Hip injuries account up to 17% of musculoskeletal dance injuries (Trentacosta et al. 2017), second only to foot and ankle injuries. The majority of hip injuries are due to overuse and lack of stability in overly mobile hips. Hip injuries can be one of the most challenging to work with due to the complexity surrounding why the injury has occurred in the first place, the demands dancers place on their hips and the fact that our hips are such an integral part of every aspect of our lives. It is therefore important to find the true cause of pain for the individual dancer and work with them to manage the symptoms as well as achieve long-term correction and prevention.
Remember: the term ‘flexibility’ refers to muscles while the term ‘hypermobility’ refers to ligaments.
Muscles and ligaments are two distinct types of tissues which perform very different functions in the body. Here’s a quick anatomy primer:
Muscles are contractile tissues that cross over one or more joints in your body. When a muscle contracts, it causes movement of the joint it crosses.
Ligaments, on the other hand, are short bands of fibrous connective tissue that connect bone-to-bone and effectively “fasten” our joints together. Ligaments do not contract or create movement in the body. Instead, ligaments serve as the “seat belts” of our joints. They are our back-up system to stabilise our joints if our body moves in a way that would otherwise take a joint beyond its normal range of motion.
When we stretch, our intention should be to lengthen our muscles, NOT our ligaments. When muscles stretch, they return to their original length after the stretch is released – this property of muscles is called elasticity. However, when ligaments stretch, they do not return to their original length as well as a muscle does. If over stretched, they will permanently stay at that new length and are referred to as “lax”. Lax ligaments are longer effective as joint stabilisers and can be a source of injury and pain.
Read on and find out more…
The hip is a ball and socket joint designed for stability as it carries the weight of the torso and upper body. Maintenance of this stability is important for long-term hip health, particularly as dancers utilise the huge range of mobility available at this joint as well.
Did you know that the hip joint has not completely developed and growth plates closed until the ages of 16-18! Some parts of the pelvis do not fuse until the age of 22. This means when we are working with our dancers we need to be aware of the normal development of the hips and pelvis to ensure that they are not placing excessive forces through bones and joints that are still growing and changing. This is especially important when working with students who have hypermobile joints. As a physiotherapist, I am seeing younger and younger dancers coming in to clinic with hip pain. Rehabilitating a hip injury is detailed and takes a lot of concentration and body awareness to find the deep muscles. This can be really hard for young dancers to comprehend and manage.
Prevention is always better than cure!
Some common hip complaints
· Snapping hip – often described as “dislocating” their hip, the ITB shifts forward over the greater trochanter. Can be pain free initially but pain may develop overtime, especially with repeated “snapping”.
· Clicking hip (dancers hip) – repetitive click that occurs at the front of the hip with grand battement to second due to the iliopsoas tendon flicking over the AIIS. Students with clicking in their hip are often overusing their psoas major muscle to stabilise the spine due to weakness in the deep back stabilisers.
· Anterior femoroacetabular impingement – inflammation due to compression between the neck of the femur and then top of the acetabulum. Often occurs with repeated full flexion of the hip in seconde.
· Labral tear – the labrum is designed to deepen the hip socket and help with stability. As dancers utilise extreme ranges of their hip the labrum can suffer from wear and tear either as an acute injury or overtime. Often dancers feel that stretching or cracking the front of the hip helps with pain but this just further develops instability and inflammation.
Each of these conditions should be assessed and managed by your health professional to ensure they are correctly diagnosed and your return to dance is successful.
· Rest – giving the body and tissues time to heal! This is so important as the more you push an aggravated hip the longer it will take to recover!
· Posture – One of the first things I look at with dancers is their normal standing posture. This can be tricky in a clinical setting as dancers are very good at showing us what the right thing is. However, watch how they stand when they are talking to their friends before and after class, how do they stand between exercises during class, how do they sit when doing their homework or travelling in the car or on the bus?
· Gait (walking pattern) – How you walk in your normal daily life will have a huge impact on the tension and load around the hip complex. The way we walk is a learnt pattern and can be corrected and changed just like any other movement.
· Modifying class load – work with the leg in parallel and gradually increase the range of turnout. Work with the leg at 45 degrees until you have achieved good control and stability of the hip without pain.
What doesn’t help?
· Overstretching the front of the hip
· Cracking the hip or low back
· Attempting “core strengthening” exercises such as sit ups or crunches
Rehabilitation consists of a combination of hip stability exercises looking at ensuring there is a balance between all the muscles around the hip, core and deep back muscle activation, stability and endurance and modification of class load to ensure these deep muscles get a chance to develop without gripping with the more superficial ones. Below are some exercises to try that may help with starting to stabilise the hip and low back region. However as always, if you have any questions or any pain develops with these exercises, make an appointment with your health professional.
Stabilising the hip:
1. Core activation and breath
a. Lying on your back with knees bent place hands down low on your abdomen
b. Take a slow deep breath in expanding the torso in all directions
c. As you breathe out feel a gentle collecting sensation through lower abdominals, pelvic floor and deep back muscles
d. Make sure you keep the muscles at the front of the hips relaxed and the low back gently lifted
e. Hold this position for 10 breaths to work on the deep muscle endurance
2. Adductors – Cushion squeezes
a. Find your neutral spine lying on your back with a small cushion between your knees
b. Activate and collect your deep core muscles
c. Slowly squeeze the cushion using the muscles at the top of your inner thighs
d. As you squeeze and relax make sure the front of your hips stay relaxed and that your spine remains still
e. Hold for 3 natural breaths the release. Repeat 10-15 times to build endurance
3. QF (deep turnout muscle) activation – Heel squeeze
a. Lying on your tummy with knees slightly open and bent and feet on a chair with heels together. If you have tight hip flexors place a folded towel under your hips
b. Gently press the heels together and use fingers underneath glutes to feel for QF activation without use of the big glute muscles
c. Aim for x10 slow sustained holds
4. Iliopsoas complex – Hip suck in crook lying
a. Lying on with knees bent and feet on the floor
b. Visualise the thighbone of one leg sinking into the hip socket
c. Hold this for 3 breaths and then relax, repeat x10 providing you have good technique
d. Try adding a small leg float ensuring that the leg continues to feel light and there is no pain
Article written by Haydee Ferguson.
Physiotherapist with a dance history spanning more than 25 years.
Courtesy of Tulsa Ballet