Contents

Introduction

"Dance is nature. Listen to your heart. It dances with its own rhythm. The biggest thing that classical dance and music do to you is help attain balance between your mind and soul." Pandit Birju Maharaj (Sarkar 18.05.2023).

Dance brings tranquility to its performer and inspiration to those experiencing that performance. Much of that performance depends on the artist's health and state of mind. To give a mind-blowing performance, dancers must be in excellent emotional and physical health. Indian Classical Dance involves such coordinated elements which are a fusion of spiritual, emotional, mental and the physical attributes. This can be confirmed by referring to Bharat Muni's’ - Natya Shastra ' - the guide to Indian classical dance which states in its first Shloka (Sanskrit for verse, stanza, or proverb): "Where the hand gestures are, the eyes follow; Where the eyes go, the mind follows; Where the mind is, there the feeling evolves; Where the feeling evolves, the expression ultimately arise” (Khunteta 2020).

Kathak, having its prime origin in North India, is counted among the nine classical dances of India (Dance 2024; Morelli 2010). The essence of Kathak dance, a form of storytelling and composition, can be traced back to its Sanskrit origins, specifically the terms "Kathaka" (Lalli 2004) and "Katha" (Shah 2007). "Kathaka" refers to a skilled narrator or reciter (Lalli 2004) while "Katha" signifies a story (Shah 2007). Over the past few years, Kathak has undergone changes, leading to a shift in the way it is practiced and perceived (Shah 2007). Kathakars (the Kathak narrators or performers) conveyed tales from grand epics and ancient mythology through the mediums of dance, melodies, and musical expressions (Massey 1999). The grand epics and ancient mythology also include the world's longest poem – Mahabharata – which is the basis of several Kathak performances. The performing art of Kathak has flourished as an oral tradition, passed down through generations via verbal guidance and practical training, continually evolving and benefiting from the valuable contributions of each subsequent generation (Shah 2007). Kathak follows an aesthetic tradition of guru-shishya parampara (Morelli 2010) which literally means an act of passing down whatever has been learnt and followed in tradition from the teacher to the disciples. This tradition nurtured close relationships with disciples engaging in long-term studies and periodically residing in the guru's home (Morelli 2010).

It was noted that Indian classical dance forms have always been linked to therapeutic values (Chatterjee, Sudhakar, Singh, Raghupathy n.d., Kashyap) as cited in (Vishwakarma 2022). The practitioners of Kathak utilize the dance form to aid in the healing process and enhance overall well-being (Vishwakarma 2022). Spirituality has an intimate connection with Kathak dance and health-related behavior can moderate spirituality (Bożek et al. 2020). The spiritual component of a classical dance style such as Kathak, influences the creation of many types of strategies, such as changing one's perspective on pain to modify one's behavior in response to it. The study and practice of Kathak dance serves as a catalyst towards high pain tolerance and often Kathakars consider pain as an opportunity to improve their skill (Harrison et.al, Pollard-Smirh & Thomson and Wainwright et.al) in (Soundy and Lim 2023; Tarr and Thomas 2011).

Characteristics of Kathak Dancers

“Nritta” and “Nritya” are two major aspects around which Kathak dancers revolve their performances. The former refers to the pure dancing, whereas the latter is the expression-based element (Koskoff 2008). The commencement of nritta based performance begins with a piece at a reduced speed focusing on the soft actions of wrist, eyebrows and neck that is referred to as Thath (Walker 2016; Nettl et al. 1998). The Thath is based upon a set of mnemonic syllables called bols traditionally that help to identify the rhythm. Once the Thath is completed the pace of Kathak starts increasing with the dancer importing extra energy with grace (Nettl et al. 1998). With the elevating tempo, the Kathak dancer starts performing intricate footwork along with sharp gestures. In the language of Kathak, we refer to such footwork-based sequences as Tatkars (Figure 1A) which are synced to the musical beats (tala) in a well-coordinated manner (Khokar 1984; Nettl et al. 1998). The Nritya is the other aspect of a Kathak dance, which conveys a message or story to the audience through the inclusion of expressions, emotions and movements based upon the sequence of connection of words and beats (tala) (Descutner 2010).

Figure 1  (A) In this visual tale is shown the tatkar i.e, the footwork sequences. The arrows signify the movement of the feet whereas the black big circle on the ground depicts the intensity with which the movement by a Kathak dancer is performed; this produces a slapping effect when feet are tapped on the ground. The words TA and AA are some of the bols (the rhythmic sequence with count) that are a part of oration, called padhant, at the time of practice.
(B) Figure showing the ankle bells or ghungroos tied on the legs of a Kathak dancer. These are small metallic bells generally made of brass tied on a thread to form a musical anklet that produces percussive sounds. Indian classical dancers have a tradition to worship ghungroos every time they start either practicing or performing. The Guru, teacher, touches the ghungroos of the student as a part of the blessing. (Original creation by co-author ASD).

When a performer starts with the intricate footwork or tatkar, the sound produced resembles a tight slapping effect due to the interaction of the foot and the floor or ground. This sound is perfect enough to echo in a hall. The grounding force generates energy in the body via vibrations, thus adding to the increased balancing. The energy flow occurs in a much-channelized format – from the feet into the body. What makes this piece amazing is that while tapping the feet on ground, the dancer is so well coordinated with her/his mind and body that no focus goes on watching the legs, instead the feet guide the dancer as the muscle memory is well trained (Pendurkar 2022).

