Risk Factors for Lower-Extremity Injuries in Female Ballet Dancers: A Systematic Review

The Efficacy of Physical Fitness Training on Dance Injury: A Systematic Review

Greater levels of physical fitness have been linked to improved dance performance and decreased injury incidence. The aim was to review the efficacy of physical fitness training on dance injury. The electronic databases CINAHL, Cochrane Library, PubMed, Web of Science, MEDLINE, China National Knowledge Infrastructure were used to search peer-reviewed published articles in English or Chinese. Studies were scored using Strength of the Evidence for a Conclusion and a risk bias checklist. 10 studies met the inclusion criteria from an initial 2450 publications. These studies offered physical fitness training for professional (n = 3) and pre-professional dancers (n = 7), participant sample size ranged between 5 to 62, ages from 11 to 27 years, and most participants were females. Assessment scores were classified as Fair (n = 1), Limited (n = 7), and Expert Opinion Only (n = 2) and risk of bias scores ranged from 22.7-68.2 %. After physical fitness training, 80 % of studies reported significant benefits in injury rate, the time between injuries, pain intensity, pain severity, missed dance activities and injury count. This review suggests that physical fitness training could have a beneficial effect on injury incidence in dance. The evidence is limited by the current study methodologies.

Perspectives and Experiences of Dance-Related Injuries: A Qualitative Survey of Adolescent Pre-Professional Ballet Dancers in Australia

Objective: To explore perspectives and experiences of adolescent ballet dancers in Australia in relation to dance-related injuries and their impact, injury risk factors, prevention, and treatment. Design: Adolescent ballet dancers aged from 12 to 19 years in Australia were invited to participate in an online qualitative survey. Methods: Responses to open-ended questions were analyzed thematically using grounded theory while quantitative information was summarized with descriptive statistics and triangulated with qualitative data. Results: Nineteen adolescent dancers reported experiencing pain and multiple injuries but hiding or ignoring injuries due to fear. Dancers recognized the significant physical and psycho-social impact of dance-related injuries on themselves and others. Several risks and injury prevention strategies were identified by dancers. Dancers perceived that treatments were not always informed or effective. Conclusion: Findings suggest that adolescent ballet dancers experience multiple dance-related injuries but require support to disclose injuries, participate in injury prevention, and access treatment. Health professionals may improve quality of care by increasing their understanding of ballet and providing specific management advice. Dance teachers may benefit from further education to support their students. Clinical trials are required to confirm or negate the validity of proposed injury risks and the effectiveness of injury prevention strategies and treatments.

Development and Feasibility of an Adolescent Dancer Screen

Background

Adolescent dancers are at high risk for injuries due to the physical demands of dance training and the physiological changes that occur during adolescence. Though studies report high injury rates, there are few standardized screening tools available for adolescent dancers.

Hypothesis/Purpose

To develop and describe a standardized, feasible, evidence-based, and clinically relevant screen for adolescent dancers.

Study Design

Descriptive Epidemiology Study.

Methods

Dancers at two suburban pre-professional dance studios, in two cohorts, participated in the Columbia Adolescent Dancer Screen (CADS) that includes dance injury history, health questionnaires (EAT-26, SF-36, DFOS), aerobic capacity, range of motion, strength, balance/orthopedic special tests, and dance technique. Participants were asked to complete a weekly injury surveillance questionnaire derived from the Dance-Specific Oslo Sports Trauma Research Centre Questionnaire on Health Problems for 14 weeks following the screening. Feasibility was assessed using process and content analysis in four areas: practicality, demand, implementation, and adaptation.

Results

Descriptive data were collected from 32 female dancers aged 11-17 with cohort one averaging 18.57 dance hours per week and cohort two averaging 10.6 dance hours per week. The screen was practical, able to screen seven to eight dancers per hour utilizing nine assessors and requiring a one-hour commitment from dancers. Cost and space requirements were considered and kept to a minimum while utilizing portable equipment. All screening slots were filled with all dancers agreeing to follow-up injury surveillance, indicating high demand. The screen was implemented with two cohorts with revisions to improve efficiency applied for the second cohort.

