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Risk Factors for Lower-Extremity Injuries in Female Ballet Dancers

A Systematic Review

L. Biernacki, Jessica, MD*; Stracciolini, Andrea, MD†,‡,§; Fraser, Joana, MD†,‡,§; J. Micheli, Lyle, MD†,‡,§; Sugimoto, Dai, PhD†,‡,§

doi: 10.1097/JSM.0000000000000707
Critical Review: PDF Only

Background: Ballet dancers have a high prevalence of injuries to the lower extremity. Many studies have investigated the relationship between dance injury and risk factors. However, risk factors for lower-extremity injury comparing recreational- and elite-level ballet dancers are scarce.

Objective: To systematically review available original studies to assess risk factors for lower-extremity injury in female ballet dancers between recreational and elite ballet dancers.

Data Sources: Five online databases [Web of Science, PubMed, OVID (Medline), EBSCO, and ProQuest] were searched systematically.

Study Selection: Included studies had an analytic study design published in the past 11 years and investigated an association between potential risk factors and lower-extremity injury in female ballet dancers.

Study Appraisal: Assessed independently by 2 reviewers using the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine.

Results: Seventeen studies were included. Alignment was a risk factor for lower-extremity injury in both recreational and elite ballet dancers. In elite ballet dancers, poor lumbopelvic movement control, inappropriate transversus abdominis contraction, decreased lower-extremity strength, and poor aerobic fitness were risk factors for lower-extremity injury. In recreational ballet dancers, hypermobility of the hip and ankle and longer training hours were risk factors for lower-extremity injury. Mean DB score was 15.94 (SD 1.57). The majority of studies were retrospective cohort studies or had poor follow-up, with 7 level 2b studies, 6 level 3b studies (cross-sectional), and 4 level 1b studies (prospective cohort with good follow-up).

Conclusions: Alignment was identified as a common risk factor for recreational and elite ballet dancers. Other risk factors differed between recreational ballet dancers and elite ballet dancers. Future studies are warranted to use a prospective study design, identify dance level–specific risk factors, and implement evidence-based prevention strategies.

*Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia;

The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts;

Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts; and

§Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts

Corresponding Author: Jessica Biernacki, MD, Melbourne Medical School, University of Melbourne, Parkville 3010, VIC, Australia (

The authors report no financial or conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received July 07, 2017

Accepted October 13, 2018

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