Dr. William Hamilton is an orthopedic surgeon specializing in foot and ankle injuries in performers and athletes. He is a consultant for New York City Ballet, American Ballet Theatre and their schools.
Have you got lumbago—with or without sciatica?? These are old-fashioned terms: lumbago simply means low back pain, and sciatica is pain that radiates down the leg sometimes with numbness, tingling, or weakness in the muscles. Let's look at back pain in dancers.
This is the second of a two-part series on the spine. This first post dealt with the cervical spine, or neck; the thoracic spine or ribcage; and scoliosis. Part II discusses the lumbar spine or lower back, and the sacrum or the part of the pelvis that the spine rests upon.
The lumbar spine
This is where most of the problems occur. Normally the lumbar spine has five vertebrae between the ribcage and the pelvis. However, there are often congenital (present at birth) abnormalities in the region. One of the more common ones occurs when the lowermost vertebra, L5, is joined to the sacrum below, either on one side or both. Dancers with this problem complain of stiffness in their port de bras and arabesques because they are trying to do with four vertebrae what everyone else is doing with five!
There is an area of increased stress where the rigid thoracic spine joins the flexible lumbar spine, and a second area where the lumbar spine joins the rigid pelvis below. Both of these areas can have problems. A common strain occurs at the junction of the thoracic and lumbar segments in male dancers who do a lot of partnering. It is usually muscular and heals with therapy, but they need to back off for a while and let it heal. These dancers may need to work on their upper-body strength to help prevent this injury.
Between the Lumbar and the Sacrum
The majority of back problems come from the lowermost segment of the back—the Lumbosacral spine. This area is put under extreme stress when performing grand battements, port de bras, arabesques, and attitudes and is prone to muscle strains, disc disease and stress fractures.
Muscle pulls or strains are characterized by pain, spasm, and stiffness. The pains may radiate into the buttocks but not usually down the legs. They usually resolve with relative rest (don't do what hurts), mild anti-inflammatories, and physical therapy. Rehab after the symptoms improve is important to prevent recurrences.
The discs that lie between the vertebrae are somewhat like a doughnut in that they have a firm outer ring but a soft center. Under extreme pressure, the ring can rupture and allow the center to protrude, like a slash in a tire that allows the inner tube to poke out. Unfortunately, the place where this occurs is exactly where the nerve root is trying to exit through its foramen. Nerves are very sensitive to pressure so they become swollen and irritated. The pain in the irritated nerve radiates down the course of the sciatic nerve from the buttock to the leg and foot, causing the characteristic tingling, numbness, and weakness associated with the “herniated disc." These symptoms can range from mild to severe. The vast majority of the mild and moderate cases will heal with conservative therapy, especially in young, healthy dancers. Severe cases with marked weakness of the leg or those that don't heal may require surgery, which usually allows the dancer to return to their career.
Stress fractures in the lumbar spine are common in dancers and gymnasts. They have a characteristic presentation: unilateral (on one side), low back pain that keeps coming back or won't go away. Pain with the arabesque, attitude, or grand battement on the affected side is a stress fracture till proven otherwise! These have a fancy name: spondylolysis, or a breaking down of the spine. The diagnosis is usually made on an X-ray, an MRI, or a bone scan. Treatment is complicated and depends upon the stage of the fracture; whether it is fresh or old, i.e. whether it has the potential to heal with immobilization (a brace) or whether it is un-healed (a fibrous union) in which case it is managed by physical therapy and rehabilitation. These fractures are relatively common in dancers and, if managed correctly, usually don't interfere with a career in dancing.¨
Does your knee hurt when you land from a jump, go downstairs, do grands pliés, or sit with it bent for long periods of time? That's why it's called the “jumper's knee."
Exactly what is it? It is a strain of the tendon called the patellar tendon that runs from the lower pole of the patella (kneecap) to the upper part of the tibia or shin. It's common in male ballet dancers & basketball players who jump a lot—duh! Let's look at the anatomy.
The large muscle in the front of the thigh is called the quadriceps, meaning four heads. This muscle feeds into the upper part of the patella and provides the power used to straighten the knee. That force passes through the kneecap down to its bottom tip where it is connected to the tibial tubercle (by means of the patellar tendon), a bump on the front of the upper tibia. Whether taking off or landing from a jump, a lot of force goes through the patella.
Other Problems with the patella—“the painful patella syndrome:"
Subluxation, where it goes out, but slips back in, and dislocation where it goes all the way out and stays out. These conditions common in adolescent females with ligamentous laxity (hyper-mobility), especially in ballet dancers who turn out from the knee rather than the hip.
Osgood-Schlatter's Disease or “the choirboy's knee" is a condition often seen in young (mostly male) athletes where they strain the attachment of the patellar tendon at its insertion to the growth plate on the upper tibia. It is characterized by a swollen, tender lump just below the knee and is related to the amount of running and jumping done. The more you do, the more it hurts, and vice versa. It tends to come and go but disappears when growth is over, around age 16. In the olden days, they thought that young boys got it from kneeling in church, but they really got it playing soccer after school. This syndrome is the juvenile version of the jumper's knee, but it occurs at the other end of the patellar tendon, where it attaches to the growth plate.
