Welcome back to the Dancer Blog! This week we’re moving up to the hip in our ongoing discussion of common dance injuries by taking a look at acetabular labral tears. As has been our tradition, we are going to discuss the anatomy of the hip joint, the pathomechanics involved in this injury as well as what treatment and recovery might look like.
Let’s start with anatomy. The hip, which connects the leg to the pelvis, is a fairly simple joint to understand from the anatomical standpoint. Known formally as the femoroacetabular joint, the hip is composed of effectively two bones, ok four technically, and a shock absorber. Why did I go from two bones to four? Well, the pelvis as we know it is actually the result of three different bones fusing together. These bones are the Ilium, this is that big bony prominence that you can feel on the side of your hip that most people think is their hip joint. The Ischium, you can feel this when sitting down on a hard chair. And the Pubis, known more simply as the pubic bone.
When we are born, these three bones are separate and as we age they fuse together. The point where all three converge is a bony landmark called the Acetabulum. If you’re thinking about the hip joint as a ball and socket joint, the Acetabulum is the socket. Connecting to the Acetabulum is the Femur. The femur is your leg bone and at the top of the femur is the femoral head, this is the ball in the ball and socket joint.
Between the femoral head and the acetabulum is the acetabular labrum. This is a horseshoe
shaped piece of cartilage that functions as a shock absorber for the hip. Think of the acetabular labrum as the meniscus of the hip. Like the meniscus in the knee, the acetabular labrum receives little blood supply. This means that natural repair is difficult if not impossible.
So how does an acetabular labrum tear occur? That’s the million dollar question and if you’ve been reading my other blogs on injuries such as ACL Tears and Meniscus Tears you have no doubt seen a trend beginning to form. Like the aforementioned injuries, acetabular labral tears occur following intense torsional force. This is to say, and say it with me, sudden and unexpected rotation or pivoting movements. Funny, it’s almost like every injury that occurs commonly in dancers, happens via the same pathomechanics but in a different joint. That’s because IT DOES!
Yes many of these common dance injuries all have similar methods by which the injury occurs. Now this would be the third time that I break down how the way that we train as dancers and the heavily choreographed nature of dance actually safeguards us against these injuries so instead of repeating myself yet again I’m just going to redirect you back to my blogs on ACL tears and Meniscus tears.
What I AM going to cover again is the difference between the circumstances behind how these injuries occur in dance versus other sports. Generally speaking, ACL tears, meniscus tears and acetabular labrum tears are the result of a sudden, traumatic injury. At least this is the case for the vast majority of non-dancer athletes. These injuries are the result of a soccer player trying to maneuver around an opposing player or a football player getting tackled through the knee. In non- dancer athletes, these injuries are a sudden occurrence.
The same is not exactly true in dance. Now don’t get me wrong, these injuries often appear as sudden and traumatic but the reality is a bit more complex. Let’s look at the example of the dancer performing a tour jeté. A dancer landing this step may very well appear to experience a “sudden, traumatic” acetabular labrum tear as a result of the rotational forces going through the hip joint when the tour jeté fouettes at its apex. As the dancer lands they may experience burning, sharp pain, or locking deep within their groin or hip socket signalling that the labrum has torn.
You might be inclined to believe that the sudden fouette through a split position is what caused the labrum to tear, and to be clear, it did. But that’s not really the whole story. Last week I discussed how forcing your turnout at the barre will, slowly and over time, result in increased stress and laxity on the medial meniscus. Well, calling back to my blog on the unhealthy nature of Oversplits, you will recall that stretching through oversplits results in derangement and increased laxity of the hip joint. Increased laxity is a fancy way of saying increased flexibility. Now recall my Flexibility and Strength blog and note that we discussed how increased flexibility without strength leads to instability. The increased laxity and instability within the hip results in one more force going through the acetabular labrum.
