Labral Tears of the Hip

            "To keep the body in good health is a duty... " - Buddha

               The joints in our bodies are protected by two types of cartilage.  Hyaline cartilage covers the surface of the bones and protects them from the friction damage that would occur if the bony surfaces rubbed against each other.  White fibrous cartilage can be found in joints that are subjected to frequent stress.  This type of cartilage helps keep joints intact and acts as a shock absorber.

            Movements that are repeated over and over again will gradually start to wear away cartilage just as a stream will erode the surface of a rock over time.  When joints are placed in unnatural positions, such as a turned out position, the body’s weight cannot be distributed normally over the joint, and undue stress is placed upon it.  Unnatural joint positions also occur when the dancer's body is misaligned or the dancer has a muscular imbalance.  When this stress is combined with repetitive movements, tiny tears begin to occur in the cartilage.  After a while these tears increase and result in bigger tears.  Additionally, jumps, leaps, pivots, and turns create enough force to cause cartilage damage on their own.  It is not surprising then that those who participate in ice hockey, soccer, football, golf, and ballet are at a greater risk for developing tears in the cartilage of the hip joint.

From arthroscopichipsurgeon.com

           
The labrum is a ring of white fibrous cartilage that can be found along the edge of the acetabulum, or the socket in the pelvis where the femur sits.  Its job is to hold the femoral head in place by increasing the depth of the hip socket. 

            The labrum often tears away from the acetabulum due to overuse and small injuries that may occur during twisting or pivoting movements and accumulate over time.  Dancers who experience a labral tear may complain of pain in the front of the hip, feel a “catch” in the joint when moving, experience stiffness in the hip, and/or have a limited range of motion at the joint.  These feelings may get worse after a long walk, or after staying in one position for a long time.  As the tear grows, the pain may radiate down the leg, to the side of the hip, or toward the lower back, and may become constant enough and severe enough to cause the dancer to avoid certain exercises and/or lessen the amount of time spent in class or rehearsals.

            If left untreated, a torn labrum can cause a shift in the way the femoral head sits in the acetabulum and increase the stress on the joint, predisposing the dancer to arthritis.

From arthroscopichipsurgeon.com

            Labral tears are diagnosed through an MRI scan of the hip.  More and more frequently, medical professionals are trying to avoid surgery and work instead with physical therapists to help dancers with this injury.  Anti-inflammatories will help with pain management, and physical therapists can work with dancers to eliminate any muscular imbalances they may have and to strengthen the muscles of the hip.  If the pain continues, cortisone shots can also help.  Because the inner side of the labral cartilage has no blood vessels, it has no way to repair and/or heal itself as do other soft tissues like muscles and tendons.

            If physical therapy does not work, or if the tear is too severe, surgery may be required.  During the surgery, any pieces of cartilage that have completely torn off can be removed, and the surgeon will trim the torn edge of the labrum and re-attach it to the edge of the acetabulum.  The recovery time for this type of surgery is a long one – 4-6 months with physical therapy for rehabilitation.

            The good news is that, although labral tears have been very common among ballet dancers, dance medicine specialists believe that education can play a key role in decreasing the risk.  Providing both dance educators and dancers with information about proper anatomical training, the dangers of muscular imbalances, the dangers of fatigue and overuse of the body, and the benefits of cross-training can help produce healthier dancers who can dance longer, stronger and happier without this type of injury.

Injuries of the Hip

            “There are three steps you have to complete to become a professional dancer: learn to dance, learn to perform, and learn how to cope with injuries.” - D. Gere

 The most common hip injuries among dancers are muscle strains, tendonitis, and bursitis.

            Dancers tend to have muscular imbalances because they repeat the same exercises and use the same muscles in the same ways over and over again.  These imbalances lead to tightness in certain muscle groups.  Tight muscles are susceptible to injury since they have a limited range of motion.  As a result, dancers often strain their hamstrings. 

            The hamstrings run along the back of the thigh and are responsible for extending the hip joint and flexing the knee.  As with all injuries, the dancer should rest the leg and use ice and anti-inflammatories to reduce pain and swelling.  Once healing begins, gentle stretching and rolling the injured area with a tennis ball or foam roller will help with scar tissue tightness and rehabilitation.

From physioanswers.com

            Tendonitis refers to the irritation and inflammation of any of the tendons that connect the muscles at the hip joint.  Tendonitis manifests itself as pain around the joint and develops gradually.  At the onset, the pain will lessen, or even disappear,  when the dancer is moving but will increase afterward.  Eventually, the pain will become constant and radiate to the knee and/or lower back.  The dancer will feel stiff and tight in the morning or after dancing and moving, and stretching will be uncomfortable.  Rest, ice, and anti-inflammatories will lessen the swelling and irritation and help to alleviate the discomfort.  Being sure to warm up the area completely before dancing will help as well. 

            Tendonitis is usually caused by muscular imbalances and/or alignment issues that place stress on certain areas of the hip.  When exercises are repeated over and over again while the body is misaligned and not working correctly, the tendons become irritated and inflamed.  A physical therapist who knows about dance can help determine the cause and help to correct alignment issues and/or suggest cross-training exercises to help with imbalances so the tendonitis does not keep recurring.

            Another condition that can be caused by muscular imbalances and/or misalignment in the body is bursitis.  Bursae are tiny fluid-filled sacs that help prevent and reduce friction at joints where body parts are constantly moving against each other.  The most common type of bursitis is trochanteric bursitis, which occurs on the outside of the hip. 

stretch for IT band

gluteal stretch

            Dancers with this condition complain of pain on the outside of the hip when lying down or when pressure is applied to the area.  This pain increases during activity and is felt especially when walking up stairs.  Stretching the iliotibialband or a stretch of the gluteal muscles, which tend to be tight in dancers, may help relieve pressure on the bursa. 

