Scand J Med Sci Sports 2002: 12: 230235

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COPYRIGHT BLACKWELL MUNKSGAARD 2002
ISSN 0905-7188

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MEDICINE & SCIENCE

IN SPORTS

Self-reported hamstring injuries in student-dancers

C. Askling 1, H. Lund 1, T. Saartok 2, A. Thorstensson 1
1

Department of Sport and Health Sciences, University College of Physical Education and Sports, Stockholm, Sweden, 2Department of
Surgical Sciences, Section of Sports Medicine, Karolinska Institutet, Stockholm, Sweden
Corresponding author: Carl Askling, Department of Sport and Health Sciences, University College of Physical Education and Sports,
Box 5626, SE-114 86 Stockholm, Sweden
Accepted for publication 21 September 2001

Dancing involves powerful movements as well as flexibility

exercises, both of which may be related to specific injuries to
the musculo-tendinosus tissue, e.g., the hamstring muscle
complex. In this study, the occurrence of acute and overuse
injuries to the rear thigh in dancers was investigated retrospectively by means of a questionnaire. All but one (n 98)
of the student-dancers (age 1725 years) at the Ballet
Academy in Stockholm participated. The results demonstrated that, during the past 10 years, every third dancer
(34%) reported that they had acute injuries and every sixth
dancer (17%) had overuse injuries to the rear thigh. Most
(91%) of the acute injuries were subjectively located to an
area close to tuber ischiadicum. The majority (88%) stated
that the acute injury occurred during slow activities in flexi-

bility training, e.g., splits, and only a few (12%) in powerful

movements. Continuing problems were reported by 70% of
the acutely injured dancers. Many of the dancers neglected
their acute injury (14 did not even stop the ongoing dance
activity) and they also greatly underestimated the recovery
time. Only 4 dancers (12%) received acute medical assistance. Thus the results, based on the recollection of the
subjects, indicated that stretching could induce severe
strain injuries to the proximal hamstrings in dancers.
Extrapolating these results to the practice, it can be recommended that stretching exercises be executed with caution in
connection with dancing sessions and training, and that,
information about the seriousness and acute treatment of
such injuries be added to the student-dancers' curriculum.

Dancing is an activity with high physical and artistic

demands. Although dance is considered to be a performing art, the athleticism of the dancers is without
question. Musculoskeletal injuries are the most frequent medical problems among dancers in classical
ballet and modern dance (Bowling, 1989). Professional
dancers have a high prevalence of self-reported workrelated aches and pains of the musculoskeletal system
(Ramel & Moritz, 1994). It has been suggested both by
researchers and dancers that this is partly owing to
inadequate training and that, in spite of daily practice,
the dancers would not be properly prepared for the
demands of the dance performance (Ramel & Moritz,
1994; Ramel, Thorsson, Wollmer, 1997; Ramel, Moritz, Jarnlo, 1999).
Student-dancers take several 60- to 90-min dance
classes each day in addition to their daily performance
or rehearsal schedules. In addition, they often perform
extracurricular dance and other athletic activities.
Dance training can generally be characterized as intermittent exercise with bouts of brief duration (Dahlstrom, 1996). Dance training, as well as performance,
involves both dynamic and static work of large and
small muscle groups, and also emotional stress. Thus,
preparation for a career in dance is accompanied by a
high potential risk for physical injury.

Hamstring strains are common injuries in sports with

high demands on speed and force, e.g., sprint running
and soccer (Garett, Califf, Bassett, 1984; Kujula,
Orava, Jarvinen, 1997; Clanton & Coupe, 1998; De
Smet & Best, 2000). There is also anecdotal evidence
that these injuries may be frequent in other sports, such
as dancing, which include powerful movements.
However, hamstring strains are complex injuries that
probably involve a multifactorial aetiology (Agre,
1985; Worrell, 1994; Thorsson, 1996). In a recent case
study involving one dancer and one sprinter, Askling,
Tengvar, Saartok, Thorstensson (2000) raised the question of a possible link between the aetiology and character of an acute hamstring strain. They found that the
dancer was injured in the rear thigh during a well controlled slow stretching, which constitutes an integral
part of most dancers' warm-up, training and performance. Furthermore, the stretch induced hamstring
strain in the dancer was demonstrated to be a partial
tendon rupture close to tuber ischiadicum and not an
injury to the muscle itself as in the sprinter (Askling
et al., 2000). The primary aim of this study was therefore to investigate, by means of a questionnaire, the
previous occurrence of hamstring strains among a
larger group of student-dancers, with particular emphasis on injury location and aetiology.

