. Out of these, 30 were repeated in different databases, which gave a 
final total number of 490 articles. Of these, 130 matched by title, 60 by abstracts and 33 
by quick full-text overview. Finally, there were 6 full-text articles on the defined topic 
matching also the inclusion and exclusion criteria. An overview of the search and selec-
tion procedure is presented in the PRISMA diagram in Figure 1, while the extended and 
detailed search results for individual databases using different search strings (syntaxes) 
are presented in Table 1. An overview of the finally selected articles’ titles, journals’ 
impact factors, field of study and injuries considered are shown in Table 2.



99

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

Figure 1: Search and selection procedure for the literature review

Search and selection procedure in the study

In
cl

ud
ed

O
ve

rv
ie

w
Se

ar
ch

Hits in the databases:
PubMed (n = 77)
ScienceDirect (n = 324)
SAGE (n = 97)
PlosOne (n = 9)
Cochrance Library (n = 13)

Consulted article title 
(n = 520)

Articles included in the study 
(n = 6)

Excluded articles before consulting 
abstract:
Duplicated articles (n = 30)
Unsuitable title (n = 360)

Unsuitable articles according to 
abstract (n = 70)

Excluded articles:
Without impact factor (n = 15)
Minor participants involved (n = 7)
Unsuitable content (n = 2)
Amateur dancers involved (n = 2)
Inability to get full-text (n = 1)

Unsuitable articles according to 
content (n = 27)

Consulted article abstracts 
(n = 130)

Quick full-text overview 
(n = 60)

Compliance with selected 
criteria (n = 33)



100

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Ta
bl

e 
1:

 D
et

ai
le

d 
se

ar
ch

 re
su

lts
 a

cr
os

s d
at

ab
as

es
 u

si
ng

 d
iff

er
en

t s
ea

rc
h 

st
ri

ng
s (

sy
nt

ax
es

) 

N
o.

Se
ar

ch
 st

ri
ng

s
D

at
ab

as
e

To
ta

l 
hi

ts

Su
ita

bl
e 

ar
tic

le
s b

y 
tit

le

D
up

lic
at

ed
 

ar
tic

le
s

Su
ita

bl
e 

ar
tic

le
s b

y 
tit

le

Su
ita

bl
e 

 
ar

tic
le

s 
by

 q
ui

ck
 

fu
ll-

te
xt

 
ov

er
vi

ew

Su
ita

bl
e 

ar
tic

le
s 

by
 im

pa
ct

 
fa

ct
or

Su
ita

bl
e 

ar
tic

le
s b

y 
th

e 
cr

ite
ri

a 
an

d 
fu

ll-
te

xt

1

“r
eh

ab
ili

ta
tio

n”
 

an
d 

“b
al

le
t”

 
an

d 
“d

an
ce

rs
” 

an
d 

“a
nk

le
” 

an
d 

“i
nj

ur
y”

SA
G

E
42

7
1

5
5

0
0

Sc
ie

nc
eD

ire
ct

20
5

54
11

6
2

0
0

Pu
bm

ed
31

17
0

14
8

6
3

Pl
os

O
ne

0
0

0
0

0
0

0
C

oc
hr

an
e 

Li
br

ar
y

0
0

0
0

0
0

0
27

8
78

12
25

15
6

3

2

“p
re

ve
nt

io
n”

 
an

d 
“b

al
le

t”
 

an
d 

“d
an

ce
rs

” 
an

d 
“a

nk
le

” 
an

d 
“i

nj
ur

y”

SA
G

E
55

17
8

4
4

0
0

Sc
ie

nc
eD

ire
ct

11
9

34
3

13
5

2
1

Pu
bm

ed
46

22
6

13
6

7
1

Pl
os

O
ne

9
2

0
1

1
0

0
C

oc
hr

an
e 

Li
br

ar
y

0
0

0
0

0
0

0
22

9
75

17
31

16
9

2

3
“b

al
le

t”
 a

nd
 

“i
nj

ur
y”

 a
nd

 
“p

re
ve

nt
io

n”
C

oc
hr

an
e 

Li
br

ar
y

6
2

0
2

1
1

1

 
6

2
0

2
1

1
1

4
“b

al
le

t”
 a

nd
 

“d
an

ce
r”

 a
nd

 
“a

nk
le

”
C

oc
hr

an
e 

Li
br

ar
y

7
5

1
2

1
2

0

7
5

1
2

1
2

0
TO

TA
L

52
0

16
0

30
60

33
18

6



101

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113
Ta

bl
e 2

: F
in

al
ly

 se
le

ct
ed

 a
rt

ic
le

s’ 
tit

le
s, 

jo
ur

na
ls

’ i
m

pa
ct

 fa
ct

or
s, 

fie
ld

 o
f s

tu
dy

, i
nj

ur
ie

s c
on

si
de

re
d 

an
d 

su
m

m
ar

y o
f s

tu
di

es
’ r

es
ul

ts

No.

Author (year of 
publication)

Title

Impact factor

Article type

Field of study 
(prevention, injury, 
rehabilitation)

Results

Ankle sprain

Ankle fracture

Achilles tendinopathy

Rupture of Achilles 
tendon
Posterior impingement 
syndrome
Anterior impingement 
syndrome
Tendinitis of flexor 
hallucis longus

1
Ve

ra
 e

t a
l. 

(2
02

0)

A
n 

In
ju

ry
 

Pr
ev

en
tio

n 
Pr

og
ra

m
 

fo
r P

ro
fe

ss
io

na
l 

B
al

le
t

2.
49

2
C

lin
ic

al
 

st
ud

y

Pr
ev

en
tio

n 
(d

an
ce

-s
pe

ci
fic

 
in

ju
ry

 p
re

ve
nt

io
n 

pr
og

ra
m

m
e)

82
%

 d
ec

re
as

e 
in

 in
ju

ry
 ra

te
 fo

r t
he

 
in

te
rv

en
tio

n 
gr

ou
p 

an
d 

an
 e

xt
en

de
d 

pe
rio

d 
fr

om
 p

re
vi

ou
s i

nj
ur

y 
to

 
su

bs
eq

ue
nt

 in
ju

ry
.

