ORTHOPEDIC CONSULT
From Advances in Pediatrics, presented April 14-17, 2005, sponsored by California Chapter 2, American Academy of
Pediatrics (AAP)
James G. Garrick, MD, Clinical Professor of Pediatrics, University of California, San Francisco, School of Medicine
| THE CHILD DANCER: FORGOTTEN ATHLETES
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| Introductory remarks: relevance of topic to pediatric practice—more little girls taking ballet than little boys playing
sports; girls involved with dance tend to get poor medical care
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| Ballet injuries: ballet dancers mostly female (66% in pediatric-to-adolescent medicine age group); injuries mostly
lower extremity; pediatric dancers appear to have higher incidence of foot injuries (tend to be too young to know how
to manage problems, eg, blisters, calluses, corns); almost all injuries resulting from ballet have gradual onset (eg,
overuse problems, muscle and tendon strains); not many acute injuries (low incidence of sprains; majority of fractures
stress, not acute fractures); generally, patients do not present as soon as pain starts, but come for treatment 4 to 6 wk
after injury becomes symptomatic
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| Demands of ballet: to be successful, dancer must have “abnormal” body (femoral retroversion; fully or hyperextended
knees; excessive plantar flexion at ankle [180°]; excessive dorsiflexion at ankle; >90° dorsiflexion of first metatarsophalangeal
[MTP] joint)
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| Rules in managing ballet injuries
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 | Never tell patient to stop dancing: instead, learn enough about what she does in dance class to advise what she can and
cannot do (eg, no jumping or quick turns during “center” portion of class; do “barre” portion of class, but not center;
“floor barre” allowed; can perform all activities of class in Pilates program)
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| Always provide alternative for time missed from dancing: Pilates; exercise bicycle (excellent for increasing endurance);
no running or treadmill (generally bad for dancers); must be careful with elliptical trainers (associated with more problems
than any other device in fitness studio)
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| Every dancer who presents with overuse injury requires rehabilitation program: patients do not present to physician
when injury starts hurting; they come after symptoms present for some time and they have been favoring extremity;
can “accept on faith” they will have weakness and probably decreased range of motion; can begin isometric exercises
on day of injury; other options include electric muscle stimulator (especially to enhance quadriceps strength) and
Thera-Band
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| Not much surgery for ballet injuries: dancers generally do not develop problems requiring surgery; those few operations
effective in dancers tend to be excisional procedures (reconstruction often not effective; eg, anterior crucial
ligament surgery may prevent instability problems but can rob dancer of enough motion to end her career); inconsequential
complications of many surgical procedures devastating in dancers
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| Steroid injections in weight-bearing joints: never indicated in children (dance students) with overuse injuries; only rarely
indicated in professional dancers; injections in and around weight-bearing tendons (eg, patellar, Achilles) probably
never indicated (good evidence in orthopedic literature that steroid weakens tendon for ≤6 wk); if necessary to prescribe
anti-inflammatory agent (eg, in dancer with acute tendinitis), 4-day burst of prednisone probably best approach
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| Patients should rarely, if ever, be placed in casts: rule of thumb is that, for every day immobilized, patient must spend
2 to 3 days later on working to undo damage caused by immobilization (weakness becomes profound; best to avoid
cast immobilization all together)
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| Ankle sprains: most common acute injury seen in dancers; almost all occur in plantar flexion with toe pointed; should
never be treated with cast immobilization; occasionally involve avulsion fractures of fifth metatarsal; management—
compression (must be focal); when patient sprains ankle, capsule and ligaments torn, resulting in bleeding; prevention
of swelling most important part of management; swollen ankle results in loss of motion, inability to use muscles, and
ultimately, muscle weakness; initial management of ankle sprains in dancers extremely important
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| Posterior ankle impingement: may follow sprain or may occur at point when dancer has started to vigorously pursue
career in ballet (practicing 3-4 hr/day, 6 days/wk; preparing for auditions); patients usually 15 to 19 yr of age; possible
causes (os trigonum; posterior process of talus); patient has posterior pain en pointe or releve (ie, in plantarflexed
position), but not getting there; important distinction, as patient will often present complaining of Achilles tendinitis;
