Orthopedic & Biomechanics 561

Joint Range of Motion and Patellofemoral Pain in

Dancers

Authors N. Steinberg1,2, I. Siev-Ner3, S. Peleg1, G. Dar4, Y. Masharawi5, A. Zeev2, I. Hershkovitz1

1
Affiliations Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
2
The Zinman College of physical Education and Sports Sciences at the Wingate Institute, Netanya, Israel
3
Orthopedic Rehabilitation Department, Sheba Medical Center, Tel-Hashomer, Israel

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4
Department of Physical Therapy, Faculty of Social Welfare & Health Studies, University of Haifa, Haifa, Israel
5
Department of Physiotherapy, School of Health Professions, Tel Aviv University, Israel

Key words Abstract and limited hamstrings and lumbar spine were
●▶ injuries
▼ significantly less prone to developing PFPS com-
●▶ dance
The aim of the present study was to determine pared to dancers with average ROM: 19.2 % vs.
●▶ knee joint
the association between joint range of motion 26.2 % (p = 0.014); 13.7 % vs. 26.1 % (p < 0.001);
●▶ joint range of motion

●▶ patellofemoral pain (ROM) and patellofemoral pain syndrome (PFPS)
syndrome in young female dancers. The study population
included 1 359 female dancers, aged 8–20 years.
All dancers were clinically examined for current
PFPS, and their joint ROM was measured at the
lumbar spine and the lower extremities. 321
of the 1 359 dancers (23.6 %) experienced PFPS.
Prevalence of the syndrome increased with the
dancer’s age (p < 0.001). Dancers with hypo ROM
in hip external rotation, ankle plantar-flexion,
ankle/foot pointe, hip abduction, hip extension,
12.2 % vs. 26.2 % (p < 0.001); 10.0 % vs. 25.3 %
(p < 0.001); 12.6 % vs. 24.2 % (p < 0.001); and 9.3 %
vs. 28.2 % (p < 0.001), respectively. The group
with the smallest prevalence of PFPS (10.2 %)
manifested restricted ROM at both the hip and
ankle/foot joints. Dancers with decreased hip and
ankle/foot joints ROM are less prone to develop
PFPS. When making an association between joint
ROM and injuries, not only the ROM at the tar-
geted joint should be considered, but also the
ROM at neighboring joints.

accepted after revision
December 30, 2011
Bibliography
DOI http://dx.doi.org/
10.1055/s-0031-1301330
Published online:
May 4, 2012
Int J Sports Med 2012; 33:
561–566 © Georg Thieme
Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Dr. Nili Steinberg
Tel-Aviv University
Sackler Faculty of Medicine,
Anatomy and Anthropology
Ramat Aviv 69978
Tel-Aviv
69978 Tel Aviv
Israel
Tel.: +972/3/640 9495
Fax: +972/3/640 7306
knopp@wincol.ac.il
Dancers are perceived by the public as having fit
and slim bodies and large joint range of motion
(ROM) [19], the latter considered being an advan-
tage in many types of dance performances [21].
Nonetheless, for attaining and maintaining the
intense demands of various dance positions and
to avoid injuries, dancers not only need flexible
joints but also sufficient strength and balance
[6, 20, 24, 30]. Proper dance technique relies
heavily on extended joint ROM in the lumbar
spine and lower limbs [11], something that not
all young dancers are capable of. Several studies
have shown, for example, that most young danc-
ers are not capable of producing an external rota-
tion in the lower limbs greater than 60 °, required
for “ideal” ‘turnout’ (involving external rotation
at the hip, external rotation at the knee, tibial
torsion, and abduction of the forefoot at the mid-
tarsal joint) [26], or 180 ° of plantar-flexion in the
ankle/foot joints for “ideal” ‘en pointe’ position
[3, 33]. Van Dillen and colleagues [39] suggested
that limited joint ROM in certain joints such as
the hip (rotation), may be a contributing factor in
the development or persistence of injuries or
symptoms (such as low back pain) in athletes
who regularly perform rotation-related exer-
cises. Aalto and colleagues [1] demonstrated that
recreational dancers who practice ‘en pointe’ in a
‘turnout’ position with insufficient joint stability
predispose themselves to injury. Dancers who
lack the required joint ROM for ideal positions
tend to develop compensatory strategies [2, 18],
which, in turn, may lead to an injury [15, 25].
Negus and colleagues [25] claimed that in the
absence of adequate ROM, attempts to achieve
“ideal” positions may expose the dancer to injury.
For example, poor hip external rotation can be
compensated by anterior pelvic tilt, external
rotation of the tibia, and pronation of the feet, all
of which can lead to various injuries [4, 10, 23, 35].
Most previous studies have looked for the asso-
ciation between common dance injuries such as
PFPS, and risk factors such as technique faults,
poor ‘turnout’ and inappropriate compensatory
strategies [13, 25]. Little research exists on the
relationships between joint ROM in the lower
extremity joints and self-reported injuries
among dancers [4]. According to Hincapié et al.
[15], this is a severe shortcoming in our knowl-
edge and limits our ability to develop preventive

