The Hyperflexible Hip: Managing Hip Pain in the Dancer and Gymnast - PubMed (original) (raw)

The Hyperflexible Hip: Managing Hip Pain in the Dancer and Gymnast

Alexander E Weber et al. Sports Health. 2015 Jul.

Abstract

Context: Dance, gymnastics, figure skating, and competitive cheerleading require a high degree of hip range of motion. Athletes who participate in these sports use their hips in a mechanically complex manner.

Evidence acquisition: A search of the entire PubMed database (through December 2013) and additional searches of the reference lists of pertinent articles.

Study design: Systematic review.

Level of evidence: Level 3.

Results: Whether innate or acquired, dancers and gymnasts have some hypermobility that allows their hips to be placed in potentially impinging or unstable positions required for their given activity. Such extremes of motion can result in both intra-articular and extra-articular impingement as well as compensatory osseous and muscular pathology. In addition, dancers and gymnasts are susceptible to impingement-induced instability. Dancers with innate generalized hyperlaxity are at increased risk of injury because of their activities and may require longer recovery times to return to play. Both nonoperative and operative treatments (arthroscopic and open) have an important role in returning flexibility athletes to their preoperative levels of sport and dance.

Conclusion: Because of the extreme hip motion required and the compensatory soft tissue laxity in dancers and gymnasts, these athletes may develop instability, impingement, or combinations of both. This frequently occurs in the setting of subtle pathoanatomy or in patients with normal bony anatomy. With appropriate surgical indications and the correct operative technique, the treating surgeon can anticipate high levels of return to play for the gymnast and dancer with hip pain.

Keywords: dance; femoroacetabular impingement; gymnastics; hip injury; impingement; instability.

PubMed Disclaimer

Conflict of interest statement

The following authors declared potential conflicts of interest: Asheesh Bedi, MD, is a paid consultant for A3 Surgical and Smith & Nephew; Christopher M. Larson, MD, is a paid consultant for A3 Surgical and Smith & Nephew, and holds stock/stock options from A3 Surgical.

Figures

Figure 1.

Figure 1.

(a) Ballet turnout. Dance places a great deal of emphasis on the turnout, which is the amount of lower extremity external rotation with the knees in extension. The hip is thought to contribute 50% to 70% of the rotation. Reprinted with permission from

http://www.shutterstock.com/g/smoxx

. (b) Lower extremity external rotation with the knees in extension is common to other flexibility sports as well, as can be seen in this skater. Yuna Kim, 2007 National Sports Festival Winter Games,

http://www.flickr.com/photos/queenyuna/5017220486/

, used under a Creative Commons Attribution-NonCommercial-NoDerivatives License.

Figure 2.

Figure 2.

Preoperative (a) anterior-posterior pelvis and (b) false-profile radiographs from an adolescent dancer with hip pain preventing her from dancing. These show acetabular dysplasia with (a) retroversion and (b) limited anterior coverage. (c) She underwent arthroscopy and periacetabular osteotomy to evaluate the status of her labrum, improve the lateral acetabular coverage, and correct the version. Intraoperatively, the labrum was hypertrophic and degenerative (arrow), which was consistent with her diagnosis of mild dysplasia and instability. (d) The postoperative radiograph shows improved lateral coverage and neutral acetabular version. Ac, acetabulum; FH, femoral head.

Figure 3.

Figure 3.

Both (a) side splits and (b) front splits are common in flexibility sports and dance. In ballet, these positions are called grand écart facial and grand écart lateral, respectively. These 2 positions as well as the développé à la seconde (c, in ballet; d, in a skater) and the (e) grand plié have been found to cause impingement at the posterior-superior aspect of the acetabulum in morphologically normal hips. Figure (c) reproduced with permission,

http://www.shutterstock.com/g/df028

. Figure (d) Yuna Kim 2009 World Figure Skating Championships, Los Angeles, California,

http://www.flickr.com/photos/queenyuna/6368356397

, used under a Creative Commons Attribution-NonCommercial-NoDerivatives License. Figure (e) reproduced with permission, Sergey Petrov,

http://www.shutterstock.com/g/irtish

.