Chondromalacia of the patella is roughening of the undersurface where it articulates with the end of the femur, or thighbone. It is characterized by painful grinding of the patellofemoral joint with pliés and sautés. (We usually separate painful grinding from painless grinding because many dancers have the painless type as they get older and it's usually not a problem.) This can cause symptoms similar to the jumper's knee.
“Housemaids knee" or prepatellar bursitis is a squishy build-up of fluid in the bursa (sac) under the skin covering the kneecap. It is seen in people who kneel at work, like gardeners and carpet layers.
In the Jumper's Knee, the pain is usually coming from a very specific point in the attachment of the tendon to the tip of the patella and not from the knee joint itself. It can often be located with the tip of one finger. Most of the time it is a chronic, ongoing condition that slowly gets worse with time. The diagnosis can be confirmed by injecting a small amount of local anesthetic into the sore spot. If this relieves the pain, then the diagnosis is confirmed. It also is a handy way of separating pain that is coming from inside the knee (chondromalacia) from pain that is coming solely from the tendon. It is exacerbated by tightness or contracture of the quadriceps mechanism and unrecognized eccentric weakness when the muscle lengthens as you plié. The workup usually includes regular x-rays, and an MRI to look for bony abnormalities at the tip of the patella and to see the extent of the damage to the tendon. The condition is usually due to one small portion of the tendon that has pulled loose from its attachment to the patella and has failed to heal.
We like to divide treatment of the jumper's knee into three steps:
Step 1: Mild anti-inflammatories; “modified activities," i.e. don't do what hurts; ice after dancing; and physical therapy. This therapy can include modalities, stretching, eccentric strengthening of the quadriceps, and acupuncture.
Step 2: One (and only one!) small shot of corticosteroid into the tender area to diminish the pain and inflammation, followed by slow rehab. This is an area where multiple shots of cortisone could cause complete rupture of the tendon!
Step 3: Either a PRP (Protein Rich Plasma) injection or surgical scraping of the area to get it to heal.
In general, like many overuse injuries, the longer you have had them, the longer it is going to take to heal. You pay a price by working with an injury while it is painful. The good news is that the jumper's knee is very treatable and rarely ends a career or leads to a long-term disability. But IT NEEDS TREATMENT!
William G. Hamilton, MD is an orthopedic surgeon in private practice in New York City. He is the orthopedic consultant for the New York City Ballet, American Ballet Theatre, the School of American Ballet, and the JKO School of Ballet at ABT. He specializes in foot and ankle injuries in dancers and athletes. He is past president of the American Orthopedic Foot and Ankle Society.
Do you have a sprained ankle that won't heal? It's not that rare. Studies have shown that 10 to 30 percent of sprains will have symptoms later. So what is a sprained ankle anyway? It's the most common injury in all of sports and dancing.
Dancing pushes your body to its limit. If you roll over on your ankle when landing from a jump, you can sprain or injure the ligaments on the outer (lateral) side that hold the joint together. This is different from a "strain," which affects your tendons and muscles. An easy way to remember this distinction is this: You sprain your ankle, but you strain your Achilles tendon. The degree of injury varies, depending on the damage to the ligaments. We determine this by a physical exam and X-rays that help us classify the ankle sprain as Grade I (mild), II (moderate), or III (severe). The most serious sprain involves a complete tear of the ligaments with marked instability that often requires surgery. Fortunately, most sprains are Grade I or II and heal in three to six weeks. The exceptions are those that continue to cause trouble. This is the "sprained ankle that won't heal."
In medical circles, residual problems from sprained ankles cause considerable angst, because they can be hard to diagnose and difficult to treat-especially when telltale signs are ignored by stoic dancers. Problems with old sprains tend to fall into three categories: swelling, pain, and instability ("giving way").
It's normal for a sprained ankle to swell, sometimes for four to six weeks, or longer. But swelling that persists for more than three months may be a sign of trouble. The lining of the capsule surrounding a joint is called the synovium, and anything inside the joint that irritates the synovium will cause it to secrete fluid. Swelling inside of a joint is often a sign that something is causing irritation. (The swelling that is seen from the outside is a combination of soft tissue swelling around the joint and fluid within the joint itself.) In the ankle there are several reasons for this condition. While these may seem alarming, treatment is possible. But first, let's take a look at the culprits.
Chronic synovitis Sometimes there is damage to the surface of the joint that does not show up on any tests, such as an X-ray or MRI, even though it continues to cause irritation and excess fluid.
A bone chip At the time of injury, a bone chip may have been knocked loose, leaving a "loose body" floating around inside to cause trouble.
An OCD lesion "OCD" in sports medicine stands for osteochondritis dissecans (not obsessive compulsive disorder). The easiest way to think of this is like a cavity in a tooth. It is something that leaves a small hole in the surface on the ankle bone (the talus) with a dead piece of bone in it. An MRI study will usually pick this up.
A bone bruise This is not black and blue. Instead, it feels like an achy pain that is difficult to explain and lasts for months. There is edema, or fluid, within the bones themselves that we can only see on an MRI study. Fortunately, it is rarely serious and gradually fades away.