2
M

or
to

n 
(2

01
3)

Th
e 

vi
rtu

os
o 

fo
ot

1.
77

4
R

ev
ie

w

in
ju

ry

1.
 A

ny
 in

ju
ry

 to
 th

e 
fo

ot
 a

nd
 a

nk
le

 
w

ill
 h

av
e 

a 
rip

pl
e 

eff
ec

t f
ur

th
er

 u
p 

th
e 

ki
ne

tic
 c

ha
in

.
2.

 A
ny

 c
lin

ic
al

 e
xa

m
in

at
io

n 
sh

ou
ld

 
in

vo
lv

e 
a 

gl
ob

al
 p

er
sp

ec
tiv

e.
3.

 C
or

re
ct

 e
ar

ly
 d

ia
gn

os
is

 a
nd

 
tre

at
m

en
t i

s v
ita

l t
o 

th
ei

r p
hy

si
ca

l, 
ps

yc
ho

lo
gi

ca
l a

nd
 fi

na
nc

ia
l w

el
l-

be
in

g.
4.

 W
he

n 
tre

at
in

g 
a 

da
nc

er
, t

he
 

cl
in

ic
ia

n 
sh

ou
ld

 a
ls

o 
be

 a
w

ar
e 

of
 

th
e 

hi
gh

 to
le

ra
nc

e 
fo

r p
ai

n 
in

 th
is

 
el

ite
 g

ro
up

 o
f a

th
le

te
s.

x
x

x
x

x

re
ha

bi
lit

at
io

n
x

x
x

x

3
R

ie
tv

el
d 

(2
01

3)
D

an
ce

rs
 a

nd
 

m
us

ic
ia

ns
’ i

nj
ur

ie
s

1.
77

4
R

ev
ie

w

in
ju

ry
1.

 U
ni

la
te

ra
lly

 p
ai

nf
ul

 a
ra

be
sq

ue
 

is
 a

 sp
on

dy
lo

ly
si

s /
 st

re
ss

 fr
ac

tu
re

 
of

 th
e 

ve
rte

br
al

 a
rc

h 
un

til
 p

ro
ve

n 
ot

he
rw

is
e.

2.
 P

os
te

rio
r a

nk
le

 im
pi

ng
em

en
t, 

w
ith

 o
r w

ith
ou

t t
en

ov
ag

in
iti

s o
f t

he
 

m
.fl

ex
or

 h
al

lu
ci

s l
on

gu
s i

s t
he

 m
os

t 
co

m
m

on
 d

an
ce

rs
’ i

nj
ur

y.
3.

 T
he

 ru
le

 o
f t

hu
m

b 
is

 to
 n

ot
 

op
er

at
e 

on
 a

 h
al

lu
x 

va
lg

us
 in

 a
n 

ac
tiv

e 
da

nc
er

 o
r d

an
ce

-te
ac

he
r.

x
x

x

re
ha

bi
lit

at
io

n
x

x



102

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

No.

Author (year of 
publication)

Title

Impact factor

Article type

Field of study 
(prevention, injury, 
rehabilitation)

Results

Ankle sprain

Ankle fracture

Achilles tendinopathy

Rupture of Achilles 
tendon

Posterior impingement 
syndrome

Anterior impingement 
syndrome

Tendinitis of flexor 
hallucis longus

4
Vo

ss
el

le
r 

et
 a

l. 
(2

01
9)

A
nk

le
 In

ju
rie

s i
n 

D
an

ce
rs

2.
28

6
R

ev
ie

w

in
ju

ry
1.

 A
 te

am
 a

pp
ro

ac
h 

to
 tr

ea
tm

en
t 

w
ith

 k
no

w
le

dg
ea

bl
e 

ph
ys

ic
al

 
th

er
ap

is
ts

 c
an

 o
bv

ia
te

 th
e 

ne
ed

 fo
r 

su
rg

ic
al

 tr
ea

tm
en

t.
2.

 If
 su

rg
ic

al
 tr

ea
tm

en
t p

ro
ve

s 
ne

ce
ss

ar
y,

 g
oo

d 
re

su
lts

 c
an

 b
e 

ac
hi

ev
ed

 w
ith

 so
un

d 
su

rg
ic

al
 

te
ch

ni
qu

e 
an

d 
a 

w
el

l-t
ho

ug
ht

-o
ut

 
re

ha
bi

lit
at

io
n 

pr
og

ra
m

m
e.

x
x

x

re
ha

bi
lit

at
io

n
x

x

5
K

ad
el

 
(2

01
4)

Fo
ot

 a
nd

 A
nk

le
 

Pr
ob

le
m

s i
n 

D
an

ce
rs

0.
93

0
R

ev
ie

w

in
ju

ry

1.
 T

o 
ke

ep
 d

an
ce

rs
 h

ea
lth

y,
 th

e 
he

al
th

 c
ar

e 
te

am
 a

nd
 th

e 
da

nc
er

 
m

us
t w

or
k 

to
ge

th
er

.
2.

 T
he

 p
hy

si
ci

an
 m

us
t b

e 
an

 
ad

vo
ca

te
 fo

r t
he

 d
an

ce
r a

nd
 w

or
k 

to
 p

ro
vi

de
 a

n 
ac

cu
ra

te
 d

ia
gn

os
is

 
an

d 
an

 e
ffe

ct
iv

e 
tre

at
m

en
t s

tra
te

gy
.

