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SPINE

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 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.

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.

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.

Spondylosis
“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.

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.

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.

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.

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.