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Understanding hip pathology in ballet dancers

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.

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).

Fig. 1
figure 1

The search processes

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).

Fig. 2
figure 2

The prevalence of hips with damage at the chondrolabral junction (including articular lesions and labral tears). Odds ratio and confidence interval values for individual studies given by comparing these values with those in the general population. Prevalence measured a per hip and b per person. Chondrolabral damage at the hip joint seems to occur at a higher rate in ballet dancers than in the general population

Fig. 3
figure 3

The prevalence of degenerative disease of the hip in ballet. Odds ratio and confidence interval values for individual studies given by comparing these values with those in the general population. Prevalence measured a per hip and b per person. Degenerative disease at the hip joint seems to occur at a higher rate in ballet dancers than in the general population

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].

Fig. 4
figure 4

a The prevalence of osseous abnormalities in ballet dancers’ hips. Odds ratio and confidence interval values of individual studies given by comparing these values with those of the general population. Prevalence measured a per hip and b per person. Osseous abnormalities at the hip joint occurs at a similar rate in ballet dancers than in the general population

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).

Fig. 5
figure 5

Schematic diagram indicating the postero-superior impingement identified across four studies. Red: this area represents the position of cartilage damage reported by Duthon et al., Kolo et al., and Charbonnier et al., Green: this area represents peak compression forces identified by Assassi and Thalman using in silico modelling of ballet hip movements. Blue: this area represents the location of impingements modelled to occur in extremes of motion achieved in ballet by Charbonnier et al. and Assassi and Thalman

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.

Table 1 Search strategy
Table 2 Point prevalence of injuries sustained in ballet
Table 3 Incidence of injuries sustained in ballet
Table 4 Risk factors specific for hip injuries in ballet dancers
Table 5 Outcomes for specific interventions reported in ballet dancers

References

  1. 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

    Google Scholar 

  2. 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

    PubMed  Google Scholar 

  3. 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

    PubMed  Google Scholar 

  4. Arksey H, O’Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol Theory Pract 8:19–32

    Google Scholar 

  5. 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

    PubMed  Google Scholar 

  6. Bauman PA, Singson R, Hamilton WG (1994) Femoral neck anteversion in ballerinas. Clin Orthop Relat Res 302:57–63

    Google Scholar 

  7. 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

    PubMed  Google Scholar 

  8. 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

    PubMed  Google Scholar 

  9. 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

    CAS  PubMed  Google Scholar 

  10. Byrd JWT, Jones KS (2004) Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 20:385–391

    PubMed  Google Scholar 

  11. 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

    PubMed  Google Scholar 

  12. 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

    PubMed  Google Scholar 

  13. 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

    PubMed  Google Scholar 

  14. Dagenais S, Garbedian S, Wai EK (2009) Systematic review of the prevalence of radiographic primary hip osteoarthritis. Clin Orthop Relat Res 467:623–637

    PubMed  Google Scholar 

  15. 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

    CAS  Google Scholar 

  16. 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

    PubMed  Google Scholar 

  17. 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

    PubMed  Google Scholar 

  18. Dušek T (2001) Influence of high intensity training on menstrual cycle disorders in athletes. Croat Med J 42:79–82

    PubMed  Google Scholar 

  19. 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

    PubMed  Google Scholar 

  20. 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

    Google Scholar 

  21. 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

    PubMed  Google Scholar 

  22. 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

    PubMed  Google Scholar 

  23. 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

    Google Scholar 

  24. 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

    PubMed  Google Scholar 

  25. 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

    Google Scholar 

  26. Giori NJ, Trousdale RT (2003) Acetabular retroversion is associated with osteoarthritis of the hip. Clin Orthop Relat Res 417:263–269

    Google Scholar 

  27. 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

    Google Scholar 

  28. 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

    Google Scholar 

  29. 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

    PubMed  Google Scholar 

  30. 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

    CAS  PubMed  PubMed Central  Google Scholar 

  31. 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

    CAS  PubMed  Google Scholar 

  32. 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

    PubMed  Google Scholar 

  33. 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

    PubMed  Google Scholar 

  34. 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

    Google Scholar 

  35. 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

    PubMed  Google Scholar 

  36. 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

    CAS  PubMed  Google Scholar 

  37. 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

    PubMed  Google Scholar 

  38. Kant M (2007) The Cambridge companion to ballet. In: Kant M (ed) Cambridge companion to ballet. Cambridge University Press, Cambridge