3.
 M

on
ito

rin
g 

pe
rf

or
m

an
ce

 a
nd

 
re

he
ar

sa
l l

oa
d,

 fi
tn

es
s, 

an
d 

ge
ne

ra
l 

he
al

th
 o

f t
he

 d
an

ce
r w

ill
 h

el
p 

to
 

m
ax

im
is

e 
th

e 
da

nc
er

’s
 h

ea
lin

g 
po

te
nt

ia
l.

4.
 C

or
re

ct
io

n 
of

 m
us

cl
e 

im
ba

la
nc

es
, a

tte
nt

io
n 

to
 p

ro
pe

r 
te

ch
ni

qu
e,

 se
qu

en
tia

l s
ki

ll 
pr

og
re

ss
io

n,
 a

nd
 p

ro
pe

r s
ho

e 
fit

 
m

ay
 h

el
p 

lim
it 

ac
ut

e 
in

ju
rie

s t
o 

th
e 

da
nc

er
.

5.
 C

re
at

iv
ity

 is
 n

ee
de

d 
to

 m
od

ify
 

tre
at

m
en

t p
la

ns
 to

 a
cc

om
m

od
at

e 
th

e 
da

nc
er

’s
 n

ee
d 

to
 m

ai
nt

ai
n 

st
re

ng
th

, fl
ex

ib
ili

ty
, a

nd
 fi

tn
es

s 
du

rin
g 

re
co

ve
ry

.

x
x

x
x

x
x

re
ha

bi
lit

at
io

n
x

x
x

x
x



103

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

No.

Author (year of 
publication)

Title

Impact factor

Article type

Field of study 
(prevention, injury, 
rehabilitation)

Results

Ankle sprain

Ankle fracture

Achilles tendinopathy

Rupture of Achilles 
tendon

Posterior impingement 
syndrome

Anterior impingement 
syndrome

Tendinitis of flexor 
hallucis longus

6
C

am
pb

el
l 

et
 a

l. 
(2

01
9)

In
tri

ns
ic

 m
od

ifi
ab

le
 

ris
k 

fa
ct

or
s i

n 
ba

lle
t 

da
nc

er
s:

 A
pp

ly
in

g 
ev

id
en

ce
-b

as
ed

 
pr

ac
tic

e 
pr

in
ci

pl
es

 
to

 e
nh

an
ce

 c
lin

ic
al

 
ap

pl
ic

at
io

ns

1.
92

6
R

ev
ie

w

Pr
ev

en
tio

n 
(r

is
k 

fa
ct

or
s a

nd
 

sc
re

en
in

g 
to

ol
s 

id
en

tifi
ca

tio
n)

1.
 Id

en
tifi

ca
tio

n 
of

 se
ve

n 
in

tri
ns

ic
 

m
od

ifi
ab

le
 fa

ct
or

s s
pe

ci
fic

al
ly

 
fo

r b
al

le
t d

an
ce

rs
 a

nd
 se

ve
n 

ap
pr

op
ria

te
 sc

re
en

in
g 

to
ol

s.
2.

 In
tri

ns
ic

 m
od

ifi
ab

le
 ri

sk
 fa

ct
or

s:
 

hy
pe

rm
ob

ili
ty

, f
at

ig
ue

, o
ve

ru
se

, 
ne

ur
om

us
cu

la
r d

ys
fu

nc
tio

n,
 d

eg
re

e 
of

 tu
rn

ou
t, 

w
ea

kn
es

s o
f c

or
e 

an
d 

lo
w

er
 e

xt
re

m
ity

 m
us

cu
la

tu
re

, a
nd

 
lo

w
er

 e
xt

re
m

ity
 ra

ng
e 

of
 m

ot
io

n 
(R

O
M

) d
is

cr
ep

an
ci

es
.

3.
 A

pp
ro

pr
ia

te
 sc

re
en

in
g 

to
ol

s:
 

M
ov

em
en

t C
om

pe
te

nc
y 

Sc
re

en
in

g 
(M

C
S)

, B
ei

gh
to

n 
H

yp
er

m
ob

ili
ty

 
Sc

al
e 

(B
H

S)
, R

ol
lin

g 
(to

 d
et

ec
t 

co
m

pe
ns

at
io

n 
an

d 
ne

ur
om

us
cu

la
r 

dy
sf

un
ct

io
n)

, S
ta

r E
xc

ur
si

on
 

B
al

an
ce

 T
es

t (
SE

B
T)

, F
un

ct
io

na
l 

A
gi

lit
y 

Sh
or

t-T
er

m
 F

at
ig

ue
 

pr
ot

oc
ol

 (F
A

ST
-F

P)
, S

lo
w

 L
in

ea
r 

O
xi

da
tiv

e 
Fa

tig
ue

 p
ro

to
co

l (
SL

O
-

FP
) a

nd
 T

ot
al

 P
as

si
ve

 T
ur

no
ut

(T
PT

).



104

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Results of the most common prevention and treatment procedures of ankle 
injuries in ballet dancers

The physiotherapy procedures discussed in the reviewed articles have been collec-
ted and arranged by individual types of injuries in Table 3. The review showed that the 
most common procedures in the treatment of ankle injuries in ballet dancers are the fol-
lowing: rest (Kadel, 2014; Morton, 2013), ice therapy (Kadel, 2014; Vosseller, Dennis, 
& Bronner, 2019), muscle strengthening (Kadel, 2014; Morton, 2013), night brace (Ka-
del, 2014; Vosseller et al., 2019) and optimising ballet technique (Morton, 2013; Kadel, 
2014; Vosseller et al., 2019; Rietveld, 2013). For injury prevention purposes, mainly 
strengthening and stretching exercises are used, to which functional joint stabilisation 
and plyometric exercises can be added (Vera et al., 2020).

