Abstract
Purpose
The literature on hip injuries in ballet dancers was systematically evaluated to answer (1) whether the prevalence of morphological abnormalities and pathology of hip injuries in dancers differs from the general population (2) if there are any specific risk factors which contribute to a higher rate of hip injury and (3) what are the outcomes of primary and secondary intervention strategies.
Methods
A systematic literature search of Medline, EMBASE and the Cochrane Library was undertaken for all literature relating to hip injuries in ballet dancers using the PRISMA guidelines. Reference lists were also searched for relevant literature. Clinical outcome studies, prospective/retrospective case series published between 1989 and October 2021 were included. Review articles (non-original data), case reports, studies on animals as well as book chapters were excluded.
Results
The search yielded 445 studies, of which 35 were included for final analyses after screening. This included 1655 participants, of which 1131 were females. The analyses revealed that damage at the chondrolabral junction and degenerative disease of the hip may develop at a higher rate in ballet dancers than in the general population (odds ratio > 1 in 15/18 cohorts). The intra-articular lesions were more frequently found in postero-superior region of the hip suggesting an alternative impingement mechanism. Furthermore, numerous risk factors specific for hip injury in ballet were highlighted amidst a wide body of literature which consistently reports risk factors for a more generic ‘dancer vulnerability’.
Conclusion
Ballet dancers may suffer from both higher rates of chondrolabral damage and degenerative disease in their hips. In contrast to other sports, the intra-articular lesions are more frequently found in postero-superior region of the hip. Future research clarifying the prevalence of osseous abnormalities and prevention strategies in dancers may be pivotal in delaying the development of hip disease in this cohort.
Level of evidence
Level IV.
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Introduction
Ballet is a traditional and highly technical form of dance which began in Italy before its export to France and Russia where it prospered during the Renaissance period [38]. The discipline combines athletic expertise with art to incite emotion in its audience. Dancers usually begin training at a very young age with males and females tending to take on more athletic and technical components of dance pieces, respectively [72].
Professional dance companies report that as many as 67–95% of their dancers are injured on annual basis [24]. Similarly, an injury incidence of 1.1 injuries per dancer per annum has been described in a 10-year retrospective study [63]. Ballet dancers take on a high athletic load. Dancers typically perform over 200 jumps during a class, the majority of which are landed unilaterally, exposing their lower limbs to ground reaction forces as high as nine times their body weight [20, 46]. A systematic review found dancers to suffer from a high rate of hip injury at 17.7%, of which 9 of 13 cohorts were ballet dancers alone [76]. In the selected cohorts, the incidence of hip injury was 0.09 per 1000 h. Another retrospective study found that 21.6% of injuries in elite adolescent ballet dancers occurred at the hip [24]. Seventy-five percent of injuries were overuse or non-traumatic in nature [69] with many aetiological factors proposed, including supra-physiological demands, extreme ranges of motion, improper technique, dance-specific biomechanics [34], morphological abnormalities and poor strength and conditioning. In addition to the short term consequences, repetitive injury predisposes dancers to long-term pain [67, 70], disability [67], a decreased quality of life [28] and increased rates of hip osteoarthritis (OA) [3, 16].
The combination of risk factors is unique to ballet. As such, the underlying pathology and consequent management of the ballet dancer’s hip requires a personalised approach. Primary prevention strategies recognise and alleviate risk factors for hip injury. Secondary and tertiary prevention strategies aim to delay disease onset and severity. They must include a comprehensive approach to the dancer’s injury, appreciating the unique demands of dance and consequent hip pathology. It has been assumed that correcting range of motion (ROM) limiting morphological abnormalities (impingement, dysplasia, version, ligament, and muscular tightness) would allow resumption of athletic activity, however, impingement characteristics and the specific requirements of joint motion vary greatly across different sports. In ballet dancers, it has been reported that impingement and degenerative change is likely to occur through supra-physiological range ROM, rather than aberrant bony morphology, although ROM limiting factors have been suggested to further vary between dancers [32].
For these reasons, the literature regarding hip injuries in ballet dancers was systematically evaluated to answer (1) whether the prevalence of morphological abnormalities and pathology of hip injuries in dancers differs from the general population (2) if there are any specific risk factors which contribute to a higher rate of hip injury and (3) what are the outcomes of primary and secondary intervention strategies. This may aid in the development of intervention strategies targeted towards the unique risk factors and pathology seen in the hips of ballet dancers.
