Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: A case report

Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: A case report

Accepted Manuscript Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: a case report Lynnette Khoo-Sum...

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Accepted Manuscript Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: a case report Lynnette Khoo-Summers, PT, DPT, Associate Professor, Nancy J. Bloom, PT, DPT, MSOT, Associate Professor PII:

S1356-689X(15)00017-X

DOI:

10.1016/j.math.2015.01.015

Reference:

YMATH 1678

To appear in:

Manual Therapy

Received Date: 3 August 2014 Revised Date:

27 January 2015

Accepted Date: 28 January 2015

Please cite this article as: Khoo-Summers L, Bloom NJ, Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: a case report, Manual Therapy (2015), doi: 10.1016/j.math.2015.01.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Send all correspondence to: Lynnette Khoo-Summers [email protected] 314-286-1586 (voicemail) 314-286-1473 (fax number)

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Nancy J. Bloom, PT, DPT, MSOT Associate Professor Washington University School of Medicine Program in Physical Therapy Department of Orthopedic Surgery 4444 Forest Park Blvd Campus Box 8502 St Louis, MO 63108

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Authors: Lynnette Khoo-Summers, PT, DPT Associate Professor Washington University School of Medicine Program in Physical Therapy Department of Orthopedic Surgery 4444 Forest Park Blvd Campus Box 8502 St Louis, MO 63108

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Title: Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: a case report

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ABSTRACT Dancers are at risk for developing groin pain that is due to acetabular labral tears. Although surgical management of labral tears has been reported extensively, conservative management

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has been poorly described. This case report describes the examination, diagnosis, and treatment of groin pain in a professional ballet dancer with a suspected acetabular labral tear. Treatment focused on decreasing anterior hip joint stresses and improving the precision of hip

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motion through correction of alignment and movement impairments noted during functional activities and dance. Successful outcomes included a reduction in pain and return to

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professional ballet dancing.

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MANUSCRIPT Introduction Physical therapists often receive referrals for individuals with a diagnosis of

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acetabular labral tear. This diagnosis is frequently based on the physician’s physical examination and plain radiographs (Hunt et al., 2012). Although arthroscopy is the gold standard for making the diagnosis, physicians often recommend a trial of conservative

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management before ordering a magnetic resonance arthrogram (MRA) or considering surgery (Rakhra, 2011). Consequently, therapists are often treating patients with

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suspected, rather than confirmed labral tears. Therefore, clinicians must be familiar with the literature related to labral pathology and be prepared to perform a thorough history and examination to identify alignment and movement impairments that may be associated with a labral tear.

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Based on the literature, the most typical symptom reported by individuals with labral tears is anterior groin pain. Other common symptoms include “catching, clicking, or locking” (Burnett et al., 2006; Neumann et al., 2007). Activities associated with pain

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include prolonged sitting, donning shoes and socks, pivoting, kicking, walking, and running (Mitchell et al., 2003; Byrd and Jones, 2004; Burnett et al., 2006). Dancers who

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repeatedly perform movements requiring excessive ranges of hip motion are particularly vulnerable to labral tears (Kocher et al., 2006; Martin and Sekiya, 2008). According to Kocher et al. (2006) labral tears accounted for 40% of total hip injuries and 20% of all musculoskeletal injuries in the dancer population. Regarding a physical examination, the tests most often described in the literature are provocative tests of the hip joint, such as the Impingement or FABER tests (Kenna

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and Murtagh, 1989; MacDonald et al., 1997). There is limited information on tests to identify movement and alignment factors which may contribute to excessive hip joint stresses. Both Lewis and Sahrmann (2006) and Yazbek et al (2011) described an

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examination that included tests of alignment, muscle length, strength, range of motion, and gait. Lewis and Sahrmann (2006) also suggested the evaluation of muscle

activation, stiffness, and precision of hip motion during each test. However, neither of

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these authors provided details for performing the tests.

Traditionally, physical therapy treatment for labral tears has included patient

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education, exercise, and activity modification. Recently there has been additional attention placed on improving the precision of hip motion and decreasing anterior hip joint stresses (Hunt et al., 2007; Yazbek et al., 2011; Hunt et al., 2012), but details of these interventions have not been well described or supported by research. Therefore,

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the purpose of this case report is to describe a movement system examination, diagnosis, and treatment for a professional ballet dancer with a suspected acetabular labral tear.

