Review Article

Musculoskeletal Injuries and Pain in Dancers

A Systematic Review Update
Craig L. Jacobs, D.C., M.Sc., F.C.C.S.(C.), Cesar A. Hincapié, D.C., M.H.Sc.,
and J. David Cassidy, Ph.D., Dr.Med.Sci.

Abstract such as stress and coping strategies affect critiqued. Twenty-nine studies were
The objective of this study was to assemble injury frequency and duration; history of deemed scientifically admissible. Key
and synthesize the best available literature a previous lateral ankle sprain is associated findings included a high prevalence
from 2004 to 2008 on musculoskeletal with an increased risk of ankle sprain in and incidence of lower extremity and
injury and pain in dancers. MEDLINE the contralateral ankle in dance students; back injuries, primarily of the overuse
and CINAHL were the primary sources of fatigue may play a role in ACL injury in
dancers; acute hamstring strains in danc-
soft-tissue variety. The investigators
data. Indexed terms such as dance, dancer, found the dance medicine literature
dancing, athletic injuries, occupational ers affect tendon more than muscle tissue,
often resulting in prolonged absence from to be sparse and lacking in rigorous
injuries, sprains and strains, musculoskel-
dance. It is concluded that, while there are scientific methodology. Nevertheless,
etal diseases, bone density, menstruation
disturbances, and eating disorders were positive developments in the literature on they concluded that musculoskeletal
used to search the databases. Citations the epidemiology, diagnosis, prognosis, injury is an important health issue for
were screened for relevance using a treatment, and prevention of MSK inju- dancers at all skill levels, and there is
priori criteria, and relevant studies were ries and pain in dancers, much room for little information on risk factors. The
critically reviewed for scientific merit improvement remains. Suggestions for purpose of this new review is to pro-
by the best-evidence synthesis method. future research are offered. vide a best-evidence synthesis update

A
After screening, 19 articles were found of musculoskeletal injury and pain in
to be scientifically admissible. Data from systematic review of the lit- dancers, focusing specifically on the
accepted studies were abstracted into erature on musculoskeletal literature from 2004 to March 2008.
evidence tables relating to: prevalence (MSK) injury and pain in A systematic review objective and
and associated factors; incidence and risk dancers from the year 1966 to Octo- methodology was applied, based on
factors; intervention; and injury charac- ber 2004 was performed by Hincapié
teristics and prognosis of musculoskeletal the previous Hincapié study.
and colleagues in 2008.1 This was an
injury and pain in dancers. Principal important step for the field of dance Methods
findings included: a high prevalence and
medicine and science, as it represented Literature Search
incidence of lower extremity, hip and
back injuries; preliminary evidence that the first time that this literature had The primary reference sources for
psychosocial and psychological issues been systematically reviewed and this study were the electronic da-
tabases MEDLINE and CINAHL
(both 2004 to March 2008). It was
Craig L. Jacobs, D.C., M.Sc., F.C.C.S.(C.), is with the Artists’ Health Centre decided, a priori, not to search addi-
Research Program at Toronto Western Hospital and in the Division of Clinical tional databases that were used for the
Education at Canadian Memorial Chiropractic College, Toronto, Canada. Cesar previous review, as these had yielded
A. Hincapié, D.C., M.H.Sc., and J. David Cassidy, Ph.D., Dr.Med.Sci., are with only duplicate or low-quality papers
the Artists’ Health Centre Research Program at Toronto Western Hospital, in the
Division of Epidemiology at the Dalla Lana School of Public Health, University
that were deemed either ineligible or
of Toronto, and in the Division of Health Care and Outcomes Research, Toronto inadmissible. Indexed terms and text
Western Research Institute, University Health Network, Toronto, Canada. words such as dance, dancer, dancing,
athletic injuries, occupational injuries,
Correspondence: J. David Cassidy, Ph.D., Dr.Med.Sci., University Health sprains and strains, musculoskeletal
Network. LuCliff Place 700 Bay Street Suite 2201, Toronto, Ontario M5G 1Z6, diseases, bone density, menstruation
Canada; [email protected].
disturbances, and eating disorders were

