Hip Pain―Allied Health Track S. Clifton Willimon, M.D.
2014 Pediatric Orthopaedic & Sports Medicine Seminar Saturday, November 8, 2014 Hip Pain―Allied Health Track S. Clifton Willimon, M.D. Andrea Carmin, P.T., D.P.T., S.C.S. ♦ All handouts are the property of the presenters and are not to be reproduced without permission. If handouts are not included for the session, they were not provided by the presenter. Adolescent Hip Pathology: Exam, Diagnosis, Treatment Cliff Willimon, M.D. Children’s Orthopaedics of Atlanta Children’s Healthcare of Atlanta ‐Medical Director, Orthopaedic Quality and Outcomes Pediatric and Adolescent Hip Pathology S. Clifton Willimon, M.D. The Following relationship exists: Smith & Nephew Endoscopy - Consultant MD1 Children’s Healthcare of Atlanta Outline • Unique Considerations • The Work-up • History and Physical Exam Pearls – – – – – – – Apophyseal Injuries FAI Snapping Hip SCFE Legg-Calve-Perthes Dysplasia Pearls Children’s Healthcare of Atlanta Challenges of the Young Athlete • Impulsive and Emotional • Parental/Coach Influence • Managing expectations – Timing of return to play – Stem cells – The next sports legend… Children’s Healthcare of Atlanta More Challenges of the Young Athlete • Growth Remaining • Core Instability • Laxity/Hypermobility • Prior Surgery: DDH, LCP, SCFE • Family History: JRA, SLE, Sickle Cell Children’s Healthcare of Atlanta Hip Pathology in the Athlete Adult Athlete Fracture/Dislocati on Sprain/Strains Coxa Sultans Hip Impingement Labral Tears Arthritis Athletic Pubalgia Neoplasm Pediatric Athlete Y O U N G A T H L E T E Legg-Calve-Perthes Disease Slipped Capital Femoral Epiphysis Hip Dysplasia Apophysitis/Apophyseal Avulsions Epiphyseal Dysplasia Infection Stress Fracture Synovial Disease (PVNS) Children’s Healthcare of Atlanta Pediatric and Adolescent Hip • Intra‐articular – – – – – – – – • Extra‐articular labral tears loose bodies chondral damage / AVN FAI • CAM • • Pincer sub-spinous impingement Legg‐Calve‐Perthes Disease Slipped Capital Femoral Epiphysis Synovial Disorders – Coxa Sultans (Snapping hip) •Interna •External – Greater trochanteric bursitis – Femoral neck stress fracture Regional – – – – Apophyseal avulsion Adductor strain sacroiliac joint pain athletic pubalgia • sports hernia • osteitis pubis Children’s Healthcare of Atlanta Don’t Miss… • Septic Arthritis • Femoral neck stress fracture • Dislocation • SCFE • Urologic/Spine Children’s Healthcare of Atlanta “Assessment of the hip joint is fairly succinct, but assessment of the hip region can be quite complex. “ -J.W. Thomas Byrd Children’s Healthcare of Atlanta Staying out of trouble… • A long road to get to you… – 3‐4 providers before you – Months/years of pain • Frustration • Internet diagnosis • High expectations Clohisy JC et al. CORR 2009 Philippon KSSTA. 2007 Burnett JBJS 2006 Children’s Healthcare of Atlanta Hip – Clinic Visit • • • • • History Exam Imaging Diagnostic Injections Patient Expectations Children’s Healthcare of Atlanta History & Physical – key points HISTORY – Superficial vs. Deep – Can the patient recreate the pain with palpation? – Quality of physiotherapy? – Knee pain is HIP PAIN until proven otherwise… EXAMINATION – Observe gait – Core strength assessment single leg squat, gait Children’s Healthcare of Atlanta Suspect Intra-articular source • C‐sign • Assymetric ROM • Provocative tests – Positive intra‐articular – Negative extra‐articular • Relief with diagnostic injection • Supportive Imaging Children’s Healthcare of Atlanta Suspect Extra-articular Source • • • • Radicular symptoms Normal range of motion Coxa saltans Provocative tests – Negative intra‐articular • Imaging findings not supportive Children’s Healthcare of Atlanta Low Back Pain • Secondary pain due to splinting – Overactive quadratus lumborum • Primary spine pathology – Radiculopathy – Spinal stenosis • Negative Lumbar work‐up – L4, L5 radicular symptoms – Spastic psoas Children’s Healthcare of Atlanta Anterior Impingement Test • “FADDIR” – Flexion, ADDuction, Int.Rotation • Does this