How to keep your hips pliable and pain free
By Suzanne Martin, PT, DPT
Hips—we love ’em in the dance world. They make life worthwhile by letting us kick, swivel, turn, jump, everything—you name it. We probably spend half of our dance lives cultivating the perfect demi- and grand plié. Yet more and more, dancers from my generation of baby boomers and even some Generation Xers are crowding the corridors of surgery centers on their way to hip procedures.
My husband, a former ballet boy, has had both hips replaced, and so has my sister-in-law, who is Graham-trained, with up-to-the-ears extensions. (My own chronically stiff and painful left hip hasn’t reached that point, but it was one of the big reasons I stopped teaching a few years back.)
I attended the IADMS (International Association for Dance Medicine and Science) conference about 10 years ago, when there was still a stigma attached to hip replacements. But with so many baby boomers out there today, and with so many of them requiring arthritis surgery, hip replacements have become almost commonplace and are no longer discussed in whispers by medical professionals. Dancers have also become more comfortable considering hip replacements as the procedure’s level of quality has improved and news spreads of people continuing to dance after undergoing such surgery. (Think Broadway divas Liza Minnelli and Bebe Neuwirth, and ballet dancers William Starrett and Wayne Sleep.)
Still, statistics on the frequency of hip surgeries are hard to come by. To my knowledge, neither the Arthritis Foundation nor the American Academy of Orthopaedic Surgeons can provide usable numbers. A few years ago I tried to gain access to the AGMA (American Guild of Musical Artists) membership rolls to ask dance professionals whether they had undergone hip procedures, but union privacy laws prevailed.
Why so many hip injuries in dancers? A joint that is used repetitively in extreme ranges of motion will wear out more quickly because the cartilage undergoes unusual amounts and types of friction. Couple that with the fact that dancers who have superb mobility in a joint tend to “showcase” that mobility (or flexibility) again and again—it’s what makes them stand out from the crowd. Hypermobile people often can’t feel when their joint is correctly positioned, but they can be taught what is correct via mirrors and by learning how the correct position feels. That’s why good dance training is so important.
Still, several questions spring to mind. How do dancers damage their hips so severely that surgery becomes the only option? Is there anything we can do to reverse this trend?
Three categories of dancers are most at risk for hip damage. First are the fortunate young “noodles,” dancers with super-flexibility and natural extension. This group may have shallow hip sockets and/or overly elastic ligaments (when the connective tissue that holds the bones in place is like a stretched-out waistband), which cause incorrect and repeated rubbing within the hip socket. (The thigh should move in the cup-shaped hip socket with precision and not jostle around like a bouncing ping pong ball.) There actually is some benefit to being a bit tight when beginning dance training and acquiring flexibility through proper stretching.
My own informal study of the hips of elite female dancers found that although these dancers display fascinatingly high extensions, the range of their hip joints is not very different from the general population. So where is a dancer’s range coming from? As the dancer overextends in one area, other parts of the body compensate to make it happen, which can strain numerous joints. Let’s look at a person landing from a petit allegro jump. The acceleration of gravity means the person lands with four times her body weight, which puts great force on the overextended hip joint as well as all the other joints down the line. This force is repeated every time she lands, and after too many landings, the system can fail.
The frightening thing is that, according to my favorite orthopedic book, Orthopedic Physical Assessment by David J. Magee, the hip endures two and a half times a person’s body weight with every step. Just think of what this means for dancers, with all that increased force of jumps. Eventually, this pressure causes the lining of the hip socket, as well as the cartilage covering the ball, to erode.
This “noodle” category also includes dancers who have a connective tissue disorder, which can be measured through blood tests. This condition, although relatively rare, is a type of arthritis and may not reveal itself until a dancer is in her 20s. Typically it starts with pain or stiffness in the hands, but bunion pain can also be a symptom. I know of one dancer in her 30s who suffered from this condition. She eventually underwent a “metal-on-metal” procedure, in which both the femur head and the socket were lined with metal caps. She is thrilled to be out of pain and with all her range intact.
