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Bridget J. Quinn, M.D.

Division of Sports and Dance MedicineDivision of Sports and Dance Medicine

Children’s Hospital Boston

• ART = OCCUPATION = PASSION

• What makes this population unique?• Specialized medical team

• Dance Terminologygy

• Common Moves

• Correct Technique

• Dancer’s Mentality

• Risk Factors for Injury

• Common Injury Patterns

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• Dancer $16.37/h• Principle dancer $170,000/y

• Frequently lack health insurance

• Musicians and singers $22.36/h• Also lack health insurance

• Entertainers and performers $18.41/h

• Physicians/surgeons $83.59/h

• Tom Brady $8,000,000/y

http://www.bls.gov

• 1400 Italian Renaissance dukes competed with each other in entertainment (dance)

• 1547 Catherine de Medicis, of Florence, became queen of France

I t d d titi t t i t t • Introduced competitive entertainment to French court

1600-1700 King Louis XIV danced in ballets at his court

› 1661 founded the Royal Academy of Dancing

Early 1800 women began to dance en pointe

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• 1st treatise on disability in performing artists in 1713• Past 20-30 yrs. organization of specialized medical programs

• British Association of Performing Arts Medicine (orchestra)• Performing Arts Medicine Association (PAMA)g M ( M )• International Association of Dance Medicine and Science (IADMS)

• Multidisciplinary approach• Physician• Physical/Occupational Therapist• Nutritionist• Psychologist• Teacher

• Pain or physical dysfunction results in missed participation in class, rehearsal, or performance – Liederbach. JDMS. 2000.

Discrepancy b/w # of reported injuries and amount of pain reportedreported

• 95% dancers have ongoing pain• Annual frequency of reported injury 23-84%

• the definition of injury, or how dancers' perceive injury with respect to pain and activity limitation thresholds

• Dancer’s described injury as something that stops them from dancing or moving normally

• Patterns representative of motion and demand particular to each sport/art• Clarinet’s weight on the thumb• String player with bad posture• Ballerina dances in demi and en pointe

• Different forms of dance have different injury patterns• Ballet: foot and ankle• Modern: knees and backModern: knees and back• Irish Step: foot and ankle• Break Dancer: wrist, finger, shoulder, knee

• Gender roles (in ballet)• ♀ Foot and ankle• ♂ Back pain

• Causes• Occupational demands• Movement demands• Training oversight

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Principles and steps on which classical ballet is built 5 Positions of feet

› ALL require turnout ideally at 180° Moves quickly in any direction while presenting a full view of body position

and alignment to the audience

Alignment (keep head/shoulders/hips vertically aligned)g ( p / / p y g ) 7 Styles of Classical Training

› Vagonova (Russian), Cecchetti (Italian), French, Royal Ballet School and Royal Academy of Dance (English), Balanchine (American), BournonvilleSchool (Danish)

• Begin serious training ~ 8y/o• By age 12 can take 4-6 classes per

week• Boston Ballet

• School• Trainee• Pre-Professional• Boston Ballet II• Company

• Corp• Backdrop

• Soloists• Principles

• Highest rank• Perform solos and pas de deux

• Barre• Neuromuscular coordination• Conditioning• Performance enhancement

• Center• Adagio (slow movements for

balance and control)• Allegro (fast movements for

speed and exactness)

• Ends• Jumps• Pointe (women)

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• Endurance• StrengthStrength• Flexibility• Aesthetically pleasing

Intrinsic• Flexibility• Anatomic alignment• Muscle/tendon imbalance• P diti i

Extrinsic

• Training• Volume

• Intensity

• Extreme range of motion• Poor conditioning• Nutrition• Psychological stress• Illness• Previous Injury• Growth

Extreme range of motion

• Repetitive nature

• Technique

• Footwear

• Surface

Acute• TRAUMATIC and sudden• Ankle inversion injuries most

common

OOveruse• Develops over time

• Repetitive stress

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Increase stress on a specific area = INJURY

• Greatest risk when returning after period of relative inactivity• Start of season or after a break

• Overachievers

• Fatigue• D l t l fl • Decrease neuromuscular control, reflex

activity, and power

• 90% lifetime incidence

• 80% lower extremity• Foot injuries greatest in women (en pointe)

• 20% Spine• Men with partnering

• ½ injuries represent strain, sprain, tendinitis

• Examined epidemiologic, medical, and financial aspects of injuries to dancers of the Boston Ballet company from 1993-1998• Injuries were evenly distributed b/w age, rank, and gender

in the companyp y

• 29 surgeries (2/3 performed on males)• 73% injuries in lower extremities• ¾ were strains/sprains, tendinitis, contusions• Ankle (30%) & foot/toes (17%) most frequent sites• Cost to the company

• Average $549,812 per year

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• Standardized preventive health protocol• Benefits the dancer, dance company, and the art form

• Over 30 professional ballet companies participating• Demographic information• Past medical/surgical/menstrual/social historyPast medical/surgical/menstrual/social history• Screen

• Height, weight, BMI, blood pressure, heart rate• 3 minute step test• Flexibility• Strength• Functional assessment