Steinberg N et al. Joint Range of Motion … Int J Sports Med 2012; 33: 561–566
562 Orthopedic & Biomechanics

strategies for musculoskeletal injuries in dancers. Furthermore,
no study has yet examined this relationship via the kinematic
chain theory. This theory suggests that movement at one joint of
the lower extremity may affect all other joints by chain reaction
[27]. When one joint cannot preserve a correct movement, a
Finally, we divided the dancers into 18 groups based on their
joint ROM categories in 3 joints: hip (external rotation), knee
(extension), and ankle/foot (pointe). For example, dancers with
average ROM at the hip, hyper ROM at the knee and average ROM
at the ankle/foot were classified into group “K” (see ●
▶ Table 3).

chain reaction will start and cause the other adjacent joints to
achieve a “false” position. This incorrect movement might result
in the development of an injury.
The “3-joint model” suggests that the occurrence of an injury in
the target joint depends, among other things, on the joint ROM
in the neighboring distal and proximal joints. In light of the
above model, the aim of the current study is to determine the
association between ROM at the hip and ankle/foot joints in
regard to the PFPS in young female dancers.
The research was approved by a Human Subjects Review Board
in accordance with the Helsinki Declaration, and was conducted
in accordance with the ethical standards of the International
Journal of Sports Medicine [14]. Approval was also obtained
from the Ministry of Education and each school's administra-
tion. A consent form was signed by each participant and one
parent, and the rights of the dancers were protected.
Data analysis
To test for an association between ROM (hypo, average, and hy-

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per categories) and PFPS, the following statistical analysis was
Methods carried out: first, Chi-square tests were conducted for each joint
▼ separately to check for an association between ROM categories
A group of 1 359 female dancers, aged 8–20 years, participated and PFPS. Second, following the assignment of the dancers into
in the study. The dancers were recruited from different dance 18 groups based on their ROM categories (see ● ▶ Table 3), all

