Injury Awareness And Prevention For Dancers Mariners Physical Therapy Mark Kirsch MPT Genevieve Sepulveda Injury Statistics With Dancers • Professional dancers lifetime prevalence of injury: – 80% Ankle, 57% Knee, 51% Foot • Preprofessional dancers lifetime prevalence of injury: – 43% Ankle, 46% Knee, 26% Foot • Low back injuries are also common in modern dance and ballet. Epidemiology • Modern dancers average 2 injuries/year • Ballerinas average 3 injuries/year • 95% of ballerinas and 82% of modern dancers have at least 1 injury/year • 91% Modern dancers experience symptoms lasting one week. – Out of these dancers, 84% continue to perform despite injury Why Young Dancers are at Risk for Injuries • Increased dance time for 10-15 hours per week to 20-25 hours • Experiencing growth spurt(s) with changes in muscle and ligament strength • Girls experience body shape changes from the age of 12-17. • Hormonal changes significantly affect the integrity of the ligaments in the body and in the stability of joints • Attempting higher level of movement patterns with greater speed Pain You will have pain in your career as a dancer. It’s important to recognize good versus bad pain. Good pain: Muscle burning during dance activities and body aches following intense workout. Good pain usually resolves in 12-24 hours. Bad pain: Burning, tingling , numbness, sharp, prolonged ache, and stinging. Bad pain can last > 24 hours and returns with increased activity. Bad pain will be consistent over 2-3 weeks. Management of Pain Good pain will resolve quicker with prolonged light aerobic activities for 15-20 minutes when performed following the day of onset. Bad pain requires greater awareness of your body to manage. 1. Bad pain usually requires modification in program to heal. 2. Identify the intensity and duration of pain using a 0-10 scale (0 = no pain to 10 = worst pain that you ever have felt). 3. Superficial sharp pain is usually a muscular and /or ligament injury. Deep sharp pain is usually joint or a possible sign of instability (lumbar spine). Burning/tingling/numbness related pain usually identifies nerve involvement. Bad Pain/Symptoms Burning/tingling/numbing symptoms are usually due to over stretching multiple parts of your body at once. These symptoms can occur minutes and/or hours after initial injury. If symptoms are only during dance activities and are very light, avoid end range (excessive stretching) motions and symptoms should resolve. Sharp/ache pain superficial and deep are usually traumatic or insideous (gradual) onset. • Traumatic pain (muscle pulls/strains, spines, contusions) respond to RICE, braces, wrapping, and immobilization. • Insideous pain with dancers is usually identified as over use. As your muscles fatigue, the load on the joint ligament structures increases. When the ligaments are having difficulty controlling the joint(s), the joint(s) or surrounding tissue are more susceptible to injury. Common Dance Foot, Ankle, Knee, Hip Injuries Ankle/Foot Injuries • • • • • • • Dancer’s Fracture *Sesamoiditis *Hallux Valgus and bunion *Hallux Rigidus Plantar Fascitis Achilles Tendonitis Lateral Ankle Sprain Ankle Anatomy Anatomy of the Ankle/foot Dancer’s Fracture • This is the most common acute fracture seen in dancers. Fracture occurs at the 5th metatarsal, long bone on the outside edge of the foot. • The cause is usually due to landing from a jump on an inverted (turned-in foot). • Symptoms will include immediate pain and swelling. • Treatment usually requires immobilization while the bone heals followed by rehabilitation to rebuild foot and ankle mobility and strength. Sesamoiditis • Inflammation to the small bone underneath the big toe. • Sesamoids are two very small bones the size of kernel of corn. • They are not attached to any other bones and they function to deflect pressure from the great toe flexor tendons and provide a smooth surface in which to slide upon. • Symptoms are usually caused by excessive demi-pointe with decreased medial ankle control leading to increased great toe pressure. Sesamoiditis (Cont.) • Treatment usually includes “J “ cushion, taping the toe slightly downward (plantar flexion) • It may take several months for symptoms to resolve. • Proper assessment of strength should be performed on the dancer to identify muscle imbalances. • Surgical intervention should only be considered after all conservative measures have been exhausted. Hallux Valgus and Bunion • Hallux valgus is seen at a significant younger age in dancers than the normal population. • Onset of symptoms are gradual associated with postural and biomechanical faults involving other joints. – Tendencies that lead to bunions include pronation (rolling in) during turned out position and difficulties with controlling knee and hip internal rotation. *Treatment is dictated on early intervention. Hallux Rigidus • This condition is characterized by pain and/or restriction of movement at the joint of the big toe. • To achieve full demi-pointe the metatarsal phalangeal joint must be able to make 90 degree angle. Full Demipointe Half Demipointe Sickling Hallux Rigidus (Cont.) • Treatment in the acute stages decreases the risk for joint related changes. Early treatment consisting of ice massage and stretching have been shown to decrease symptoms quickly. It is also important to stretch the toe into a demi-pointe position in a nonweight bearing position (30 second bouts/pain