Physical Therapy in Sport 31 (2018) 42e51

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original Research

Risk factors for musculoskeletal injury in elite pre-professional

modern dancers: A prospective cohort prognostic study
Shaw Bronner a, b, *, Naomi G. Bauer a, c
a
ADAM Center, New York, NY, USA
b
Alvin Ailey American Dance Theater, New York, NY, USA
c
Department of Physical and Occupational Therapy, Duke University Health System, Durham, NC, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To examine risk factors for injury in pre-professional modern dancers.
Received 15 September 2016 Design: With prospectively designed screening and injury surveillance, we evaluated four risk factors as
Received in revised form categorical predictors of injury: i) hypermobility; ii) dance technique motor-control; iii) muscle tight-
22 December 2017
ness; iv) previous injury. Screening and injury data of 180 students enrolled in a university modern dance
Accepted 23 January 2018
program were reviewed over 4-yrs of training. Dancers were divided into 3-groups based on predictor
scores. Dance exposure was based on hours of technique classes/wk. Negative binomial log-linear ana-
Keywords:
lyses were conducted with the four predictors, p < 0.05.
Hypermobility
Motor-control
Results: Dancers with low and high Beighton scores were 1.43 and 1.22 times more likely to sustain
Muscle tightness injury than dancers with mid-range scores (p
0.03). Dancers with better technique (low or medium
Previous injury scores) were 0.86 and 0.63 times less likely to sustain injury (p ¼ 0.013 and p < 0.001) compared to those
with poor technique. Dancers with one or 2e4 tight muscles were 2.7 and 4.0 times more likely to
Level of evidence: sustain injury (p
0.046). Dancers who sustained 2e4 injuries in the previous year were 1.38 times more
Prospective cohort prognostic study
likely to sustain subsequent injury (p < 0.001).
Level 1
Conclusions: This contributes new information on the value of preseason screening. Dancers with these
risk factors may benefit from prevention programs.
© 2018 Elsevier Ltd. All rights reserved.

1. Introduction from small sample size, absence of exposure determination, need

Increasingly, best practice in dance healthcare includes presea-
son screening. However, the value of screening is questioned
(Cavanaugh, Miller, & Henneberger, 1995; Gamboa, Roberts,
Maring, & Fergus, 2008; Garrick, 2004). Recent efforts have been
made to develop, validate, and implement appropriate screening
tools that determine dancer readiness for the workloads to which
they are subjected (Allen, Nevill, Brooks, Koutedakis, & Wyon,
2013; Angioi, Metsios, Koutedakis, Twitchett, & Wyon, 2009;
Bowerman, Whatman, Harris, & Bradshaw, 2013; Bronner &
Rakov, 2014; Gamboa et al., 2008; Gibbs et al., 2006; Karim,
Millet, Massie, Olson, & Morganthaler, 2011; Kropa, Green,
Harwood, Close, & LaNoue, 2015; Twitchett et al., 2010). Studies
that seek to identify risk factors in dancers have generally suffered
* Corresponding author. ADAM Center, 322 W. 52 St. #199, New York, NY 10101-
0199, USA.
E-mail address: sbronner@alvinailey.org (S. Bronner).
for prospective study design, diverse injury definitions, and self-
report of injury rather than diagnoses determined by healthcare
professionals. We continue to lack prospective evidence of injury
risk factors (Caine, Goodwin, Caine, & Bergeron, 2015). There is
weak evidence suggesting insufficient or forced turnout, excessive
joint mobility, imbalances in strength and flexibility, poor postural
alignment or motor-control, aerobic conditioning, disordered
eating, and previous injury may be contributors to injury
(Bowerman, Whatman, Harris, & Bradshaw, 2015; Bronner,
Ojofeitimi, & Spriggs, 2003; Coplan, 2002; Roussel et al., 2009)..
Emphasis is placed on the aesthetics of flexibility in dance,
pushing lower extremity postures to increasing extremes (Daprati,
Iosa, & Haggard, 2009). Without proper training and conditioning,
such extremes can result in joint and ligament injuries. These
forces, along with genetic predisposition, have important ramifi-
cations in the dancer with generalized joint laxity (GJL) or hyper-
mobility. Previous studies focused on the prevalence of
hypermobility in ballet (Klemp & Learmonth, 1984; McCormack,
Briggs, Hakim, & Grahame, 2004; Sanches, Oliveira, Osorio,

