Premier Highland dancer sports injuries
- Mar 6
- 12 min read
Original Article
Premier Highland dancer sports injuries
Tan, Michelle C. BSa; Cortez, Angela N. MDb; Chiou-Tan, Faye Y. MDc
Journal of the International Society of Physical and Rehabilitation Medicine 6(4):p 119-124, December 2023. | DOI: 10.1097/ph9.0000000000000023
Open
Abstract
Objective:
The objective of this paper is to document sports injuries in premier Highland dancers. Highland dance originated in Scotland and is a relatively unknown sport to physiatrists and sports physicians. It is not the same as Irish dance performed in tap shoes but has some similarities to ballet with regard to the turnout of the leg in the first position.
Methods:
An Institutional Review Board approved, prospective, telephone survey was conducted to document demographics, area, type, and age of injury in premier Highland dancers.
Results:
A total of 22 premier Highland dancers met the inclusion criteria for the study. In the hip region, injuries included apophysitis at the anterior superior iliac spine. In the knee region, knee effusions, shin splints, and hairline stress fractures of the tibia were reported. In addition, less common injuries in sports, such as tibialis anterior strain and plantaris tendon partial rupture, were noted. In the ankle/foot region, sprains and tears of anterior tibiofibular, calcaneofibular, posterior talofibular ankle ligaments, and plantar fasciitis were observed, as well as fractured metatarsals in the foot and degenerative arthritis.
Conclusion:
Injuries resulting from improper alignment in “turnout” (external rotation at the hip) and overuse syndromes from intense and long hours of training to reach national and international competitive premier level were observed. Uncommon injuries, such as tibialis anterior strain and plantaris tendon partial rupture, were also noted that were unique to the jumping and heel/toe maneuvers performed in this sport.
History, dances, and maneuvers
The first record of Scottish Highland dance was in 1285 at the wedding of Alexander III, King of Scots. However, these dances are likely to date back to much earlier periods (https://www.historic-uk.com/HistoryUK/HistoryofScotland/Highland-Dancing/). The Sword dance is performed over 2 intersecting swords and is a battle dance with there being records of several royal members receiving performances of these dances over the centuries. Examples include: Swedish King John III in 1573 (in an aborted assassination attempt using the swords as weapons), Queen Anne of Denmark in 1589 and her husband King James VI (of Scotland) and I (England/Ireland) in 1617, and King Charles I in 1633 (https://www.historic-uk.com/HistoryUK/HistoryofScotland/Highland-Dancing/).
Highland activities came to an abrupt halt after the Battle of Culloden in 1746. At that time, an Act of the English Parliament was passed to ban the carrying of weapons and the wearing of kilts. This deprived the dancers of both their swords and outfits for performance. Although this Act was repealed in 1785, Highland culture did not become robust again until 1842 when Queen Victoria visited Scotland (https://www.historic-uk.com/HistoryUK/HistoryofScotland/Highland-Dancing/).
Mechanics of Highland dance
Highland dance is performed in leather ghillie shoes. There is little cushioning in these tight-fitted shoes and the best are made to emphasize a dancer’s point. A dancer’s competitive uniform consists of a velvet jacket and plaid woolen kilt with matching woolen socks.
There are 4 main characteristic dances that are required to be performed in a Highland competition (https://batd.co.uk/genre/highland-dance/). The first dance is the Highland Fling (https://batd.co.uk/genre/highland-dance/). One characteristic of this dance is the “shedding” (Fig. 1). The dancer must be externally rotated on both the working and supporting foot. The dancer’s working foot goes from the superior portion of the gastrocnemius to the front just below the knee while simultaneously hopping in time with the music with the supporting foot. Another movement is the toe maneuver requiring repeated forced dorsi/plantar flexion of the foot as the heel and toe of the foot are placed on the dance floor (Fig. 2).