230

Hamstring muscle injuries

Materials and methods
The population studied comprised all 99 student-dancers (in the
following referred to as dancers) in professional training at the
Ballet Academy in Stockholm, Sweden, during the spring of 1999.
The Ballet Academy educates dancers of all ages in modern and
classical dance-techniques. The dancers in this study included a
mix of dancers at different stages of the 4-year-education.
A questionnaire was constructed and pretested on eight professional dancers to identify and eliminate any ambiguous formulations. The questionnaire was of a `one-time' retrospective
type, with no time limit to the retrospection. The questions
mainly concerned history of acute and overuse injuries to the
rear thigh. Acute injury was defined as a sudden sharp pain
or `pop' that the dancer could relate to a specific situation.
Overuse injury was defined as a problem with insidious onset
that continued to bother the dancer during a period of at least
2 weeks. In addition, questions were asked about associated
factors, e.g., demographic data, training background, present
training situation, extracurricular dance and other sport activities, acute medical treatment and rehabilitation of the injury.
All participants were informed of the background and purpose
of the study, and the injury definitions were explained. The
informed consent given by all dancers included that their participation in the survey was completely voluntary. Because all the
dancers could not attend the first time, a second occasion was
arranged. Six dancers had to be interviewed by phone. One
person could not be reached. For clarification of some of the
written answers in 15 questionnaires, supplementary information
was collected by phone. All questionnaires were treated confidentially and all informations were made anonymous in the statistical analysis.
For the description of data, mean and range values were used.
The Chi-square test was applied for statistical evaluation of
differences between groups. The level of significance was set at
P < 0.05.

Results
Background data
Ninety-eight of the 99 dancers (99%), 76 (78%) women
and 22 (22%) men answered the questionnaire. The
mean age of the whole group was 21 years (range
1725) (Table 1). Average body mass index (BMI),
based on the dancers' own statement of body mass and
height, was 21.5 kg m 2 (range 18.026.2) (Table 1).
Nine dancers (9%) had participated in dance training
for more than 10 years before the day of the questionnaire, 39 (40%) for 610 years and 50 dancers (51%) for
15 years. Sixty-four (65%) of the dancers had been

regularly active in other sports before starting their systematic dance training (Table 1). The average schedule
for the dancers in the Academy classes included 23
training hours per week; 35 weeks per year. In addition
to the Academy schedule, 48 dancers participated in
extra dance lessons and/or performances lasting
more than 2 h per week. Similarly, 25 dancers reported
extracurricular athletic training to the same amount
(Table 1).

Injury
Fifty dancers (51%) reported a history of injury to the
rear thigh. Thirty-three of those injuries (66%) were
categorized as acute, and 17 (34%) were classified as
overuse injuries.

Acute injury
Of the 33 dancers reporting acute injury, 9 (27%)
had been injured within the last 12 months, 15 (45%)
15 years ago and 9 (27%) 610 years ago. Of these, 4
dancers had experienced more than one acute injury.
Only the latest injury was included in this study.
Twenty-nine (88%) were acutely injured during a
slow, controlled, voluntary stretching of the muscles
of the rear thigh. Only four dancers (12%) in the acutely
injured group were injured during a powerful and
energetic movement such as a `grande jete'. The
dancers' descriptions of the location of the acute injury
corresponded in all the cases with an injury to the
proximal part of the hamstring muscles (fig. 1). Three
of the four dancers that were injured during powerful
movements had a somewhat more distal injury location
(fig. 1).
Twenty-two of the acute injuries (66%) occurred
when the dancers were stretching in a split in the sagittal
plane (fig. 2) and 4 (12%) when doing a side split. At the
time of the injury 23 (70%) of the acutely injured
dancers experienced a sharp pain, 10 (30%) had a burning feeling, 16 (48%) heard a sound, often described
as a `pop' or a `snap', and 9 (27%) dancers reported
that they felt that something in the rear thigh was torn.
Several of the dancers had experienced combinations of
these symptoms when injured.