A Kathak dancer carries a rich knowledge of both asymmetry and symmetry from within as they acquire the ability to move various body parts in an independent manner. Dancing to a rhythm with fast movement yet smooth transitions amid the bols of the sequence, reflects the increased flexibility component of Kathak performers (Pendurkar 2022). Previous studies also reveal the great store of muscular strength and endurance among Kathak dancers. The abdominal strength and endurance of Kathak dancers are notably much higher than other dance forms, accompanied by an exceptional level of flexibility in the lower back. Dancers at all levels of physical and spiritual ability strive for further improvement by adapting their fitness goals and strategies (Kulshreshtha et al. 2022).

The weight of a dancer's body while performing Kathak, if observed from both the horizontal and vertical axis, gets uniformly distributed. Neither the deviation in the lower body movements nor in the sharp bends in the upper body movements can be observed among Kathak dancers. The basic posture maintained is the standing one (Centre for Cultural Resources and Training 2020).

The Ghungroos, small bells that Kathak dancers wear on each ankle, may vary in quantity from just one to numerous and may reach a mass of about 2-2.5kg. These bells are fixed in place by a strong cotton string (Figure 1B). These bells add to the rhythm of the dance and add weight to the lower leg and ankle. The chakkars (pirouettes) (Figure 2A) are eye-catching movements that Kathak dancers perform which are knitted into various sequences that are a part of Kathak dance routines, such as Tukdas, which depend upon balancing skills, tempo and toughness. Kathak dancers perform three types of chakkars – 1) right-to-left balance spin done with the help of taking five steps at a time (usually performed by a beginner level dancer), 2) a bi-step spin (Figure 2B) performed with a coordination of increased balancing and control in moderate speed, and 3) the fast paced spin performed on a heel (usually) with the utmost accurate rate and higher balancing skill (Pendurkar 2022).

Figure 2  (A) Illustration capturing a turning posture during the chakkar or bhramari (pirouette). This is a one-step chakkar that the male Kathak performer is taking; left leg is still in its place and helping to swirl or rotate the entire body in a circular manner. The arrows showcase the pattern of the movement. The attractive element of bhramari is that the dancer doesn't look down to the feet while performing the move, rather in a very rapid manner the feet lead the entire body.
(B) In this illustration is shown the bhramari or the chakkar performed by a Kathak dancer. This swirling movement is based on three steps. This generally is performed at a moderate tempo. The entire body is straight with the hands opening outwards. (Original creation by co-author ASD).

When it comes to balancing, the reports have suggested that the balancing ability of the left leg is much greater among the dancers than the right one because in the Kathak dance the fast spinning and taking rounds follow the same direction, with the left leg balancing the body in the whole run. Therefore, dancers have also been termed as skilled athletes (Kulshreshtha et al. 2021; Wyon et al. 2007) and aesthetic sports participants (Arcelus et al. 2014; Dosil and Díaz 2008) by some of the previous studies.

Types of injuries associated with Kathak dance

According to the World Health Organization (WHO), the identification of musculoskeletal injuries and conditions can be traced by the presence of persisting pain along with a hindrance in performing any movement with full completion. These injuries and conditions can range from short-term to long-term types or even life-long, from childhood till the older age (WHO 2022).

Due to the distinctive features of each dance style, it follows that there exist specific types of injuries that are particular to each modality (Bhutada and Pawar 2022). The existing literature notes that there is a limited amount of literature available on injuries related to Indian classical dance (Anbarasi et al. 2012; Prakash 2016). It was observed among all types of professional dancers that traumatic injuries were the most common typ (Malkogeorgos et al. 2011; Masal and Borkar 2021; Prakash 2016) (Smith et al. 2015). When it comes to the injuries among Kathak dancers, lower extremity and back musculoskeletal injuries are likely to be the most common. The following associated injuries might occur among Kathak dancers (Kadel 2006; Nair et al. 2018; Sabharwal and Singh 2017b; Bhutada and Pawar 2022; Prakash 2016):

Why study the back and lower extremity musculoskeletal injury among Kathak Dancers only?

Compared with the other Indian classical dance forms, Kathak is considered to involve more footwork, rapid movements, and complex weight shifts generating stress on specific muscles and joints. Hence, the probability of back and lower extremity-based injuries for Kathak dancers is increased. Kathak dancers also wear Ghungroos (ankle bells). The investigation of the movement patterns among Kathak dancers associated with the proper tightening of the Ghungroos is equally important as many dancers face the issue of either extreme tightening of the bells or loose tying of the ankle bells. This understanding can aid in designing injury prevention strategies. Certain muscle groups become either extremely active or under-active as Kathak involves the repetition of the movements which in body turns generate a muscular imbalance. Such imbalance is a requirement of Kathak dance to keep the footwork both intricate and fast paced. A consequence is that Kathak dance technique may lead to changes in the skeletal-muscular structure associated with injury risk. These reasons make Kathak an apt choice for study of back and lower extremity musculoskeletal concerns.

