Performing Arts Medicine is a branch of occupational medicine that formally addresses the medical concerns of those who play musical instruments, sing or dance.1 It covers the overall health, prevention and management of injuries related to artists of all types as they practice their craft. While injuries may be similar to that of the general population, there are unique injuries that performers sustain.
Dance medicine and science investigates the causes of dance injuries, promotes their care, prevention and safe post-rehabilitation return to dance, and explores the ‘how’ of dance movement. Some specific concerns include the biomechanical, physiological, and neuromotor aspects of dance, nutrition, psychological issues, and the body therapies and somatics area.2
Music medicine and the physiology of music-making have been recognized as early as 1700s, with articles describing injuries in keyboard and violin players, and musician’s cramp (focal dystonia) as early as the 1800s.3 Modern history has seen an increased awareness of overuse injuries and other musculoskeletal problems affecting performance.
Non-musculoskeletal issues in performing arts medicine include nutrition (risk of relative energy deficiency in sport (RED-S)), hearing loss, vocal health, dental issues, respiratory disorders, and performance anxiety.
Performing arts demands are varied, and consequently the etiology of injuries is varied. Dancers tend to more frequently sustain injuries that are acute or traumatic, such as an ankle sprain after landing from a jump. Musicians tend to have more repetitive stress and posture-induced injuries, such as tendinopathy from poor technique or ergonomics while holding a musical instrument. Other conditions like focal dystonia are relatively rare and develop over time without clear etiology, and most commonly affect guitarists, pianists, and woodwind players.4
Performing Arts Medicine has considerable overlap with Sports Medicine, as athletes and performing artists have common challenges such as daily play or practice, playing through pain, competing or performing in challenging environments, having the pressure to succeed and the risk for career-threatening injuries. Travel and jet lag, nutrition, hydration, overuse injuries and performance anxiety can also affect both populations.5 However, there are issues unique to performing artists. Dancers need to be athletic while executing steps gracefully. Musicians are considered “small muscle athletes” due to extensive use of hands and fingers.
Epidemiology, including risk factors and prevention
Epidemiology and risk factors for injuries in performing artists vary depending on the type of performing art, and they differ among dancers of different styles and among different instrumentalists.
For dancers, prevalence rates for injuries are very high, especially among classical ballet dancers, followed by jazz/contemporary dancers, and can result in significant loss of time from occupation. The lifetime prevalence of injury among professional ballet dancers has been reported to be as high as 95%. Modern dancers and younger ballet students suffer injury rates from 40-80%. A survey of 134 contemporary dance students who were followed during one academic year, found that 96.9% of the students reported at least 1 health problem, with injury incidence of 80.8%.6 Not surprisingly, the foot and ankle make up 30-65% of all reported injuries.7 Risk factors include age (injuries are more severe with advanced age), gender (no overall difference between men and women, however women suffer more foot/ankle injuries while men suffer more shoulder/back injuries), strength, flexibility, pedagogy, skill (novice dancers carry higher risk than elite dancers), costume type, shoe selection, dance surface, theater environment, and rehearsal and performance schedules.7,8 Overall, research on injury risk factors in the broad arena of dance is limited. A systematic review examining musculoskeletal risk factors for preprofessional modern and ballet dancers found that the quality and level of evidence is lacking, and thus consensus regarding risk factors for dance injuries remains difficult.9 A retrospective, cross-sectional study found that the training situations that generated the most injuries in classical ballet and jazz/contemporary dancers include excessive use and dynamic overload, whereas tap/folk dance had the highest risk of injury due to excessive use.10 There is some level 2 evidence to support previous injury and insufficient psychological coping are associated with higher risk of musculoskeletal injury.10
Injuries in musicians are also extremely common. A large survey11 of 2,212 orchestra members revealed that 82% had a medical problem at some point in their careers, while 76% had experienced a problem severe enough to affect their performance ability. Similarly, a literature review of publications related to performance-related musculoskeletal disorders (PRMD) and performance-related pain (PRP) found that practice time (1.5-2 hours), history of PRMD/PRP, young/adolescent or older age, female gender (possibly due to hand size and higher rates of joint laxity), lack of warm up, type of instrument (consider poor ergonomics and weight of the instrument), and obesity were all associated with increased risk of injury.12 Neuroticism/perfectionist personality were identified by many as being associated with development of dystonia. Other risk factors include required posture, repetitious finger work, general health/conditioning (consider flexibility, strength, endurance, and nutrition); repertoire, technique, change in playing time or teacher,13 temperature, stress and lack of rest.14
Common acute injuries in dancers include:
- Ankle sprains
- ACL tears and other ligamentous knee injuries
- Hip flexor strains
Repetitive use injuries that are common in dancers result from the unique stresses that occur due to dance:
- Lumbar spine pain and irritation
- Anterior knee pain
- Hoffa’s fat pad irritation from increased knee recurvatum
- Hip labral injuries
- Shoulder labral injury
- Chronic shoulder instability in modern dancers
- Posterior tibialis and flexor hallucis tendinopathy
- Irritation of foot ossicles such as os trigonum syndrome and accessory navicular irritation
- Hallux valgus
- Skin abrasions and toenail bed injuries
- Chronic groin pain
Repetitive use syndromes of the upper limbs are common among musicians.15 Lower extremity injuries are less common in musicians.
