SPINE

The following information is intended as a resource and should not be used to self-diagnose or treat. Use of non-steroidal anti-inflammatory drugs (NSAID’s) may be used to reduce inflammation and pain associated with that inflammation. Dancers should be aware that dancing while taking NSAID’s can mask pain, which can lead to further tissue injury.

Structure
The spine is made up of 24 moveable segments and 9 fused segments (at the bottom). The upper segments are called cervical vertebrae, the segments around the rib cage are called thoracic vertebrae, and the lower back segments are called the lumbar vertebrae. The two lower, fused segments of the spine are the sacrum and the coccyx. Due to the extreme ranges of motion and artistic demands placed on dancers, the lumbar spine vertebrae typically are the most often injured segments. Dancers can also sustain injuries to the sacrum, particularly with the joint articulation between the sacrum and the lowest lumbar spine segment, or with the sacrum and the two pelvic bones.

Common Injuries

Low Back Strain
Kissing Spines
Schuermann's Disease
Spondylolysis
Spondylolithesis
Herniated Disc
Sacroiliac Joint Sprain

Low back muscle strain and spasm
“I pulled something in my back.”

Causes
Muscle strains and lumbar sprains are the most common causes of low back pain. A low back muscle strain occurs when the muscle fibers are abnormally stretched or torn. Causes can include an acute injury such as lifting a heavy object or a sudden movement or fall. Other causes include repetitive injuries such as improper technique or working on the same lift over and over. Muscle tearing such as this will lead to guarding and spasm of the back musculature to protect the area from further harm. Dancers will typically experience pain exclusively in the low back area.

Treatment
Dancers will do well with conservative treatment of low back strains and spasm. Initial treatment will include rest, ice, and anti-inflammatory medicines. A consult with a physical therapist can help identify areas of weakness, tightness, or postural faults that may have predisposed the dancer to injury. The dancer may also want to critically look at any technical faults including lifting technique to help prevent future injury.

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Kissing spines – interspinous sprain
“I have pain when I overarch my back.”

Kissing spines is a term for a condition in which the spinous processes of adjacent vertebra are touching. It is also known as Baastrup's disease or syndrome.

Causes
Kissing spines can either be caused by trauma or degenerative factors. Injuries that involve sudden, forceful flexion of the spine, such as driving accidents, falls, sudden torsions, or severe direct blows can be causative factors. It can also be caused by degenerative changes in the interspinous ligaments along the tips of the spinous processes of the vertebrae. It can affect the cervical vertebrae, but in dancers it commonly affects the lower lumbar vertebrae. Dancers will typically notice pain and limitation with both extension and flexion motions.

Treatment
Initially, ice and rest are indicated to reduce local tissue inflammation and swelling around the injured tissue. A physician may recommend anti-inflammatory medication to assist with pain and edema. A physical therapist consult is also valuable to help the dancer regain strength and mobility deficits. The dancer should also be instructed in proper body mechanics with everyday tasks (e.g., getting in/out of bed) to ensure no further unnecessary stress is applied to the injured area. Symptoms usually decrease after 3 days and should subside between 1-6 weeks. A safe return to full class or performance is ideally only possible when the dancer feels neither pain nor discomfort, so that muscles can react and perform appropriately. Any pain-avoiding behavior caused by remaining symptoms could place the patient at risk for re-injury.

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Schuermann's disease
“My back hurts at the end of the day.”

Scheuermann disease (also known as juvenile kyphosis) is a deformity in the thoracic or thoracolumbar spine in children. It involves a degeneration of bony segments of the spine, gradually increasing to the point where the natural curvature of the spine begins to change.

Causes
The exact cause of the disease is not known. Some attribute the disease to trauma to the growing spine or hormonal and nutritional deficiencies. Parents of dancers will typically notice a change in their child’s posture, usually a flattening out or rounding of the spine. In later stages, there will be tenderness over the spinous process segments on the back of the spine. Dancers will typically complain of backache at the end of physically strenuous days.

