THE HIP

The following information is intended as a resource and should not be used to self-diagnose or treat. Use of non-steroidal anti-inflammatory drugs (NSAID’s) may be used to reduce inflammation and pain associated with that inflammation. Dancers should be aware that dancing while taking NSAID’s can mask pain, which can lead to further tissue injury.

Structure

The hip joint is a very stable joint. It is comprised of a ball and socket mechanism, where the head of the thighbone (femur) connects with the cup-shaped acetabulum on the pelvis. Along with this structural connection, strong ligaments around the hip help to reinforce the joint’s integrity. Several muscle groups also help support the hip and provide movement in all three planes. Two of the largest and most important of these are the iliopsoas and gluteus maximus muscles, responsible for flexing and extending the hip, respectively. Beneath the gluteus maximus, six deep rotators work hard to properly maintain hip rotation demanded specifically by ballet technique.

Common Injuries

Trochanteric Bursitis
Snapping Hip
Iliacus Tendinitis
Piriformis Syndrome
Femoral Stress Fracture
Osteoarthritis

Trochanteric Bursitis:
“I have pain over the side of my hip.”

Inflammation of trochanteric bursae is a common cause of hip pain in dancers. The greater trochanter of the femur is a broad, flat section of bone that serves to anchor several large muscles at the outer hip. The trochanteric bursa lies underneath the attachment of some of these muscles and serves to cushion and reduce potential friction between bones, tendons, and muscles.

Causes
There are many potential causes of trochanteric bursitis in dancers. Some conditions can arise from acute injury or impact. Most commonly however, trochanteric bursitis has no specific method of injury. Potential causes can include overuse, a structural imbalance of the lumbar spine, muscular imbalances in the hip and/or pelvis, a leg length discrepancy, or a lateral snapping hip.

Treatment
Conservative measures will normally be sufficient to resolve trochanteric bursitis. An assessment by a physician or clinician to identify structural or mechanical imbalances is essential. A stretching and/or strengthening program can assist with correcting such imbalances. For acute pain and inflammation, ice and anti-inflammatory medications can also be helpful.

Snapping hip:
“My hip snaps when I do grande battement or developpe a la seconde.”

Causes
Usually painless and harmless, a snapping hip can occur as a muscle or tendon passes over a bony structure. Occurring frequently in dancers, two kinds of snapping hip exist.
- Lateral snapping hip, the most common form, generally involves movement of the IT Band over the greater trochanter.
- Anterior snapping hip, usually presents as a more internal kind of snapping, as the iliopsoas tendon passes over a bony prominence on the front of the pelvis or the femur.

Treatment
If there is no pain associated with snapping hip, there is no need for treatment. Painful conditions should be assessed by a physician or clinician for soft tissue or joint restrictions or any strength or flexibility deficits. Dancers may need to reduce their rehearsal regimen until symptoms decrease. Anti-inflammatory medication may be indicated to assist with decreasing edema.

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Iliacus tendinitis:
“I have pain in the front of my hip, near my groin.”

Diagnosed most often in younger dancers, iliacus tendinitis affects the iliacus muscle, at the lower portion of the iliopsoas muscle at the front of the hip. This can also be referred to as iliopsoas syndrome.

Causes
Iliacus tendonitis often results from overuse during dance activities. It can affect modern dancers more often, due to the increased emphasis on hip flexion and internal rotation. Pain is most often felt in front of the hip, often in the groin. Pain and often crepitus is felt on palpation over the iliacus muscle.

Treatment
Conservative measures are normally sufficient in dealing with the pain associated with iliacus tendonitis. A dancer may need to reduce their rehearsal regimen until symptoms decrease. Anti-inflammatory medication can assist with reducing swelling along the tendon. An assessment by a physical therapist or athletic trainer can assist with soft tissue management and correcting muscular or structural imbalances that may also be present.

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Piriformis syndrome:
“I have pain in my buttock and low back.”

The piriformis is a muscle that lies underneath the gluteus maximus muscle in the buttock. It is small compared to other muscles around the hip and thigh, and it aids in external rotation (turning out) of the hip joint.

Causes
The piriformis muscle and its tendon have an intimate relationship to the sciatic nerve--the largest nerve in the body--which supplies the lower extremities with motor and sensory function. Due to the nature of dance and the emphasis on hip rotation and turnout, the piriformis muscle can become tight and restricted in dancers. The proximity of the piriformis muscle to the sciatic nerve can cause pain to radiate into the buttock and lower extremity.

Treatment
Conservative measures are normally sufficient in dealing with pain. An assessment with an athletic trainer or physical therapist can be helpful to identify areas of hip weakness or restrictions that may be contributing factors. Deep tissue massage to the piriformis can be helpful in relieving muscle spasms. Anti-inflammatory medication can assist with reducing swelling in the muscle group and along the sciatic nerve. Dancers may have to temporarily reduce their rehearsal regimen to decrease acute symptoms.

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Stress fracture of the femoral neck:
“I’ve had a deep pain in the front of my hip for a while now. It hurts during class.”

Stress fractures of the femoral neck are not as common as other conditions illustrated here, but they can occur with dancers. Repeated training with either faulty technique or muscle imbalance can increase the risk for a stress fracture.

Causes
Dancers typically notice pain in the groin, hip girdle, or anterior thigh. Symptoms can occur during or after class and can be elicited with passive movement and stretching, particularly internal rotation of the hip or turn-in. A physician may request an X-ray or bone scan to confirm the diagnosis.

Treatment
Depending on the severity of injury, time off from class and rehearsals or performances may be indicated. Dancers may be required to avoid weight bearing on the hip with the use of crutches. Weight bearing is gradually increased over several weeks to a few months. Pool workouts may be helpful during the rehabilitative phase to decrease the load placed on the hip during exercise.

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Osteoarthritis:
“I have been dancing all my life and now have a constant hip pain.”

Osteoarthritis involves inflammation and degenerative breakdown of the cartilage lining the ends of the bones within a joint. Healthy cartilage normally protects the joint, allowing for smooth movement and shock absorption. Without the usual amount of cartilage, the bones rub together, causing pain, swelling and stiffness.

Causes
The most common causes of osteoarthritis are previous injuries, joint overuse and aging. It is also suspected that there is a genetic component to the disease. Dancers may have little or no complaints of hip pain until the disease has progressed significantly. With significant arthritis, dancers will start to notice pain with many activities, including walking, ascending stairs, and even at rest.

Treatment:
A physician can confirm a diagnosis of arthritis with an X-ray. Arthritis is a degenerative condition and there is presently no cure. The dancer should maintain existing flexibility in the hip joints to help prevent injuries caused by friction. A consult with a physical therapist is helpful to determine if strength deficits or imbalances exist and help to correct them. Severe conditions may require total hip replacement surgery once pain becomes no longer tolerable.

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Hip Injuries:Prevention/tips for dancers:
1. Try to maintain flexibility in the hip joints, including the iliopsoas, iliotibial band (ITB) and gluteal muscles. This will help prevent injuries caused by friction. This may involve some stretches which are not covered in class, so try to do them after class when you are really warm, and hold them for a minimum of 30 seconds.

2. Keep a balance between left and right side leg strength, to avoid overworking muscles, and muscle imbalance issues.

3. Make sure you eat enough foods with sufficient calcium, for strong healthy bones.

4. Avoid dancing on hard or uneven floors for prolonged periods of time. Most joint damage occurs after continued stress, so take breaks.

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