What can you do? Treatment for chronic swelling, no matter what the cause, usually requires sleeping with the leg elevated on a pillow at night and putting on an elastic ankle support in the morning when you get out of bed. If the swelling is minimal and is slowly going away with no other symptoms, it is OK to dance, but go easy on the jumps and grand plies till all the swelling is gone. However, if it doesn't feel so good then don't do it! An ankle support (no need for metal hinges, etc.) usually feels good at this stage.
It also helps to avoid the saltshaker, which leads to water retention. With diligence, the swelling should go away. However, if the leg is swollen up the shin, something else may be happening, and it needs to be checked out by your doctor. Swelling that does not go away is a sign that something more is wrong. Normal joints do not swell.
There are several common causes of ankle pain that does not go away:
The sinus tarsi syndrome Lingering inflammation, scar tissue, or a partly torn ligament can occur in the hollow place in the side of the anklebone called the sinus tarsi (sinus in Latin means hollow or sunken and the tarsus is the ankle). This is the most common cause of the sprained ankle that won't heal. While it can be difficult to discern this problem on an X-ray or MRI, a physical exam by a dance medicine specialist can pinpoint the diagnosis by locating the exact area that hurts.
A tarsal coalition Residual pain in the sinus tarsi after the original sprain heals can also be due to an unrecognized tarsal coalition. The ankle has two components: the regular ankle joint that moves up and down, and the subtalar (ST) joint beneath it that moves in and out. Together, they make up the ankle joint complex. Some people are born with limited motion in their ST joint because the bones in this area are joined together where they ought to be separate—a coalition. It can usually be seen on an X-ray or MRI. This condition is present in about five percent of ankles. It usually occurs in one ankle only, rather than both. As with a sprain, it can be mild, moderate, or severe. In dancers, it is usually mild or it would have caused trouble before the sprain. Dancers with mild symptoms can often work around it.
The high ankle sprain This is marked by tenderness in the front of the ankle on the outside. Unlike routine ankle sprains where the main damaged ligaments lie right in the sinus tarsi, this one affects a ligament that is higher up, at the level of the ankle joint itself. This is the so-called "high" ankle sprain, which can be a real bugaboo because it takes two to three times longer to heal than a routine sprain. It may not show up on medical tests, so the diagnosis is usually made on the basis of the physical exam.
Secondary problems Lastly, there are several conditions, such as FHL tendonitis ("dancer's tendonitis") and the os trigonum syndrome that seem to pop up out of nowhere. Dancers often think that the residual pain is part of the healing process when it is actually a separate problem. Later the sprain may heal, but these conditions can continue to be painful and may even require surgery if left unaddressed.
"My ankle gives way" is probably the second most common leftover problem with ankle sprains after the sinus tarsi syndrome. We doctors see it all the time. Many things can cause this problem. Fortunately most respond to appropriate treatment.
Peroneal weakness There are two peroneal tendons that run parallel down the outside of the ankle; one is short and the other is long. Their major function is to keep the ankle from rolling over and prevent sprains. After an injury they can remain weak, so the ankle is poorly protected from further roll-overs. It's easy at this point to fall into the vicious cycle of "Because it's weak it rolls over and because it rolls over it's weak," which can go on for months. If this is the problem, it is easy to fix. Simply restore the normal peroneal strength with physical therapy. A few months of daily use of a theraband, under the guidance of a physical therapist, will usually strengthen the peroneals. (They gain strength faster if the exercises are done in the full "tendu" position.)
Laxity of the ankle ligaments Grade I sprains do not usually damage the ankle ligaments to any extent, but repeated Grade II or Grade Ill injuries can lead to permanent looseness of the ligaments that hold the anklebones together. This is a difficult situation, because they can be tightened only by surgery. The surgery is quite effective, but the recovery is usually three months or more. So it is nice to avoid it if you can.
Many loose ankles often give way because of a combination of looseness and weakness. These can often be brought up to full strength with physical therapy and then they don't give way anymore. The number one indication for ankle ligament surgery is the failure of rehab to correct the problem.
Pain, swelling and instability
The problems associated with a recurring sprained ankle can co-exist and produce all three symptoms. In this ease the diagnosis is particularly difficult. There is one last problem that might be going on:
Peroneal tendon damage With repeated sprains, the peroneal tendons can develop small longitudinal rents or tears. When this happens, the tendons swell up in the sheathes that surround them and cause achy pains, chronic swelling and weakness that cannot be corrected by exercise. This problem is easy to miss and hard to correct because it usually gets worse in spite of all treatment. Fortunately, this condition also responds well to surgery.
The best way to diagnose these various problems is to see a sports or dance medicine specialist for a history, physical exam, and appropriate studies. Your doctor may request X-rays followed by an MRI, CT and/or bone scan. Physical therapy is usually the first step in the recovery. Do not try to treat yourself! There is an old expression in medicine that says, "Someone who treats themselves has a fool for a physician." Merde!
William G. Hamilton, M.D. is the orthopedic consultant for New York City Ballet, American Ballet Theatre, The School of American Ballet and the Jacqueline Kennedy Onassis Ballet School.