Conclusion

The CADS is a feasible screening tool for adolescent dancers that overcomes barriers by being pragmatic, evidence-based, and efficient. Screening can be implemented to obtain baseline values, inform wellness recommendations, and establish relationships with medical professionals.

Level of Evidence

Level 3b.

Excessive Knee Internal Rotation during Grand Plié in Classical Ballet Female Dancers

Classical ballet dancers are exposed daily to physically demanding movements. Among these, the Grand Plié stands out for its biomechanical complexity, particularly the stress applied to the knee joint. This study investigates the knee kinematics of healthy professional classical ballet dancers performing the Grand Plié. Twenty dancers were evaluated with a motion analysis system using a marker-based protocol. Before measurements, the self-reported Global Knee Functional Assessment Scale was delivered for the knees' functional ability, and the passive range of knee motion was also assessed. The average score on the Global Knee Functional Assessment Scale was 94.65 ± 5.92. During a complete circle of the Grand Plié movement, executed from the upright position, the average maximum internal rotation of the knee joint was 30.28° ± 6.16°, with a simultaneous knee flexion of 134.98° ± 4.62°. This internal rotation observed during knee flexion exceeds the typical range of motion for the joint, suggesting a potential risk for knee injuries, such as meniscal tears. The findings provide an opportunity for future kinematic analysis research, focusing on the movement of the Grand Plié and other common ballet maneuvers. These data have the potential to yield valuable information about the knee kinematics concerning meniscus damage.

Body Posture and Low Back Pain: Differences between Folk and Ballroom Dancers

(1) Background: Dance is extremely diverse in its styles. Each of them presents different training, dynamics, and figures that may impact the body posture and the occurrence of low back pain. This observational study aimed to compare the sagittal curvatures and the range of motion (ROM) of the spine, as well as the low back pain occurrence and its intensity between folk and ballroom dancers. (2) Methods: Fifty-one participants took part in the study (nineteen folk dancers, fifteen ballroom dancers, and seventeen non-dancers) aged 18-32. Study groups did not differ in anthropometric parameters as well as in dancing experience and training frequency. Study procedures included a self-administered questionnaire and a physical examination of the sagittal spine curvatures and ROM. The questionnaire included questions about epidemiological data and the occurrence of chronic pain and its intensity using a Visual Analogue Scale (VAS). (3) Results: There was a significant difference in thoracic kyphosis angle between study groups (p = 0.02). The greatest angle was found in folk dancers and the lowest in ballroom dancers (40 vs. 33 respectively). We have found no significant differences in spine ROM, low back pain occurrence, and intensity between study groups (p > 0.05). We have found no correlation between low back pain and spine curvatures and ROM in dancers (p > 0.05), however, we found a very strong and negative correlation between thoracic spine range of motion and the pain intensity in non-dancers (R= -0.95, p = 0.003). The analysis also revealed that only in folk dancers, but not in ballroom dancers, the BMI correlates positively with dancing experience (R = 0.67, p = 0.002). (4) Conclusions: There are no differences in low back pain occurrence and pain intensity between folk and ballroom dancers, however, the prevalence of low back pain in dancers is very high. Folk dancers seem to have more flexed body posture compared to ballroom dancers.

Spinal Counts, Impact, and Partnering Movements in Ballet, Modern, and Hip Hop dance: A YouTube Video Analysis Study

INTRODUCTION

Dancers have self-reported a link between spinal extension movements and low back pain (LBP). Researchers have not reported the total number or frequency that spinal movements occur in ballet, modern, or hip-hop dance classes or performances. The purpose of this study was to report the number of spinal movements dancers are exposed to in different dance environments.