Methods
Study design
A scoping review was designed based on the methodological frameworks outlined by Arksey and O’Malley [4] and advanced by others [13, 45]. PRISMA [78] and the Joanna Briggs Institute [61] guidelines were similarly followed.
Eligibility criteria
Clinical outcome studies, prospective/retrospective case series published between 1989 and October 2021 were included. Review articles (non-original data), case reports, studies on animals as well as book chapters were excluded. During the screening process, articles not specific to hip injury or ballet dance were excluded. Similarly, studies describing biomechanics with no reference to pathology were excluded.
Search strategy
A computer-assisted search of Embase, MEDLINE and the Cochrane Library for articles related to hip injuries in ballet dancers was completed on the 11th of October 2021 using the search terms “hip” and “ballet or ballerina”. The process for screening is detailed in Fig. 1 and the search strategy breakdown in Table 1. Two independent reviewers (YS and MP) completed the screening process, individually and blinded from one another, with any disagreements resolved by a third reviewer (VK).
Data extraction
All included studies were charted by two independent reviewers (YS and MP) and then discussed for synthesis. Data were extracted and summarised on Microsoft Excel using a template which reflected the study objectives. The extracted data included the key characteristics of the studies including the study authors, year of publication, population, design, age, sample size, hip-specific aetiological factors, prevalence of pathology and clinical outcomes.
Comparison of prevalence
Where possible, the prevalence of hip pathology in ballet dancers was compared to non-athletic controls to appreciate the hip pathology that the ballet dancers are pre-disposed to. This was possible where the study itself included a non-athletic control or where the prevalence was reported for similar populations in the literature. The control and population prevalence values were compared to values in ballet populations in order to determine an odds ratio for the development of a given pathology and given ballet participation [14, 15, 17, 23, 26, 27, 32, 36, 44, 62, 65, 77, 81]. This was not possible for the reported values of certain hip injury diagnoses due to the lack of comparative controls in the literature.
Results
The search yielded 445 studies, of which 35 were included for final analyses after screening. This included 1655 participants, of which 1131 were females (Fig. 1). Thirty-four of the included studies were observational, whilst one was of an in silico design.
Prevalence
The prevalence of degenerative hip pathology, osseous abnormalities and of specific hip injuries were recorded. This was compared to the prevalence of hip disease within the general population for the study populations displayed in Figs. 2, 3 and 4. Damage at the chondrolabral junction as well as degenerative disease appears to have a higher prevalence in ballet dancers than in the general population (Figs. 2, 3).
The prevalence of osseous abnormalities which may act to predispose to degenerative disease is reported in Fig. 4. Additionally, borderline dysplasia (LCEA 20°–25°) was reported at a high prevalence of 15–53% [33, 36, 44, 49, 54, 55]. Femoral version was also investigated in three studies. One study measured version using MRI which did not differ to femoral version in the general population [6], whilst the other studies assessed version using ultrasound or an inclinometer and did not include controls [29, 30].
The incidence of injuries sustained in ballet was reported both as point prevalence and as incidence per 1000 dance hours. Point prevalence is presented in Table 2. The prevalence of ligamentum teres injuries (55%) was higher than what tends to be reported for the general population [49], and higher than athletic controls who participate in tennis, netball or basketball(p = 0.001) [54]. The prevalence of hip joint effusion-synovitis was higher than in controls who participate in tennis, netball or basketball [50]. The prevalence of iliopsoas snapping was also higher than estimated within the general population [82]. The lack of wider population studies made it difficult to compare the incidence of injury per 1000 dance hours, which is presented in Table 3 [2, 43, 72].
Risk factors for hip injury in ballet
Risk factors specific to hip injury in ballet dancers are displayed in Table 4 [9]. Important factors which may have no effect on injury included generalised joint hypermobility [52,53,54, 57], BMI and the strength of the external rotators [21] and both obturator internus and externus [51]. Factors which have been reported to have an effect on hip injury include extreme ranges of motion and subluxation episodes leading to impingement and degenerative disease [5, 11, 19, 39]. The presence of impingement-type osseous morphology including cam and/or pincer morphology, low neck shaft angle (NSA < 125°) and acetabular version < 10° or > 20° also contributed to degenerative disease [56, 58, 59]. Hip pain was associated with reduced iliopsoas strength [22], low alpha angles [7], and female sex [72]. Increasing age was associated with ligamentum teres tears and degenerative hip disease, but also a lower rate of snapping hip. Finally, ballet as a discipline in itself influenced the frequency and location of soft tissue hip injury [73].