https://doi.org/10.1016/j.ptsp.2018.01.008
1466-853X/© 2018 Elsevier Ltd. All rights reserved.
 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51
Crippa, & Martin-Santos, 2015) and contemporary dancers (Roussel
et al., 2009; Ruemper & Watkins, 2012), but none were found
studying modern dancers. Prospective studies demonstrating the
relationship of dancers to increased risk for injury due to increased
GJL are lacking.
Several other risk factors that may contribute to injury such as
muscle tightness, motor control, and previous injury, have been
proposed in dancers and other athletes. Restrictions in hamstring
and quadriceps flexibility were risk factors in athletes who devel-
oped hamstring and quadriceps injuries, or patellar tendinitis
(Witvrouw, Bellemans, Lysens, Danneels, & Cambier, 2001;
Witvrouw, Danneels, Asselman, D'Have, & Cambier, 2003). Other
studies reported no relationship between poor muscle flexibility
and increased injury risk (Engebretsen, Myklebust, Holme,
Engebretsen, & Bahr, 2010; Yeung, Suen, & Yeung, 2009). Due to
conflicting evidence, given the preoccupation of dancers concern-
ing muscle extensibility, and to distinguish muscle tightness from
joint hypo- or hypermobility, we analyzed flexibility in lower ex-
tremity muscle groups.
Faulty dance technique involving poor alignment and motor-
control are frequently cited as possible risk factors for injury
(Ahonen, 2008; Steinberg et al., 2012). Some screens include dance-
specific movements (Gamboa et al., 2008; Steinberg et al., 2012).
Others have employed core-specific tests (Roussel et al., 2009) or
the Functional Movement Screen (FMS) (Allen et al., 2013; Kropa
et al., 2015). In our injury clinics, we found that correction of er-
rors in technique frequently eliminated musculoskeletal problems.
Therefore, we selected common dance-specific movements for
analysis of dance technique as a risk factor for injury.
Finally, previous injury is the most frequently cited risk for
future injury (Fulton et al., 2014; Hagglund, Walden, & Ekstrand,
2006). This can include re-injury to the same tissue or injury
elsewhere due to unaddressed muscle imbalances or altered pro-
prioception, motor-control, and biomechanics.
The identification of risk factors for musculoskeletal injury is
critical to reduce the incidence of injuries and related personal,
organizational, and financial costs. The purpose of this study was to
examine four risk factors for injury in pre-professional modern
dancers. We hypothesized dancers at increased risk for musculo-
skeletal injury would have: i) high or low Beighton scores for
hypermobility; ii) decreased dance technique motor-control; iii)
Fig. 1. Beighton test. Abbreviations: Metacarpal ephalangeal, MCP.
43
muscle tightness (decreased lower extremity muscle flexibility);
and iv) increased history of injury in the previous year.
2. Methods
2.1. Study design
This study was a retrospective review of a prospectively
designed cohort study. Determination of the a priori sample size
needed for Goodness-of-fit, X2 tests, effect size ¼ 0.40, df ¼ 4, po-
wer (1-b) ¼ 0.95, and a ¼ 0.05, was N ¼ 117 participants. This study
was approved by the University Internal Review Board for retro-
spective analysis of data.
2.2. Participants
Participants were enrolled in a university Bachelor of Fine Arts
(BFA) pre-professional modern dance program. This program is
part of a larger organization, including two professional modern
dance companies and an annual enrollment of 250 students in the
pre-professional division. Inclusion criteria were students enrolled
in the BFA program for the full four years who underwent freshman
screening. Students were accepted by audition and met the scho-
lastic requirements of the affiliated university. Exclusion criteria
were dancers enrolled in other programs at this organization.
Screens from seven incoming classes of BFA students, 183 dancers
from 2005 to 2011 and Injury Clinic (IC) data representing 4-yrs for
each freshman cohort, were reviewed. Three dancers were
excluded from analysis due to incomplete screening forms, result-
ing in 180 dancers (inclusion rate 98%).
2.3. Protocol
The protocol for this investigation consisted of data collection in
two parts, preseason screening and 4-yrs of IC data compiled with
standardized data collection forms. The preseason screening tests
and Injury Clinics were conducted by the same in-house physical
therapists (PTs), specializing in dance medicine.
Prior to undergoing preseason screening, participants filled out
a demographics questionnaire and were asked to list diagnosis and
date of prior injuries sustained during the previous year. The
44 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51
preseason screen included measurement of height, weight, blood
pressure, postural analysis, turnout, joint range of motion (ROM),
muscle strength, muscle flexibility, balance, GJL measured by the
Beighton test, aerobic fitness, and dance technique analysis. For this
study, we focused on four areas as possible risk factors: i) hyper-
mobility (GJL); ii) dance technique; iii) muscle flexibility; and iv)
injury during the previous year.
The 9-point Beighton test was used to determine GJL (Fig. 1).
This scale is considered the gold standard literature for assessing
hypermobility when combined with the Brighton Criteria to di-
agnose Benign Joint Hypermobility Syndrome (BJHS) (McCormack
et al., 2004). Our inter-rater reliability of the Beighton was high
(r ¼ 0.86) (Garlington, Ojofeitimi, & Bronner, 2006) and comparable
to that reported by Boyle et al. (Boyle, Witt, & Riegger-Krugh, 2003;
Hicks, Fritz, Delitto, & Mishock, 2003).
During dance technique motor control testing, dancers were
asked to perform three movements: i) second position grand plie
;
veloppe
ii) de
a
 la seconde (stance side); and iii) saute
s (jumps) in
first position (Fig. 2). Using visual inspection, the examiners
recorded a binary decision on a check-list for whether there was
motor control/alignment problem or no problem in each of the
following areas: i) lumbo-pelvic stability; ii) hip turnout; iii) knee

