The first "dancer tidbit" I can offer is that most dancers use the term "hip joint" interchangeably to mean the buttocks, iliac crest, sacroiliac joint, or the actual hip joint. Always ask the dancer to point to the painful region; you may be surprised at where they point.
Anterior hip pain is a common problem in dancers, especially when they have advanced to a higher level in dance or are dancing as part of a long-running performance. As dancers advance in level, so do the hours and intensity of dance classes. Usually the hip joint itself is not the primary problem in young dancers; the problem is the fatigue and/or injury of the muscles that move the hip joint.
There are four main muscles in dancers that cause anterior hip pain: the rectus femoris, sartorius, psoas and iliacus. When one or more of these muscles is injured, it spasms to protect itself, producing abnormal pulling and aberrant biomechanics of the hip joint. This causes irritation and decrease flexibility of the hip, which in turn, causes tendonitis, arthralgia and effusion. The change in the hip biomechanics will eventually recruit other muscles into spasm, especially the piriformis muscle (known to dancers as the "turn-out muscle"). Compensations will occur, creating low back stiffness and knee pain on the injured hip side.
The dancer's history of injury will usually present as follows: At first, he or she will only present with insidious anterior hip pain during hip flexion. At this point, the dancer may have taken over-the-counter or prescribed medicines. The medicines may offer some relief, but they will not cure this problem; in fact, without proper manual care, the use of such medications will prolong it.
As time progresses and the dancer continues to practice without seeking chiropractic treatment, he or she starts to lose mobility of the hip. The anterior hip pain is now constant and hurts in numerous ranges of motion. The dancer cannot fully lift his or her leg or even walk without pain. The dancer will also notice low back tightness and may even experience knee pain. It is usually at about this point that the dancer will walk into your office for treatment. If you are lucky, the dancer will seek treatment early on, but don't count on it. Dancers are a different breed of people - they perform incredible feats of strength at the extreme limits of possible human movements and they do it with a smile, no matter how much pain they are experiencing.
Dancer tidbit #2: Don't be fooled; do not jump on the iliopsoas bandwagon. Most practitioners who are not experienced with dance techniques will assume that the problem is an iliopsoas muscle strain. This may be the case, but it is not the most probable strain. The most probable cause of anterior hip pain in young dancers is a strain of the rectus femoris, followed by the sartorius, psoas and iliacus, respectively.
Why the rectus femoris? In dancers, the fectus femoris is a highly overused muscle. Dance technique constantly requires dancers to perform hip flexion at or above 90 degrees, with knee extension (rectus femoris primary action). Once in this position, dancers are also required to abduct and externally rotate the hip, switching a portion of the stress to the sartorius muscle as they hold this new position. The dancer will then return to the prior position, switching the stress back to the rectus femoris.
To determine which muscle is the primary cause of the anterior hip pain, palpate the region of the ASIS. If the problem is the rectus femoris and/or the sartorius, this palpation will reproduce the chief complaint of anterior hip pain. Next, palpate along the individual muscles from origin to insertion, to determine if one or both muscles are involved. If the problem stems from the iliopsoas, the ASIS region will palpate as normal or minimal pain, whereas the femoral triangle region will palpate as positive for reproducing the chief complaint of anterior hip pain. (Note: If there are no signs of psoas tightness, check the iliacus by deep palpation. If this reproduces the chief complaint, then the primary problem is an iliacus strain.)
Dancer tidbit #3: It is normal for dancers to experience sharp anterior pain with passive hip flexion near the end range. This is because the anterior hip structures and capsule are overstretched in dancers and will actually get pinched in the hip joint as you flex the dancer's thigh. This pain can be reduced by taking out tissue slack from medial to lateral with your thumb as you flex the hip.
In all of these cases, manipulation of the spine, hip, knee, ankle and foot, followed by interferential current surrounding the hip and anterior thigh, with ice on the area of the chief complaint and with moist heat over the thigh, will provide immediate relief. Within one to three treatments, all of the compensatory pains and recruited muscles will reduce, leaving you with only the primary injury. The dancer should be allowed to return to barr? work as long as she or he immediately ices after practicing.
Once the compensatory pains are resolved, it's time to focus on the primary injury. Basic chiropractic sports injury treatments, utilizing manipulation, ultrasound, cross-friction massage and interferential current with ice, should suffice. Once the pain to palpation is slight, the patient should return to centre work with the restriction of pain-free dance techniques only. Treatment can now be reduced to manipulations and manual specific muscle stretches.
The key to treatment is manipulation, which restores the normal biomechanics of the hip, allowing the individual to return to dance without compensating or running the risk of re-injury. The lack of manipulation is why the medical and physical therapy models of treatment usually fail in cases of anterior hip pain in dancers.
Dancer tidbit #4: When it comes to dance injuries, chiropractors are the doctors of first choice. During performances, dancers for the most part cannot be taped or braced; it restricts their motion and may be seen by the audience. They cannot be injected with cortisone or lidocaine, and they cannot ingest painkillers or muscle relaxers; they need to be able to feel every part of their bodies and cannot be dizzy while performing. They cannot have deep-tissue massage, which will over-relax their muscles before dancing. What they need is a doctor who can diagnosis biomechanical/musculoskeletal injuries and provide quality manual care. What they need is you - a doctor of chiropractic.
Jack Giangiulio, DC,
Newport Beach, California
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