The second is the Sword dance (Fig. 1). This challenging dance is performed over 2 intersecting swords. The goal is to dance over within the middle of the 4 quadrants created by the swords without disturbing them or their considerable-sized hilt. Stepping on the sword has resulted in ankle sprains and tears from landing improperly on the foot. Touching the sword in any manner results in disqualification from placing. The pace of the dance quickens in the later portion of the dance after a clap of the hands challenging an already fatigued dancer to perform at their highest level of error-free endurance and perfection. The most common position in this dance is the “half point” (Fig. 2). The half point requires the dancer to bear weight on the first 3 toes while lifting the other foot. Dancers often use this position in “Pas de Basque” A “Pas de Basque” requires the dancer an aerial extension of her leg to the second position (toe of the working foot in line with the heel of the supporting foot) and then jumping to land in the third position on the half point. The “beat” of the supporting foot requires momentary weight-bearing on the half point as the supporting foot is lifted and placed back down. When dancers bear weight in this position, the muscle strength in their toes is not strong enough which can lead to injury due to lack of support.
The third dance is the Seann Triubhas. In addition to many heel-toe maneuvers, the dancer is required to spend most of the time on the ball of the foot. At the end of the dance, there is a joyous jump known as a “leap” which is a mid-air split (Fig. 1). The goal of attaining 180 degrees in the split is the most ideal. This requires the dancer to be able to elevate high enough to allow time to achieve the 180-degree split while still staying on the beat of the bagpipe music. The Seann Triubhas is known for many aerial positions while simultaneously hopping on the supporting foot. Examples of these dances performed in competition are shown in Figure 1.
The fourth dance is the Strathspey and Highland Reel or an altered version known as Strathspey and Half Tulloch. This folk reel dance involves 4 dancers. This dance incorporates many of the elements required in the previously mentioned dances, including the challenging extension high cuts, mid-air extensions of both legs require a landing on one foot while the other performs a double hit in the back of the gastrocnemius. Unlike the other solo competition dances, this one is performed in a group thus their performance might affect one’s own.
Introduction
Scottish Highland dancing is an international, competitive, high-impact sport. It involves vertical jumps with a series of extensions, splits in mid-air, and complex footwork all completed with exact precision and timing on the beat provided by live bagpipe music. The majority of Highland dancers will start at a young age around 3 to 5 years. Premier Highland dancers, the highest class in terms of skill, will practice 3–6 hours a day for at least 5 or 6 days a week. Due to this intensive schedule, these dancers are likely to accumulate injuries from repetitive movement and stress. However, injuries from this sport have not been documented in the medical PubMed literature. The aim of this study is to report injury types and locations in these unique dancers in hopes of educating Highland dancers, fitness instructors, dance teachers, and the medical world of the knowledge of the location and types of injuries that Highland dancers sustain to prevent or treat them. There is a renewed interest in Highland dancing after being depicted in popular books and shows, such as Outlander1,2 and Disney’s Brave3.
Although once an exclusively male activity, today 95% of the dancers are females (https://www.historic-uk.com/HistoryUK/HistoryofScotland/Highland-Dancing/). As Scottish migrants moved across the world, they brought their Highland dance competitions and festivals with them. In addition to Europe, competitive games are now regularly organized across the world including Australia, Canada, South Africa, New Zealand, and the United States (https://www.historic-uk.com/HistoryUK/HistoryofScotland/Highland-Dancing/). Dancers of diverse ethnicities and races are all encouraged to participate in this inclusive environment. All competitions and qualifiers culminate at the World Highland Dancing Championships Cowal Highland Gathering in Dunoon, Argyll in Scotland.
Aside from case reports, there is limited sports injury medical literature in the area of Highland dance. A review of PubMed was conducted using the search terms “Highland dance” and “Highland dancer.” There was only one relevant case study that reported a base fracture of the second metatarsal4.
Methods
This is a prospective study surveying injuries incurred by Highland dancers. This study was approved by the Institutional Review Board of the senior authors’ medical school. Informed consent was obtained before the survey. Inclusion criteria were adults, premier (elite) Highland dancers registered with the Royal Scottish Official Board of Highland Dancing, and participants whose injuries were incurred due to dancing (rather than other trauma, eg, skiing or motor vehicle accident). The exclusion criterion was dancers who began their careers late (as adults age 18 or older), since they may have already had injuries from other sports in their youth. Twenty-five premier dancers were screened, and 22 premier dancers met the criteria.