Outcomes for treatment of hip pathology in ballet dancers
The outcomes for specific interventions are displayed in Table 5. Additionally, two studies reported on the effect of previous self-reported hip injury on ballet dancers’ current quality of life. Gross et al. [28] reported a decreased HOOS QoL score (p = 0.0001), whilst Biernacki et al. [8] reported a significant negative correlation between iHOT-12 scores and the total number of past hip injuries.
Discussion
The most important finding of the present study was that that damage at the chondrolabral junction and degenerative disease of the hip may develop at a higher rate in ballet dancers than in the general population. Second, in contrast to other sports, the intra-articular lesions are more frequently found in postero-superior region of the hip. Snapping syndromes of the hip, effusion-synovitis and ligamentum teres injuries are also highly prevalent in ballet dancers. The data regarding FAI and dysplasia is more heterogenous and less consistent, requiring further evaluation. The concept of micro-instability and hip impingement-subluxation has been widely proposed and may be considered as an antecedent and consequence of other hip pathologies.
Numerous risk factors specific for hip injury in ballet were identified, amidst a wide body of literature which consistently reports risk factors for a more generic ‘dancer vulnerability’. This is an important step towards introducing preventative strategies for hip disease in dancers. With regards to outcomes, a 100% return to dance was described in conservative management of snapping hip [42], and a high rate was also described after peri-acetabular osteotomy [60] (PAO: 63%) and arthroscopy [80] (97%).
Degenerative disease
The consequences of hip OA are devastating, both functionally and economically. Studies reported both increased rates of chondrolabral junction damage (including ‘labral tears’, ‘cartilage lesions’, ‘articular cartilage lesions’) and of end-stage degenerative disease (Figs. 2, 3). The odds ratio was greater than one for 12/15 and 3/3 cohorts, respectively. As labral tears and articular cartilage lesions form a single layer which is likely to be damaged concurrently, the data were combined to form the chondrolabral junction. Damage to this layer may represent an early stage in the subsequent development of degenerative hip disease.
The only longitudinal study available, however, concluded that in the majority of dancers, cartilage defects do not progress over 5 years [58]. Despite this, those with cartilage lesions do become symptomatic albeit with participation being affected minimally. A further study with larger population sizes and longer follow-up would help clarify how the degenerative process develops and how it is exacerbated by ballet.
Osseous abnormalities
The incidence of osseous abnormalities such as FAI or dysplasia, however, is more variable and further investigation is required for definitive conclusions (Fig. 4). Despite this, dancers with FAI seem to suffer from greater rates of subluxation, instability, and pain. Where studies did not report a matched control population, the ballet population prevalence was compared to the prevalence reported in non-sporting populations within the literature. Future studies will benefit from matching ballet dancers with non-athletic controls for accurate comparison and determination of aetiology.
Bony abnormalities such as dysplasia may enhance the dancer’s ROM despite simultaneously decreasing hip-joint stability and predisposing the dancer to hip injury and early onset OA. Conversely, abnormalities which limit hip ROM such as FAI may exacerbate abutment between the femoral head–neck junction and the acetabular rim, thereby decreasing joint mobility. FAI [25, 35] and dysplasia [1, 75] have both been shown to increase the risk of osteoarthritis in athletic and general populations [83]. In ballet dancers, impingement-type morphology was related to cartilage defects [56] in one study and related to both labral tears and instability in another [66].
Whilst it is mechanistically attractive to attribute functional impairment and degenerative disease to these bony abnormalities, hip instability can be both an antecedent and consequence of other hip pathologies in the ballet population. In a professional ballet company, 89% of dancers had hip subluxation, 36% of which broke the suction seal of the hip joint [59]. In all movements, subluxation accompanied impingement highlighting the contribution of bony morphology in exacerbating instability related pathology. An association between impingement and micro-instability has been shown using ultrasound scans [66] and MRI [12]. Interestingly, impingement zones were located at the superior and postero-superior areas of the acetabulum which corresponds to the diagnosed damaged areas in the labrum. Furthermore, all of these hips were morphologically normal. Kolo et al. [39] and Duthon et al. [19] both illustrated similar findings with MRI reporting subluxation and a high prevalence of supero-posterior chondrolabral injury, without evidence of cam or pincer morphologies. It has therefore been theorised that intermittent subluxation induced incongruency may instigate an early degenerative process in the dancers’ hip. As such, the pathogenesis of FAI in ballet dancers seems to differ from that in other sporting populations, with a subluxation-impingement-type injury occurring which may be exacerbated by abnormal bony morphology. The chondral and labral pathology occurs in the postero-superior position of the hip, in comparison to the antero-superior position commonly observed in non-dancing athletes. The finite element modelling of Assassi et al. [5] provides further weight to this theory, evidencing cartilage hyper-compression in the postero-superior positions of the hip during extreme ROMs in ballet. These forces reflect the impinging hip identified in earlier studies and act as a mechanism for recurrent microtrauma during dance, ultimately leading to degenerative hip disease (Fig. 5).
