Osteoporosis International

, Volume 28, Issue 10, pp 2903–2912 | Cite as

Bone mineral density in vocational and professional ballet dancers

  • T. AmorimEmail author
  • Y. Koutedakis
  • A. Nevill
  • M. Wyon
  • J. Maia
  • J. C. Machado
  • F. Marques
  • G. S. Metsios
  • A. D. Flouris
  • N. Adubeiro
  • L. Nogueira
  • L. Dimitriou
Original Article



According to existing literature, bone health in ballet dancers is controversial. We have verified that, compared to controls, young female and male vocational ballet dancers have lower bone mineral density (BMD) at both impact and non-impact sites, whereas female professional ballet dancers have lower BMD only at non-impact sites.


The aims of this study were to (a) assess bone mineral density (BMD) in vocational (VBD) and professional (PBD) ballet dancers and (b) investigate its association with body mass (BM), fat mass (FM), lean mass (LM), maturation and menarche.


The total of 152 VBD (13 ± 2.3 years; 112 girls, 40 boys) and 96 controls (14 ± 2.1 years; 56 girls, 40 boys) and 184 PBD (28 ± 8.5 years; 129 females, 55 males) and 160 controls (27 ± 9.5 years; 110 female, 50 males) were assessed at the lumbar spine (LS), femoral neck (FN), forearm and total body by dual-energy X-ray absorptiometry. Maturation and menarche were assessed via questionnaires.


VBD revealed lower unadjusted BMD at all anatomical sites compared to controls (p < 0.001); following adjustments for Tanner stage and gynaecological age, female VBD showed similar BMD values at impact sites. However, no factors were found to explain the lower adjusted BMD values in VBD (female and male) at the forearm (non-impact site), nor for the lower adjusted BMD values in male VBD at the FN. Compared to controls, female PBD showed higher unadjusted and adjusted BMD for potential associated factors at the FN (impact site) (p < 0.001) and lower adjusted at the forearm (p < 0.001). Male PBD did not reveal lower BMD than controls at any site.


Both females and males VBD have lower BMD at impact and non-impact sites compared to control, whereas this is only the case at non-impact site in female PBD. Maturation seems to explain the lower BMD at impact sites in female VBD.


Associated factors Ballerinas Bone mass Elite dance Prevalence 



This work was supported by the Portuguese Foundation for Science and Technology [PhD grant number SFRH/BD/88585/2012]. Thanks are expressed to the radiology services of the Beatriz Angelo Hospital. A very special thanks goes to all participants who volunteered.