MATERIALS AND METHODS

We analyzed 65 dance videos on YouTube.com for dance movements within 7 dance environments: ballet class and performance, modern class and performance, and hip-hop breaking, ciphers (large groups), and battles ("1v1s"). Two reviewers recorded counts of spinal (spinal flexion, extension, lateral flexion, and rotation), impact (jumps, leaps, and falls), and partnering movements (lifts, catches, and leans). Data analyses were processed in Jamovi (the jamovi project, Sydney, Australia). We reported movement totals, percentages, frequency, ranges, means with standard deviations (SD), and medians with interquartile range (IQR). We calculated significant differences using Mann-Whitney U tests.

RESULTS

Video length ranged from 3 to 141 minutes (mean ± SD: 38.4 ± 38.3, range: 138). the average spinal extension movements ranged from 2 ± 0.8 to 7 ± 9.6 movements per minute across genres. Modern dance class had the most spinal flexion (89 ± 53.6), rotation (60 ± 40.8), and lateral flexion (74 ± 20.7) movements. Ballet performance had the most spinal extension movements (77 ± 69.8), jumps (74 ± 48), and leaps (19 ± 18.2). Hip-hop breaking had the highest number of falling movements (2 ± 2.3). Partnering movements were only present in ballet performance, modern dance performance, and hip-hop breaking environments.

CONCLUSIONS

Movements that increase LBP occur often in all 3 dance genres. Dancers can expect frequent exposure to spinal extension movements; therefore, we recommend strengthening back and core musculature for all dancers. We recommend that ballet dancers also strengthen their lower extremity muscles. For modern dancers, we recommend strengthening their obliques. For hip-hop dancers, we recommend increasing muscular power and muscular endurance.

Ballet Rehabilitation: A Novel Return to Sport Protocol

Dance injuries and re-injuries are common but can be difficult to rehabilitate because of the unique demands and motor skills required. During tissue healing, pain resolves prior to tissue maturation and re-injury often occurs if the original injury is not properly rehabilitated.

The purpose of this narrative review is to analyze the existing literature addressing ballet injury, re-injury, and recovery, and to provide clinicians with timing guidelines for entering and implementing a Return to Sport (RTS) ballet rehabilitation protocol designed to prevent re-injury by progressive, sport-specific tissue loading. Thus far, a literature-based ballet-specific and body region-specific late-stage rehabilitation RTS protocol has not been established. The authors sought to address this literature gap by combining this comprehensive narrative review with our extensive clinical expertise to develop a late-stage rehabilitation RTS protocol to help guide medical clinicians treating injured ballet dancers.

Biomechanical Risks Associated with Foot and Ankle Injuries in Ballet Dancers: A Systematic Review

Professional ballet dancers can be classified as dance artists and sports performers. This systematic review aims to consider the biomechanical risk factors for foot and ankle injuries in ballet dancers, as this could potentially reduce the impact that 'cost of injury' may have on ballet companies. An additional outcome was to examine the effects of injury on the career of ballet dancers. This study searched articles in four electronic databases for information in peer-reviewed journals. The included articles examined the relationships between biomechanical factors and the relationship between ballet shoes and foot performance. There were 9 articles included in this review. Among these articles, two focused on the peak force of the foot using two types of pointe shoes, three focused on overuse injuries of the ballet dancer's foot, one article focused on the loading of the foot of a dancer, and three articles focused on the function and biomechanics of the foot in dancers. This review also found that the pointe shoe condition was the most important factor contributing to a foot injury; overuse injury related to high-intensity training and affected both the ankle and the foot; and metatarsophalangeal joint injury related to the function and structure of the foot. Finally, strengthening the lower extremity muscle is also a recommendation to improve muscle coordination and reduce injuries.

Effectiveness of physiotherapy interventions for injury in ballet dancers: A systematic review

Background

The unique repetitive nature of ballet dancing, which often involves transgressing endurance limits of anatomical structures, makes dancers prone to injury. The following systematic review aims to assess the effectiveness of physiotherapy interventions in the treatment of injuries in ballet dancers.