have patient identify exactly where pain located; ask whether it hurts to go into position, or only when ankle in maximum
plantar flexion; if patient has posterior ankle impingement, can reproduce pain passively on examination by
forcing ankle into maximum plantar flexion; pain and/or tenderness can be posteromedial or lateral
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| Management: get lateral x-ray with patient in maximal plantar flexion (preferably weight-bearing); should be able to
see impingement (posterior part of tibia and heel bone unable to come into contact with each other because of extra
piece of bone or process on back of talus); before considering surgery, also get magnetic resonance imaging (MRI)
to rule out other (uncommon) conditions that can cause this type of pain; treatment—take patient off pointe; lower
releve; strengthening program with Thera-Band; prednisone burst; single capsular steroid injection occasionally indicated;
ultimate treatment surgical removal of extra piece of bone causing impingement
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| Anterior tibial stress fracture (“dreaded black line”): injury seen almost exclusively in ballet dancers; patients
present with recurrent problem; have prominent anterior tibia (subcutaneous bump) with focal tenderness; unlike most
stress fractures, these have tendency to become overt; management—treatment same as for regular stress fracture (decrease
pain-producing activities); can place intramuscular (IM) nail in tibia, but while this may prevent overt stress
fracture, also robs dancer of some knee extension; speaker’s approach is to use small drill to drill out black line (actually
nonunion, ie, scar that has formed that new bone cannot cross); done as outpatient procedure under local anesthetic;
patient can immediately resume any activities not pain producing; takes 2 mo for fracture to heal
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| Anterior knee pain: results from dancer turning out foot to make her turnout look better; problem is that turnout done
from knee down, which encourages patella to go further laterally, resulting in patellofemoral symptoms; patients need
to go on quadriceps strengthening program (done with electric muscle stimulator)
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| Sartorius tendinosus: pain in anterior of hip; physical therapist helps resolve problem
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| Spondylolysis: stress fracture of lumbar spine; more commonly associated with ballet than with any other activity; also
result of forced turnout (dancers flex hips to increase external rotation, extend trunk, but leave pelvis flexed, so as not
to lose rotation; wind up lordotic or swaybacked; this position causes spondylolysis); if dancer presents with low back
pain that is worse when she is extended; ask if it hurts when in arabesque (if reply positive, almost always spondylolysis);
usually unilateral; can be seen on x-ray; bone scan required to determine if new onset; most effective management
Pilates program (ie, core strengthening program focusing on abdominal and low back muscles)
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| DIAGNOSIS AND MANAGEMENT OF OVERUSE INJURIES
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| Patient history: overuse injuries almost always due to change—history must be detailed enough to identify nature of
change (may be in quantity of activity, eg, in mileage run, number of repetitions of weights, or amount of weight lifted; or
in quality of activity, eg, addition of hills in course of run; may be in environment, either internal [eg, recent illness or injury]
or external [eg, tennis racquet; shoes]); identifying change important for educating patient and preventing recurrence
of injury; overuse injury always gradual in onset—when asked, patient will not remember when pain started
(pain first manifests after activity; after 7 days, pain starts to occur during activity; patient typically comes to physician at
point pain occurring instead of activity; eg, speaker starts to see children with lower extremity problems when they begin
obviously limping; unfortunately, usually 4-6 wk into course of injury; important to ask for exact location of pain—
may lead to diagnosis; child who can identify specific point of pain has focal tendonitis or stress fracture
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| Physical examination: often frustrating; all patients with overuse problems have loss of strength and muscle mass (but if
physician unaccustomed to looking for this, can be difficult to find); may have loss of motion and flexibility (easier to
find); may have tenderness (but cannot depend on this being present); may have swelling (but usually seen later in course
of injury); patients with fulminant type of tendinitis can have “snowball” crepitation
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| Management: choices are referral (better to first attempt management of injury, and refer only if treatment not effective);
medication; rest; rehabilitation
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| Referral: indications for referral—locked joints (ie, abrupt loss of motion); sudden, significant swelling; laxity and