schools and were active in a variety of dance disciplines: classi- groups were compared to group “A” by Chi-square test. To over-
cal ballet, modern dance, jazz, and composition lessons. In the come type I error due to multiple testing, we applied the Bonfer-
first stage, dancers were interviewed for personal details (such roni correction to set the p value for significant. A logistic regres-
as age), body features (weight, height), and total hours of dance sion (forward stepwise) was performed to allocate predicting
practice per week (see ● ▶ Table 1). In the second stage, each par- variables for PFPS (controlling for age). Risk ratio (RR) was cal-
ticipant was physically screened for passive joint ROM at the culated as the ratio of the probability of dancers with hypo (or
combined ankle/foot plantar-flexion (pointe), plantar-flexion of hyper) ROM in a given movement to develop PFPS vs. the prob-
ankle joint, dorsiflexion of ankle joint, external rotation of hip ability of dancers with average ROM.
joint, internal rotation of hip joint, abduction of hip joint, flexion
of hip joint, flexion of knee joint, extension of knee joint, lumbar
spine and hamstrings, and active extension of hip joint. Joint
Table 1 Number of dancers, body features (weight, height), and total hours
ROM was measured bilaterally using a goniometer and measur-
of dance practice per week, by age.
ing tape, following the technique recommended by Hoppenfeld
[16] and described in detail in Steinberg et al. [34]. Dancers were Age N Weight Height H. of practice
classified into 3 groups of joint ROM: hypo ROM ( > − 1 S.D. of (Kg) (cm) (per week)
mean), average ROM ( ± 1 S.D. of mean), and hyper ROM ( > +1S.D. ̅
X S.D ̅
X S.D ̅
X S.D
of mean) (see ● ▶ Table 2), based on ROM distribution for each
8–9 105 27.3 7.6 129.1 14.4 3.3 0.9
joint obtained for the general dancer population (see Steinberg 10–11 246 32.1 7.3 139.7 9.1 4.7 2.5
et al. [34]). No warm-up was performed prior to testing. 12–13 304 39.4 9.4 150.5 9.2 7.3 3.3
In the third stage, all dancers were questioned about current 14–16 642 49.5 8.3 158.9 15.2 10.9 4.4
knee pain evoked by movements or exercises that disturbed 17–20 62 51.5 9.6 155.9 17.6 12.0 5.6
their dance practice or daily life activity. Dancers who reported
current physical constraints were clinically examined by a phy-
sician to eliminate other knee problems, such as: a) knee align- Table 2 Hypo ROM, average ROM and hyper ROM in different joints and
movements.
ment (knee valgus/knee varum), and orientation of the patella in
relationship to the tibia (e. g., tibial torsion); b) anterior/poste- ROM Hypo Average Hyper
rior stability of the knee joint (Lachman test and drawer sign), ROM( °)* ROM( °)** ROM( °)***
and lateral/medial stability; c) medial/lateral laxity of the ankle/foot pointe ≤ 75 76–90 ≥ 91
patella; d) tears in the meniscus (McMurray test and Appley ankle plantar-flexion ≤ 45 46–64 ≥ 65
test). ankle dorsiflexion ≤5 6–15 ≥ 16
A dancer was considered positive for PFPS only if: a) all the above hip external rotation ≤ 50 51–60 ≥ 61
risk factors (knee alignment, stability, laxity, and meniscus hip internal rotation ≤ 45 46–65 ≥ 66
tears) were rejected, b) the pain could be reproduced during hip abduction ≤ 45 46–59 ≥ 60
clinical examination, c) knee swelling was evident, or d) a posi- hip extension ≤ 20 21–39 ≥ 40
tive grinding sign and/or a positive Patellar Inhibition Test (PIT) hip flexion ≤ 135 136–150 ≥ 151
was obtained when the knee and especially the patella were pal- knee flexion ≤ 140 141–150 ≥ 151
knee extension – 0 ≥5
pated, contracted and stretched.
lower back & ≥ 1 cm distance – Forehead
Dancers were excluded from the PFPS group if they had concom-
hamstrings between fore- touching the
itant injury or pathology of other knee structures (e. g., menisci, head and knees knees
collateral and cruciate ligaments, patellar tendon, iliotibial band, * > − 1 SD from the mean
pes anserinus), a history of knee surgery, or patellofemoral dis- ** ± 1 SD from the mean
location or subluxation. *** > +1 SD from the mean

Steinberg N et al. Joint Range of Motion … Int J Sports Med 2012; 33: 561–566
 Orthopedic & Biomechanics 563