Other causes of hip instability are also likely to play a role in the development of OA. In ballet dancers, a higher frequency of ligamentum teres tears are found in comparison to non-dance athletes (55%, p = 0.001) [54] and isolated LT tears have been associated with premature OA [64] and hip pain [10]. It is, however, unknown whether there is a role of other osseous factors, such as version, in contributing to hip instability and long-term degeneration in ballet dancers, and current suggestions are speculative.
Risk factors for hip injury
One of our studies’ main objectives was to investigate the ballet dancers’ vulnerability to hip injury. Many specific risk factors are presented in Table 4 although no clear patterns emerge, except for the subluxation-impingement mechanism described above. There is, however, a lack of clarity between specific risk factors for hip injury and risk factors for overall injury, or dancer vulnerability, throughout the literature. This distinction is important as the studies which focused on risk factors for overall injury yielded no quantitative data for our analysis. Some important risk factors identified for overall injury are discussed.
The majority of dance injuries are overuse, highlighting a lack of recovery in the training regimes of ballet dancers. Liederbach et al. [47] found that for dancers reporting injuries, 90% were “feeling tired at time of injury,” and roughly 80% were during high intensity work or when they had been dancing for more than five hours. Matters relating to fatigue such as training duration, hours, intensity, seasonal/transition times have all been associated with injury and so Lin et al. [48] propose that fatigue impairs muscle output and postural control, both of which increase the risk of injury. This risk may be exacerbated by factors such as inadequate strength and conditioning. Indeed, a study by Koutedakis et al. [41] noted that muscle flexibility, anaerobic power, and leg strength actually increased during a period of rest. In addition, Twitchett et al. found [79] that dancers with a lower level of fitness suffered from more injuries. Dancers may benefit from a more functional approach to strength and conditioning as dance training may not build a strong aerobic foundation in comparison to other sports [40, 68]. For example, a core strengthening program was shown to improve several fitness parameters such as jumping, proprioception, co-ordination and dynamic balance [37]. Similarly, a wider approach to the health of ballet dancers may help prevent injury as dysfunctional eating behaviour and/or menstrual abnormalities may contribute to injury and poor recovery. Dancers, especially ballerinas, have a higher prevalence of RED-S (formerly female athlete triad) than many other sports [18, 71].
In addition to the subluxation-impingement-type injury, extreme ranges of motion may push dancers to employ compensatory mechanisms along their kinetic chain. For example, the lack of a perfect turnout can result in overpronation (“rolling”), increased lumbar lordosis and torsion (“screwing”) at the knees. Extreme ranges of motion can also result in soft tissue adaptations and laxity which whilst perhaps initially being protective may eventually allow greater stress to be placed on the hip joint such as during subluxation episodes [19, 31, 39, 74].
Outcome of preventative strategies
Very few studies have investigated the efficacy of preventative strategies and return to dance in ballet populations. Sixty-three percent of young female dancers with dysplasia returned to dance after PAO. There was an overall improvement in their pain, sports-related and daily activities, and hip function assessed by the HOOS and the mHHS [60]. A high return to dance (97%) was also evident after hip arthroscopy with 63% returning to a better level of participation. Statistically significant increases were observed for HOOS and mHHS [80]. It is important to note that the cohort was predominantly female with, at most, borderline dysplasia, and no radiographic evidence of hip OA. The careful selection of patients with a treatable cam lesion and without significant joint laxity or dysplasia may be critical to ensuring good patient outcomes [12]. Similarly, in a mixed cohort of dancers, all returned to dance after conservative management for the treatment of iliopsoas syndrome [42]. Future study investigating the efficacy of preventative strategies on hip injury specifically are required to best guide future practise. Similarly, further work identifying and alleviating specific risk factors such as strength or core training for muscular imbalances may enable healthcare professionals to prevent hip injury in ballet dancers.
