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Abstract

Background: Ballet dancers are deemed at a great risk of overuse injuries due to high training loads, biomechanical requirements related to technique, maturation, hypermobility, and injury history. Sex differences are known from previous studies, which have mainly focussed on all injury types particularly on the foot and ankle complex. Aims: To critically analyse the literature for differences between female and male professional and pre-professional ballet dancers in terms of prevalence, incidence, severity, and anatomical location of overuse injuries. Methods: The search for published original peer-reviewed articles from 2000 to July 2025 was conducted on PubMed, Web of Science, and Embase. The protocol was registered on PROSPERO (CRD420251104232). Screening, data extraction, and analysis were conducted by multiple independent reviewers according to PRISMA guidelines. The Newcastle-Ottawa Scale and AXIS were used for quality assessments including risk of bias. Meta-analysis of the difference between males and females for prevalence and anatomical location was calculated using a log-odds ratio; incidence was analysed using effect size. The Grade tool was used to assess certainty. Results: Nine cohort and 2 cross-sectional studies were included (n = 1650 dancers). The foot and ankle complex were the most affected region in both sexes. No significant difference was found in the prevalence, incidence, or anatomical location of overuse injuries in females compared to males (P > .05). Only 2 studies with contrasting findings were included for severity. All studies but 1 were of high quality; The certainty was very low. Discussion: Findings indicated that overall, the prevalence, incidence, and anatomical location of overuse injuries do not differ between male and female ballet dancers. However, these results refer to pre-professional and professional ballet dancers only. The findings of this study should be interpreted with caution due to low certainty score assessed by using the GRADE tool.

Keywords

ballet dancers sex differences overuse injuries epidemiology dance medicine

Key Points

The foot and ankle complex is the most affected area by overuse injuries in both male and female ballet dancers.

No significant differences have been found between male and female ballet dancers in the prevalence, incidence, or anatomical location of overuse injuries.

The limited number of studies examining the severity of overuse injuries highlights the need for further high-quality, original research to enable meaningful comparisons.

Introduction

Overuse injuries develop gradually when a specific part of the body is subjected to repeated stress or strain.¹ Mechanisms associated with overuse injuries include repetitive movements,² inadequate recovery time, and excessive loading.³ Ballet dancers may be at an increased risk of overuse injuries due to a multifactorial complex consisting of, low energy availability and high energy expenditure, and in some dancers reduced bone mineral density.⁴ However, bone mineral density profiles in male and female ballet dancers have been reported to be heterogenous.⁴ Whilst reduced bone mineral density has been documented in subgroups⁵ characterised by low energy availability or menstrual dysfunction, it is not a universal feature amongst all ballet dancers.^4,5 The prevalence of overuse injuries is generally more common than traumatic injuries in ballet.⁶ However, pre-professionals have been reported to be prone to overuse injuries because of technical issues like jumping asymmetry⁷ before optimal conditioning, whereas professionals are at risk because of longer training hours, higher performance demands, and cumulative physical stress over time.⁸ Anatomical differences are also apparent in locations of overuse injuries; lower extremity injuries were more common in both professional⁹ and pre-professional ballet dancers.¹⁰ Moreover, in pre-professional dancers, conditions such as tenoperiostitis of the tibia and ankle impingement and tendinopathies were the most common overuse injuries.¹⁰ Comparatively, professional dancers, experience a wider anatomical distribution of injuries in addition to the lower limb⁹ due to the greater cumulative exposure.¹¹

With regards to sex, differences in the prevalence of certain overuse injuries, such as stress fractures, are known in other athletic populations.¹² This can be attributed to sex-specific factors with 1 example being hormonal variations and menstrual irregularities.¹³ Menstrual dysfunctions can disrupt oestrogen levels, resulting in diminished bone mineral density and impaired musculoskeletal health; this increases the susceptibility to overuse injuries such as stress fractures.¹⁴ However, whether these mechanisms result in comparable sex-related differences in ballet dancers remain uncertain due to the limited and inconsistent evidence.^4,9 Other sex differences have been reported in terms of severity⁴ and anatomical location.¹⁵ Male dancers lost 9 days to injury in comparison to 3 days lost by female professional ballet dancers.⁶ Anatomically, male dancers have been found to be more likely to sustain overuse injuries in the knee joint whereas female dancers in the foot and ankle.¹⁵

Overall, the current body of evidence offer limited direct comparisons of overuse injury epidemiology between male and female ballet dancers. One review⁹ has previously investigated the prevalence of overuse injuries, Smith et al⁹ observed that females had a significantly higher prevalence of overuse injuries in comparison to males. Although other systematic reviews^11,16 have investigated musculoskeletal injuries in pre-professional ballet dancers, they did not solely focus on overuse injuries as the main outcome. Furthermore, Smith et al⁹ focussed on prevalence, revealing a considerable gap for other epidemiological outcomes like incidence, severity, and anatomical location.

Therefore, the aim of this systematic review was to analyse differences in the prevalence, incidence, severity, and anatomical location of overuse injuries between male and female ballet dancers at a professional and pre-professional level. This will allow identification of differences which can lead to clinical implications such as greater awareness of sex-specific factors in overuse injury like menstrual cycles during musculoskeletal screening in female dancers.

Methods

This review was conducted according to the PRISMA (2020) guidelines for systematic reviews¹⁷ and registered on PROSPERO (CRD420251104232).

Eligibility Criteria

The eligibility criteria were modelled in a Population, Exposure, Comparator, Outcome (PECO) format.¹⁸ The population were professional and pre-professional male and female ballet dancers, and the exposure was ballet training. Amateur/recreational ballet dancers were excluded. The comparison was between male and female ballet dancers, and the outcomes included prevalence, incidence, severity, and anatomical location of overuse injuries.