74
 Journal of Dance Medicine & Science • Volume 16, Number 2, 2012 75

used in searching the databases. The For each citation rated as probably tors’ recommendations for further
reference lists of all relevant studies relevant or of unknown relevance, study (see below).
were examined for additional or un- the entire paper was obtained, and
published literature. in the second-level screening, these Results
were deemed to be either relevant or After applying our inclusion and
Screening for Relevance to Best- irrelevant to the systematic review. exclusion criteria to 536 identified
Evidence Synthesis Objectives Two substantive and related themes abstracts, 55 papers were judged to be
All citations identified through use from the previous systematic review relevant. Of these, 19 dealt with MSK
of the operative search strategy were by Hincapié and colleagues were injuries and pain in dancers and were
screened, and included: English lan- maintained: 1. MSK injuries and critically reviewed. Ultimately, 13
guage reports; published reports of pain, and 2. metabolic and nutritional (68%) were accepted as scientifically
original research, systematic reviews, disorders.1 This paper reports on the admissible (Fig. 1). These studies are
conference proceedings, government first of these themes. the basis for our findings and consist
reports, guidelines or unpublished of nine cohort studies and four cross-
“grey literature” manuscripts; stud- Critical Review of the Literature sectional studies.
ies containing original raw data All studies judged relevant were
on at least 20 human participants, critically appraised. The appraisal Characteristics of Musculoskeletal
including a control group if present; assessed scientific merit and clinical Injury in Dancers
studies examining the prevalence, relevance by using a priori criteria A previous review reported that the
incidence, associated factors, risk and electronic critical review forms.2 most prevalent MSK injuries in danc-
factors, diagnosis, interventions, These forms prompted the reviewer ers are sprains, strains, and tendinopa-
economic costs, prognosis, or other to focus on issues of study design, thies, primarily affecting the lower
aspects of MSK injury, pain, and study population, issues related to extremities and back.1 Some studies
metabolic or nutritional disorders conduct of the study, participa- in the current review did not report
in dancers; and studies of dancers in tion rates, follow-up rates (where exact locations of injuries; however,
any form of artistic dance, such as relevant), measurement issues and of those that did, lower extremity
ballet, modern, tap, theatrical, folk, analysis. Quality appraisal criteria injuries still predominated, followed
Flamenco, break-dancing, ballroom were derived from fundamental by the hip and low back (Tables 1
dancing, and ice dancing. Excluded principles of epidemiologic meth- and 2). Five studies accepted for this
were: studies on recreational or exer- ods, measurement, and design.3,4 review focused on specific injuries, in-
cise forms of dance such as aerobics Two investigators performed inde- cluding snapping hip syndrome, ankle
or social dancing in clubs, parties pendent in-depth reviews. Decisions injuries, anterior cruciate ligament
or raves; studies on the cognitive, concerning a study’s methodological (ACL) injuries, and acute hamstring
behavioral, or learning aspects of quality and scientific merit were made strain.7-11
dance; narrative, editorial, or clini- by consensus of the investigators
cal reviews, opinion papers, letters after full discussion. Studies were Prevalence and Associated Factors
to the editor, and editorials; stud- considered scientifically admissible, of Musculoskeletal Injury and
ies of conditions with questionable which could include accepting part Pain in Dancers
clinical relevance or asymptomatic or all of the findings, or scientifically Four cross-sectional studies were
presentation; studies using cadavers inadmissible due to fatal biases and accepted on the prevalence and as-
or non-human subjects; and finally, methodological flaws. sociated factors of MSK injury and
studies reporting findings not specific pain (Table 1). These studies varied
to dancers (e.g., those in which danc- Data Abstraction into Evidence geographically in representing source
ers’ information was combined with Tables populations from Canada, Germany,
other athletes’ information, such that Studies relevant to MSK injuries and Brazil, and Turkey. Inclusion and
results could not be evaluated specifi- pain in dancers were identified as exclusion criteria also varied con-
cally for dancers). relating to: prevalence and associated siderably across the studies. One
Based on these inclusion and ex- factors; incidence and risk factors; in- study focused solely on professional
clusion criteria, two reviewers (CLJ tervention; and injury characteristics ballet dancers,12 one on professional
and CAH) independently appraised and prognosis. Data from admissible contemporary dancers,13 one study
the relevancy of each citation found studies were abstracted into evidence focused on a mix of professional bal-
in the electronic search through a tables relating to these topic areas, let dancers and elite ballet students,7
two-level screening process, with dis- facilitating synthesis of the informa- and one on ballet and folk-dance
agreements resolved by consensus. In tion according to the best-evidence students.14
the first-level screening, reviewers cat- synthesis method.5,6 These evidence Case definitions for injury also
egorized citations as probably relevant, tables summarize the study’s findings varied considerably. For example, one
of unknown relevance, or irrelevant. and form the basis for the investiga- study defined injury as “any medical
76 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science