in second; B. De
Fig. 2. Dance technique motor control test. A. Grand plie
Prob; Within normal limits, WNL.
alignment; iv) ankle-foot alignment; and v) in de veloppe

a la sec-
onde: ‘sitting into the stance hip’. The examiner walked around the
dancer to evaluate frontal and sagittal plane alignment as the
sequence was repeated several times. A total of 13 points could be
accrued [grand plie
(4), de
veloppe

a la seconde (5), jumps (4)]. For
example, during second position grand plie
, if the knees are not
aligned with the hips and ankles (e.g. in dance vernacular, ‘rolling
in’), it is judged a ‘problem’. Higher scores (9e13 points) indicated
poor technique, medium scores were 5e8 points, and low scores
(0e4 points) indicated good technique. An unpublished study of
inter-rater reliability of the two examiners demonstrated high
reliability (r ¼ 0.88).
Four lower extremity muscles groups were evaluated for flexi-
bility restrictions: hamstrings, iliopsoas, rectus femoris, and ilioti-
bial band (ITB). Hamstring length was assessed by measuring ROM
of the passive straight leg raise (SLR) with the limb in neutral
rotation. The SLR test was selected because dancers, more flexible
than non-dancers, max out with the knee extension test. For this
test, each dancer lay in supine with the contralateral limb resting
on the plinth. The limb was flexed at the hip passively, with the
knee extended, while the pelvis was stabilized, until mild tissue
resistance was detected and measured according to standard
veloppe

a la seconde; C. Saute

s (jumps) in first position; D. Scoring worksheet. Abbreviations: Problem,
 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51 45

