DANCE MEDICINE:GENERAL CONSIDERATIONS FOR REHABILITATION

Megan Meier, MD

Oklahoma Sports and Orthopedics Institute

OUTLINE

• Common Dance Injuries

• Etiology of Dance Injuries

• Training Oversights

• Dance Rehabilitation

OUTLINE

• What constitutes a dance injury?

• What injuries are commonplace in dance?

• What is known about the etiology of those injuries?

HARKNESS CENTER

• “Must possess a trained eye sensitive to the full palette of demands and nuances of movement from the form to which the dancer wishes to return”

• Partnership with the injured dancer’s teacher or artistic director is essential

• Understand work setting

INJURIES

• 50-80% of dancers report an overuse injury at some point in their career

• 65% of dance injuries are overuse and 35% trauma

• 46% of amenorrheic dancers experience a stress fracture in their career

INJURY PATTERNS

BALLET VS. MODERN

INJURY PATTERNS: MALE VS. FEMALE

• Over a 9 year period studying dancers in the Joffrey Ballet

• 35% higher incidence of foot and ankle injury in female dancers

• Higher incidence of back pain in male dancers

• Boston Ballet-1 year period

• females had twice the foot and ankle injuries

• males predominately had knee, hip/thigh, back and shoulder injuries

ETIOLOGY OF DANCE INJURIES

• Dance training is “dictated by artistic traditions” and aesthetics, not scientific principles

• Occupational Demands

• Movement Demands

• Training Oversights

OCCUPATIONAL DEMANDS

• Physical Tendencies

• Hypermobility

• chronically overstretched muscles and decreased muscle spindle output and reflex force characteristics

• Poor proprioception related to changes in tissue length

• (ex) ACL injuries linked to altered muscle recruitment patterns associated with long amortization phase in the stretch reflex response

• Dance is an intense, highly repetitive, high impact activity—the above imbalances and deficits pose significant risks for injury.

OCCUPATIONAL DEMANDS

• Tightness and Weakness

• Harkness- 800 healthy adult (college and professional)

• 76% calf tightness

• 63% + Thomas test for hip flexor tightness

• 68% failed plantar flexor endurance testing

• 50% failed functional quadriceps control testing (bench stepping)

• 38% failed supine double leg lowering for abdominal strength.

OCCUPATIONAL DEMANDS

• Thinness and Low Energy Expenditure

• Ballet and modern dancers tend to be on average only 75% and 88% of expected body weight respectively

• Inadequate energy intake and expenditure

• Female athlete triad- amenorrhea, disordered eating (not necessarily eating disorders), and osteopenia/osteoporosis

• Not just a problem for females!

OCCUPATIONAL DEMANDS

• Psychological tendencies

• High focus and drive

• More injuries related to the “more enterprising” dancers and overachiever personality type

• Dancers less likely to seek care from a physician or physical therapist

• In one retrospective study of professionals, only 20% sought medical care for an injury

• Visits often cost prohibitive—professional dancers often live near the poverty level

• Lack of time due to rehearsal schedules

• The notion that physicians “viewed their problems as more incidental than they wished”

MOVEMENT DEMANDS

• Posture and Alignment- example: “turnout”

• Base of support- not only the feet

• Balance and proprioception- often innate and improperly rehabilitated after injury

• 40% of dancers at Harkness fail Romberg or demonstrate increased sway

MOVEMENT DEMANDS ON SPINE AND PELVIS

• Asymmetrical loading during end-range movements

• Sacroiliac dysfunction most common 2/2 movement demands and ligamentous laxity

• Functional hypermobility of the pelvis- square torso with large lower extremity movements.