Use and abuse
People do tend to gravitate toward dance if they are flexible. If they are not, they find ways to make their movements bigger and more spectacular. This group—dancers who perform such big movements that they injure a hip—is the second category of dancers at risk.
One frequent diagnosis is the hip labral tear. The hip ligaments that tie the thighs to the pelvis are outrageously strong. Yet one common movement in dance, grand battement à la seconde, promotes the loosest position of the thigh bone in the hip socket. This means that the potential is great for the thigh bone to come out of the socket during this movement.
I recently treated a dance teacher friend who had partially dislocated her hip. She was demonstrating a contretemps in a grand allegro combination and landed a bit off-center of her support leg. I managed to guide the bone back into the socket. Miraculously, she had not torn the labrum, the cartilage that lines the socket. (The femur head attaches to the socket with a loose ligament. In newborns, this ligament—ligamentum teres—holds the thigh in close proximity to the pelvis. Eventually, it may dissolve, but if it doesn’t, it can pull on the socket cartilage and cause a tear.) Labral repairs are becoming more common, but it’s better to avoid the situation by building strong hip and psoas muscles through exercise. Dancers who feel a snapping or clicking in the hips can learn how to hold the femur in the socket with specific exercises.
Last, there is garden-variety osteoarthritis. One hypothesis for the cause of this condition is that one hip gets more wear due to a body imbalance. (Treatment for this—by adjusting and balancing a pelvis—is my manual therapy specialty; I probably adjust three to five of these every time I work with a ballet company.)
Repetitive choreography, like sauté arabesque on the same leg or leaping only to one side, can create this kind of imbalance. We call these problems “laterality,” meaning doing too much to one direction. One side of the pelvis can dip down onto the thigh, causing improper bone positioning in the hip socket, which leads the pelvic socket bones to rub abnormally on the femur. Over time, this abnormal pressure can wear out the joint.
Keeping up with hip health
What can you do to avoid hip issues like these? A lot. Be sure to cross-train and break up repetitive patterns. When working on flexibility, make sure your effort is equal from side to side. Remember exercises such as the frog stretch—lie on the abdomen with the legs in second position; push up on forearms and tuck the pelvis. This gives equal pliability to the pectineus muscles at the very top of your inner thighs.
One great end-of-the-day pelvic balancer is the “constructive rest position” recommended by mind–body wellness pioneer Mabel Todd. Lie on your back with both legs bent at a 90-degree angle, feet flat on the floor. Tie the thighs together with something inelastic, like a yoga strap, to release the muscles. Stay and breathe for 5 to 10 minutes.
Also, work on your strength with some simple exercises like these: Get a stretchy band and tie a loop onto the leg of a heavy sofa or table leg. Stand and face the loop and slip one foot into it.
* Holding your knees together, bend the knee of the looped leg (think hamstring curl). Then straighten the knee and push the heel behind you (think parallel tendu derrière).
* Turn so the looped leg is on the side, away from the furniture anchor. Press the foot to the side with the leg in parallel.
* Turn 180 degrees and press the looped leg (same leg, but now close to the anchor) across the body in front of the support leg, again in parallel.
* In each of these positions, do 10 repetitions and hold the last repetition in a stretch for 10 counts. Repeat all on the other leg.
Nutrition also plays a part in joint health. Ligaments need adequate protein every day to stay strong. Make sure you are getting enough protein to meet the U.S. recommended dietary allowance of 0.8 grams per kilogram of body weight for adults. (In terms of servings, that’s about the equivalent of three packs of playing cards.)
Strong ligaments and muscles also depend on strong bones. Eat enough calcium-rich foods such as dairy products, almonds, and leafy greens to meet the RDA daily recommendation of 1,000 mg per day for ages 19 to 50 (or 1,200 if over 50), or take a daily supplement. Joint health supplements like chondroitin and glucosamine can, over time, have a positive impact on your cartilage.
Remember: dance is like golf. Proper body mechanics and good technique never go out of style. Challenge yourself to continue your quest for the perfect form. Your hips depend on it. The good news is that information about joint health is more readily available than ever. And if a surgical intervention becomes necessary, there are plenty of options to get you moving again.
I have faith in you.