Table 1 them. Exposure hours were calculated per grade year and used to
Demographics and screening characteristics. determined injuries (inj)/1000-hrs dance exposure. Injury data
Gender Female Male Total were analyzed by number of discrete injuries/dancer. MAI and TL-
# Subj (%) 140 (78) 40 (22) 180 (100)
inj/1000-hrs exposure were calculated for the total 4-yr period.
Age (yrs) 18.10 ± 0.53 18.28 ± 1.04 18.15 ± 0.68 Additionally, MAI and TL-inj/1000-hrs exposure were separated
Dance (yrs)* 11.90 ± 3.21 7.20 ± 3.65 10.89 ± 3.85 into overuse and traumatic rates.
Height (m)* 1.65 ± 0.07 1.75 ± 0.05 1.67 ± 0.07 Dancers were divided into triad groupings based on their four
Mass (kg)* 56.27 ± 5.87 66.85 ± 7.95 58.57 ± 7.72
risk factor scores: i) composite Beighton scores grouped as high
BMI* 20.63 ± 1.41 21.77 ± 2.34 20.87 ± 1.72
Previous Injury 0.74 ± 0.87 0.42 ± 0.68 0.67 ± 0.85 (5e9), medium (3e4), and low (0e2); ii) technique motor-control
scores grouped as high (9e13), medium (5e8), and low (0e4),
Beighton 3.80 ± 2.01 2.85 ± 1.87 3.59 ± 2.08
SLR ( )** 105 ± 23 95 ± 18 102 ± 22
with higher scores indicating poorer performance; iii) muscle
HS 38% 23% 41% tightness scores classified into 0, 1, or 2e4 muscle tightness; and iv)
Psoas 14% 10% 13% previous injuries were grouped into 0, 1, or 2e4 injuries.
RF 90% 87% 90%
ITB 93% 95% 94%
LE Tightness 89% 87% 88%
2.4.1. Statistical analyses
Dance technique 6.58 ± 3.27 6.36 ± 3.31 6.53 ± 3.27 Separate t-tests compared genders in screening data including
age, height, mass, years of dance training, SLR, and previous injury
Abbreviations: number of subjects, # subj; percent, %; years, yrs; meters, m; kilo-
grams, kg; Body Mass Index, BMI; straight leg raise, SLR; Hamstrings, HS; Rectus (p < 0.05).
femoris, RF; Iliotibial Band, ITB. Annual hours of exposure were converted to the natural log and
Note: HS tight if
90 for lowest HS; % is positive for tight. used as the offset variable for further analyses. Injury data were
*p
0.001.
analyzed using discrete MAI and TL-inj per dancer per grade year.
**p ¼ 0.012.
Generalized Estimating Equations (GEE) negative binomial logistic
regressions were conducted to account for over-dispersion and
goniometer positions. Iliopsoas, rectus femoris and ITB were non-independence (time-dependent data corrected using an
assessed with the modified Thomas and Ober tests. Measurement autoregressive correlation structure) of the data (IBM SPSS version
of SLR, Ober and modified Thomas tests demonstrated high intra- 21.0, IBM Corp, Armonk, NY). We conducted separate analyses of
tester and inter-tester reliability (r  0.88) (Cejudo, Sainz de four categorical predictors of injury, i) Beighton score; ii) technique
Barbara, Ayala, & Santonja, 2015; Clapis, Davis, & Davis, 2008; motor-control; iii) muscle tightness; and iv) previous injury, with
Ferber, Kendall, & McElroy, 2010; Neto, Jacobsohn, Carita, & the dependent variables MAI, traumatic-MAI, overuse-MAI, and TL-
Oliveira, 2015; Reese & Bandy, 2003). Restrictions in flexibility inj, and determined incident rate ratios (IRR) with 95% confidence
were assessed using a ‘tight’ or ‘not tight’ binary decision. Rectus intervals (CI), p < 0.05. Secondary analyses were conducted to
femoris was considered tight if knee flexion was
90 . Iliopsoas determine relationships between hamstring injuries v. hamstring
was considered tight if the hip did not reach 0 of hip extension. ITB ROM and Beighton category and joint injury v. joint subluxation/
was considered tight if the hip remained abducted. Hamstrings dislocation.
were considered tight if ROM was
90 .
In-house IC were available for 4-hrs every weekday throughout 3. Results
fall and spring semesters to all pre-professional dancers for injury
triage, evaluation and treatment, or cross training. All visits were 3.1. Preseason screening
documented by the physical therapists using a standardized intake
form. Dancers’ mean age was 18.14 ± 0.68 yrs with 10.89 ± 3.85 years
of dance training. There were differences between genders in
height, mass, BMI, years of dance training, (p ¼ 0.001) but not age
2.4. Data analysis (Table 1). Dancers reflected a mixture of ethnicities: 89 (50%)
Caucasian, 54 (30%) African American, 15 (8%) Hispanic, 9 (5%)
Demographic information and screening results were entered Asian, and 13 (7%) Other. There were no differences between gen-
into an electronic database. We examined two definitions of ders in Beighton or dance technique scores, lower extremity
musculoskeletal injury, i) medical attention injury (MAI) defined as a tightness, or previous injuries. Females demonstrated increased
discrete injury evaluated by a PT at IC between 2005 and 2015; and SLR compared to males (p ¼ 0.012).
ii) time-loss injury (TL-inj), a subset of MAI, that involved one or
more days of time-loss from dancing following the event. Due to
the robustness of the MAI data set, this definition of injury was Table 2
Overview of injuries.
selected as our primary dependent variable.
Injuries were classified by body region, tissue category, and side. MAI TL-inj
If a dancer had multiple injuries or bilateral complaints at the same Total inj 1672 288
visit, each was recorded as a discrete injury. A second complaint of # injured dancers* 500 180
the same injury within 8-wks was considered a recurrent injury Dancers with 0 inj* 220 540
(Fuller et al., 2006) and was not documented as an additional Dancers >4 inj 128 4
Dancers >10 inj 6 0
injury. Injuries were coded for traumatic or overuse mechanism of Inj/dancer 2.32 0.40
injury. Overuse injury was defined as injury of gradual onset Inj/inj dancer 3.34 1.59
resulting from repetitive micro-trauma and traumatic injury was
Inj/1000-hrs 3.28 0.57
defined as resulting from a specific macro-traumatic event (Roos & Traumatic inj/1000-hrs 0.49 0.19
Marshall, 2014). Overuse inj/1000-hrs 2.80 0.37
Dance exposure was calculated based on dancers’ hours of Abbreviations: Medical Attention Injury, MAI; time-loss injury, TL-inj; Number, #;
technique classes/wk (1.5-hrs/class) in a 34-wk school year. Re- Injury, Inj; hours, hrs.
hearsals were not included as there was no mechanism to track *Note: 180 dancers * 4yrs ¼ 720 total.
46 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51

3.2. Rate and distribution of injuries Table 3

Predictors of medical attention and time-loss injury.

There were 1672 discrete MAI during this study (Table 2). Of the Predictor % Inj Significance IRR (95% CI)
180 dancers, 84% sustained at least one MAI during their 4-yrs. MAI
Mean MAI per dancer was 2.32 and TL-inj was 0.40. Injury per Beighton category
injured dancer was 3.34 and 1.59 for MAI and TL-inj respectively. High (5e9) 38 0.03 1.221 (1.076-1.386)
There were 3.28 MAI/1000-hrs exposure and 0.57 TL-inj/1000-hrs Low (0e2) 35 0.02 1.427 (1.258-1.617)
Medium (3,4) 27 1
exposure, with 2.3-times as many overuse injuries compared to
traumatic injuries. Distribution of MAI by body region found the MAI
greatest percentage of injuries occurred in the lower extremity Technique category
Low (0e4) 31 0.013 0.865 (0.772-0.970)
(64.7%). The majority occurred at the hip/groin (20.17%), knee Medium (5e8) 37 <0.001 0.632 (0.561-0.711)
(12.29%) and foot (12.17%) areas (Fig. 3). High (9e13) 32 1