Results related to ankle sprain

Kadel (2014) states that the ankle sprain is the most common ballet injury. Most 
often, an inversion ankle sprain occurs (the foot turns inward). Conservative rehabili-
tation should thus include: a compression bandage, ice therapy, ankle brace, wearing 
good athletic shoes outside of ballet training and rest from training as long as the ankle 
is painful. Some sprains also require the wearing of a special therapeutic shoe, which 
the ballet dancer wears when walking and sleeping. It is recommended that dancers 
who have had multiple ankle sprains perform floor barre ballet classes, combined with 
pilates and gyrotonics training before returning to the ballet halls (Kadel, 2014).

Results related to Achilles tendinopathy

Morton (2013) states that Achilles tendinopathy occurs in both men and women 
and can be seen in many other dance styles as well. For conservative rehabilitation, 
both authors recommend rest, use of physiotherapy and careful active stretching of the 
Achilles tendon and triceps surae muscles. Kadel (2014) states that it is useful to add 
deep tissue massage, while Morton (2013) adds that it is also necessary to correct any 
incorrect ballet technique (e.g. foot tilt in the direction of pronation, incomplete lan-
ding) so that dancers avoid new injuries and, in their free time, to wear shoes that are 
large, wide, hard and supportive for the feet.

Results related to Achilles tendon rupture

Kadel (2014) and Morton (2013) state that Achilles tendon rupture occurs after the 
age of 30 and that the injury is more common in men than in women. Kadel (2014) adds 
that the rupture of the Achilles tendon is felt as a sharp pain and that the ballet dancer 



105

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

Table 3: Physiotherapy and other procedures discussed in the articles included in the 
literature review

Author(s) 
(Year of publication) Injury Physiotherapy and other procedures

Morton (2013)
Kadel (2014) Sprain

Compression bandage, ice therapy, ankle brace, 
wearing good athletic shoes outside of ballet 
training and taking a rest from training, wearing 
a special therapeutic shoe, ankle and core 
strength exercises, sensorimotor training, range 
of motion (ROM) training, manual therapy (ankle 
mobilisation) and edema control

Morton (2013)
Kadel (2014)

Achilles 
tendinopathy

Rest, physiotherapy, careful active stretching of the 
Achilles tendon and triceps surrae muscles, deep 
tissue massage and elimination of incorrect ballet 
technique

Morton (2013)
Kadel (2014)

Rupture of 
Achilles 
tendon

There is no conservative treatment, as surgery is 
recommended

Morton (2013)
Kadel (2014)
Rietveld (2013)
Vosseller et al. (2019)

Posterior 
impingement 
syndrome

Limiting painful activities, including stopping 
tiptoe dancing, physiotherapy (muscle 
strengthening and ankle mobilisation), eliminating 
improper ballet technique, ice therapy and anti-
inflammatory medications

Rietveld (2013)
Vosseller et al. (2019)
Kadel (2014)

Anterior 
impingement 
syndrome

Avoiding ballet jumps, squats/demi-pliés; raising 
the heel with an insole in both ballet shoes and day 
shoes; physiotherapy (correction of incorrect foot 
posture) and the use of day and night braces.

Morton (2013)
Kadel (2014)
Rietveld (2013)
Vosseller et al. (2019)

Tendinitis 
of m. flexor 
hallucis 
longus

Rest; discontinuing the use of ballet pointe, grand 
plié and jumps; physiotherapy, stretching the flexor 
hallucis longus; optimising dance technique; anti-
inflammatory medications, ice therapy, ultrasound 
therapy; functional exercise; good everyday 
footwear and use of a night brace.

/ Ankle 
fracture /



106

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

is unable to rise to half-toes or demi-pointe. An Achilles tendon rupture usually occurs 
during a rebound or eccentric load landing. It also means that the Thompson’s test is 
positive. The authors do not mention conservative treatment, as surgery is recommen-
ded for this injury. Despite undergoing surgery, the dancer will be able to continue their 
dance career, but rehabilitation may take up to a year (Morton, 2013; Kadel, 2014).

Results related to posterior impingement syndrome

The authors describe posterior impingement syndrome or “dancer’s heel” as a pain-
ful condition occurring due to the compression of soft tissues on the back of the tibiae 
and calcaneus during plantar flexion (Rietveld, 2013; Vosseller et al., 2019; Kadel, 
2014; Morton, 2013). For conservative treatment, it is first recommended to limit ballet 
activity that is painful, including ceasing to dance on the toes (Kadel, 2014; Morton, 
2013; Vosseller et al., 2019), as well as using physiotherapy, where muscle strengthe-
ning and ankle mobilisation (Kadel, 2014; Morton, 2013), eliminating incorrect ballet 
technique (Kadel, 2014; Vosseller et al., 2019) and using ice therapy and anti-inflam-
matory drugs (Vosseller et al., 2019). Rietveld (2013) recommends that if the condition 
does not subsequently improve, an injection of cortisol is used, which also acts as an 
anti-inflammatory drug (corticosteroid). If conservative treatment does not help, surge-
ry is recommended (Rietveld, 2013; Vosseller et al., 2019; Kadel, 2014; Morton, 2013).

Results related to anterior impingement syndrome

Anterior impingement syndrome can be the result of hypertrophied (thickened) soft 
tissues or osteophytes at the anterior edge of the tibiotalar joint (Kadel, 2014). Kadel 
(2014) hypothesises that osteophytes are the result of repeated ankle sprains or micro-
traumas from extreme dorsiflexion and plantarflexion positions. In conservative treat-
ment, Kadel (2014) recommends avoiding ballet jumps and squats/demi-pliés and heel 
elevation with insoles in both ballet shoes and day shoes. Physiotherapy should also 
include correcting incorrect foot posture. Using day and night splints can relieve pain 
and inflammation. If the pain persists, surgery is recommended (Kadel, 2014).