Keeping the above backdrop in mind, this review is conducted to contribute to the existing literature by providing a comprehensive overview of the occurrence and treatment approaches for back and lower extremity musculoskeletal injuries in Kathak dancers. The following are the objectives of this study:

The organization of the review is driven by the following hypotheses:

Methods

Literature Search Strategies

This comprehensive narrative review is based on a search of relevant articles, research papers, books and book chapters conducted across a wide array of online sources, utilizing the following search engines:

The keywords used for the searches were: “Spiritualism”, "Musculoskeletal Injuries", "Lower Extremity Injuries", "Kathak", "Classical Dance", "Stress" and "Ankle Pain". (Figure 3). The management and organization of the source materials identified during the search process were facilitated through the utilization of Google Docs and Google Sheets. The review process involved three distinct stages. In the first stage, a preliminary assessment of the papers was conducted based on the reading of their titles and abstracts. The second stage comprised a thorough and detailed examination of relevant items. Lastly, in the third stage, all relevant information from the sources was systematically compiled and organized in the form of a table, categorized under topical headings.

Inclusion Criteria

Exclusion Criteria

Figure 3  The flowchart representing the selection criterion used in the review.

There are no new or prospective data in this review. No participants were involved, rather all information is from previously published sources.

Results

Causes of Musculoskeletal injuries among Kathak dancers

Participation in a variety of dancing movements is associated with an elevated risk of musculoskeletal injuries (Malkogeorgos et al. 2011). In the case of Kathak artists, it is common to experience significant back problems as well as endure foot injuries such as painful heels and calf muscles (Basavarajaiah 2011). The practice of Kathak dance involves the execution of high-speed swirling movements across the dancer's entire body (Sivkishen 2015). During a performance, Kathakar's dynamic movements and precise footwork are perfectly timed to the tala (musical beats), showcasing footwork sequences called tatkars (Khokar 1984; Myers et al. 2003). Tatkar is a set of beautiful tapping work. Excessive and repetitive tapping can contribute to the development of inflammatory conditions like dancer's tendinitis, as well as the flattening of the medial arch (Haas 2010).

“Today, Kathak is being highly appreciated and performed on a common platform with flamenco and tap dancing; it’s a novelty in itself,” said Nandani Mehta, a Bangalore-based Kathak dancer (DHNS 11.08.2012). According to an article published in Hindustan Times, a Mumbai-based Kathak dancer pointed out the difference between the tap dancing and Kathak’s footwork, “The difference is that while Kathak dancers perform barefoot, with ghungroos, tap dancers wear metal-soled shoes'' (Kadakia 20.01.2017). The ghungroo (ankle bells) that can be found on each ankle emphasize and amplify the tapping and other work of the legs and feet. Less prevalence of injuries are reported among the tap dancers (Mayers et al. 2003) according to a previous study whereas one of the reports suggest the common issues, such as blisters, shin splints and ankle sprains, may persist among them (Mohanathasan 2021; Russell 17.01.2012). Among Kathak dancers, the foot experience an increased strain due to the additional weight and pressure exerted by the ghungroos (Sabharwal and Singh 2017a; Sivkishen 2015). Kathak dancers are highly prone to various foot problems and injuries due to the constant exposure of their feet to forces that can cause instability and postural deviations (Sabharwal and Singh 2017a). A dancer's lower limb strength plays a definite and important role in their overall fitness (Hamilton et al. 2008; Otari and Puntambekar 2021; Masal and Borkar 2021). An enhanced muscular strength is an indicator of excellent dance performance (Koutedakis et al. 2005). At the same time, experienced dancers are at an elevated risk of experiencing pain due to strain and have a strong ethic to continue dance even when suffering from musculoskeletal injuries (Valenti et al. 2011).

One must give due consideration to the flexibility possessed by the dancers as only then may particular remarks be given regarding the occurrence of injuries (Prakash 2016). Dancers who have spent several years performing physically demanding positions are likely to experience the majority of dance-related injuries, primarily due to the consistent stress placed on weight-bearing joints (Anbarasi et al. 2012). The force generation can also be affected by body mass, and participant populations with diverse body mass index (BMI) may present different degrees of risks for dance-related injuries (Prakash 2016). Although learners may make a bit of modifications to their postures to adjust according to their body inclinations, the core and basic movements remain the same overall (Morelli 2010). Previous studies have shown that out of all the performing dancers, back pain is the most common of all the injuries suffered. Whether this is also true for Kathak dancers is not known.

Also, a study conducted by Chandan and colleagues suggests that changes in lower limb motion and muscle activity can be attributed to neurological and rheumatoid diseases (Chandan et al. 2018). Previous research indicated that the presence and prevalence of muscle tightness increases the chance of various injuries (Chandan et al. 2018). These findings for Kathak dancers are in keeping with data regarding classical ballet dancers which claims that 64–80% of their injuries constitute the lower extremities, with soft tissues and muscles being the most affected (Shan 2005).

Factors Affecting Injuries in Kathak Dancers:

One can hardly blame any single factor when it comes to the prediction of the occurrence of the injuries, yet there can always be a probability for injury due to the amalgamation of extrinsic, intrinsic and condition-based elements which are more or less responsible for the injuries to occur (Arcelus et al. 2014; Dosil and Díaz 2008; Liederbach et al. 2008). These factors include muscle fatigue, imbalance, weakness, age related issues, and inadequate warm-up. If prior injuries have occurred to the same tissues this could be underlying causes of new injury (Askling et al. 2008; Croisier 2004; Cross et al. 2004; Garrett et al. 1984; Gupta et al. 2004; Ibrahim et al. 2007; Ojofeitimi and Bronner 2011; Petersen and Hölmich 2005; Renstrom 1992; Sherry and Best 2004; Tyler et al. 2002).