MAI
3.3. Injury predictors Muscle tightness category
2-4 muscles 89 0.001 4.107 (1.783-9.461)
3.3.1. Hypermobility 1 muscle 9 0.046 2.695 (1.016-7.150)
0 muscles 2 1
Mean Beighton scores were 3.59 ± 2.08 (range 0e9). We
examined dancers with joint-related injuries and found that the MAI
majority (77.6%) had either low (40.7%) or high (36.9%) Beighton Previous injury category
2-4 injuries 14 <0.001 1.378 (1.209-1.571)
scores. We further separated joint instability diagnoses and found
1 injury 33 ns 1.050 (0.942-1.171)
that the majority (88.3%) were dancers with low (34.8%) or high 0 injuries 53 1
(43.5%) Beighton scores.
TL-inj
Dancers with low and high Beighton scores were 43% and 22% Beighton category
more likely to sustain MAI [low: IRR ¼ 1.427 (CI ¼ 1.258e1.617), High (5e9) 38 0.004 1.545 (1.146-2.083)
p ¼ 0.02; high: IRR ¼ 1.221 (CI ¼ 1.076e1.386), p ¼ 0.03] compared Low (0e2) 35 0.004 1.569 (1.151-2.138)
to those with medium scores (Table 3). Dancers with low and high Medium (3,4) 27 1
Beighton scores were 1.5-times as likely to sustain TL-inj as those Abbreviations: Injury, inj; Incident Rate Ratio, IRR; Confidence Interval, CI; Medical
with medium scores [low: IRR ¼ 1.545 (CI ¼ 1.146e2.083), Attention Injury, MAI; Time-loss Injury, TL_inj; Not significant, ns.
p ¼ 0.004; high: IRR ¼ 1.569 (CI ¼ 1.151e2.138), p ¼ 0.004].

the other sequences. Lumbo-pelvic stability was a common prob-

3.3.2. Technique motor-control
Mean technique motor-control scores were 6.53 ± 3.27 (range
0e13). Dancers with medium (5e8) and low (0e4) technique
scores, indicating better alignment, were 37% and 13% less likely to
sustain MAI respectively [medium: IRR ¼ 0.632 (CI ¼ 0.561e0.711),
p < 0.001; low: IRR ¼ 0.865 (CI ¼ 0.772e0.970), p ¼ 0.013]
compared to those with high scores (9e13), indicating poor tech-
nique. Control of developpe
a la seconde alignment of the stance
limb was difficult in the greatest number of students compared to
lem across all movements.
3.3.3. Muscle tightness
The majority of dancers (89%) had two or more tight muscle
groups. Tight ITB was the most common finding (92%), followed by
tight rectus femoris (88%), hamstrings (41%), and iliopsoas (13%).
Dancers with one or more tight muscles were 2.7e4 times more
likely to sustain MAI [one muscle: IRR ¼ 2.695 (CI ¼ 1.016e7.150),
p ¼ 0.046; 2e4 muscles: IRR ¼ 4.107 (CI ¼ 1.783e9.461), p ¼ 0.001]
(Table 3). Further investigation of the relationship of muscle
tightness to overuse and traumatic MAI found no association be-
tween tightness and traumatic injury. However dancers with 1e4
restricted muscles were 3.5e5 times more likely to sustain subse-
quent overuse MAI [one muscle: IRR ¼ 3.58 (CI ¼ 1.356e9.359),
p ¼ 0.010; 2e4 muscles: IRR ¼ 4.997 (CI ¼ 2.169e11.511), p < 0.001].

3.3.4. Previous injury

Dancers who sustained 2e4 injuries in the year prior to entering
the program were 38% (IRR ¼ 1.378 (CI ¼ 1.209e1.571), p < 0.001)
more likely to sustain subsequent MAI compared to those with no
previous injuries.