Methods

The review was performed in line with the PRISMA statement on preferred reporting items for systematic reviews and meta-analyses. Six electronic databases (PubMed, Ovid Embase, Cochrane, Medline, PEDro, Google Scholar) were queried. The study populations comprised active ballet dancers and/or ballet school attendees with acute and chronic injuries and those with persistent pain. There were no restrictions regarding age, sex, ethnicity or nationality. The Modified McMaster Critical Review Form for quantitative studies was used to assess the methodological quality of the studies reviewed in accordance with the relevant guidelines.

Results

Out of the total of 687 articles subjected to the review, 10 met the inclusion criteria. Diverse physiotherapeutic interventions were described and effectiveness was assessed using different parameters and measurements. Overall, the results indicate that physiotherapy interventions in ballet dancers exert a positive effect on a number of indices, including pain, ROM and functional status.

Conclusions

Due to the small amount of evidence confirming the effectiveness of physiotherapeutic interventions in ballet dancers after injuries and methodological uncertainties, it is recommended to improve the quality of prospective studies.

The Case for Retiring Flexibility as a Major Component of Physical Fitness

Flexibility refers to the intrinsic properties of body tissues that determine maximal joint range of motion without causing injury. For many years, flexibility has been classified by the American College of Sports Medicine as a major component of physical fitness. The notion flexibility is important for fitness has also led to the idea static stretching should be prescribed to improve flexibility. The current paper proposes flexibility be retired as a major component of physical fitness, and consequently, stretching be de-emphasized as a standard component of exercise prescriptions for most populations. First, I show flexibility has little predictive or concurrent validity with health and performance outcomes (e.g., mortality, falls, occupational performance) in apparently healthy individuals, particularly when viewed in light of the other major components of fitness (i.e., body composition, cardiovascular endurance, muscle endurance, muscle strength). Second, I explain that if flexibility requires improvement, this does not necessitate a prescription of stretching in most populations. Flexibility can be maintained or improved by exercise modalities that cause more robust health benefits than stretching (e.g., resistance training). Retirement of flexibility as a major component of physical fitness will simplify fitness batteries; save time and resources dedicated to flexibility instruction, measurement, and evaluation; and prevent erroneous conclusions about fitness status when interpreting flexibility scores. De-emphasis of stretching in exercise prescriptions will ensure stretching does not negatively impact other exercise and does not take away from time that could be allocated to training activities that have more robust health and performance benefits.

Generalized Joint Hypermobility and Injuries: A Prospective Cohort Study of 185 Pre-Professional Contemporary Dancers

Generalized joint hypermobility (GJH) has been mentioned as one of the factors associated with dance injuries, but the findings are inconclusive. This study aims to investigate whether GJH, based on different Beighton score cut-off points, is a potential risk factor for injuries in pre-professional dancers. Four cohorts of first-year pre-professional dancers (N = 185), mean age 19.1 ± 1.3 years, were screened on musculoskeletal functioning at the start of their academic year. The Beighton score was used to measure GJH. During the academic year, the dancers completed monthly questionnaires about their physical and mental health. Based on the Oslo Sports Trauma Research Centre Questionnaire on Health Problems (OSTRC), three injury definitions were used (i.e., all complaints, substantial injury, and time-loss injury). To examine potential risk factors for injuries, univariate and multivariate regression models were applied. The response rate of monthly completed questionnaires was 90%. The overall mean (SD) Beighton score was 2.8. The 1-year injury incidence proportion was 67.6% (n = 125), 43.2% (n = 80), and 54.6% (n = 101) for all complaint injuries, substantial injuries, and time-loss injuries, respectively. The multivariate analyses showed a significant association between a previous long lasting injury in the past year and the three injury definitions (p < 0.05). Pre-professional contemporary dancers are at high risk for injuries and hypermobility. However, these two variables are not associated with each other. Health professionals should take injury history into account when assessing dance students, because this variable is associated with increased injury risk.