Exploring the high pain tolerance amid the spiritual aspect of Kathak: Is the attitude really positive or does it lead to negative outcomes?

The well-known Kathak artist Pandit Chitresh Das once said, “As dancers, we don’t go to the temple to worship the deity, we become the deity through dance, and by this, a profoundly devotional practice is established in which the dancer can often feel transformed to a higher level of connection to the essence of that particular god or goddess they are portraying” (Shaikh 2014). In the light of Kathak dance, the statement by Pandit Das captures the essence of the spiritual and devotional aspect of this particular classical dance form. A Kathak dancer, when dedicating a piece to a specific god or goddess, connects to the deity and feels that spirituality around their soul by going beyond the physical movements and external expressions. Kathak is rooted in spirituality and devotion. In the process of accepting and internalizing the role, the dancers undergoes a transformative stage. This transformation leads to a greater sense of spiritual connection and feeling of unity with the divine.

Quoting another statement given by Akram Khan which signifies an aesthetic element of Kathak as a classical dance form, “It can erase walls and boundaries within us. This may be momentary, but serves as a reminder that the walls are man-made, mainly coming from a place of fear” (Howlett 2018). The statement explains the interconnectedness that Kathak as a dance form provides. Kathak has an additional beauty where the sharing happens as a harmonious interplay within the group since the dancer or group of dancers can be seen on stage but behind them is a team of musicians providing rhythm. The history of Kathak is one of great transformations among the people, their everyday society, and their religious culture because of the spiritual and divine connections. This is well explained by the words of Pandit Das, “From its early form as devotional expression dedicated to the Hindu gods, Kathak gradually moved out of the Hindu temples and was brought into the lavish darbars (courts) of the Mughal emperors as a form of entertainment taking on aspects of Persian music and poetry, along with movements and gestures that were uniquely indicative of Mughal culture. Kathak is said to be the only classical dance that is an outcome of Hindu and Muslim cultures. I repeat – cultures” (Shaikh 2014). His strong emphasis on the word “cultures” means it all. A great evolution was witnessed in the history of Kathak, in large part due to its power to transcend geographic and cultural boundaries. The Kathak dancers plays a central role in these social and spiritual transformations. With this role come feelings of great responsibility for a high level of performance. Both opportunities for excellence and risks for failure and injury come with these feelings.

In one of his interviews, Guru Sri Mysore B. Nagaraj shared a beautiful instance when he was performing for the very first time abroad, “During my first performance there I noticed that I was not connecting to the audience through the stories from our epics and gestures that are easily recognizable in our culture like holding a flute to show Krishna. She (the organizer) told me the story of how all the residents of the island, except those who followed an old man to safety in the church, had died in a storm. For the next performance, I presented this story in my dance, and the audience connected immediately” (Nair 2022). The connectivity of oneself with divine power is of great importance to the dancers, but at the same time the professional dancers has to connect with the audience and for this crafting a performance that effectively communicates and engages is necessary. By this a bridge of understanding allows the audience to connect with their emotions and the greater spirituality.

“Dance is a form of worship and this body is an instrument of devotion. I strongly believe in this statement and try to pass it on to all my students as well. For me, dance is the means to attain what many would call spiritual bliss or a higher plane of consciousness, frankly a high on dance. This is what drives me. I believe the purpose of my art is to share this bliss with the audience through performance” (Nair 2022).

In many cultures, dance has been considered as a sacred form and Indian classical dance falls under this category. As a classical dancer, one views the dance as more than a mere performance. It is a pathway to spiritual bliss and a higher plane of consciousness. The purpose of an Indian classical dancers is not just entertainment but also to share this spiritual bliss that comes along with the movements and expressions during the portrayal of the character with the one who is watching it. In turn, this can be sensed among the audience in the form of energy they express.

In addition to spiritual/religious feelings, Kathak dancers face social issues related to gender identity. These issues may provoke feelings of stress that could affect the dance and the risk for physical injury. Gender has an intimate relationship with Kathak as a classical dance form. The character that is portrayed by the artist is completely gender neutral, meaning that the artist has to reflect whatever role is being depicted to the audience irrespective of the gender of the character being played or the gender of the artist. Kathak has always been an accepting form of dance, and this can be confirmed by the statement given during an interview by Devendra S. Manglamukhi, India’s first transgender Kathak performer and teacher, “Life is not a bed of roses. Hence, I have chosen to be an artist and convey the meaning of life through art. I want to inspire the others in my community through Indian classical dance and do well in the stream of my classical dance. I want inclusion in society through Indian classical dance and music. I want equality, respect, acceptance, love and nothing more” (Jain 2020). Art has this unique way of touching people’s hearts and thereby generating a positive impact among all. With the power to transcend language and gender-based barriers, the dance form strengthens the feeling of oneness. At the same time, the artist can strongly feel that the journey may come with challenges, just as life itself is not always so smooth. Guru Nagaraj also claims that, “Male dancers are in demand everywhere” (Nair 2022).

