Dancers experience a high incidence of injury due to the extreme
physical demands of dancing. The majority of dance injuries are
chronic in nature and occur in the lower extremities and low back.
Researchers have indicated decreased core stability (CS) as a risk
factor for these injuries. Although decreased CS is suggested to neg-
atively affect lower extremity joint motion and lumbar control
during activity, this relationship has not been extensively discussed
in previous dance literature. Understanding the relationship
between CS and injury risk is important to help reduce dance injury
incidence and improve performance. The purposes of this review
were to discuss 1) the core and components of CS, 2) the relation-
ship between CS and injury, 3) CS assessment techniques, and 4)
future dance CS research areas. CS is the integration of passive
(non-contractile), active (contractile), and neural structures to mini-
mize the effects of external forces and maintain stability. CS is main-
tained by a combination of muscle power, strength, endurance, and
sensory-motor control of the lumbopelvic-hip complex. CS assess-
ments include measuring muscle strength and power using maximal
voluntary isometric and isokinetic contractions and measuring
endurance using the Biering-Sorensen, plank, and lateral plank
tests. Measuring sensory-motor control requires specialized equip-
ment (e.g., balance platforms). Overall, limited research has com-
prehensively examined all components of CS together and their
relationships to injury. Rather, previous researchers have separately
examined core power, strength, endurance, or sensory-motor con-
trol. Future researchers should explore the multifactorial role of CS
in reducing injury risk and enhancing performance in dancers. Med
Probl Perform Art 2012; 27(3):143–148.
injury.1–7In fact, dancers experience a higher incidence of
anterior knee pain and low back pain than other types of ath-
letes.8The injuries are primarily chronic and non-traumatic
resulting from overuse and microtrauma to soft tissues
including sprains, strains and tears of muscular or ligamen-
tous tissue, tendonitis, spine injuries, stress fractures,
patellofemoral syndrome, plantar fasciitis, and low back
pain.1,4,7,9–11A variety of factors influence injury risk reports
including the particular style of dance evaluated, age, previ-
ance is an extremely demanding physical activity with a
high incidence of lower extremity and low back
ous injury, training level, and the operational definition of
injury.4Although the methodologies differ between studies,
high injury rates are continually reported in the dance injury
epidemiology literature. Previous researchers have cited
decreased core stability (CS) as a risk factor for lower extrem-
ity and low back injuries.12–18
Researchers examining the etiology of lower extremity
injuries and low back pain suggest a significant relationship
between injury risk and CS.12,19Deficits in CS have been
shown to increase the risk of non-contact injuries such as
ankle sprains, patellofemoral pain, anterior cruciate ligament
rupture, stress fractures, muscle strains, iliotibial band fric-
tion syndrome and chronic low back pain in athletes.12–18To
understand this relationship, it is imperative to discuss the
elements that comprise the core, the definition of CS, and
the components of stability.
Thus the purposes of this review were to discuss 1) the
core and components of CS, 2) the relationship between CS
and injury, 3) CS assessment techniques, and 4) future dance
CS research areas.
THE CORE AND COMPONENTS OF CS
The core has been described as a muscular box (or corset)
that stabilizes the lumbopelvic complex in static positions
and during dynamic limb movements.12,20The core is com-
prised of passive and active structures and a neural control
unit (Figure 1).19,21The passive elements consist of ligaments,
bones, cartilage, fascia and other non-contractile properties.
Although they provide the structure of the core, they require
support from the surrounding musculature, the active ele-
ments. Without appropriate support from the spinal mus-
cles, the spine can become unstable under loads as small as
90 N, which is less than the weight of an average adult’s
upper body.21The active structures of the core, which are
composed of the deep and superficial muscles, provide sta-
bility and movement within the core.21
The active structures are further partitioned into the local
and global stabilization systems (Figure 2).22,23The global sta-
bilization musculature consists primarily of superficial, fast-
twitch muscle fibers. The erector spinae, external obliques,
rectus abdominis, and quadratus lumborum, which have the
capability to produce powerful and rapid torques, are examples
of muscles included in the global stabilization system.21–23In
contrast, the local stabilization system provides precise inter-
segmental motion. This system is comprised of deep, slow-
Core Stability: Implications for Dance Injuries
Jatin P. Ambegaonkar, PhD, ATC, Ashley M. Rickman, MS, and Nelson Cortes, PhD
Dr. Ambegaonkar is Director, Sports Medicine Assessment, Research, and
Testing (SMART) Laboratory, and Coordinator, Exercise, Fitness, and
Health Promotion (EFHP) Graduate Program, Athletic Training Educa-
tion Program (ATEP), George Mason University, Manassas, Virginia.
