In conversation with Erica Gethen Smith, Physiotherapist at The Royal Ballet School

At The Royal Ballet School, we strive to nurture healthy, strong, and resilient young dancers, providing them with the necessary tools and support to meet the demands of their future careers.

Healthcare is a top priority at the School, and our world-class Healthy Dancer Programme responds to this, working together with our Artistic team in a fully integrated and holistic approach to classical ballet training.

Erica Gethen Smith is one of 20 expert healthcare professionals at The Royal Ballet School, responsible for providing physiotherapy to our White Lodge students. She has recently returned from the International Association for Dance Medicine and Science (IADMS) conference in Ohio, where she shared her research on the incidence of foot and ankle injuries in pre-professional dancers.

We spoke with Erica about combining her passion for the art form and interest in physiotherapy, as well as her recent research.

Can you tell me about your background and what inspired your interest in dance?

I danced professionally for seven years. I trained from a very young age like all our dancers, and then went to Arts Educational School, London at 16 years old where I completed the classical dance course.  From there I went on and danced in contemporary and commercial roles both in the UK and abroad. I retrained as a physiotherapist as a mature student and was always fascinated with anatomy and physiology and how this influenced dance.

When you started studying to become a physiotherapist, had you always wanted to work with dancers?

I always wanted to work with dancers and combine my two passions! I’ve been a physio for 20 years, and it was always my dream to work with either a dance school or a dance company. I’ve been working with dancers for the last ten years in private practice in my own clinic, for a local dance school in Godalming and also for a private clinic where I’d see dancers from many dance genres and backgrounds with different capabilities.

Whilst working within the NHS, I was a Foot and Ankle Advanced Physiotherapy Practitioner; many of the injuries that we see within any dance cohort are foot and ankle and lower limb injuries. Dancers can injure all parts of the body, but there’s a real predominance of foot and ankle injuries, so these skills developed around my foot and ankle speciality have helped me with my dance rehabilitation and physio.

You bring extensive experience in a number of settings to your role as Physiotherapist at White Lodge. Can you tell me about your role and what a day looks like for you at the School?

I’m part of the Healthcare team here at White Lodge, and we treat dancers from ages 11 to 16. I work alongside my physio colleague, Richard Meaden and we’re part of the broader Healthcare team, consisting of our Health Care Manager, Strength and Conditioning coach, Pilates instructor, School Nurse, Sports & Exercise Medicine Consultant, Psychologist, Counsellor, Nutritionist and our Ballet Rehabilitation coach.

Our role here is very much about ensuring the holistic care of the dancer and from a physio perspective assessing the dancer’s injuries, profiling, educating them about their bodies and helping them make a full recovery through individual rehabilitation plans. From a wider perspective, when we profile them, we’re looking at their strength markers, range of movement and whether they’ve got any predisposition to injuries, and identifying where we can help them to avoid those injuries by putting training practices in place. We all play our part within that, and they very much overlap.  

The physio team may treat a student in the acute phase of an injury and take them through to their mid-phase. As they go further on in their rehab journey Pilates, strength and conditioning and ballet rehab will have a greater input. For some, counselling may be involved in their injury recovery process or general well-being. As part of the collaborative treatment plan we are also fortunate to have a weekly clinic with our Sports and Exercise Medicine Consultant where we refer students with more complex presentations for further assessment and then discuss their cases as part of the wider team.

As an ex-professional dancer, what do you enjoy most about working with dancers?

Having worked with a lot of different patient groups over my years as a physio, what’s great about working with dancers is they are passionate to improve and get back into class, doing what they love. They are usually very diligent, and many are perfectionists, so they work really hard to complete their exercises, improve and then we can progress their rehab. It’s great to have that enthusiasm; they have the same passion for getting them better as we do for treating them.

As an ex-dancer, I also love working with the Artistic team. This morning, I spent time with Giacomo [Ciriaci], who is our Rehabilitation Ballet coach, and it was great to be in a rehab ballet session with him and one of my students. I could listen to what he was saying to the student and then be able to integrate it from my point of view as a physio and use the same cues and messages throughout the student’s rehab sessions. This collaborative working is so important for the dancers.

In your experience, do you find that physio for dancers is different from other sports disciplines?

It all comes from a basis of understanding the anatomy, the stage of the injury, movement patterns and how an injury may progress. That is the same in any area, whether it’s with a sportsperson or a member of the general public, we all recover from an injury in the same way. But in dancers, they have greater demands in terms of the level of training and loading they undergo, all at a time when they are growing, so they have to be treated quite differently and carefully, especially during growth periods.

Research is an integral component of the School’s Healthcare programme, helping us better understand our students’ needs and bring dance to the forefront of sports science. Can you tell me about the research you have conducted?

I’ve just finished my Masters in Sports and Exercise Medicine at Queen Mary University of London, and as part of that, we had to conduct a research project. My research project was in conjunction with English National Ballet School and was looking at foot and ankle injuries and whether there was a link with calf muscle endurance. The study looked at 16 to 19-year-old dancers to see if there was a correlation between how strong they were from an endurance point of view and whether there was an increase incidence of foot and ankle injury.

It’s an ongoing project under the guidance of Dr Manuela Angioi at QMUL. The project looked at how many heel rises the dancer could do, and we investigated this with a straight knee and a bent knee heel rise. I was investigating gender differences in relation to the foot and ankle injury, whilst my colleague, Callum East was looking at year groups.  Although we didn’t find anything that we would call statistically significant from the results, clinically the results may have importance.

We know from our experience within dance that if you’re stronger within your soleus and gastroc muscles, which make up the calf musculature, you will have more control around your ankle. We found that the year one group at English National Ballet School appeared to show a trend of increased foot and ankle injury if a student had a lower number of bent knee heel raises. This may have an implication for their training needs which the team at ENBS may now consider.

What was it like presenting your research in Columbus, Ohio?

We were invited to submit an abstract to the International Association of Dance Medicine and Science (IADMS) annual conference. The importance of Dance Science is crucial to our development of evidence-based dance rehab which is still steadily growing, as sports science has over the past 25 years.

We were very lucky to be successful in our submission and in October, I presented the research study in Columbus, Ohio at the annual IADMS conference. It was great to share our research at an international conference with lots of dancers, dance educators, and other healthcare professionals attending.

It was also a fantastic opportunity to network and learn about the research that’s being conducted around the world and how that’s being integrated at different levels, from local dance schools to colleges, vocational schools like ours and dance companies.

And lastly, what are some benefits for students of having access to a physio at School?

I think from an education point of view, it’s really important for us to educate and empower the young dancers on how to look after their bodies in terms of training, but also in terms of nutrition, rest, recovery and resilience. Lots of dancers are really driven, so they want to dance the whole time, but they may not understand how important it is to allow themselves time to rest and recover so that they are at their best for their classes, training and the huge amount growth and development they undergo at this time.

Having the ability to access the Healthcare team to flag an injury or concern when it is a small niggle, before it develops into something more is a great advantage. In this setting we are fortunate that the students are able to come to a drop-in session during the day, or schedule an appointment with us usually within 24-48 hours, enabling them to continue their training.