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

74

used in searching the databases. The
reference lists of all relevant studies
were examined for additional or un-
published literature.
Screening for Relevance to Best-
Evidence Synthesis Objectives
All citations identified through use
of the operative search strategy were
screened, and included: English lan-
guage reports; published reports of
original research, systematic reviews,
conference proceedings, government
reports, guidelines or unpublished
“grey literature” manuscripts; stud-
ies containing original raw data
on at least 20 human participants,
including a control group if present;
studies examining the prevalence,
incidence, associated factors, risk
factors, diagnosis, interventions,
economic costs, prognosis, or other
aspects of MSK injury, pain, and
metabolic or nutritional disorders
in dancers; and studies of dancers in
any form of artistic dance, such as
ballet, modern, tap, theatrical, folk,
Flamenco, break-dancing, ballroom
dancing, and ice dancing. Excluded
were: studies on recreational or exer-
cise forms of dance such as aerobics
or social dancing in clubs, parties
or raves; studies on the cognitive,
behavioral, or learning aspects of
dance; narrative, editorial, or clini-
cal reviews, opinion papers, letters
to the editor, and editorials; stud-
ies of conditions with questionable
clinical relevance or asymptomatic
presentation; studies using cadavers
or non-human subjects; and finally,
studies reporting findings not specific
to dancers (e.g., those in which danc-
ers’ information was combined with
other athletes’ information, such that
results could not be evaluated specifi-
cally for dancers).
Based on these inclusion and ex-
clusion criteria, two reviewers (CLJ
and CAH) independently appraised
the relevancy of each citation found
in the electronic search through a
two-level screening process, with dis-
agreements resolved by consensus. In
the first-level screening, reviewers cat-
egorized citations as probably relevant,
of unknown relevance, or irrelevant.
Journal of Dance Medicine & Science • Volume 16, Number 2, 2012
For each citation rated as probably
relevant or of unknown relevance,
the entire paper was obtained, and
in the second-level screening, these
were deemed to be either relevant or
irrelevant to the systematic review.
Two substantive and related themes
from the previous systematic review
by Hincapié and colleagues were
maintained: 1. MSK injuries and
pain, and 2. metabolic and nutritional
disorders.1 This paper reports on the
first of these themes.
Critical Review of the Literature
All studies judged relevant were
critically appraised. The appraisal
assessed scientific merit and clinical
relevance by using a priori criteria
and electronic critical review forms.2
These forms prompted the reviewer
to focus on issues of study design,
study population, issues related to
conduct of the study, participa-
tion rates, follow-up rates (where
relevant), measurement issues and
analysis. Quality appraisal criteria
were derived from fundamental
principles of epidemiologic meth-
ods, measurement, and design.3,4
Two investigators performed inde-
pendent in-depth reviews. Decisions
concerning a study’s methodological
quality and scientific merit were made
by consensus of the investigators
after full discussion. Studies were
considered scientifically admissible,
which could include accepting part
or all of the findings, or scientifically
inadmissible due to fatal biases and
methodological flaws.
Data Abstraction into Evidence
Tables
Studies relevant to MSK injuries and
pain in dancers were identified as
relating to: prevalence and associated
factors; incidence and risk factors; in-
tervention; and injury characteristics
and prognosis. Data from admissible
studies were abstracted into evidence
tables relating to these topic areas,
facilitating synthesis of the informa-
tion according to the best-evidence
synthesis method.5,6 These evidence
tables summarize the study’s findings
and form the basis for the investiga-
75
tors’ recommendations for further
study (see below).
Results
After applying our inclusion and
exclusion criteria to 536 identified
abstracts, 55 papers were judged to be
relevant. Of these, 19 dealt with MSK
injuries and pain in dancers and were
critically reviewed. Ultimately, 13
(68%) were accepted as scientifically
admissible (Fig. 1). These studies are
the basis for our findings and consist
of nine cohort studies and four cross-
sectional studies.