<Author: Please provide professional titles for author and co-
Address correspondence to: Dr. Jatin P. Ambegaonkar, Sports Medicine
Assessment, Research & Testing (SMART) Laboratory, George Mason Uni-
versity, 10900 University Boulevard, MS 4E5, Manassas, VA 20110,
USA. Tel 703 993 2123, fax 703-993-2025. firstname.lastname@example.org.
twitch muscles such as the transverse abdominis, multifidi,
internal oblique, deep transversospinalis and pelvic floor.21–23
RELATIONSHIP BETWEEN CS AND INJURY
All musculature in the human body, including the core mus-
culature is controlled by the neural system. The neural con-
trol unit transmits sensory information from the propriocep-
tive structures to the central nervous system for
interpretation; the central nervous system then responds to
external stimuli by transmitting motor responses in anticipa-
tion or in response to a postural disturbance.19For instance,
in healthy individuals, trunk muscle activity precedes lower
extremity muscle activity.24In other words, the central nerv-
ous system creates stability of the core by co-contraction prior
to gross movements.24In addition, reflex reactions in the
muscles following a sudden perturbation results in a coordi-
nated response in order to return the body to equilibrium
and prevent excessive forces to the passive structures of the
core.25Stability of the core requires coordinated muscle acti-
vation in order to stabilize the individual spinal segments,
minimize the effects of external forces, provide intra-abdomi-
nal pressure, and reinforce the thoracolumbar fascia.26When
the passive, active, and neural systems work in harmony, the
body is able to better withstand external perturbations and
produce maximal and efficient movement while minimizing
excessive forces on the surrounding joints.21
On the contrary, insufficient CS leads to harmful com-
pensations and increased strain on the passive structures
during gross limb movements.12Evidence suggests a relation-
ship between decreased CS and a higher incidence of lower
extremity injuries, especially in females.12,14,17For example,
insufficient trunk and hip musculature strength, endurance,
and/or neuromuscular control are known to affect knee load-
ing and knee injuries.27,28Similarly, inadequate stabilization
of the trunk as result of poor extensor muscle endurance,
faulty firing rates, and imbalanced local and global muscula-
ture has been associated with the occurrence of low back
pain.29This relationship between CS and injury is especially
pertinent in performing artists (e.g., dancers) given that they
primarily suffer from lower extremity and low back injuries.
CS in Dancers
Assessing CS in an individual is critically important to estab-
lish a baseline before effective injury prevention training can
be employed. Unfortunately, limited empirical studies have
evaluated CS in dancers.30–33To date, the literature has largely
focused on pelvic alignment.30,32,33In particular, individual-
ized observation and training has been shown to reduce ante-
rior pelvic tilt and thus improve static pelvic alignment in
dancers.30,32However, previous research has found no rela-
tionship between sagittal plane pelvic alignment and low back
pain.33Lumbopelvic control in dancers has also received
some, albeit little, attention in recent years. The pressure
biofeedback device (Chattanooga Inc., Chattanooga, TN) has
been used to evaluate lumbopelvic control in dancers during
a preseason screening to identify factors that may predispose
the dancer to injury.34However, the testing methods have not
been validated during functional dance training/perform-
ance. Investigating the motion of the pelvis during dynamic
dance movements may provide more insight into the nature
of CS and its relationship to pelvic control.
Further, the role of specialized biomechanical and physio-
logical equipment may become of increasing importance in
dance research relating to CS. For example, Chatfield and
colleagues35employed electromyography, motion-capture and
force plates to evaluate differences between beginner and
expert dancers in core activation (abdominals and erector
spinae), postural sway, and movement coordination.
