Hip pain in dancer

Hi. I am looking for some help problem solving with a patient who is a 55 year old ex-professional ballet dancer with hip pain. Her pain is intermittant and has had gradual onset over the last few years, recently increasing in frequency and intensity. She sometimes notices an ache in her hip which can progress to a sharp pain at the post aspect of the hip with prolonged walking (>2hrs and with up/down grade). The only specific motion that can reproduce the pain (which is sharp, post hip, but difficult to palpate) is "frog pose"...laying supine with the soles of the feet touching and hips in ER, ABD, and FLex. However, standard FABER position with the ipsilateral foot resting on the contralateral thigh is pain free with full ROM and tolerates over pressure. Her x-ray is clear, no sign of arthritis. No MRI has been done. IT band is very tight, but other hip ROM is good. Knee ROM is full. Pelvic alignment appears normal. She has a gait deviation on the ipsilateral side of externally rotating after midstance--as she moves through stance phase and her heel lifts it twists inward.

I have not treated many dancers and I am wondering if anyone is familiar with hip injuries common for ballet dancers, maybe there is some there is something I should be checking for in that regard. I'm not sure why FABER is clear, but frog pose hurts.

Any ideas?

Sounds very specific the the amount or extension in relation to the external rotation. As dancers walk in more external rotation in normal gait I suspect she does the same. The frgo post would have her in more relative extension with the external rotation than the FABER test.

Initially reading I was thinking about the other leg during gait so it is great you mention it. e.g. A lack or ability to internally rotate from mid to late stance will mean that the contralateral hemipelvis will remain slightly posterior (in reference to the horizontal plane) during that sides swing phase. This will cause a heal strike in a postion of excessive external rotation (not really in the hip but due to the direction the pelvis is facing) and therefore excessive pronation through stance (an unstable stance therefore) which will lead to a less that ideal heal strike again...etc...etc. I suppose what I am saying as this can get rather confusing, is that a problem with the rotation of the leg on one side during stance phase can cause problems on the other. As your observation suggests this then I would begin by treating the restriction and normalising the movement on that leg and see what affect that has.

Good luck and keep us in the picture :)

hi
i agree with physiobob
there is a need to consider the biomechanical inter-relationships in such cases.
that is application of movement impairment approach of shirley shehrman.her theory of relative flexibility -should be kept in mind while evaluating movement alterations
the relative flexibility is simply stated as "the body segments follows the path of least resistance
so reduced flexibility/mobility of one segment is compensated by excessive flexibility/mobility in another segment

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Originally Posted by ABCphysio

Hi. I am looking for some help problem solving with a patient who is a 55 year old ex-professional ballet dancer with hip pain. Her pain is intermittant and has had gradual onset over the last few years, recently increasing in frequency and intensity. She sometimes notices an ache in her hip which can progress to a sharp pain at the post aspect of the hip with prolonged walking (>2hrs and with up/down grade). The only specific motion that can reproduce the pain (which is sharp, post hip, but difficult to palpate) is "frog pose"...laying supine with the soles of the feet touching and hips in ER, ABD, and FLex. However, standard FABER position with the ipsilateral foot resting on the contralateral thigh is pain free with full ROM and tolerates over pressure. Her x-ray is clear, no sign of arthritis. No MRI has been done. IT band is very tight, but other hip ROM is good. Knee ROM is full. Pelvic alignment appears normal. She has a gait deviation on the ipsilateral side of externally rotating after midstance--as she moves through stance phase and her heel lifts it twists inward.

Any ideas?

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I must admit I need to clarify exactly where she is feeling the pain. From the sounds of things, it sounds less a 'true hip/groin' pain and more a gluteal/lateral thigh/SIJ/Lumbar spine pattern. Is this correct?

Have you cleared any lumbar/sacral pathology? In particular I would be looking at her SIJ, as her gait pattern seems to indicate some form of dysfunction or block. I'd be trying some SIJ OP's in that 'frog position' to see if it made a difference to her pain levels or her biomechanics.

The only other thing that I was thinking of that could be another cause was a posterior labral tear. But then it depends where exactly she is feeling the pain.

Interested to hear more about this.

Cheers,
Quickstart.

Did Linbin mean Shirley A Sahrmann and her brilliant book on Movement impairment syndromes? Maybe one should look more at the movement dysfunction / muscle imbalance / movement control side. I've had a lady of the same age who dances still but tango and latin american stuff, she has various "hip" pains and more..... And frog position during lifting the leg in tango. Not being specialized I got her to a praxis where the doctors do see alot of professional dancers and the physios are more in that direction. She had a muscle imbalance problem including of course pelvis-lumbar regions. Plus triggerpoints. I remember discussing excessive hip movements and joint laxity (particularly anterior) in ballet dancers once in a "kinetic control" course. Your dancers hypermobility and muscle imbalance has continued over years and I suspect a treatment direction of core stability/ kinetic control local stabilisers-global stabilisers/pilates is where this patient should head.

hi judith
i meant the same only.her concepts are really healpful