Characteristics of Musculoskeletal
Injury in Dancers
A previous review reported that the
most prevalent MSK injuries in danc-
ers are sprains, strains, and tendinopa-
thies, primarily affecting the lower
extremities and back.1 Some studies
in the current review did not report
exact locations of injuries; however,
of those that did, lower extremity
injuries still predominated, followed
by the hip and low back (Tables 1
and 2). Five studies accepted for this
review focused on specific injuries, in-
cluding snapping hip syndrome, ankle
injuries, anterior cruciate ligament
(ACL) injuries, and acute hamstring
strain.7-11
Prevalence and Associated Factors
of Musculoskeletal Injury and
Pain in Dancers
Four cross-sectional studies were
accepted on the prevalence and as-
sociated factors of MSK injury and
pain (Table 1). These studies varied
geographically in representing source
populations from Canada, Germany,
Brazil, and Turkey. Inclusion and
exclusion criteria also varied con-
siderably across the studies. One
study focused solely on professional
ballet dancers,12 one on professional
contemporary dancers,13 one study
focused on a mix of professional bal-
let dancers and elite ballet students,7
and one on ballet and folk-dance
students.14
Case definitions for injury also
varied considerably. For example, one
study defined injury as “any medical
76 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science
Figure 1 Systematic review inclusion and exclusion.
problem resulting from dance par-
ticipation that restricted subsequent
participation for at least one day be-
yond the day the injury occurred.”12
Another defined injury as needing
to fulfill at least one of the following
criteria: absence from one or more
performance or rehearsal, removal
from a performance without the pos-
sibility of returning, or need for tradi-
tional medical assistance.13 One study
focusing on snapping hip syndrome
identified cases by questionnaire, ask-
ing dancers if their hips could “snap,
pop, crack, click, or dislocate.” These
investigators additionally asked the
dancers to report on their worst injury
now, in the past year, and ever, but
did not provide an explicit definition
of injury.7 The fourth cross-sectional
study focused on foot problems and
used a visual analog scale to measure
daily foot pain.14
Prevalence estimates were vari-
able given the different time periods
studied and case definitions and were
not always clearly reported. Due to
this heterogeneity, it is not possible
to report a pooled prevalence estimate
of MSK injury in dancers. Seasonal
prevalence (10.5 months) of at least
one injury in a German ballet com-
pany was 87%.12 Lifetime prevalence
of joint injuries was reported at 47%,
with 20% reporting ankle injuries as
the most important lifetime injury (all
females), and 16% reporting knee in-
juries as most important (all males).13
In a Canadian study investigating
snapping hip syndrome, 91% of danc-
ers reported a snapping hip, 58% had
pain associated with the snap, and 7%
took time off because of the condition,
although no time frames were given.7
Three of the four prevalence studies
reported on factors associated with
MSK injury or pain in dancers. A
positive correlation between stress and
absence due to injury was found in a
German ballet company. Additional
correlations were also reported for
anxiety, depression, anger, fatigue,
confusion and sleep problems. Strong
social support and good sleep habits
were positively correlated with fewer
days missed from dance due to in-
jury.12 Ballet movements associated
with snapping hip syndrome were
grand battement à la seconde (42%),
grand plié (25%), and développé à
la seconde (22.8%).7 In a Turkish
study exploring second toe length
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
dancers.18 One study from the USA
included professional ballet and mod-
ern dancers, as well as university level
dancers.10 Four of the studies included
both male and female dancers, while
the three university based studies from
the USA and Croatia involved only
female dance students (Table 2).