Treatment
A physician will typically confirm the diagnosis of Schuermann’s disease with an X-Ray. The major goal of management is to prevent progression of the disease and further curving of the spine. In the early stages of the disease, extension exercises and postural education are beneficial. A consult with a physical therapist can help identify areas of muscle weakness or tightness that the dancer may need to improve. Bracing, rest, and anti-inflammatory medication may also be helpful to decrease pain. In most cases, the dancer may continue with class and rehearsals, but should avoid painful movements. Swimming may allow the dancer to maintain a strength training and conditioning regimen without putting excessive stress on the back. Surgery is seldom needed except in the most severe cases. In these cases, the spinal column is fused, or joined together where necessary.

Technical Tip:
Unfortunately there is no way to prevent this disease occurring in the young dancer. However kyphosis or curvature of the spine can occur later in life as a result of osteoporosis, so maintaining good bone health by eating well, and taking in enough calcium can be helpful in preventing osteoporosis.

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Spondylolysis
“My back hurts when I arch.”

Spondylolysis is the occurrence of a stress fracture in one or more of the vertebrae of the lumbar spine. (See diagram below) It commonly begins on one side of the vertebrae, and then may extend to the other side.

Causes
Spondylolysis can have a hereditary component, but also is attributed to repeated stress to the lumbar spine. Activities such as dance and gymnastics put a great deal of stress on the lower back and require over-stretching or hyperextension of the spine. Dancers may notice no symptoms until there is sudden trauma, such as a hyperextension injury. Pain will typically occur with port de bras or cambré backwards. The dancer may notice pain initially only with dancing. Pain may then occur with normal activities of daily living, and further progress to pain which interferes with sleep.

Treatment
Physicians can diagnose spondylosis with an x-ray to the lumbar spine. Dancers will likely be required to reduce their activity level and/or modify their technique in class. For severe cases, a short period of bed rest can be beneficial. Tissue healing can take as long as 2-3 months. During this time, participation in activities such as swimming, biking and limited weight lifting is usually permissible as long as it is pain-free. Physicians may prescribe a brace such as the modified Boston brace which prevents any extension of the lumbar spine. Dancers may be required to wear this brace for several hours a day, reducing this time as healing progresses. A physical therapist consult is helpful to assist the dancer with strength and flexibility training and to prepare the dancer for return to full dance activities.

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Spondylolisthesis
“I have back and buttock pain when I arch back.”

Spondylolisthesis is the forward slippage of a vertebra on the one below. (See diagram below) It commonly will be present with spondylolysis and is typically seen in girls more than boys.

Causes
Causes of spondylolisthesis include stress fractures (caused by repetitive hyper-extension of the back), and traumatic fractures caused by a direct force or sudden twist. The dancer will typically complain of localized pain or a pain that radiates into both buttocks, stiffness in the lower back, and increased irritation after activity. Dancers with spondylolisthesis usually display a significant lumbar spine curvature (lordosis) with tightness in the hamstrings.

Treatment
Treatment varies depending on the severity of the spondylolisthesis. Most dancers require only strengthening and stretching exercises issued by a physical therapist, combined with activity modification (avoiding hyperextension of the back). Some physicians recommend the use of a rigid brace to assist with stabilization of the joint. Conservative therapy for mild spondylolisthesis is successful in about 80% of cases. For cases with severe pain not responding to therapy, if the slip is severe, or there are neurologic changes, the slipping vertebra might need to be surgically fused. This surgery will limit lumbar spine range of motion and has a higher incidence of nerve injury than most other spinal fusion surgeries. Therefore surgery is only considered after all conservative treatments have been exhausted.

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Herniated Lumbar Disc
“I have low back pain and pain occasionally shoots down my leg.”

Between each vertebrae are discs, made up of a combination of strong connective tissues which hold one vertebra to the next. These discs act as a cushion between the vertebrae. As individuals age, the center portion of the disc (nucleus pulposus) may start to lose water content, making the disc less effective as a cushion. This may cause a displacement of the disc’s center through a crack in the outer layer (known as a herniated or ruptured disc). A herniated lumbar disc can ultimately press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg called "sciatica".