"Yes, classical dance is one of the ways to connect with the divine. Hence it is called a sadhana (one of a number of spiritual practices or disciplines which lead to perfection). I tell my students to imagine that each time they strike a pose (sama), let their eyes look at God Krishna, that way there is an inherent bhakti (devotion) in the dance. The tatkar (footwork) practice should be like a japa (chant) where instead of ‘hare ram hare krishna’ we are saying ‘na dhin dhin na’ (The bols used during Tatkar and the sound made by the Tabla drums). When dance is done with that emotion, it connects us to the divine,” said the late Kathak dance exponent Pandit Birju Maharaj (Art Of Living 2015). The way Pandit Maharaj explained the spiritual connection of Kathak dance is extremely valuable.

Shining the light on the firmness and stability that comes through Kathak, the name of Shruti Gupta who holds an international honor in Limca Book of Records for dancing barefooted at an altitude of 17,198 feet and performed at five Himalayan passes should come up. Quoting her, “I don’t get a headache and altitude problem because, in my daily walk of life, I don’t prefer a car. I get most of my work done by walking and in addition, I practice yoga and dance most of my time. That's why I don’t get into problem dancing at such a high altitude” (Chorol 2016). This shows the divine connection and firmness within the Kathak dancers that make them tough enough to perform at very high altitudes and with pain and injury at any altitude.

Seema Mehta, the disciple of Pandit Das, spoke of the preservation and the connection of Indian classical dance art and spirituality. In her words, “If it had not been for the artists over the centuries, the oral tradition of religious storytelling would not have been preserved. It’s such a shame that society doesn’t value this aspect of our culture nor see the connection between art and spiritualism” (Shaikh 2014). By celebrating and supporting artists, we can ensure the preservation of these aspects of the culture and spirituality so that it continues to enrich the future generations.

It is appropriate here to quote Khan regarding the comment he made on Indian classical dance and its spiritual connection, “Indian dancers place themselves in the shoes of Gods as well as mortals. And empathy is extraordinarily important—facial expressions and subtle body language communicate so much. I feel we’re drifting away from empathy in today’s world, and dance invites us to return to it” (Howlett 2018). In today’s digital and fast-paced century, genuine human connections and ultimately empathy may be lacking, yet Indian classical dances like Kathak provide the social, emotional, and spiritual aspects that can lead to reconnection. Khan additionally added, “As a dancer, one must strive to elevate their mind and soul. Always remember Dance is a medium of worship and your body is an instrument of devotion” (Howlett 2018). Indian classical dance hence can be termed as a channel that expresses devotion towards the divine.

During the choreography of one of his thematic works on God Shiva’s Panchavaktram (the five-face person), Guru Nagaraja uttered this statement in an interview, “This intrigued me and as I researched deeper into the topic l was able to paint a mental picture of each of the five forms of God Shiva. All I had to do after that was to manifest this mental image on stage through the dance, costumes, and lighting” (Nair 2022). As an Indian classical dance artist gets more and more connected with the divinity and spirituality of the performance, whatever else occurs is of little or no interest. This includes injury, discomfort, or pain. For once the dancers enters the stage of developing the mental pictures described by Guru Nagaraja the divine connection is all-powerful.

According to the dancers, suffering is an important element in order to become a polished and successful performer (Soundy and Lim 2023). When it comes to suffering and pain, it can be bifurcated into the categories of good and bad pain, where the former refers to the pain related to the focus on strengthening and training of the muscles. Experiencing good pain makes you more pain tolerant. Bad pain refers to the circumstances based on obvious injury such as the pain from a burn. Bad pain is associated with having no preparation for the unexpected situation (Tarr and Thomas 2011; Tarr and Thomas 2021). A dancer reveals that if there is no pain suffered then there is no effort put in—as stated by Markula, P and cited by (Soundy and Lim 2023). This indicates that even though the dance performers do experience pain they take pride in themselves and understand this pain as an achievement. This shows their high pain tolerance but at the same time it also leads towards the health-based ignorance behavior of the dancers.

The existing literature accepts that the dancers continue performing no matter what circumstances prevail, ignoring the acute injuries —as stated by McEwen, K and cited by (Soundy and Lim 2023). This shows the casual attitude toward injury and risky behavior of the dancers. Another aspect is if the dancers do pay attention to their pain and injuries, then they might be limited by medical advice which will not let them perform. This means a failure to the performer. The studies show that even though rest was a mandatory part of medical advice in order to heal faster, the dancers wished to perform for the scheduled show by suffering through the pain (Soundy and Lim 2023). This attitude might affect the dancers in the long run with more serious, even permanent, musculoskeletal issues.

Our hypothesis that, “The spiritual connection among Kathak dancers allows for high pain tolerance leading towards the ignorance of injuries ultimately affecting them in the longer term”, turns out to support the published evidence. Kathak dancers should be aware of the fact that despite high pain tolerance, ignoring the pain or injuries might affect them in the future. Therefore, they should focus on their positive approach toward pain tolerance by seeking medical advice and undergoing routine checkups so that minor injuries do not lead to permanent physical and spiritual damage.