Case definitions for injury varied
in this group of studies as well. One
study did not explicitly define injury.8
Five studies used definitions of in-
jury based on being unable to dance,
time-loss from dance class, rehearsal,
or performance, or the dancer being
forced to modify technique.10,11,15,16,18
Three studies incorporated use of the
Self Estimated Functional Inability
because of Pain (SEFIP) question-
naire, with one study using it as
the sole measure of MSK pain.15-17
One study focusing on ankle sprain
defined it as an inversion injury that
had resulted in either local swelling or
bruising and limping for more than
one day.11 A study of anterior cruciate
ligament (ACL) injury defined it as a
first-time partial or complete rupture
of the ligament, confirmed by clinical
and radiologic examination.10
Incidence estimates were reported
in the accepted studies as cumulative
incidence proportions (i.e., number of
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
12
Adam et al., 2004 Professional ballet dancers
(30 F/24 M mean age 26.6
Cross-sectional years; SD:6.2 yrs) from
a major German ballet
Germany company. Company members
represented 20 countries.
78% response rate (54/69)
(n = 54)
Scialom et al., 200613 Professional dancers (14
F/16 M) of a contemporary
Cross-sectional Brazilian dance company. No
age range reported.
Brazil
75% response rate (30/40)
(n = 30)
Winston et al., 20077 Professional ballet dancers and
students from the National
Cross-sectional Ballet of Canada and Canada’s
National Ballet School. Aged
Canada 16 years or more.
92% response rate for
questionnaire (87/95, 57 F/30
M)
26 participants (of 47 who
Case Definitions
Dance injury defined as
“any medical problem
resulting from dance
participation that
restricted subsequent
participation for at least
one day beyond the day
the injury occurred.”
Injury defined as at least
one of following items:
absence from at least
one performance or
rehearsal, removal from a
performance without the
possibility of returning,
and need for traditional
medical assistance.
Dancers were asked about
their “most important
injury.”
Self-reported hip that will
“snap, pop, crack, click,
or dislocate.”
No explicit definition of
injury given for injury
prevalence data.
Prevalence Associated Factors
Season prevalence (10.5 months) Correlation between stress
of at least one injury: 87% and absence due to injury.
Additional associations
noted for anxiety,
depression, anger, fatigue,
and confusion and absence
due to injury. Sleep
problems moderately
associated with absence
due to injury. Social
support and sleep duration
positively associated with
fewer days missed.
Lifetime prevalence measured N/A
for most important injury. Joint
injuries were most frequent
(47%), with 20% reporting
ankle injury (all females) and
16% reporting knee injury (all
males).
91% reported snapping hip, Movements associated
80% had bilateral symptoms, with snap: Grand
58% had pain associated with battement à la seconde
the snap, and 7% took time off (42%), grand plié (25%),
because of the condition. 60% développé à la second
of dancers could voluntarily snap (22.8%).
hip.
Ankle injuries were most
frequent for all time frames
(“worst injury now, in past year,
Other Findings
Percentage of
workdays missed:
17.5% corps de
ballet; 11.7%
soloists.
Overall average
days missed due
to injury was
42.8/286.
50% of injuries
occurred during
rehearsals. 73%
sought medical
care, 60% within
one day. 47%
reported that
injury prevented
them from dance
activity during
“some months”.
2 clinicians could
palpate 46 of the
50 self-reported
snapping hips.
Ultrasound
showed a snapping
iliopsoas tendon
(59%), iliotibial
band (4%), and
unidentified
(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
in student dancers, and found that
clinic-recorded injury incidence was
30% for the first academic semester
and 36% for the second semester,
while self-reported injury incidence
with longer second toe = 3.7. Mean
Mean VAS score for ballet students
Liederbach and colleagues did not
find any greater risk for ACL injury
based on sex, style of dance, race,
oral contraceptive use, or other in-
trinsic physiological variables. The
investigators did observe that most

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

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

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
Country Source Population
8
Schmitt et al., 2005 Students in dance group
studied at state academy for
5-month, professional dance training in
prospective, double Germany.
cohort (n = 42; 31 F/ 11 M; ages 14-
23; 8 lost to follow-up)
Germany Control group of students
matched for age and sex with
no dance or sport-specific
training (n = 40).