  39. 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

    Google Scholar 

  40. Koutedakis Y, Jamurtas A (2004) The dancer as a performing athlete: Physiological considerations. Sport Med 34:651–661

    Google Scholar 

  41. 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

    CAS  PubMed  Google Scholar 

  42. Laible C, Swanson D, Garofolo G, Rose DJ (2013) Iliopsoas syndrome in dancers. Orthop J Sport Med. https://doi.org/10.1177/2325967113500638

    Article  Google Scholar 

  43. 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

    Google Scholar 

  44. 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

  45. Levac D, Colquhoun H, O’Brien KK (2010) Scoping studies: advancing the methodology. Implement Sci 5:1–9

    Google Scholar 

  46. 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

    Google Scholar 

  47. 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

    Google Scholar 

  48. 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

    PubMed  Google Scholar 

  49. 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

    PubMed  PubMed Central  Google Scholar 

  50. 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

    PubMed  Google Scholar 

  51. 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

    Google Scholar 

  52. 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

    PubMed  Google Scholar 

  53. 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

    PubMed  Google Scholar 

  54. 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

    Google Scholar 

  55. 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

    PubMed  Google Scholar 

  56. 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

    PubMed  Google Scholar 

  57. 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

    Google Scholar 

  58. 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

    Google Scholar 

  59. 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

  60. 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

    PubMed  PubMed Central  Google Scholar 

  61. 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

    PubMed  Google Scholar 

  62. 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

    PubMed  Google Scholar 

  63. 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

    PubMed  Google Scholar 

  64. Rao J, Zhou YX, Villar RN (2001) Injury to the ligamentum teres: Mechanism, findings, and results of treatment. Clin Sports Med 20:791–800

    CAS  PubMed  Google Scholar 

  65. 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

    PubMed  Google Scholar 

  66. 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

    PubMed  Google Scholar 

  67. 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

    Google Scholar 

  68. Schantz PG, Åstrand PO (1984) Physiological characteristics of classical ballet. Med Sci Sports Exerc 16:472–476

    CAS  PubMed  Google Scholar 

  69. 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

    Google Scholar 

  70. 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

    CAS  PubMed  Google Scholar 

  71. Smolak L, Murnen SK, Ruble AE (2000) Female athletes and eating problems: a meta-analysis. Int J Eat Disord 27:371–380

    CAS  PubMed  Google Scholar 

  72. Sobrino FJ, Guillén P (2017) Overuse injuries in professional ballet: influence of age and years of professional practice. Orthop J Sport Med 5:2325967117712704

    Google Scholar 

  73. 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

    Google Scholar 

  74. 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

    PubMed  Google Scholar 

  75. 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

    CAS  Google Scholar 

  76. Trentacosta N, Sugimoto D, Micheli LJ (2017) Hip and groin injuries in dancers: a systematic review. Sports Health 9:422–427

    PubMed  PubMed Central  Google Scholar 

  77. 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

    PubMed  Google Scholar 

  78. 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

    PubMed  Google Scholar 

  79. 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

    PubMed  Google Scholar 

  80. 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

    PubMed  Google Scholar 

  81. 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

    PubMed  Google Scholar 

  82. 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

    PubMed  Google Scholar 

  83. 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

    PubMed  Google Scholar 

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As first author, YS drafted the manuscript and contributed to all aspects of the paper. MP and VK contributed significantly to the design, data analysis and manuscript development process. OE, RE, AN and EA contributed significantly to study design and data accumulation and final edits of the paper. All authors read and approved the final manuscript.

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Correspondence to Vikas Khanduja.

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Singh, Y., Pettit, M., El-Hakeem, O. et al. Understanding hip pathology in ballet dancers. Knee Surg Sports Traumatol Arthrosc (2022). https://doi.org/10.1007/s00167-022-06928-1

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Keywords

  • Ballet
  • Dancer
  • Hip
  • Injury
  • Pathology
  • Prevalence
  • FAI
  • Dysplasia
  • Outcomes.