An overview of injuries to the ballet dancer

Kathleen Nachazel, LAT, ATCUPMC Sports Medicine

Athletic Training and Development

My background• Undergraduate Degree

Ohio University 1987• Medical College of Ohio

Springfield High School1987-1992

• UPMC Sports Medicine August 1992 to present

Medical Coverage for PBT

• In studio for rehearsals• All performances• Team coverage at studio

–Athletic Trainer (me) 1 day a week for 3 hrs–PT 2 days a week for 2 hrs.–On-call MD with weekly onsite visits

• Annual pre/early season screenings–During paid time for dancers

Day in the life of a ballerina• 9:45…

PBT staffing• Apprentice• Corps de Ballet• Soloist• Principal

Basic Ballet Foot Positions

First Position Second Position Fourth Position

Fourth Position side view Fifth Position Fifth Position side view

Positions of the Arms

First Position Second Position

Third Position Fourth Position Fifth Position

MOVEMENTS IN DANCE

Plié Releve Saute: to jump

Preventing Injuries• Maintain conditioning once rehearsals set in• Pay attention to recovery time once

exhaustion from many performances set in• According to Marijeanne Liederback of

Harkness Center for Dance Injuries, the 3rd

week of training/performances is when fatigue takes over

Intrinsic Causes of Injury• Insufficient flexibility, range of motion

strength• Strength and/or flexibility imbalances• Insufficient cardiovascular conditioning• Poor technique• Prior history of injury• Nutritional deficiencies

Extrinsic Causes of Injury

• Incorrect shoe fit• Floor surface• Cold studios• Difficult choreography• Insufficient warm-up

If good technique is developed andmaintained, the chance of sustaining a danceinjury is minimized.

Minor technical faults can produce major problems for the dancer, either in the actual treatment of the injury, or more often in theprevention of recurrences of the injury.

Common Technique Mistakes

• Progression to the next level of dance too soon

• “Cheating” your turnout• “Whacking” your leg up• Sickling and Winging• Lack of plié when jumping

Cheating Your Turnout• Using friction between

your feet and the floor instead of the muscles in your hips to achieve your position

• Can cause injuries all they way up the chain

Cheating your turnout• If your knees

don’t line up with your 2nd toe when you plié you are cheating your turn out

Whacking your leg up Sickling• Compensation for

lack of full mobility • Instead of a straight

line from the hip thru the leg to the midfoot, the foot is turned inward.

Demi-plie• Sickling in demi-plie

Winging• Instead of a

straight line from the hip thru the leg to the mid foot, the foot is turned outward

Lack of plie• The heel does not reach the ground

resulting in knee and foot pain

Improper landing a jump

Ballet specific evaluation

• Hips– External and internal rotation– Q angle– Antiversion and retroversion– Short/ long leg– Hip extension and flexion

Ballet specific evaluation

• Knees– Patellar position

• Medial, later, inferior, superior– Flexed or hyperextended– Genu varum-bow legged– Genu valgum- knocked knees

Ballet specific evaluation

• Ankle– Weight forward of plum line– Weight behind plum line– Subtalar neutral– Restricted plie or releve– Tendinitis around the malleolus

Ballet specific evaluation

• Foot– Mid tarsal joints (arch)– Pronated or supinated– Metatarsals and toes– Dropped metatarsal head– Bunion– Claw or hammer toes

Most common injuries

• Overuse• Lower Extremity

– Low Back– Hip– Lower Leg– Ankle– Foot

Low Back

• Individuals with long-standing hip pathology often have a history of low-back pain or SI Joint dysfunction.

• Weakness of the muscles that stabilize the lumbopelvic complex is often observed

Back injuries“whacking your back” Spondylolysis

• Stress fracture of the spine creating a forward slippage of the vertebra

• S/S:– Step off deformity– Pain with activity– with WB positions– Point tender lateral to the

spinous process

Spondylolisthesis

• Stress fracture of the pars interarticularis of the vertebrae (spinal column)– Due to repetitive

stress– Persistent back pain

that increases with hyperextension

Hip Injuries

• Hip Flexor• Labral Tear• IT band i.e.. “snapping hip”• Bursitis

Hip Flexor and Iliotibial Band Tendinosis (Snapping Hip)

• “Snapping or Clicking” • Contributing factors:– Poor turn out / rolling– Trunk, hip weakness– Underlying ligament

instability– Hip inflexibility

Labral tear• Caused by impact or

“shear” injury• Sudden onset deep

lateral and deep groin pain

• Contributing factors:– Ligamentous laxity,

tight hip flexors– Poor turn out– Trunk weakness

• Inversion ankle sprain• Anterior/ Posterior Ankle Impingement• Tendinosis

– Flexor hallucis tendinitis– Achilles tendinitis

• 5th metatarsal fracture

Foot and ankle Anterior Ankle ImpingementBone spur formation in theanterior ankle or soft tissue impingement• Causes

