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An overview of injuries to the An overview of injuries to the

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An overview of injuries to the An overview of injuries to the Powered By Docstoc
					An overview of injuries to the
       ballet dancer


      Kathleen Nachazel, ATC
      UPMC Sports Medicine
           My background
UPMC Sports Medicine
Contracted to Pittsburgh Ballet Theater
  90% time administrative
  10% time at Pittsburgh Ballet Theater
Team coverage provided at PBT studio
  Athletic Trainer (me) 1 day a week for 3 hrs
  PT 2 days a week for 2 hrs
  Massage therapist 2 days a week for 2 hrs
  On-
  On-call MD with weekly onsite visits
   Medical Coverage for PBT
In studio
All performances and dress rehearsals
             on- i
  ATC or PT on-site
  MD on call
Annual pre/early season screenings
  During paid time for dancers
        Preventing Injuries
4 Points to consider
  Access to health care providers
  Pre-
  Pre-season musculoskeletal evaluation
  Referral source for evaluation and treatment
  G d teachers who can detect and correct poor
  Good t h         h       d t t d          t
  technique
   Intrinsic Causes of Injury

Insufficient flexibility or range of motion
                  g
Insufficient strength
Strength and/or flexibility imbalances
Ins ffi i nt cardiovascular conditioning
Insufficient rdi s l r nditi nin
Poor technique
Prior history of injury
Nutritional deficiencies
   Extrinsic Causes of Injury

Incorrect shoe fit
Floor surface
Fl        f
Cold studios
Difficult choreography
   su c e t warm-
             wa
Insufficient warm-up
   Most common injuries

Overuse
O
Lower Extremity
  Ankle
  Foot
  Lower leg
  Hip
  Low Back
If good technique is developed and maintained,
the chance of sustaining a dance injury is
minimized.

Minor technical faults can produce major
problems for the dancer, either in the actual
treatment of the injury, or more often in the
prevention of recurrences of the injury.
Common Technique Mistakes

Progression to the next level of dance too soon
“Cheating”
“Ch i ” your turnout
“Whacking” your leg up
Sickling and Winging
Lack of plié when jumping
      Cheating Your Turnout
Using friction between
your feet and the floor
instead of the muscles in
your hips to achieve your
position
Can cause injuries all
they way up the chain
         Cheating your turnout
If your knees don’t
line up with your
2nd toe when you
  lié
plié you are
cheating your turn
out
       Whacking your leg up
Whacking your leg up
                     Sickling
Sickling
instead of a straight line
from the hip thru the leg
            p             g
to the midfoot, the foot
is turned inward.
                  Demi-
                  Demi-plie
            demi-
Sickling in demi-plie
                    Winging
Winging
instead of a straight line
from the hip thru the
leg to the midfoot, the
foot is turned outward
               Lack of plie
The h l does not
Th heel d         t
reach the ground
resulting in knee and
foot pain
Improper landing a jump
Whacking your back
           Musculoskeletal Injuries
STRUCTURE                  OVERUSE            ACUTE
Bone                       stress fx          fracture
Muscle/Tendon              tendinosis         strain
Ligament                   sprain (stretch)   sprain (tear)
Cartilage
       Covering (articular) arthritis         chondral inj.
       Cushioning                              meniscal tear
Other soft tissue          bursitis           labral tear
                                              (joint lining)
       Overview of injuries
Low back
Hip
Lower extremity
L           i
Ankle
Foot
               Low Back
                 long-
Individuals with long-standing hip pathology
                        low-
often have a history of low-back pain or SI Joint
dysfunction
dysfunction.
Weakness of the muscles that stabilize the
lumbopelvic complex is often observed
Proprioceptive training of the trunk muscles is a
 i l             in h bili i
vital component i rehabilitation
  Back injuries
whacking your back
Spondylolysis/Spondylolisthesis
Stress fracture of the spine
creating a forward slippage of
the vertebra
   Forceful Hyperextension
   Chronic Stress
S/S:
   Step off deformity
   Pain with activity
   ↑ with WB positions
   Point tender lateral to the
   spinous process
            Spondylolysis
      (Vertebral stress fracture)
Contributing factors           Treatment:
  Weak trunk muscles             Relative Rest
           p       (sway
  Lordotic posture ( y           Bracingg
  back)                          Technique eval and
     Poor turn out               adjustment
               flexors
     Tight hip flexors, weak
                                 R h bili i (hi
                                 Rehabilitation (hip,
     hamstrings
                                 trunk strengthening)
  Over turning (feet)
           Spondylolisthesis