Results related to tendinitis of flexor hallucis longus

Flexor hallucis longus tendinitis injury is very common in dancers. This injury is 
also called “dancer’s tendinitis” (Morton, 2013; Kadel, 2014; Rietveld, 2013). It is 
more common in the female population due to the repetitive movement from dorsi-
flexion (demi-plié) to plantarflexion (standing on the tips of the toes). For conservative 
treatment, it is recommended to rest and stop using ballet pointe shoes, stop performing 
grand plié and jumps (Kadel, 2014; Morton, 2013; Vosseller et al., 2019), use physi-



107

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

otherapy (Kadel, 2014), stretch the flexor hallucis longus, optimise dance techniques 
(Rietveld, 2013; Vosseller et al., 2019), use anti-inflammatory drugs (Kadel, 2014; Vos-
seller et al., 2019), ice therapy, ultrasound, functional exercise, good daily footwear 
and, if necessary, night braces (Kadel, 2014; Vosseller et al., 2019).

Results related to ankle fracture

Unfortunately, the ankle fracture was not mentioned in the analysed articles, nor 
was rehabilitation.

Results related to the prevention of ballet dancers’ injuries

Out of all the retrieved articles, injury prevention exercises in ballet dancers were 
discussed by Campbell et al. (2019) and Vera et al. (2020) only. Campbell et al. (2019) 
identify seven different intrinsic modifiable risk factors for injury: i) hypermobility, ii) 
fatigue, iii) overuse, iv) degree of turnout, v) neuromuscular dysfunction, vi) weakness 
of core and lower extremity musculature, and vii) lower extremity range of motion 
discrepancies, which are all commonly present in the ballet population. The authors 
emphasise that much care must be taken when creating an injury prevention program-
me for ballet dancers and take into account the mentioned seven internal factors in 
order to avoid the most common ballet injuries.

Vera et al. (2020), however, addressed a general whole-body injury prevention pro-
gramme for ballet dancers. The study was conducted on 39 professional dancers with 
19 dancers in the control group (9 men and 10 women, average age 26.6 ± 4.0 years) 
and 20 dancers in the experimental group (11 men and 9 women, average age 25.1 ± 
5.1 years). The dancers carried out the injury prevention programme 3 times a week. It 
included a total of 24 exercises, which were arranged in such a way that each training 
day included different exercises. The injury prevention exercise programme lasted 30 
minutes per session over a period of 52 weeks. Dancers performed 10–30 repetitions or 
15–45 seconds of each exercise in 2 to 3 sets with 30 to 60 seconds of rest between sets. 
When the exercises were no longer challenging enough for the participants the intensity 
was increased by carrying out more difficult variants of the exercises, using stronger 
elastics and free weights. The dancers carried out the injury prevention programme wi-
thout supervision, however, they had supervision for as long as they needed. The results 
of this study showed an 82% reduction in injuries and a longer period of time passing 
before the reappearance of old or appearance of new injuries.



108

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

DISCUSSION

The aim of this literature review was to identify the most common, most effective 
and up-to-date injury prevention and physiotherapy procedures for ankle injuries in 
ballet dancers. The results of the review and qualitative analysis performed showed 
that, despite the small number of studies in this field, the research questions on the sta-
te-of-the-art physiotherapy treatments and the most common and effective prevention 
procedures for ballet dancers’ ankle injuries could be at least partly answered. 

Most of the articles were review articles (5 out of 6), which means that relatively 
few original scientific studies on prevention and physiotherapeutic procedures for an-
kle injuries have been performed in the last 10 years. This prevented the authors from 
directly answering the question of which prevention and physical therapy procedures 
are most effective. However, it was possible to identify the state of the art and the most 
common physiotherapy treatments and prevention procedures for ankle injuries in bal-
let dancers.

It was found that among all injuries, ankle injuries are the most common in ballet 
dancers and seven different ankle injuries were most commonly evidenced in the re-
viewed literature. These are ankle sprain, Achilles tendinopathy, rupture of the Achilles 
tendon, anterior and posterior impingement syndromes, tendinitis of m. flexor hallucis 
longus and ankle fracture. This is in accordance with earlier studies, where the inci-
dence of Achilles, peroneal, flexor hallucis longus and tibialis posterior tendinopathies, 
ankle impingement, stress fractures and metatarsalgia was the highest in ballet dancers 
(Nilsson et al., 2001 in Sobhani, Dekker, Postema, & Dijkstra, 2012) or in theatrical 
dancers (Rovere et al., 1983 in Sobhani et al., 2012), as well as in running and soccer 
(Sobhani et al., 2012). Comparing the results of this literature review to studies in other 
sports, where most frequently studied are soccer, running and gymnastics, it has been 
similarly shown that the most frequently studied overuse injuries are Achilles tendi-
nopathy (in 44% of studies) and tendinopathy of other foot and ankle muscles, such as 
toe extensors and flexors, the tibialis anterior and posterior, and peroneal tendinopa-
thies, as well as plantar fasciitis and stress fractures (Sobhani et al., 2012). However, 
weak methodology and poor reporting were highlighted, especially lack of a clear case 
definition, description of assessment procedures and reporting sample characteristics 
(Sobhani et al., 2012), showing the need for more and better original scientific studies.

Regarding rehabilitation, the most frequently used modalities and/or interventions 
for the management of ankle injuries in ballet dancers are rest, ice therapy, muscle 
strengthening exercises, foot braces and dance technique optimisation. Of course, tre-
atment of each individual injury has also some individual and specific modalities and 
procedures, as presented in Table 3. Interestingly, among all evidenced injuries, specific 
physiotherapy treatments for ankle fractures could not be found in this literature review, 
even though earlier studies identified stress fractures as one of the prevalent injuries in 
ballet and theatrical dancers as well as in athletes of other sports (Sobhani et al., 2012). 