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History

A 29-year-old female professional ballet dancer (height=1.67 m, weight=52.6 kg)

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was referred to an outpatient physical therapy facility with a diagnosis of right acetabular labral tear. Although an MRA was not performed, the diagnosis was based on positive findings from the physician’s physical examination and negative findings from plain films. Informed consent was obtained and the rights of the patient were protected. At the time of the initial examination, primary complaints included sharp, stabbing, right groin pain, clicking, and occasionally a feeling of the right hip getting

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“stuck”. An example of a dance movement associated with pain and clicking was a passé. Otherwise, the patient was healthy and was taking no medication. Prior to the onset of groin pain, the patient participated in dance 36 hours per week and was the

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principal dancer in a company.

Although symptoms improved with rest, most functional and dance activities aggravated them. She was unable to sit for greater than 30 minutes, stand more than

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15 minutes, or walk greater than 5 minutes. The intensity of pain was rated at 7/10 on an 11-point numerical rating scale (Price et al., 1994). A score of 36.25% from the Non-

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arthritic Hip Score (Christensen et al., 2003) was obtained. Examination

A movement system examination as described by Sahrmann (2002) was performed. The patient’s self-selected posture or movement pattern was assessed

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during each test and symptom behavior was monitored. If a posture or movement caused pain, a correction was made in an attempt to modify the observed impairment and reduce symptoms. The correction provided important information for determining a

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movement system impairment (MSI) diagnosis. Although a complete list of the examination items performed is provided in Table 1, only those tests which had

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significant findings are described below. Her preferred standing alignment was forward sway of the pelvis, posterior pelvic

tilt, bilateral femoral internal rotation, and knee hyperextension. The combination of posterior pelvic tilt and knee hyperextension resulted in hip hyperextension. Pain decreased when cues were given to correct forward sway, unlock her knees, and align her knees over her feet. She preferred to sit up straight with her legs crossed thigh over

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thigh but this was painful. Pain decreased by uncrossing her legs and sitting on a pillow to decrease the amount of hip flexion. Impairments were identified in supine during two passive movement tests: hip

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flexion and a straight leg raise. Ideally during hip flexion, the femoral head should spin within the acetabulum (Neumann, 2010). However, during both tests, groin pain

increased and an impairment designated as femoral anterior glide, was observed.

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Femoral anterior glide was assessed by monitoring the path of the proximal femur (Fig. 1). The test was considered positive because the examiner’s hand moved in an

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anterior-superior direction (Fig. 2). As a follow-up, the examiner repeated the test while applying a correction manually to prevent anterior glide. During the follow up test, groin pain previously reported during hip flexion was decreased.

In prone, impaired motion and muscle activation were observed during active hip

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extension. Imprecise motion was indirectly assessed through palpation of the proximal femur (Fig. 3A). During hip extension, the examiner’s hand moved toward the plinth (hip internal rotation or femoral anterior glide) and the pain increased (Fig. 3B). In addition,

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the activation of the gluteus maximus appeared delayed because hip extension began before observation of a muscle contraction. When cued to activate the gluteals, the pain

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decreased and the examiner’s hand did not move (Fig. 3C). During rocking backward in quadruped, posterior pelvic tilt was observed early in

the motion and groin pain increased at the end of the motion. Corrections were made to avoid posterior pelvic tilt and limit hip flexion ROM which decreased the pain (Fig.4). Passive hip flexion and rotation ROM were measured (Reese et al., 2010) and strength of the hip muscles was tested (Kendall and Kendall, 2005). Refer to Table 2 for

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specific results. In summary, although ROM for hip flexion and rotation was normal, the onset of groin pain occurred before end range. Weakness was noted in the gluteus maximus and hip external rotators. Because the pain increased when the hip was

rotators, a strength grade was not given.

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placed in the test position for the iliopsoas, posterior gluteus medius and hip internal

The anterior impingement test (MacDonald et al., 1997), FABER (flexion-

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abduction-external rotation) (Kenna and Murtagh,1989), and Stinchfield test (McGrory, 1999) were performed. All tests were positive for groin pain. The more aggressive Scour

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test (Maitland, 1975) was not performed because symptoms were increased with other provocative tests.