4. Discussion

This analysis contributes robust support for the value of pre-

Fig. 3. Distribution of medical attention injuries (MAI) by body region.
season screening in pre-professional modern dancers. Our results
support all four hypotheses regarding injury predictors of muscu-
loskeletal injury. Dancers with either high or low Beighton scores,
high composite technique scores reflecting decreased technique
motor-control, lower extremity muscle tightness, or two or more
previous injuries in the past year were more likely to sustain
musculoskeletal injury. These findings are discussed in more detail
below.
 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51
4.1. Rate and distribution of injuries
We reported injuries/1000-hrs exposure using two definitions:
MAI and TL-inj. Our MAI exposure rates were higher than MAI re-
ported in pre-professional ballet dancers (Gamboa et al., 2008;
Leanderson et al., 2011). The 0.57 TL-inj/1000-hrs exposure were
higher than that reported for our organization's two professional
modern dance companies (0.16 TL-inj/1000-hrs) (McBride, Gill, &
Bronner, 2015; Ojofeitimi & Bronner, 2011), but lower than re-
ported for a mixed cohort of pre-professional dancers (1.5e4.0/
1000-hrs) (Echegoyen, Acun ~ a, & Rodríguez, 2010), pre-professional
ballet students (0.77e1.38 TL-inj/1000-hrs exposure) (C. L. Ekegren,
Quested, & Brodrick, 2014; Gamboa et al., 2008) and professional
ballet companies (0.90e4.04 Tl-inj/1000-hrs) (Allen et al., 2013;
Ramkumar, Farber, Arnouk, Varner, & McCoullock, 2016).
Many of our incoming students were primarily trained in ballet.
The modern dance vocabulary of Horton, in parallel positions, and
Graham technique, with extensive floorwork, were unfamiliar to
many of the dancers. The number of technique classes (12e15/wk)
was more dancing than most of our students were accustomed to.
The higher injury rates in these student dancers compared to our
professional dancers may be explained by this high number of daily
technique classes. Our professional dancers take only one tech-
nique class per day dance prior to approximately 6-hrs of rehearsals
or performances. Lower injury rates in this student cohort,
compared to pre-professional ballet students, may be due to
training in diverse styles. The varied movements may balance
stresses to the body, rather than only dancing en pointe or turned
out.
Consistent with previous dance injury data (Bronner & Wood,
2016; C.L. Ekegren, Quested, & Brodrick, 2014; Nilsson,
Leanderson, Wykman, & Strender, 2001; Ramkumar et al., 2016;
Stubbe et al., 2015; Walden, Hagglund, & Ekstrand, 2005), the
majority of injuries were to the lower extremity. We found fewer
foot and ankle injury frequencies in this cohort compared to those
reported in pre-professional and professional ballet dancers
(Gamboa et al., 2008; Nilsson et al., 2001; Ramkumar et al., 2016).
Higher foot-ankle injuries may be found in ballet populations due
to extensive work en pointe. While our female dancers take pointe
classes, this is limited to specific pointe and partnering classes. We
found higher hip and groin injuries compared to professional
modern dancers or other pre-professional or professional ballet
dancers (Bronner & Wood, 2016; C.L. Ekegren et al., 2014; Nilsson
et al., 2001; Ramkumar et al., 2016). This may be related to unfa-
miliar techniques such as Graham and Horton. Further analysis of
the types of injuries sustained in this cohort is currently underway.
4.2. Beighton score and injury
Classification scores for hypermobility using the Beighton scale
range from 4 (McCormack et al., 2004; Roussel et al., 2009;
Ruemper & Watkins, 2012) and 5 (Gannon & Bird, 1999; Klemp
& Learmonth, 1984) in dance literature, to 3 and  5 in sports
literature (Hardin, Voight, Blackburn, Canner, & Soffer, 1997;
Russek, 2000). We classified 5 hypermobility scores as ‘high’ in
order to test the theory initially proposed by Krivickas and Feinberg
(Krivickas & Feinberg, 1996) suggesting that athletes at opposite
ends of the spectrum (those with extreme tightness or ligamentous
laxity) were more likely to sustain injury. Deighan (Deighan, 2005)
subsequently reiterated that this might also be the case in dancers,
proposing that dancers categorized by Beighton score would reflect
a U-shaped curve in which dancers with high or low scores are
more likely to sustain injury than those with medium scores.
However, no research was conducted to investigate this theory. The
U-shaped theory is supported by the results of our research (Fig. 4).
47
In addition to increased injuries in the high and low Beighton
groups, we also found that dancers in the high and low Beighton
groups were more likely to sustain joint-related injuries than the
medium group. The high Beighton score group accounted for the
majority of joint instability diagnoses.
In this cohort, 38% of dancers were hypermobile using the 5
cutoff scores, while 44% were classified as hypermobile using 4
cutoff scores. Using a cutoff score 4, Klemp and Learmonth (1984)
reported a hypermobility rate of 9.5% in a professional ballet
company, while McCormack et al. (2004) reported that 90% of
student and professional ballet dancers were hypermobile. Studies
of adolescent ballet dancers reported a 70% rate of hypermobility
(cutoff 4) (Longworth, Fary, & Hopper, 2014). Ruemper and
Watkins (2012) reported 69% of college age contemporary dance
students were hypermobile. Dancers with hypermobility may have
decreased proprioception placing them at greater risk for injury
(Keer & Simmonds, 2011). Regardless of the cutoff, dancers’
hypermobility exceeds that of the general population with hyper-
mobility prevalence ranging from 10 to 30%, depending on age,
gender, and race (Larsson, Baum, & Mudholkar, 1987; Larsson,
Baum, Mudholkar, & Srivastava, 1993).
4.3. Technique motor-control and injury
Technique motor-control was determined based on perfor-
mance of three dance-specific movements; skills performed mul-
