Anterior Hip Pain in a Preprofessional Ballet Dancer

By Mitchell B. Green, D.C.

Background

No one can deny the beauty and grace of a ballet dancer performing on stage, but dancers present a special challenge to the chiropractic rehabilitation specialist. Because ballet goes “against” the body’s natural tendencies, years of training in ballet can exact a toll that may prove to be deleterious to the dancer’s musculoskeletal system; not only is the dancer at risk for short term injury, but long-term damage requiring consistent and specific treatment may also be a possibility. The injured dancer deserves a practitioner who is competent in differential diagnosis: it is imperative to be able to identify not only the damaged structures at the site of pain, but also the functional movement patterns that are potentially the underlying cause of the condition. When special populations such as classical ballet dancers present for treatment, it is critical to be familiar with the wide variation of “normal” that is possible. Most dancers, for example, can perform hip flexion in the supine position well beyond the widely accepted 90 degree norm. Yet, due to pain, an injured dancer might achieve only 90 degrees. While this might be a normal finding for the non-dancing general population, it would definitely not be normal in the ballet dancer. Therefore, the clinician needs to accurately interpret data based on the variations present within a given population and proceed accordingly. In addition, the practitioner should be able to rule out more serious injuries that require immediate medical attention. Also, the physician needs to be well acquainted and comfortable with a wide range of both passive and active rehab modalities and techniques. They should be well versed in methods to enhance both the dancer’s basic and more complex array of movements.

Case Presentation

SDG is an 18 year-old female pre-professional ballet dancer who presented for evaluation and treatment. She was referred by her ballet instructor for chronic hip pain that plagued her on and off over the past year. She also reported occasional mild lower back pain that had occurred infrequently over the past several years. Her dance routine is quite intensive. Including classes and rehearsals, her training usually runs for 5-6 hours, 6 days per week. She revealed in consultation that the front of her left hip had been painful off and on for about 12 months. However, she also indicated that she could not recall any specific event, episode or injury that initiated her first bout of pain. Her one visit to the family internist regarding this problem, approximately 6 weeks prior to our initial consultation, resulted in a referral for an MRI examination of the left hip. The examination was negative for abnormality, disease, dislocation or fracture; therefore, a referral to physical therapy was prescribed. In addition, she also received a prescription for 400 mg of ibuprofen, three times per day for 7 days. She was seen by the physical therapist on three occasions and
received massage therapy, ultrasound and advice on stretching. She described the results of her physical therapy as minimally productive. SDG denied contralateral lower extremity or thoracic pain. She also further denied cervical pain. There was no correlative indication of familial history and the review of systems was negative.

SDG presented as a bright, well nourished Caucasian teenager. Physical examination revealed her height to be 5’4″ and weight 107lbs. Her basal temperature was 98.4 and her blood pressure on the left side was 100/72 and her resting heart rate was 67 bpm.

Upon examination, all orthopedic tests (Kemp’s, Lasegue’s, Gaenslaen’s and Goldthwaite’s tests) were negative. Deep tendon reflexes were +2 right and left for the Achilles and
patella. Manual muscle testing was 5/5 bilaterally for the quadriceps and hamstrings. Dorsi and plantar flexion were equal bilaterally. Pathological reflexes were absent. Range of motion tests of the lower back, hips, knees and ankles revealed only slight loss of motion in the right ankle (18 of 22.4 degrees). Palpation revealed mild/moderate hypertonicity in the erector spinae, quadratus lumborum and piriformis bilaterally; however, it was worse on the left.

SDG’s initial QVAS for the left hip was 6/10 and 2/10 for the lower back. Her Oswestry rating was 6% indicating minimal to no disability. Her lower extremity functional scale
was 87.5%. At the time of her transition to active care her QVAS was 2-3/10 demonstrating a minimum of 50% improvement.

The patient was treated palliatively 5 times over the course of a 2 week period with diversified joint manipulation to the spine and left hip. Cox flexion-distraction was utilized for the lower lumbar spine.1 Interferential muscle stimulation was applied over the anterior superior left hip for pain control. She was transitioned to an active rehabilitative program after the 5th session and treated for an additional 6 weeks. See the following sections for treatment details. SDG was treated for a total of 17 visits.

