Pelvic region bone density, soft tissue mass, and injury frequency in female professional ballet dancers and soccer athletes

Abstract

We recently observed a high prevalence of low pelvic bone mineral density (BMD) in female professional ballet performers. Because this population is susceptible to musculoskeletal overuse injuries, we aimed to determine which regions of the pelvis may be at greatest risk compared to general population females (GENPOP) as well as professional female soccer players (SOCCER, a comparison to other elite athletes regularly subjected to high degrees of loading). Three groups of age-matched females [(GENPOP; n = 38, 27±1yrs), (BALLET; single company, n = 36, 26±3yrs), (SOCCER; single NWSL® club, n = 34, 25±1yrs)] consented to have their BMD and body composition assessed (DEXA, GE®). In addition to soft tissue and total and regional BMD analyses, a segmental analysis of the pelvis was performed to determine site-specific BMD for the iliac fossa, iliac fossa/iliac crest/ilium combined, pubic bone, ischium, and sacrum. A mixed-model ANOVA followed by a Tukey's post-hoc test was used to compare the groups (Type-I error; α = 0.05). The BALLET group had lower pelvic BMD for all measures (Avg.%Diff. = 15%-27%, p<0.001) compared to the SOCCER group and for the ischium (Avg.%Diff.= 8%; p=0.007) and sacrum (Avg.%Diff. ​= ​7%; p = 0.028) compared to the GENPOP group. The BALLET group had lower lean mass for all measures compared to the other groups (Avg.%Diff. = 12%-18%; p < 0.01). Professional ballet performers exhibit reduced pelvic region soft tissue and site-specific BMD not previously detected using standard DEXA analyses. These findings highlight which pelvic regions may benefit from preventative strength training and/or nutritional interventions.

Keywords

Ballet / Bone / Bone density / Athlete / Female athlete

Ethical approval statement

The procedures were approved by the institutional review board for research involving human subjects (IRB# PRO00024667), and all participants provided informed consent for their data to be used for research purposes prior to participating in the experimental procedures.

Submission statement

The results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The manuscript has not been published and is not under consideration for publication elsewhere.

Conflict of interest

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

References

[1] B.S. Lambert, M.T. Cain, T. Heimdal, et al.. Physiological Parameters of bone health in elite ballet dancers. Med. Sci. Sports Exerc., 52 (8) ( 2020), pp. 1668-1678, DOI: 10.1249/MSS.0000000000002296

[2] T. Amorim, Y. Koutedakis, A. Nevill, et al.. Bone mineral density in vocational and professional ballet dancers. Osteoporos. Int., 28 (10) ( 2017), pp. 2903-2912, DOI: 10.1007/s00198-017-4130-0

[3] C. Castelo-Branco, F. Reina, A.D. Montivero, M. Colodrón, J.A. Vanrell. Influence of high-intensity training and of dietetic and anthropometric factors on menstrual cycle disorders in ballet dancers. Gynecol. Endocrinol., 22 (1) ( 2006), pp. 31-35, DOI: 10.1080/09513590500453825

[4] J. Vescovi, S. Jamal, M.J. De Souza. Strategies to reverse bone loss in women with functional hypothalamic amenorrhea: a systematic review of the literature. Osteoporos. Int., 19 (4) ( 2008), pp. 465-478, DOI: 10.1007/s00198-007-0518-6

[5] P. Burckhardt, E. Wynn, M.-A. Krieg, C. Bagutti, M. Faouzi. The effects of nutrition, puberty and dancing on bone density in adolescent ballet dancers. J. Dance Med. Sci., 15 (2) ( 2011), pp. 51-60

[6] A.F. Doyle-Lucas, J.D. Akers, B.M. Davy. Energetic efficiency, menstrual irregularity, and bone mineral density in elite professional female ballet dancers. J. Dance Med. Sci., 14 (4) ( 2010), pp. 146-154

[7] N. Keay, I. Fogelman, G. Blake. Bone mineral density in professional female dancers. Br. J. Sports Med., 31 (2) ( 1997), pp. 143-147, DOI: 10.1136/bjsm.31.2.143

[8] K.M. Khan, R.M. Green, A. Saul, et al.. Retired elite female ballet dancers and nonathletic controls have similar bone mineral density at weightbearing sites. J. Bone Miner. Res., 11 (10) ( 1996), pp. 1566-1574, DOI: 10.1002/jbmr.5650111025

[9] W.D.V.M. Lichtenbelt, M. Fogelholm, R. Ottenheijm, K.R. Westerterp. Physical activity, body composition and bone density in ballet dancers. Br. J. Nutr., 74 (4) ( 1995), pp. 439-451, DOI: 10.1079/bjn19950150

[10] H.P. Dimai. Use of dual-energy X-ray absorptiometry (DXA) for diagnosis and fracture risk assessment; WHO-criteria, T-and Z-score, and reference databases. Bone, 104 ( 2017), pp. 39-43, DOI: 10.1016/j.bone.2016.12.016

[11] T.K. Koo, M.Y. Li. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med, 15 (2) ( 2016), pp. 155-163, DOI: 10.1016/j.jcm.2016.02.012

[12] T.A. Burkhart, K.L. Arthurs, D.M. Andrews. Manual segmentation of DXA scan images results in reliable upper and lower extremity soft and rigid tissue mass estimates. J. Biomech., 42 (8) ( 2009), pp. 1138-1142, DOI: 10.1016/j.jbiomech.2009.02.017

[13] S.S. Sawilowsky. New effect size rules of thumb. J. Mod. Appl. Stat. Methods, 8 (2) ( 2009), p. 26, DOI: 10.22237/jmasm/1257035100