            Bursitis can also be caused by trauma to the hip.  A fall in which the hip collides with the floor can irritate the bursa sac and cause a painful inflammation.  Ice and anti-inflammatories will help with the pain and irritation.  If the attack of bursitis cannot be traced to a specific trauma, then a physical therapist should be consulted to determine the cause of the condition and help correct it.

Understanding Why the Hip Snaps

“We will be in tune with our bodies only if we truly love and honor them.” - Harriet Lerner

            The hip joint is an important one for all dancers to understand since it is responsible for flexing and extending the leg, rotating the leg inward and outward, and moving the leg away from the center of the body (abduction) and pulling the leg in toward the center of the body (adduction).

            The hip joint is a ball and socket joint which allows the leg to move in all different directions.  The head of the femur, or thigh bone, fits neatly into a pocket in the pelvis and is held in place by a web of different muscles, tendons, and ligaments.

            An often heard complaint from many dancers is that they hear and feel a snapping or popping in the joint during movements like grand plié and developpé.  The audible noise is a clicking sound, and dancers often simultaneously experience a shift in the skeleton, and it is referred to as hip snapping syndrome.

            The “snapping” of the hip occurs when a muscle or a tendon passes directly over a bone.  The two most common types of snapping at the hip are lateral hip snapping and anterior hip snapping. 

from www.online.epocrates.com

            Lateral hip snapping involves the iliotibial band which is the tendon portion the gluteus maximus and tensor fascia lata muscles.  It runs along the outside of the thigh and attaches to the skeleton near the top of the tibia, one of the bones found in the lower leg.  At the top of the femur, there a bony projection on the outside of the bone called the greater trochanter.  When the leg is extended, the iliotibial band lies just behind the greater trochanter, but when the leg bends, or flexes, at the hip joint, the iliotibial band passes over the greater trochanter and if the tendon or any of its muscles are tight, a snapping will occur as it slides across it.

from www.physioadvisor.com.au

            Anterior hip snapping happens at the front of the hip as opposed to the side of the hip and involves the iliopsoas, which is the merging of the iliacus and psoas muscles.  The iliacus begins at the inside back of the pelvis, while the psoas is attached to the lower vertebra, and they combine to attach to the inside of the femur on a small bony projection called the lesser trochanter.  When the leg is flexed, or bent at the hip, and turned out, the iliopsoas lays across the hip joint.  As the leg extends and moves toward the body, if the muscle is pulled tight, it will snap as it moves across the femoral head.

            Dancers may find that hip snapping syndrome occurs during a growth spurt since bones grow faster than muscles and muscles are taut until they catch up. 

            As long as this snapping is not painful, it does not indicate a serious problem, but it can be a sign of a muscular imbalance.  If the snapping occurs all of the time, there is a good chance that the bursa sacs surrounding the hip joint can become irritated.  The job of a bursa sac is to provide a cushion between soft tissue like muscles and tendons and bones to reduce friction. As the tight tendons and muscles rub closely against the bones the bursae may become inflamed and painful, resulting in bursitis. 

            Keeping the muscles of the hip joint healthy by embarking upon a supplemental conditioning program that strengthens and stretches all of the hip muscles equally will help eliminate any imbalances and contribute to healthy dancing.

           

            

Alignment: Developing a Strong Foundation

"When you find that your life is out of alignment with your grandest idea of yourself, seek to change it." -Neale Donald Walsch

         A contractor would never try to build on an unstable infrastructure, yet each day dancers attempt multiple pirouettes and complicated combinations upon misaligned bodies that provide a shaky foundation.

         Correct body alignment allows for efficient muscle use, encourages a less bound and more relaxed approach to movement, reduces the risk of injury, and contributes to ease of movement.

         Whenever a dancer has difficulty with balance or executing a step, which he or she should be strong enough to do, it is important to first observe his or her body alignment.  Just as a building will weaken if there is a crack in the foundation, the body is weakened by misalignment.

         Before each class a dancer needs to re-establish a strong base by being certain that all five toes are flat on the floor.  Body weight should be equally distributed on each foot in a triangular pattern formed by the base of the big toe, the heel, and the base of the pinky toe.  The ankle should be lifted so that the base of the tibia is not rolling forward and causing the foot to pronate, or roll inward.  Subsequently, the knee joint should be centered over the ankle, and the hip joint should be centered over the knee.  The base of the ribcage should be in line with the pelvis while the sternum is lifted and the shoulders rest on the body, similar to how frosting rests upon a cake.  The neck should be lengthened with the head lifting as if it were a helium-filled balloon.

         Dancers are often told to “pull up their centers” which often causes a disconnect between the upper and lower halves and the front and back halves of the body. When a dancer “pulls up” the stomach, the tendency is to “sit” or relax into the back of the hips and open the ribcage, resulting in a swayed back.  Dancers engage their abdominal muscles, tuck the pelvis, and hyperextend their legs and believe they are properly aligned.

         This ideology results in gripping muscles instead of lengthening them, stressing ligaments instead of strengthening muscles, and skeletal misalignment.

         Instead, dancers need to think of the ankle being lifted by the patella, or kneecap, and the leg being lengthened by the pelvis lifting and lengthening the quadriceps and hamstrings.  Dancers also need to remember to lengthen the back of the torso as well as the front as if the entire upper body were being sucked up through a straw.  Additionally, it is important for dancers to lengthen through the front and back of the neck equally to avoid the turtling of the head that often occurs.

         Simply thinking about dance posture differently will help align the body, engage the muscles in a different way, and produce a lengthening of the body which will increase the efficiency of movement, improve mechanics and balance, and lead to healthy dancing.