instability; neurologic signs or symptoms distal to injury; failure of management; no clue to diagnosis
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| Medication: nonsteroidal anti-inflammatory drugs (NSAIDs; effective analgesics; powerful enough that patient can get
worse while on NSAID and not realize it, because medication masks pain); oral corticosteroids (to determine if swelling
cause of pain or to manage rapid-onset swelling; give prednisone burst, 20 mg twice/day, with food; patient will notice decrease
in symptoms within 36 hr; patient needs to understand that lack of pain does not mean he or she is well; must agree
to go ahead with rehabilitation program prescribed before being given medication); corticosteroid injections (indications
rare; avoid weight-bearing joints; use caution when considering injection in other joints, eg, acromioclavicular [AC],
shoulder; possible complications include depigmentation and subcutaneous fat atrophy)
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| Rest: patient should be advised to avoid just those activities that are painful, and to keep active within his or her sport
(as with dancers, advising patient to stop sport entirely results in loss of patient); maintain conditioning (exercise bicycle
recommended; start patient with no resistance, then increase resistance gradually over time; cross-country ski
machine also good, but patient must be taught how to use it; step machine; rowing machine; use caution when putting
patient on elliptical trainer)
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| Rehabilitation: every patient with overuse injury requires rehabilitation program (to regain strength, endurance, and
flexibility); no one gets better while symptomatic
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| Overuse injuries/knee problems: patellofemoral dysfunction (PFD; anterior knee pain); patellar tendinitis (jumper’s
knee); Osgood-Schlatter apophysitis (jumper’s knee in skeletally immature); iliotibial band (ITB) tendinitis (pain in
lateral aspect of knee)
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| Patellofemoral dysfunction: most common injury seen in sports medicine clinics; caused by any activity (especially running
and jumping); more common in women than in men; gradual onset; may follow previous inadequately rehabilitated
injury; pain more often medial than lateral; swelling may occur if problem prolonged; symptoms include pain
with squatting, going up and down stairs, sitting for long periods, and possibly, joint stiffness after sitting too long; on
examination, patients have atrophy and decreased tone of vastus medialis portion of quadriceps; may have effusion
(but not necessary for diagnosis); x-rays of no value at first visit (possibly of value later if treatment fails); MRIs of no
value and should not be ordered
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| Treatment: avoidance of specific painful activities; quadriceps rehabilitation program (eg, isometrics; cycling excellent
for strengthening vastus medialis, but works both legs; therefore, need to spend more time working on patient’s
symptomatic side; speaker recommends single-leg weight press; might also consider placing patient in patellar stabilizing
sleeve; advantages of leg press; speaker no longer uses knee extensions, as they put 3 times more pressure
on patellofemoral joint than leg press)
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| Overuse problems in shoulder: second most common overuse injury; can be scapular-stabilizing muscle insufficiency
(resulting in pain between shoulder blades); problem with rotator cuff (resulting in pain over shoulder itself); pain at
medial scapular border; on examination, patient’s shoulder may have shifted forward or may exhibit some lateral
scapular winging; patients often complain of shoulder “going out,” cannot fully rotate with arm in abducted position;
usually describe pain as being down in arm; rotator cuff symptoms tend to occur at lower border of deltoid
muscle (aching-type pain; worse with overhead activities; may be referred to lateral deltoid region; generally, no
tenderness to speak of; patient usually has positive impingement test)
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| Treatment: all patients with shoulder problems should be placed on rehabilitation program of Fungo exercises (clockwise
and counterclockwise circles; modified shoulder shrug; abductions; sawing); patients asked to begin by doing 25 of each
exercise every morning and night, then increasing by 5/day, until doing 50 of each exercise twice daily; if shoulder overuse
problem seen early, rehabilitation program may be only treatment necessary; if Fungo exercises fail to resolve problem,
refer patient to physical therapist
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Educational Objectives
| The goal of this activity is to provide listeners with a better understanding of orthopedic problems in the child dancer
and of the diagnosis and management of overuse injuries. After hearing and assimilating this program, the clinician
will be better able to:
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| 1. Cite the frequency and describe the types of injuries seen in pediatric ballet students.