• Hip and lumbar hyperextension

• Incidence of spondylolysis and spondylolisthesis- 12-17%, similar to elite gymnasts and higher than the general population (6%)

MOVEMENT DEMANDS OF HIP

• Snapping Hip- extraarticular- anterior/lateral/posterior and intra-articular

• Most common TFL/ITB snapping over GT or iliopsoas tendon at the iliopectineal eminence

• Internal-synovial chondromatosis, loose bodies, OCD, osteocartilaginousexostosis, labral tear, or inverted labrum

• Piriformis syndrome-related to shortening and tightness from turnout posture

MOVEMENT DEMANDS AT THE KNEE AND LEG

• On average, 200 jumps per class, often with some transverse plane rotation about the tibiofemoral joint

• Patellofemoral Pain syndrome- high frequency of eccentric loading due to the repetitive landing

• “Shin splints”- MTSS to tibial stress fractures- from improper mechanics, double heel contact or no heel contact

MOVEMENT DEMANDS- FOOT AND ANKLE

• Releve

• Releve en pointe- bone on bone forces are 10X the body weight- compare to a runner doing a 6m mile

• Releve’- 2X the body weight across the great toe MTP (worsened by winging)

• Loss of anatomic stability of the talocrural joint

• Flexor Hallucis longus and other soft tissues have higher tensile forces due to 1st

ray being at a mechanical disadvantage>>FHL can progress to rupture with prolonged forces and inflammation >>can progress to stenosing tenosynovitis causing “trigger toe.”

MOVEMENT DEMANDS- FOOT AND ANKLE

• Releve’

• Releve’ en pointe- bone on bone forces are 10X the body weight- compare to a runner doing a 6m mile

• Releve’- 2X the body weight across the great toe MTP (worsened by winging)

• Loss of anatomic stability of the talocrural joint

• Flexor Hallucis longus and other soft tissues have higher tensile forces

• Foot fractures- 2nd metatarsals, pedal sesamoids, and Lisfranc joint

• Posterior ankle impingement

MOVEMENT DEMANDS- FOOT AND ANKLE

• Releve’

• Lateral cuboid compression forces related to imbalance of dorsiflexors to plantarflexors leading to extended pronation in gait cycle phases

• “Sickling”- increased lateral ankle sprain often accompanied by “dancer’s fracture” a spiral fracture of the shaft of the fifth metatarsal or distal fibular fracture, interosseous membrane irritation, and or subluxation/dislocation of the peroneal tendons

MOVEMENT DEMANDS- FOOT AND ANKLE

• Plie’• Anterior ankle impingement-

• more frequently in males than females

• associated with high impact landing from large jumps into demi plie’

• Causes anterior impingement and osteophyte development

• associated with eccentric weakness of the calf with compensatory pronation or supination resulting in capsulitis of the first MTP

MOVEMENT DEMANDS- FOOT AND ANKLE

• Plie’

• Poor fitting shoes

• Inadequate strength-weaker dorsiflexors in relation to plantarflexors

TRAINING OVERSIGHTS• Periodization- lack of rest cycles and step-up training phases lacking due to

rehearsal schedules

• Specificity- related to difference in training and artistic variation from baseline technique in choreography

TRAINING OVERSIGHTS

• Overload training- sudden increase in classes/rehearsals- body unable to adapt

• Over-training- inability to adapt positively to training stresses over a sustained, long-term, and intense manner

WORK-HARDENING

American Physical Therapy Association- “a highly structured program encompassing not only physical rehabilitation but also vocational and psychological preparedness in order to return to work”

• Broad based conditioning

• Career specific tasks in work situations

• Consider style-specific, staged rehabilitation program

• Dancer must be comfortable with:

• Stylistic demands of movements

• Stage sets/costumes

• Understanding why the injury happened and prevention of reinjury

DESIGNING A DANCE REHAB PLAN

• Consider obtaining normative data for capacities of healthy dancers

• Periodization to the dancer’s training/rehearsal schedule

• Set guidelines related to fatigue

• Always question outside activities such as home exercises and workouts

• Address stressors, dietary habits, and health status (including menstrual history)

RESOURCES

• Liederbach, M. “General Considerations for Guiding Dance Rehabilitation.” J Dance Med Sci. 4(2): 54-63, 2000.

• Hamilton, L., Hamilton, W., Meltzer, J. etal: “Personality, stress and injuries in professional ballet dancers. Am J Sports Med 17(2):263-267, 1989.

• Batson, G. “Update on proprioception: considerations for dance education.” J Dance Med Sci. 13 (2): 35-41, 2009

• Kerr, G, Krasnow, D. “The nature of dance injuries.” Med Probl Perform Artists, 9 (1):7-9, 1994.

QUESTIONS?