and forefoot disorders, ballet students

with longer second toes had more
callosities, more foot pain, and more
frequent signs of first metatarsal pha-
langeal joint inflammation.14 Overall,
these reported correlations are crude
in nature, and no studies made use of
multivariable analysis to assess inde-
pendence of the associated factors.
Incidence of and Risk Factors for
Musculoskeletal Injury and Pain
in Dancers
Seven cohort studies on the incidence
of and risk factors for MSK injury and
pain were accepted (Table 2). The co-
horts are primarily from high school,
university, and state academy dance
programs in the United States,15,16
Germany,8 Croatia,15 and Australia.11
A Korean study included professional
ballet dancers, university level ballet
dancers, and high school level ballet
Figure 1 Systematic review inclusion and exclusion. dancers.18 One study from the USA
included professional ballet and mod-
ern dancers, as well as university level
problem resulting from dance par- one injury in a German ballet com- dancers.10 Four of the studies included
ticipation that restricted subsequent pany was 87%.12 Lifetime prevalence both male and female dancers, while
participation for at least one day be- of joint injuries was reported at 47%, the three university based studies from
yond the day the injury occurred.”12 with 20% reporting ankle injuries as the USA and Croatia involved only
Another defined injury as needing the most important lifetime injury (all female dance students (Table 2).
to fulfill at least one of the following females), and 16% reporting knee in- Case definitions for injury varied
criteria: absence from one or more juries as most important (all males).13 in this group of studies as well. One
performance or rehearsal, removal In a Canadian study investigating study did not explicitly define injury.8
from a performance without the pos- snapping hip syndrome, 91% of danc- Five studies used definitions of in-
sibility of returning, or need for tradi- ers reported a snapping hip, 58% had jury based on being unable to dance,
tional medical assistance.13 One study pain associated with the snap, and 7% time-loss from dance class, rehearsal,
focusing on snapping hip syndrome took time off because of the condition, or performance, or the dancer being
identified cases by questionnaire, ask- although no time frames were given.7 forced to modify technique.10,11,15,16,18
ing dancers if their hips could “snap, Three of the four prevalence studies Three studies incorporated use of the
pop, crack, click, or dislocate.” These reported on factors associated with Self Estimated Functional Inability
investigators additionally asked the MSK injury or pain in dancers. A because of Pain (SEFIP) question-
dancers to report on their worst injury positive correlation between stress and naire, with one study using it as
now, in the past year, and ever, but absence due to injury was found in a the sole measure of MSK pain.15-17
did not provide an explicit definition German ballet company. Additional One study focusing on ankle sprain
of injury.7 The fourth cross-sectional correlations were also reported for defined it as an inversion injury that
study focused on foot problems and anxiety, depression, anger, fatigue, had resulted in either local swelling or
used a visual analog scale to measure confusion and sleep problems. Strong bruising and limping for more than
daily foot pain.14 social support and good sleep habits one day.11 A study of anterior cruciate
Prevalence estimates were vari- were positively correlated with fewer ligament (ACL) injury defined it as a
able given the different time periods days missed from dance due to in- first-time partial or complete rupture
studied and case definitions and were jury.12 Ballet movements associated of the ligament, confirmed by clinical
not always clearly reported. Due to with snapping hip syndrome were and radiologic examination.10
this heterogeneity, it is not possible grand battement à la seconde (42%), Incidence estimates were reported
to report a pooled prevalence estimate grand plié (25%), and développé à in the accepted studies as cumulative
of MSK injury in dancers. Seasonal la seconde (22.8%).7 In a Turkish incidence proportions (i.e., number of
prevalence (10.5 months) of at least study exploring second toe length injury cases per population at risk for
Table 1 Studies of Prevalence and Associated Factors of Musculoskeletal Injury and Pain in Dancers
Study, Design, and Subjects, Setting, and
Country Response Rate Case Definitions Prevalence Associated Factors Other Findings
12
Adam et al., 2004 Professional ballet dancers Dance injury defined as Season prevalence (10.5 months) Correlation between stress Percentage of
(30 F/24 M mean age 26.6 “any medical problem of at least one injury: 87% and absence due to injury. workdays missed:
Cross-sectional years; SD:6.2 yrs) from resulting from dance 17.5% corps de
a major German ballet participation that Additional associations ballet; 11.7%
Germany company. Company members restricted subsequent noted for anxiety, soloists.
represented 20 countries. participation for at least depression, anger, fatigue,
one day beyond the day and confusion and absence Overall average
78% response rate (54/69) the injury occurred.” due to injury. Sleep days missed due
problems moderately to injury was
(n = 54) associated with absence 42.8/286.
due to injury. Social
support and sleep duration
positively associated with
fewer days missed.
Scialom et al., 200613 Professional dancers (14 Injury defined as at least Lifetime prevalence measured N/A 50% of injuries
F/16 M) of a contemporary one of following items: for most important injury. Joint occurred during
Cross-sectional Brazilian dance company. No absence from at least injuries were most frequent rehearsals. 73%
age range reported. one performance or (47%), with 20% reporting sought medical
Brazil rehearsal, removal from a ankle injury (all females) and care, 60% within
75% response rate (30/40) performance without the 16% reporting knee injury (all one day. 47%
possibility of returning, males). reported that
(n = 30) and need for traditional injury prevented
medical assistance. them from dance
activity during
Dancers were asked about “some months”.
their “most important
injury.”
Winston et al., 20077 Professional ballet dancers and Self-reported hip that will 91% reported snapping hip, Movements associated 2 clinicians could
students from the National “snap, pop, crack, click, 80% had bilateral symptoms, with snap: Grand palpate 46 of the
Cross-sectional Ballet of Canada and Canada’s or dislocate.” 58% had pain associated with battement à la seconde 50 self-reported
National Ballet School. Aged the snap, and 7% took time off (42%), grand plié (25%), snapping hips.
Canada 16 years or more. No explicit definition of because of the condition. 60% développé à la second Ultrasound
injury given for injury of dancers could voluntarily snap (22.8%). showed a snapping
92% response rate for prevalence data. hip. iliopsoas tendon
questionnaire (87/95, 57 F/30 (59%), iliotibial
M) Ankle injuries were most band (4%), and
frequent for all time frames unidentified
26 participants (of 47 who (“worst injury now, in past year, (33%).
Journal of Dance Medicine & Science • Volume 16, Number 2, 2012