In addition to limitations already discussed, our scoping review included a wide variety of study designs and thus, the level of evidence was not constant. Additionally, a significant proportion of the literature is based on a small number of subjects who are reported on across numerous studies. Due to the heterogeneity of current studies, we were unable to perform a systematic review and meta-analysis of the prevalence of degenerative disease, bony abnormalities, or other hip pathology in ballet dancers. Similarly, the number of subjects with certain pathologies, such as hip OA, were low. Studies prior to 1989 were excluded due to the paucity of literature prior to this year.
Conclusion
Ballet dancers are a unique sporting population who combine artistry with athleticism. This study shows that ballet dancers may suffer from both higher rates of chondrolabral damage and degenerative disease in their hips. The intra-articular lesions are more frequently found in postero-superior region suggesting an alternative impingement mechanism. Longitudinal studies investigating specific risk factors for hip injury will be beneficial by establishing causal links and stimulating effective preventative and treatment strategies.
References
Agricola R, Heijboer MP, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Waarsing JH (2013) Pincer deformities and mild acetabular dysplasia: the relationship between acetabular coverage and development of hip OA in the nationwide prospective check cohort. Osteoarthr Cartil 21:S52–S53
Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M (2012) Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther 42:781–790
Angioi M, Maffulli GD, McCormack M, Morrissey D, Chan O, Maffulli N (2014) Early signs of osteoarthritis in professional ballet dancers: a preliminary study. Clin J Sport Med 24:435–437
Arksey H, O’Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol Theory Pract 8:19–32
Assassi L, Magnenat-Thalmann N (2016) Assessment of cartilage contact pressure and loading in the hip joint during split posture. Int J Comput Assist Radiol Surg 11:745–756
Bauman PA, Singson R, Hamilton WG (1994) Femoral neck anteversion in ballerinas. Clin Orthop Relat Res 302:57–63
Biernacki JL, D’Hemecourt PA, Stracciolini A, Owen M, Sugimoto D (2020) Ultrasound alpha angles and hip pain and function in female elite adolescent ballet dancers. J Dance Med Sci 24:99–104
Biernacki JL, Stracciolini A, Griffith KL, D’Hemecourt PA, Owen M, Sugimoto D (2018) Association between coping skills, past injury and hip pain and function in adolescent elite female ballet dancers. Phys Sportsmed 46:385–392
Blankenstein T, Grainger A, Dube B, Evans R, Robinson P (2020) MRI hip findings in asymptomatic professional rugby players, ballet dancers, and age-matched controls. Clin Radiol 75:116–122
Byrd JWT, Jones KS (2004) Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 20:385–391
Charbonnier C, Kolo FC, Duthon VB, Magnenat-Thalmann N, Becker CD, Hoffmeyer P, Menetrey J (2011) Assessment of congruence and impingement of the hip joint in professional ballet dancers: a motion capture study. Am J Sports Med 39:557–566
Coleman SH (2019) Editorial commentary: “dancing the hip away”—does joint laxity correlate with worse outcome in dancers undergoing hip arthroscopy for femoral acetabular impingement? Arthroscopy 35:1109–1110
Colquhoun HL, Levac D, O’Brien KK, Straus S, Tricco AC, Perrier L, Kastner M, Moher D (2014) Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol 67:1291–1294
Dagenais S, Garbedian S, Wai EK (2009) Systematic review of the prevalence of radiographic primary hip osteoarthritis. Clin Orthop Relat Res 467:623–637
Dickenson E, Wall PDH, Robinson B, Fernandez M, Parsons H, Buchbinder R, Griffin DR (2016) Prevalence of cam hip shape morphology: a systematic review. Osteoarthr Cartil 24:949–961
van Dijk C, Ernst H, Lim L, Poortman A, Marti RK (1995) Degenerative joint disease in female ballet dancers. Am J Sports Med 23:295–300
Doherty M, Courtney P, Doherty S, Jenkins W, Maciewicz RA, Muir K, Zhang W (2008) Nonspherical femoral head shape (pistol grip deformity), neck shaft angle, and risk of hip osteoarthritis: a case-control study. Arthritis Rheum 58:3172–3182