Group N Hip external Knee ankle/foot Injured P value*,** Table 3 Division of the dancers
into 18 groups based on their
rotation extension pointe dancers ( %)
hip, knee, and ankle/foot ROM
A 503 average average average 26.4 categories.
B 128 hypo average hypo 10.2 0.0002
C 143 hypo average average 27.3 0.920
D 24 hypo average hyper 20.8 0.708
E 11 hypo hyper hypo 18.2 0.538
F 21 hypo hyper average 23.8 0.999
G 5 hypo hyper hyper 0 0.180
H 214 average average hypo 22.4 0.298
I 84 average average hyper 25.0 0.887
J 28 average hyper hypo 14.3 0.152
K 67 average hyper average 31.3 0.396
L 13 average hyper hyper 46.2 0.114
M 12 hyper average hypo 8.3 0.279
N 56 hyper average average 28.6 0.862

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O 9 hyper average hyper 22.2 0.920
P 6 hyper hyper hypo 16.7 0.920
Q 12 hyper hyper average 25.0 0.823
R 4 hyper hyper hyper 0 0.532
*Comparison with group A
**Bonferroni correction (p = 0.0029)

Reliability of measurements
30
Intra-class correlation (ICC) values appear in Steinberg et al. [34],
testifying to high intra- and inter-tester reliabilities of all meas- 25
Dancers with PFPS (%)

urements.
20

15
Results
10
▼
All dancers were non-professional female dancers, age 8–20 5
years (see ● ▶ Table 1).

Of the 1 359 dancers, 321 (23.6 %) were found to be positive for 0

8–9 10–11 12–13 14–16 17–20
PFPS. Prevalence of PFPS increased with age (p < 0.001); only Age (years)
5.5 % of the girls in the young age cohort (8–9 years) manifested
PFPS upon examination, whereas in the 12–20 year-old age Fig. 1 Prevalence of PFPS in 5 age cohorts.
group, 24–28 % of the girls had PFPS (●▶ Fig. 1).

No association was found between knee ROM (hyper-extension)

and PFPS (see ● ▶ Table 4). Dancers with limited ROM at the hip
and ankle/foot joints were less prone to developing PFPS
(see ● ▶ Table 4). For example, 19.2 % of the dancers with below
average hip external rotation ROM had PFPS, a much lower rate
compared to dancers with average hip external rotation ROM
(26.2 %) (p = 0.014). Furthermore, 13.7 % of dancers with “hypo”
ankle plantar-flexion ROM and 12.2 % of dancers with “hypo”
ankle/foot pointe ROM were found positive for PFPS, compared
to 24.5–26 % of dancers with average/hyper ROM (p = 0.001). The
risk ratio (RR) and confidence interval (CI) values appear
H – dancers with average ROM at the hip and knee and hypo
ROM at the ankle/foot (15.7 %), group C – dancers with hypo
ROM at hip and average ROM at the knee and ankle/foot (10.5 %),
and group B – dancers with hypo ROM at the hip and ankle/foot
and average ROM at the knee (9.4 %). Very few dancers mani-
fested a combination of hyper ROM in one joint and hypo ROM in
the other. Dancers with hypo ROM at the hip and ankle/foot and
average ROM at the knee (group B) were significantly less prone
to developing PFPS compared to group A (10.2 % vs. 26.4 %)
(●▶ Table 3). The results of the logistic regression analysis appear

in ●▶ Table 4. Only dancers with hypo ROM manifested signifi- in ●▶ Table 5. The variables entered into the equation predicting