Table 1. Background data (means and ranges) for participating dancers (n 98; 76 women, 22 men)
Variables

Women

Men

All

Age (years)
Body mass (kg)
Body height (m)
BMI (kg/m2)
Previous dance (n, years)1
Previous athletic training (n, years)2
Present extracurricular dance training (n, hours)3
Present extracurricular athletic training (n, hours)4

21 (1725)
58.0 (4568)
1.67 (1.531.82)
20.6 (18.023.9)
76 (6.6, 215)
50 (5.6, 114)
36 (4.4, 29)
20 (2.7, 25)

22 (1725)
69.0 (5384)
1.75 (1.631.89)
22.3 (18.026.2)
22 (4.5, 110)
14 (6.7, 117)
12 (4.5, 29)
5 (4.6, 28)

21 (1725)
59.9 (4584)
1.69 (1.531.89)
21.5 (18.026.2)
98 (6.1, 115)
64 (5.8, 117)
48 (4.5, 29)
25 (3.1, 28)

1,2

> 2 times/week before starting at the Ballet Academy.

3,4

> 2 h/week in addition to training at the Ballet Academy.

231

Askling et al.
All of the 33 dancers in the acutely injured group
stated that they were injured in connection with the
dance activity, 8 of the injuries happening at the
Ballet Academy and 7 during extracurricular activities
(18 injuries were encountered before entering the
Academy). The stretching induced injuries (n 29)
occurred during the stretching activities performed
before a dance session (n 5; 17%), in the beginning
(n 6; 21%), in the middle (n 1; 3%) or at the end
(n 6; 21%) of a dance session or during stretching
activities immediately thereafter (n 11; 38%). Five
(15%) dancers had experienced minor symptoms, e.g.,
stiffness and pain, from the rear thigh preceding the
acute injury.
At the injury occasion, 19 (58%) dancers immediately
stopped the ongoing activity, while 14 (42%) did not,
according to their recollection. After the acute injury,
22 of the dancers (66%) reported that they rested from

training for various lengths of time, whereas 10 dancers

stated that they continued their ordinary training in
spite of their injury. (One dancer answered that she
did not remember whether she continued or not.)
When comparing the group who had rested from
training after their injury with the group who had not,
there was no statistical difference concerning continuing problems after the injury.
Half of the acutely injured dancers (16/33) thought
that they could go back to dancing without problems
within a week (2 dancers gave an estimated expected
recovery time of less than a month, one of more than
a month, and 14 stated that they did not know).
However, the estimated actual recovery time for these
16 dancers became significantly longer, 2 weeks 80
months (median 8 months). Within the whole group
of acutely injured dancers, the 23 (70%) dancers who
had completely recovered at the time of the questionnaire reported that problems had continued for a
period of 2 weeks 24 months after the injury (median
2 months). The ten dancers who were still suffering
from the injury at the time of the investigation stated
that they had been so for 680 months (median
42 months).

Overuse injury
Of all the dancers, 17 (17%; 16 women and one man)
stated that they had experienced overuse injury to the
rear thigh. The first main symptoms reported were stiffness and slowly emerging pain. Four (24%) of these
dancers rested up to 4 weeks from training because of
these symptoms, whereas 13 (76%) did not rest at all.

Associated factors

Fig. 1. The localisation of the acute injury (n 33). Right leg

(n 13) left leg (n 20). The four dancers injured during powerful movements are marked with &.

Fig. 2. Stretching in a split in the sagittal plane.

232

There were no significant differences in age, body

mass, body height or BMI between the groups with
acute and no injuries (Table 2). The number of men
and women in the group of dancers with acute injuries showed that women had a higher relative occurrence of reported injuries than men (27/76 36% vs.

Hamstring muscle injuries

Table 2. Mean values for factors potentially associated with the occurrence of acute hamstring injuries
Acutely injured

Uninjured

Variables

Women

Men

All

Women

Men

All

Dancers (n)
Age (years)
Body mass (kg)
Body height (m)
BMI (kg/m2)
Previous dance (n, years)1
Previous athletic training (n, years)2
Present extracurricular dance training (n, hours)3
Present extracurricular athletic training (n, hours)4

27
22
58.4
1.66
21.1
27 (6.0)
19 (6.7)
14 (3.9)
11 (2.6)

6
22
68.0
1.77
21.6
6 (4.3)
4 (4.5)
2 (4.0)
1 (2.0)

33
22
63.2
1.68
21.4
33 (5.7)
23 (6.3)
16 (3.9)
12 (2.6)

33
21
56.0
1.66
20.3
33 (6.4)
19 (4.8)
20 (4.3)
5 (2.4)

15
22
70.3
1.79
21.9
15 (4.3)
11 (7.1)
8 (4.9)
3 (4.3)

48
21
60.5
1.70
21.6
48 (5.8)
30 (5.6)
28 (4.5)
8 (3.1)

1,2

> 2 times/week before starting at the Ballet Academy.

