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dance injuries

Dance Injuries: Back and hip pain Dancing to the wrong rhythm

Lower trunk injuries follow a predictable pattern among dancers unless they are properly treated. Sean Fyfe explains.

Dancers with lumbopelvic/hip dysfunctions are incredibly challenging for sports injury professionals to diagnose and treat. What follows is derived from my own recent experience of working with both ballet and contemporary dancers, drawing together some of what I have learned about their diagnosis and treatment.

Two important points must be made right at the start. Firstly, the lumbar spine, pelvis and hip should never be considered separately: a complex interplay exists between them. Subtle changes or inadequacies in one area will have a definite impact on the surrounding areas. The sports therapist’s assessment and management needs to reflect an appreciation of this.

Secondly, you will need to focus less on identifying painful structures and more on the mechanical dysfunction, which requires you to have a thorough understanding of the function of the lumbopelvic hip complex. And we are not just talking here about ‘normal’ function as it applies to the general population, but normal for dancers, which is considerably different in terms of range of movement and muscle control.

Of course, mechanical dysfunction will often, over time, lead to a more serious structural pathology. A prime example is spondylolysis and spondylolisthesis, a common injury in dancers. You should always seek to exclude these pathologies; and if they are present take appropriate action. Before the patient returns to dancing, however, the underlying mechanical dysfunction must be corrected.

Unusual moves, extreme control

Let’s look at two aspects of the movements that dancers perform, as a way of illustrating why they commonly present with specific muscle imbalances.

Unusually, dancers (and, indeed, gymnasts) perform repetitive open-chain movements with their lower limbs. Most sports follow a more natural movement pattern, with the lower limb undertaking closed chain, while the upper limb is reserved for the open-chain movements. These open-chain lower-limb movements require a high level of dynamic control through the whole lumbopelvic hip complex.

Take, for instance, the ‘grand battement’ (high kick) move (see diagram 1). The dancer begins in turnout and must hold the stance leg in turnout. The other leg is then flexed and abducted while keeping the knee straight. The muscle work should be:

  • flexion movement initiated with iliopsoas and TFL;
  • gluteus medius abducts;
  • external rotators of the hip continue to activate;
  • activation of rectus abdominis allows the pelvis to posteriorly rotate as the hip flexes.

Diagram 1: The ‘grand battement’ (high kick)

Diagram 1: The ‘grand battement’ (high kick)

This action faces the acetabulum (hip socket) in a cephalad direction (upwards) to clear the acetabular rim from the glenoid. The posterior rotation must take place without flexion of the thoracic spine so that the dancer maintains good trunk posture. The posterior rotating pelvis imparts flexion on the lumbar spine. The segmental stabilisers of the lumbar spine need to be active to prevent shear forces between segments.

A problem shared… the case of four dancers with lumbopelvic pain

Although Kim, a full-time contemporary dance student, was 19 years old, she had only been dancing seriously for three years. Kim presented to physiotherapy after a month of suffering lumbar spine discomfort centrally and front thigh pain on both sides in the L3 nerve distribution area. Initially the pain in her lumbar spine and thighs was most apparent after dancing sessions, but it progressed to pain on movements involving extension and thigh pain on performing plies (squats done in turnout with a straight spine). Posturally Kim had a poor lordosis (flat lumber spine) and upper trunk posture. On palpation she was very tender both centrally at L2 and L3 and unilaterally at L3/4 and L2/3; and less tender but stiffer at L4 and L5. Her thoracic spine from T7 down was also stiffer and demonstrated less than acceptable extension for a dancer. Her hip extension was tight, particularly through TFL.

Kim was suffering from lumbar spine instability and L3 nerve root irritation caused by hypomobility in other areas of the kinetic chain and a lack of segmental stabilisation in the mid lumbar spine. The good news is that we had caught the injury early, ahead of any significant loss of structural integrity in the spine.

Liz was not so lucky. Her professional ballet career ended as a result of chronic back pain from a Grade II spondylolisthesis. My first encounter with Liz was three years after she finished her career, when she sought advice for her condition, which had become very painful on a daily basis.

During the final two years of her career Liz had received ‘patch up’ treatment and had continued to dance, completely unaware of the structural damage she was inflicting on herself. Investigations eventually revealed the spondylolisthesis, prompting her decision to retire. Liz’s physical situation today represents the injury status that Kim could progress to if she were to continue to dance without correcting the areas of hypomobility and retraining the stabilisers of her lumbopelvic region.