- Trigger finger
- Nerve compression syndromes, such as carpal tunnel syndrome, ulnar neuropathy16
- Muscle contracture, myofascial pain or trigger points
- Focal dystonia (typically manifested as involuntary flexion of the 4th and/or 5th digits of the hand)
The most frequently diagnosed upper extremity disorder amongst pianists are muscle contracture or trigger finger; high string players commonly develop weak or overused lumbrical muscles, neck and shoulder pain.17 Low string instruments commonly get thumb, radial wrist and forearm pain caused by excessive wrist flexion and thumb hyperextension, while up to two-thirds of percussionists have musculoskeletal pain from tenosynovitis and/or arthritis in bilateral hands and wrists. Wrist and thumb pain, deQuervains tenosynovitis and tenosynovitis of the flexor tendons, and nerve irritation/compression in the upper extremities (median and ulnar nerves) are common in wind instruments due to the weight of the instrument.
Essentials of Assessment
History taking should be specific to the needs and demands of a performance artist. Aside from inquiring about actions that aggravate the symptoms and their impact on common functional tasks like driving, lifting or holding objects, performance-specific questions are also necessary.
Dancers should be asked about:
- level of experience (i.e. age started, total years dancing)
- styles of dance
- movements that aggravate or relieve symptoms
- practice and performance schedule
- most frequent corrections from teacher
- types of shoes, costumes, props, performance surface/environment
- any recent changes to dance regimen, partners, or choreographers
- diet/nutrition screening and body mass index (BMI)
- menstrual status assessment
- other physical activity or dancer wellness program
For musicians, it is important to know:
- what instrument(s) they play
- acquisition of a new instrument or associated equipment like a neck strap, bow or carrying case
- new teacher
- duration of studying the instrument
- primary musical genre
- total playing time prior to the injury – including individual practice, rehearsals, lessons, and performances
- future playing demands
- recent increases in practice time or intensity
- presence of warm-up period prior to playing
- scheduled breaks during practice, and duration of breaks
- which playing techniques (chords or scales, for example) aggravate symptoms
- whether symptoms have resulted in the patient stopping or cutting back from playing
- other physical activity or participation in musician wellness programs
As with all patients, one must perform a thorough investigation of the musculoskeletal and neurological systems. Pay special attention to abnormalities or asymmetries in resting and dynamic posture, spinal and pelvic alignment, joint ranges of motion, muscle imbalances in tension, bulk, or flexibility, poor firing patterns like scapular dyskinesis, etc. Assess for increased laxity in conditions such as hip dysplasia or shoulder instability.
Clinical functional assessment: mobility, self-care, cognition/behavior/affective state
The artist should be observed performing his or her craft in real time. Dancers should perform common steps and positions, especially those which aggravate symptoms, preferably with their costumes, shoes, and props.
Musicians should similarly bring their instruments in to the evaluation when possible. An ergonomic assessment of the musician-instrument interface (holding or supporting and playing the instrument) while seated or standing is necessary. It is helpful if the musician is observed playing different musical passages. A video assessment can also be useful, since some symptoms and physical examination findings occur with fatigue or repetitive movements. Symptoms may also be very subtle and easily missed in real time but can be picked up on slowed-down video replay.
Special attention should be paid to the artists’ behavior and affective state, as anxiety/depression and eating disorders have been found to be very prevalent especially in the dance population.18
Appropriate laboratory studies will depend on the suspected condition but are not typically necessary. Work-up may include a complete blood count, basic metabolic panel, thyroid function tests, creatine kinase and hormonal levels. Genetic testing may be indicated if considering joint hypermobility syndrome or other genetically predisposed condition like a neuromuscular disorder.
Similar to laboratory studies, necessary imaging will also depend on the suspected condition. This may include X-rays, ultrasound, and magnetic resonance imaging (MRI). MRI can detect soft-tissue injuries and is more sensitive than X-rays for detecting compression or insufficiency fractures but is more costly and less real-time than ultrasound. For evaluation of bone stress injuries, which are common in dancers, dual-energy X-ray absorptiometry (DEXA) and bone scan imaging should be obtained to evaluate for potential bone density loss commonly seen with RED-S.