tiple times within technique classes on a daily basis. Dancers who
were unable to maintain good alignment and control during these
movements were classified as having decreased motor-control.
Dancers with poor technique motor-control were more likely to
sustain injury.
Skill level has been associated with injury in athletes with
conflicting findings. Some studies report that athletes with low skill
levels are at increased risk of injury (Koch et al., 2016; Peterson,
Junge, Chomiak, Graf-Baumann, & Dvorak, 2000), while others
report those at high skill level are at greater risk (Hopper, Hopper, &
Elliott, 1995; Wijdicks et al., 2014). Comparisons are difficult
because there may be differences due to sport, exposure, or how
skill is defined. Skill may be based on playing league and not on
specific performance tests. Researchers focusing on neuromuscular
control of the lumbo-pelvic region reported dancers with poor
control were at increased risk for lower extremity and back injury
(Roussel et al., 2009). In this analysis, we found lumbo-pelvic sta-
bility was a common problem across all technique movements in
the screen although we did not test this lumbo-pelvic control as a
specific predictor. Recently the FMS was tested on dancers, but its
usefulness as a screening tool to predict injury is unclear, as
1.6
1.4
1.2
Incident Rate Ratio
1
0.8
0.6
0.4
0.2
0
Low (0-2) Medium (3,4) High (5-9)
Beighton Score
Fig. 4. Beighton category and incident rate ratio of medical attention injuries.
48 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51
consistent cutoff scores remain undetermined (Allen et al., 2013;
Kropa et al., 2015). Furthermore, the FMS may be inappropriate
for the desired motor skills necessary to be successful in dance
because ballet and modern training alter the way dancers jump,
balance, and perform ‘squats’ which affect FMS scoring (Kiefer et al.,
2011; Volkerding & Ketcham, 2013).
Only a few researchers have reported assessing dance technique
motor-control as part of their screening process (Bowerman,
Whatman, Harris, Bradshaw, & Karin, 2014; Gamboa et al., 2008;
Molnar & Esterson, 1997; Steinberg et al., 2012). Gamboa et al.
(2008) found no technique differences between injured and non-
injured dancers, however they did not examine dance technique
as a predictor using logistic regression analyses (Bahr & Holme,
2003). In a younger population of adolescent ballet dancers,
Bowerman et al. (2014) measured pelvis and knee alignment in two
dance-specific movements (fondu, a single knee demi-plie
, and
temps leve
, a single leg jump) and reported a relationship between
poor alignment and increased overuse injury risk.
We focused on motor-control of basic movements common to
technique classes, assessing lumbo-pelvic stability, and hip, knee,
ankle alignment in bilateral and single limb stances. We selected
this analysis because when encountering injury at the student level,
we found that the most effective intervention was correction of
alignment and motor-control of their basic dance movements. Due
to time constraints in our screening protocol, we only evaluated
one limb, selecting the dancer's non-preferred side, and did not
conduct any continuous measures. Currently, a large inter- and
intra-rater reliability study of the dance technique station is
underway.
4.4. Muscle tightness and injury
Similar to sports, the majority of ballet and modern dance in-
juries occur in the lower extremity (Caine et al., 2015; McBride
et al., 2015; Roberts, Nelson, & McKenzie, 2013; Solomon,
Solomon, Micheli, & McGray, 1999). A number of studies have re-
ported muscle tightness as a risk factor for injury in athletes,
including figure skaters (Okamura et al., 2014), soccer players
(Witvrouw et al., 2003) and collegiate athletes (Krivickas &
Feinberg, 1996). No studies demonstrating a relationship between
changes in muscle tightness, following intervention, with decreases
in injury were found. A confounder is previous history of muscle
strains, such as hamstring strains, that may remain restricted in
flexibility and/or strength and require a multivariate model to
control for interactions (Bahr & Holme, 2003). Another caveat in
studying muscle tightness is that passive measures may not reflect
dynamic flexibility (Gleim & McHugh, 1997). The dynamic flexi-
bility requirements of a given sport can differ greatly. The need for
force production and flexibility in a basketball jump shot differ
greatly from that in a grand jete
or leap.
Increased flexibility is a requirement for dancers compared to
most sports (Hamilton, Hamilton, Marshall, & Molnar, 1992).
Working at the extremes of motion required in ballet and modern
dance puts muscles at the greatest mechanical disadvantage
(Kumar, 2001), with increased risk for injury. In our findings,
dances with two or more tight muscle groups were at four times
the risk for injury. We were surprised to find that 88% of the
dancers had two or more tight muscle groups. These results suggest
that, as much time as dancers spend stretching, they may be not be
optimizing when, how, or which muscles they stretch.
4.5. Previous injury
Previous history of injury is the most frequently cited risk factor
for future injury in dancers (Kenny, Whittaker, & Emery, 2016) and
other athletes (Emery, 2003; Fulton et al., 2014; Hagglund et al.,
2006; Murphy, Connolly, & Beynnon, 2003), and is substantiated
by these results. These include ankle (Hiller, Refshauge, Herbert, &
Kilbreath, 2008; Tyler, McHugh, Mirabella, Mullaney, & Nicholas,
2006) and hamstring strains (Askling, Lund, Saartok, &
Thorstensson, 2002; Askling, Saartok, & Thorstensson, 2006;
Woods et al., 2004). Athletes and dancers may be returning to
sport or dance-specific activities too soon with insufficient reha-
bilitation. Regional interdependence theory suggests the need to
address not only the injured area but also proximal and distal
deficits that may place the individual at risk for subsequent injury