Stress fracture of the
pars interarticularis
of the vertebrae
(spinal column)
  Due to repetitive
  stress
  Persistent back pain
  that increases with
  hyperextension
   yp
         Hip Injuries
Hip Flexor
Labral Tear
   b d i “snapping hip”
IT band i.e.. “ i hi ”
Bursitis
  Hip Flexor and Iliotibial Band
   Tendinosis (Snapping Hip)
“Snapping or Clicking”     Contributing factors:
caused by a tight tendon                           g
                             Poor turn out / rolling
sliding over a femoral       Trunk, hip weakness
prominence                   Underlying ligament
                             instability
                             Hip inflexibility
                   Labral tear
Caused by impact or
“shear” injury
Sudden onset deep p
lateral and deep groin
pain
Contributing factors:
  Ligamentous laxity, tight
  hip flexors
  Poor turn out
  Trunk weakness
             Hip treatment
                                 joints,
Maintain flexibility in the hip joints including
    iliopsoas,
the iliopsoas, iliotibial band (ITB) and gluteal
muscles
Active Release Technique
Hip lid
Hi glides
Psoas release
    Lower Extremity Injuries
Lisfranc joint sprains
Great toe sesamoid injuries
Pl       l di        i
Plantar plate disruption
Ankle tendinosis
Ankle sprains
    Lower Extremity Injuries
FHL
Cuboid subluxation
Os Trigonum
O Ti
     Lisfranc joint sprains
Lisfranc ligament connects the first ray to the middle
and lateral columns of the foot.
             g            y            y
Axial loading with medially or laterally directed
                       hyper-
rotational forces on a hyper-plantar flexed midfoot.
                                 p
Often associated with an ankle sprain when p        y
                                               poorly
landing a jump.
                 Treatment
Mobilization of the talus
Release of the calf muscle
Strengthening of the anterior
leg muscles
Ice
Retraining of the pointe in
tendu
Corticosteroid injection ??
             Ankle Tendinosis
Micro-
Micro-tears and
degeneration of ankle
tendons
  Lateral - peroneal
           p                 ,
  Medial - posterior tibialis,
  flexor hallicus longus
  Posterior - achilles
Progressively
increasing pain
            Ankle Tendinosis
Contributing factors:          Treatment
  Incorrect weight               Relative rest
  distribution (weight back,     Pain control
  sickling)                      Rehabilitation w/
  Inflexibility, weakness        emphasis on strength
  (calves)                         d balance
                                 and b l
                                 Technique eval
                 Ankle Sprains
Tearing of lateral
ligaments of the ankle
    p
Important to rule out
associated fractures
The most common
injury in dancers
Symptoms:
  acute lateral pain and
  instability after “rolling”
  ankle
                Ankle Sprains
Contributing                   Treatment:
factors:                         PRICE
  I d
  Inadequately rehabilitated
             l h bili d                  motion,
                                 Rehab: motion
  previous sprain                strength, balance
              ,
  Weak ankle, intrinsic foot
  muscles
    Anterior Ankle Impingement
Bone spur formation in the
anterior ankle
  Causes
     repeated forced plantar
     flexion past end range
  Treatment
     Functional training and
     strengthening
           Os Trigonum
   Posterior Ankle Impingement
Causes
  An accessory bone of the foot.
            p
  Extreme plantar flexion of
  releve en pointe in the ballet
  dancer
Treatment
T
  Mobilization of the talus
  Release of calf
  Strengthen anterior leg muscles
 Posterior Tibialis Tendinosis
                      ankle,
Tender over medial ankle possible midfoot
(arch)
Lateral pain upon progression of injury
Pain with resisted internal rotation
Single leg heel raise strength greatly reduced
        Peroneal Tendinosis
Lateral ankle sprain which worsens with activity
May complain of “snapping” or “popping”
Pain       l i      l    l   l kl
P i on palpation along lateral ankle
Pain with inversion
Weak eversion
            hopping
Repeated “hopping” on Pointe
               Dancer’s Fracture
       (Acute fracture of 5th metatarsal)
 p                   g
Spiral fracture through the
shaft of the 5th (baby) toe
Sudden severe pain after
“ lli ” onto lateral foot
“rolling”       l    lf
Contributing factors
   Ankle instability /
   weakness
   Poor balance
   Floor surface/ shoes
 Dancer s
 Dancer’s Fracture Treatment
Treatment:
  Immobilization
     g y             y
  Surgery occasionally
  necessary
  Complete rehabilitation
  before return to dance
  Address underlying
  weakness and technical
  problems
                       Foot
Sinus Tarsi Syndrome      Cuboid subluxation
Stress fractures          1st MTP
Tendinosis                Bunions
Plantar fascitis
Flexor Hallucis Longus Disorders
Causes
  Repetitive stress
  Tight gastroc
        Cuboid Dislocation
Causes
Lateral midfoot pain
I bili       “work through the f ”
Inability to “   k h     h h foot”
Reduced plantar flexion
Dropped fourth metatarsal head
Manual Reduction
Taping
    Metatarsal Stress fractures
2nd metatarsal fx
common in dancers
           p
Localized pain associated
with activity
             g
Contributing factors:
  Sudden change in training
  Intrinsic foot weakness
  Toe length discrepancies
  Hard surface, poor shoe
  fit
 Great Toe Sesamoid Injuries
Tiny bones of the foot
Protect the FHL tendons, reduce friction, and
absorb weight
Causes
  Forced demi plie
  Improper landing of a jump
          Other foot injuries