[14] C. Foster, M.E. Armstrong.What types of physical activities are effective in developing muscle and bone strength and balance?. J Frailty Sarcop Falls, 3 (2) ( 2018), p. 58, DOI: 10.22540/JFSF-03-058

[15] D.D. Brown. Nutrition, bone health, and the young dancer. Prevention of Injuries in the Young Dancer, Springer ( 2017), pp. 187-201

[16] D. Logue, S.M. Madigan, E. Delahunt, M. Heinen, S.-J. Mc Donnell, C.A. Corish. Low energy availability in athletes: a review of prevalence, dietary patterns, physiological health, and sports performance. Sports Med., 48 (1) ( 2018), pp. 73-96, DOI: 10.1007/s40279-017-0790-3

[17] N.M. Hirsch, J.C. Eisenmann, S.J. Moore, S.D. Winnail, M.A. Stalder. Energy balance and physical activity patterns in university ballet dancers. J. Dance Med. Sci., 7 (3) ( 2003), pp. 73-79

[18] A. Ivković, M. Franić, I. Bojanić, M. Pećina. Overuse injuries in female athletes. Croat. Med. J., 48 (6) ( 2007), p. 767, DOI: 10.3325/cmj.2007.6.767

[19] M. Quintas, R. Ortega, A. López-Sobaler, G. Garrido, A. Requejo. Influence of dietetic and anthropometric factors and of the type of sport practised on bone density in different groups of women. Eur. J. Clin. Nutr., 57 (1) ( 2003), pp. S58-S62, DOI: 10.1038/sj.ejcn.1601817

[20] H. Hirschfeld, R. Kinsella, G. Duque. Osteosarcopenia: where bone, muscle, and fat collide. Osteoporos. Int., 28 (10) ( 2017), pp. 2781-2790, DOI: 10.1007/s00198-017-4151-8

[21] N. Kawao, H. Kaji. Interactions between muscle tissues and bone metabolism. J. Cell. Biochem., 116 (5) ( 2015), pp. 687-695, DOI: 10.1002/jcb.25040

[22] U. Tarantino, E. Piccirilli, M. Fantini, J. Baldi, E. Gasbarra, R. Bei. Sarcopenia and fragility fractures: molecular and clinical evidence of the bone-muscle interaction. J. Bone Joint Surg., 97 (5) ( 2015), pp. 429-437, DOI: 10.2106/JBJS.N.00648

[23] H. Tilg, A.R. Moschen. Adipocytokines: mediators linking adipose tissue, inflammation and immunity. Nat. Rev. Immunol., 6 (10) ( 2006), pp. 772-783, DOI: 10.1038/nri1937

[24] M.L. Bouxsein, P. Szulc, F. Munoz, E. Thrall, E. Sornay-Rendu, P.D. Delmas.Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk. J. Bone Miner. Res., 22 (6) ( 2007), pp. 825-831, DOI: 10.1359/jbmr.070309

[25] S. Ishii, J.A. Cauley, G.A. Greendale, et al.. Pleiotropic effects of obesity on fracture risk: the Study of Women's Health across the Nation. J. Bone Miner. Res., 29 (12) ( 2014), pp. 2561-2570, DOI: 10.1002/jbmr.2303

[26] D. Scott, R.M. Daly, K.M. Sanders, P.R. Ebeling. Fall and fracture risk in sarcopenia and dynapenia with and without obesity: the role of lifestyle interventions. Curr. Osteoporos. Rep., 13 (4) ( 2015), pp. 235-244, DOI: 10.1007/s11914-015-0274-z

[27] D.-C. Chan, C.-B. Chang, D.-S. Han, et al.. Effects of exercise improves muscle strength and fat mass in patients with high fracture risk: a randomized control trial. J. Formos. Med. Assoc., 117 (7) ( 2018), pp. 572-582, DOI: 10.1016/j.jfma.2017.05.004

[28] P.J. Smith, B.J. Gerrie, K.E. Varner, P.C. McCulloch, D.M. Lintner, J.D. Harris. Incidence and prevalence of musculoskeletal injury in ballet: a systematic review. Orthop J Sports Med, 3 (7) ( 2015), DOI: 10.1177/2325967115592621. 2325967115592621

[29] T.O. Smith, L. Davies, A. De Medici, A. Hakim, F. Haddad, A. Macgregor. Prevalence and profile of musculoskeletal injuries in ballet dancers: a systematic review and meta-analysis. Phys. Ther. Sport, 19 ( 2016), pp. 50-56.

[30] A.M. Vera, B.D. Barrera, L.E. Peterson, et al.. An injury prevention program for professional ballet: a randomized controlled investigation. Orthop J Sports Med, 8 (7) ( 2020), DOI: 10.1177/2325967120937643

[31] A.W. Clark, M.K. Goedeke, S.R. Cunningham, et al.. Effects of pelvic and core strength training on high school cross-country race times. J. Strength Condit Res., 31 (8) ( 2017), pp. 2289-2295, DOI: 10.1519/JSC.0000000000001729

[32] E.J. Roelofs, A.E. Smith-Ryan, M.N. Melvin, H.L. Wingfield, E.T. Trexler, N. Walker. Muscle size, quality, and body composition: characteristics of division I cross-country runners. J. Strength Condit Res., 29 (2) ( 2015), p. 290, DOI: 10.1519/JSC.0000000000000729

The authors would like to thank James Nelson (Executive Director), Stanton Welch (Artistic Director), Carina Nasrallah (Athletic Trainer), Haley Goble (Research Coordinator), Dr. Kevin Varner (Medical Director) and all of the dancers from the Houston Ballet Company for their support and participation in this study. The authors would also like to thank the Houston Dash organization for their participation in this investigation.