Detailed information on the inclusion and exclusion criteria can be seen in Table 1.

Table 1.

Eligibility Criteria. Inclusion and Exclusion Criteria Used for Selecting Studies on Overuse Injuries in Ballet Dancers.

Inclusion criteria	Exclusion criteria
Pre-professional ballet dancers Professional ballet dancers Male and female Any type of overuse injury Studies that include overuse injuries in males and females Cohort studies Case-control studies Cross-sectional studies Randomised control trials Non-randomised control trials	Amateur/recreational ballet dancers Other dance styles Other aesthetic sports Systematic reviews Conferences, abstracts, and PHD theses Lay webpages Lay articles Case studies Studies not differentiating overuse and acute injury

Information Sources

Studies were identified and retrieved across 3 electronic databases (PubMed, Web of Science, and Embase). The search was conducted on 01 July 2025 by 4 independent reviewers (R.R., A.W., S.T., T.R.). Citation searching was conducted by 4 independent reviewers (R.R., A.W., S.T., T.R.) on 06 July 2025 and identified 2 further studies.

Search Strategy

The search strategy evolved from the PECO format of the eligibility criteria. Synonyms were used with these keywords to expand the reach of the search terms (Table 2). This systematic review did not focus on 1 specific type of overuse injury; keywords like “Medial Tibial Stress Syndrome” and “Achilles Tendinopathy’ were also included. This allowed the initial search to be broader. However, a timeframe filter was set; only studies from and after 2000 were included.

Table 2.

Keywords Used in Search Strategy. List of Keywords Applied in the Literature Search to Identify Relevant Studies on Female and Male Ballet Dancers and Overuse Injuries.

Ballet	AND	Men	AND	Women	AND	Overuse injury
OR		OR		OR		OR
Ballet dancers		Males		Females		Stress injury
		OR		OR		OR
		Boys		Girls		Repetitive strain injury
						OR
						Stress fractures
						OR
						Medial tibial stress syndrome
						OR
						Shin splints
						OR
						Patellofemoral pain syndrome
						OR
						Anterior knee pain
						OR
						Metatarsal fracture
						OR
						Lower back pain
						OR
						Spondylolysis
						OR
						Spondylolisthesis
						OR
						Sesamoid fracture
						OR
						Achilles tendonitis
						OR
						Achilles tendinopathy
						OR
						Stress reaction injury

Selection Process

Studies were added to Covidence¹⁹ software to streamline and aid the process. Duplicates found by Covidence were automatically removed and any other duplicates were manually removed. Two independent reviewers (R.R., A.W.) were involved in all stages of the screening process: title, abstract, and full text. After the reviewers agreed on a decision, the study was either removed or moved to the next stage of screening. Discrepancies and conflicts were resolved by a third reviewer (MA) who was not involved in the initial selection phase of the screening process.

Data Collection Process

Data extraction was performed manually with no use of automation tools. As with the selection process, 2 independent reviewers were involved in the data extraction process. After the reviewers (R.R., R.D.) independently performed the data extraction process, a third independent reviewer (M.A.) looked at the extracted items and finalised the collected information. Discrepancies were solved by reaching consensus.

Data Items

The outcomes included: prevalence, incidence per 1000 hours, severity (time loss due to injury), and anatomical location of overuse injuries. The outcome measures were used to compare the difference in overuse injuries between male and female ballet dancers.

Other extracted information included: author, year of publication, study design, study length, number of participants, age, definition, reporting and number of overuse injuries, number of total injuries and dance exposure.

No changes were made to eligibility criteria in this process. However, not all studies were compatible with all the items that were extracted. If the studies included had information present on any of these outcomes, they were extracted in the data collection process.

Risk of Bias and Quality Assessment

To assess the risk of bias, the quality assessment tools utilised were the Newcastle-Ottawa Scale (2000)²⁰ for cohort studies and AXIS (2016), the critical appraisal tool for cross-sectional studies.²¹ Two reviewers (R.R., R.D.) independently assessed the quality of each study using the appropriate tools. The scores were reviewed independently (M.A.), and any discrepancies were discussed to reach a consensus (Supplemental Material; Appendices 1 and 2).

The Newcastle Ottawa Scale²⁰ consists of 3 domains: selection (4 items, 4 points), comparability (1 item, 2 points), and outcomes (3 items, 3 points). The selection domain consists of the representativeness of the cohort, selection of the non-cohort group, ascertainment of exposure, and presence of outcome at the start of the study. The comparability domain compares the cohorts based on design or analysis. The outcomes domain consists of assessment of outcome, follow up times, and attrition rate. The overall quality is based off the number of points in each domain, that is, 3 or 4 points in selection and 1 or 2 points in comparability and 2 or 3 points in outcomes is of good quality. Zero or 1 point in any domain results in poor quality.²²

The AXIS²¹ tool consists of 5 domains (20 points): introduction (1 point), methods (10 points), results (5 points), discussion (2 points), and other (2 points). The tool evaluates the clarity of aims, appropriateness of design, sample representativeness, validity of measurements, handling of bias, statistical transparency, consistency and completeness of results, discussion quality, limitations, conflicts of interest, and ethical approval. Each point is scored as yes (=1) or no/unclear (=0). A total score is often converted to a percentage, with ≥70% indicating high quality, 60% to 69.9% fair quality, and <60% low quality.²³

Effect Measures

Anatomical location was recorded and reported as nominal data, whereas prevalence, incidence, and severity were continuous data.