Causes
A disc herniation may occur suddenly in an event such as a fall or an accident. Often, a twisting or torsional movement is involved. Disc problems may also occur gradually with repetitive straining of the lumbar spine.

Symptoms
Most commonly, dancers will experience low back pain, but also leg pain over the outside of the thigh, the lower leg, or foot. The pain is often described as an electric shock type of symptom.
Severe cases of herniated lumbar disc injury will appear as bowel or bladder problems. Individuals with bowel or bladder complaints or who are having numbness around the genitals require immediate medical attention.

Treatment
An evaluation by a physician and physical therapist is critical to resolution of the dancer’s symptoms. The physician may request an x-ray or MRI to identify the location and severity of the disc herniation. Anti-inflammatory medications may be prescribed to assist with acute pain and local edema. A physical therapist will determine where physical deficits exist and instruct the dancer on postural corrections and activity modifications that might need to be made.

Conservative management of a herniated disc can often be sufficient to allow a dancer to return to full activity. If conservative management fails, surgical treatment may be recommended if there is a significant neurological component (i.e. leg weakness or numbness). Surgery is performed to remove a portion or all of the disc, and free up space around the compressed nerve. Recovery times from disc surgery vary from person to person, but a dancer should expect to have activity restrictions for 6-8 weeks following surgery.

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Sacroiliac Joint Sprain
“I have pain low in my back, especially when I lie on my side.”

The sacroiliac joint is a firm, small joint that lies at the junction of the spine and the pelvis. The joint does not have a lot of motion, but it is critical to transferring the load of your upper body to your lower body and can become quite painful when injured.

Causes
Certain situations increase the risk of straining the sacroiliac joints. During pregnancy, the ligaments in the sacroiliac area soften and lengthen. This may also occur with prolonged bending or lifting and with degenerative arthritis. In dancers, potential for sacroiliac injury is significant due to the extreme ranges of motion and artistic demands placed on dancers. Dancers with sacroiliac pain may or may not recall a method of injury. Symptoms may present over the sacroiliac joint, or it may be referred, usually to the groin and the posterior thigh, and less often to the leg. Pain may become worse when they lie on the affected side

Treatment
During the acute phase of injury, pain may be relieved by rest and anti-inflammatory medication. Physical therapy to assist with joint mobilization and stretching and strengthening exercises can be very helpful. As with any ligamentous injury, a period of decreased intensity of class or rehearsals may be required for healing. Dancers are nearly always able to return to their usual daily routine after a few days or, at most, a few weeks of therapy.

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Spine Injuries: Prevention / Tips for dancers

1. Muscular imbalances or weaknesses of abdominal and posterior spinal muscles may constitute a risk factor to sustain an injury. Keep the abdominal and back muscles strong and the hamstring muscles flexible to help avoid back injury.

2. The stabilization of the spine depends on appropriate and fast muscle reactions to suddenly changing postures of the spine. Proprioceptive training of the trunk muscles is a vital component in rehabilitation of low back injuries.

3. A good upright posture while standing, sitting, and lifting during everyday life and implementing exercising routines takes unnecessary strain off the spinal structures and help avoid injury.

4. Try to limit the amount of dancing each day, especially repetitive movements such as back bending – this will help prevent overuse injuries.

5. Make sure you always fully warm up before class, rehearsal or performance.

6. Try to maintain careful technique, and resist temptation to ‘cut corners’ to achieve movements such as forcing turnout, or tilting the pelvis.

7. It is particulalry important to remember to maintain correct technique in positions which stress the spine, such as arabesque and attitude, and being aware of ‘lengthening’ the torso during any back-bending movements.

8. Seek medical care for chronic back pain. Early vertebral stress fractures, particularly in adolescents and young adults, may heal with rest.

9. Aerobic fitness can increase blood flow and oxygenation to all tissues, including the muscles, bones, and ligaments of the spine. Dancers should be encouraged to cross-train year round to maintain aerobic fitness.

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