For a former professional dancer, Liz was now physically functioning at a low level. The retirement and ongoing pain had led to significant disuse. She stood and moved with a severe posterior tilt to offload extension in her spine; her core stabilisers were very weak and, because of her posture, were barely activating, and her gait demonstrated excessive lumbar spine movement and bilateral Trendelenberg (sagging of the pelvis on each side when stepping).

Liz and Kim underwent the same process of retraining their core stability: learning how to activate in isolation the segmental stabilisers in neutral, then with movement, and finally moving out of neutral spine as activation of the other stabilising muscles was introduced. Kim obviously started at a much higher level and could be progressed more rapidly to exercises that placed a greater load on her lumbar spine. With Liz we also needed to do some posture and gait retraining.

Kim and Liz both achieved the functional status they were aiming for and a long-term plan for the management of their lumbar spines. Kim returned to her full- time dancing programme stronger and more flexible, and Liz was experiencing very little pain day to day. I was pleasantly surprised with how quickly Liz’s problem turned around. Within three months her posture, gait and stability were completely changed and she was continuing to dream of one day opening her dance company.

Jenny was 12 years old and dancing almost full-time as well as attending school, leaving her with very little spare time. And as is typical with young athletes, it was Jenny’s body conditioning that was losing out. She had started to develop anterior hip pain on both sides and an audible clunk on the eccentric phase of open-chain lower limb movements on the right, which was the most painful side. Jenny demonstrated all the muscle imbalances in Table 1 (see below) and, at a very early stage, the corresponding structural changes outlined in Table 2 (see below).

Of particular importance was the anterior femoral head displacement and associated loss of hip-joint rotation. Jenny would feel an impingement pain in her hip quadrant, and was tender to palpate through most of the anterior hip; her teacher had also commented on her need to improve her turnout.

We did a lot of trigger point work, especially through the short external rotators, coupled with various hip-joint capsule mobilising and seatbelt stretching techniques, to restore rotation to the hip joint. Alongside this a strengthening programme targeted rotational hip control in different ranges of flexion and extension; activation of glut max and med; and lower abdominal activation and strength to improve Jenny’s control of concentric and eccentric posterior tilt with open chain movements. Once she was painfree we continued to progress the exercises so that she was able to carry out a high-level exercise routine to maintain and improve the function of her dancing body.

Philippa’s was an almost identical presentation. However, Philippa, a full-time contemporary and ballet student, was 20 years old and had been suffering with the bilateral hip pain for two years. We followed a very similar path of management. The restriction to Philippa’s hip rotation range of movement was worse and my suspicion that her hips had undergone more long-term arthrokinematic adaptations seemed to be confirmed by the way they responded to treatment and rehabilitation.

While Jenny was able to practise and perform pain free and with a much improved turnout within a month, Philippa’s body took longer to respond. She required more intensive hip-joint mobilisation and stretching, and demonstrated less carryover between sessions with her own stretching; hence pain took longer to diminish. As Philippa continued her strengthening and home flexibility routine, we introduced some hip-joint flexibility maintenance treatment. Had these problems been detected and addressed earlier, through proper musculoskeletal screening, I believe she would have been able to improve a lot more quickly.

Liz, Kim, Jenny and Philippa are good examples of how common dance injuries follow a predictable path of progression, if the underlying causes are not picked up early and treated, along with proper education and ongoing body maintenance.

In dance, lumbar spine movement is biased towards extension. In standing, dancers are trained to stand in anterior tilt, which imparts extension on the lumbar spine, and most dance choreography involves a lot of extension-based movements. One such is the ‘backward bridge’ . For this movement it is important that there is flexibility through the whole system: hip extension, range of posterior tilt of the pelvis relative to the hips and extension of the lumbar and thoracic spine. The danger is that excessive movement takes place at a segment in the lower lumbar spine because of a lack of stabilisation and/or poor mobility in other areas of the chain.