Although innovative in the field of dance research, the study
has little utility in the realm of CS and its relationship to
injury prevention. Future dance research should continue to
employ more innovative methods of measuring CS in order
to determine CS deficits in dancers.
There is a lack of evidence examining CS or the relation-
ships between CS and injuries in dancers. Further, the
research done to date has been mostly small, uncontrolled
case series with single within-subject designs and small
sample sizes. To our knowledge, no published literature exists
examining CS in dancers using large randomized controlled
trials. Still, to assess CS as a whole, it is imperative to under-
stand the components of CS and their individual relation-
ships to various injuries.
CS ASSESSMENT TECHNIQUES
CS is a continuum from power, strength, endurance, and
sensory-motor control of the lumbopelvic-hip complex mus-
Medical Problems of Performing Artists
FIGURE 1. Components of core stability.
Passive Structures: Non-contractile: ligaments, bones,
cartilage, fascia and other non-
Neural Control System: Sensory-motor system
culature (Figure 3). Previous work suggests that injuries occur
when deficits in one of these components cause reduced
lumbopelvic stability prior to and during gross movement of
the peripheries.12,21The reduction in stability causes com-
pensatory adjustments in the trunk and lower extremities,
which often leads to inefficient force production and injury.
A theoretical injury model is described in Figure 4. Zazu-
lak et al.18discovered a connection between decreased core
proprioception and insufficient sensory-motor control of the
lower extremities, which has been shown to result in dynamic
malaligment of the knee and eventual injury. In addition,
imbalanced or delayed recruitment patterns in the core mus-
culature have been shown to improperly increase spinal load-
ing and induce low back injury.36Given that dancers experi-
ence a high rate of lower extremity and low back injuries and
a relationship has been established between CS and injury
risk, dancers should be thoroughly evaluated for insufficient
CS in an attempt to identify injuries. This identification will
enhance injury prevention programs that may lead to a
decrease in injuries and health care costs.
CS has been measured in the general athletic population
using multiple techniques with a focus on core strength,
endurance, power, or sensory-motor control. While some of
the assessments are relatively easy to conduct, others require
more specialized equipment and expertise. As a result, some
aspects of CS have received more attention than others due
to the nature of the testing protocols. However, each compo-
nent of CS should be evaluated in relation to injury inci-
dence in order to obtain a complete representation of a
dancer’s injury risk.
Core Muscle Power
Although muscle power (force X time) is an important con-
cept when considering CS, surprisingly there is currently lim-
ited evidence (if any) that shows a high correlation between
core power and lower extremity or low back injuries. As the
center of the kinetic chain, the core is responsible for trans-
ferring ground reaction forces from the lower to the upper
body during powerful athletic maneuvers.20,43However, lim-
ited research has shown that decreased power of the core mus-
culature results in increased injury incidence. Core training
does not appear to improve performance measures in athletes
nor does it result in increases in power-development during
sports skills.44This may be the result of interventions that
train the core for endurance, strength or sensory-motor con-
trol, which are uniquely different than power. Although field
tests such as the front and side abdominal power tests are very
easy to execute, they have not been shown to indicate CS
deficits or injury risk. Consequently, more innovative tests of
core power should be explored in relation to injury incidence.
Core Muscle Strength
Core muscle strength is an important factor on the CS con-
tinuum. Stability of the trunk is achieved through the regu-
FIGURE 2. Components of the active core musculature.
