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Manipulative treatment of hip pain in a ballet student: a case study.


A 14-year-old female ballet student was referred to physical therapy for examination and treatment of left inguinal region pain. A single session of non-thrust manipulation resulted in an immediate and lasting improvement in symptoms. This case report includes a description of the relevant examination and treatment procedures as well as a discussion of hip instability and the acetabular labrum.


Hip pain is a significant source of morbidity for ballet dancers and accounts for approximately 10% of all reported injuries. (1) The excessive degree of hip external rotation has been proposed as a causal factor. (1-3) Accordingly, hip pain secondary to joint instability has been reported in many types of high-performance athletes. (4) Symptomatic instability probably exists on a continuum ranging from the occult to the gross level. Instability may result from either excessive stretching of capsuloligamentous structures or macrotrauma. Both inappropriate stretching technique3 and overt hip dislocation (5) have been described in ballet dancers. Patients who have been diagnosed as having hip instability are reported to present with pain and often describe the sensation of "giving way." (4)

Acetabular labrum tears may be associated with hip instability and have recently been described as a significant source of groin pain in athletes. The labrum is a fibrocartilaginous tissue that encircles the rim of the acetabulum. Morphologically, it may promote mechanical and physiologic joint stability by either deepening the hip socket or by forming a seal that aids in the development of negative intra-articular pressure. (6) Additionally, the labrum enhances a fluid film lubrication mechanism that in theory may serve as a means to reduce direct joint surface contact and thus contribute to a more even load distribution between the opposing joint surfaces. (7)

The mechanism of labral injury is highly variable but is often associated with minor trauma such as twisting or rotating on a weight-bearing lower extremity. Epidemiological studies have demonstrated that labral tears occur with equal frequency in both genders and in all age groups. (8-10) Studies have demonstrated that labral pathology is a common finding in the adult hip and may be a consequence of age-related degeneration. (11,12) Clinical features of a symptomatic tear are variable and are associated with a broad range of clinical findings. (13)

In general, pain is experienced in the inguinal region but may also be trochanteric or gluteal in location. Symptomatic onset may be sudden or gradual. The pain is frequently described as being sharp with a catching or locking sensation. Symptoms may be reproduced during clinical examination with passive range of motion tests that combine flexion and rotation. (13)

Case Report Data

A healthy 14-year-old female ballet student was referred to physical therapy with complaints of left inguinal region pain. The student had been actively engaged in ballet training for eight years and was aspiring to perform at the professional level. Average time spent in training was 8 to 12 hours per week. The symptomatic onset was insidious but immediately followed an intensive four-week training period during which she was dancing 35 to 40 hours per week. Following the initiation of the painful symptoms she continued to dance for approximately one month and then reported to her primary care physician. At this time, radiographic examination was performed and determined to be normal. The patient was diagnosed with non-specific hip pain and subsequently referred to physical therapy.

Physical Therapy Examination

Subjectively, the pain was described by the patient as being located deep in the anterior aspect of the left inguinal region and was rated at worst 7/10 (pain scale: 0/10 = no pain, 10/10 = worst pain imaginable). The pain was intermittent and was elicited only during ballet practice. Specifically, the patient complained of a painful catching sensation experienced in an arc-like manner that occurred as the hip was abducted through the horizontal plane (developpe a la seconde).

Spinal range of motion and static postural assessment were unremarkable. With the patient positioned supine, passive range of movement testing of the hips in the cardinal planes (flexion, internal and external rotation, abduction, and adduction) was determined to be full and painless. However, the combination of passive hip flexion and adduction resulted in the reproduction of the patient's pain. Hip external rotation testing in 90[degrees] of flexion on the symptomatic left side was determined to be greater in magnitude (by approximately 10[degrees] to 15[degrees]) than on the asymptomatic right side.