Compliance with ethical standards

Conflicts of interest



  1. 1.
    Harvey N, Dennison E, Cooper C (2010) Osteoporosis: impact on health and economics. Nat Rev Rheumatol 6(2):99–105CrossRefPubMedGoogle Scholar
  2. 2.
    Barrett-Connor E (1995) The economic and human costs of osteoporotic fracture. Am J Med 98(suppl2A):S3–S8CrossRefGoogle Scholar
  3. 3.
    International Society for Clinical Densitometry. Updated 2013 official positions for adult and pediatric. (Accessed May 2, 2016).
  4. 4.
    Nattiv A, Loucks AB, Manore MM et al (2007) American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exerc 39(10):1867–1882CrossRefPubMedGoogle Scholar
  5. 5.
    World Health Organization (2004) WHO scientific group on the assessment of osteoporosis at primary health care level. WHO Summary Meeting Report. WHO, BrusselsGoogle Scholar
  6. 6.
    Scofield KL, Hecht S (2012) Bone health in endurance athletes: runners, cyclists, and swimmers. Curr Sports Med Rep 11(6):328–334CrossRefPubMedGoogle Scholar
  7. 7.
    Pollock N, Grogan C, Perry M, Pedlar C, Cooke K, Morrissey D et al (2010) Bone mineral density and other features of the female athlete triad in elite endurance runners. Int J Sport Nutr Exerc Metab 20:418–426CrossRefPubMedGoogle Scholar
  8. 8.
    Amorim T, Wyon M, Maia J et al (2015) Prevalence of low bone mineral density in female dancers. Sports Med 45:257–268CrossRefPubMedGoogle Scholar
  9. 9.
    Burckhardt P, Wynn E, Krieg MA et al (2011) The effects of nutrition, puberty and dancing on bone density in adolescent ballet dancers. J Dance Med 15(2):51–60Google Scholar
  10. 10.
    Keay N, Fogelman I, Blake G (1997) Bone mineral density in professional female dancers. Br J Sports Med 31:143–147CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Dolyle-Lucas AF, Akers JD, Davy BM (2010) Energetic efficiency, menstrual irregularity, and bone mineral density in elite professional female ballet dancers. J Dance Med Sci 14(4):146–154Google Scholar
  12. 12.
    Litchtenbelt WD, Fogelholm M, Otteenheijm R et al (1995) Physical activity, body composition and bone density in ballet dancers. Br J Nutr 74:439–451CrossRefGoogle Scholar
  13. 13.
    Khan KM, Green RM, Saul A et al (1996) Retired elite female ballet dancers and nonathletic controls have similar bone mineral density at weightbearing sites. J Bone Miner Res 11(10):1566–1574CrossRefPubMedGoogle Scholar
  14. 14.
    To W, Wong M (2011) Does oligomenorrhea/amenorrhea and underweight imply athlete female trial syndrome in young female dancers? Eur J Sport Sci 11(5):335–340CrossRefGoogle Scholar
  15. 15.
    Bachrach LK, Hastie T, Wang MC et al (1999) Bone mineral acquisition in healthy Asian, Hispanic, black, and Caucasian youth: a longitudinal study. J Clin Endocrinol Metab 84:4702–4712PubMedGoogle Scholar
  16. 16.
    Cobb KL, Bachrach LK, Greendale G et al (2003) Disordered eating, menstrual irregularity and bone mineral density in female runners. Med Sci Sports Exerc 35:711–719CrossRefPubMedGoogle Scholar
  17. 17.
    Practice Committee of the American Society for Reproductive Medicine (2004) Current evaluation of amenorrhea. Fertil Steril 82:266–272CrossRefGoogle Scholar
  18. 18.
    Dimitriou L, Weiler R, Lloyd-Smith R, Turner A, Heath L, Nic J, Reid A (2014) Bone mineral density, rib pain and other features of the female athlete triad in elite light weight rowers. BMJ Open 4(2):1–9CrossRefGoogle Scholar
  19. 19.
    Crawford PB, Obarzaner E, Morrison J, Sabry ZI (1994) Comparative advantage of 3-day food records over 24-hour recall and 5-day food frequency validated by observation of 9- and 10-year-old girls. J Am Diet Assoc 94(6):626–630CrossRefPubMedGoogle Scholar
  20. 20.
    Duke PM, Litt IG, Gross RT (1980) Adolescent’ self-assessment of sexual maturation. Pediatrics 66(6):918–920PubMedGoogle Scholar
  21. 21.
    Pocock NA, Sambrook PN, Nguyen T et al (1992) Assessment of spinal and femoral bone density by dual X-ray absorptiometry: comparison of lunar and hologic instruments. J Bone Miner Res 7(9):1081–1084CrossRefPubMedGoogle Scholar
  22. 22.
    Hagiwara S, Engelke K, Yang S et al (1994) Dual X-ray absorptiometry forearm software: accuracy and intermachine relationship. J Bone Miner Res 9(9):1425–1427CrossRefPubMedGoogle Scholar
  23. 23.