• 5 turned out position of feet that form a 180° line

• Absolute determinant at hip is femoral neck anteversion• Some additional turnout with stretching

h l d ili f l li & the capsule and iliofemoral ligament & strengthening

• Plasticity 11-12 y/o

• Anteversion angles similar in age-matched non-dancers

• Forcing turnout INJURY• “screwing out”• Sway back into extension

• Dance training comes from artistic tradition NOT scientific principles

• Forcing turnout

• Poor hip alignment in secondPlié

“Rolling in” Normal “Rolling out”

“Winging” “Sicling”Normal

Relevé

“Rolling in” Normal “Rolling out”

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• Generalized hypermobility common• Allows extreme end range of motion

• Decrease in joint hypermobility syndrome (JHS) in ascending order from school to company (corps de from school to company (corps de ballet to soloist to principle)• Greater injury risk (especially overuse)

• Prolonged recovery period

• Overstretched muscles/tendons • Overuse damage, degeneration,

mechanical failure

• Poor proprioception

Briggs J, et al. Rheumatology. 2009;48:1613-1614.

• Genu recurvatum/ “Sway back”• Complement the pointed foot or

arabesque• Causes

• Ligamentous laxity• Compensation for limited foot plantarflexion

(pointing)(pointing)• Poor trunk stability

• Associated with• Muscle imbalance: overactive quadricep and

underdeveloped hamstring• Lumbar lordosis• Tight hip flexors• Patellar displacement• Increased load to the lower leg leading to

“shin splints” and stress fractures

Imbalance of opposing muscular structures Tight gastrocnemius-soleus

complex

Weak dorsiflexion

Tight hip external rotators

Impair shock absorption

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• Adolescent growth spurt• 11-13 y/o girls• 12-14 y/o boys

• Growth plate (physeal cartilage) is more susceptible to injury• Growth plate is weaker than

associated soft tissue (i.e. ligaments) trauma

• Bone lengthens faster than soft tissues• Muscle imbalance• Tendon inflexibility

• Growth can exacerbate overuse injuries

• 3-4 yrs. ballet training• Sufficient ankle and foot plantarflexion range

of motion• Foot aligned parallel to tibia

• Good lower extremity alignmentGood lower extremity alignment• Good trunk and pelvic (“core”) strength• Strong legs/feet/ankles

• Can hold a passe en demi-pointe w/ good alignment

• Releve en pointe has ankle bone-on-bone forces 10 x the dancer’s body weight• Equal to runner doing 6 min. mile

“When she can do something once she’s up there.” –George Balanchine

• 9 elite ballerinas from Boston Ballet• Aerobic fitness (VO2 max) greater in dancers than non-dancers but

lower than endurance athletes (runners)• Dancers utilize both aerobic and anaerobic metabolic pathways (short duration but

high intensity)high intensity)

• High # of cigarette smokers• Strength

• Strong lower extremities and weak upper extremities• Strong muscle endurance (repetitive activity)

• Ankle plantar flexors to dorsiflexors ratio 6.1:1• Homogeneous in height, weight, age, body composition

• Average percentage of body fat 15.3%

• Increased flexibility

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• Dance, figure skating, diving, gymnastics • Traits of perfectionism, control, competence

• 6.5% professional ballet students anorexia• Female dancers keep body weight 10-20% below ideal

body weight• Teenage pre-professional ballet dancers average 87%

expected body weight• College-age modern dancers average 88% expected ideal

body weight

• Anna Pavlova described as a waif or sparrow, “ethereal as a cloud”• Adulation emphasizes commitment to the art form• “She danced on bleeding feet”

• Male n = 29, Female n = 39 before and after a performance season

• Calebrese et al. found that professional female dancers consumed only 71.6% of the

• No significant change in body composition in males

• Significant decrease in both body weight and percentage of body weight as fat in females

• (Fat % Pre: 12.8 + 2.7; Post: 11.5 + 2.1 (p<0.05))

RDA of nutrients

• Bensen et al. 69% ballet dancers in college program intake of less than 70% RDA for nutrients

• Disordered eating• Anorexia

• Bulimia

• Disorder NOS

Including behaviors not in DSM IV and concept of “energy availability”

• Amenorrhea

• Osteoporosis “Functional hypothalamic amenorrhea” and various types of menstrual dysfunction

Including less severe forms of poor bone health

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Nattiv A, et al. Med Sci Sports Exerc. 2007 Oct;39(10):1867‐82.

• Eating disorder: clinical mental disorder defined by DSM-IV and characterized by abnormal eating behaviors, an irrational fear of gaining weight, and false beliefs about eating weight and shapeeating, weight, and shape.

• Disordered eating: various abnormal eating behaviors including restrictive eating, fasting, frequently skipped meals, diet pills, laxatives, diuretics, enemas, overeating, binging and purging.

• 90% of women’s peak bone mass is accrued by age 18!

Bailey DA, et al. J Bone Miner Res 1999;14(10):1672-9.

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• Eumenorrheic dancers have greater bone BMD than eumenorrheic non-dancers

• Benefit is lost with menstrual irregularity

• A dancer with 1 component of the Triad should be evaluated for the other 2!