Synthesis Methods

The extracted information was used to tabulate baseline characteristics, number of overuse and total injuries, prevalence, incidence per 1000 hours, severity, and anatomical location of overuse injuries in male and female ballet dancers.

If prevalence was recorded, they were extracted to be used in the analysis. In instances where it wasn’t reported, prevalence was calculated by dividing the number of overuse injuries by the total number of injuries in male and female ballet dancers.²⁴ The synthesised result was re-expressed as an odds ratio through a random effects meta-analysis model. Confidence intervals and significance were also calculated.

For the incidence per 1000 hours of overuse injuries the data was extracted from the studies, if present. Otherwise, they were calculated using the number of overuse injuries/(dance exposure (hours) × 1000). The incidence per 1000 hours were re-expressed as log (incidence rate ratio) = log (female incidence rate/male incident rate) with standard error. Furthermore, a 2 one-sided test was also performed to determine significance.

For the anatomical location of overuse injuries in males and females a log odds ratio and confidence interval were used to analyse the difference between sex in 3 different categories: lower extremity, upper extremity, and other. A random effects model was used to calculate a log odds ratio and confidence interval.

Meta-analysis was conducted on sex differences in the prevalence, incidence per 1000 hours and anatomical location of overuse injuries using random effects model on Jamovi 2.4.14.²⁵ Heterogeneity (tau²) was estimated using the restricted maximum-likelihood estimator for prevalence, incidence per 1000 hours and anatomical location of injuries.²⁶ Additionally, the Q-test for heterogeneity and the I² statistic was also calculated.²⁷

Reporting Bias Assessments

A funnel plot was generated to visualise if there was any publication bias in the studies included in the meta-analysis for prevalence, incidence per 1000 hours and anatomical location of overuse injuries. Studentised residuals were used to assess whether studies may be outliers alongside rank correlation and regression tests.²⁸ Funnel plot asymmetry was checked using the standard error of the observed outcomes as a predictor.

Certainty Assessment

The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool²⁹ was utilised to assess the certainty in differences between the prevalence, incidence, and anatomical locations of overuse injuries in male and female ballet dancers. Two independent reviewers (R.R., A.W.) assessed the certainty of the results and reached a consensus on any conflicts through discussion.

Results

Study Selection

Initially 437 studies were identified, and 173 duplicates were removed resulting in a total of 264 studies to be screened. One hundred and ninety-seven studies were removed in the Title and Abstract screening phase resulting in 68 studies included for full text screening. Sixty-six studies were screened but the full text for 2 studies^30,31 could not be retrieved. A further 57 studies were then removed resulting in 9 studies^15,32
-39 that met the eligibility criteria. Following the full-text review, 2 additional studies^40,41 were added through citation searching, resulting in a total of 11 studies (n = 1650 dancers) included in this review. The screening process and reasons for exclusion are reflected in the PRISMA diagram in Figure 1.

Figure 1.

PRISMA flow diagram.

Baseline Characteristics of Included Studies

The 11 studies included both professional^{15,35,36,39
-41} and pre-professional ballet dancers,^32
-34,37 with sample sizes ranging from 42³⁸ to 476.³³ One study³⁸ included both pre-professional and professional dancers. Four studies^32
-34,37 had a higher proportion of female dancers in comparison to males. Sex-specific dance exposure wasn’t included in 4 studies.^32,35,37,40 Furthermore, 5 studies^15,32
-34,40 did not include age information of participants. Dance exposure varied greatly, ranging from 24 523 hours in pre-professionals³⁴ to 631 429 hours¹⁵ in professionals. Table 3 depicts in detail all included studies’ characteristics.

Table 3.

Characteristics of Included Studies (n = 11). Descriptive Data on Study Design, Population Demographics, and Dance Exposure for Each Included Study.

Study	Study design	Level of training	Age (mean ± SD)			No of male dancers	No of female dancers	Total no of dancers	Dance exposure (h)
Study	Study design	Level of training	Male	Female	Average	No of male dancers	No of female dancers	Total no of dancers	Male	Female
Nilsson et al (2001)¹⁵	Cohort	Professional	N/A	N/A	28.3	48	50	98	260,000	371,429
Twitchett et al (2008)³²	Cross-sectional	Pre-professional	N/A	N/A	17.3 ± 1.02	11	31	42	N/A	N/A
Leanderson et al (2011)³³	Cohort	Pre-professional	N/A	N/A	10-21	179	297	476	211,250	336,250
Allen et al (2013)⁴¹	Cohort	Professional	Y 1 – 23 ± 4	Y 1 – 25 ± 5	N/A	80	83	163	124,571	127,571
			Y 2 – 24 ± 4	Y 2 – 25 ± 5
			Y 3 – 24 ± 4	Y 3 – 26 ± 5
Bowerman et al (2014)³⁴	Cohort	Pre-professional	N/A	N/A	16 ± 1.58	16	30	46	8,541	15,982
Sobrino et al (2015)³⁵	Cross-sectional	Professional	25.24 ± 5.4	26.27 ± 5.92	25.79 ± 5.69	70	75	145	N/A	N/A
Mattiussi et al (2021)³⁶	Cohort	Professional	27.9 ± 8.5	28.0 ± 8.3	N/A	57	66	123	216,452	237,179
Mendes-Cunha et al (2022)³⁷	Cohort	Pre-professional	15.58 ± 2.3	14.47 ± 2.77	14.87 ± 2.63	22	48	70	N/A	N/A
Drysdale et al (2023)³⁸	Cohort	Professional/pre-professional	22.0 ± 3.0	22.3 ± 4.8	N/A	33	40	73	154,245	186,963
Junge et al (2024)³⁹	Cohort	Professional	27.8 ± 5.2	28.3 ± 5.3	28.1 ± 5.2	34	33	57	25,603	39,510
Katakura et al (2024)⁴⁰	Cohort	Professional	N/A	N/A	N/A	219	236	455	N/A	N/A

Abbreviation: Y, year.