Figure 4.

Figure 4.

In (a) high-kick dance, (b) gymnastics, and some ballet positions, impingement occurs between the anterior-inferior iliac spine (AIIS) and distal femoral neck, as can be seen in this (c) 3-dimensional computer simulation of high-flexion impingement. Figure (a) reprinted with permission,

http://www.shutterstock.com

. Figure (c) reprinted with permission from Larson et al.

Figure 5.

Figure 5.

Radiographs and intraoperative images from a 30-year-old former high-level studio dancer with right anterior hip pain and pain with straight flexion typical of impingement between the anterior-inferior iliac spine (AIIS) and distal femoral neck. Hip range of motion was 105° in straight flexion, 15° of internal rotation, and 60° of external rotation in flexion. (a) The preoperative Dunn lateral view shows sclerosis on the distal femoral neck (solid arrows). (b) Intraoperatively, she had focal bruising and synovitis around the AIIS with (c) cortical sclerosis distal on the femoral neck, consistent with high range of motion impingement. (d) She underwent rim osteoplasty around the AIIS and femoral neck osteoplasty extending distally on the neck to eliminate the impingement. (e) The postoperative Dunn lateral radiograph demonstrates the AIIS and femoral neck osteoplasties (open arrows). FH, femoral head; L, labrum.

Figure 6.

Figure 6.

This patient has bilateral dysplasia with acetabular retroversion. (a) The sourcils are short, the posterior acetabular walls are both medial to the center of rotation of the femoral head, and the anterior acetabular wall crosses in front of the posterior acetabular wall. (b) The false-profile radiograph of the right hip demonstrates deficient anterior coverage. (c) The patient underwent bilateral periacetabular osteotomy with subsequent hardware removal once the osteotomies had healed. The postoperative radiograph shows improved coverage and correction of acetabular version on both hips.

Figure 7.

Figure 7.

Radiographs and intraoperative images from a 15-year-old female ballet and studio dancer with left anterior groin pain provoked by dance. (a) Anterior-posterior pelvis radiograph reveals normal acetabular coverage and version. (b) A Dunn lateral radiograph demonstrates a pincer groove at the anterior femoral neck with otherwise normal head-neck offset and a slightly prominent anterior-inferior iliac spine (AIIS; solid arrows). She underwent acetabular rim osteoplasty under the AIIS and femoral neck osteoplasty to eliminate the impingement and resultant levering between the AIIS and femur. (c) The postoperative Dunn lateral radiograph demonstrates the acetabular and femoral neck osteoplasties (open arrows).

Figure 8.

Figure 8.

Arthroscopic photos of capsular repair. (a) Prior to repair, the interportal capsulotomy (mid-anterior to anterolateral portals) is visible along the femoral neck. The capsule is repaired with a suture passing instrument that allows the edges of the capsule to be (b) opposed or plicated. (c) After the repair, the interportal capsulotomy has been closed.

Similar articles

Cited by

References

    1. Adib N, Davies K, Grahame R, Woo P, Murray KJ. Joint hypermobility syndrome in childhood. A not so benign multisystem disorder? Rheumatology (Oxford). 2005;44:744-750. - PubMed
    1. Akiyama M, Nakashima Y, Fujii M, et al. Femoral anteversion is correlated with acetabular version and coverage in Asian women with anterior and global deficient subgroups of hip dysplasia: a CT study. Skeletal Radiol. 2012;41:1411-1418. - PubMed
    1. Albers CE, Steppacher SD, Ganz R, Tannast M, Siebenrock KA. Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH. Clin Orthop Relat Res. 2013;471:1602-1614. - PMC - PubMed
    1. Ali AM, Teh J, Whitwell D, Ostlere S. Ischiofemoral impingement: a retrospective analysis of cases in a specialist orthopaedic centre over a four-year period. Hip Int. 2013;23:263-268. - PubMed
    1. Ali AM, Whitwell D, Ostlere SJ. Case report: imaging and surgical treatment of a snapping hip due to ischiofemoral impingement. Skeletal Radiol. 2011;40:653-656. - PubMed

LinkOut - more resources