Supplemental assessment tools
Nerve conduction and electromyographic (EMG) studies can be helpful for radiculopathies and peripheral nerve injuries or suspected nerve entrapment. Motion and video analysis may be useful for clinicians but also patients as a form of biofeedback.
Footwear, costumes (weight), set design, stage set up, overly rigid and non-level stage surfaces may increase the risk of injury for dancers.
Musicians risk injury when working in cramped quarters, and/or use non-adjustable furniture and music stands, because these can alter postures and restrict movement.
For all performers, lighting, temperature, noise levels and air quality (when performing outdoors) are possible risk factors for injury.
Social role and support system
Psychosocial stressors, depression or anxiety, disordered eating, sleep, personality, coping and the absence of a support system are associated with the risk of injury in dancers.8,19 Among musicians, long hours at work, work content, high job demands, low control/influence, and the lack of social support have been linked to musculoskeletal pain.20 Performers may be reluctant to seek medical help due to insurance issues such as workers compensation and limited private coverage.
Many performing artists are reluctant to seek medical help, since they may be perceived as being unreliable, weak, or having inferior talent. They also fear “losing their gig” if they admit to injury. They are more likely to seek advice from their teachers,21 try home or alternative treatments and may delay seeking medical care. Performers may perceive pain as a normal consequence of practicing their art,22 (i.e., “no pain, no gain”) and may play or dance through the pain. Adhering to a rehabilitation program, especially limiting activity, may be difficult.
Rehabilitation Management and Treatments
Generally, treatment involves relative rest, adjustments in technique and ergonomics, modifications of the performer-instrument interface, relaxation, and body awareness (for example, Alexander technique or Feldenkrais method), physical and/or occupational therapy (with a focus on stretching right/overused muscles, strengthening weak/underused muscles), use of splints, adaptive devices, modalities, analgesic or anti-inflammatory medications, local injections, or surgery.23 The Pomodoro method is recommended for appropriate work/rest cycle for musicians, as longer practice sessions have been associated with increased risk for injury.12 Use of hearing protection should also be implemented to avoid potential hearing loss.
Coordination of care
Treating a performer involves a multifaceted approach and, depending on the diagnosis, may require referrals to physical and occupational therapists, athletic trainers, otolaryngologists, audiologists, geneticists, nutritionists, endocrinologists and mental health professionals.
Patient and family education
Patient education centers on reducing injury risk. Educating dance and music instructors is also important, since they are often the first of sources of advice for performers. In general, dancer/musician wellness programs and having good nutrition and exercise should be recommended to improve overall mental and physical health. Methods to reduce specific injury include using proper technique and practice habits, doing strength training and general conditioning exercises,24 having adequate hydration, nutrition, rest and sleep, doing a warm-up and cool-down routine, and limiting practice to 45-50 minutes at a time, coupled with a 10-15 minute break. For musicians, achieving ergonomically correct posture (adjusting music stands for optimal viewing angle), musician-instrument interface, as well as alternating repertoire and using mental practice or singing to conserve musculoskeletal strength and energy can assist in injury prevention.25
Cutting Edge/Emerging and Unique Concepts and Practice
Performing Arts Medicine benefits from the use of technological advances in motion analysis such as videography, force plates and surface EMG, blood flow restriction, e-stim, shockwave therapy in both clinical and research settings. The evolving field of regenerative medicine may also provide additional treatment options.
Gaps in the Evidence-Based Knowledge
Standardized clinical guidelines for management of injuries in performing artists still do not exist, mainly due to the relative lack of evidence-based and laboratory research compared to Sports Medicine. The dynamics of human artistic performance are complex, and trying to isolate single variables that can be studied scientifically is difficult.26 Quantitative and qualitative research and increased collaboration amongst performing artists, clinicians, educators, and researchers is helping to develop effective, targeted, and relevant health promotion and performance optimization strategies for performing artists worldwide.27 More research is needed to provide specific guidance on practice time, causes of dystonia or mental health disorders among performing artists, to better assist in development of prevention/treatment protocols.
- “Performing arts medicine.” Segen’s Medical Dictionary. 2011. Farlex, Inc. https://medical-dictionary.thefreedictionary.com/performing+arts+medicine. Accessed November 5, 2017
- Harkness Center for Dance Injuries. https://med.nyu.edu/hjd/harkness/students/dance-medicine-science-career. Accessed November 3, 2017
- Harman SE. The Evolution of Performing Arts Medicine. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science and Medicine, Inc.; 2010: 1-24.
- Chiaramonte R, Vecchio M. Rehabilitation of focal hand dystonia in musicians: a systematic review of the studies. Rev Neurol. 2021 Apr 16;72(8):269-282. English, Spanish. doi: 10.33588/rn.7208.2020421. PMID: 33851716.