Additionally, the FABER (flexion, abduction, and external rotation) test on the symptomatic side revealed an increased range of movement relative to the right side. Isometric testing of all relevant hip musculature was determined to be strong and painless (graded 5/5). Sacroiliac joint pain provocation tests were negative. Neurosensory exam was normal. The patient was capable of consistently reproducing her pain while in the standing position during the performance of active hip abduction between 75[degrees] and 100[degrees]. There was no pain elicited below or above 75[degrees] and 100[degrees], respectively.

A modification of Cryiax's manipulation for the reduction of loose bodies (14) was performed as a component of the initial examination. The patient was positioned supine on a standard examination table with the hip in approximately 30[degrees] flexion, 30[degrees] abduction, and slight external rotation. The therapist was positioned at the end of the table along side the leg to be treated, facing the patient. The patient's foot was stabilized against the therapist's abdomen. The therapist held the patient's lower leg just above the ankle with both of his hands. The manipulative procedure was performed by applying strong traction through the long axis of the femur while simultaneously abducting the lower extremity through a movement are of approximately 60[degrees]. The traction force was released at the end of the abduction phase. The procedure was performed in a slow and controlled manner (approximately three seconds). Five repetitions were performed. The procedure was painless.

Immediately following the manipulative procedure, the patient was requested to repeat the formerly pain provoking movement (developpe a la seconde). The abduction movement arc was rendered full range and painless. Subsequent passive range of motion testing revealed that flexion and adduction stress was no longer pain provocative but the pattern of excessive external rotation was unchanged.

At the conclusion of the initial consultation the patient was encouraged to return to ballet practice in order to test the hip under actual training conditions. Follow-up telephone conversation one week later revealed the patient had successfully returned to symptom free dancing. An additional telephone call six months after treatment confirmed the patient remained free from painful symptoms. However, the patient did report that she had experienced on one occasion, a transient episode of giving way.


Hip pain associated with ballet dancing is a common malady. The potential etiological sources are numerous and may be related to either a local or a referred phenomenon. A multitude of conditions specific to the hip's osseous or articular constituents are commonly recognized as specific diagnostic entities. However, the combined presence of several key physical findings highlighted in this case report defy a common diagnostic label and appear to warrant additional consideration. Specifically, the key features of this particular case that are noteworthy include: 1. the presence of excessive hip external rotation on the symptomatic side, 2. the presence of a painful arc, 3. the reproduction of pain with combined rather than isolated passive range of movement tests, and 4. the rapid and lasting improvement in symptoms following manipulation.

The subject in this case report presented with increased hip external rotation mobility on the symptomatic side relative to the asymptomatic side. Excessive external rotation mobility has been suggested as being indicative of joint hypermobility and instability and may play a role in the development of painful conditions in both the shoulder and hip. (1-3) Excessive unilateral external rotation, in the absence of aberrant osseous or articular geometry, may be related to an increase in mobility of the capsule-ligamentous restraints. Because of the amount of stretching inherent to ballet training and the abnormally large range of external rotation required to create a perfect turnout, the latter is probably most likely in the dance population. The articular capsule of the hip joint is a fibrous collagenous structure that encircles the proximal femur and acetabulum and is reinforced by capsular ligaments (iliofemoral, pubofemoral, and ischiofemoral components). The capsule-ligamentous tissues play an integral role in the maintenance of stability as they are sensitive to stretch and serve as an afferent source of proprioceptive information. Excessive external rotation stretching may render the tissues inefficient as static restraints and diminish the structures sensitivity to position sense.