Definition of Overuse Injuries

Across the studies, overuse injuries were defined as gradual onset^15,32
-41 and not caused by an acute or traumatic event. The injuries were also defined as recurrent in type and location.^{15,35,37,38,41} Bowerman et al only studied overuse injuries.³⁴ The number of overuse and total injuries can be seen in Table 4.

Table 4.

Number of Overuse and Total Injuries. Summary of the Definition, Reporting, and Number of Overuse Injuries, Number of All Injuries, Stratified by Sex and Study.

Study	Study length	Definition of overuse injuries	Reporting of overuse injuries	Number of overuse injuries		Total number of overuse injuries	Number of all injuries		Total number of all injuries
Study	Study length	Definition of overuse injuries	Reporting of overuse injuries	Male	Female	Total number of overuse injuries	Male	Female	Total number of all injuries
Nilsson et al (2001)¹⁵	5 y	Non-traumatic	Medical records	110	157	267	182	208	390
Leanderson et al (2011)³³	7 y	Non-traumatic	Medical records	130	207	337	169	269	438
Allen et al (2013)⁴¹	3 y	Non-traumatic	Physiotherapy records	190	214	404	389	323	712
Bowerman et al (2014)³⁴	0.5 y	Gradual onset	Physiotherapy records	24	35	59	24	35	59
Sobrino et al (2015)³⁵	5 y	Non-traumatic	Occupational health and trauma service records	171	195	366	229	257	486
Mattiussi et al (2021)³⁶	4.6 y	Gradual onset	Physiotherapy records	124	150	274	243	300	543
Mendes-Cunha et al (2022)³⁷	3 y	Gradual onset	Medical records	24	48	72	40	70	110
Drysdale et al (2023)³⁸	3.94 y	Gradual onset	Physiotherapy records	204	239	443	441	512	953
Junge et al (2024)³⁹	0.8 y	Gradual onset	Self-report	37	80	117	86	148	234
Katakura et al (2024)⁴⁰	3 y	Gradual onset	Physiotherapy records	131	243	374	221	367	588

Abbreviation: n, number of injuries.

Risk of Bias and Quality Assessment

Nine studies^{15,33,34,36
-41} were evaluated using the Newcastle-Ottawa Scale (2000). The tool was modified so that items 2 and 5 were given a score of N/A due to the studies being single arm cohort studies, reducing the total points to 6. Eight studies^{15,33,34,36
-38,40,41} were deemed to be of good quality. One study³⁹ was deemed to be of poor quality. Junge et al³⁹ lost a point on items 3 and 6 as both the exposure and outcome data were collected through self-reporting. Furthermore, all studies except Allen et al⁴¹ lost a point on item 4 – outcome of interest present at the start of the study; only Allen et al⁴¹ explicitly stated that there were no injuries present at the start of the study.

Two studies^32,35 were assessed using the AXIS tool. The scores from the tool indicated that there were clear aims and objectives, and it also reflects that the study had strengths in design and result presentation. Both studies were of high quality as the scores are more than 70%. However, the tool also highlighted areas of the studies which was lacking such as justification of the sample size (item 3), selection process (item 6), and discussion of limitations (item 18). There was also a lack of information on funding sources (items 19) in both studies, but there was no information on conflict of interest (item 20) in Sobrino et al.³⁵ Furthermore, no information was present regarding non-responders (items 7, 13, and 14) in both studies (Tables 5 and 6).

Table 5.

Quality Assessment for Cohort Studies (Newcastle-Ottawa Scale). Appraisal of Methodological Quality of Cohort Studies Included in the Review.

Study	Selection				Comparability	Outcome
Study	Item 1 (*)	Item 2 (*)	Item 3 (*)	Item 4 (*)	Item 5 (**)	Item 6 (*)	Item 7 (*)	Item 8 (*)	Score	Comment
Nilsson et al (2001)¹⁵	*	N/A	*	0	N/A	*	*	*	5/6	Good quality
Leanderson et al (2011)³³	*	N/A	*	0	N/A	*	*	*	5/6	Good quality
Allen et al (2013)⁴¹	*	N/A	*	*	N/A	*	*	*	6/6	Good quality
Bowerman et al (2014)³⁴	*	N/A	*	0	N/A	*	*	*	5/6	Good quality
Mattiussi et al (2021)³⁶	*	N/A	*	0	N/A	*	*	*	5/6	Good quality
Mendes-Cunha et al (2022)³⁷	*	N/A	*	0	N/A	*	*	*	5/6	Good quality
Drysdale et al (2023)³⁸	*	N/A	*	0	N/A	*	*	*	5/6	Good quality
Junge et al (2024)³⁹	*	N/A	0	0	N/A	0	*	*	3/6	Poor quality
Katakura et al (2024)⁴⁰	*	N/A	*	0	N/A	*	*	*	4/6	Good quality

Item 5 can be scored with a maximum of scored as ** compare to the other Items which can be scored * - however in this table none of the studies were assessed for comparability hence the N/A.

Table 6.

Quality Assessment for Cross-Sectional Studies (AXIS Tool). Assessment of the Quality of Cross-Sectional Studies Using the AXIS Checklist.

