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Childhood dancers are the forgotten athletes; limiting ballet while doing other exercises is the best tack to take with these young patients.

LAS VEGAS -- The worst advice a physician can give to an injured young ballet dancer is to "quit dancing," a San Francisco sports medicine physician said at a meeting sponsored by the American Academy of Pediatrics and California Chapter 2 of the AAP.

"This is the last time you will see this girl. This will drive [her] into the arms of irregular practitioners," said James G. Garrick, M.D., director of the Center for Sports Medicine, Saint Francis Memorial Hospital, San Francisco.

Physicians must realize that these are committed young people who follow instructions. "There are more little girls taking ballet than little boys playing football, soccer, or baseball," Dr. Garrick commented. Limiting ballet while doing other exercises works when ballet dancers are injured.

Seventy-seven percent of ballet injuries occur in females, with 32% occurring between the ages of 12 and 17 years. Injuries usually are in the lower body--26% occurring in the foot, 21% in the knee, and 17% in the ankle. But in student dancers, one-third of injuries occur in the foot and toes.

Younger dancers have more foot injuries, said Dr. Garrick, whose clinic has treated more than 5,000 ballet dancers. "They have more foot injuries because they are too young to take care of their feet. In time, they learn."

But fortunately, the injury rate is quite low in the younger ages and only starts to rise in the teenage years when "girls get pretty serious about dancing," he said. These girls are taking two or three dance classes a day, three or four times a week.

Most of the injuries--42%--are attributed to overuse, Dr. Garrick said. Overuse injuries are highest among younger student dancers.

Ballet also requires abnormal body motion with femoral retroversion, hyperextended knees, excessive ankle dorsiflexion, and excessive ankle plantar flexion.

When an injury does occur, physicians should request that the dancer limit her ballet until the injury heals instead of requesting she stop dancing. Dr. Garrick said a dancer can be asked to not jump and make quick turns, and to do more barre work where there is support and they are working on extending range of motion in a way that doesn't require strength.

Dr. Garrick recommended Pilates and an exercise bicycle for dancers to stay in shape once an injury occurs; running on a treadmill or track should be avoided. "Always provide an alternative for time missed from dancing," he said. "Recommend exercise that doesn't require painful motion of anything that will worsen the injury."

Begin isometrics on the day of injury. Use electrical muscle stimulation, if possible, and resistance bands to strengthen muscles with limited range of motion exercises, he said.

Ankle sprains are the most common acute injury and usually are lateral. Dr. Garrick recommended horseshoe compression in the area to prevent swelling. "It's important to get some compression in this area." If the ankle swells, then there is a loss of motion and then a loss of muscle strength, which makes patients more apt to have future sprained ankles.

Another common injury is posterior ankle impingement in the back of the ankle.

"This usually occurs in a dancer's career when they are starting to get very serious, commonly in ages 15-19 years," he said. "Often it occurs with intense rehearsals or preparing for auditions."

Physicians need to reproduce the pain actively or passively to diagnose. If taking x-rays, then the ankle should be flexed and bearing weight if possible. At times, MRI is necessary and can reveal cysts or ganglia, compromised articular cartilage, or posterior talus.

Other injuries that can occur are stress fractures, knee injuries, hip pain, and spondylolysis.

Dr. Garrick said surgery isn't commonly used in ballet dancers, adding that few procedures are effective for these injuries.

"There are minor complications in many operations that are disasters for ballet dancers," he said. "They can lose extension with knee surgery resulting in months of no meaningful dancing and can lose dorsiflexion of the toe that can end a career."

Dr. Garrick also said steroid injections in younger dancers should not be used, but occasionally oral prednisone can serve as a safe alternative in selected cases.
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Title Annotation:Clinical Rounds
Author:Little, Linda
Publication:Pediatric News
Geographic Code:1USA
Date:Aug 1, 2005
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