Performing arts athletes such as dancers, cheerleaders, and gymnasts present a unique set of issues for their treating medical team. These sports demand highly specialized motions and loading patterns that differ from running, cutting, and pivoting types of sports. When considering hip-specific pathologies related to these athletes, it is important to consider the specific movements required in these sports and how the athlete has compensated for many years in order to prepare, train, and perform at a high level.
One of the most important considerations is the potential for increased instability of their hips relative to most other athletes. These athletes develop characteristic hip morphologic conditions. When comparing power sports athletes, such as cheer and gymnastics, to non-power sports athletes, an increase in cam morphology was seen in power athletes on radiographs. However, there was not a demonstration of any differences related to hip dysplasia between the different types of athletes or non-athletes.1 Commonly, these performers possess a significant increased range of motion related to hypermobility of their hips due to both bony and soft tissue structures, which may be an advantage in their performance. However, this instability of their hips can have pathological consequences.
Issues with a low-volume acetabulum related to dysplasia, rotational abnormalities of the femur and acetabulum, impingement related to acetabular and femoral morphology can all be present and may need to be addressed.2 In addition, labrum tears and ligamentum teres tears are commonly diagnosed.3 Research suggests that these performing arts athletes may develop intra-articular damage at the chondrolabral junction and degenerative changes more frequently than the general population. In addition, they may experience alternative impingement mechanisms that create pathological lesions in the posterior superior portion of the acetabulum which contrasts with the more common anterior superior lesions seen in most impingement type patients.4
Due to specific performance demands, it is important to consider that the surgical treatment and rehabilitation of these patients should be approached differently. One study compared athletes competing in “flexion sports” such as dance, gymnastics, and cheerleading to those competing at a high level in “non-flexibility sports” like running, soccer, volleyball, and softball. When comparing these two groups and otherwise controlling for multiple variables, they showed that the flexion sport athletes had more femoral head cartilage lesions noted at the time of surgery, along with a higher rate of ligamentum teres tears noted. However, both groups demonstrated similar improvement in clinical patient reported outcomes and a similar return to sport rate of 76%.5
One of the most important considerations and biggest evolution in the care of these patients involves the concept of identifying and understanding micro instability of the hip. 6 Historically, many of these athletes possessed bony anatomy that would be considered low-normal or borderline in terms of acetabular morphology. Instability of the hip may also be related to increased ligamentous laxity. While firm diagnosis of connective tissue diseases such as hypermobile Ehlers-Danlos is challenging, one study showed an 88% prevalence of genetic variants related to connective tissue diseases in a cohort of professional dancers. While this may be a high estimate, it clearly indicates that soft tissue connective tissue disorders play a role in the care of these athletes. 7 In addition, growing evidence shows that some of these patients may not do as well when treated with hip arthroscopy for femoral acetabular impingement. A study performed looking at dancers and hip arthroscopy showed a 97% rate of return to dance at 7 months postoperatively, and while many returned to the same or higher level of dance, many reported a decrease in the amount of hours they were devoting to dance. 8 Another study that reported outcomes for patients again undergoing hip arthroscopy but within a 'borderline' dysplastic population showed that while all groups did improve the clinical patient-reported outcomes, only a 76% return to sport rate at over 8 months after surgery. In addition, these patients returned to the same level of activity 45% of the time and a lower level of sport at a 52% rate. Interestingly, the high school and collegiate athletes had a higher return to sport rate of 91%.
Peri-acetabular osteotomy (PAO) is a type of surgery where indications have evolved and matured a great deal over the last few decades. As the PAO procedure has been refined, the indications for this type of surgery in patients who might not have been classically defined as dysplastic or unstable have expanded. In a systematic review of studies evaluating PAO, there was an overall 70% return to sport rate for competitive athletics. Although many athletes can be successful in getting back to athletics, many transition to more low-impact sports, and at a lower volume than before their surgery.9
There is some evidence to suggest that treating intra-articular hip pathology via arthroscopy at the same time as a PAO may improve outcomes versus a PAO alone. One smaller single-center study of patients undergoing concomitant hip arthroscopy and PAO showed not only significant improvement in clinical outcome measures but a return to sport rate of nearly 82%.10 There is a great deal of research currently being published in this space as the indications and recommendations for treatment of these patients are evolving rapidly. What seems to be clear from the emerging literature is that there is a subset of patients who may have some instability of the hip related to soft tissue or bony structure, in addition to findings of impingement or labral tears, and that these patients may have somewhat worse outcomes than other patients undergoing hip arthroscopy alone. These patients may be better served with a PAO procedure, possibly with a hip arthroscopy to also address intra-articular pathology.
In conclusion, athletes participating in sports such as dance, gymnastics, and cheer create different demands on their hip joints than athletes in other sports and may be predisposed to certain hip conditions because of their unique connective tissue and anatomic structural makeup. These athletes need to be evaluated and treated in a careful and specific way that is sensitive to their individual presentations and treatment goals.11
References
- Westermann RW, et al. Activity level and sport type in adolescents correlate with the development of cam morphology. JB JS Open Access. 2021 Nov 11;6(4):e21.00059.
- Harris JD, Gerrie BJ, Varner KE, Lintner DM, McCulloch PC. Radiographic prevalence of dysplasia, cam, and pincer deformities in elite ballet. Am J Sports Med. 2016 Jan;44(1):20-7.
- Vera AM, Nho SJ, Mather RC, Wuerz TH, Harris JD. Hip instability in ballet dancers: a narrative review. J Dance Med Sci. 2021 Sep 15;25(3):176-190.
- Singh Y, Pettit M, El-Hakeem O, Elwood R, Norrish A, Audenaert E, Khanduja V. Understanding hip pathology in ballet dancers. Knee Surg Sports Traumatol Arthrosc. 2022 Oct;30(10):3546-3562.
- Saks BR, Monahan PF, Maldonado DR, Jimenez AE, Ankem HK, Sabetian PW, Lall AC, Domb BG. Pathologic findings on hip arthroscopy in high-level athletes competing in flexibility sports. Am J Sports Med. 2022 Mar;50(4):1028-1038.
- Safran MR. Microinstability of the hip-gaining acceptance. J Am Acad Orthop Surg. 2019 Jan 1;27(1):12-22.
- Vera AM, Peterson LE, Dong D, Haghshenas V, Yetter TR, Delgado DA, McCulloch PC, Varner KE, Harris JD. High prevalence of connective tissue gene variants in professional ballet. Am J Sports Med. 2020 Jan;48(1):222-228.
- Ukwuani GC, Waterman BR, Nwachukwu BU, Beck EC, Kunze KN, Harris JD, Nho SJ. Return to dance and predictors of outcome after hip arthroscopy for femoroacetabular impingement syndrome. Arthroscopy. 2019 Apr;35(4):1101-1108.e3.
- Leopold VJ, Szarek A, Hipfl C, Pumberger M, Perka C, Hardt S, Löchel J. Changes in sports activity after periacetabular osteotomy: a qualitative and quantitative analysis. Am J Sports Med. 2023 Feb;51(2):481-486.
- Jimenez AE, Lee MS, Owens JS, Maldonado DR, LaReau JM, Domb BG. Athletes undergoing concomitant hip arthroscopy and periacetabular osteotomy demonstrate greater than 80% return-to-sport rate at 2-year minimum follow-up. Arthroscopy. 2022 Sep;38(9):2649-2658.
- Weber AE, Bedi A, Tibor LM, Zaltz I, Larson CM. The hyperflexible hip: managing hip pain in the dancer and gymnast. Sports Health. 2015 Jul;7(4):346-58.