Dušek T (2001) Influence of high intensity training on menstrual cycle disorders in athletes. Croat Med J 42:79–82
Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, Coppens E, Hoffmeyer P, Menetrey J (2013) Correlation of clinical and magnetic resonance imaging findings in hips of elite female ballet dancers. Arthroscopy 29:411–419
Dworak LB, Gorwa J, Kmiecik K, Ma̧czyński J (2006) A study characterizing dynamic overloads of professional dancers. Biomechanical approach. Acta Bioeng Biomech 7:77–84
Emery S, Cook J, Ferrar K, Sophie; M, (2021) Deep hip external rotator muscle size in ballet dancers compared to non-dancing athletes, and associations to pain. Phys Ther Sport 51:58–64
Emery S, Cook J, Ferris A-R, Smith P, Mayes S (2019) Hip flexor muscle size in ballet dancers compared to athletes, and relationship to hip pain. Phys Ther Sport 38:146–151
Ezoe M, Naito M, Inoue T (2006) The prevalence of acetabular retroversion among various disorders of the hip. J Bone Jt Surg 88:372–379
Gamboa JM, Robert LA, Fergus A, Roberts LA, Maring J, Fergus A (2008) Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. J Orthop Sports Phys Ther 38:126–136
Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA (2003) Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 417:112–120
Giori NJ, Trousdale RT (2003) Acetabular retroversion is associated with osteoarthritis of the hip. Clin Orthop Relat Res 417:263–269
Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A (2010) Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey. J Bone Jt Surg 92:1162–1169
Gross C, Rho M, Aguilar D, Reese M (2018) Self-reported hip problems in professional ballet dancers: the impact on quality of life. J Danc Med Sci 22:132–136
Hafiz E, Hiller CE, Nicholson LL, Nightingale EJ, Grimaldi A, Refshauge KM (2016) Femoral shaft torsion in injured and uninjured ballet dancers and its association with other hip measures: a cross-sectional study. J Dance Med Sci 20:3–10
Hamilton D, Aronsen P, Løken JH, Berg IM, Skotheim R, Hopper D, Clarke A, Briffa NK (2006) Dance training intensity at 11–14 years is associated with femoral torsion in classical ballet dancers. Br J Sports Med 40:299–303
Hamilton WG, Hamilton LH, Marshall P, Molnar M (1992) A profile of the musculoskeletal characteristics of elite professional ballet dancers. Am J Sports Med 20:267–273
Han S, Kim RS, Harris JD, Noble PC (2019) The envelope of active hip motion in different sporting, recreational, and daily-living activities: a systematic review. Gait Posture 71:227–233
Harris JD, Gerrie BJ, Varner KE, Lintner DM, McCulloch PC (2016) Radiographic prevalence of dysplasia, cam, and pincer deformities in elite ballet. Am J Sports Med 44:20–27
Hendry D, Campbell A, Ng L, Harwood A, Wild C (2019) The difference in lower limb landing kinematics between adolescent dancers and non-dancers. J Danc Med Sci 23:72–79
Hoch A, Schenk P, Jentzsch T, Rahm S, Zingg PO (2020) FAI morphology increases the risk for osteoarthritis in young people with a minimum follow-up of 25 years. Arch Orthop Trauma Surg 141:1175–1181
Inoue K, Wicart P, Kawasaki T, Huang J, Ushiyama T, Hukuda S, Courpied JP (2000) Prevalence of hip osteoarthritis and acetabular dysplasia in French and Japanese adults. Rheumatology 39:745–748
Kalaycioglu T, Apostolopoulos NC, Goldere S, Duger T, Baltaci G (2020) Effect of a core stabilization training program on performance of ballet and modern dancers. J strength Cond Res 34:1166–1175
Kant M (2007) The Cambridge companion to ballet. In: Kant M (ed) Cambridge companion to ballet. Cambridge University Press, Cambridge
Kolo FC, Duc SR, Becker CD, Charbonnier C, Magnenat-Thalmann N, Pfirrmann CWA, Lubbeke A, Duthon VB, Hoffmeyer P, Menetrey J, Duc SR, Lubbeke A, Duthon VB, Magnenat-Thalmann N, Hoffmeyer P, Menetrey J, Becker CD (2013) Extreme hip motion in professional ballet dancers: dynamic and morphological evaluation based on magnetic resonance imaging. Skelet Radiol 42:689–698
Koutedakis Y, Jamurtas A (2004) The dancer as a performing athlete: Physiological considerations. Sport Med 34:651–661