Noh et al., 200518 Professional ballet dancers,
university-level ballet dancers,
10-month, and high school level ballet
prospective, multiple dancers from Korea.
cohort
(n = 105)
Korea
Weigert, 200515 Female dance majors and
minors in a predominately
1 academic year, modern dance program at the
prospective, single University of Wisconsin.
cohort
(n = 38)
USA
(continuted on next page)
Inclusion/Exclusion
Criteria
Inclusion: Attendance
at a state academy for
professional dance
training for study group.
Exclusion: Severe
functional orthopaedic or
neurologic deficits of the
lower extremities resulting
in loss of ROM, strength,
paralysis, paresthesia, or
injury with interruption
of 7 subsequent days of
training during previous
month.
No explicit inclusion/
exclusion criteria
reported. 27 professional
dancers, 19 university
dancers, and 59 high
school dancers (101
F/4 M; mean age,
20.5 ± 5.5 years)
provided information
on psychosocial factors
associated with injury.
Inclusion: Female dance
majors and minors
studying modern dance.
No specific exclusion
criteria.
Case Definitions
Self reported questionnaires
and interviews at baseline and
5-month mark. No explicit
definition of injury.
Injury defined as “any medical
problem resulting from dance
participation that restricted
subsequent practice and
performance for at least one
day.” An injury scale addressed
the frequency and duration of
injury during the 10-month
study period.
Injury defined as any painful
problem attributed to dance that
had caused the student to miss a
class or rehearsal or modify their
technique.
Questionnaire regarding injuries
at baseline and at end of both
first and second semesters.
Included SEFIP.
Incidence Risk Factors
4 self-reported ankle No indications of
injuries recorded during risk found between
study period in the dance injured and non-
group (12% cumulative injured subjects
incidence). in proprioception
test scores (angle
replication, one-
legged standing
test).
10-month incidence Dancers who
injury 37.1% for all reported low levels
dancers. Frequency of of psychosocial
injury for professional coping on “freedom
dancers and university from worry” and
students greater than for “confidence and
ballet institute students. achievement
Professional dancers had motivation” (2
a significantly greater subscales of the
duration of injury Athletic Coping
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.
Self reported injury N/A
incidence 67% for first
semester and 77% for
second semester. Mean
number of days missed/
modified = 7 (SD, 12) for
first semester and 9 (SE,
Journal of Dance Medicine & Science • Volume 16, Number 2, 2012
16) for second semester.
Mean total pain score 4.9
(SD, 4) for first semester
79
and 5.6 (SD, 3.6) for
second semester.

Table 2 Studies of Incidence of and Risk Factors for Musculoskeletal Injury and Pain in Dancers
Study, Design, and
Country Source Population
17
Miletic et al., 2007 Female students in a university
aesthetic sports program
6 week prospective (ballet, rhythmic gymnastics,
double cohort and modern dance) aged
19-25.
Croatia
One group with previous
dance experience (24) and
the other group with no
experience (21).
N = 45
(n = 30)
Weigert and Female dance majors and
Erickson, 200716 minors in a university
program (predominantly
1 academic year modern dance curriculum)
prospective single aged 18-26 years during 2
cohort academic semesters.
(n = 30)
USA
Hiller et al., 200811 Adolescent dancers in
performing arts secondary
13-month school and local dance school.
prospective single (n = 114; 94 F / 21 M)
cohort
Australia
(continued on next page)
Inclusion/Exclusion
Criteria Case Definitions
No specific inclusion/ Self Estimated Functional
exclusion criteria noted. Inability due to Pain
Questionnaire measured pre-
(after 1 week of program) and
post-training (after 6 weeks of
program) period.
Anthropometric measurements
taken at study entry.