Item number	Twitchett et al (2008)³²	Sobrino et al (2015)³⁵
Item 1 (Y/N)	Y	Y
Item 2 (Y/N)	Y	Y
Item 3 (Y/N)	N	N
Item 4 (Y/N)	Y	Y
Item 5 (Y/N)	Y	Y
Item 6 (Y/N)	Y	Y
Item 7 (Y/N)	N	N
Item 8 (Y/N)	Y	Y
Item 9 (Y/N)	Y	Y
Item 10 (Y/N)	Y	Y
Item 11 (Y/N)	Y	Y
Item 12 (Y/N)	Y	Y
Item 13 (Y/N)	N	N
Item 14 (Y/N)	N	N
Item 15 (Y/N)	Y	Y
Item 16 (Y/N)	Y	Y
Item 17 (Y/N)	Y	Y
Item 18 (Y/N)	Y	N
Item 19 (Y/N)	Y	Y
Item 20 (Y/N)	Y	N
Score	16/20	15/20

Prevalence

The prevalence of overuse injuries was calculated as a proportion over the total number of injuries from 9 studies.^{15,32
-37,40,41} This can be seen in Table 7. The overall sample consisted of professional (n = 1051) and pre-professional ballet dancers (n = 634). Drysdale et al³⁸ studied both professional and pre-professional dancers (n = 73). There appears to be a consistent pattern across most of the studies; the prevalence of overuse injuries was higher in female dancers in comparison to males across the studies except in Leanderson et al³³ and Mattiussi et al.³⁶

Table 7.

Prevalence of Overuse Injuries/Total Injuries (%) by Sex and Study.

Study	Prevalence of overuse/total injuries (%)
Study	Male	Female
Nilsson et al (2001)¹⁵	60.4	75.5
Leanderson et al (2011)³³	69.9	70
Allen et al (2013)⁴¹	48.8	66.3
Sobrino et al (2015)³⁵	74.7	75.9
Mattiussi et al (2021)³⁶	51	50
Mendes-Cunha et al (2022)³⁷	60	68.6
Drysdale et al (2023)³⁸	46.3	46.7
Junge et al (2024)³⁹	43	53.8
Katakura et al (2024)⁴⁰	59.3	66.2

A total of 9 studies^{15,32
-37,40,41} were initially included in the analysis using a random effect model. The observed log odds ratios ranged from −0.0412 to 0.7209, with the majority estimates being positive. The estimated average log odds ratio based on the random-effects model was = 0.2347 (95% CI: 0.0418-0.4276), and the average outcome differed significantly from 0 (z = 2.3844, P = .0171).

According to the Q-test, the true outcomes appear to be heterogeneous (Q(8) = 17.8674, P = .0222, tau² = 0.0447, I² = 54.5050%). A 95% prediction interval for the true outcomes is given by −0.2225 to 0.6920.

An examination of the studentised residuals revealed that 1 study (Allen et al⁴¹) had a value larger than ±2.7729 and may be a potential outlier in the context of this model. The rank correlation and the regression test results were P = .6122 and P = .7681, respectively.

Therefore, the meta-analysis was conducted again after removing the identified outlier.⁴¹ The revised forest plot can be seen in Figure 2 with 8 studies included.^15,32
-37,40

Figure 2.

Forest plot and funnel plot – prevalence of overuse injuries in female versus male ballet dancers (outlier removed).

The observed log odds ratios ranged from −0.0412 to 0.4434, with many estimates being positive. The estimated average log odds ratio based on the random-effects model was = 0.1289 (95% CI: −0.0068 to 0.2645). Therefore, the average outcome did not differ significantly from 0 (z = 1.8618, P = .0626).

According to the Q-test, there was no significant amount of heterogeneity in the true outcomes (Q(7) = 5.7503, P = .5692, tau² = 0.0000, I² = 0.0000%).

An examination of the studentised residuals revealed that none of the studies had a value larger than ±2.7344 and hence there was no indication of outliers in the context of this model. Neither the rank correlation nor the regression test indicated any funnel plot (Figure 2) asymmetry (P = .2751 and P = .2023, respectively).

Incidence

There was no consistent pattern amongst the studies in the incidence per 1000 hours; in 4 studies^33,36,39,41 females had higher incidence, in 2 studies^34,38 males had higher incidence, and in 1 study¹⁵ there was no difference in the incidence. The incidence per 1000 hours in males, females, and overall is reported in Table 8.

Table 8.

Incidence of Overuse Injuries. Incidence Rates of Overuse Injuries Reported per 1000 Hours of Dance Exposure in Males, Females, and Overall.

Study	Male incidence (per 1000 h)	Female incidence (per 1000 h)	Overall incidence (per 1000 h)
Nilsson et al (2001)¹⁵	0.42	0.42	0.42
Leanderson et al (2011)³³	0.62	0.62	0.62
Allen et al (2013)⁴¹	1.53	1.68	1.60
Bowerman et al (2014)³⁴	2.81	2.19	2.4
Mattiussi et al (2021)³⁶	0.56	0.63	0.58
Drysdale et al (2023)³⁸	1.32	1.28	1.3
Junge et al (2024)³⁹	1.45	2.02	1.80

Meta-analysis of incidence as log (incidence rate ratios) can be seen in Figure 3 as a forest plot.

Figure 3.

Forest plot and funnel plot – incidence of overuse injuries in female versus male ballet dancers.

A total of 7 studies^{15,33,34,36,38,39,41} were used in the random-effect meta-analysis. The log (IRR) ranged from −0.23 to 0.30. The overall effect estimate was 0.0398 (95% CI: −0.225 to 0.305) which was not statistically significant (P = .769).