When asked to assume first position in ballet, the patient achieved sufficient hip external rotation but also exhibited posterior pelvic tilt. When performing a demi-plié in

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first position, she stayed in posterior tilt and the right groin pain increased (Fig. 5). Manual assistance and verbal cues were provided to help the patient assume first position without posterior pelvic tilt and maintain a neutral pelvic alignment while flexing

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the hips. As a result pain decreased.

During the passé movement, posterior pelvic tilt was again observed and the

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pain increased (Figs. 6, 7). Hip hyperextension as a result of posterior pelvic tilt combined with end range hip external rotation potentially placed excessive stresses on the anterior hip joint structures. Correction of posterior pelvic tilt during the passé motion resulted in decreased pain. Clinical Impression

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Two diagnoses were identified as a result of the history and examination of this patient. First, there was support for a diagnosis of acetabular labral tear based on the location of pain in the anterior groin, the presence of clicking and locking, and increased

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pain during sitting, walking, dance movements, as well as positive provocative tests. Second, a MSI diagnosis of femoral anterior glide was determined (Sahrmann, 2002). Anterior glide was demonstrated across a number of movement tests,

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particularly those involving hip flexion and extension. These tests were associated with increased pain and when the movement impairment was corrected, the pain decreased.

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Key factors contributing to stress to the anterior hip structures included the habit of standing in hip hyperextension, the habit of tilting the pelvis posteriorly during a variety of ballet movements, and pain or weakness of her iliopsoas, external rotators, and gluteal muscles. Weakness of these muscles potentially contributed to imprecise motion

Intervention

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and poor control of the hip joint (Retchford et al., 2013).

Conservative management of this condition consisted of education about faulty

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postures and movement impairments, supervised practice of walking and dance steps, and a home exercise program. The primary focus of treatment was to decrease stress

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to the labrum and anterior hip joint structures by correcting alignment, restoring precise hip flexion, and improving muscle performance during basic functional activities, ballet, and exercise. The muscles addressed were the iliopsoas, external rotators, gluteus medius and maximus. Cues were given during movement or exercise to activate these muscles with the goal of maintaining precise hip motion and minimizing activation of the muscles that cross both the hip and the knee such as the hamstrings or rectus femoris.

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Education for functional activities included corrections for impairments in standing and sitting as previously described in the examination. Corrections for gait included instructions to lift the heel sooner after midstance. Earlier heel rise is

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associated with hip and knee flexion thereby reducing anterior hip joint stresses (Lewis and Sahrmann, 2006). The home exercise program consisted of a variety of exercises to improve muscle performance and precision of hip flexion and extension. Functional

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activities and exercises with specific cues for performance are listed in Table 3. Table 4 outlines factors, such as the amount of upper extremity support and hip range of motion,

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used to progress the level of difficulty for dance movements. Outcomes

The patient was discharged after six visits that took place over the course of two months. Although mild groin pain occurred with fouetté turns and grand jetés, pain

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during activities of daily living and most dance movements decreased from 7/10 to 0/10. The Non-arthritic Hip Score changed from 36.25% to 97.5%. Five months after discharge, follow up by phone indicated that the patient had no pain and was working as

Discussion

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a principal ballet dancer.

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This case report described the examination and successful conservative

treatment of a professional ballet dancer with a suspected acetabular labral tear. Although never confirmed by MRA or arthroscopy, her clinical presentation was similar to what has been reported in the literature for labral tears (Burnett et al., 2006; Hunt et al., 2007; Martin and Sekiya, 2008; Martin et al., 2010). In addition, alignment and movement tests associated with increased anterior hip joint forces were positive (Lewis

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and Sahrmann, 2006). Yazbek et al. (2011) reported similar positive outcomes after nonsurgical treatment of acetabular labral tears in four individuals. The authors believe the examination described in this case report was more

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comprehensive than what has been previously published for individuals with hip pain. In addition, basic dance related movement tests were described. The examination allowed the clinician to determine both the most likely source of groin pain and a diagnosis of

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the movement and alignment impairments that potentially caused the reported pain. The MSI diagnosis provided a better guide to treatment than primarily focusing

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on the pathoanatomical diagnosis of labral tear. Because the movement impairment was one of increased accessory joint mobility, the emphasis of treatment was on stopping anterior glide and restoring precise hip motion. As a result, the authors believe stress to the anterior hip joint structures and resulting pain were reduced. While other

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case reports utilizing a MSI diagnosis to direct treatment have been published for the low back (Maluf et al., 2000; Harris-Hayes et al., 2005), knee (Harris-Hayes et al., 2008), neck (McDonnell et al., 2005) and shoulder (Caldwell et al., 2007), this is the first

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case report for the hip joint.