cant RR relative to dancers with average ROM; pointe RR = 0.47
(CI: 0.3–0.7); ankle plantar flexion RR = 0.52 (CI: 0.4–0.8); hip
abduction RR = 0.40 (CI; 0.3–0.6); hip extension RR = 0.52 (CI;
0.4–0.8). Similar patterns were found for the prevalence of PFPS
among dancers with limited hamstrings and lumbar spine ROM
(p < 0.001), among dancers with limited hip abduction ROM
(p < 0.001), and among dancers with limited hip extension ROM
(p < 0.001). No association between ROM and PFPS was found in any
of the other movements examined (e. g., ankle dorsiflexion ROM).
The relative number of dancers in each of the 18 groups is shown
in ●▶ Table 3. Group A – dancers with average ROM in all 3 move-
ments is the largest (37 % of all dancers), followed by group
PFPS were age (OR = 1.105; CI = 1.061–1.150), hypo ROM in hip
abduction (OR = 0.396; CI = 0.246–0.637), hypo ROM in ankle/
foot pointe (OR = 0.506; CI = 0.316–0.810), and hyper ankle dorsi-
flexion (OR = 1.527; CI = 1.079–2.160).
Discussion
▼
The main finding of the current study is that dancers with
decreased hip and ankle/foot ROM have a lower prevalence of
PFPS, and that PFPS is more affected by the amount of movement
in the ankle/foot and the hip than by the amount of movement

Steinberg N et al. Joint Range of Motion … Int J Sports Med 2012; 33: 561–566
564 Orthopedic & Biomechanics

Table 4 Prevalence of dancers with patellofemoral pain by ROM category in different movements at the hip, ankle and knee joints*.

Hypo ROM Average ROM Hyper ROM Hypo Hyper

vs. Ave. vs. Ave.
N % Risk CI N % Risk N % Risk CI p** p**
Ratio Ratio Ratio
pointe 25 12.2 0.47 0.3–0.7 261 26.2 1.00 34 24.5 0.94 0.7–1.3 0.001 0.675
ankle PF 34 13.7 0.52 0.4–0.8 210 26.1 1.00 73 26.1 1.00 0.8–1.3 0.001 0.996
ank. dorsi. 47 20.3 0.85 0.7–1.2 219 24 1.00 55 26.7 1.11 0.8–1.4 0.227 0.418
hip ext.rot. 64 19.2 0.73 0.6–1.0 187 26.2 1.00 70 23.5 0.90 0.7–1.2 0.014 0.368
hip int.rot. 38 27.1 1.14 0.8–1.5 247 23.7 1.00 34 21.4 0.90 0.7–1.3 0.369 0.524
hip abd. 26 10.0 0.40 0.3–0.6 193 25.3 1.00 92 30.7 1.21 0.9–1.4 0.001 0.073
hip flex. 32 21.9 0.91 0.7–1.3 256 24 1.00 21 22.3 0.93 0.6–1.4 0.585 0.722
hip exten. 25 12.6 0.52 0.4–0.8 232 24.2 1.00 49 32.2 1.33 1.0–1.6 0.000 0.034
knee flex. 62 21.0 0.88 0.7–1.2 190 23.8 1.00 54 26.6 1.12 0.8–1.4 0.326 0.413
knee exten. – – 279 23.4 1.00 42 25 1.07 0.8–1.4 – 0.653

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low. back and ham. 29 9.3 – – – 290 28.2 0.000 –
*Due to missing data sample size varied from one measurements to another
**Bonferroni correction (p = 0.004)

Table 5 Predicted variables for patellofemoral pain: logistic regression analysis.

Model components Variables in the equation Coefficient S.E p-value Odds ratio C.I. (95 %)
patellofemoral pain age 0.100 0.021 0.000 1.105 1.061–1.150
syndrome hip abduction1 − 0.926 0.242 0.000 0.396 0.246–0.637
hip abduction2 0.116 0.151 0.443 1.123 0.835–1.510
ankle/foot pointe1 − 0.681 0.240 0.005 0.506 0.316–0.810
ankle/foot pointe2 − 0.428 0.213 0.044 0.652 0.430–0.988
ankle dorsiflexion1 − 0.079 0.196 0.689 0.924 0.630–1.358
ankle dorsiflexion2 0.423 0.177 0.017 1.527 1.079–2.160
1
= Girls with Hypo ROM vs. girls with average ROM
2
= Girls with Hyper ROM vs. girls with average ROM