could voluntarily snap hip) for and ever”), with hip injuries in
clinical and ultrasound exam. second place for “past year.”
(Continuted on next page)
77
 78 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science

injury), as well as incidence density of injury. 18 Miletic and associates

inflammatory signs
rates (i.e., number of injury cases per found that previous dance experi-

of the first MTP

Other Findings population-time at risk for injury). ence in Croatian dance students did

associated with
callosities were
Number of Ten-month cumulative injury inci- not have an effect on their SEFIP
dence ranged from 37.1% to 77%.15,18 scores; however, higher BMI score
The five-month cumulative incidence was a significant predictor of SEFIP

joint.
of ankle injuries was reported as 12%.8 score in the inexperienced group at
The 13-month cumulative incidence both pre-training and post-training
MTP joint inflammation. of ankle injuries was reported as measurements. Lower calf circum-
28.9% in another study, with the inci- ference was a predictor of higher
more callosities, higher
longer second toes had

VAS scores, and more

frequent signs of first

dence density rate at 0.21/1000 dance SEFIP score at pre-training for

Ballet students with
Associated Factors

hours.11 One study collected clinic- the inexperienced group as well.17

recorded and self-reported injury data Liederbach and colleagues did not
in student dancers, and found that find any greater risk for ACL injury
clinic-recorded injury incidence was based on sex, style of dance, race,
30% for the first academic semester oral contraceptive use, or other in-
and 36% for the second semester, trinsic physiological variables. The
while self-reported injury incidence investigators did observe that most
with longer second toe = 3.7. Mean
Mean VAS score for ballet students

Mean VAS score for ballet students

was 67% for the first semester and ACL injuries occurred late in the
equal or shorter second toe = 3.5.
with equal or shorter second toes

Mean VAS score for folk dancers

VAS score for folk dancers with

77% for the second semester.15 The day and in the season. They suggest,
with longer second toes = 6.7.

incidence of ACL injuries was 0.0009 therefore, that fatigue may play a
Abbreviations: MTP joint , Metatarsophalangeal joint; F, females; M, males; MSK, musculoskeletal; VAS, visual analogue scale.

per 1000 exposures. 10 This study role in ACL injury.10 Four of the
also reported 3721 injuries (all body seven prospective studies made use
regions) over a five year period. Per- of multivariable analysis to adjust
centages by body region injured are for important covariates in assess-
Prevalence

shown in Table 2. ing the independent correlation of

Given the heterogeneity of incep- possible risk factors.10,11,17,18
= 4.3.

tion periods, diverse source popula-

tions, and varied case definitions Interventions for Musculoskeletal
for injury in the accepted incidence Injury and Pain in Dancers
joint inflammation, and
number of callosities on

studies, the variability in incidence We accepted one cohort study of

VAS for daily foot pain.

the toes were recorded.

deformities, first MTP
relation to the hallux,
Second-toe length in

estimates shown in Table 2 is not an intervention for MSK injury in

surprising, and an overall summary dancers (Table 3). In contrast to
Case Definitions

incidence estimate could not be cal- the intervention studies included

culated. in the previous review, which fo-
Five of the seven incidence stud- cused on injury prevention and
ies explored risk factors for injury management programs,1 this study
in dancers (Table 2). Two studies focuses on psychological interven-
focused on ankle injuries,8,11 one on tion programs for the reduction of
ACL injuries,10 one on psychosocial injury.19 It was a 48-week partially
F/5 M; aged 13-19 years) and

Total eligible dance students

Classical ballet students (25

25 folk dancers (20 F/5 M;

factors as risk for injury,18 and one randomized, multiple cohort study
Turkish dance students. 30

on previous experience and body of female ballet students in Korea.