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| 2. Outline the basic rules of ballet injury management.
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| 3. Diagnose and effectively manage dance-related injuries such as ankle sprains, posterior ankle impingement,
anterior tibial stress fractures, anterior knee pain, and spondylolysis.
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| 4. Diagnose overuse injuries by detailed patient history and physical examination.
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| 5. Describe and effectively apply the methods available for treatment of pediatric overuse injuries.
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Discussed on This Program
Hydrocodone bitartrate and acetaminophen [Vicodin, others]
Ibuprofen [Advil, others]
Prednisone [Deltasone, Liquid Pred, Meticorten, Orasone, Panasol-S, Prednicen-M, Prednisone Intensol
Concentrate, Strerapred, Strerapred DS]
Suggested Reading
Aronen JG, Garrick JG: Sports-induced inflammation in the lower extremities. Hosp Pract (Off Ed) 34:51, 1999;
Brown TD, Micheli LJ: Foot and ankle injuries in dance. Am J Orthop 33:303, 2004; Bruns W, Maffulli N: Lower
limb injuries in children in sports. Clin Sports Med 19:637, 2000; Chambers HG: Ankle and foot disorders in skeletally
immature athletes. Orthop Clin North Am 34:445, 2003; Chen FS et al: Shoulder and elbow injuries in the skeletally
immature athlete. J Am Acad Orthop Surg 13:172, 2005; Davis EK: Sports and recreational injuries in children
and adolescents: prevention and education. J Okla State Med Assoc 97:18, 2004; Demorest RA, Landry GL: Prevention
of pediatric sports injuries. Curr Sports Med Rep 2:337, 2003; Garrick JG, Lewis SL: Career hazards for the
dancer. Occup Med 16:609, 2001; Garrick JG, Requa RK: Ballet injuries. An analysis of epidemiology and financial
outcome. Am J Sports Med 21:586, 1993; Hawkins D, Metheny J: Overuse injuries in youth sports: biomechanical
considerations. Med Sci Sports Exerc 33:1701, 2001; Hogan KA, Gross RH: Overuse injuries in pediatric athletes.
Orthop Clin North Am 34:405, 2003; Hutchinson MR, Ireland ML: Overuse and throwing injuries in the skeletally
immature athlete. Instr Course Lect 52:25, 2003; Khan K et al: Overuse injuries in classical ballet. Sports Med
19:341, 1995; Kidd PS et al: Repetitive strain injuries in youth. J Am Acad Nurse Pract 12:413, 2000; Lord J, Winell
JJ: Overuse injuries in pediatric athletes. Curr Opin Pediatr 16:47, 2004; Petrucci GL: Prevention and management
of dance injuries. Orthop Nurs 12:52, 1993; Schafle MD: The child dancer. Medical considerations.Pediatr Clin
North Am 37:1211, 1990; Solomon R et al: The young dancer. Clin Sports Med 19:717, 2000; Wiesler ER et al: Ankle
flexibility and injury patterns in dancers. Am J Sports Med 24:754, 1996.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Garrick was recorded at Advances in Pediatrics, presented April 14-17, 2005, in Las Vegas, and sponsored by
California Chapter 2 of the American Academy of Pediatrics (AAP). The Audio-Digest Foundation thanks Dr. Garrick
and California Chapter 2 of the AAP for their cooperation in the production of this program.
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