    Fredericson M, Chew K, Ngo J, Cleek T, Kiratli J, Cobb K (2007) Regional bone mineral density in male athletes: a comparison of soccer players, runners and controls. Br J Sports Med 41(10):664–668CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Holroyd C, Cooper C, Dennison E (2008) Epidemiology of osteoporosis. Best Pract Res Clin Endocrinol Metab 22(5):671–685CrossRefPubMedGoogle Scholar
  25. 25.
    Guadalupe-Grau A, Fuentes T, Guerra B et al (2009) Exercise and bone mass in adults. Sports Med 39(6):439–468CrossRefPubMedGoogle Scholar
  26. 26.
    Greene DA, Naughton GA (2006) Adaptive skeletal responses to mechanical loading during adolescence. Sports Med 36(9):723–732CrossRefPubMedGoogle Scholar
  27. 27.
    Vainionpää A, Korpelainen R, Leppäluoto J, Jämsä T (2005) Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women. Osteoporosis Int 16(2):191–197CrossRefGoogle Scholar
  28. 28.
    Koutedakis Y, Sharp NC (2004) Thigh-muscles strength training, dance exercise, dynamometry, and anthropometry in professional ballerinas. J Strength Cond Res 18(4):714–718PubMedGoogle Scholar
  29. 29.
    Twitchett T, Angioi M, Koutedakis Y et al (2009) Video analysis of classical ballet performance. J Dance Med Sci 13(4):124–128PubMedGoogle Scholar
  30. 30.
    Bonewald LF (2011) The amazing osteocyte. J Bone Miner Res 26(2):229–238CrossRefPubMedGoogle Scholar
  31. 31.
    Bonewald LF, Johnson ML (2008) Osteocytes, mechanosensing and Wnt signaling. Bone 42:606–615CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Heinonen A, Sievänen H, Kannus P, Oja P, Pasanen M, Vuori I (2000) High-impact exercise and bones of growing girls: a 9-month controlled trial. Osteoporosis Int 11:1010–1017CrossRefGoogle Scholar
  33. 33.
    Koutedakis Y, Jamurtas AZ (2004) The dancer as a performing athlete: physiological considerations. Sports Med 34(10):651–661CrossRefPubMedGoogle Scholar
  34. 34.
    Bounjour J, Chevalley T (2014) Pubertal timing, bone acquisition, and risk of fracture throughout life. Endocr Rev 35(5):820–847CrossRefGoogle Scholar
  35. 35.
    Claessens ALM, Beunen GP, Nuyts MM et al (1987) Body structure, somatotype, maturation and motor performance of girls in ballet schooling. J. Sports Med 27:310–317Google Scholar
  36. 36.
    Peel N (2014) Disorders of bone metabolism. Surgery 33(1):15–20Google Scholar
  37. 37.
    Ma N, Gordon C (2012) Pediatric osteoporosis: where are we now. J Pediatr 161(6):983–990CrossRefPubMedGoogle Scholar
  38. 38.
    Hage RPE, Courteix D, Benhamou CL, Jacob C, Jaffré C (2009) Relative importance of lean and fat mass on bone mineral density in a group of adolescent girls and boys. Eur J Appl Physiol 105(5):759–764CrossRefPubMedGoogle Scholar
  39. 39.
    Ilich JZ, Kerstetter JE (2000) Nutrition in bone health revisited: a story beyond calcium. J Am Coll Nutr 19(6):715–737CrossRefPubMedGoogle Scholar
  40. 40.
    Eisman JA (1999) Genetics of osteoporosis. Endocr Rev 20(6):788–804CrossRefPubMedGoogle Scholar
  41. 41.
    Heaney RP, Abrams S, Dawson-Hughes B et al (2000) Peak bone mass. Osteoporosis Int 11:985–1009CrossRefGoogle Scholar
  42. 42.
    Ekegren CL, Quested R, Brodrick A (2014) Injuries in pre-professional ballet dancers: incidence, characteristics and consequences. J Sci Med Sport 17(3):271–275CrossRefPubMedGoogle Scholar
  43. 43.
    Allen N, Nevill AM, Brooks JH et al (2012) Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther 42(9):780–790CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2017

Authors and Affiliations

  • T. Amorim
    • 1
    • 2
    Email author
  • Y. Koutedakis
    • 2
    • 3
  • A. Nevill
    • 2
  • M. Wyon
    • 2
    • 4
  • J. Maia
    • 1
  • J. C. Machado
    • 5
  • F. Marques
    • 6
  • G. S. Metsios
    • 2
    • 3
  • A. D. Flouris
    • 3
  • N. Adubeiro
    • 7
  • L. Nogueira
    • 7
  • L. Dimitriou
    • 8
  1. 1.Centre of Research, Education, Innovation and Intervention in Sport, Faculty of SportsUniversity of PortoPortoPortugal
  2. 2.Faculty of Education, Health and WellbeingUniversity of WolverhamptonWalsallUK
  3. 3.School of Sports and Exercise SciencesUniversity of ThessalyTrikalaGreece
  4. 4.National Institute of Dance Medicine and ScienceLondonUK
  5. 5.i3S - Instituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
  6. 6.Faculty of PharmacyUniversity of PortoPortoPortugal
  7. 7.School of Health Technology of PortoPolytechnic Institute of PortoPortoPortugal
  8. 8.London Sport InstituteMiddlesex UniversityLondonUK

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