recreate the pain? • Indicates antero‐lateral pathology • Relatively Gentle • Adolescent – apophysitis Children’s Healthcare of Atlanta Palpation • Soft Tissue & Bony – Greater Trochanter • Abductor – ASIS • Sartorius – AIIS • Rectus Femoris – Iliac Crest • Obliques – SI Joint – Pubic Rami/Symphsis • Adductor • Rectus abd. Children’s Healthcare of Atlanta Common Adolescent Hip Problems • Apophysitis • Apophyseal Fracture – Subspinous Impingment • Femoroacetabular Impingement • Dysplasia • Snapping Hip – Interna – Externa • Legg‐Calvè‐Perthes Disease • Slipped Capital Femoral Epiphysis Children’s Healthcare of Atlanta The Growth Plates of the Hip • Proximal Femur Appears at 4‐6 months and fuses at approx 14/16 years of age • Growth Plate / Physis – Triradiate cartilage fuses at 12 for girls and 14 for boys Children’s Healthcare of Atlanta Iliac Crest Apophysis Iliac Crest ASIS ASIS AIIS AIIS Ischial Tuberosity Children’s Healthcare of Atlanta Apophysitis/Apophyseal Fracture • Rarely operative – Ischial tuberosity fx • Rest, Ice, NSAIDs • Activity Modification • Physiotherapy – Core & Hip Mechanics – Flexibility Children’s Healthcare of Atlanta AIIS Impingement • “Sub‐spinous impingement” – – – – AIIS avulsion fx Iatrogenic (osteotomy, rim rsxn) Developmental Overgrowth? • May recall injury during adolescence • Pain with deep hip flexion Children’s Healthcare of Atlanta Subspinous Impingement • Recently classified: – Type I – above rim – Type II – at level of rim – Type III – distal to rim – 14 patients reported so far – Full return to sports – No revisions Larson Arthroscopy 2011 Hetsroni CORR 2012 Hetsroni Arthroscopy 2012 Children’s Healthcare of Atlanta Femoroacetabular Impingement? • A mechanical conflict – femoral head – acetabular rim • Diagnosis – History and Physical • Imaging to confirm Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta Treat the patient … NOT the IMAGING Children’s Healthcare of Atlanta FAI: CAM Pathology • Bony prominence head‐ neck junction – “Pistol grip” – Anterior to lateral location • Chondral injury often precedes labral tear and significant symptoms • “silent killer” Children’s Healthcare of Atlanta FAI: CAM Pathology Decreased IR +Ant Impingement Test Alpha Angle >55° Most commonly present with Pincer =Mixed type FAI α Children’s Healthcare of Atlanta FAI: Pincer Pathology deep acetabulum ‐crushing of labrum ‐secondary chondral injury ‐contre‐coup chondral injury Children’s Healthcare of Atlanta FAI: CAM Pathology MRI poorly detects chondral delamination Underlying Pathology CAM •Femoroplasty •Chondroplasty/microfx -Disruption of chondrolabral junction. -Preferential chondral injury. Relative labral preservation Consider rim trimming if grade IV and adequate CEA chondral flap Children’s Healthcare of Atlanta Pincer-type FAI: Arthroscopy Underlying Pathology Crushed Labrum Ossified Labrum Pincer Rim trimming Fragment Excision Contre-coup Children’s Healthcare of Atlanta Coxa Saltans = Snapping Hip • Iliopsoas (Interna) Flexion Abduction External Rotation – “Heard” • Iliotibial Band (Externa) – “Seen” – Patients referred/concerned for dislocating hip Extension Adduction Internal Rotation Children’s Healthcare of Atlanta Snapping Hip Treatment • Painless snapping – Reassurance – “party trick” • Painful snapping – Physical therapy – Avoid intentional snapping – Occasionally surgical Children’s Healthcare of Atlanta Iliopsoas Impingement Labral tear best seen on axial and radial views (3 o’clock location) Children’s Healthcare of Atlanta Legg-Calve-Perthes Disease Perthes Disease Idiopathic Osteonecrosis Femoral Head Children’s Healthcare of Atlanta Legg-Calvè-Perthes • Idiopathic osteonecrosis of the femoral head – – – – – Male>Female Age 4‐12 Limp Pain (hip or knee) 10% bilateral Children’s Healthcare of Atlanta Legg-Calvè-Perthes • Acute – Non‐operative management “contain hip” – Preserve ROM – Surgery for older patients (femoral/acetabular osteotomy) • Complex Deformity – Impingement and Dysplasia Children’s Healthcare of Atlanta Slipped Capital Femoral