For ankle sprains, as the most common injury in sports, at the time of injury, Chen, 
McInnis and Borg-Stein (2019) first recommend the application of the Ottawa Ankle 



109

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

Rules to assess risk of fracture and reduce unnecessary radiographs, since these rules 
represent highly sensitive tools for detecting fracture in the setting of acute ankle spra-
in. Further, they report that modalities, such as RICE therapy (rest, ice, compression 
and elevation), electrical stimulation, oral and topical nonsteroidal anti-inflammatory 
drugs (NSAID) and Tylenol do not accelerate recovery, but are reasonable interventions 
for short term pain reduction. They also suggest early mobilisation (manual therapy) 
after acute lateral sprain as it has been shown to improve ankle dorsiflexion, pain reduc-
tion and stride length and thus accelerate return to play. Besides this, the introduction of 
early neuromuscular training programmes, typically balance and proprioception tasks 
with recurrent voluntary or involuntary destabilisation during exercise showed to be 
beneficial in all athletes with ankle sprains to reduce the risk of recurrent sprains, since 
ankle joint position sense, muscle reaction time and functional outcome scores improve 
with such exercises (Chen et al., 2019). In addition, the same authors found that altho-
ugh neuromuscular training programmes are effective for the prevention of recurrent 
sprains, the evidence for reducing the rate of first-time ankle sprains is not so robust. 
In addition, non-rigid ankle bracing is recommended for 1 year after ankle sprain to 
prevent recurrent sprain. Finally, Chen et al. (2019) endorse surgical referral and con-
sideration of stabilisation for cases of chronic ankle instability that do not respond to 
non-operative measures after concomitant pathologies have been ruled out.

The retrieved studies in this literature review and the presented physiotherapy mo-
dalities, procedures and/or treatments are also the most up-to-date ones for ballet dan-
cers’ ankle injuries, which are in line also with professional guidelines for physical the-
rapy, medical and sports rehabilitation such as the Clinical Practice Guidelines (Martin 
et al., 2021).

Regarding the most up-to-date and effective prevention procedures for ankle inju-
ries in ballet dancers, based on the only available study of Vera et al. (2020) it is clear 
that too little original scientific studies, especially randomised controlled investigati-
ons, have been performed in the last 10 years. Nevertheless, Vera et al. (2020) found 
out as much as an 82% reduction in injuries after a 52-week period of a whole-body 
prevention exercise, as well as longer period of time for the recurrence of old or occur-
rence of new injuries in ballet dancers. However, for all sports/athletes in general, Chen 
et al. (2019) recommend the introduction of early mobilisation after acute ankle sprain 
injuries and early (as soon as tolerated after injury) as well as preventive neuromuscular 
training programmes for reducing the risk of recurrence of ankle sprains, resulting in 
higher overall activity levels without increasing pain, swelling, or the rate of reinjury 
when compared with traditional RICE therapy (Bleakley et al., 2010).

On the other hand, due to lack of original scientific studies it was not possible to 
determine whether and which of these procedures are the most effective. To answer 
this question, we would need to quantitatively analyse, using meta-analysis, the results 
of the control and experimental groups before and after the intervention in a larger or 
more relevant number of original scientific articles/studies and compare the effect sizes 
of each intervention in these studies. 



110

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

In addition to an injury prevention programme, which should be implemented by all 
ballet dancers regardless of age and gender, the authors believe that it is also necessary 
to reduce or limit the risk factors of elite/professional ballet injuries, as found out by Bi-
ernacki et al. (2018) and Campbell et al. (2019). These parameters are: alignment, poor 
lumbopelvic movement control, inappropriate transversus abdominis contraction, dec-
reased lower-extremity strength, and poor aerobic fitness (Biernacki et al., 2018), and 
hypermobility, fatigue, overload, degree of leg opening, neuromuscular dysfunction, 
trunk and lower extremity weakness, and lower extremity range of motion commonly 
present in the ballet dancer population (Campbell et al., 2019).

This means that firstly, the duration of the ballet class could be reduced by focusing 
on the quality of the training and optimising the training techniques, means and me-
thods used. This could reduce one of the essential training parameters that affects inju-
ries, i.e. the extent or the volume of exercise (duration, number of repetitions, sets, etc.), 
which would affect both the onset of fatigue and the possibility of acute and chronic 
overuse injuries. Secondly, nutritional consultants or nutritionists should be involved in 
ballet institutions, as this would avoid injuries resulting from malnutrition or nutritio-
nal deficiencies, as well as too frequent nutritional disorders, especially among female 
ballet dancers (Obrul, 2020). Thirdly, as far as environmental conditions are concerned, 
the ballet dancers themselves have no influence on them, but the management of the 
ballet institution has and as such should ensure that the dancers have optimal and safe 
working or training conditions (e.g. suitable temperatures, the right choice of floor and 
work space). Ballet dancers are ultimately responsible for choosing suitable training/
dance shoes – ballet pointe shoes, but also for choosing suitable everyday shoes, beca-
use the wrong ones can also cause certain micro-injuries, which over time can lead to 
other, more serious injuries. Unfortunately, the individual has no influence on certain 
causes or risk-factors, such as general accidents and anatomical factors. However, they 
have an influence on previous injuries or on their occurrence in the future, namely by 
following prevention guidelines and recommendations as much as possible in the given 
situation.

This literature review showed that in the future more original scientific studies ba-
sed on different injury prevention programmes for the whole body or specific body 
parts, for instance for the foot and ankle, are needed or studies older than 10 years 
should be analysed. However, by analysing older studies, it would be inappropriate to 
consider the prevention procedures to be the most up-to-date. 

In addition, future research should involve more professional ballet dancers so that 
the findings have less variance and greater statistical power. It would also be advisable 
for researchers to work with dance or ballet institutions so that ballet dancers would 
have injury prevention exercise programmes included in their daily or at least weekly 
schedules. In this way, a greater and more accurate insight into the effectiveness of 
injury prevention procedures could be achieved.

The findings of this literature review should also be tested with further studies to de-
termine which physiotherapy and injury prevention procedures are the most appropria-
te and efficient in the treatment or prevention of ankle or other injuries in ballet dancers. 