The 2 one-sided tests, using bounds of −0.5 to 0.5 showed that equivalence test was significant (z = −3.402, P = .000334). The null hypothesis test was non-significant (z = 0.294, P = .769). This indicates that the observed effect is statistically not different from 0 and statistically equivalent to 0. Furthermore, according to the Q-test, there was no heterogeneity observed across the studies (Q(6) = 0.882, P = .990, tau² = 0, I² = 0%).

The funnel plot (Figure 3) did not reveal any signs of publication bias. This is supported by the Kendall’s tau (τ = 0.048, P = 1.000) and Egger’s regression intercept (−0.057, P = .955) test, which indicated no asymmetry in the distribution of effect sizes.

Severity

The severity of injuries was recorded in 2 studies^32,41 (Table 9). Twitchett et al,³² found that pre-professional female dancers experienced a greater number of days being lost due to overuse injuries compared to their male counterparts. Contrastingly, Allen et al,⁴¹ reported that professional male ballet dancers experienced a longer duration of time lost to injury compared to females during the first and second year of the observation period. However, in the third year, female dancers had a greater number of days lost to overuse injuries.

Table 9.

Severity of Overuse Injuries. Average Time Loss Due to Overuse Injuries, Stratified by Sex.

Study	Severity (time loss to overuse injury)
Study	Male	Female
Allen et al (2013)⁴¹	Y 1 – 9 d (8-11)Y 2 – 6 d (4-8)Y 3 – 11 d (8-14)	Y 1 – 3 d (3-4)Y 2 – 5 d (4-7)Y 3 – 17 d (13-23)
Twitchett et al (2008)³²	2.5 ± 6.4 d	6.9 ± 17.9 d

Abbreviations: Y, year; d, days.

Due to the limited number of studies, the methodological difference in reporting the severity, a range in 1 study and the standard deviation in another, they could not be pooled for further analysis.

Anatomical Location

Five studies^{15,33,35,37,38} reported on the anatomical location of overuse injuries and separated them by sex. To allow a synthesised manner of expressing the location, 3 major categories were formed in this review to describe the location of injuries. Lower extremity refers to injuries from the hip down to the feet. Upper extremity injuries were considered from the shoulder to the hands. The final category, “other” consisted of lower back, upper back, and neck injuries (Table 10).

Table 10.

Anatomical Location of Overuse Injuries. Distribution of Overuse Injuries by Anatomical Region and Sex.

Study	Study length (y)	Lower extremity (n)		Upper extremity (n)		Other (n)
Study	Study length (y)	Male	Female	Male	Female	Male	Female
Nilsson et al (2001)¹⁵	5	72	102	10	0	14	26
Leanderson et al (2011)³³	7	103	182	2	3	25	22
Sobrino et al (2015)³⁵	5	117	144	7	1	34	37
Mendes-Cunha et al (2022)³⁷	3	14	39	0	1	8	10
Drysdale et al (2023)³⁸	4	158	178	8	9	38	52

The foot and ankle complex were the most injured region in the “lower extremity” and the lower back was the most affected region in the “other” category. The least affected region of overuse injuries across all the studies^{15,33,35,37,38} was the upper extremity category, mainly in the shoulder.

Meta-analysis was conducted using a log odds ratio between females and males to explore significant differences at any of the 3 categories.

The first category was the lower extremity, and the results can be seen in Figure 4. The observed log odds ratios ranged from −0.1630 to 0.7061, with the majority of estimates being positive. The estimated average log odds ratio based on the random-effects model was = 0.2587 (95% CI: −0.0717 to 0.5891). The average outcome did not differ significantly from 0 (z = 1.5347, P = .1249). This indicates that there was no significant difference between females and males regarding the likelihood of overuse injuries in the lower extremities.

Figure 4.

Forest plot and funnel plot – lower extremity overuse injuries in females versus males.

The Q-test for heterogeneity was not significant, but some heterogeneity may still be present in the true outcomes (Q(4) = 5.7378, P = .2196, tau² = 0.0489, I² = 35.1286%). A 95% prediction interval for the true outcomes is given by −0.2862 to 0.8036.

An examination of the studentised residuals revealed that none of the studies had a value larger than ±2.5758 and hence there was no indication of outliers in the context of this model. Neither the rank correlation nor the regression test indicated any funnel plot (Figure 4) asymmetry (P = .4833 and P = .1113, respectively).

The second category was the upper extremity (Figure 5). The observed log odds ratios ranged from −3.4403 to 0.3102. The estimated average log odds ratio based on the random-effects model was = −0.8491 (95% CI: −2.0730 to 0.3748). The average outcome did not differ significantly from 0 (z = −1.3597, P = .1739). Therefore, whilst the average log odds ratio is negative, suggesting females may have fewer overuse injuries in the upper extremity than males, this difference is not statistically significant.

Figure 5.

Forest plot and funnel plot – upper extremity overuse injuries in females versus males.

According to the Q-test, there was no significant amount of heterogeneity in the true outcomes (Q(4) = 7.7007, P = .1032, tau² = 0.8837, I² = 48.2250%). A 95% prediction interval for the true outcomes was given by −3.0610 to 1.3628.

An examination of the studentised residuals revealed that none of the studies had a value larger than ±2.5758 and hence there was no indication of outliers in the context of this model. Neither the rank correlation nor the regression test indicated any funnel plot (Figure 5) asymmetry (P = .2333 and P = .2367, respectively).