free). Ice Massage Stretching Plantar Fascitis • Over use injury involving the sole of the foot. • Onset of pain usually after class of following a lengthy weight bearing activities with greater risk on non-sprung floors. • Direct relationship with calf tightness resulting in greater forces at the heel when landing due to lack of dorsiflexion (ankle bending) • If treated early with rest/ice followed by stretching, pain should resolve quickly. Chronic symptoms will most likely require a night splint to increased the length of the sole to allow it to heal. Achilles Tendonitis • Tendonitis can occur in a variety of tendons, however the most common tendon involved is the Achilles. – Is usually able to withstand forces of 1000 pounds – Connects to the calf muscles which are responsible for releve and jumping which is a significant portion of dancing. Causes for this injury are usually related to overtraining, particularly heavy training during a short period of time. Other factors include: – Returning to dance after a long period of time – Lack of calf flexibility – Dancing on a non-sprung floor Treatment includes ankle strengthening, gradual introduction into pointe and jumping activities, and stretching when out of the acute phase. Dancers need to exercise caution with stretching the Achilles tendon beyond the point of comfort. Lateral Ankle Sprains • Most common injury to professional dancers is ankle sprains. • Most common mechanism is landing on the outside of the foot or another dancer’s foot after a jump. • Importance of proper management to allow good healing and return of stability. Repeated low grade ankle sprains will lead to significant instability of the ankle. • Treatment with RICE and proper bracing . Wearing the brace for 3-4 weeks post resolution of pain will allow proper healing. Your Time to look at the Foot/Ankle Ankle/Foot Position Hold pressure for a minimum of 5 seconds Hold pressure hard for minimum of 5 seconds Left picture is the starting position Right is the finished position Left picture is the starting position Right picture in the finished position with pulling toes up and in Left picture is the finished position with toes down and in (left moving) Right picture is the finished position with toes out (winged) and down (right moving) Dragging feet in with large toe staying on the ground Pressure Testing Injuries to the Knee • • • • • • *Anterior Knee Pain *Knee Hyperextension *Patellar-Femoral Compression Syndrome Patellar Malalignment Meniscus Tear Ligamentous Injuries Anatomy of the Knee • Largest Joint in the body • Bony surfaces and surrounding structures that with heavy dance activities will sometimes support four times a person’s body weight. Anatomy of the Knee (Muscles/Tendons) Anterior Knee Pain • The structure of the knee is such that even small changes of its alignment or distribution of weight can cause aggravation at the joint. • Sudden increases in training frequency are associated with anterior knee pain. • Large growth spurts in a short period of time will result in loss in strength and greatly decreased flexibility. During growth spurts bones grow more rapidly than muscles resulting in greatest stress on the tendon/muscular junction. • Symptoms of anterior knee pain can range from swelling, tenderness, popping/cracking, and changes in weight bearing tolerance. Difficulties with stairs, squatting (plies), jumping, and pain in the knee with standing after prolonged sitting. Anterior Knee Pain (Cont.) • Symptoms can also result from minor trauma to the knee that goes unchecked. Compensatory strategies occur quickly. Muscle imbalances occur to the quadriceps with greater lateral muscular recruitment. It can be several months past original trauma when gradual onset of pain occurs with increased work load. Anterior Knee Pain (Cont.) • Treatment is usually conservative with a focus on return of medial knee musculature, decreasing anterior knee forces with possible taping, and regain eccentric control to decrease tendon/joint loading. • When a dancer returns to class activities it is important to warm-up before hand, avoid training on hard surfaces, and wear well supportive shoes to reduce stress on the front of the knee. Knee Hyperextension (Genu Recurvatum) • Ballet dancers have the highest percentage of knee hyperextension compared to other sports. • Trends that lead to hyperextension in youths includes “locking the knee” when beginning single leg stance activities. When dancers lack the length for prolonged holds, he/she will lock the knee to maintain dancing activities versus stopping. Also some dancers have predisposition towards ligamentis laxity. • Associated problems include : 1. A muscle imbalance in the thigh, in which the quadriceps muscles can be overactive and the hamstrings subsequently are not as well developed 2. Patella displacement or sublaxation can occur, due to poor quadriceps development and/or general ligamentis laxity. 