Recruitment was performed by notifying local, and regional Highland dancers/dance companies and the national dance organization to give awareness of the availability of participating in the study as per Institutional Review Board–approved guidelines. Once the study participant notified the investigators of an interest in the study, they were emailed the consent form to review and given the opportunity to ask questions. The research team was available to explain the consent form and answer questions regarding the survey. The survey was conducted through telephone interviews. Demographic information, type, location, and age at the time of injury were collected from elite dancers who self-reported their medical results. Action or type of dance being performed was also recorded. As survey participants were of adult age at the time of the interview, they were able to accurately repeat/read the medical diagnoses given to them from their personal past medical records provided by their sports physician or orthopedic surgeon. This approach was taken, since realistically it would not be possible to obtain health information portabiity and accountability act permission to access older, nonelectronic medical records and imaging for each dancer in various medical charts across the nation. Diagnoses were made through appropriate imaging techniques, including musculoskeletal ultrasound, magnetic resonance imaging, plain films, and expert physical examination, as directed by their sports medicine or orthopedic surgeon physician.
Results
Twenty-two premier (elite) Highland dancers were included in the study. All the dancers were females with the mean age at the time of the interview 25.5 ± 9.3 years old (median age: 21.0 y old). The average age dancers started was 4.7 ± 2.1 years of age, and the average length of their career was 17.8 ± 6.0 years. Demographics showed 68.2% were white, 13.6% Asian, 9.0% Mixed, and 4.5% African American. The average age of the first injury was 15.5 ± 5.9 years (median: 13.5 y old), and second to fourth injuries (if that many incurred) at age 17.5–17.7 years.
Types and locations of injuries
In the hip region, apophysitis at the anterior superior iliac spine was reported in 4 injuries. In the knee region, 2 knee effusions and 1 patellar tendinitis were reported. In the calf region, 9 shin splints were reported (Fig. 3).
In the ankle/foot region, ligamentous and musculoskeletal injuries included: 7 sprains and 3 tears of anterior tibiofibular, calcaneofibular, and posterior talofibular ligaments, 3 arch of the foot sprains, 1 first metatarsal tendinitis, and 3 plantar fasciitis. In addition, less common injuries, such as tibialis anterior strain and plantaris tendon partial rupture, were observed. Also, in the ankle/foot region, bony injuries included: 11 fractured metatarsals and 1 navicular fracture (Fig. 4). Bony degenerative metatarsal joints in youth were also reported.
Discussion
Highland dance injuries
As can be seen from this paper, reported injuries occurred in the lower limbs rather than the upper. Many of these injuries result from improper alignment and overuse.
The groin and knee injuries seen in these dancers have similarities to ballet injuries from the shared use of a turnout position. Improper turnout places abnormal forces into the hip and knee joints and their surrounding soft tissue structures, especially when poor core and hip muscular control allows for improper pelvic posture, or a “forced” turnout leads to excessive tibial rotation at the knee. Long-term concerns, if not corrected, include the risk of degenerative joint disease and chronic pain.
The high number of Achilles and shin splint injuries in these dancers appear distinctive to Highland dance and the amount of jumping exclusively on the ball of the foot. Achilles and shin splint injuries are both overuse injuries commonly encountered in jumping sports, such as track and field. The Achilles tendon undergoes tension with jumping and standing on the toes, though when overall volume exceeds the tendon’s capacity, such as when one is fatigued or during large increases in training volume, tendinopathy arises. In shin splints, the tibial bone absorbs impact forces from jumping and when in excess, similar to the Achilles, leads to a stress reaction.
There are a few unusual injuries notable in this population. The first is an injury to the plantaris muscle. The plantaris is a vestigial muscle used for jumping. Humans have evolved, so that this muscle is small with a lengthy tendon. Injury occurs in activities with repetitive jumping as seen in the sport of Highland dance. This injury can sometimes be confused with a gastrocnemius tear and thus ultrasound examination is needed to identify the lesion to prescribe the correct treatment. A second injury is the tibialis anterior strain. This is thought to be due to repeated dorsi and plantar flexion needed for constant jumping and landing with both concentric and eccentric loading. Again, musculoskeletal ultrasound is useful to make this diagnosis. The final is degenerative joint disease in youth, reflecting the repetitive and overuse syndromes for this elite group of dancers.