Discussion

As with any other patient, the attending clinician must rule out serious disease and injury in the dancer that might be categorized as urgent and require further medical intervention. Once a case has been accepted, the next step is to help reduce pain as soon as possible: this is accomplished using modalities that have been agreed upon by the doctor and patient. Liebenson, et al. point out that 50% of patients were found to be significantly better within 4 visits or two weeks of starting chiropractic care; 75% were better by 12 visits.2

During the initial phase, care for the dancer resembled that of other populations. This included following PRICE protocols until a measure of stability emerged.3 Unfortunately, many patients leave care before true rehabilitation has commenced; this leaves them at risk to suffer repeated injurious episodes. Dancers are a particularly driven group, sometimes to the point of obsession: they often state that the work they do in class, rehearsals and performance is “rehab enough.” They typically resist sitting out of a class even during this initial phase of care. This is a particularly unenlightened position that can lead to a more severe injury and resultant disability. As Sonia Rafferty, M.Sc., points out, “the concept of rest intervals is significantly absent in dance pedagogy.”4 Hopefully, the practitioner can help to change this by expressing and continually reinforcing to the injured patient the various principles of healing and rehabilitation.

For those who do continue with care, the real challenge begins. SDG had minimal range of motion issues. In fact, except for her minimal loss of right ankle mobility, she presented as extremely flexible with excellent posture. She exceeded expectations in the one-legged balance testing with eyes open and closed. So the question was: bow could she be challenged her in an active rehab program that would also help her improve as an elite classical dancer? The goal was to help prevent injury, but also possibly enhance an already superb performance ability.

The course of treatment chosen was largely based on Sensory Motor Stimulation (SMS). According to Liebenson, “SMS can be beneficially used as a part of any exercise program because it helps to improve muscle coordination and motor programming or regulation and it increases the speed of activation of a muscle. It was used originally to improve the unstable ankle after an injury; however it can be used for a variety of conditions. Chronic back pain syndromes are one of the most important indications. Better control of the trunk, improved activation of the gluteal muscles and thus better control of the pelvis is achieved.”5

“Balance training using unstable surfaces such as Thera Band Stability Trainers and Rocker I Wobble Boards are increasing in popularity both in rehabilitation and sports performance. In addition, balance training has been shown to be beneficial in preventing injuries across the lifespan, from athletes to older adults.

German researchers published a systematic review of the efficacy of balance training for neuromuscular control and performance enhancement in the Journal of Athletic Training.
20 randomized clinical trials of balance training met their inclusion criteria for the review. As with many systematic reviews, the authors noted a lack of methodological quality and conflicting findings between studies. Nonetheless, they were able to make some conclusions:

  • Balance training is effective at improving static postural sway and dynamic balance in both athletes and non-athletes.
  • Balance exercises are recommended for postural and neuromuscular improvements, particularly for rehabilitation and preventive purposes.
  • To improve strength, jumping or sports performance other interventions such as strength training are more effective than balance training.
  • Longer balance training durations of 6 to 12 weeks seem more effective than shorter 4 week durations.”6

Functional Training and Rehabilitation

The first phase of active rehabilitation for SDG consisted of floor based exercises: these were primarily used for improving stability of the lower back, and helped limber the spine and pelvis. She was taught and quickly learned cat-camel (cow), quadruped leg reach and bird dog maneuvers. The overhead squat, side bridges, planks and various supine bridges were added to her regimen, as recommended by Stuart McGill in his book, Low Back Disorders: Evidence-Based Prevention and Rehabilitation.1 Additionally, there was utilization of a moderately packed foam roll to release the appropriate region from contracture.

While performing these maneuvers care was taken to observe, point out and correct basic dysfunctional movement patterns. This was done by bringing these patterns to her attention, with the use of verbal prompting for correction. In SDG’s case it was noted that her left thigh abducted when moving into hip extension, indicating hyperactivity of the iliotibial band on the left. This also confirmed inhibition of the left gluteus maximus, as well as possible weakness or inhibition of the gluteus medius on the same side.

It was also noted that she had considerable trouble with the overhead squat. SDG was graded as a l on Gray Cook’s FMS scoring scale 0-3.8 This was due to a bilaterally tight gasctrocnemius/soleus complex and right ankle restriction with resultant hyper hip flexor activity. To facilitate better movement control, a half foam roll measuring 4″ was placed under her heels to improve the maneuver. Over the course of treatment that heel elevation was gradually reduced. It is interesting to note that dancers are actually taught a variation
of a squat from early training: the plie’. This dance movement is taught with the feet in four possible positions. The grand plie’ (full descending movement) in second position is the only plie’ that does NOT require the dancer to elevate their heels. This is because less knee flexion occurs during the movement, putting less tension on the gasctrocnemius/soleus complex. As a result, there is greater elongation in the calf and the heels are able to remain on the floor. The hips are as close to full turnout as possible (90 degrees of external
rotation) for each plie’ regardless of foot position. When performing a squat, SDG was instructed to externally rotate her hips to 45 degrees (instead of 90 degrees as when performing a plie): this improved her biomechanics somewhat.