– repeated hyper dorsi forced position – Check winging and sickling– Abnormal motion through the

mortise– Male dancers- pain with landing

from jumps– Lack eccentric strength and motion

Anterior Ankle ImpingementTreatment– Evaluate underlying

instability– Stretching in plantar flexion– Global ankle strengthening– Functional training – Mobilization– Eccentric strengthening

Posterior Ankle Impingement

• Causes– With or without an accessory

bone of the foot.– Extreme plantar flexion of

releve en pointe in the ballet dancer

– Retro calcaneal bursitis

Posterior Ankle Impingement

• Treatment– Mobilization of the talus– Release of calf – Strengthen anterior leg muscles

Posterior Tibialis Tendinosis

• Tender over medial ankle, possible midfoot (arch)

• Lateral pain upon progression of injury• Pain with resisted internal rotation• Single leg heel raise strength greatly

reduced

Peroneal Tendinosis

• Lateral ankle sprain which worsens with activity

• May complain of “snapping” or “popping”• Pain on palpation along lateral ankle• Pain with inversion• Weak eversion

Flexor Hallucis Longus Disorders

• Tender over medial ankle• Crepitus upon progression of injury• Catching of the great toe• Pain with plantar/ dorsi flexion• Causes

– Repetitive stress– Tight gastrocnemius

Dancer’s Fracture(Acute fracture of 5th metatarsal)

• Spiral fracture through the shaft of the 5th (baby) toe

• Sudden severe pain after “rolling” onto lateral foot

• Contributing factors– Ankle instability– Weakness– Poor balance– Floor surface/ shoes

Dancer’s Fracture Treatment

• Treatment:– Immobilization – Surgery occasionally necessary– Complete rehabilitation before return to

dance– Address underlying weakness and technical

problems

Metatarsal Stress fractures• 2nd metatarsal fx common in

dancers• Localized pain associated with

activity• Contributing factors:

– Sudden change in training– Intrinsic foot weakness– Toe length discrepancies – Hard surface, poor shoe fit

Treatment• Mobilization of the

talus• Release of the calf

muscle• Strengthening of the

anterior leg muscles

• Ice• Retraining of the

pointe in tendu

Other foot injuries

• Plantar fascitis• Bunions• Cuboid dislocation/subluxation

Cuboid Dislocation

• Causes• Lateral midfoot pain• Inability to “work through the foot”• Reduced plantar flexion• Dropped fourth metatarsal head

Manual Reduction Taping

Improving turnout• Stretching

– Hip flexors– Butterfly and pretzel

stretches• Hip Strengthening

– External Rotators, Adductors, Abductors

• Practice!

Improving turnout

• Additional Tools:– Standing Firm– Rotational Discs

Rehabilitation

• Consistent with rehab of elite athletes• Re-balance the soft tissue structures• Correct improper technique• Balance/proprioception• Core strengthening

Dance Specific Rehabilitation

• Pool exercises• Corrective conditioning class• Basic rehabilitation barre• Reformer footwork• Manual therapy • Flexibility exercise• Strengthening exercises

Return to Dance• Progression to full dance with rehab

classes and modification of activity.• Consider occupational stresses and the

psyche of the athlete • Nutritional considerations

Modified doming exercises

Core Strength Foam roller

Trigger points Summary

• Injuries are very common in dance

• Early recognition and treatment promotes early, safe return to dance

• Treatment (even of minor injuries) always includes rehabilitation and technique evaluation

Bonus round

• Job opportunities• Educational opportunities• Networking opportunities

Job opportunitiesPerforming Arts Medicine Resources• http://www.nata.org/career-education/career-center/find-

job

• Linkedin– Performing Arts Athletic Training

• This group is designed to connect healthcare professionals working or interested in working in the performing arts. This website will provide an avenue for interested professionals to connect and network among others in this exciting field.

Educational opportunities

• International Association for Dance Medicine & Science (IADMS)

• Harkness Center for Dance Injuries• http://www.med.nyu.edu/hjd/harkness/education

• NATA Emerging settings– http://multibriefs.com/briefs/NATA-ES/NATA-

ES012016.php

Networking opportunities

• NATA• EATA• Performing Arts Athletic Training Society

(PAATS)• Facebook: NATA Committee on Practice

AdvancementTwitter: @NATA_COPA

Manual therapy practice• Active Release Technique• Trigger point release• Cross fiber massage• Hip glides• Psoas release• Mobilization of the talus