Review of the medical literature and comparison of Highland dance to ballet
With the majority of dance-related injuries recorded in literature being related to ballet, this can be used as a base of knowledge for further understanding some overlap in injuries with Highland dancers. Ballet is the most similar to Highland dancing. There are some studies on ballerinas recorded in the literature. With other modern dance forms, such as hip hop or tap, the legs tend to remain in anatomic neutral position with no external rotation. Ballet uses external rotation often; it can serve as a useful model of comparison. Most common ballet injuries happen to the lower extremity. Issues with poor lumbopelvic movement control, poor cardio and aerobic strength, hypermobility of the foot and ankle, and contraction of the transversus abdominus at inappropriate times are all common causes of injury found in the literature5. Proper alignment of the body is very important in ballet5.
Proper alignment is also critical in Highland dancing. Ballet and Highland dancing have many similarities. With both using aerial extensions that are externally rotated and complex footwork, the one major difference between the two is the “ball of the foot,” (metatarsophalangeal joints). While ballet dancers spend most of their time either “en pointe,” weight-bearing on the tip of the toe, or flat, Highland dancers constantly land on the “ball.” This requires constant hopping which is absent in ballet. Highland dancers spend little time on the ground and aim to land and repel themselves upwards as fast as possible to complete aerial movements. With Highland dancers spending most of their time in the air, it is important that their alignment is correct. False alignment leads to unbalanced movements and can often be the cause of several common Highland dance injuries. Proper alignment is along the entire body. Proper posture, not leaning forward or backward, along with joint alignment all affect a dancer’s ability to jump off the ground higher and faster. The acetabulofemoral joint should be in line with the knee joint which is in line with the 3 ankle joints. When a dancer is properly “turned out,” externally rotated, then all these joints should form a straight line. When one of these joints is slightly out of line, it causes injury.
A review of the literature did not identify medical injury surveys validated for Highland dancers or dancers in general, thus a survey was created for this study. Although surveys of dancer injuries have been performed in the past,6,7 the location and type of injuries were not specific enough for the medical literature in that they only recorded body areas with symptoms. For example, the Oslo Sports Trauma Research Center Questionnaire records the location of pain or injury of the lower extremities as “lumbar spine, pelvis/buttock, hip/groin, thigh, knee, lower leg, ankle, foot/toes7.”
Rehabilitation strategies
Rehabilitation strategies center around temporary activity modification and relative rest until symptoms resolve. In the case of tendinopathies, employing resistance exercises, particularly eccentric loading exercises, to the affected tendon can encourage tendon remodeling. A robust rehabilitation program should also include preventative strategies, correcting factors that may have predisposed the dancer to injury. Exercises that improve lumbopelvic control can protect the hip and groin from injury and can also improve lower extremity alignment, thereby guarding against injuries from improper turnout. Improving aerobic fitness through cross-training can protect the dancer from early fatigue and counter-strength imbalances in highly stressed areas. Lastly, gradually increasing training regimens, rather than sudden bursts in training activity, can allow for appropriate tendon adaptations to circumvent overuse tendinopathy.
Conclusion
This paper reports sports injuries in a series of premier Highland dancers. Several injuries result from overuse from the long hours and intense training regimen needed to perfect their craft. In addition, there are unique injuries in Highland dancers related to constant jumping for aerial maneuvers, such as plantaris tears, and heel/toe (dorsi/plantar flexion) maneuvers causing tibialis anterior muscle strain.
Ethical approval
This project was approved by the local institutional review board (IRB).
Sources of funding
None.
Author contributions
M.C.T: concept, design, intellectual content, data acquisition, data analysis, manuscript preparation, editing, and review. A.C.: design, intellectual content, data analysis, manuscript preparation, editing, and review. F.Y.C.T: concept, design, intellectual content, data analysis, manuscript preparation, editing, and review, and corresponding senior author.
Conflicts of interest disclosures
M.C.T. was sponsored by Harry Farrar IV Memorial Educational Scholarship for the advancement of the field of Highland Dance. The remaining authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
IRB approved project H-49546.
Guarantor
None.
Data Availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declaration of Generative AI and AI-assisted technologies in the writing process
No AI tools/services were used during the preparation of this work.
References
1. Gabaldon D. Outlander. Dell publisher; 1st edn; 1992.
2. Outlander. Accessed August 1, 2023. https://www.starz.com/us/en/series/outlander/21796.
3. Andrews M, Chapman B, Purcell S. Brave. Walt Disney Studios Motion Pictures, 2012.
Keywords:
Highland dance; sports injuries; dance; ballet
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
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