Additional factors believed to have contributed to positive outcomes include

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young age, short duration of symptoms, and the fact that this was her first episode. It is unlikely that the use of ice and medication played a major role since both had been used previously with little effect. Future research needs to be done on larger samples of dancers or other

populations with groin pain and suspected or confirmed labral tears. The reliability and validity of tests for femoral anterior glide and the diagnostic category need to be

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established. Finally, studies to assess the effectiveness of the interventions described in this case report need to be done. CONCLUSION

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This case report describes a comprehensive history and examination used to determine the cause of groin pain, anterior hip joint stresses, and imprecise hip motion in a

professional ballet dancer with a suspected acetabular labral tear. The diagnosis of

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femoral anterior glide provided specific guidelines for intervention. Positive outcomes

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included resolution of symptoms and return to professional dancing.

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ACKNOWLEDGEMENTS We would like to acknowledge Shirley Sahrmann PT, PhD, FAPTA for her guidance and assistance in writing this manuscript.

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Table 1: Initial results of alignment and movement tests for the right hip Test item Result# Standing: Alignment Forward sway of pelvis, posterior pelvic tilt, bilateral femoral internal rotation, and knee hyperextension (painful)* Forward bending and return Hips move more readily than the lumbar spine in the first 50% of the range. Final ROM in hips is increased (>90˚) and lumbar spine is normal. Return was normal. No increase in symptoms Spine motions: extension, sidebending and rotation Partial squat (demi-plié)

Normal movement and ROM. No increase in symptoms.

Single leg stance (passé) Sitting: Alignment Knee extension

Posterior pelvic tilt - increased groin pain*

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Posterior pelvic tilt - increased groin pain*

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Sits up straight with legs crossed thigh over thigh (painful)* No hip rotation noted with knee extension. Hamstring length did not limit motion. No increase in symptoms.

Supine: 2 joint hip flexor length test

Not assessed due to severity of hip pain at initial evaluation

Unilateral hip and knee flexion

Passive: + femoral anterior glide - increased groin pain* Active: not tested Passive: + femoral anterior glide - increased groin pain* Active: not tested Increased groin pain on the right; normal motion on the left

Hip abduction/external rotation from hooklying Sidelying: Hip abduction/external rotation Prone: Knee flexion

Increased groin pain on the right; normal motion on the left

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No lumbopelvic motion noted Normal motion at the hip and knee - no increase in symptoms No lumbopelvic motion noted. Normal hip range of motion - no increase in symptoms.

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Hip rotation

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Straight leg raise

Hip extension/knee extended

+ femoral anterior glide - increased groin pain* Delayed gluteus maximus muscle activation

Quadruped: Rocking backward Posterior pelvic tilt and pain at end range of motion* # Only results for the right lower extremity are reported. Results for the left lower extremity were normal and asymptomatic * Follow up test is described in the examination section of the paper

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Table 2: Objective measures for PROM and strength Left

Right (initial)

Right (discharge)

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PROM 120˚

100˚ (painful)

120˚ (no pain)

Hip External Rotation (sitting)

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45˚

47˚

Hip Internal Rotation (sitting)

35˚

30˚ (painful)

30˚ (no pain)

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Strength

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Hip Flexion (supine)

Hip External Rotators (sitting)

4/5

Hip Internal Rotators (sitting)

3+/5

Able to hold test position 3+/5 (no pain but hesitant) but painful

Iliopsoas

4/5

Able to hold test position but painful

Posterior gluteus medius

4/5

Gluteus maximus

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3+/5

4/5 (no pain)

Unable to hold test position and painful

5/5 (no pain)

3+/5

4+/5

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4/5

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Specific description of the exercise or functional activity • • •