FIGURE 3. Continuum of core stability.
lation of force by the muscles that surround the trunk.20,37
Although some degree of core strength is necessary in order
to resist forces that act on the core, only minimal amounts
of strength are needed to resist perturbations to the body
structure.12The stiffness required to stabilize the spinal seg-
ments and provide stability may be achieved through mini-
mal activation of the abdominal muscles—as little as 5% of a
maximal voluntary contraction for daily activities and 10%
of a maximal voluntary contraction for physically demand-
ing activities.38Therefore, in terms of CS, strength measure-
ments using isokinetic or isometric (dynamometry) testing
have a limited degree of utility.39–41Some degree of core
strength is crucially important in preventing injury, however
it is important to measure all aspects of CS in order to
acquire a complete representation of an individual’s injury
Core Muscle Endurance
Core muscle endurance, another factor, has been widely
used to evaluate CS and its relationship to lower extremity
and low back injuries particularly because the tests are
easily administered.15,42Given that the local stabilization
system is composed of slow-twitch muscle fibers that pro-
duce tonic contractions to stiffen the spinal segments, core
endurance measures are critically relevant. McGill42devel-
oped a test battery, which includes the lateral, flexor, and
back extensor musculature endurance tests. In addition,
the abdominal plank test has been utilized to measure ante-
rior core endurance in athletes.15Although the literature
shows a relationship between trunk muscle endurance and
low back pain, the link to lower extremity injuries is less
obvious.15,16,26Therefore, it is unclear whether improve-
ments in core endurance lead to reductions in lower
extremity dance injuries. Future research should investigate
relationships between core endurance and dance injuries,
particularly to the lower extremities, to confirm or refute
the need for interventions.
Core Sensory-Motor Control
Deficits in sensory-motor control have been distinctly corre-
lated to both low back pain and lower extremity injuries, par-
ticularly to the knee and ankle.13,17,18,45Core proprioception as
well as muscle recruitment and activation timing of the local
and global stabilization systems are especially important in
maintaining lumbopelvic-hip stability and avoiding injury. It
has been hypothesized that in healthy individuals, the stabi-
lization system activates prior to gross movement in order to
resist the perturbations caused by global muscle contractions,
minimize compression and shifting of an unstable spine, and
allow for a more efficient contraction by the prime mover.12
There is evidence that decreased core proprioception predicts
knee injury in collegiate female athletes due to impaired
dynamic knee stability.18Further, delayed muscle reflex
responses during sudden force release have been found to be a
preexisting factor for patients who acquire a low back injury.14
Sensory-motor control is often measured with specialized
equipment such as electromyography,42the sudden force
release device,17,45pressure biofeedback,46the level belt,47the
stability platform (Lafayette Instrument Co.),48and the core
proprioceptive repositioning apparatus.18Measuring sensory-
motor control is advantageous because the research supports
a significant correlation between sensory-motor control and
future injuries.13,17,18,45However, several of the current meth-
ods require considerable proficiency with and access to
expensive or cumbersome equipment. Regardless, sensory-
motor control continues to be a central factor in determining
Overall, limited research exists evaluating CS in dancers. The
relationship of CS and dance injuries is also understudied.
Furthermore, the limited existing work has examined ballet
and modern dancers. As differing genres of dance having dif-
fering CS demands, it is important to examine whether the
Medical Problems of Performing Artists
FIGURE 4. Theoretical model of core stability deficits leading to injury.
relationships among CS, injuries, and performance are simi-
lar across the various dance genres. It would be beneficial to
experiment with alternative ways to measure CS that relate
specifically to dance movements and technical requirements.
Further analysis should compare different dance populations
separated by categories such as age, training level, injury his-
tory, or dance style, in order to determine each population’s
Additionally, research should evaluate all aspects of CS
(strength, endurance, power, and sensory-motor control) in
order to ascertain norms for the dance population as well as
to determine when CS deficits lead to specific injuries. Inves-
tigating the relationship between CS and specific dance
injuries may also provide insight into the manner in which CS
measures may predict injuries. If CS deficits were identified
through pre-participation screenings, preventative measures
could be implemented into a dancer’s training program in
order to potentially reduce injury occurrence. Finally, neuro-
muscular training programs should be designed specifically
for dancers so that they receive an intervention that is tailored
to the unique physical and aesthetic requirements of dance.
The following are the practical implications for dancers and
1. Implement pre-participation screenings conducted by quali-
fied clinicians to determine pre-participation CS deficits.
2. Examine evidence-based information to understand CS and
its components, and help optimize teaching dance techniques.
Despite several assessments available for measuring CS, sev-
eral dilemmas exist in CS and dance research. More studies
are needed that explore the role of CS in injury incidence
and prevention, and performance enhancement in dancers.
