Slide 1. Slide 2. Slide 3. Dancer & Gymnast Injuries Henry B. Ellis, MD DFW Sports Medicine Symposium March 24, Pediatric Sports Medicine Clinic

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1 Slide 1 Dancer & Gymnast Injuries Henry B. Ellis, MD DFW Sports Medicine Symposium March 24, 2017 Slide 2 Pediatric Sports Medicine Clinic 25% 20% 15% 10% 5% 0% 3% Primary Sport 18% 21% 13% 10% 10% 4% 5% 7% 7% Softball Cheer/Tumble Gymnastics Volleyball Dance/Drill Team/Ballet Baseball/t ball Basketball Other Slide 3 Pediatric Sports Medicine Clinic 75% do not participate in another sport 50% train 5+ days/week 70% gymnasts 60% dancers 40% 30% 20% 10% 0% 24% 29% 1-5 hours 6-10 hours 12% 14% hours hours 7% 7% hours hours 3% 3% hours hours

Slide 4 Pediatric Sports Medicine Clinic 40 30 20 10 0 How many weeks per year do you participate in your sport?

2 Slide 4 Pediatric Sports Medicine Clinic How many weeks per year do you participate in your sport? Cheer/Tumble Dance/Drill Team/Ballet Gymnastics Slide 5 Pediatric Sports Medicine Clinic How many years have you participated in this sport? Cheer/Tumble Dance/Drill Team/Ballet Gymnastics Slide 6 Dance

3 Slide 7 Demi-plié En pointe Slide 8 Relevé Slide 9 Equipment

Slide 10 Dance Injuries Causes: fatigue, stress, bad luck, faulty technique Risk factors: poor strength/flexibility, previous injury, poor nutrition, summer intensive classes Most important source of

4 Slide 10 Dance Injuries Causes: fatigue, stress, bad luck, faulty technique Risk factors: poor strength/flexibility, previous injury, poor nutrition, summer intensive classes Most important source of dance injuries: Compensation of insufficient ER of hips 3 compensatory mechanisms to mimic better turn out Lumbar hyperlordosis hip flexion Bending knees ER of lower legs Hyperprotonation of feet abduction of forefeet Slide 11 Dance Injury Epidemiology 67-95% of company dancers per year: On average: injuries per dancer per contract year Overuse injuries: #1 Most common locations: Foot & ankle Hips, lumbar/thoracic/cervical spine Knee Miller et al., 20 Slide 12 Gymnastics

Epidemiology 2.155 injury incidence per 1000 exposure hours 2.859 elite 2.820 high-level 1.667 intermediate 0.

5 Slide 13 Gymnastics Injuries Causes: fatigue, stress, faulty technique, repetition Risk factors: poor strength/flexibility, previous injury, poor nutrition, intensive training schedule Most important source of injuries: Slide 14 Gymnastics Injury Epidemiology injury incidence per 1000 exposure hours elite high-level intermediate novice Overuse injuries: #1 Most common locations: Lower Extremity 60.9% Lumbar/thoracic/cervical spine Knee Saluan, et al., 2015 Slide 15 Dancers & Gymnasts

6 Slide 16 General Principles of Treatment They know their body best! Identity Investment Relative rest: Cross-training Help them identify what they can do Sport-specific recommendations barre, avoid au milieu, avoid jumps, poolbarre Flat ground vs. tumble track, trampoline, upper body only, low beam Mental practice : Visualization is cornerstone Slide 17 Medical Problems Eating & nutritional disorders Energy availability Menstrual disorders Low bone mineral density Burnout Smoking Slide 18 Musculoskeletal Injuries - Shoulder Shoulder Instability SLAP/Labral Tears Impingement

Slide 19 Musculoskeletal Injuries - Elbow Medial Epicondylitis Medial Epicondyle Fracture Elbow Dislocation

or Impingement Slide 20 Musculoskeletal Injuries Wrist/Hand Physeal Stress Reaction Stress Fracture Tendonitis Distal

) Spondylolysis Unilateral, painful arabesque in adolescence = stress fx until proven otherwise 2.

7 Slide 19 Musculoskeletal Injuries - Elbow Medial Epicondylitis Medial Epicondyle Fracture Elbow Dislocation Osteochondritis Dissecans Ulnar Collateral Ligament Insufficiency Radial Head Stress Fracture Olecrannon Stress Fracture or Impingement Slide 20 Musculoskeletal Injuries Wrist/Hand Physeal Stress Reaction Stress Fracture Tendonitis Distal Radius Fracture Slide 21 Musculoskeletal Injuries - Back LBP 1.) Spondylolysis Unilateral, painful arabesque in adolescence = stress fx until proven otherwise 2.) Kissing spines Lumbar spinal processes touch in hyperlordosis Tx: conservative, improve core stability 3.) Scoliosis 4.) Lumbar facet sprain 5.) SI joint sprain 6.) Discogenic back pain 7.) Paraspinal muscle spasm

Slide 22 Musculoskeletal Injuries - Hip 80% are Sprain/Strains around the hip Treatment: Rest Short Term Protected Weight Bearing May require physical therapy in higher end athletes Anticipated