at the knee joint itself. This finding supports the “3-joint model”,
which suggests that ROM at all joints involved in a specific kin-
ematics chain movement, must be considered when an injury
occurs. Many movements in the lower extremities require coor-
dinated actions between the hip, the knee and the ankle/foot
joints (such as walking, running, and jumping); failure to per-
form the correct pattern of movement in one joint may result in
inappropriate direction of force and false motion in the other
joints [45].
In particular, the relationship between hip movement and knee
movement suggests that deviation from normal hip ROM might
change the effectiveness of the muscles acting on the knee joint
[40]. Hence, when dancers perform the ‘turnout’ position with
restricted hip external rotation ROM, their quadriceps femoris
elevates the patella in an almost vertical direction along the tro-
chlear groove (as illustrated in ● ▶ Fig. 2a). Nevertheless, when
dancers force themselves to reach hyper-external rotation at the
hip joint with knees flexed (as in pli’e), the patella moves later-
ally over the lateral condyle, and muscle activation of the rectus
femoris is less effective [41]. In this position, the vastus lateralis
muscle increases the force of contact between the patella and
the femur, resulting in a gradual grinding of its cartilage (as
illustrated in ●▶ Fig. 2b) [12, 32]. Previous studies have demon-
strated that excessive lateral tracking of the patella might be
associated with chondromalacia patellae [32] and patellofemo-
ral pain [42]. Conversely, dancers who perform dancing with
limited hip external rotation ROM, and who practice controlled
‘turnout’ (during pli’e), direct the action of their muscles (to
move the patella above the second toe) and preserve the correct
kinematic movement pattern, thus preventing knee injuries [5].
Considering the movements at the ankle/foot and knee joints,
we should realize that combined movement in these joints must
be coordinated in order to prevent injuries [36]. Many injuries of
the lower extremities are attributed to lack of synchrony
between various movements at the knee and foot joints, result-
ing in false absorption of forces that are transferred from the
ground along the lower extremity [12, 36, 37]. Several studies
have suggested a positive association between insufficient
plantar-flexion and injuries among dancers [8, 28]. Additionally,
it was found that hyper-mobility at the foot joint might increase
the forces and the stresses at the foot, predisposing athletes to
patellofemoral pain [7]. Our explanation for the association
between limited plantar-flexion/pointe and the low prevalence
of PFPS is that dancers with restricted plantar-flexion/pointe
ROM can generate smaller acceleration when pushing off from
the ground (for high jumping and other dance requisites). Hence,
when landing with the knee flexed, the patellofemoral joint
absorbs smaller compressive forces from the femur and trans-
forms less force into tensile forces directed towards the quadri-
ceps muscle, the patellar tendon, and the patellar cartilage [12].
Most previous studies that have attempted to elucidate the asso-
ciation between ROM and injuries were unidirectional, that is,
they focused on the relationship between specific joint ROM and
injury [29, 38, 44]. For example, hyper-extension of the knee
(genurecurvatum) was found to be associated with increased
risk for ACL injuries [38]; increased tightness of the hamstring or