3. The unusually high amount of loading placed on the lower leg can result in “shin splints” or even, in more severe cases, tibial stress fractures. Patella-Femoral Compression Syndrome (Chondromalacia) • Anterior knee pain can be have patella-femoral syndrome (PFCS) related symptoms. Chomdramalacia is a softening or wearing away of the articular cartilage (joint surface) under the patella, resulting in pain and inflammation. • Chondramalacia is a progressive disorder that starts gradually and progressive increases with pain usually associated with jumping and/or grande plie. Big Picture View of Patella Related Pain • Anterior knee pain usually starts from the ground up. Address the ankle instabilities (inside>outside) to control position of knee in hip alignment. • Medial knee strength is almost always lacking with anterior knee pain. • Hip abduction (away from the body) strength is almost always lacking with patellar related issues. • If you don’t address all three components you will have returning symptoms that result in compensatory strategies. Compensatory strategies will lead to other problems that can be more serious then the knee pain. Patellar Malalignment • A displaced patella occurs when the knee cap (patella) slips out of the groove of the femur. The patella can slip momentarily (subluxation) or remained displaced (dislocation). – Subluxations are noted with momentary pain, followed by feeling of unsteadiness or a tendency for the knee to “give way” – Dislocations are significantly painful and disabling usually with visible physical deformity. Causes can be trauma from landing on a knee or dynamic activities of running/cutting, jumping, and/or sudden changes in direction. Higher percentage of patella related injuries when fatigued leading to dynamic instability. X-rays should always be taken if injuries are suspected of occurring to rule out any fracture to the bony surfaces. Bracing is appropriate for several weeks followed by rehabilitation. Anatomy of the Knee Meniscus Tear • Meniscus tears often present with “locking up” of the knee. • Meniscus is the two “C” shaped cartilage between the knee that protects the joint surfaces of the femur and the tibia from grinding against each other. Pain usually presents on the inner outer joint line described as deep and sharp. • Causes of injuries to the meniscus usually occur from some type of landing, jumping, twisting activity. • Severity of tears include severe with immediate pain swelling and lack of weight bearing on the involved leg. Minor tears may become painful for the dancer after some time has passed. – Minor tear will usually have minor swelling and pain only be noted during specific dance related activities verses walking and standing. Meniscus Tear (Cont.) • Treatments range from arthroscopic surgery for the severe tears to dance modification and controlled strengthening for the minor tears. • Technical tip for decreasing meniscus related injuries: – “Screw home” turnout by planting the feet at the desired angle of turnout and subsequently straightening knee is perhaps the number one offender for knee injuries to the menisci. Working correctly by turning out “from the hip” can prevent many unwanted injuries including tears and disruptions to this protective cartilage of the knee. Ligamentis Injuries Ligamentis injuries are usually traumatic in nature. Four major ligaments control the integrity of the knee: • Anterior Cruciate Ligament (ACL) is in the inner knee and controls the tibial shifting forward and medial. Symptoms associated with an ACL trauma includes usually an audible “pop”, immediate swelling, sharp pain that can resolve in 2-7 days, and return to normal straight plane activities without pain. Feeling of instability with twisting activities that can reproduce pain and lead to further injury if ligament is severely torn. Severe ACL injuries usually result in surgery for correction. • Posterior Cruciate Ligament (PCL) in at the back of the inner knee. This ligament controls the tibia from excessive posterior lateral shifting. The PCL is rarely injured in dance related activities. Ligamentis Injuries (Cont.) 3) Lateral Collateral Ligament (LCL) is at the superficial outside portion of the knee. Injury occurs when a forces or load is applied in excessive to the medial knee toward the outer knee. 4) Medial collateral ligament (MCL) is at the superficial inside portion of the knee. Injury occurs when a forces or load is applied in excess to the lateral knee toward the inner knee. • LCL and MCL injuries that are minor should still avoid twisting activities due to risk for further injuries. Severe injuries to the LCL and MCL should be braced for 5-10 weeks allowing the ligaments to heal without surgical intervention. Anatomy of the hip Hip Injuries • Trochanteric Bursitis • Snapping Hip • Iliacus/Iliopsoas strain Anatomy of the Hip Trochanteric bursitis • Inflammation of the trochanteric bursa is a common cause of hip pain in dancers. The bursa is a fluid filled sac that decreases pressure between bone, tendon, and muscles. Symptoms include a deep ache or sharp pain to the lateral hip region with lateral leg movements and single leg stance activities on the injured hip. • Greater trochanteric bursitis is potentially caused by overuse, a structural imbalance of the lumbar spine, muscular imbalance in the hip and/or pelvis, or a leg length discrepancy. • Treatment is usually conservative with RICE in the early phases of healing, followed by correction of muscular imbalances to allow proper healing without irritation to the inflamed tissue. Snapping Hip • Hip snaps usually with grande battement or developpe a la seconde. • Usually painless and harmless and can occur in two places. 1. Lateral snapping hip usually involves the iliotibial (IT) band over the greater tronchanter. 