(Wainner, Whitman, Cleland, & Flynn, 2007).
4.6. Limitations
Gender specific analyses were not performed due to a small
sample size. Male dancers comprised only 22% of this population,
which did not provide adequate power to determine gender dif-
ferences in the four injury predictors (Bahr & Holme, 2003).
Due to time constraints, we did not use the Brighton criteria to
assess GJL (Grahame, Bird, & Child, 2000). Rather, we used the 9-pt
Beighton test, one of two major measures within the Brighton
criteria. All dance and sports studies we reviewed focused on
Beighton scores to define hypermobility. The intensive monitoring
and availability of IC services may appear to introduce bias. How-
ever, clinic services were provided to 350 or more students per
semester from all pre-professional programs. BFA students
accounted for only 20% of these students. Selection of the specific
predictive risk factors was developed in this retrospective review of
the data therefore clinicians were unaware of the purpose of this
study.
Rehearsal hrs/wk could not be tracked which may have resulted
in reduced exposure hour calculations and therefore inflated
injury/1000-hrs rates. Other studies have employed similar in-
house screening and physical therapy clinic data to determine
injury risk factors in elite pre-professional ballet students (Gamboa
et al., 2008).
We hold a post-screen workshop to explain dancers’ screening
results and instruct students in appropriate warm-up and
stretching. This may have biased our injury rates downwards.
However, this information is common knowledge and is regularly
shared in technique classes and at IC but often is not implemented
habitually by the students. The strength of this study is the pro-
spective cohort study design with standardized data collection,
measuring potential risk factors before injuries occurred, ample
number of participants, similar hours of exposure across the cohort,
and use of logistic regression models to calculate incident rate ra-
tios (Bahr & Holme, 2003).
4.7. Clinical implications
We recommend the adoption of a standardized screening in-
strument and injury surveillance tracking for pre-professional
dancers, administered by trained healthcare professionals. In
2006, professional dance companies in the United States adopted a
common post-hire pre-season health screen developed by the
Medical Taskforce of Dance/USA (Southwick, Gibbs, Bronner, &
Cassella, 2008), demonstrating that consolidation of efforts are
feasible. They are currently working toward adoption of a common
surveillance system.
During screening, Beighton, muscle flexibility, and dance tech-
nique tests can be easily administered by trained individuals to
screen dancers for injury risk. Sport healthcare professionals
recommend tailoring pre-participation screens to the specific
population (e.g. sport, age and level of player) (Batt, Jaques, & Stone,
 S. Bronner, N.G. Bauer / Physical Therapy in Sport 31 (2018) 42e51
2004). Similarly, our pre-professional dance screen differs from our
professional screen to accommodate age, training and technique.
Study of new hires in physically strenuous jobs reported that post-
hire screening was predictive of injury and those that ‘passed’ had
47% lower injury rates (Anderson & Briggs, 2008).
Dancers can be instructed in the most appropriate ways to
reduce their risk of injury. Further focus on the relationship be-
tween specific impairments related to previous injury is necessary
to ensure proper rehabilitation. Remediation regarding joint pro-
tection, muscle stretching, and technique alignment are critical
areas that must be addressed. In our experience, dancers frequently
skip warming up and go straight to stretching. To decrease re-
injury, we recommend that students with more than 1-injury in
the previous year attend boot-camp to address lumbo-pelvic,
hamstrings-adductors, and calf-Achilles tendon problems. This
would include assessment of jumping and implementation of
eccentric training progressions (Arnason, Andersen, Holme,
Engebretsen, & Bahr, 2008; Hagglund, Walden, & Ekstrand, 2007).
Finally, dancers frequently grip their muscles in attempts to force
themselves into required shapes. This results in poor compensatory
patterns. Part of boot-camp should involve use of turnout discs at
the barre to educate the dancer in proper alignment and use of the
deep external rotators.
5. Conclusions
This research contributes positive information on the value of
preseason screening. Four risk factors demonstrated significance as
injury predictors. Dancers with either high or low Beighton scores,
technique scores reflecting decreased technique motor-control,
lower extremity muscle tightness, or two or more injuries in the
past year were more likely to sustain MAI. High or low Beighton
scores were also significant predictors for TL-inj. This study also
provides new information on TL-inj/1000-hrs exposure for a pre-
professional modern dance cohort, which was lower than those
found in ballet students. Future investigation following the
implementation of new prevention programs will be necessary to
ensure their effectiveness in decreasing injury rates.
Ethical approval
This study was approved by Northeastern University Internal
Review Board under protocol number 13-08-31.
Funding
None declared.
Conflicts of interest
None declared.
Acknowledgements
The authors thank the dancers and administrative staff of The
Ailey School for their participation and support of the annual pre-
season screening and Injury Clinic programs. We also thank all the
physical therapists, athletic trainers, dance faculty, and other vol-
unteers that assisted us in our annual screenings, particularly Dana
Hash-Campbell, Sheyi Ojofeitimi, Sara Rakov-Aingorn, and Tracye
Rawls Martin. We thank Katherine Pierce, Brielle Barclay, Daniella
De La Fuente, Emily Coombes, Jessica Galvez, and Lily Wood for
their assistance in data entry.
49
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