Subjects, Setting, and

physique as determinants for SEFIP Case definitions for injury were

aged 17-20 years).

scores. 17 Schmitt and colleagues defined as any medical problem

found no association between ankle resulting from dance participation
Response Rate

not reported.

proprioception test scores and ankle that restricted subsequent practice

injury in German dance students.8 and performance for at least one
Hiller and co-workers reported day. Cases were recorded by survey
that a history of previous lateral as well as by training staff, who
Table 1 (continued)

ankle sprain was associated with an recorded injury frequency and dura-
14

increased risk of future sprain of tion. The investigators found that a

Oztekin et al., 2007
Study, Design, and

the contralateral ankle.11 Noh and broad-based coping skills interven-

Cross-sectional

coworkers found that Korean pro- tion enhanced those skills more
fessional dancers and students with than the autogenic training inter-
Country

lower coping scores on two sub- vention of controls and reduced

Turkey

scales of the Athletic Coping Skills injury frequency and duration. 19

Inventory had higher frequency Controls, however, were selected
Table 2 Studies of Incidence of and Risk Factors for Musculoskeletal Injury and Pain in Dancers
Study, Design, and Inclusion/Exclusion
Country Source Population Criteria Case Definitions Incidence Risk Factors
8
Schmitt et al., 2005 Students in dance group Inclusion: Attendance Self reported questionnaires 4 self-reported ankle No indications of
studied at state academy for at a state academy for and interviews at baseline and injuries recorded during risk found between
5-month, professional dance training in professional dance 5-month mark. No explicit study period in the dance injured and non-
prospective, double Germany. training for study group. definition of injury. group (12% cumulative injured subjects
cohort (n = 42; 31 F/ 11 M; ages 14- Exclusion: Severe incidence). in proprioception
23; 8 lost to follow-up) functional orthopaedic or test scores (angle
Germany Control group of students neurologic deficits of the replication, one-
matched for age and sex with lower extremities resulting legged standing
no dance or sport-specific in loss of ROM, strength, test).
training (n = 40). paralysis, paresthesia, or
injury with interruption
of 7 subsequent days of
training during previous
month.
Noh et al., 200518 Professional ballet dancers, No explicit inclusion/ Injury defined as “any medical 10-month incidence Dancers who
university-level ballet dancers, exclusion criteria problem resulting from dance injury 37.1% for all reported low levels
10-month, and high school level ballet reported. 27 professional participation that restricted dancers. Frequency of of psychosocial
prospective, multiple dancers from Korea. dancers, 19 university subsequent practice and injury for professional coping on “freedom
cohort dancers, and 59 high performance for at least one dancers and university from worry” and
(n = 105) school dancers (101 day.” An injury scale addressed students greater than for “confidence and
Korea F/4 M; mean age, the frequency and duration of ballet institute students. achievement
20.5 ± 5.5 years) injury during the 10-month Professional dancers had motivation” (2
provided information study period. a significantly greater subscales of the
on psychosocial factors duration of injury Athletic Coping
associated with injury. than the university and Skills Inventory-28)
institute students. had a higher
frequency of injury.
These 2 factors
explained 21%
of the variance in
frequency of injury.
Weigert, 200515 Female dance majors and Inclusion: Female dance Injury defined as any painful Self reported injury N/A
minors in a predominately majors and minors problem attributed to dance that incidence 67% for first
1 academic year, modern dance program at the studying modern dance. had caused the student to miss a semester and 77% for
prospective, single University of Wisconsin. class or rehearsal or modify their second semester. Mean
cohort No specific exclusion technique. number of days missed/
(n = 38) criteria. modified = 7 (SD, 12) for
USA Questionnaire regarding injuries first semester and 9 (SE,
Journal of Dance Medicine & Science • Volume 16, Number 2, 2012

at baseline and at end of both 16) for second semester.

first and second semesters. Mean total pain score 4.9
Included SEFIP. (SD, 4) for first semester
79