The final category was “other,” and the results can be seen in Figure 6. The observed log odds ratios ranged from −0.8267 to 0.4008. The estimated average log odds ratio based on the random-effects model was = −0.1247 (95% CI: −0.5444 to 0.2950). The average outcome did not differ significantly from 0 (z = −0.5825, P = .5602). Therefore, although females are slightly less likely than males to experience overuse injuries in the “other” regions, this difference was not significant.

Figure 6.

Forest plot and funnel plot – “other” overuse injuries in females versus males.

The Q-test for heterogeneity was not significant, but some heterogeneity may still be present in the true outcomes (Q(4) = 8.5703, P = .0728, tau² = 0.1185, I² = 53.8343%). A 95% prediction interval for the true outcomes is given by −0.9192 to 0.6697.

An examination of the studentised residuals revealed that none of the studies had a value larger than ±2.5758 and hence there was no indication of outliers in the context of this model. Neither the rank correlation nor the regression test indicated any funnel plot (Figure 6) asymmetry (P = .8167 and P = .3044, respectively).

Certainty Assessment

Certainty was assessed using the GRADE tool²⁹ for all outcomes that were meta-analysed. The outcome initially started with a low score of ++ due to the included studies being cohort and cross-sectional studies which were observational. One point was deducted due to imprecision. No further points were reduced or added to the synthesised results. This resulted in a final certainty level of very low according to the GRADE tool for prevalence, incidence, and severity.

Summary of Findings

A summary of the main outcomes can be seen in Table 11. Meta-analysis of sex difference in prevalence, incidence, and anatomical location of overuse injuries in female and male ballet dancers can be seen in the GRADE summary table (Table 12).

Table 11.

Summary of Findings. Synthesis of Results From the Included Studies on Prevalence, Incidence, Severity, and Location of Overuse Injuries.

Outcomes (differences in male and female ballet dancers)	Findings	Meta-analysis
Prevalence of overuse injuries	From analysis of the 8 studies^15,32 -37,40 there was no significant difference in the prevalence of overuse injuries between female and male dancers (P > .05)	Log odds-ratio using a random-effects model
Incidence of overuse injuries	From the analysis of 7 studies,^{15,33,34,36,38,39,41} there was no significant difference in the incidence of overuse injuries in females and male ballet dancers (P > .05)	Size effect using a random-effects model
Severity of overuse injury	Only 2 studies^32,41 were used and they had contrasting results. No clear pattern could be seen from the limited results	N/A
Anatomical location of overuse injuries	Five studies^{15,33,35,37,38} analysed the difference in anatomical location of overuse injuries	Log odds-ratio using a random-effects model
	Lower extremity – there was no significant difference between females and males (P > .05)
	Upper extremity – there was no significant difference between females and males (P > .05)
	Other – there was no significant difference between females and males (P > .05)

Table 12.

GRADE Summary of Findings. Summary of Certainty of Evidence Using the GRADE Approach for Key Outcomes.

Outcome		Overall estimate (95% CI)	P value (statistical significance)	Number of participants (studies)	Certainty of evidence (GRADE tool²⁹)
Difference in the prevalence of overuse injuries in female and male ballet dancers		0.129 (−0.007 to 0.265)	.063	1660 (8 cohort, 1 cross-sectional)	Very low
Difference in the incidence of overuse injuries in female and male ballet dancers		0.0398 (−0.255 to 0.305)	.769	1036 (7 cohort)	Very low
Difference in the anatomical location of overuse injuries in female and male ballet dancers	Lower extremity	0.259 (−0.072 to 0.589)	.125	862 (4 cohort, 1 cross-sectional)	Very low
	Upper extremity	−0.849 (−2.073 to 0.375)	.174
	Other	−0.125 (−0.544 to 0.295)	.560

Discussion

We critically reviewed the evidence published from 2000 onwards for differences in prevalence, incidence, severity, and anatomical location of overuse injuries between male and female ballet dancers. We included pre-professional and professional dancers only. Overall, the results indicated that there was no significant difference in the prevalence, incidence per 1000 hours and anatomical location of overuse injuries in females and male ballet dancers. Severity could not be meta-analysed due to limited number of studies.

Sex differences in overuse injury prevalence were analysed with a log odds ratio in 8 studies.^15,32
-37,40 Meta-analysis showed that there was no significant difference in the prevalence of overuse injuries between males and females. This is in contrast with previous research,⁹ that reported females having significantly higher prevalence of overuse injuries. However, Smith et al⁹ included participants with varying levels of training, from amateurs to professionals. Our analysis revealed a consistent pattern across most of the studies; the prevalence of overuse injuries was higher in female dancers in comparison to males. However, meta-analysis did not find significant differences between sexes. This could imply that, more than intrinsic biological differences, common loading factors across both sexes, such as elevated training volumes, repetitive choreography, and accumulated mechanical stress may contribute more to increasing injury risk.

Incidence was included in 7 studies.^{15,33,34,36,38,39,41} Meta-analysis indicated that there was no significant difference in the incidence of overuse injuries between males and females. This suggests that both sexes develop new overuse injuries at similar rates over time. Despite established sex-based physiological differences, this parity may be explained by the standardised training conditions in ballet, where both male and female dancers are exposed to similarly high volumes of repetitive loading and exposure.⁸

Severity was only included in 2 studies^32,41 and showed no clear pattern. As there are no previous reviews which focussed solely on incidence of overuse injuries between male and female dancers, it is challenging to check the consistency and appropriateness of our results to current body of knowledge. However, this indicates the lack of literature and the need for more research regarding this specific epidemiological outcome.

