Case Study - Professional Dancer with Low Back Pain

Joe Heiler PT, CSCS

The patient in this case is a 33 yo F 'retired' professional dancer with complaints of bilateral low back pain. Pt is still teaching dance full-time and competing in a local 'Dancing with the Stars' type competition. The patient has a history of another back injury in high school while high jumping (pars fx), and then again while majoring in dance in 2001 (unsure of exact injury). The low back continued to be painful for a number of years while performing so she retired in 07'. She has felt better since then but now that she is competing again she is starting to have the same problems.

Other Relevant Hx:

Has avoided over extending her back for years now. Reports slumping when she sits will relieve her symptoms but still limited to about 30 minutes.

L post. tib tendinosis 2 years ago, improved but will still feel at times.

L knee medial meniscus tear 05', no surgery, and will lock up at times

Neck injury from MVA in 04', can still be a problem occasionally.

L knee pain (sounds like PFPS from her description), on and off over past couple years.

The patient does not want to have to stop her dancing so the goal is to get her through the competition and hopefully decrease her symptoms at the same time.

Day 1 Presentation:

SFMA

DN - c. spine flexion, c. flex/rot, all shoulder (Lumbar Spine ext. to compensate), MS flexion (flat LS and excessive mobility), MS Rotation B (mobility R > L), DOS, SL stance L (pelvis not level)
FN - SL stance R
DP - MS Extension (very limited, immediately hinges LS before hips move and immediately painful)

Breakouts

Cervical - FN active supine c. flex/rot B, DN flexion active/passive
Shoulders - DP prone active/passive LRF, FN MRE prone
MS Rotation - t-spine ext/rot. FN active, seated hip internal rotation FN R, DN L (A and P); seated hip ER DN B (A and P)
MS flexion - ASLR and hips FN mobility and stability, prone rocking - DN for lumbar flexion mobility

PRI

Adduction Drop Test (+) B, Thomas test (-) B, Toe Touch (-), full deep squat = PEC patterned

Day 1 Interventions:

GT lumbar and thoracic paraspinals, QL, Lats B static in child's pose position and with breathing work

Case Study - Professional Dancer with Low Back Pain

Pelvic repositioning - supine 90/90 hip lift and 3pt. belly press or standing/seated floor reach = immediately improves Add. Drop test to (-) bilaterally. She is to do 1 of the 4 every 2 hours until next visit in 3 days to maintain (-) Add. Drop.

SFMA changes - MS flexion still lacking lumbar flexion, MS extension DP but significant increase in quantity and quality of movement (pain only at end range). MS rotation improved quantity B to FN to R but still DN to L.

Day 2 Presentation:

Three days later pt reports 50% reduction in back pain intensity when present, frequency 75% reduced.

SFMA - MS rotation R is FN, MS rotation L remains DN; MS extension DP at end range but continues to be much improved (good hip extension now).

PRI - (-) Add. drop test B, (+) PADT (Pelvic Ascension Drop Test - basically an active Add. drop test that demonstrates frontal plane control of pelvis and hips).

Day 2 Interventions:

GT lumbar and thoracic paraspinals, QL, Lats B with movement and breathing work

Pelvic repositioning supine 90/90 hip lift w/balloon

L side lying knee toward knee

R side lying adductor pull back with L hip FA IR

L retro step-up (5-10 reps on a 4" step 2-3 x daily to lock in L hip IR - there are a few aerobic steps at her dance school that she can use much easier than getting on the floor to exercise throughout the day).

Post treatment SFMA - MS rotation FN R, clears to the L but with effort so remains DN

Post treatment PRI - (-) PADT - essentially she can perform the Add. Drop test independently maintaining good pelvic control. Hruska Add. Lift Test = 3/5 B

Day 3 Presentation:

One week later reports back pain intensity when present 1-2/10, frequency <5% of the day - can eliminate back pain with exercises.

SFMA - MS rotation R is FN, MS rotation L remains DN on L; MS extension DN now; B shoulder MRE is FN, B shoulder LRF still DN (minor LS extension contribution). Lumbar spine flexion mobility is much improved but remains DN therefore MS flexion remains DN.

PRI - (-) Add. drop test B, (-) PADT (Pelvic Ascension Drop Test), Hruska Add. Lift Test = 3/5 B

Day 3 Interventions:

No GT today

Pelvic repositioning supine 90/90 hip lift w/balloon, added shoulder flexion to the movement to focus on shoulder mobility without lumbar contribution.

L side lying knee toward knee and R side lying adductor pull back with L hip FA IR all performed efficiently with balloon.

Progressed PRI exercises to L side lying R hip abduction with L hip IR/ADD and also standing L single leg stance with R Glute Max (getting to standing exercise quickly as they are much easier for her to perform at home and work with some regularity) - with balloon.

Hip airplane to SL reaches with level pelvis - see my recent video on combining PRI and SFMA methods with these movements

Post treatment SFMA - MS rotation FN B without effort; shoulder LRF now FN. Post treatment PRI - Hruska Add. Lift Test = 5/5 B

Day 4 Presentation:

One week since last appointment and pt reports no pain even with end range extension. Has began to put some extension based moves back into her routine, but "nothing too crazy" per the pt.

Day 4 Interventions:

Hip Airplane to SL Deadlifts

Continue with the last 2 PRI exercises (inc. balloon whenever she has the chance)

Final SFMA

FN - C. extension and flexion/rotation, Shoulder MRE/LRF, MS rotation B, DOS, SL stance
DN - Cervical flexion, MS flexion (improved LS flexion but still limited) and MS Extension (meets mobility requirement but still some hinging in LS)

Final PRI

(-) Add. Drop and PADT tests, 5/5 Hruska Add. Lift Test

The patient is currently participating in a local dance competition, much like 'Dancing with the Stars' so between work and the dancing she is holding off on more PT at this time. I checked in with her 3 weeks after her last appointment and she remains pain free as well as reporting doing her PRI exercises daily plus the SL deadlifts 2x per week.

I would love to see her another time or two post-competition but we'll see. It would be nice to take her through the FMS and Y Balance to see if some higher level testing reveals anything further, and also as a way to further develop a long term program for her. For now though she is doing well, and hopefully she has learned a thing or two that will keep her injury free in the long run.

One final note on using the balloon. I think its critical to use the balloon with athletes that live in extension like dancers, gymnasts, weight lifters, etc as its so hard to break that pattern. So far the balloon seems like what has helped to break that pattern the best.