Koutedakis Y, Myszkewycz L, Soulas D, Papapostolou V, Sullivan I, Sharp NCC (1999) The effects of rest and subsequent training on selected physiological parameters in professional female classical dancers. Int J Sports Med 20:379–383
Laible C, Swanson D, Garofolo G, Rose DJ (2013) Iliopsoas syndrome in dancers. Orthop J Sport Med. https://doi.org/10.1177/2325967113500638
Leanderson C, Leanderson J, Wykman A, Strender LE, Johansson SE, Sundquist K (2011) Musculoskeletal injuries in young ballet dancers. Knee Surg Sport Traumatol Arthrosc 19:1531–1535
Lee AJJ, Armour P, Thind D, Coates MH, Kang ACL (2015) The prevalence of acetabular labral tears and associated pathology in a young asymptomatic population. Bone Jt J 97-B:623–627
Levac D, Colquhoun H, O’Brien KK (2010) Scoping studies: advancing the methodology. Implement Sci 5:1–9
Liederbach M, Richardson M, Rodriguez M, Compagno J, Dilgen F, Rose D (2006) Jump exposures in the dance training environment: a measure of ergonomic demand. J Athl Train 41:S85
Liederbach MATC, Compagno JPTM (2001) Physiological aspects of fatigue-related injuries in dancers psychological aspects of fatigue-related injuries in dancers. J Dance Med Sci 5:116–120
Lin CF, Lee WC, Chen YA, Hsue BJ (2016) Fatigue-induced changes in movement pattern and muscle activity during ballet releve on demi-pointe. J Appl Biomech 32:350–358
Martin RL, McDonough C, Enseki K, Kohreiser D, Kivlan BR (2019) Clinical relevence of the ligamentum teres: a literature review. Int J Sports Phys Ther 14:459–467
Mayes S, Ferris A-R, Smith P, Cook J (2020) Hip joint effusion-synovitis is associated with hip pain and sports/recreation function in female professional ballet dancers. Clin J Sport Med 30:341–347
Mayes S, Ferris A-R, Smith P, Cook J (2018) Obturator externus was larger, while obturator internus size was similar in ballet dancers compared to nondancing athletes. Phys Ther Sport Off J Assoc Chart Physiother Sport Med England 33:1–6
Mayes S, Ferris A-R, Smith P, Garnham A, Cook J (2016) Similar prevalence of acetabular labral tear in professional ballet dancers and sporting participants. Clin J Sport Med 26:307–313
Mayes S, Ferris A-R, Smith P, Garnham A, Cook J (2016) Professional ballet dancers have a similar prevalence of articular cartilage defects compared to age- and sex-matched non-dancing athletes. Clin Rheumatol 35:3037–3043
Mayes S, Ferris AR, Smith P, Garnham A, Cook J (2016) Atraumatic tears of the ligamentum teres are more frequent in professional ballet dancers than a sporting population. Skelet Radiol 45:959–967
Mayes S, Ferris AR, Smith P, Garnham A, Cook J (2017) Bony morphology of the hip in professional ballet dancers compared to athletes. Eur Radiol 27:3042–3049
Mayes S, Smith P, Cook J (2018) Impingement-type bony morphology was related to cartilage defects, but not pain in professional ballet dancers’ hips. J Sci Med Sport 21:905–909
Mayes S, Smith P, Stuart D, Cook J (2020) Joint hypermobility does not increase the risk of developing hip pain, cartilage defects, or retirement in professional ballet dancers over 5 years. Clin J Sport Med 31:e342–e346
Mayes S, Smith P, Stuart D, Semciw A, Cook J (2020) Hip joint cartilage defects in professional ballet dancers: a 5-year longitudinal study. Clin J Sport Med 31:e335–e341
Mitchell RJ, Gerrie BJ, McCulloch PC, Murphy AJ, Varner KE, Lintner DM, Harris JD (2016) Radiographic evidence of hip microinstability in elite ballet. Arthroscopy 32:1038–1044e1
Novais EN, Thanacharoenpanich S, Seker A, Boyle MJ, Miller PE, Bowen G, Millis MB, Kim Y-J (2018) Do young female dancers improve symptoms and return to dancing after periacetabular osteotomy for the treatment of symptomatic hip dysplasia? J Hip Preserv Surg 5:150–156
Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB (2015) Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 13(3):141–146
Polat G, Şahin K, Arzu U, Kendirci AŞ, Aşık M (2018) Prevalence of asymptomatic femoroacetabular impingement in Turkey; cross sectional study. Acta Orthop Traumatol Turc 52:49–53
Ramkumar PN, Farber J, Arnouk J, Varner KE, Mcculloch PC (2016) Injuries in a professional ballet dance company: a 10-year retrospective study. J Dance Med Sci 20:30–37