Exploring the prevalence of back and lower extremity musculoskeletal injury among Kathak dancers

Analyzing Back Injuries and their prevention among Kathak Performers

According to the study conducted by Nair and colleagues (Nair et al. 2018), musculoskeletal pain is the major experience that Indian dancers undergo during professional life, constituting 73.5% of all complaints. Back pain is the most common of all the injuries suffered (Evans et al. 1998; Leanderson et al. 2011; Nair et al. 2018; Nilsson et al. 2001; Shah et al. 2012), approximately 17% of the total injuries occurring at the lower region of the body occurs at the low back and pelvis region, as per the data provided by Alvin American Dance Center (Ojofeitimi and Bronner 2011). Factors like extreme tilt of the anterior pelvic region, rigidness of back extensor muscles and less strengthen core muscles can be blamed as primary causes behind the reported occurrence of back pain among professional classical dancers (Khan et al. 1995; Kline et al. 2013; Micheli 1983; Rickman et al. 2012).

There are several possible themes for prevention that emerge from this examination of the factors that may lead to the musculoskeletal injuries. These are:

Analyzing Hip Injuries and their prevention among Kathak Performers

Indian classical dancers have often reported pain around the hip area, especially the dancers who perform Bharatanatyam dance form, as conducted by the survey (Anbarasi et al. 2012). Often the dancers undergo injuries due to the sudden stretching when movements are performed that involve hip flexion and the extension of knees, reportedly this occurs during the excessively performed motion (Askling et al. 2002; Askling et al. 2006; Askling et al. 2007; Askling et al. 2008) (Figure 4A). If we observe the anatomy of a human body, the stabilizers of the pelvis area are the adductors, including adductor longus, adductor brevis, adductor magnus, and gracilis when combined with the abdominals. If during the practice or performance the dancers experiences any inconsistency or imbalance among these muscles, then there may be an injury. Repeated inconsistency may result in a chronic dysfunction (Deleget 2010). According to a previous study, greater energy is required among professional dancers to enhance the flexibility component (Harley et al. 2002). Quadriceps strains are occasionally observed among dancers. The reason behind this can be the enhanced flexibility of the body, although the Kathak dancers can be susceptible to this while performing the jump-based movements (Figure 4B). The jumping movement in Kathak itself requires proper coordination along with the landing skills which involves stretching, especially during the tihais (a rhythmic pattern that involves the repetition of the phrase in a set of three) (Figure 5B). With practice, the dancers achieve an incremental gain of flexibility, in turn elongating muscles. This initially requires proper guidance by the guru (dance teacher) with a gradual initiation.

Figure 4  (A) Illustration capturing a posture performed by a female Kathak dancer with a high probability of becoming imbalanced as the complete weight of the body is upon one single leg. The female dancer is in complete Kathak attire known as Angarakha and churidaar pajama along with sets of jewelry like bangles, necklaces, nose-ring and forehead ornament. Ghungroos are tied on the ankles and a red dye called Alta or mahawar is applied on the dancer's feet.
(B) A jump element is illustrated here. The angle of the body matters and usually this jump is so high that if not done in an articulated and correct manner the landing may create problems related to the lower extremity, ultimately affecting long-term health. (Original creation by co-author ASD).

Figure 5  (A) Shown here is a part of toda, i.e, the set of general syllables that starts from first beat called Sam and after two or more repetitions comes back to the first beat. Here, the performer is wearing the other outfit of Kathak, the Ghagra (a long skirt), choli (blouse) and an odhni (veil)
(B) Image depicting a Kathak dancer in stationary position just after performing the tihai (rhythmic segment comprising three identical sections) with grace. (Original creation by co-author ASD).

The adolescent age, specifically between 14 and 16 years is the age group where most of the lateral snapping hip injuries occur (Winslow and Yoder 1995). “Snapping hip is a condition in which you feel a snapping sensation or hear a popping sound in your hip when you walk, get up from a chair, or swing your leg around. The snapping sensation occurs when a muscle or tendon (the strong tissue that connects muscle to bone) moves over a bony protrusion in your hip” (Alaia 2020). One possible reason behind this could be the continuous interaction of soft tissues and tendons around the hip joint among dancers undergoing the adolescent phase, which leads to the changes in the musculoskeletal system as well. A study reveals that lateral hip pain is experienced by almost 30% of the dancers studied (Ireland et al. 2003; Mascal et al. 2003). In the context of Kathak dance, intricate movements involving the hip joint, for example twists and leg extensions, are common and repeated. In the long run, such movements may potentially result in friction between the tissues and tendons around the hip causing the snapping sensation.

There is a relationship between hip injuries and pain in other regions of the leg. Patellofemoral pain, for example, occurs due to the inadequate strengthening of hip abductors (Ireland et al. 2003; Mascal et al. 2003; Zazulak et al. 2007). Due to suffering from patellofemoral pain, the Kathak dancers may undergo a limited range of motion and, if imposed in excessive manner, can result in altering the dance techniques of the performance. The complex biomechanics and functional relationship between knee and hip joints make either of them affected if a dancer suffers from patellofemoral pain. In a nutshell, it can be stated that dancers may experience weakness in specific muscle groups contributing to this kind of pain and the possible cause can be the biomechanical compensation in the hip region and pelvis created due to muscular imbalance (Liederbach and Richardson 2007).

A comprehensive approach can help in addressing the injuries around the hip. The possible strategies that could be followed in these lines are:

Analyzing Thigh Injuries and their prevention among Kathak Performers

When it comes to the dance-based thigh injuries, the few available studies report a prevalence of between 5% to 16% of all types of injury occurrences. These studies surveyed many types of dance genres. The most frequently occurring thigh injuries are hamstring strains (Laws and Apps 2005; Deleget 2010; Ojofeitimi and Bronner 2011).