Unilateral and bilateral patellofemoral pain in young female dancers: Associated factors

Aiming to evaluate the prevalence of unilateral/bilateral patellofemoral pain (PFP) among young dancers, and to investigate whether different factors are associated with PFP in young dancers, 132 dancers aged 12-14 years were assessed for PFP. Anthropometric parameters, proprioception ability, dynamic postural balance (DPB), and muscle strength were measured. PFP was found in 64.1% of the dancers. No significant differences in the prevalence of dancers with no, unilateral, or bilateral PFP at different ages were found. Significant age effects were found for anthropometric and developmental measurements, and for intensity of training. PFP effect was found for DPB asymmetry, ankle proprioception, and leg-length %height. A higher hip abductor/adductor ratio was associated with PFP in 14-year-old dancers. Binomial logistic regression showed that increased number of hours per day (h/day) and decreased number of hours per week (h/week), low proprioception scores, greater leg length as %height, and more anterior DPB asymmetry were significant predictors of PFP. In conclusion: unilateral/bilateral PFP is common among young dancers. Body morphology, reduced ankle proprioception ability, DPB asymmetry, and increased h/day of practice are associated with PFP. Dance teachers should start monitoring the impact of training and implement injury modification/prevention strategies when their students are at a young age.

Do Grade II Ankle Sprains Have Chronic Effects on the Functional Ability of Ballet Dancers Performing Single-Leg Flat-Foot Stance? An Observational Cross-Sectional Study

Ballet dancers have a higher risk than the general population of ankle sprains. Ankle proprioception is of the utmost importance for executing static and dynamic positions typical of ballet dancing. Ankle sprains can create changes in functional ability that may affect ballet performance. The aim of this cross-sectional observational study is to evaluate if non-professional ballet dancers that were previously injured with a grade II ankle sprain carry a long-term stability deficit in ballet specific positions (passé, arabesque) and in single-leg flat-foot stance, thereby affecting ballet performance. We enrolled 22 amateur female ballet dancers, 11 who previously had a grade II ankle injury and 11 who had no history of ankle injury. Stabilometric data (Center of Pressure Speed and Elipse Area) were assessed with the postural electronic multisensory baropodometer in normal, arabesque, and passè positions with both open and closed eyes. Using an unpaired t-test, we compared healthy and pathological feet of the ankle injury group for a standard monopodalic position and two ballet-specific positions. No difference between pathological and healthy feet of non-professional ballet dancers who suffered grade II ankle injury was detected. According to the parameters considered in this study, grade II ankle sprains seem to have a favorable prognosis in the sample that we evaluated.

Injury Occurrence and Return to Dance in Professional Ballet: Prospective Analysis of Specific Correlates

Professional ballet is a highly challenging art, but studies have rarely examined factors associated with injury status in ballet professionals. This study aimed to prospectively examine gender-specific correlates of injury occurrence and time-off from injury in professional ballet dancers over a one-year period. The participants were 99 professional ballet dancers (41 males and 58 females). Variables included: (i) predictors: sociodemographic data (age, educational status), ballet-related factors (i.e., experience in ballet, ballet status), cigarette smoking, alcohol drinking, and consumption of illicit drugs; and (ii) outcomes: injury occurrence and time-off from injury. Participants were questioned on predictors at the beginning of the season, while data on outcomes were collected continuously once per month over the study period. Dancers reported total of 196 injuries (1.9 injuries (95% CI: 1.6–2.3) per dancer in average), corresponding to 1.4 injuries per 1000 dance-hours (95% CI: 1.1–1.7). In females, cigarette smoking was a predictor of injury occurrence in females (OR: 4.33, 95% CI: 1.05–17.85). Alcohol drinking was a risk factor for absence from dance in females (OR: 1.29, 95% CI: 1.01–4.21) and males (OR: 1.21, 95% CI: 1.05–3.41). Less experienced dancers were more absent from dance as a result of injury than their more experienced peers (Mann-Whitney Z: 2.02, p < 0.04). Ballet dancers and their managers should be aware of the findings of this study to make informed decisions on their behavior (dancers) or to initiate specific programs aimed at the prevention of substance use and misuse in this profession (managers).