The above protocol was followed twice weekly for two weeks, which served as a prelude to all future rehab sessions. On the fourth visit, SDG had progressed to 1 set of 5 cat/camels, 8 quadruped leg reaches each side alternating, 8 bird dogs each side alternating, and (3) sets of 6 reps of squat variations: overhead, elevated split, and goblet squats. The goblet squat was utilized to encourage greater ankle mobility. During this period of time SDG reported little to no discomfort in her left hip and was eager to proceed o the next phase of active rehabilitation.

At the start of week 5 of care and week 3 of active rehab, SDG performed one legged balance exercises on the floor, bilaterally, for 120 seconds. Then she proceeded to each successive Thera Band stabilizer pad, in order of ascending difficulty. She progressed from green to blue and finally to black. She had to perform at each level for 90 seconds with her eyes open before transitioning to the next, increasingly unstable surface. SDG was also introduced to small foot positioning, at first passively, followed by active assist, and finally active self-induction.

Throughout the course of her remaining care she began all her SMS sessions with 6 minutes of rocker board activity. At that point, different balletic moves were blended into SDG’s active care.

While standing on each Thera Band exercise pad, SDG was instructed to perform 5 slow degage movements bilaterally, to the front, side and back. Degage is performed by keeping the leg straight and lifting the foot. She was encouraged to keep her standing and elevated hip in turnout to assist in strengthening the associated muscles and thus, support her ballet work. Additional movements performed while alternating with one leg on a Thera Band stabilizer that became part of her rehabilitation included: (1) Fondu, which is described as lowering the body while on one leg, (2) Battement, which is the raising of a leg into the air and bringing it down again, with both knees straight, and (3), Developpe which refers to
the leg being drawn to the knee of the supporting leg before being slowly extended to an open position and held for control. The hips should be kept level and square to the
direction the dancer is facing.9

SDG was introduced to the round board during the last week of her rehabilitation. At that point two different levels of difficulty were employed. In addition to any combination of the

above movements performed on the Therapads, she also performed an arabesque on the round board. On the last day of our work together, SDG performed all of the different balletic movements discussed, on unsteady surfaces. She added 5’ plies to each arabesque on the round board, and she was asked to hold for a 5 count on the last plie.

At the end of the last visit she reported no pain and had returned to fully engage in all aspects of her ballet studies. Her exiting Lower Extremity Functional Scale was rated at
100%.

Conclusion

The integration of active rehab principles to the patient’s goals is paramount to a successful outcome. This case illustrates how active rehab care can help a classical ballet dancer
return to performance, while correcting and strengthening cardinal movements. It also points out the necessity for developing and understanding a body of information not necessarily applicable to the general population. The implications of principle based, functional rehabilitation and its application to other specialized populations should prove to be very exciting for the chiropractic rehabilitation specialist.

Competing Interests

The author reports no competing interests.

Written consent was obtained from the patient for publication of this report.


Bibliography

1 Cox, James M. Low Back Pain Mechanism, Diagnosis and Treatment. Williams and Wilkins. (1999) Print. Pp.273-343.
2 Liebenson, Craig. Rehabilitation of the Spine: A Practitioner’s Manual. Philadelphia: Lippincott, Williams, and Wilkins. (2007) Print.
3 Hyde, Thomas E. and Gengenbach, Marianne S. Conservative Management of Sports Injuries. Sudbury, Ma. Jones and Bartlett, 2007. Print.
4 Rafferty, Sonia. Considerations for integrating fitness into Dance Training. Journal of Dance Medicine and Science, Vol.14, Number 2, (2010)
5 Liebenson, Craig. Rehabilitation of the Spine: A Practitioner’s Manual. Philadelphia: Lippincott, Williams, and Wilkins. (2007) Print.
6 www.hygenicblog.com/2011/07/01/systematic -review-supports­ Balance -training. Web.
7 McGill, Stuart. Low Back Disorders: Evidence based Prevention and Rehabilitation. Human Kinetics, (2002). Print p. 221-229.
8 Cook, Gray. Movement: Functional Movement Systems, Screening­ Assessment-Corrective Strategies. On Target Publications. (2010) Print. p. 81
9 www.balletterms.org. Web.