and 5.6 (SD, 3.6) for

second semester.
(continuted on next page)
 80
Table 2 Studies of Incidence of and Risk Factors for Musculoskeletal Injury and Pain in Dancers
Study, Design, and Inclusion/Exclusion
Country Source Population Criteria Case Definitions Incidence Risk Factors
17
Miletic et al., 2007 Female students in a university No specific inclusion/ Self Estimated Functional SEFIP overall mean score No significant
aesthetic sports program exclusion criteria noted. Inability due to Pain 4.9 ± 4.24 at pre-training difference of dance
6 week prospective (ballet, rhythmic gymnastics, Questionnaire measured pre- and 2.98 ± 2.29 at post- experience on total
double cohort and modern dance) aged (after 1 week of program) and training assessment. pain score.
19-25. post-training (after 6 weeks of
Croatia program) period. BMI significant
One group with previous predictor of
dance experience (24) and Anthropometric measurements SEFIP score in
the other group with no taken at study entry. the inexperienced
experience (21). group at both
N = 45 timepoints. Calf
circumference a
(n = 30) predictor of SEFIP
score at pretraining
test.
Weigert and Female dance majors and Inclusion: Female dance Subjects filled out questionnaire Clinic recorded injury N/A
Erickson, 200716 minors in a university majors (30) enrolled in at baseline, end of semester incidence was 30% for
program (predominantly modern dance class over 2 1 and end of semester 2. first semester and 36.4%
1 academic year modern dance curriculum) semesters. Injury defined as any problem for the second semester.
prospective single aged 18-26 years during 2 that caused pain or limited Self-reported injury
cohort academic semesters. Exclusion: Dance majors participation in dance activities. incidence was 67% for
(n = 30) not enrolled in a modern Subjects were also asked to first semester and 77%
USA dance class. Male students estimate number of days of for second semester. 4/9
Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science

excluded. dance class or rehearsal missed injuries seen at clinic

due to injury. were traumatic and five
were overuse injuries. In
Onsite clinic information the second semester, 7/8
recorded for study subjects, injuries were overuse and
including whether injury 1 was traumatic. Mean
was traumatic or overuse. number of days missed or
Participants also filled out modified was 7.27 (SD
the Self Estimated Functional 11.61) for first semester
Inability due to Pain and 8.73 (SD 16.35) for
Questionnaire (SEFIP). second semester.
Hiller et al., 200811 Adolescent dancers in Inclusion: All dance Ankle sprain defined as an 38 ankle sprains sustained History of previous
performing arts secondary students in the inversion injury that had resulted by 33 dancers (28.9% of lateral ankle sprain
13-month school and local dance school. performing arts secondary in either swelling or bruising in dancers). Incidence rate associated with an
prospective single (n = 114; 94 F / 21 M) school and local dance the area and limping for more of sprains during dancing increased risk of
cohort school. than one day. was 0.21/1000 hours future sprain of
dancing. contralateral ankle.
Australia Exclusion: No exclusion 18 possible predictors measured (HR=3.90, 95%
criteria at baseline. CI 1.49 to 10.22).
(continued on next page)
 Journal of Dance Medicine & Science • Volume 16, Number 2, 2012 81

rather than randomized and were

the day and season.

role in ACL injury.

from a different institution than

most ACL injuries

fatigue may play a

contraceptive use,

variables for ACL

or other intrinsic

happened late in

Authors suggest
those receiving the intervention,

No statistically

type, race, oral

Observed that
for sex, dance
increased risk
Risk Factors so cautious interpretation of these

occurrence.
significant
results is warranted.

Abbreviations: ACL, anterior cruciate ligament; BMI, body mass index; F, females; M, males; MSK, musculoskeletal; ROM, range of motion; SEFIP, Self Estimated
Injury Characteristics and
Prognosis for Musculoskeletal
Injury and Pain in Dancers

ankle; 8% knee; 11% hip;

documented over 5-years.

years by anatomic region:
3721 injury reports over

6% knee; 9% hip; 12%

We accepted one cohort study of
Ballet: 57% foot/ankle;
reportable injuries per

Incidence = 0.009 per

extremity; 10% other.
16% spine; 8% upper
Injury location over 5
5 year (average of 2.5

injury characteristics and prognosis

Modern: 47% foot/

spine; 13% other.
(Table 4). No studies of this sort had
year per dancer.)

12 ACL injuries

1000 exposures.
been deemed scientifically admissible
in the previous review. This was a
Incidence

two-sample prospective cohort study

from Sweden investigating dancers
and sprinters with first-time acute
hamstring strains. Findings include
participation in a class, rehearsal,
time partial or complete rupture

key clinical differences between the

time lost beyond the day of the

ACL injury definition: a first-

complete or partial session of

possibility of a dance injury.”

Injury definition: Any injury

groups, as well as a significantly

or performance in which a
of the ligament confirmed

dancer was exposed to the

longer return to pre-injury level of

Exposure definition: “any
by clinical and radiologic
resulting in one or more

performance for the dancers (median

50 weeks).9 Mechanisms of injury
Table 2 Studies of Incidence of and Risk Factors for Musculoskeletal Injury and Pain in Dancers

injury event itself.

Case Definitions

appear to be different between the

groups, with all dancer injuries re-
examination.

sulting from slow stretching types of

exercise, whereas the sprinters’ injuries
occurred during high speed sprinting.
Functional Inability due to Pain Questionnaire; CI, confidence interval; HR, hazard ratio.