Epiphysis • Most common adolescent hip disorder • • • • Age 10‐14 Obese Limp Hip or knee pain • Obligate ER • Loss of IR THINK SCFE!!! Children’s Healthcare of Atlanta SCFE = Early intra-articular pathology • Arthroscopy prior to in situ fixation – 5 patients – Findings • Synovitis, acetabular cartilage erosions, hematoma, labral tears Futami JPO 1992 Children’s Healthcare of Atlanta Slipped Capital Femoral Epiphysis • Natural history – Healed slips lead to deformity – Secondary FAI articular cartilage damage – Residual SCFE deformity leads to early onset osteoarthritis • Patients followed into 40’s and 50’s • Mild slip‐ – radiographic OA ‐16‐43%, severe OA in 7‐10% • Severe slip‐ – radiographic OA –60‐100%, severe OA in 33‐40% Boyer JBJS 1981, Ordeberg CORR 1984, Carney JBJS 1991 Children’s Healthcare of Atlanta Slipped Capital Femoral Epiphysis Treatment Options – In Situ Screw Fixation – Unstable SCFE may need more invasive treatment – Surgical dislocation Children’s Healthcare of Atlanta Hip Dysplasia Borderline => Lat CEA 20-25° Dysplastic => Lat CEA <20° Male:Female 1:3 Insidious Onset (97%) Pain Groin 72% Lateral 66% + Impingement Sign Nunley JBJS 2011 Children’s Healthcare of Atlanta Dysplasia • “shallow socket” • Large Labrum – Compensates for lack of bony coverage – labrum and cartilage fails Groin Pain http://hipdysplasia.org Children’s Healthcare of Atlanta Dysplasia – PAO + Scope True Dyplastic undergoing open corrective procedures: Intra-articular findings in symptomatic DDH of the hip – – – Hip arthroscopy performed during corrective osteotomy 23 hips in 22 patients All female, average age 16.4 Results – – – – Cartilage degeneration- 78% Acetabular lesion 72%, Femoral head lesion 17% Labral tear-78% Anterior superior 72%, Superior 44% Fujii JPO 2009 Children’s Healthcare of Atlanta Patient Expectations • Operative • History, exam, imaging – Anticipated procedures » Microfracture » Labral treatment – Coxa Saltans » Painful? • Rehab – Importance of PT – Realistic timeline for RTP • 4‐6 months • Outcomes – Risk for revision/failure Children’s Healthcare of Atlanta Intra-operative Risk • Traction – Perineum – Dorsum of foot • Lateral Femoral Cutaneous Nerve Injury – Anterolateral thigh Children’s Healthcare of Atlanta Complications and Revisions • Residual Impingement – Incomplete resection of CAM and/or Pincer • • • • Labral Pathology Underlying Dysplasia Unrecognized pathology Intra‐articular Adhesions • Steep Learning Curve – Not a direct translation of knee/shoulder scope skills – Different pathology • Interpreting/recognizing subtle radiographic findings, concomitant pathology – Time‐consuming! Children’s Healthcare of Atlanta Intra-Articular Adhesion Willimon et al. KSSTA 2014 Children’s Healthcare of Atlanta Post-op Hip Arthroscopy Pearls • • • • • • Crutches for 4 weeks CPM 4‐6 hours per day 4‐6 month recovery Rectus femoris or Psoas Tendonitis Hamstring dominant hip extension Phases of Rehab – Protect repair, restore motion, re‐establish core and pelvic muscular activation/patterns – Strengthening and gait training – Dynamic pelvic stability – Return to play progression Children’s Healthcare of Atlanta Conclusions: Adolescent Hip • Careful history and exam essential • Don’t neglect (or forget) the differences from the adult hip • Arthroscopy –safe, but challenging technique • Indications in this age group continue to expand • Early intervention may serve to prevent future problems. Children’s Healthcare of Atlanta Thank You Cliff Willimon, M.D. 919-323-5601 [email protected] Rehab of the Adolescent Hip Andrea Carmin, PT, DPT, SCS Objectives • Identify key components of a hip evaluation • Determine special considerations for sport specific treatment interventions • Explain treatment strategies for DDH • Describe treatment considerations for FAI • Identify the different types of snapping hip and the treatment approach for each • Identify common sites of apophysitis around the hip Children’s Healthcare of Atlanta 2 Evaluation: Subjective • WHEN does it hurt? • WHERE does it