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.