111

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

It would thus make sense to conduct randomised controlled clinical research to verify 
the success and effectiveness of specific injury prevention programmes in  practice.

Limitations of the study

One of the major limiting factors of this study was the quite restrictive inclusion and 
exclusion criteria, which most probably significantly limited the amount of literature 
retrieved. Especially the age of the study and the impact factor, as could be seen from 
the PRISMA diagram in the Methods section (Figure 1).

CONCLUSION

In this literature review the most common, effective and up-to-date injury preven-
tion and physiotherapy procedures for ballet dancers’ ankle injuries were qualitatively 
analysed. It was found that ballet dancers experience a high incidence of ankle injuries, 
which is also the case in other sports, especially in soccer, running and gymnastics, yet 
there have been very few in-depth and original scientific studies on this topic in the last 
10 years, with only one randomised controlled investigation in the field of prevention 
of ballet injuries in general. Due to the small number of retrieved articles, it was not 
possible to directly answer the question on what the most successful physiotherapy 
procedures for the treatment of ankle injuries in ballet dancers are. However, it was 
possible to determine the most up-to-date procedures that were used in the reviewed 
literature, which actually represent the general guidelines for treatment, regardless of 
where the injury occurs. 

The most common procedures for treating ankle injuries in ballet dancers were 
shown to be rest, ice therapy, muscle strengthening, use of a night brace and optimising 
ballet technique (Morton, 2013; Kadel, 2014; Vosseller et al., 2019; Rietveld, 2013). 
For prevention purposes, mainly strengthening and stretching exercises are used, to 
which functional joint stabilisation and plyometric exercises can be added (Vera et al., 
2020). Clearly, further high-quality research designs with a low risk of bias are neces-
sary to further evaluate the effectiveness of specific prevention exercises programme 
and the optimal timing of the intervention for the prevention of ankle injuries in ballet 
dancers. Also, future studies are needed to validate this conclusion regarding injury pre-
vention exercise programmes to properly and efficiently address future ankle injuries 
and to reduce the risk of a subsequent injuries in professional ballet dancers. 

Acknowledgements

The first and the last author contributed equally to the preparation of this article.



112

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

REFERENCES

Bickle, C., Deighan, M., & Theis, N. (2018). The effect of pointe shoe deterioration on 
foot and ankle kinematics and kinetics in professional ballet dancers. Human Movement 
Science, 60, 72–77. https://doi.org/10.1016/j.humov.2018.05.011.

Biernacki, L., Stracciolini, J. A., Fraser, J., Micheli, L. J. & Sugimoto, D. (2018). 
Risk factors for lower-extremity injuries in female ballet dancers: a systematic re-
view. Clinical Journal of Sport Medicine, 31(2), 64–79. https://doi.org/10.1097/
JSM.0000000000000707.

Bleakley, C. M., O’Connor, S. R., Tully, M. A., Rocke, L. G., Macaulez, D. C., Bran-
dbury, I. … McDonough, S. M. (2010). Effect of accelerated rehabilitation on func-
tion after ankle sprain: randomised controlled trial. BMJ, 340(c1964), 1–7. https://doi.
org/10.1136/bmj.c1964.

Campbell, R. S., Lehr, M. E., Livingston, A., McCurdy, M., & Ware, J. K. (2019). In-
trinsic modifiable risk factors in ballet dancers: Applying evidence based practice prin-
ciples to enhance clinical applications. Physical Therapy in Sport: Official Journal of the 
Association of Chartered Physiotherapists in Sports Medicine, 38, 106–114. https://doi.
org/10.1016/j.ptsp.2019.04.022.

Chen, E. T., McInnis, K. C. & Borg-Stein, J. (2019). Ankle sprains: evaluation, rehabi-
litation, and prevention. Current Sports Medicine Reports, 18(6), 217–223. https://doi.
org/10.1249/JSR.0000000000000603.

Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J. & Bleakley, C. (2014). The 
incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis 
of prospective epidemiological studies. Sports Medicine, 44 (1), 123–140. https://doi.
org/10.1007/s40279-013-0102-5.

Ekegren, C. L., Quested, R., & Brodrick, A. (2014). Injuries in pre-professional ballet 
dancers: Incidence, characteristics and consequences. Journal of Science and Medicine 
in Sport, 17(3), 271–275. https://doi.org/10.1016/j.jsams.2013.07.013.

Kadel, N. (2014). Foot and ankle problems in dancers. Physical Medicine and Rehabilitation 
Clinics of North America, 25(4), 829–844. https://doi.org/10.1016/j.pmr.2014.06.003. 

Leanderson, C., Leanderson, J., Wykman, A., Strender, L. E., Johansson, S. E., & 
Sundquist, K. (2011). Musculoskeletal injuries in young ballet dancers. Knee surgery, 
Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 19(9), 1531–1535. 
https://doi.org/10.1007/s00167-011-1445-9. 

Martin, R. L. M., Davenport, T. E., Fraser, J. J., Sawdon-Bea, J., Carcia, C. R., Car-
roll, L. A., ... Carreira, D. (2021). Ankle stability and movement coordination impa-
irments: lateral ankle ligament sprains revision 2021. Journal of Orthopaedic & Sports 
Physical Therapy, 51(4), 155–195. https://doi.org/10.2519/jospt.2021.0302.

Meeusen, R. & Borms, J. (1992). Gymnastic injuries. Sports Medicine, 13(5), 337-356. 
https://doi.org/10.2165/00007256-199213050-00004.

Morton, J. (2013). The virtuoso foot. Clinical Rheumatology, 32(4), 439–447. https://doi.
org/10.1007/s10067-013-2187-5. 