Plantar fascitis
Bunions
     Improving your turnout
                 turn-
Much of your turn-out is determined at birth
After age 11 or 12 it is unlikely that you can
mold the bony architecture of your hips to
                  turn-
achieve further turn-out
H           ll is
However, all i not l ! lost!
             Improving turnout
Stretching
   Hip flexors
           y     p
   Butterfly and pretzel
   stretches
Hip Strengthening
   External Rotators,
   Adductors, Abductors
Pr ti !
Practice!
          Improving turnout


Additional Tools:
  Standing Firm
  Rotational Discs
             Rehabilitation
Consistent with rehab of elite athletes
Re-
Re-balance the soft tissue structures
C       improper technique
Correct i             h i
Balance/propreception
Core strengthening
Dance Specific Rehabilitation
Pool exercises
Corrective conditioning classes
Basic h bili i barre
B i rehabilitation b
Reformer footwork
Dance Specific Rehabilitation
                  ie
Manual therapy i.e. massage and trigger point
release
Flexibility exercise
Strengthening exercises
          Return to Dance
Progression to full dance with rehab classes and
modification of activity.
Consider occupational stresses and the psyche
of the athlete
Nutritional     id i
N i i l considerations
Ankle Exercises
Lower Body Strength
Flexibility
Core Strength
Foam roller
Trigger points
               Summary
Injuries are very       Treatment
common in dance         (even of minor
Early recognition and   injuries) always
treatment promotes      includes rehabilitation
early safe return to
early,                  and technique
dance                   evaluation
Questions?
Practice Manual Reduction
              References
Howse, J
Howse J. Dance Technique and Injury
Prevention. 3rd edition
Solomon, R. J. Solomon,
Solomon R J Solomon and SC MintonMinton.
Preventing Dance Injuries. 2nd edition
Journal of D
J                Medicine d Science
       l f Dance M di i and S i
Molnar, Marika, PT, Foot and Ankle Injuries in
the Dancer: Examination and Treatment
Strategies

				
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