case-based sports medicine: overuse injuries in performance sport athletes jordan d. metzl, m.d

Case-Based Sports Medicine:

Overuse Injuries in Performance Sport Athletes

Jordan D. Metzl, M.D.

www.DrJordanMetzl.com

Program Outline

• General Issues of Dancers

• Medical Issues of Dancers

• Orthopedic Issues of Dancers

• Dance Injury Prevention (Preparticipation Screening)

What Are the Performance Sports?

• Ballet• Gymnastics• Figure Skating

– Grace– Athleticism– Thinness– Precision– Perfectionism

Health Benefits of Performance Sports

• Psychological• Social• Bone density• Weight control• Athleticism

History of Ballet Dance

• Originated in renaissance Italy

• Brought to France by Catherine De Medici (1518-1589)

• Flourished under Louis XIV at Versailles

• Positions in ballet derived from foot positions in fencing

5 Foot Positions of Ballet Dance

• First – heels together, 90 degrees

• Second – heels shoulder width

• Third –90 degree alignment of foot

• Fourth – turn out with foot in between

• Fifth – need maximum ER to “close in 5th”

Level of Dancer

• Weekend• After school• Pre-professional

school• Company

Specialization and Dance

• What are goals/objectives?

• In order to be good, need to start early?

• Exclusion of other sports?

• Varied types of dance?

Performance Enhancement?

• Drugs?• “Extra” edge?• Weight issues• Influence and politics

– Boston ballet experience (Heidi Gunther)

Medical Issues of Female Athletes

• Medical Issues– Bone– Female Athlete Triad

• Anorexia – Nutritional

• Amenorrhea– Hormonal

• Osteopenia– Future bone health?

Medical Development of the female athlete

• Adolescent Development– Sexual Development– Skeletal Development– Physiologic

Development– Psychological

Development

Sexual Development in Dancers

• Menarche 2-3 years later than controls

• Primary amenorrhea– Absence of menses by

age 16

• Progression of sexual development correlated with rest

Female Athlete Triad

• Amenorrhea– Primary – Secondary

• Anorexia– Anorexia athletica

• Osteoporosis– Osteopenia

Anorexia Athletica

• Absolute Criteria– Weight loss >5%– Absence of medical

illness– Excessive fear of

obesity– Caloric restriction

• Relative criteria– Primary amenorrhea– GI complaints– Compulsive exercise– Disordered body

image

Axis of Rotation

• Sense of center• Vital to performance

sport athletes• Changes dramatically

during SMR IV-V• Most frequent time of

disordered eating issues

Culture of Disordered Eating

Recent Studies Regarding Medical Issues of Dancers

Adolescent BMD in Dancers

• Oligo/amenorrheic dancers BMD as compared to controls with similar profiles

• No significant difference in control group vs. dancer group

• Value of weight loading exercise, menstrual history

Bone Mineral Density Differences between Adolescent Dancers and Non-

exercising Adolescent Females • To WW, et al. J Pediatr Adolesc Gynecol. 2005

Oct;18(5):337-42 • 35 adolescent female dancers (17-19 yrs old) vs. 35

adolescent controls• DEXA of both groups• BMD values much greater for dancers compared to

eumenorrheic controls• Ward's triangle 0.816 g/cm(2) vs. 0.720, P = 0.003;

trochanter 0.777 g/cm(2) vs. 0.682; P < 0.001) were significantly higher in the eumenorrhoeic dancers as compared to controls

Psychological Development

• Adolescent Development– Sexual Development– Skeletal Development– Physiologic

Development– Psychological

Development

Psychological Considerations

• Only 23% of female and 33% of male professional dancers are satisfied with their bodies

• Adolescent dancers who begin puberty on time (12.9 years) have a lower body image than their peers

Issues to Consider When Counseling for Healthy Bones

• Body Habitus– Disordered eating, anorexia athletica, anorexia

nervosa

• Lifestyle– smoking, drinking, caffeine ingestion

• Diet– calcium, calories (calcium counting sheet)

• Heredity• Sex Hormone Levels• Previous Bone Injury (Dexa?)

Keeping Dancers Medically Healthy

• Preventive education• Recognition of

disordered eating, altered body image

• Making sure that health care team and teaching institution are on same page

Orthopedic Issues in Dancers

Common Orthopedic Issues in Dancers

• Scoliosis• Overuse Injury

– Bone• Sesamoid• Tibial• Femoral

– Tendon• Ankle• Iliopsoas

– Apophyseal

• Acute Traumatic Injury– Romeo and Julliet

Scoliosis

• 15% of dancers• Most common type is

adolescent idiopathic• Girls>Boys• Skeletal delay?

Forward Flexion Test

Injuries in Dancers

Is the School on Board?

Which Body Type Is Favored?

• Flexibility• “Natural” turnout• “Normal” Femoral

anteroversion is 15 degrees

• External tibial torsion• Roughly 60% above

knee, 40% below knee (turnout)

• Foot – Type– ROM at 1st MTP

The Ballet Pointe Shoe

Correct age to go en pointe?

• Beginning Stage Dancer– 8-12 years of age– Pre-pointe

• Middle Stage Dancer– 12-16 years of age– Major health issues

• Apprentice Stage Dancer– 16-older– Pre-professional stage

Common Injuries in Dancers

Posterior Ankle Pain

• 14 year old dancer• Pain in posterior

ankle• Pain with pointe• Pain with releve• Posterior ankle

impingement

Os Trigonum

Mechanical Factors

Mechanical factors causing posterior impingement (FHL)

Hip Pain in Dancers

• 12 year old dancer• “Snapping” hip• Noise with hip flexion• ? Pain

The Snapping Hip Syndrome

Iliopsoas Tendonitis

acet

IPM

IPM=iliopsoas muscleIP= iliopsoas tendon

IP

Needle tip

Common fem vessels

Injection Site

Bone Overuse Injury

• 15 year old ballet dancer

• Pain with dance• Having trouble with all

activities, particularly landing jumps

Pediatric Bone Health

• Children attain 90% of peak bone mass by 18 years of age

• Bone density increases by 6-8% per year in teens

• Multiple factors determine adult bone health

Bone Injury in the Female AthleteActivity

BiomechanicsBone Density

Injuries in dance company: effect of comprehensive management on injury

incidence

• Bronner S et al. Am J Sports Med. 2003 May-Jun;31(3):365-73

• 5 year injury data in professional company

• 3 years without intervention, 2 years with intervention of screening program

• Roughly 60% decrease in injury rate with preventive screening program

Dance Medicine Physical Therapy

Pilates Method

• Born early 1900’s, Germany

• Rickets, weak body• “Art of centrology”• WW I – orderly in

hospital treated disabled soldiers

“Reformer”

• Core muscle strength• Trunk stability• Injury prevention

Conclusions

• Dance is great for health!

• Medical and orthopedic issues

• Parents, teachers can take an active role in health prevention!

• Don’t “dance through the pain”