Location of pain was closer to the is-

chial tuberosity in dancers, suggesting
participating institutions.
Inclusion: All dancers in

more tendinous tissue injury than in

exclusion criteria noted.
Exclusion: No specific

the sprinters.
Inclusion/Exclusion

Discussion
This systematic review is an update
of a previous study examining the
Criteria

scientific literature on MSK injuries

and pain in dancers. Many promising
findings arose from this update. First
1 university level conservatory

and foremost, 68% (13 of 19) of the

modern dance company and
Dancers from 2 ballet and 1

published studies that were deemed

of dance (n = 298; 183 F /

relevant and met inclusion criteria

were accepted. This is a substantial
Source Population

increase from the 31% of studies

that were accepted in the previous
systematic review, and may signify an
improvement over time in the qual-
115 M)

ity of scientific studies of dancers.1

Solomon and Solomon, compilers
of the Dance Medicine and Science
Bibliography, have noted and raised
Study, Design, and

5-year prospective

concern regarding a steady decrease in

Liederbach et al.,

the number of publications in dance

medicine and science from 1989
Country

through 2003, following a surge in

200810

cohort

such publications between 1977 and

USA

1988.20 However, the current study

 82
Table 3 Study of Interventions for Musculoskeletal Injury and Pain in Dancers
Authors, Study
Design, and Country Subjects and Setting Intervention Evaluated Outcomes and Follow-up Key Fndings and Limitations
19
Noh, 2007 Female ballet students Autogenic training (n=12) ACSI-28; History of injury defined Broad-based coping skills intervention enhanced
at 2 Korean dance and broad-based coping as any medical problem resulting coping skills more than the autogenic training
48 week, partially- institutes (n=45) skills training including from dance participation that intervention or controls and reduced injury
randomized, 3 cohort aged 14-19 years autogenic training, restricted subsequent practice and frequency and duration.
study with low coping skills imagery, and self talk performance for at least one day,
based on ACSI-28 (n=12) compared to recorded via survey as well as training Limitations include selection of controls rather than
Korea pretest scores. control group (n=12). staff who recorded injury frequency randomization. Additionally, controls were from a
and duration; adherence diary. separate institution than the intervention groups.
Abbreviations: ACSI-28, Athletic Coping Skills Inventory-28

Table 4 Study of Injury Characteristics and Prognosis for Musculoskeletal Injury and Pain in Dancers
Authors, Study
Design, and Country Subjects and Setting Inclusion/Exclusion Criteria Outcomes and Follow-up Key Findings
9
Askling et al., 2006 Dancers and sprinters History of first time acute 4 clinical examinations at All dancers sustained hamstring injuries during
with first time sudden pain in posterior thigh 2,10,21, and 42 days post- slow stretching (11 sagittal, 4 side split). All
2-sample prospective hamstring injuries. during training, competing, injury. sprinters sustained injuries during maximal sprint
cohort 15 dancers (14 F, or performing. Clinical Hip flexibility with flexometer; in competition. Dancers’ greatest pain localized to
1 M; aged 16-24) exam must reveal pain with pain with BorgCR-10 scale; 1 (0.7) cm from ischial tuberosity with sprinters’
Sweden professional and hamstring palpation, passive knee flexion strength with greatest pain localized to 12 (6) cm from ischial
students of classical SLR, and isometric hamstring dynamometer. tuberosity.
and modern dance. contraction. Clinical diagnosis Follow-up at 3,12, and 24 Initial loss of strength and flexibility greater in
18 sprinters (8 F, confirmed with MRI. months post-injury. Subjects sprinters than dancers. No significant difference
Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science

10 M; aged 15-28) asked to record week when they in strength between the legs in the dancers at 3
competing at national Exclusion: Extrinsic posterior could train or perform at pre- week follow-up. Flexibility difference between legs
or international level. thigh trauma, chronic low back injury level. persisted at 6 weeks for both groups. Both groups
n = 33 pain, pregnancy, and previous could perform more than 90% of test values of the
history of hamstring strain in uninjured leg at 6 weeks.
same leg. 54 subjects excluded
due to previous injury. Return to pre-injury levels significantly longer for
dancers (median 50 weeks, range 30-76) than for
sprinters (median 16 weeks, range 6-50).