In other words, a dancer who trained by incorporating oversplits or who focused entirely on hip flexibility without strength is a dancer who actively pursued an environment in their hip where an acetabular labrum tear is now likely. Like the meniscus tear, the acetabular labrum tear is now not just a possible outcome, it’s one we are pursuing. This is why proper training and conditioning is so, so, SO important. We need to look at how we are conditioning our body and if need be questions some of the traditional cultural norms in the dance industry. Because yes, the fouette through a split caused the labrum to tear in the movement. But it's the years of training to gain that perfect 180 degree turnout and hip hyperflexibility that allowed for the right circumstances.
Alright, so you have an acetabular labrum tear, what now? Well the answer shouldn’t shock you at this point. The same pathomechanics that lead to a meniscus tear, ACL tear and even many ankle injuries have caused this labral tear and as such the treatment options also share commonalities. As always, the two options are surgical care and conservative care.
The surgical options is generally one of three; debridement, repair or reconstruction.
Debridement is where the surgeon goes in and simply cuts away the damaged aspects of the acetabular labrum. Repair sees the surgeon actually stitching together a torn acetabular labrum and reattaching it. And reconstruction sees the surgeon removing the irreparable part of the acetabular labrum and replacing it with tissue from another part of your body, this is called an autograph, or with tissue from a cadaver, this is called an allograph.
Following surgery, the dancer will undergo a rehabilitative program to restore motion and
strength to the hip. The conservative option of care is the same as the surgical option only it skips the surgery. This is another opportunity to mention options such as Plasma Rich Platelet injections which can be used in conjunction with both the surgical and conservative options to enhance the effect of either. Just remember that the research on PRP is still rather limited.
And remember in all cases of acetabular labrum tears, there is no one size fits all treatment model. You need to work with your healthcare provider to find the option that is best for you and that is best for your specific labral tear. This is once again why it is so important to have a healthcare provider who understands your needs as a dancer. Failing to properly rehabilitate a torn labrum for dance will result in a much higher chance for reinjury.
Ok, so that’s acetabular labrum tears in a nutshell. At this point we have effectively gone through the more common and severe injuries of the lower chain for dancers. Next week we’re gonna wrap it up and put a bow on it by expanding our discussion on the culture of dance training and how it plays into dance injury and prevalence as well as what we can do to change things.
In the meantime, this week’s dancer shout out is Rena Bernardini. Rena is new to Rochester originally coming from Summers, NY. She began dancing at the Westchester Ballet center and went on to perform with the Dance Theater of Westchester. She began her collegiate studies at the Boston Conservatory of Dance and later had the opportunity to transfer to the Rambert School in London, England. While abroad Rena performed at the Royal Opera House and worked with the English National Ballet’s Dance for Parkinson's program. She was a member of the Ballet Theater of Maryland and served as the Auer Academy youth Co-Director with Fort Wayne Ballet. Speaking of teaching, Rena is currently becoming certified in the American Ballet Theater’s National Training Curriculum in the levels pre-primary through level five. She’s also on faculty with Roc Dance located in Webster where she teaches a variety of techniques and styles. That’s where I teach! Rena also joined the New York State Ballet this year as an apprentice. Rena’s made it her mission to not only grow as an artist herself but to help the next generation of artis grow as well and that’s something I totally support.
One last note, if you’ve been reading these blogs then you know that the New York State Ballet is a good friend of ours here at Pinnacle Hill Chiropractic. And as we all know, COVID-19 has left many sectors of the American economy struggling to survive. Among these are the arts. It’s never been more important to support local businesses and art communities. With that said, I’d like to draw some attention to the New York State Ballet’s upcoming production of The Nutcracker. Performances will be held on December 23rd, 26th and 27th. Now due to social distancing and other safe health practices ticket availability is limited. The good news is, the show will be entirely streamable so there's no reason not to watch! Nutcracker is a Christmas staple if you’re a fan of dance and even if you’ve never seen a show it's a great tradition to start with the kids and grandkids. So help support local businesses and help to support the arts by visiting the New York State Ballet website and purchasing a ticket on December 12th when the box office opens.
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