3,4

> 2 h/week in addition to training at the Ballet Academy.

6/22 27%, P < 0.05). Concerning previous dance and

athletic activities, no significant differences were found
between the two groups (Table 2). This was the case
also for current extracurricular dance and athletic
training (Table 2).

Medical assistance
Twenty-nine (88%) of the acutely injured dancers did
not seek or receive any acute medical treatment. In the
period after the injury, 12 (36%) of the acutely injured
and 8 (47%) of those with overuse injuries received
professional medical treatment.
Discussion
Previous studies suggest that hamstring strain is one of
the most common soft tissue injuries in athletes
(Burkett, 1976; Garett et al., 1984; Kujula et al., 1997;
Clanton & Coupe, 1998; De Smet & Best, 2000). The
present study indicates that hamstring injuries are quite
common also among dancers, as evidenced by the high
occurrence (51%) of such injuries in the group of student-dancers investigated.
Earlier injury surveys in dancers have, however, not
identified the hamstrings as particularly injury prone
(Bowling, 1989; Ramel & Moritz, 1994). One explanation for this apparent discrepancy may be that the
present survey was focused on injuries to the hamstring
muscles, whereas previous studies used standard,
i.e., less specific, questionnaires in an ambition to
survey the overall injury pattern. Other potential explanations may be related to factors such as previous
dance experience, extracurricular training, professional
status and age. The professional classic-ballet dancers
investigated by Ramel and Moritz (1994) had an average age of 27 (females) and 28 years (males) and were
reported to have started their dance training at an age
of 9 and 12 years, respectively. The present group of
student-dancers were younger; mean (age 21 years)
and reported less years of dance training: (6 years).
A slow progression of increased training load and

intensity over many years of dance training may have

led to a decreased risk for injuries to this particular
region of the body. An alternative explanation
could be that owing to `natural selection' the dancers
prone to hamstring injury would have already left the
profession.
A conspicuous circumstance with the studentdancers investigated here, was their frequent engagement in extracurricular training. Half of the
student-dancers performed extra training or performances in addition to their scheduled training in the
Academy, with a mean duration of 9 h, i.e., up to 40%
extra training per week. Thus, there is reason to question
whether these dancers did get enough recovery time
between dance sessions. Intensive training with insufficient recovery time has been shown to lead to
`over-training' (Gorostiaga, Izquierdo, Iturralde, Ruesta, Ibanez, 1999; Koutedakis, Myszkewycz, Soulas,
Papapostolou, Sullivan, Sharp, 1999), which in turn
may be coupled to an increased vulnerability for musculoskeletal injuries. This risk could be further augmented
by a deficient energy supply, owing to lack of breaks
for meals and/or an ambition to keep a low body
weight, even though that was not substantiated by the
BMI-values obtained.
Many of the injuries were reported to occur either
before or after a dance training session, i.e., when extensive stretching is undertaken as part of the `warmup' and preparation for training or `tapering down' and
relaxation after a hard training session. Earlier studies
have indicated that poor warm-up before training or
competition may increase the risk of injury ( Ekstrand
& Gillqvist, 1983; Safran, Seaber, Garrett, 1989;
Noonan, Best, Seaber, Garrett, 1993). The present findings, based on the recollection of the subjects, indicate
that caution is warranted concerning the inclusion of
too extensive stretching in these exercises. This seems to
be true also for the period after training, where a fatigued hamstring muscle-tendon complex may be more
at risk to be torn by extensive stretching. Recent studies
have started to question the generally accepted beneficial effects of stretching, which may even result in

233

Askling et al.
injury (Taylor, Dalton, Seaber, 1990; Holmich et al.,
1999; Pope, Herbert, Kirwan, Graham, 2000). Also for
musculoskeletal injuries encountered during forceful
activities such as soccer, an increased incidence has
been demonstrated at the later stages of a match, indicating the importance of fatigue as a risk factor for
muscle injuries (Dornan, 1971; Mair, Seaber, Glisson,
stenberg & Roos, 2000).
Garrett, 1996; O