Examining power, strength, endurance, and sensory-motor
control along the CS continuum may allow for a better
understanding of how CS may influence the risk of injury.
Limited research has comprehensively evaluated all of the
components of CS in dancers. Accordingly, researchers need
to examine CS and how it is enhanced by proper training
methodology, injury reduction strategies, and interventions
Bowling A: Injuries to dancers: prevalence, treatment, and perceptions
of causes. BMJ 1989;298(6675):731–734.
Gamboa G, Roberts L, Maring J, et al: Injury patterns in elite prepro-
fessional ballet dancers and the utility of screening programs to iden-
tify risk characteristics. J Orthop Sports Phys Ther 2008;38(3):
Echegoyen S, Acuna E, Rodriguez C: Injuries in students of three dif-
ferent dance techniques. Med Probl Perform Art 2010;2:5.
Hincapie CA, Morton EJ, Cassidy JD: Musculoskeletal injuries and
pain in dancers: a systematic review. Arch Phys Med Rehabil 2008;
Kerr G, Krasnow D, Mainwaring L: The nature of dance injuries. Med
Probl Perform Art 1992;7(1):25–29.
Motta-Valencia K: Dance-related injury. Phys Med Rehabil Clin N Am
Steinberg N, Siev-Ner I, Peleg S, et al: Injury patterns in young, non-
professional dancers. J Sports Sci 2011;29(1):47–54.
Khan K, Brown J, Way S, et al: Overuse injuries in classical ballet.
Sports Med 1995;19(5):341.
Bolin DJ: Evaluation and management of stress fractures in dancers. J
Dance Med Sci 2001;5(2):37–42.
Bronner S, Ojofeitimi S, Rose D: Injuries in a modern dance company:
effect of comprehensive management on injury incidence and time
loss. Am J Sports Med 2003;31(3):365–373.
Gottschlich LM, Young CC: Spine injuries in dancers. Curr Sports
Med Rep 2011;10(1):40.
Borghuis J, Hof AL, Lemmink KA: The importance of sensory-motor
control in providing core stability: implications for measurement and
training. Sports Med 2008;38(11):893–916.
Chaudhari A, Jamison S: Influence of trunk neuromuscular control
on run-to-cut maneuver: a risk factor for ACL rupture [abstract]. J Athl
Cholewicki J, Silfies SP, Shah RA, et al: Delayed trunk muscle reflex
responses increase the risk of low back injuries. Spine 2005;30(23):
Leetun DT, Ireland ML, Willson JD, et al: Core stability measures as
risk factors for lower extremiy injury in athletes. Med Sci Sports Exerc
McGill SM, Grenier S, Kavcic N, et al: Coordination of muscle activ-
ity to assure stability of the lumbar spine. J Electromyogr Kinesiol
Zazulak BT, Hewett TE, Reeves NP, et al: Deficits in neuromuscular
control of the trunk predict knee injury risk: a prospective biome-
chanical-epidemiologic study. Am J Sports Med 2007;35(7):
Zazulak BT, Hewett TE, Reeves NP, et al: The effects of core proprio-
ception on knee injury: a prospective biomechanical-epidemiological
study. Am J Sports Med 2007;35(3):368–373.
Willson J, Dougherty C, Ireland M, et al: Core stability and its rela-
tionship to lower extremity function and injury. J Am Acad Orthop
Akuthota V, Nadler SF: Core strengthening. Arch Phys Med Rehabil
Akuthota V, Ferreiro A, Moore T, et al: Core stability exercise princi-
ples. Curr Sports Med Rep 2008;7(1):39–44.
Bergmark A: Stability of the lumbar spine. Acta Orthop 1989;60:1–54.
Comerford MJ, Mottram SL: Functional stability re-training: princi-
ples and strategies for managing mechanical dysfunction. Man Ther
Hodges PW, Richardson CA: Contraction of the abdominal muscles
associated with movement of the lower limb. Phys Ther 1997;77(2):
Oliver GD, Adams-Blair HR: Improving core strength to prevent
injury. JOPERD 2010;81(7):1–60.