Meta-analysis of the anatomical location of injuries included data from 5 studies.^{15,33,35,37,38} Results showed that there were no significant differences in the lower extremity, upper extremity, or “other” categories. However, it was observed that the foot and ankle injuries were the most affected region for overuse injuries in ballet dancers, consistent with previous research.^4,11 The upper extremity region was the least affected in both male and female dancers, although males did have higher overuse injuries in this region, albeit not statistically significant. Lower extremity injuries, especially in the foot and ankle region⁴ are likely due to technical components typical of the discipline, like dancing en pointe and jumps. Dancing en pointe is a classical feature of female ballet dancers whilst male dancers have roles of lifting and carrying female dancers, so require considerably more upper body strength and training reflected by male dancers experiencing more upper extremity injuries. Furthermore, Twitchett et al⁴² found that ballet dancers spent jumping 4.99 seconds/minute when performing, indicating the burden on the lower limb and so making it more likely to be affected by overuse injuries, highlighting the importance of incorporating strength-specific training into their conditioning programmes.⁴³

Limitations

Overall, we identified a total of 11 studies^15,32
-41 that focussed since 2000 on overuse injuries and sex differences. Future research would benefit from larger sample sizes and standardised methodologies for multiple epidemiological outcomes to reduce heterogeneity so that they can be analysed to their full extent and tested for significance.

The included studies^15,32
-41 varied in their reporting of age and other baseline variables, and were frequently not distinguished by sex. No studies presented statistical comparisons of important characteristics like training volume, years of experience, or exposure hours between males and females, and 5 studies^15,32
-34,40 completely excluded participant age. The absence of consistent demographic and exposure reporting constrains the interpretation of observed disparities in injury prevalence and hinders the adjustment for potential confounding variables. To ensure more thorough analyses and better understanding of any sex-related injury patterns, future research should guarantee thorough and sex-disaggregated reporting of participant variables, such as age, training load, and exposure measures.

Furthermore, the certainty of outcomes was found to be very low and therefore it is reasonable to state that findings should be taken with caution and so limits the confidence in the conclusion. This is important as the ability of this review is limited in terms of clinical implications such as influencing guidelines and prevention strategies in ballet dancers. This also signifies the need for further high-quality research on this topic.

Additionally, although it was not one of the outcomes of this study, future reviews could also analyse differences according to sex and level to increase the external validity of the current findings.

Practical and Clinical Applications and Implication

While the results of this review do not support prioritizing sex-specific traits at this point, additional research involving larger and more comprehensive datasets may help determine if such differences are present. At present, strategies for preventing and assessing injuries should mainly concentrate on common mechanical and training load elements that impact all dancers, while also being conscious of the importance of sex-specific factors.

These results can inspire improved clinical awareness and early screening by healthcare providers and dance educators, facilitating timely treatments that reduce injury incidence and improve performance lifespan.⁴¹

Conclusion

This review found that there was no significant difference in the prevalence and incidence of overuse injuries between female ballet dancers and male ballet dancers (P > .05).

The most affected region of overuse injuries was found to be the foot and ankle complex in both male and female dancers. However, there was no significant difference in the anatomical location of overuse injuries between females and males. The results of our review should be interpreted with caution due to the very low certainty grade, and it is possible that future analyses will identify statistically significant sex differences as the number of high-quality research increases. Future studies should incorporate uniform methods in data collection which can allow further inferential analysis of other outcomes like severity. Long term longitudinal observations could also be conducted to understand the long-term impact of overuse injuries on male and female ballet dancers and how this might differ.

Supplemental Material

sj-docx-1-dmj-10.1177_1089313X251412479 – Supplemental material for Prevalence, Incidence, Severity, and Anatomical Location of Overuse Injuries in Male and Female Ballet Dancers: A Systematic Review and Meta-Analysis

Supplemental material, sj-docx-1-dmj-10.1177_1089313X251412479 for Prevalence, Incidence, Severity, and Anatomical Location of Overuse Injuries in Male and Female Ballet Dancers: A Systematic Review and Meta-Analysis by Rubaprthisan Rupendran, Arif Ahmad Wadud, Rosie Elizabeth Davis, Sophia Gita Taglia, Tobin Alexander Rusby and Manuela Angioi in Journal of Dance Medicine & Science

Footnotes

Acknowledgements

We would like to acknowledge all colleagues based at Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London.

ORCID iDs

Rubaprthisan Rupendran

Manuela Angioi

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data will be made available upon request. The protocol was registered on PROSPERO (ref: CRD420251104232).

Supplemental Material

Supplemental material for this article is available online.

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Prevalence,Incidence,Severity,and Anatomical Location of Overuse Injuries in Male and Female Ballet Dancers: A Systematic Review and Meta-Analysis

Abstract

Keywords

Key Points

Introduction

Methods

Eligibility Criteria

Information Sources

Search Strategy

Selection Process

Data Collection Process

Data Items

Risk of Bias and Quality Assessment

Effect Measures

Synthesis Methods

Reporting Bias Assessments

Certainty Assessment

Results

Study Selection

Baseline Characteristics of Included Studies

Definition of Overuse Injuries

Risk of Bias and Quality Assessment

Prevalence

Incidence

Severity

Anatomical Location

Certainty Assessment

Summary of Findings

Discussion

Limitations

Practical and Clinical Applications and Implication

Conclusion

Supplemental Material

sj-docx-1-dmj-10.1177_1089313X251412479 – Supplemental material for Prevalence, Incidence, Severity, and Anatomical Location of Overuse Injuries in Male and Female Ballet Dancers: A Systematic Review and Meta-Analysis

Footnotes

Acknowledgements

ORCID iDs

Funding

Declaration of Conflicting Interests

Data Availability Statement

Supplemental Material

References