Table 1: Typical lumbopelvic hip complex imbalances in dancers
Overactive and tight areas Underactive and weak areas
Lumbar spine extensors (quadratus lumborum, erector spinae) Gluteus maximus
Hip flexors (iliopsoas, TFL) Rectus abdominis
Deep external rotators of the hip (piriformis, obturators internus and externus, quadratus femoris, inferior and superior gemellus) Obliques, internal and external
  Deep segmental stabilisers

It is the repetition of these types of movements that over time can lead to imbalances. Table 1 (above) summarises an overview of the muscle imbalances typically seen in a dancer suffering with injury in the lumbopelvic hip complex. Bear in mind that the definition of ‘weak’ in a dancer may be relatively strong in the average population.

These muscle imbalances may lead to arthrokinematic changes (the way adjoining joint surfaces move against each other) as listed in Table 2 (below); these should all be considered during the therapist’s assessment and management.

So we can begin to see how we would expect a dancer to change during years of training and performing. At a young age, muscle imbalances start to develop. At first, any joint restrictions will be mainly related to muscle overactivity. Over time these soft tissue restrictions lead to changes in joint surface relationships. Incorrect movement of the joints, such as lumbar spine instability or impingement of the hip joint, then lead to structural changes of joint surfaces, bone or discs. Chronic joint restrictions will promote capsular adaptations which can further affect joint movement.

Table 2: Structural changes to lumbopelvic hip complex
Nature of arthrokinematic change Reason
Anterior femoral head displacement with associated restriction to hip flexion with adduction and decreased internal rotation Increased tone through external rotators causes an anterior position of the femoral head in the acetabulum (the same mechanism that is often seen in the shoulder of the overhead athlete, where increased tone in infraspinatus and teres minor cause the humeral head to shift in the glenoid)
Reduced lumbar flexion Overactivity of the lumbar spine extensors restricts the movement into flexion. This can be deceptive because dancers have such a large range of movement when bending forward from a standing position; but the actual range of lumbar flexion is often poor
Hypomobility of thoracolumbar junction and lower thoracic spine The overactivity of the lumbar extensors and psoas, which attach in this region, increases joint compression, limiting mobility
Reduced hip extension Overactivity and tightness of hip flexors
Increased abduction, decreased adduction Tightness through ITB/TFL and posterior rotators, limiting adduction

And the downward spiral can continue. Prevention from a young age is critical to reduce the consequences of injury later in an athlete’s or dancer’s career. As I have stated in previous SIB articles, this is where I believe support practitioners can make the biggest impact, working with organisations to adjust training programmes so that from a young age athletes and dancers develop their bodies free from destructive imbalances, rather than just learning their sport or dance.

When I began working with dancers in the UK – professionals, students, contemporary and ballet – I was alarmed at how little time they devoted to training away from dancing. It is apparently normal for a full-time programme to be very largely dance, with a little pilates (which in most cases is non-specific) and some stretching. It is not uncommon to be dancing for six hours a day and doing nothing else.

The injury rates being sustained are very high. A German study (1) from 2003 found that among 77 professional ballet dancers, 88% suffered from discomfort in the lumbar spine. In an earlier Swedish study (2), researchers at Lund University found that among 128 professional ballet dancers 70% reported low back problems within the previous 12 months.

These rates are far in excess of other sports I have worked with. Dancing alone doesn’t ensure abdominal strength, good activation through glut max or activation of segmental stabilisers. In that respect, dance is no different from any other sport: its performers have to put aside the time to do specific body maintenance, in conjunction with regular screening, to give themselves the best chance of remaining injury free.

Sean Fyfe is a physiotherapist working with Metis Physio Centres in London, a multi-disciplinary clinic. He works with elite dancers and theatre performers

Illustrations by Viv Mullett

References

  1. Arendt YD, Kerschbaumer F, ‘Injury and overuse pattern in professional ballet dancers’ Z Orthop Ihre Grenzgeb 2003 May-June; 141(3):349-56
  2. Ramel E, Moritz U, ‘Self-reported musculoskeletal pain and discomfort in professional ballet dancers in Sweden’ Scand J Rehabil Med 1994 Mar; 26(1):11-6 For further reading on function of the lumbopelvic girdle, the reader is referred to Diane Lee’s book, The Pelvic Girdle, pub: Churchill Livingstone, June 2004 £ 29.99

For further reading on function of the lumbopelvic girdle, the reader is referred to Diane Lee’s book, The Pelvic Girdle, pub: Churchill Livingstone, June 2004 £ 29.99

dance injuries