Ebenbichler GR, Oddsson LI, Kollmitzer J, et al: Sensory-motor con-
trol of the lower back: implications for rehabilitation. Med Sci Sports
Reiman MP, Bolgla LA, Lorenz D: Hip function’s influence on knee
dysfunction: a proximal link to a distal problem. J Sport Rehabil
Earl JE, Hoch AZ: A proximal strengthening program improves pain,
function, and biomechanics in women with patellofemoral pain syn-
drome. Am J Sports Med 2011; 39(1):154–163.
Anderson K, Behm DG: The impact of instability resistance training
on balance and stability. Sports Med 2005;35(1):43–53.
Deckert JL, Barry SM, Welsh TM: Analysis of pelvic alignment in uni-
versity ballet majors. J Dance Med Sci 2007;11(4):110–117.
Hagins M: The use of stabilization exercises and movement reeduca-
tion to manage pain and improve function in a dancer with focal
degenerative joint disease of the spine. J Dance Med Sci 2011; Download full-text
Holt KM, Welsh TM, Speights J: A within-subject analysis of the effects
of remote cueing on pelvic alignment in dancers. J Dance Med Sci
McMeeken J, Tully E, Nattrass C, et al: The effect of spinal and pelvic
posture and mobility on back pain in young dancers and non-dancers.
J Dance Med Sci 2002;6(3):79–86.
Shoaf L: Abstract: Determining lumbopelvic posture control in uni-
versity modern dancers and its relationship to dance skill level. J
Orthop Sports Phys Ther 2009;39(1):A72–73.
Chatfield SJ, Krasnow DH, Herman A, et al: A descriptive analysis of
kinematic and electromyographic relationships of the core during for-
ward stepping in beginning and expert dancers. J Dance Med Sci
McGill S, Childs A, Liebenson C: Endurance times for low back sta-
bilization exercises: clinical targets for testing and training from a
normal database. Arch Phys Med Rehabil 1999;80(8):941–944.
Cholewicki J, VanVliet JJ, IV: Relative contribution of trunk muscles
to the stability of the lumbar spine during isometric exertions. Clin
Biomech (Bristol, Avon) 2002;17(2):99–105.
Kibler WB, Press J, Sciascia A: The role of core stability in athletic
function. Sports Med 2006;36(3):189–198.
Crowther A, McGregor AH, Strutton PH: Testing isometric fatigue in
the trunk muscles. Isokinet Exerc Sci 2007;15(2):91–97.
Nadler SF, Malanga GA, DePrince M, et al: The relationship between
lower extremity injury, low back pain, and hip muscle strength in male
and female collegiate athletes. Clin J Sport Med 2000;10(2):89–97.
Willson JD, Ireland ML, Davis I: Core strength and lower extremity
alignment during single leg squats. Med Sci Sports Exerc 2006;
McGill S. Low Back Disorders: Evidence-based Prevention and Reha-
bilitation, 2nd ed. Champaigne, IL, Human Kinetics Publishers, 2007.
Keogh JWL, Aickin SE, Oldham ARH: Can common measures of core
stability distinguish performance in a shoulder pressing task under
stable and unstable conditions? J Strength Cond Res 2010;24(2):
Parkhouse KL, Ball N: Influence of dynamic versus static core exercises
on performance in field based fitness tests. J Bodywork Mov Ther
Radebold A, Cholewicki J, Panjabi MM, et al: Muscle response pattern
to sudden trunk loading in healthy individuals and in patients with
chronic low back pain. Spine 2000;25(8):947.
Hagins M, Adler K, Cash M, et al: Effects of practice on the ability to
perform lumbar stabilization exercises. J Orthop Sports Phys Ther
Chaudhari AMW, McKenzie CS, Borchers JR, et al: Lumbopelvic con-
trol and pitching performance of professional baseball pitchers. J
Strength Cond Res 2011;25(8):2127.
Liemohn WP, Baumgartner TA, Fordham SR, et al: Quantifying core
stability: a technical report. J Strength Cond Res 2010;24(2):575–579.
Medical Problems of Performing Artists