Sitting Alignment

Gait

Supine

Quadruped

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Hip Flexion

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Standing Alignment

Correct forward sway by shifting pelvis back slightly. Decrease hip/knee hyperextension by unlocking knees. Decrease hip internal rotation by contracting buttock muscles and align the knees over the feet. • Sit back in the chair on a pillow to allow less than 90° hip flexion and more ideal alignment of the lumbar spine. • Avoid crossing legs • Lift heel sooner from midstance to push off in order to flex the hip and knee or decrease hip and knee hyperextension and reduce anterior hip joint stresses. Starting position: Hips and knees bent and feet resting on floor • Perform active assisted right hip flexion with the knee flexed using hands to pull on a towel wrapped around the distal thigh. Stop movement at the onset of pain. Prescribe only when 90°of active hip flexion can be achieved without pain Starting position: Right hip in 90° hip flexion wit h the right hand over proximal thigh and left hand on right knee • Apply a caudal/posterior glide of the proximal femur with the right hand while passively flexing the hip with the left hand. • Passively flex hip to end range and hold position for 3-5 seconds. Use hands to return thigh to chair. There should be no pain with this exercise. Progression: • As above, plus active lowering • Active hip flexion and return • Active hip flexion, apply resistance at end range, then lower • Active hip flexion with the knee flexed while avoiding posterior pelvic tilt Starting position: Left sidelying with hips and knees flexed 45° and pillow between knees • Contract buttock muscles to separate knees (active right hip abduction and external rotation). Cued to relax thigh muscles to minimize activation of lateral hamstring, tensor fascia lata-iliotibial band and sartorius. Similar to “passé” dance movement • Progress by adding resistance from elastic band placed around distal thighs Progression: Starting position: Left sidelying with hips and knees flexed 510° and pillow between knees • Slightly externally rotate the right hip then lift the whole lower extremity up and back (hip should not extend past

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Functional activity or Exercise

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Sitting

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Standing

Hip abduction with external rotation

Sidelying

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Specific description of the exercise or functional activity •

neutral) May progress by adding weight to the ankle

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Functional activity or Exercise



Prone

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Hip extension

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Standing

Stand on left foot. Slightly externally rotate right hip then contract buttock muscles and lift leg out to the side and back • Stand on right foot. Keep pelvis stable while lifting left leg out to the side Starting position: Prone with 1-2 pillows under the hips (allows hip extension motion to occur from 20° of h ip flexion toward 0°) • Bend the knee then contract buttock muscles and lift the thigh a small amount • Keeping the knee straight, contract buttock muscles and lift lower extremity a small amount off the mat

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Low to high level of difficulty

Upper extremity support



Weight bearing for the involved lower extremity



Range of motion for the involved hip



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Base of support for the lower extremities

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Dancing at the barre with upper extremity support Dancing in the center of the room without the barre Ballet slippers to pointe shoes Foot flat to demi pointe (heel raise) to full pointe position Bilateral to unilateral weight bearing movements Example: petit allegro jumps were first performed by pushing off and landing with both feet, then advanced by pushing off with both feet and landing on one foot. Finally jumps were performed by pushing off and landing on one foot. Changing the height of the leg being lifted from a tendu (toe stays on the floor) to a grand battement (full kick) or developpé in all directions.

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FIGURE 1. Hand placement for hip flexion tests in supine: (A) straight leg raise test and (B) hip flexion with the knee flexed

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FIGURE 2. Passive Straight Leg Test: (A) Ideal (B) Positive for femoral anterior glide

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FIGURE 3. Prone hip extension test: (A) starting position with fingers on greater trochanter (B) self selected faulty motion with anterior motion of the greater trochanter (femoral anterior glide or hip medial rotation) (C) corrected motion with cue to contract gluteals and no movement of the greater trochanter

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FIGURE 4. Quadruped Tests: Rocking backward: preferred and corrected

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FIGURE 5. Demi plié in first position associated with posterior pelvic tilt

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FIGURE 6. Passé position (front view)

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FIGURE 7. Passé position associated with posterior pelvic tilt (side view)

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Highlights

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• Dancer with a suspected acetabular labral tear is managed conservatively. • Key alignment and movement tests of the hip are described in detail. • A movement system impairment diagnosis of femoral anterior glide was given. • Treatment consisted of education and exercise to reduce anterior hip joint stress. • Outcomes included resolution of groin pain and return to professional dancing.