Inclusion: Female dance Subjects filled out questionnaire
majors (30) enrolled in at baseline, end of semester
modern dance class over 2 1 and end of semester 2.
semesters. Injury defined as any problem
that caused pain or limited
Exclusion: Dance majors participation in dance activities.
not enrolled in a modern Subjects were also asked to
dance class. Male students estimate number of days of
excluded. dance class or rehearsal missed
due to injury.
Onsite clinic information
recorded for study subjects,
including whether injury
was traumatic or overuse.
Participants also filled out
the Self Estimated Functional
Inability due to Pain
Questionnaire (SEFIP).
Inclusion: All dance Ankle sprain defined as an
students in the inversion injury that had resulted
performing arts secondary in either swelling or bruising in
school and local dance the area and limping for more
school. than one day.
Exclusion: No exclusion 18 possible predictors measured
criteria at baseline.
80
Incidence Risk Factors
SEFIP overall mean score No significant
4.9 ± 4.24 at pre-training difference of dance
and 2.98 ± 2.29 at post- experience on total
training assessment. pain score.
BMI significant
predictor of
SEFIP score in
the inexperienced
group at both
timepoints. Calf
circumference a
predictor of SEFIP
score at pretraining
test.
Clinic recorded injury N/A
incidence was 30% for
first semester and 36.4%
for the second semester.
Self-reported injury
incidence was 67% for
first semester and 77%
for second semester. 4/9
Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science
injuries seen at clinic
were traumatic and five
were overuse injuries. In
the second semester, 7/8
injuries were overuse and
1 was traumatic. Mean
number of days missed or
modified was 7.27 (SD
11.61) for first semester
and 8.73 (SD 16.35) for
second semester.
38 ankle sprains sustained History of previous
by 33 dancers (28.9% of lateral ankle sprain
dancers). Incidence rate associated with an
of sprains during dancing increased risk of
was 0.21/1000 hours future sprain of
dancing. contralateral ankle.
(HR=3.90, 95%
CI 1.49 to 10.22).
 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)
competing at national Exclusion: Extrinsic posterior
or international level. thigh trauma, chronic low back
n = 33 pain, pregnancy, and previous
history of hamstring strain in
same leg. 54 subjects excluded
due to previous injury.
asked to record week when they
could train or perform at pre-
injury level.
in strength between the legs in the dancers at 3
week follow-up. Flexibility difference between legs
persisted at 6 weeks for both groups. Both groups
could perform more than 90% of test values of the
uninjured leg at 6 weeks.
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.

suggests that although quantity may
be decreasing, quality is increasing,
which should yield more robust results
for the dance community.
Those studies that were not deemed
scientifically admissible for this review
were excluded for reasons similar to
those excluded in the previous review.1
Some used a study design unsuited to
address the research question; others
provided insufficient information
about the source population, the at-
risk population, or sampling methods;
still others involved unrepresentative,
highly selected study populations.
Another promising finding is that
the majority of the studies included
in this review utilized a specific defi-
nition of musculoskeletal injury in
dancers.9-14,16,19 There is still a need for
explicit criteria for injury definition
and methods of injury reporting. This
issue has received much attention in
the recent dance injury literature. The
International Association for Dance
Medicine and Science’s Standard Mea-
sures Consensus Initiative has created
injury definition and reporting recom-
mendations that were discussed at the
organization’s 2007 annual meeting,
and will be published in a future is-
sue of the Journal of Dance Medicine
and Science.21 Bronner and colleagues
have developed a proposal for uni-
form reporting guidelines, including
a standardized definition of injury
that is wisely guided by developed
and tested injury reporting systems
for athletes.22 These efforts are to be
commended, as they will allow for
easier comparison between studies of
prevalence estimates, incidence rates,
and risk factors.
Three studies made use of the Self
Estimated Functional Inability be-
cause of Pain Questionnaire created
specifically for dancers, which showed
good agreement with pain on physical
examination in Swedish ballet danc-
ers.23 This is another indication that
dance injury researchers are moving
toward the use of scientifically vali-
dated outcome measures specific to
dancers.