Rao J, Zhou YX, Villar RN (2001) Injury to the ligamentum teres: Mechanism, findings, and results of treatment. Clin Sports Med 20:791–800
Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ (2012) Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med 40:2720–2724
Rodriguez M, Bolia IK, Philippon MD, Briggs KK, Philippon MJ (2019) Hip screening of a professional ballet company using ultrasound-assisted physical examination diagnosing the at-risk hip. J Dance Med Sci 23:51–57
Rönkkö R, Heliövaara M, Malmivaara A, Roine R, Seitsalo S, Sainio P, Kettunen J (2007) Musculoskeletal pain, disability and quality of life among retired dancers. J Danc Med Sci 11:105–109
Schantz PG, Åstrand PO (1984) Physiological characteristics of classical ballet. Med Sci Sports Exerc 16:472–476
Smith PJ, Gerrie BJ, Varner KE, McCulloch PC, Lintner DM, Harris JD (2015) Incidence and prevalence of musculoskeletal injury in ballet: a systematic review. Orthop J Sport Med 3:2325967115592621
Smith TO, de Medici A, Oduoza U, Hakim A, Paton B, Retter G, Haddad FS, Macgregor A (2017) National survey to evaluate musuloskeletal health in retired professional ballet dancers in the United Kingdom. Phys Ther Sport 23:82–85
Smolak L, Murnen SK, Ruble AE (2000) Female athletes and eating problems: a meta-analysis. Int J Eat Disord 27:371–380
Sobrino FJ, Guillén P (2017) Overuse injuries in professional ballet: influence of age and years of professional practice. Orthop J Sport Med 5:2325967117712704
Sobrino FJ, de la Cuadra C, Guillén P (2015) Overuse injuries in professional ballet: injury-based differences among ballet disciplines. Orthop J Sport Med 3:2325967115590114
Steinberg N, Hershkovitz I, Peleg S, Dar G, Masharawi Y, Heim M, Siev-Ner I (2006) Range of joint movement in female dancers and nondancers aged 8 to 16 years: anatomical and clinical implications. Am J Sports Med 34:814–823
Thomas GER, Palmer AJR, Batra RN, Kiran A, Hart D, Spector T, Javaid MK, Judge A, Murray DW, Carr AJ, Arden NK, Glyn-Jones S (2014) Subclinical deformities of the hip are significant predictors of radiographic osteoarthritis and joint replacement in women. A 20 year longitudinal cohort study. Osteoarthr Cartil 22:1504–1510
Trentacosta N, Sugimoto D, Micheli LJ (2017) Hip and groin injuries in dancers: a systematic review. Sports Health 9:422–427
Tresch F, Dietrich TJ, Pfirrmann CWA, Sutter R (2017) Hip MRI: prevalence of articular cartilage defects and labral tears in asymptomatic volunteers. A comparison with a matched population of patients with femoroacetabular impingement. J Magn Reson Imaging 46:440–451
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, MacDonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE (2018) PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 169:467–473
Twitchett E, Brodrick A, Nevill AM, Koutedakis Y, Angioi M, Wyon M (2010) Does physical fitness affect injury occurrence and time loss due to injury in elite vocational ballet students? J Dance Med Sci 14:26–31
Ukwuani GC, Waterman BR, Nwachukwu BU, Beck EC, Kunze KN, Harris JD, Nho SJ (2019) Return to dance and predictors of outcome after hip arthroscopy for femoroacetabular impingement syndrome. Arthroscopy 35:1101-1108.e3
Vahedi H, Aalirezaie A, Azboy I, Daryoush T, Shahi A, Parvizi J (2019) Acetabular labral tears are common in asymptomatic contralateral hips with femoroacetabular impingement. Clin Orthop Relat Res 477:974–979
Winston P, Awan R, Cassidy JD, Bleakney RK (2007) Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med 35:118–126
Wyles CC, Heidenreich MJ, Jeng J, Larson DR, Trousdale RT, Sierra RJ (2017) The John Charnley award: redefining the natural history of osteoarthritis in patients with hip dysplasia and impingement. Clin Orthop Relat Res 475:336–350
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Singh, Y., Pettit, M., El-Hakeem, O. et al. Understanding hip pathology in ballet dancers. Knee Surg Sports Traumatol Arthrosc 30, 3546–3562 (2022). https://doi.org/10.1007/s00167-022-06928-1
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DOI: https://doi.org/10.1007/s00167-022-06928-1