Residency Presentation

Rex & Me

Rex = 10 Months

Rex = Tricks“Sit!”

“Down!”

“Paw!”

“Bang!”

Rex: “Good Luck!”

One of my tricks...

Overview of Dance Medicine

Objectives

1.) Understand the physical and psychological needs of the dance population.

2.) Identify common dance injuries and their implications.

3.) Utilize proper physical therapy interventions to treat dance injuries.

So You Think You Can Dance?(Not just a TV show)

Potts & Irrgang, 2001

“Dancers are a unique subset of the sports medicine patient population since they must combine aspects of art and science. No Physical activity calls for greater

physical versatility than dance. From explosive bursts of speed punctuated by bravura jumping to infinitesimally exquisite precision and control creating the illusion of

gravity defying lightness, from seemingly supra-human flexibility and balance to the strength necessary to carry one another, dancers are athletes as much as they are

artists.”

Subjective History & Risk Factors to Consider

Dance Medicine

• Dancer vs. typical patient =

Extreme ROM

Anatomic Alignment

• Perfect feet?– Pes Cavus– Pes Planus• Femino 2000 “supple and rigid”

• Hip anteversion vs. retroversion

Environment

• Raked Stage

• Sprung Floor

• Non-Sprung Floor

Footwear

• Men and Women ballet slippers give poor shock absorption.

• Need for dexterity

• Pointe shoes– Readiness?– 12x BW

Internal Environment

• Illness– Increased risk of injury

• Nutrition– Female athlete triad

• Gamboa 2008“...amenorrheic for > 6 mo. Were 93% more likely to sustain a stress

fracture”

• Bolin 2001“...dancers with a stress fx were more likely to consume <75% of

Recommended daily allowance (RDA).”

Training

• Change in training– 2-4 hrs. per

afternoon vs.– 6 hrs. per day

• Injuries occur when fatigued

Injury Occurence

Fitness

• Importance of cross training

• On and Off Season

Principles of Rehabilitation of LowerExtremity Injuries in Dancers

Potts & IrrgangJournal of Dance Medicine and Science

2001: 51-60

“Class work is inadequate for increasing the physiologic capacities of strength, power, and endurance that are

required by accomplished dancers.”

PT Magazine November 2008

Demonstration

• Technique

– Alignment, Alignment, Alignment!

Demonstration

• Releve• 1st Position (turnout)• 1st Position & Plie• Grand Plie• Developpe• Arabesque

Spine

Evaluation

• Look at: Arabesque and arching• Mechanism of injury.– Pull vs. Repetitive

• Inappropriate use of trunk or hip extension

• Poor lifting (males and females)• Weak Core

Treatment

• Educate on proper lifting technique• Educate patient on proper arching

technique– “Not bend back but feel lifted up and then

extend”• Core strengthening*

Differential Dx

• Imaging to rule out Spondylolysis

Hip

Evaluation

• Look at : Developpe• “Snapping Hip” (not an issue if not

painful)• Poor flexion• Overuse of Hip Abductors• Advantage of retroversion

Treatment

• Stretching of lateral structures– ITB (Winslow & Yoder, 1995)

• Correlation between tight ITB and tibial ER

• May need to look up or down the chain• Cautious with stretching IR and Flex. May be

causing impingement (increase pain)– Neutral may be enough

• Soft tissue work

Differential Dx

• Impingement

– Labral tear– CAM– Pincer

Knee

Evaluation

• Look at: Turnout & Plie• “Screwing the knee” mechanism and

poor technique• Hip ER (most likely weak)• Knee alignment in Plie should be over

2nd toe

Treatment

• Educate• Strengthen hip ER– Spin Disc or frictionless surface practice

turnout– Plie with theraband

• Correct alignment

Differential Diagnosis

• Meniscal tears• Stress fracture – Dreaded black

line• ACL– AJSM 2008

Liederbach, et al

Incidence of Anterior Cruciate Ligament Injuries Among Elite

Ballet and Modern DancersLiederbach, Dilgen, Rose

American Journal of Sports Medicine2008: 36; 1779-1788

Liederbach, 2008

• Looked at the incidence of ACL tears in dance over 5 years

• 298 Dancers– Male and Female– Modern and Ballet

• ACL tear per Exposure as defined by NCAA

Liederbach, 2008

Liederbach, 2008• Results – .009 per 1000 exposures

• Conclusion: “Dancers experience far fewer ACL injuries than in sports may be due to proprioceptive training as protective mechanism.”

Foot and Ankle

Evaluation

• Look at: Turnout, Plie, Releve• “Sickling” = BAD• Where is the pain?

– Medial vs. Lateral• FHL, Peroneals, Achilles• 1st MTP Joint DF ROM

– Rigid? Compensate, may start sickling• Jumping

– “Double Heel Strike” = Shin Splints• Gans, PT Journal, 1985

• Ankle sprains most common injury in dance

Gamboa, 2008

• Foot & Ankle Injury Incidence over 5 years

Liederbach, 2008

• Foot & Ankle Injury over 5 years

Treatment

• STM• Correct alignment• Modalities as needed and appropriate• Restrictions on jumping

Differential Dx

• Os Trigonum

Associations between turnout and Lower Extremity Injuries in Classsical Ballet Dancers

Negus, Hopper, BriffaJOSPT 2005: 35; 307-318

Negus, 2005

• 29 Dancers• Measured static Hip ER ROM• Measured Functional Hip ER ROM• Correlation between turnout and injury

Turnout

Negus, 2005

• Results:– No correlation with static hip ER ROM– Correlation found between non-traumatic

injury and functional hip ER ROM

• Conclusion: – “Measurement of hip ER ROM is insufficient

on its own.”

Shoulder

• Males – Increased lifting

of partners

• Style of dance, type of choreography

Evaluation

• Type of dance– WBing? Lifting?

• Proper lifting technique

• Typical UE evaluation

Who's tougher?

Treatment

• RTC Strengthening

• Correct lifting technique– Legs -> Trunk -> UE– Prevent hyperlordosis

• Core strengthening

Differential Dx

• Instability– 90% success non-operative

Injury Patterns in Elite Preprofessional Ballet Dancers and the Utility of Screening Programs to

Identify Risk Characteristics

Gamboa, Roberts, Maring, FergusJOSPT 2008: 38; 126-136

Gamboa, 2008

• Can you identify those that will be injured?• 5 Year study• Analyzed Several categories– Demographics & Medical Hx– Posture– Strength & Flexibility– Orthopedic testing (ROM)– Dance Technique Function

Gamboa, 2008

• Results:– Demographics & Medical Hx

• Hx of LBP

– Posture• Right foot pronation

– Orthopedic Testing• Insufficient Plantar Flexion (right)

• Conclusion:– Difficult to find screening to predict, prevent and

manage injuries, but medical hx may be sufficient

Summary

• Many injuries result from muscle imbalance and/or improper alignment

• Look at dancers unique movement patterns• Environment may need to be adjusted and

restrictions placed• “Proximal Stability leads to Distal Mobility”– Todd S. Ellenbecher

SummarySo You Still Think You Can Dance?

(Not just a TV show)

Thank You!

Questions?