The recent dance literature is lack-
ing in some respects. For example, this
study produced no new scientifically
Journal of Dance Medicine & Science • Volume 16, Number 2, 2012
admissible studies that reported on
the validity of diagnostic procedures
or assessment tools for injured danc-
ers. Additionally, no new studies were
identified on healthcare provider
utilization and effectiveness, or care-
seeking patterns for MSK injury and
pain in dancers. Only one study on
injury characteristics and prognosis
for musculoskeletal injury and pain
in dancers was found. This was the
first study reporting on prognosis of
a specific type of injury (acute ham-
string strain) that had been deemed
scientifically admissible. The influence
of covariates such as sex and activity-
specific demands on these findings
needs to be investigated further. It is
to be hoped that further high qual-
ity studies examining prognosis and
injury characteristics of MSK injuries
affecting dancers will be produced in
the future.
Similar to the conclusion in the
previous systematic review, it can be
said that MSK injury is an important
health issue for dancers at all skill
levels. There is a high prevalence and
incidence of lower extremity, hip and
back injuries (Tables 1 and 2). Also,
there is preliminary evidence that
psychosocial and psychological issues,
such as stress affect injury frequency
and duration,18 and that broad-based
coping skill interventions decrease fre-
quency and duration of injury (how-
ever, these findings have only been
studied in Korean dance students,
and should be tested in dancers from
other cultures).19 History of a previous
lateral ankle sprain is associated with
an increased risk of opposite ankle
sprain, and fatigue may play a role in
ACL injury in dancers.10,11 There is
also preliminary evidence that acute
hamstring strains in dancers may be
caused by slow-stretching at end range
activities, seemingly affecting the ten-
don more than the muscle tissue, and
thus resulting in extensively delayed
return to pre-injury levels.9
Strengths and Limitations of
the Review
An important strength of the best
evidence synthesis approach used
here in reviewing the literature is
83
that the findings are limited to stud-
ies of superior scientific quality. This
methodology is described explicitly so
that others may reproduce or update
these findings. The systematic review
is restricted in this case, however, by
the quantity and quality of the avail-
able literature as of March 2008. All
too many studies continue to have
major scientific limitations and biases.
Conclusion and Future
Recommendations
Future research in this area of study
would benefit from clear and relevant
research questions being addressed
with appropriate study designs, from
the use of valid and meaningful case
definitions of injury and pain, and
from better reporting in accordance
with current scientific standards.
Specifically, studies regarding pre-
participation screening and its effec-
tiveness are needed. Validation studies
for the use of injury case definitions
in dancers would help to improve
current research methodology and
interpretation. A large prospective
international study of dance injuries
could shed light on the issue of long-
term effects of injury on dancers’
careers and quality of life, identify
risk factors for injury, and explore the
effect of national or cultural variables
such as access to health insurance or
healthcare. The issue of fatigue and
its relationship to injury in dancers
needs further exploration. Addition-
ally, randomized control trials explor-
ing interventions for musculoskeletal
injury are desperately needed in this
injury-prone population.
These authors continue to recom-
mend that attention be paid to issues
of bias and research methodology.1
This is extremely important for pro-
moting our knowledge of the epide-
miology, diagnosis, prognosis, treat-
ment, and prevention of MSK injuries
and pain in dancers. Future studies
should clearly identify their source
populations and be explicit in the
reporting of inclusion and exclusion
criteria. Injury recall periods should
be limited (e.g., up to six months) to
reduce recall bias when calculating
prevalence estimates. Incidence den-
84 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science
sity rates are preferable to cumulative
incidence proportions, as they provide
a more accurate measure of the popu-
lation at risk. Risk factors should be
studied in appropriate study designs,
with multivariable statistical analyses
to identify independent risk factors
after adjusting for other important
covariates.
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