Steinberg N et al. Joint Range of Motion … Int J Sports Med 2012; 33: 561–566

Fig. 2 Quadriceps femoris muscle elevates the patella along the “patel-
lar surface” in a neutral position a, and in hyper external rotation b.
quadriceps muscles exposes athletes to a higher risk for subse-
quent muscle injury [44]. Nevertheless, Orchard et al. [29] did
not find a relationship between muscles’ flexibility and injury;
that is, flexibility of the hamstring muscles was not correlated
with hamstring muscle injury.
Although joint ROM may play a significant role in the develop-
ment of injuries [8], information relating specifically to the asso-
ciation between joint ROM and knee injuries is limited, and
contradicts the current results. Reid et al. [31] found that a lower
range of passive hip adduction and internal rotation may
increase lateral knee pain; Witvrouw et al. [43] noted that
decreased flexibility of the hamstrings and quadriceps muscles
may contribute to the development of greater patellar tendonitis
in an athletic population. The authors of the present manuscript
believe that the discrepancy between these studies and ours is
due to differences in the populations studied and the type of
movements considered. It should be realized that joint ROM in
dancers is greater than that of the non-dancer population [34].
This implies that hypo ROM in dancers corresponds to average
joint ROM in the non-dancer population. Additionally, hip
adduction and hip internal rotation that were found to be related
to knee injuries [31] are not classical dance-related movements,
and are the antagonist muscles for the ‘turnout’ position that we
measured. Further research should be conducted relating to the
association between these 2 groups of muscles and knee inju-
ries.
“3-joint model”- How does restricted joint ROM in the distal
and proximal joints of the lower extremity prevent PFPS? One of
the common movements in dancing is the transition from the
pli’e to the relev’e position (from hip and knee flexion to hip and
knee extension; from ankle dorsiflexion to ankle/foot ‘en
pointe’). This kinetic chain depicts the dancer’s body as a linked
system working in a proximal-to-distal sequence, with a muscle
activating sequence that involves mainly the quadriceps femoris
and the triceps surae muscles [22]. When a dancer rises to
relev’e with limited ‘turnout’, the quadriceps muscles bring the
Orthopedic & Biomechanics 565
knee into full extension, in the correct femoral-tibial movement
sequence [22, 27]. Dancers with limited plantar flexion/pointe
manifest anterior movement of the proximal part of the tibia
(which transfers force from the ankle to the knee joint) in an
efficient and effective pattern [22, 27]. These 2 joint forces work-
ing in neutral lower extremity alignment could decrease the
impact forces transmitted through the knee, and in turn,
decrease the risk of PFPS.
Finally, following our regression analysis, age was found to be a
significant predicting variable for PFPS. Dancers over the age of
12 are at greater risk to develop PFPS compared to younger
dancers. Our results are similar to those reported in the litera-
ture for professional ballet dancers [9], but oppose to those
reported by Gamboa and colleagues [8] who found no significant
difference in age of injured and non-injured pre-professional
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ballet dancers.
PFPS may result from various other factors such as technique
faults, poor ‘turnout’, or inappropriate compensatory strategies,
and not just from ROM in the lower extremity joints [13, 25]. We
should also recognize the fact that an injury could cause a
decrease in joint ROM. An injured joint (such as the knee) may
be associated with decreased joint ROM and reduced muscle
strength [17]. In the current study, the authors cannot be sure if
the hypo/hyper ROM were an injury predictor, or if the injury
changed the natural ROM of the dancers.
Limitations of the Study
▼
The main limitation of the present study is its cross-sectional
nature, which implies that some of the parameters exhibited
(such as rate of injury) may be affected by sampling bias. In addi-
tion, we could not control for participants not reporting their
injury, or parameters such as load/type of exercises, as dancers
were sampled from various schools and studied with different
teachers. Direct comparison with our findings is problematic,
because: a) no previous study has sought a direct association
between joint ROM and PFPS among dancers; b) our study popu-
lation included only young dancers, and c) the methodology we
utilized was different than that used in previous studies.
Conclusions
▼
This study found that decreased ROM of the hip and foot joints
appears to have a protective effect on PFPS. Through many years
of stretching and lengthening training, most dancers try to
increase their natural joint ROM, which might lead to serious
lower extremity injuries. Our results indicate that dancers
should be aware of their personal limitations, and should avoid
any efforts to compensate for limited ROM by false technique in
other joints. Therefore, when studying the association between
joint injuries and joint ROM, attention should be directed to the
ROM not only in the targeted joint but also in the neighboring
joints.
Acknowledgment
▼
We gratefully acknowledge Dina Olswang for English editing;
Anna Bechar for the drawings; Vain foundation, Zinman College
of Physical Education and Sports Sciences, Wingate Institute;
Steinberg N et al. Joint Range of Motion … Int J Sports Med 2012; 33: 561–566
566 Orthopedic & Biomechanics
Dan-David foundation; The Tassia and Dr. Joseph Meychan chair
of the history and philosophy of medicine Sackler Faculty of
Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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