• Suspect when:• Weight loss• Decline in performance• Change in mood• Frequent injury/illness• Fracture, low BMD• Menstrual dysfunction• Poor score on Eating

Questionnaire

• Improper technique

• Training

• Footwear

• Hard floor or change in flflooring

• Conditioning

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• Forcing turnout

• Poor hip alignment in secondPlié

“Rolling in” Normal “Rolling out”

“Winging” “Sicling”Normal

Relevé

“Rolling in” Normal “Rolling out”

• 16-20 hrs./week• Abrupt increase in training

• Duration (how long)• Frequency (how often)• Intensity (how hard)

• Type• Follow 10% rule

• Increase activity no more than 10% per week• Includes intensity and time of exercise

• Ballet slipper• Pointe shoe

• Construction: box, shank, sole• Toe box width, too soft (“dead” shoe)

• The Sugar Plum Fairy will go through one pair of pointe shoes per performancep p p

• Ballet pointe shoes used in one season of The Nutcracker would circle Boston Common!

• Outside studio• Supportive footwear

• Place 3-12X their body weight on joints during dance

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• Most dance floors have 2 components• a surface floor

• resistance or the appropriate f i ti f th t l f d friction for the style of dance being performed

• Typically made from vinyl or linoleum

• a subfloor “sprung floor”• resilience or spring to help protect

the dancers' joints and muscles from injury

• Warm-Up• 15 -30 minutes• Start with center & move outward

• Cool-Down• 10 – 15 minutes• Slowly lower heart rate• Stretch with slower movements• Stretch with slower movements

• Adequate sleep• Cross-conditioning

• Variety of physical activities

• Foot/Ankle• Ankle Sprain

• FHL Tendinitis

• Os Trigonum

• Hip• Iliopsoas tendinits

• Labral Tear

• Spine• Knee

• Patellofemoral Syndrome

• Patellar Malalignment

• ACL injury

• Meniscus tear

p• Spondylolysis

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• Anterior Talofibular Ligament• Mechanical stability

• prevents supination in demi-pointe• Rotation stability during outside turns

• Risk• Inadequate rehabilitation of previous injuryInadequate rehabilitation of previous injury• Poor technique in landing from jumps (foot supinated)• Fatigue• Sickling in of the foot during releve

• Rehabilitation: in a functional manner • ROM: stretch achilles• Strength: theraband to strengthen peroneal (pointed and

flexed), manual resistance• Proprioception: wobble board• Water barre

• Acts as the Achilles tendon of the great toe• Completes push-off during striding or jumping

• Common cause of posteromedial ankle pain in dancer• Pointe work or when trying to raise arch• Crepitus and triggering

• RiskP th h fib t l b hi d th ll l• Passes through fibro-osseous tunnel behind the malleolus

• Grand plie causes muscle belly to jam into the tunnel• Adhesions can mimic pseudo hallux rigidus w/ limited great

toe dorsiflexion• Pronation (natural or forced turnout)• Lack of ankle strength

• Treatment• NSAIDs, orthotics in street shoes, US, iontopheresis,

stretching/strengthening

• Jump and balance training shown to reduce ACL injury rates

• 5-year prospective study• 298 dancers from 3 professional and 1

conservatory dance organizationy g• 12 ACL injuries over 5 years• Incidence 0.009 per 1000 exposures• 92% involved landing from jump on 1 leg• Most occurred late in day/season• ♀ modern dancers had 3-5 x greater RR

• Dance training focuses on lower extremity alignment, jump, and balance may protect against ACL injury• Do more than 200 jumps per 1.5 hour class• Predictable environment

Liederbach M, Dilgen F, Rose D. The American Journal of Sports Medicine. 2008; 36(9):1179-1787.

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• Pain in the front of the knee• Stairs, prolonged sitting (“theater sign”), grande plie, deep knee

bends, turnout, running, and/or jumps• Develops over time• Originates from the patellofemoral joint and the supporting

structuresstructures• Overload of the patellar as it articulates with the groove of the

femur• Causes

• Overuse and poor technique• Lateralization of the patella• Anatomical factors

• Treatment• Technique• Physical Therapy

• Hip flexion/external rotation• Overuse• Internal snapping caused by subluxation of the

iliopsoas tendon• Pain deep in the groin• Clinical Exam

P i h fl i• Provocative hyperflexion test• Place pt. in frog leg position and ask them to flex

and adduct against resistance• Limb placed in hyperextension and abduction, slowly

rotate the hip internally

• Rehabilitation• Peritendinous corticosteroid injection• Surgery

• Complete or partial release of the iliopsoas tendon

• Causes• Traumatic

• Running, twisting, slipping• Congenital

• Dysplasia• Degenerative• Femoroacetabular Impingement

• Pincer-type (acetabularovercoverage)

• CAM type (lack of femoral head-neck offset)

• Misdiagnosed• Avg. 3.3 healthcare providers

before being correctly diagnosed• Wait avg. 21 mos. for diagnosis

• Anterior groin pain aggravated by prolonged standing, sitting, or walking

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• Floor Barre

• Water Barre

• Pilates

• Gyrotonics• Gyrotonics

• Transition dance class