Injury location
Overall, the dancers' reports of their injuries were generally very similar regarding, e.g., activity at the time of
injury and injury location. Approximately 9 of 10
acutely injured dancers stated that they were injured
while stretching, which is a slow, voluntarily controlled
activity that ends in an extreme joint position, in this
case most often a sagittal split (fig. 2) or a side split
position. These positions are both integral parts of
normal every-day training. This finding is in contradiction to all previous studies, which indicate that acute
hamstring injuries occur only during explosive or high
speedhigh force activities such as sprinting, jumping
and soccer playing (e.g., Burkett, 1976; Garett et al.,
1984; Stanton & Purdam, 1989; Garrett, 1996; Kujula
et al., 1997; Orchard, Marsden, Lord, Garlick, 1997;
Clanton & Coupe, 1998). The exact joint positions
where these violent pulls occur are not well documented, however, they seem to be related to the magnitude of force and/or rate of force development rather
than extreme joint positions. Thus, there appear to be,
at least, two ways to cause an acute hamstring strain,
either by slow controlled stretching to an extreme position or by exposing the, presumably activated, muscles
to an abrupt forceful stretch.
Interestingly, Askling et al., (2000) reported two
cases of acute hamstring strain injuries with diverging
aetiologies corresponding to the two types discussed
above. The results of the magnetic resonance imaging
indicated that also the tissues primarily involved varied
between the two cases. In the dancer, for whom the
injury occurred during slow stretching, the pathological changes were found in the tendon, whereas in
the sprinter, who encountered his injury during a 100-m
race, the muscle belly was primarily injured, as has
been documented before (De Smet & Best, 2000).
Furthermore, the healing time for the dancer with
tendon injury was significantly longer (18 months)
compared to the sprinter with an acute injury in the
muscle belly (3 months).
Only 15% of the acutely injured dancers reported any
preinjury symptoms, e.g., stiffness and pain. Thus,
according to the recollection of the subjects, the acute
hamstring injury appeared to occur without any
warning, which would make it hard to prevent by stopping the activity in time. Even after encountering the
injury, often experienced as a `pop' or a sharp pain,

234

only about half of the dancers stated that they stopped

their ongoing activity. Additionally, many dancers did
not rest from training during the weeks following their
injury and very few sought medical treatment. All the
acutely injured dancers greatly underestimated the time
it would take to recover and return to dance training
judging from the marked difference in times they remembered for expected vs. experienced recovery from
the injury. Neglecting an injury like that may very well
have exaggerated the effects as well as prolonged the
recovery time. This emphasizes the need for more education about the effects and acute handling of this type
of muscle strain injuries. An immediate treatment and a
rehabilitation program closely integrated with the
healing process are critical for minimizing the risks for
re-injury (Thorsson, 1996; Jarvinen, Kaariainen,
Jarvinen, Kalimo, 2000; Kannus, 2000). A high pain
threshold on the part of dancers may also be related to
the state of persistent musculoskeletal pain, ache and
discomfort, which has been reported as a more or less
`normal' condition in this occupation (Ramel & Moritz,
1994).
A limitation of this study, and other similar studies
using retrospective questionnaires to survey the prevalence of injuries, is that the injuries have occurred over
an extended period of time. Details from way back may
therefore be less clearly recollected. Another limitation
is that, in the absence of a clinical examination or a
diagnostic imaging procedure, the location of the injury
will have to rely on the memory of the dancer and his/
her ability to characterize the injury solely from the
evoked pain sensation. However, an injury of this
degree of severity causes a trauma in the life of the
dancer, which is likely to be well remembered. All
dancers could describe the circumstances around the
occurrence of the injury very vividly, in many cases
supported by notes from a training diary. Within
these and other limitations of the study, it is a strikingly
coherent picture that emerges from the results.
Perspectives
This retrospective questionnaire gives rise to some
interesting speculations as to the nature of distension
injuries to the hamstring muscles in dancers. It was
striking that a clear majority of the injured dancers
reported that their injuries occurred in connection
with slow, apparently well-controlled, stretching activities. If this is true, it widens the view on possible aetiologies for this type of injury, previously encompassing
only powerful actions, such as sprinting. Extrapolated
to practice, the results indicate that stretching activities
be carried out with caution, particularly as part of the
`warm-up' before and `cool-down' after a training session. Also, there seems to be a need for more information about the seriousness and acute treatment of
these injuries to minimize continuing problems.

Hamstring muscle injuries

Key words: hamstring strains; dancers; stretching; recovery time.

Acknowledgements
Financial support was obtained from the Swedish Center for
Sport Research and the Swedish Dancesport Federation.

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