When comparing athletes and non-athletes, dancers are found to have less strength in the thigh regions; according to the majority of the studies (Deleget 2010). Deleget proposed that dancers with especially weak thigh muscles and/or muscular imbalance have the greatest likelihood for injuries and will always be closer to their fatigue threshold (Figure 6A).

Figure 6  (A) An illustration depicting the stationary pose during Shiv tandava where the entire weight of the body comes on the left leg. This posture showcases Natraj—Indian God of Dance.
(B) Captured within this frame is a glimpse of Shiv Tandava performed by a Kathak dancer. This can be counted as a part of a risky move as the body requires more motion and the lower extremity is involved in most of the performance, including the extreme stretching which may produce stress and contribute towards the injury. (Original creation by co-author ASD).

Among the students learning different types of dance performance, it was reported that 51% of injuries were located in the posterior thigh area (Askling et al. 2002). Approximately 34% of these were chronic injuries and 66% were acute injuries. Askling and colleagues classified 88% of the injuries occurring due to slow stretching activities and 12% of the injuries occurring due to the high-speed activities.

It is observed that frequently the dancers return to dance immediately after the injury, even while still suffering from the hamstring injuries. This type of injury is one where the dancers often ignores medical guidance (Askling et al. 2002). Even after experiencing an acute hamstring injury, less than half of the professional dancers chose to stop their physical activities (Askling et al. 2006). One review of the literature recommends that a closer examination of dancer’s post-activity habits is required (Deleget 2010).

Standard medical advice is that it takes around 32 to 50 weeks to properly heal hamstring-based injury. But, most professional dancers and students estimate that recovery takes merely one to two weeks, as an average (Askling et al. 2002; Askling et al. 2006). Though this shows the desire and dedication of the dancers and students, it also shows a lack of understanding of appropriate body functioning. This may lead to problems and concerns related to health in the future.

The literature review presented here may be used to suggest that certain precautions may be adapted by the Kathak dancers to minimize the risk of thigh-based injuries:

Analyzing Knee Injuries and their prevention among Kathak Performers

An understanding of the anatomy of the knee is crucial to comprehend the specific injuries that may occur in the knee as an outcome of dancing (Prakash 2016). Understanding muscle kinesiology at the knee joint is equally important. For example, some muscles are more actively engaged than others when it comes to performing movements that involve bending the knees (Trepman et al. 1998). In order to prevent injuries at the knee joint, the effective strategy is to enhance stability with the use of strengthening exercises. The major muscles to strengthen are the quadriceps, hamstrings and gastrocnemius muscles (Andrew 2003).

Among Indian classical dancers, knee injuries were observed as the second most prevalent type accounting for approximately 28.3% of all the total injuries (Suri 2020). One reason for knee injury is that Kathak dancers must sustain a position where the knees are bent and project beyond the toes. This position exerts strain on the knee joints, increasing the risk of knee injuries. As described in the doctoral dissertation by Prakash, while talking to a health expert it was mentioned that if the execution of this position is done in the proper manner, then the probability of suffering from strain, pain or injury can be lessened (Prakash 2016). However, the nature of Kathak dance involves jumps and changes in the acceleration rate of the body. With ground contact after a jump there are reaction forces that directly or indirectly impact the body and its joints (Anbarasi et al. 2012) (Figure 6B). The fluctuations in forces experienced at the knee joint are associated with the risk for pain and injury (Prakash 2016). If the quadriceps muscles are weak, then it is possible that there will be less engagement of muscles supporting and more stress on the knee joint (Hart et al. 2010).

There is a lack of sufficient literature on knee injuries of dancers, but the following measures can be followed to prevent the injuries:

Analyzing Foot and Ankle Injuries and their prevention among Kathak Performers

Considering various types of dance genres, a total of 34% of the lower extremity injuries occur around the foot and ankle area, as per the analysis of a 5-year long study performed by Alvin Ailey American Dance Center (Ojofeitimi and Bronner 2011). Another study on dancers reported that 23–45% of all the injuries to professional dances were to the foot and ankle (Kadel 2006). In Kathak dance, there is a consistent need to position and place the ankle in an unstable and uncertain manner (Chandan et al. 2018). According to a study, the emergence of high impact forces during classical dance results in modifications to the anatomical structure of the foot's arches. The continuous and elevated stress placed on the foot arches leads to the rolling of the ankle and foot (Masal and Borkar 2021). A majority of the reports suggest that overuse injuries are most common contributors to ankle and foot-based problems (Chandan et al. 2018). As stated in a study conducted by Guruprasad and colleagues, the consistent foot tapping in Kathak is one of the factors that could be blamed for cramps and strain if performed without break (Guruprasad et al. 2019) (Figure 7A). During Kathak performances, the foot repeatedly undergoes extensive dorsiflexion and plantarflexion movements, resulting in a major strain on the respective linked muscles due to their extreme usage. Dorsiflexion is required to align the ankle to the appropriate and optimum stability (Donatelli 1985). The probability of injuring the ankle mortise (the joint composed of the tibia, fibula and talus bones) is increased when landing from a jump during the chakkar (spin around) to a position with the foot in a plantar-flexed and typically inverted position. The relaxation of all the muscles is responsible for plantar flexion and the complete plantar flexion results in the loosening of the collateral ligaments in the ankle (Neumann 2017).

