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Case-Based Sports Medicine: Overuse Injuries in Performance Sport Athletes Jordan D. Metzl, M.D.

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Presentation on theme: "Case-Based Sports Medicine: Overuse Injuries in Performance Sport Athletes Jordan D. Metzl, M.D."— Presentation transcript:

1 Case-Based Sports Medicine: Overuse Injuries in Performance Sport Athletes Jordan D. Metzl, M.D.

2 Program Outline General Issues of Dancers Medical Issues of Dancers Orthopedic Issues of Dancers Dance Injury Prevention (Preparticipation Screening)

3 What Are the Performance Sports? Ballet Gymnastics Figure Skating –Grace –Athleticism –Thinness –Precision –Perfectionism

4 Health Benefits of Performance Sports Psychological Social Bone density Weight control Athleticism






10 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

11 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 5 th ”

12 Level of Dancer Weekend After school Pre-professional school Company

13 Specialization and Dance What are goals/objectives? In order to be good, need to start early? Exclusion of other sports? Varied types of dance?

14 Performance Enhancement? Drugs? “Extra” edge? Weight issues Influence and politics –Boston ballet experience (Heidi Gunther)

15 Medical Issues of Female Athletes Medical Issues –Bone –Female Athlete Triad Anorexia –Nutritional Amenorrhea –Hormonal Osteopenia –Future bone health?

16 Medical Development of the female athlete Adolescent Development –Sexual Development –Skeletal Development –Physiologic Development –Psychological Development

17 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

18 Female Athlete Triad Amenorrhea –Primary –Secondary Anorexia –Anorexia athletica Osteoporosis –Osteopenia

19 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

20 Axis of Rotation Sense of center Vital to performance sport athletes Changes dramatically during SMR IV-V Most frequent time of disordered eating issues

21 Culture of Disordered Eating

22 Recent Studies Regarding Medical Issues of Dancers

23 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

24 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

25 Psychological Development Adolescent Development –Sexual Development –Skeletal Development –Physiologic Development –Psychological Development

26 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

27 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?)

28 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

29 Orthopedic Issues in Dancers

30 Common Orthopedic Issues in Dancers Scoliosis Overuse Injury –Bone Sesamoid Tibial Femoral –Tendon Ankle Iliopsoas –Apophyseal Acute Traumatic Injury –Romeo and Julliet

31 Scoliosis 15% of dancers Most common type is adolescent idiopathic Girls>Boys Skeletal delay?

32 Forward Flexion Test

33 Injuries in Dancers

34 Is the School on Board?

35 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 1 st MTP

36 The Ballet Pointe Shoe

37 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

38 Common Injuries in Dancers

39 Posterior Ankle Pain 14 year old dancer Pain in posterior ankle Pain with pointe Pain with releve Posterior ankle impingement

40 Os Trigonum

41 Mechanical Factors Mechanical factors causing posterior impingement (FHL)

42 Hip Pain in Dancers 12 year old dancer “Snapping” hip Noise with hip flexion ? Pain

43 The Snapping Hip Syndrome

44 Iliopsoas Tendonitis acet IPM IPM=iliopsoas muscle IP= iliopsoas tendon IP Needle tip Common fem vessels Injection Site


46 Bone Overuse Injury 15 year old ballet dancer Pain with dance Having trouble with all activities, particularly landing jumps

47 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




51 Bone Injury in the Female Athlete Activity BiomechanicsBone Density

52 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

53 Dance Medicine Physical Therapy

54 Pilates Method Born early 1900’s, Germany Rickets, weak body “Art of centrology” WW I – orderly in hospital treated disabled soldiers

55 “Reformer” Core muscle strength Trunk stability Injury prevention


57 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”

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