Nunes, G. S., Tessarin, B. M., Scattone Silva, R., & Serrão, F. V. (2019). Relationship 
between the architecture and function of ankle plantar flexors with Achilles tendon 
morphology in ballet dancers. Human Movement Science, 67. https://doi.org/10.1016/j.
humov.2019.102494.

https://doi.org/10.1016/j.humov.2018.05.011
https://doi.org/10.1097/JSM.0000000000000707
https://doi.org/10.1097/JSM.0000000000000707
https://doi.org/10.1136/bmj.c1964
https://doi.org/10.1136/bmj.c1964
https://doi.org/10.1016/j.ptsp.2019.04.022
https://doi.org/10.1016/j.ptsp.2019.04.022
https://doi.org/10.1249/JSR.0000000000000603
https://doi.org/10.1249/JSR.0000000000000603
https://doi.org/10.1007/s40279-013-0102-5
https://doi.org/10.1007/s40279-013-0102-5
https://doi.org/10.1016/j.jsams.2013.07.013
https://doi.org/10.1016/j.pmr.2014.06.003 
https://doi.org/10.1007/s00167-011-1445-9
https://doi.org/10.2519/jospt.2021.0302
https://doi.org/10.2165/00007256-199213050-00004
https://doi.org/10.1007/s10067-013-2187-5
https://doi.org/10.1007/s10067-013-2187-5
https://doi.org/10.1016/j.humov.2019.102494
https://doi.org/10.1016/j.humov.2019.102494


113

ANNALES KINESIOLOGIAE • 13 • 2022 • 2

Pia Lina VILAR, Tine KOVAČIČ, Mitja GERŽEVIČ: INJURY PREVENTION AND PHYSIOTHERAPY PROCEDURES ..., 93–113

Obrul, M. (2020). Vpliv prehrane na plesalce [The Impact of Diet on Dancers]. Akademija 
za ples Alma Mater Europaea. Retrieved from https://dance-academy.almamater.si/wp-
-content/uploads/2020/09/20_Monja-Obrul_Vpliv-prehrane-na-plesalce-revidirano.pdf 

Page, M. J., Moher D., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., 
… McKenzie, J. E. (2021). PRISMA 2020 explanation and elaboration: updated gui-
dance and exemplars for reporting systematic reviews. BMJ 372(160) 1–36. https://doi.
org/10.1136/bmj.n160. 

Rietveld, A. B. (2013). Dancers’ and musicians’ injuries. Clinical Rheumatology, 32(4), 
425–434. https://doi.org/10.1007/s10067-013-2184-8. 

Sobhani, S., Dekker, R., Postema, K. & Dijkstra, P. U. (2012). Epidemiology of ankle and 
foot overuse injuries in sports: A systematic review. Scandinavian Journal of Medicine & 
Science in Sports, 23(6), 669–686. https://doi.org/10.1111/j.1600-0838.2012.01509.x.

Steinberg, N., Adams, R., Tirosh, O., Karin, J., & Waddington, G. (2019). Effects of 
textured balance board training in adolescent ballet dancers with ankle pathology. Jour-
nal of Sport Rehabilitation, 28(6), 584–592. https://doi.org/10.1123/jsr.2018-0052.

Vera, A. M., Barrera, B. D., Peterson, L. E., Yetter, T. R., Dong, D., Delgado, D. A., … 
Harris, J. D. (2020). An injury prevention program for professional ballet: a randomi-
zed controlled investigation. Orthopaedic Journal of Sports Medicine, 8(7) 1–12. https://
doi.org/10.1177/2325967120937643.

Vosseller, J. T., Dennis, E. R., & Bronner, S. (2019). Ankle injuries in dancers. The Jour-
nal of the American Academy of Orthopaedic Surgeons, 27(16), 582–589. https://doi.
org/10.5435/JAAOS-D-18-00596. 

Vuurberg, G., Hoorntje A., Wink, L. M., van der Doelen, B. F. W., van den Bekerom, 
M. P., Dekker, R. … Kerkhoffs, G M. M. J. (2018). Diagnosis, treatment and preven-
tion of ankle sprains: update of an evidence-based clinical guideline. British Journal of 
Sports Medicine, 52(956), 1–15. https://doi.org/10.1136/bjsports-2017-098106.

Wolfe, M. W., Uhl, T. L., Mattacola, C. G., & McCluskey, L. C. (2001). Management of 
ankle sprains. American Family Physician, 63(1), 93–104. Retrieved from https://www.
aafp.org/pubs/afp/issues/2001/0101/p93.html.

https://dance-academy.almamater.si/wp-content/uploads/2020/09/20_Monja-Obrul_Vpliv-prehrane-na-plesalce-revidirano.pdf
https://dance-academy.almamater.si/wp-content/uploads/2020/09/20_Monja-Obrul_Vpliv-prehrane-na-plesalce-revidirano.pdf
https://doi.org/10.1136/bmj.n160
https://doi.org/10.1136/bmj.n160
https://doi.org/10.1007/s10067-013-2184-8
https://doi.org/10.1111/j.1600-0838.2012.01509.x 
https://doi.org/10.1123/jsr.2018-0052
https://doi.org/10.1177/2325967120937643
https://doi.org/10.1177/2325967120937643
https://doi.org/10.5435/JAAOS-D-18-00596
https://doi.org/10.5435/JAAOS-D-18-00596
https://doi.org/10.1136/bjsports-2017-098106
https://www.aafp.org/pubs/afp/issues/2001/0101/p93.html
https://www.aafp.org/pubs/afp/issues/2001/0101/p93.html

	_Hlk122510532
	_Hlk121925715
	_Hlk121925783
	_Hlk117671776
	_Hlk117676890
	_Hlk117676830
	_Hlk122521710
	_Hlk123029474
	_Hlk51764713
	_Hlk51617947
	_Hlk51764685
	_Hlk51616945
	_Hlk51676200
	_Hlk51710755
	_Hlk124939594
	_Hlk124939408
	_Hlk125008249
	_Hlk125008423
	_Hlk125010166
	_Hlk124768186
	_Hlk129167818
	_Hlk129168885
	_Hlk129939779
	_Ref116207795