Figure 7  (A) Image depicting a sudden twist during a transition of movement amid the performance. This portrays an acute sprain which generally is neglected by Kathak performers. Such sprains can lead not only to immediate pain but severe long-term injuries as well.
(B) Figure illustrating a disbalance during the performance when a piece of jugalbandi (entwined twins) is performed. The performer is standing on the thali, a brass plate, and such segments if not done under proper training can result in direct or indirect injury. (Original creation by co-author ASD).

Kathak dancers engage in high rotation-based movements of their body during chakkars. During this movement the heel serves as a pivot point and there is dorsiflexion of the ankle (Sabharwal and Singh 2017b). The left heel is most often used during the chakkar and, generally, the left leg of Kathakers possesses greater strength than the right leg. While there is a strength imbalance between the legs there is also better stability for the body when executing the typical chakkar (Kulshreshtha et al. 2022). Even so, the combination of dorsiflexion and external rotation generates more chances for the ankle to lose stability (Sabharwal and Singh 2017a). In addition, the frequent repetition of many Kathak dance postures, during the hours of either practicing or performing, results in left-right imbalances of ligament tension-relaxation, muscle strength, and ankle instability. The outcome is the dancers becomes prone to suffer injuries (Sabharwal and Singh 2017a).

One of the studies also claims that in one type of chakkar, known as bharamaris (turnouts), the foot is rotated while keeping it in a plantar-flexed position; this causes the ankle mortise to widen, resulting in the talus rotating externally which can lead to injury (Lin et al. 2006). Another study reported that the majority of the Kathak dancers are not aware of the correct way of placing the ankle (Hertel et al. 2002) ultimately leading to injuries (Figure 7B).

Dancers should undergo a regular foot assessment so as to gather knowledge regarding foot pronation issues. One study reveals that dancers may encounter pronated foot conditions leading to musculoskeletal problems throughout their dancing careers. The body’s anatomy and physiology are all connected and if any part of the lower extremity, for example the foot faces any issue, then consequently it will impact the knees (Chandan et al. 2018). A special risk for Kathak dancers comes from wearing heavy ankle bells and dancing barefoot (Anderson 2001). To compensate for this the dancers requires flexibility and correct postural angularity for the support of foot and ankle (Evans et al. 1998; Kadel 2006).

Prevention of the ankle and foot-based injuries is crucial for the Kathak dancers, and the following measures can be adapted:

In addition, ankle and foot injury prevention may be prevented by following our general hypothesis #1: The occurrence of lower extremity musculoskeletal injuries is reduced when a Kathak dancer incorporates consistent warm-up and stretching during the practice session along with suitable training related to the strengthening and conditioning of the lower extremity (Table 2).

Limitations

The study is limited to the exploration of the back and lower extremity injuries among Kathak dancers. Further research is needed to understand the association of body physique and composition of male and female dancers with risk for injury and injury type. This study only includes dancers who are facing injuries at present time. The study does not focus on people who quit dance due to these injuries in the past. The current study is based on secondary data and in the future researchers collecting primary data should compare our findings with their own.

Discussion and conclusion

To the best of our knowledge, this is the first comprehensive narrative review of the back and lower extremity musculoskeletal injuries of Kathak dancers. Our review is enhanced by relating the risk for injury with the spirituality element of Kathak dance. Our review finds that there is limited published information available on this topic—only 42 sources met the inclusion criteria. There are some differences and inconsistencies between the findings of the reviewed materials. Variations in the interest of the researchers (sport physiology, artistic dance, religion/spirituality) and in the type of publication (scientific journals, dance magazines, news stories) are likely to be some of the reasons for the diverse findings.

A focus by practitioners on the spiritual/religious nature of Kathak dance places them at risk for physical injury. The lack of awareness regarding minor lower extremity musculoskeletal injuries among Kathak dancers can result in major impairment and in poor health. Kathak Dancers should be aware that if they suffer from an acute pain during their practice session, they must not ignore it and should seek medical advice. There is an essential requirement for developing supplementary exercise training programs for practitioners. Cross–training activities such as Yoga and interventional occupational awareness programs for health can be arranged to ensure their good health. The proper warm-up before the session and cool down exercises after should be implemented as a routine practice, along with choosing the correct nutrition and diet. Kathak dancers are resilient when it comes to spiritual and mental aspects which is a positive sign, but their attitude of neglecting the pain and injuries indicates that in a long run it may impact the muscles and the skeleton contributing towards poor health. Therefore, there is a need to develop programs creating self-awareness among dancers regarding this issue and motivate them to seek the necessary supplementary training programs and medical attention before it is too late.

Data availability

All data and literature sources used for this article are available from the authors.

Authors’ contributions

Conceptualization (lead), writing – original draft (lead), digital illustration and figures (lead), methodology (lead), writing – review and editing (equal): Abhijeet Singh Dewari; Conceptualization (supporting), writing – review and editing (equal), supervision (supporting), methodology (supporting): Barry Bogin; Supervision (lead), writing – review and editing (equal): Shivani Chandel

Acknowledgements

The authors thank the Department of Anthropology at University of Delhi for support during the literature review for this study. Open Access publication is supported by The Bill & Melinda Gates Foundation via grant number OPP1125811 – Quantifying healthy birth, growth and development knowledge integration.

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