- Dick RW, Berning JR, Dawson W, Ginsburg RD, Miller C, Shybut GT. Athletes and the arts–the role of sports medicine in the performing arts. Curr Sports Med Rep. 2013;12(6):397-403.
- van Winden DPAM, Van Rijn RM, Richardson A, et al Detailed injury epidemiology in contemporary dance: a 1-year prospective study of 134 students BMJ Open Sport & Exercise Medicine 2019;5:e000453. doi: 10.1136/bmjsem-2018-000453
- Shybut GT. Foot and Ankle Injuries in Dancers. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science & Medicine, Inc.; 2010: 271.
- Liederbach, M. Epidemiology of Dance Injuries: Biophysical considerations in the Management of Dancer Health. Dance Medicine: Strategies for the Prevention and Care of Injuries to Dancers. Orthopedic Section, APA, Inc. 2008.
- Kenny SJ, Whittaker JL, Emery CA Risk factors for musculoskeletal injury in preprofessional dancers: a systematic review British Journal of Sports Medicine 2016;50:997-1003.
- Campoy, F. A. S., de Oliveira Coelho, L. R., Bastos, F. N., Júnior, J. N., Vanderlei, L. C. M., Monteiro, H. L., … & Pastre, C. M. (2011). Investigation of risk factors and characteristics of dance injuries. Clinical journal of sport medicine, 21(6), 493-498.
- Fishbein M, Middlestadt SE. Medical problems among ICSOM musicians: overview of a national survey. Med Probl Perform Art 1988; 3:1-8.
- Trevor Elam, MC, USN, Steven Mowen, MC, USAF, Christopher Jonas, MC, USAF, Occupational Injuries in Musicians: A Literature Review, Military Medicine, 2022;, usab499, https://doi.org/10.1093/milmed/usab499
- Brandfonbrener AG. Etiologies of Medical Problems in Performing Artists. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science & Medicine, Inc.; 2010: 29.
- Rousseau, C., Barton, G., Garden, P., & Baltzopoulos, V. (2021). Development of an injury prevention model for playing-related musculoskeletal disorders in orchestra musicians based on predisposing risk factors. International Journal of Industrial Ergonomics, 81, 103026.
- Fry HJH. Overuse syndrome in musicians: prevention and management. Lancet. 1986 Sept 27; 2(8509):728-31.
- Lederman RJ. Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle & Nerve. 2003:25(5); 549-561.
- Yang, N., Fufa, D. T., & Wolff, A. L. (2021). A musician-centered approach to management of performance-related upper musculoskeletal injuries. Journal of Hand Therapy, 34(2), 208-216.
- Fostervold Mathisen, T. F., Sundgot-Borgen, C., Anstensrud, B., & Sundgot-Borgen, J. (2022). Mental health, eating behaviour and injuries in professional dance students. Research in Dance Education, 23(1), 108-125.
- Mainwaring LM, Finney C. Psychological Risk Factors and Outcomes of Dance Injury: A Systematic Review. J Dance Med Sci. 2017;21(3):87-96.
- Jacukowicz A. Psychosocial work aspects, stress and musculoskeletal pain among musicians. A systematic review in search of correlates and predictors of playing-related pain. Work. 2016;54(3):657-68.
- Air ME, Grierson MJ, Davenport KL, Krabak BJ. Dissecting the doctor-dancer relationship: health care decision making among American collegiate dancers. PM&R. 2014;6(3):241-9.
- Bruno S, Lorusso A, Caputo F, Pranzo S, L’abbate N. [Musculoskeletal disorders in piano students of a conservatory]. G Ital Med Lav Ergon. 2006;28(1):25-9.
- Hoppmann RA. Musculoskeletal Problems of Instrumental Musicians. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science & Medicine, Inc.; 2010: 207-227.
- Nygaard andersen L, Mann S, Juul-kristensen B, Søgaard K. Comparing the Impact of Specific Strength Training vs General Fitness Training on Professional Symphony Orchestra Musicians: A Feasibility Study. Med Probl Perform Art. 2017;32(2):94-100.
- Yang, N., Fufa, D. T., & Wolff, A. L. (2021). A musician-centered approach to management of performance-related upper musculoskeletal injuries. Journal of Hand Therapy, 34(2), 208-216.
- Manchester RA. Research in performing arts medicine. Med Probl Perform Art. 2015;30(1):66-7.
- Ackermann BJ. The Sickness of stigmas. Med Probl Perform Art. 2017;32(3):183-184.
Original Version of the Topic
Jennifer Yang, MD, Dustin Leek, MD. Performing Arts Medicine. 2/15/2018
Sharon Ong, MD
Nothing to Disclose
Ziva Petrin, MD
Nothing to Disclose