case-based sports medicine: overuse injuries in performance sport athletes jordan d. metzl, m.d
TRANSCRIPT
Case-Based Sports Medicine:
Overuse Injuries in Performance Sport Athletes
Jordan D. Metzl, M.D.
www.DrJordanMetzl.com
Program Outline
• General Issues of Dancers
• Medical Issues of Dancers
• Orthopedic Issues of Dancers
• Dance Injury Prevention (Preparticipation Screening)
What Are the Performance Sports?
• Ballet• Gymnastics• Figure Skating
– Grace– Athleticism– Thinness– Precision– Perfectionism
Health Benefits of Performance Sports
• Psychological• Social• Bone density• Weight control• Athleticism
History of Ballet Dance
• Originated in renaissance Italy
• Brought to France by Catherine De Medici (1518-1589)
• Flourished under Louis XIV at Versailles
• Positions in ballet derived from foot positions in fencing
5 Foot Positions of Ballet Dance
• First – heels together, 90 degrees
• Second – heels shoulder width
• Third –90 degree alignment of foot
• Fourth – turn out with foot in between
• Fifth – need maximum ER to “close in 5th”
Level of Dancer
• Weekend• After school• Pre-professional
school• Company
Specialization and Dance
• What are goals/objectives?
• In order to be good, need to start early?
• Exclusion of other sports?
• Varied types of dance?
Performance Enhancement?
• Drugs?• “Extra” edge?• Weight issues• Influence and politics
– Boston ballet experience (Heidi Gunther)
Medical Issues of Female Athletes
• Medical Issues– Bone– Female Athlete Triad
• Anorexia – Nutritional
• Amenorrhea– Hormonal
• Osteopenia– Future bone health?
Medical Development of the female athlete
• Adolescent Development– Sexual Development– Skeletal Development– Physiologic
Development– Psychological
Development
Sexual Development in Dancers
• Menarche 2-3 years later than controls
• Primary amenorrhea– Absence of menses by
age 16
• Progression of sexual development correlated with rest
Female Athlete Triad
• Amenorrhea– Primary – Secondary
• Anorexia– Anorexia athletica
• Osteoporosis– Osteopenia
Anorexia Athletica
• Absolute Criteria– Weight loss >5%– Absence of medical
illness– Excessive fear of
obesity– Caloric restriction
• Relative criteria– Primary amenorrhea– GI complaints– Compulsive exercise– Disordered body
image
Axis of Rotation
• Sense of center• Vital to performance
sport athletes• Changes dramatically
during SMR IV-V• Most frequent time of
disordered eating issues
Culture of Disordered Eating
Recent Studies Regarding Medical Issues of Dancers
Adolescent BMD in Dancers
• Oligo/amenorrheic dancers BMD as compared to controls with similar profiles
• No significant difference in control group vs. dancer group
• Value of weight loading exercise, menstrual history
Bone Mineral Density Differences between Adolescent Dancers and Non-
exercising Adolescent Females • To WW, et al. J Pediatr Adolesc Gynecol. 2005
Oct;18(5):337-42 • 35 adolescent female dancers (17-19 yrs old) vs. 35
adolescent controls• DEXA of both groups• BMD values much greater for dancers compared to
eumenorrheic controls• Ward's triangle 0.816 g/cm(2) vs. 0.720, P = 0.003;
trochanter 0.777 g/cm(2) vs. 0.682; P < 0.001) were significantly higher in the eumenorrhoeic dancers as compared to controls
Psychological Development
• Adolescent Development– Sexual Development– Skeletal Development– Physiologic
Development– Psychological
Development
Psychological Considerations
• Only 23% of female and 33% of male professional dancers are satisfied with their bodies
• Adolescent dancers who begin puberty on time (12.9 years) have a lower body image than their peers
Issues to Consider When Counseling for Healthy Bones
• Body Habitus– Disordered eating, anorexia athletica, anorexia
nervosa
• Lifestyle– smoking, drinking, caffeine ingestion
• Diet– calcium, calories (calcium counting sheet)
• Heredity• Sex Hormone Levels• Previous Bone Injury (Dexa?)
Keeping Dancers Medically Healthy
• Preventive education• Recognition of
disordered eating, altered body image
• Making sure that health care team and teaching institution are on same page
Orthopedic Issues in Dancers
Common Orthopedic Issues in Dancers
• Scoliosis• Overuse Injury
– Bone• Sesamoid• Tibial• Femoral
– Tendon• Ankle• Iliopsoas
– Apophyseal
• Acute Traumatic Injury– Romeo and Julliet
Scoliosis
• 15% of dancers• Most common type is
adolescent idiopathic• Girls>Boys• Skeletal delay?
Forward Flexion Test
Injuries in Dancers
Is the School on Board?
Which Body Type Is Favored?
• Flexibility• “Natural” turnout• “Normal” Femoral
anteroversion is 15 degrees
• External tibial torsion• Roughly 60% above
knee, 40% below knee (turnout)
• Foot – Type– ROM at 1st MTP
The Ballet Pointe Shoe
Correct age to go en pointe?
• Beginning Stage Dancer– 8-12 years of age– Pre-pointe
• Middle Stage Dancer– 12-16 years of age– Major health issues
• Apprentice Stage Dancer– 16-older– Pre-professional stage
Common Injuries in Dancers
Posterior Ankle Pain
• 14 year old dancer• Pain in posterior
ankle• Pain with pointe• Pain with releve• Posterior ankle
impingement
Os Trigonum
Mechanical Factors
Mechanical factors causing posterior impingement (FHL)
Hip Pain in Dancers
• 12 year old dancer• “Snapping” hip• Noise with hip flexion• ? Pain
The Snapping Hip Syndrome
Iliopsoas Tendonitis
acet
IPM
IPM=iliopsoas muscleIP= iliopsoas tendon
IP
Needle tip
Common fem vessels
Injection Site
Bone Overuse Injury
• 15 year old ballet dancer
• Pain with dance• Having trouble with all
activities, particularly landing jumps
Pediatric Bone Health
• Children attain 90% of peak bone mass by 18 years of age
• Bone density increases by 6-8% per year in teens
• Multiple factors determine adult bone health
Bone Injury in the Female AthleteActivity
BiomechanicsBone Density
Injuries in dance company: effect of comprehensive management on injury
incidence
• Bronner S et al. Am J Sports Med. 2003 May-Jun;31(3):365-73
• 5 year injury data in professional company
• 3 years without intervention, 2 years with intervention of screening program
• Roughly 60% decrease in injury rate with preventive screening program
Dance Medicine Physical Therapy
Pilates Method
• Born early 1900’s, Germany
• Rickets, weak body• “Art of centrology”• WW I – orderly in
hospital treated disabled soldiers
“Reformer”
• Core muscle strength• Trunk stability• Injury prevention
Conclusions
• Dance is great for health!
• Medical and orthopedic issues
• Parents, teachers can take an active role in health prevention!
• Don’t “dance through the pain”