2. Anterior hip snapping is associated with the iliopsoas tendon passing over the bony prominence of the front of the pelvis or the femur. If painful, treatment includes stretching of the involved structures and controlling high hip lateral and forward leg positions. Iliac/iliopsoas tendonitis • This injury is usually associated with younger dancers and is described as sharp superficial pain at the front of the hip that increases with leg flexion activities. • Injury is more common with modern dancers due to increased emphasis on hip flexion and internal rotation. Symptoms often occur due to poor abdominal muscle endurance resulting in overuse of hip flexors leading to inflammation. • Conservative treatment with core strengthening, light stretching, and modifying activities that create pain. Symptoms usually resolve in 2-3 weeks with proper management. Anatomy of the Sacroiliac Joint FAI (Femoral Acetabular Impingement) Your time to look at the Knee Standing Assessment Lower Extremity Positioning Hip Strength Testing 1. Dancer is placed in side lying position. Place one hand on the top of the outside knee of the upper leg and press down to the other knee with moderate but firm pressure while counting to ten. – Does the leg move down immediately? (= significant weakness)? – Does the leg move down after 5-10 seconds (= mild/moderate weakness)? – Does the leg not move during the test (= strong)? 2. Dancer is placed in side lying position. Place one hand on top of the lower inside of the knee while the other knee is crossed over the front with the foot on the ground and press down to the other knee with moderate but firm pressure while counting to ten. – Does the leg move down immediately? (= significant weakness)? – Does the leg move down after 5-10 seconds (= mild/moderate weakness)? – Does the leg not move during the test (= strong)? 3 way hip abduction- Center Start- Lay on side with feet parallel. Keep legs in line with torso and midline. Raise top leg then lower down slowly. Comment- Keep hip and foot parallel. Do not turnout. Keep foot flexed. 3 way Hip Abduction - Forward Start- Lay on your side and put top leg in front of your midline - Raise and lower your top leg slowly Comment- Keep hip and foot parallel. Do not turnout. Keep foot flexed. 3 way Hip Abduction - Behind Start- Lay on your side and put top leg in front of your midline - Raise and lower your top leg slowly Comment- Keep hip and foot parallel. Do not turnout. Keep foot flexed. Guidelines for performing hurt not injured • Pain/symptoms are only noted during dancing related activities. • Pain should remain < 3/10 while dancing without significant changes in positioning. Large changes to positioning can lead to other structures getting injured. • Pain should be resolved in 2-3 weeks • If bracing is required, maintain bracing for 2-3 weeks after symptoms resolve. • Continue strengthening activities for 2-3 weeks or more following resolution of symptoms. • If motions or activities are avoided during healing, returning to these activities gradually will decrease the risk for a further exacerbation(s) (return to pain/symptoms). Work from the core outward. Trunk Strength Screening • Abdominals – 1. Dancer is placed on the back. Place one arm on top of the knees of the dancers in a 90/90 position and the other arm under the lower spine (see picture). Apply moderate pressure to the knees toward the feet and count to ten. – Does the back arch immediately (= significant weakness)? – Does the back arch after 5-10 seconds (= mild/moderate weakness)? – Does the back not arch during the test (= strong)? 2. (Obliques) Dancer is placed on the back. Place one arm on top of the knees of the dancers in a 90/90 position and the other arm under the lower spine (see picture). Apply moderate pressure to the knees at an angle from right shoulder to left foot and left shoulder to right foot and count to ten each time. – Does the back arch immediately (= significant weakness)? – Does the back arch after 5-10 seconds (= mild/moderate weakness)? – Does the back not arch during the test (= strong)? Plank- core muscles Start- Begin facedown with weight on both forearms and toes. Hold position for desired time. Comments- Lift hips so back remains straight and engage stomach towards spine. Progress to one leg. Pilates- 100’s (90-90) Start- Lay down with knees bent to a 90-90 position. -Inhale and reach arms overhead then exhale and contract abdominals lifting head and top of shoulders off table. -Breathe small short breaths 5x in then 5x out keeping the arms straight and pulsing down with every breath. Repeat 10x. Comment- Don’t let back arch away from table. Keep stomach pulled towards spine Pilates- 100’s (straight legs) Start- Lay down with knees bent on table -Inhale and reach arms overhead then exhale and contract abdominals lifting head and top of shoulders off table. Extend legs straight out. -Breathe small short breaths 5x in then 5x out keeping the arms straight and pulsing down with every breath. Repeat 10x. Oblique Planks Start – Lay on side with one forearm and side of foot supporting you. Hold side plank position for desired time. Comment-Don’t let hips drop down towards table. Keep body in a straight line. Progress to top leg in a passe position. Oblique Planks (advanced) Start – Lay on side with one forearm and side of foot supporting you. Raise top leg one foot above table. Hold side plank position for desired time. Comment-Don’t let hips drop down towards table. Keep body in a straight line.