According to Cyriax, (14) a painful arc is the situation in which pain occurs during the midranges of joint movement. Cyriax proposed that the painful arc phenomenon occurs because of the entrapment of a pain sensitive tissue between moving structures. Painful arcs are usually present during active movements where muscular forces compress joint surfaces. In this case, the patient's pain was elicited during active hip abduction only. A painful arc is a common finding at the shoulder, but is a relatively uncommon finding at the hip. The painful arc phenomenon is not in itself diagnostic but may implicate a biomechanical fault or internal joint derangement. (14)

Derangement is a non-specific term used to describe a situation in which the contents of a joint alter their position or shape so as to cause a disturbance of the normal relationship between bony surfaces. Examples include tearing and displacement of a meniscoid cartilage in the knee or an infantile radial head displacement in the elbow. Treatment of such lesions involves an attempt to reduce the derangement by either manipulative or surgical means. In this case study, a definitive cause of the painful arc cannot be established and is therefore open to speculation. Abolition of all symptoms was achieved following a manipulative trial indicating that successful reduction of the derangement was achieved. Retrospectively, because of the rapid and lasting effect of the manipulation, a mechanical versus an inflammatory source of pain must be considered as having been responsible for the genesis of symptoms.

Physical examination of the hip joint involves the performance of both isometric and range of motion tests that in concert help to establish an operational diagnosis and thus guide treatment. In this case, the patient's pain was provoked with a passive range of motion test that combined flexion and adduction. A similar combination of passive range of motion tests (flexion, adduction, internal rotation) has been demonstrated in larger cohorts to elicit the pain of acetabular labrum rim lesions with an anterior superior location. (10,15)

Summary and Conclusion

This case report describes the relevant physical examination findings and treatment of a 14-year-old female ballet student with a four-week history of inguinal pain. Information pertaining to hip instability and acetabular labrum lesions is included as it may pertain to the inception of such joint derangements. Future investigations on larger cohorts are needed to provide a more thorough understanding of both the examination and treatment of dance-related hip pain. However, in the interim, non-thrust manipulative treatment would appear to be a safe and effective treatment technique for patients with similar symptoms and physical findings.


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(3.) Reid DC, Burnham RS, Saboe LA, Kushner SF: Lower extremity flexibility patterns in classical ballet dancers and their correlation to lateral hip and knee injuries. Am J Sports Med 15(4):347-352, 1987.

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(7.) Ferguson SJ, Bryant JT, Ganz R, et al: The acetabular labrum seal: A poroelastic finite element model. Clin Biomech 15:463-468, 2000.

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(9.) Ikeda T, Awaya G, Suzuke S, et al: Torn acetabular labrum in young patients: Arthroscopic diagnosis and management. J Bone Joint Surg Br 70:13-16, 1998.

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(11.) Seldes RM, Tan V, Hunt J, et al: Anatomy, histological features, and vascularity of the adult acetabular labrum. Clin Orthop 382:232-240, 2001.

(12.) Byers PD, Contepomi CA, Farkas TA: A post mortem study of the hip joint: Including prevalence of the features of the right side. Ann Rheum Dis 29:15-31, 1970.

(13.) Narvani AA, Tsiridis E, Tai CC, Thomas P: Acetabular labrum and its tears. Br J Sports Med 37:207-211, 2003.

(14.) Cyriax J: Textbook of Orthopaedic Medicine. Volume One: Diagnosis of Soft Tissue Lesions, (8th ed). London: Bailliere Tindall, 1982.

(15.) Klaue K, Durni CW, Ganz R: The acetabular rim syndrome: A clinical presentation of dysplasia of the hip. J Bone Joint Surg Br 73:423-429, 1991.

Tom Whipple, M.S., P.T., O.C.S., Dean Plafcan, A.T.C., P.T., and Wayne J. Sebastianelli, M.D.

Tom Whipple, M.S., P.T., O.C.S., Dean Plafcan, A.T.C., P.T., and Wayne J Sebastianelli, M.D., are at Penn State Orthopaedics, Milton S. Hershey Medical Center, College of Medicine, University Park, Pennsylvania.

Correspondence: Tom Whipple, M.S., P.T., O.C.S., Penn State Orthopaedics, 1850 East Park Avenue, Suite 112, University Park, Pennsylvania 16803-6705.
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Title Annotation:Case Report
Author:Whipple, Tom; Plafcan, Dean; Sebastianelli, Wayne J.
Publication:Journal of Dance Medicine & Science
Geographic Code:1USA
Date:Apr 1, 2004
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