8 Slide 22 Musculoskeletal Injuries - Hip 80% are Sprain/Strains around the hip Treatment: Rest Short Term Protected Weight Bearing May require physical therapy in higher end athletes Anticipated recovery maybe 2-10 weeks Quadratus Femoris Slide 23 Musculoskeletal Injuries - Hip In dancers, hip rotation should be measured in prone 10% all dance injuries Common source of dance injuries Risk factors: limited ER or asymmetrical ER Tx for most hip complaints: relative rest, limit turn-out, less high legs, strengthening Sx/injxns rarely needed 1.) Piriformis syndrome Common in dancers w/ limited turn-out Usually stress related- sciatic n. compressed by piriformis m. S/S: pain worse w/ prolonged sitting, stairs, standing R/O radicular syndrome Tx: conservative, specific stretches Slide 24 Musculoskeletal Injuries - Hip 2) Snapping Hip Syndrome Internal: Ileopsoas Audible/Groin Pain Dancer/Tumblers Tx: Hip Flexor Stretching External: Iliotibial Band Popping with walking Described as hip pops in and out Visualize Tx: IT Band Stretching

turned-in is pain-free TTP at ASIS Slide 26 Slide 27 Musculoskeletal Injuries - Hip 4.

9 Slide 25 Musculoskeletal Injuries - Hip 3.) Sartorius enthesopathy/apophysitis Due to overuse of Sartorius m.- important hip flexor in turned-out position + pain w/ lifting leg in turned-out position, lifting in neutral or turned-in is pain-free TTP at ASIS Slide 26 Slide 27 Musculoskeletal Injuries - Hip 4.) Femoral-acetabular impingement (FAI) 5.) Labral tears Pain w/ FADIR Intra-articular bupivacaine injxn & MRI arthrography for dx Arthroscopic labral sx in dancersstill experimental

10 Slide 28 Musculoskeletal Injuries - Knee 25% all dance injuries Most injuries due to turned-out position 1.) Patellofemoral pain syndrome Screwing your knees : due to compensation for insufficient turn out at hips Can also cause retro-patellar chondropathy, medial meniscus tears, lateral patellar dislocations 2.) Patellar tendonitis Slide 29 Musculoskeletal Injuries - Ankle Most common- 27% of all injuries Due to extreme ROM s- dorsi/plantarflexion 1.) Achilles tendonitis Ribbon friction Character shoes Slide 30 Musculoskeletal Injuries - Ankle 2.) Anterior Impingement Aggravated by plies Cavus feet: repeated landing from jumps microtrauma osteophyte formation Often associated w/ osteophyte formation at front of distal tibia & or nose of talus Tx: simple heel raise during dance or anterior arthroscopic clean-out 3.) Posterior Impingement Dancer s heel Most common dancer s injury- w/ or w/out Dancer s tendinitis Soft tissue or bony impingement at back of ankle Causes: inflamed posterior capsule behind talus, os trigonum, enlarged posterior process + pain w/ passive plantarflexion Lat view of foot in releve- preferable Tx: cortisone for soft tiss impingement, resection for bony

Slide 31 Musculoskeletal Injuries - Ankle FHL tendonitis Dancer s tendonitis Usually occurs in pointe dancers Can coincide w/ PAI Tendovaginitis of the FHL

tunnel behind sustentaculum tali Tx: if no resolve w/ conservative therapy tendon sheath release Slide 32 Posterior Impingement Dancer s heel Distal tibia

11 Slide 31 Musculoskeletal Injuries - Ankle FHL tendonitis Dancer s tendonitis Usually occurs in pointe dancers Can coincide w/ PAI Tendovaginitis of the FHL behind medial malleolus FHL muscle belly stuck at entrance of it s tendon-sheath + postero-medial ankle pain w/ plie Dx: localized pain over FHL entrance tunnel behind sustentaculum tali Tx: if no resolve w/ conservative therapy tendon sheath release Slide 32 Posterior Impingement Dancer s heel Distal tibia osteophyte Slide 33 Musculoskeletal Injuries - Ankle 4.) Ankle sprains 5.) Peroneal tendonitis, subluxation, dislocation 6.) Tarsal tunnel syndrome 7.) Sinus tarsi syndrome

12 Slide 34 Musculoskeletal Injuries - Foot Ideal dancer s feet would be.square shaped with equal length 1 st & 2 nd MT s! Pez planus, unequal metatarsal length = risk factors for metatarsalgia, stress fx s of 2 nd MT, hammer toes 1.) Hallux valgus Don t operate!!! 2.) Lisfranc joint injuries 3.) Navicular stress fx s 4.) Cuboid subluxation Slide 35 Musculoskeletal Injuries - Foot 5.) Spiral fx of shaft of 5 th met Dancer s fracture Inversion injury while on pointe Tx: cast shoe 6.) Metatarsal shaft stress fx s Usually 2 nd -4 th mets, common in longest toe 7.) Sesamoiditis/sesamoid fx s Common in folk dancers Pain under head of 1 st met Px: long, uncertain, unsatisfactory 8.) Subtalar coalition Slide 36 Dancer s Fracture MT stress fracture Calcaneonavicular coalition Fractured sesamoid

13 Slide 37 References 1. Rietveld AB. Dancers and musicians injuries (published online ahead of print April ). Clin Rheumatol Accessed April 26, Gottschlich LM, Young CC. Spine injuries in dancers. Current Sports Medicine Reports. 2011;10(1): Madden CC, Putukian M, Young CC, McCarty EC. Netter s Sports Medicine. Philadelphia, PA: Elsevier; 2010: Slide 38 Thank You henry.ellis@tsrh.org scottishritehospital.org/sports

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