3 reinjuries occurred, all in sprinters, at 2 year

follow-up.
Abbreviations: F, females; M, males; MRI, magnetic resonance imaging; SLR, straight leg raise.
 Journal of Dance Medicine & Science • Volume 16, Number 2, 2012 83

suggests that although quantity may admissible studies that reported on that the findings are limited to stud-
be decreasing, quality is increasing, the validity of diagnostic procedures ies of superior scientific quality. This
which should yield more robust results or assessment tools for injured danc- methodology is described explicitly so
for the dance community. ers. Additionally, no new studies were that others may reproduce or update
Those studies that were not deemed identified on healthcare provider these findings. The systematic review
scientifically admissible for this review utilization and effectiveness, or care- is restricted in this case, however, by
were excluded for reasons similar to seeking patterns for MSK injury and the quantity and quality of the avail-
those excluded in the previous review.1 pain in dancers. Only one study on able literature as of March 2008. All
Some used a study design unsuited to injury characteristics and prognosis too many studies continue to have
address the research question; others for musculoskeletal injury and pain major scientific limitations and biases.
provided insufficient information in dancers was found. This was the
about the source population, the at- first study reporting on prognosis of Conclusion and Future
risk population, or sampling methods; a specific type of injury (acute ham- Recommendations
still others involved unrepresentative, string strain) that had been deemed Future research in this area of study
highly selected study populations. scientifically admissible. The influence would benefit from clear and relevant
Another promising finding is that of covariates such as sex and activity- research questions being addressed
the majority of the studies included specific demands on these findings with appropriate study designs, from
in this review utilized a specific defi- needs to be investigated further. It is the use of valid and meaningful case
nition of musculoskeletal injury in to be hoped that further high qual- definitions of injury and pain, and
dancers.9-14,16,19 There is still a need for ity studies examining prognosis and from better reporting in accordance
explicit criteria for injury definition injury characteristics of MSK injuries with current scientific standards.
and methods of injury reporting. This affecting dancers will be produced in Specifically, studies regarding pre-
issue has received much attention in the future. participation screening and its effec-
the recent dance injury literature. The Similar to the conclusion in the tiveness are needed. Validation studies
International Association for Dance previous systematic review, it can be for the use of injury case definitions
Medicine and Science’s Standard Mea- said that MSK injury is an important in dancers would help to improve
sures Consensus Initiative has created health issue for dancers at all skill current research methodology and
injury definition and reporting recom- levels. There is a high prevalence and interpretation. A large prospective
mendations that were discussed at the incidence of lower extremity, hip and international study of dance injuries
organization’s 2007 annual meeting, back injuries (Tables 1 and 2). Also, could shed light on the issue of long-
and will be published in a future is- there is preliminary evidence that term effects of injury on dancers’
sue of the Journal of Dance Medicine psychosocial and psychological issues, careers and quality of life, identify
and Science.21 Bronner and colleagues such as stress affect injury frequency risk factors for injury, and explore the
have developed a proposal for uni- and duration,18 and that broad-based effect of national or cultural variables
form reporting guidelines, including coping skill interventions decrease fre- such as access to health insurance or
a standardized definition of injury quency and duration of injury (how- healthcare. The issue of fatigue and
that is wisely guided by developed ever, these findings have only been its relationship to injury in dancers
and tested injury reporting systems studied in Korean dance students, needs further exploration. Addition-
for athletes.22 These efforts are to be and should be tested in dancers from ally, randomized control trials explor-
commended, as they will allow for other cultures).19 History of a previous ing interventions for musculoskeletal
easier comparison between studies of lateral ankle sprain is associated with injury are desperately needed in this
prevalence estimates, incidence rates, an increased risk of opposite ankle injury-prone population.
and risk factors. sprain, and fatigue may play a role in These authors continue to recom-
Three studies made use of the Self ACL injury in dancers.10,11 There is mend that attention be paid to issues
Estimated Functional Inability be- also preliminary evidence that acute of bias and research methodology.1
cause of Pain Questionnaire created hamstring strains in dancers may be This is extremely important for pro-
specifically for dancers, which showed caused by slow-stretching at end range moting our knowledge of the epide-
good agreement with pain on physical activities, seemingly affecting the ten- miology, diagnosis, prognosis, treat-
examination in Swedish ballet danc- don more than the muscle tissue, and ment, and prevention of MSK injuries
ers.23 This is another indication that thus resulting in extensively delayed and pain in dancers. Future studies
dance injury researchers are moving return to pre-injury levels.9 should clearly identify their source
toward the use of scientifically vali- populations and be explicit in the
dated outcome measures specific to Strengths and Limitations of reporting of inclusion and exclusion
dancers. the Review criteria. Injury recall periods should
The recent dance literature is lack- An important strength of the best be limited (e.g., up to six months) to
ing in some respects. For example, this evidence synthesis approach used reduce recall bias when calculating
study produced no new scientifically here in reviewing the literature is prevalence estimates. Incidence den-
84 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science

sity rates are preferable to cumulative snapping hip syndrome in elite bal- programs? Med Probl Perform Art.
incidence proportions, as they provide let dancers. Am J Sports Med. 2007 2005 Sep;20(3):115-8.
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studied in appropriate study designs, ence of professional dance training modern dancers and the effectiveness
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