hurt? • WHAT does it feel like? Children’s Healthcare of Atlanta 3 Evaluation: Objective • Strength – MMT • Hip flexion, extension, abduction, internal rotation, external rotation – Muscle activation • Glutes Children’s Healthcare of Atlanta 4 Glute Activation • Are they working? • Arthrogenic neuromuscular gluteal inhibition occurs – Freeman et al 2013 • Glute sets – Prone – ½ kneeling – Standing ‐Prone figure 4 ‐Tall kneeling Image from: Vicenzino et al 2008 Children’s Healthcare of Atlanta 5 Evaluation: Objective • Palpation – Trigger points: Glutes, TFL, QL – Tightness/Tenderness: hip flexor, adductors Children’s Healthcare of Atlanta 6 Evaluation: Objective • ROM – Hip • Limited by pain? – Low Back – Ankle dorsiflexion Children’s Healthcare of Atlanta 7 Evaluation: Objective • Functional Activities – – – – – Gait DL squat SL stance SL squat Running, plies, jumping, etc Children’s Healthcare of Atlanta 8 Treatment: Manual Therapy • Trigger points – Glutes – ITB • Manual release – Iliopsoas – Quadratus lumborum • Joint mobilizations – Mechanical: Improve ROM – Neurophysiological: modulate pain/decrease muscle tone – Nutritional: increased synovial fluid nutrient exchange Children’s Healthcare of Atlanta 9 Treatment: Manual Therapy •Inferior glides •Lateral glides •Mobilization with movement Children’s Healthcare of Atlanta 10 Treatment • Strengthening – Progress to function as quickly as possible Children’s Healthcare of Atlanta 11 Glute Strengthening • Reiman et al 2012 – Movement in multiple planes – Larger excursion of the center of mass from the base of support Multi-planer Movement COM excursion Greater muscle demand Children’s Healthcare of Atlanta 12 Glute Max Strengthening Moderate Level (2140% MVIC) -S/L hip abd -Lunge w/ fwd trunk lean -Bridge -clam (30 deg) -Lunge w/ neutral trunk -clam (60 deg) -SL bridge High Level (41-60% MVIC) -Lateral lunge -Lateral step up -Transverse lunge -Qped alt UE/LE -SL mini squat -Retro step up -Wall squat -SL squat -SL deadlift Very High Level (>60% MVIC) -Forward step up (74%) Reiman et al 2012 Children’s Healthcare of Atlanta 13 Glute Med Strengthening Moderate Level (2140% MVIC) -Prone plank -Bridge -Lunge w/ neutral trunk -SL mini squat -Retro step up -Clam (60 deg) -Lateral lunge -Clam (30 deg) High Level (41-60% MVIC) -Lateral step up -Qped alt UE/LE -Forward step up -SL bridge -Transverse lunge -Wall squats -Sidelying hip abd -Pelvic drop -SL deadlift Very High Level (>60% MVIC) -Single leg squat -Side plank Reiman et al 2012 Children’s Healthcare of Atlanta 14 Sport Specific Considerations • Dance – 11‐14 year olds: >6 hrs of dance training per week decreased femoral torsion decreased hip joint congruency labral tears (Hamilton 2006) – Iliopsoas: dynamic anterior hip stabilizer – Glute max, Glute med, TrA if weak/inhibited, lead to altered firing patterns, decreased core stabilization, and pain/pathology (Turner 2012) – Test strength through entire ROM Children’s Healthcare of Atlanta 15 Sport Specific Considerations • Running – Step rate: Lenhart et al Oct 2014 • Force demands of glute med and glute min were 3.5 times more than glute max during loading response • Increasing cadence, decreases force demands of glute med/min – Mirror gait training: Willy et al • Female runners with PFP given verbal cues in mirror • Pain with running and function improved at 1 and 3 months • Skill transfer to SL squat and step descent Children’s Healthcare of Atlanta 16 Snapping Hip • Internal – Iliopsoas over iliopectineal eminance – Snapping my also occur over lesser trochanter • External – ITB over greater trochanter Image from: Lewis 2010 Children’s Healthcare of Atlanta 17 Snapping Hip: Assessment • Flexibility – Thomas Test – Obers Test • Strength – Hip flexion (eccentric!), abduction, extension, external rotation – Core strength • Posture – Lumbar lordosis • Functional Tasks – When does snapping occur? Children’s Healthcare of Atlanta 18 Snapping Hip: Treatment • Selkowitz et al 2013 – Looked at EMG activity of Gmed vs TFL for various exercises – Found clams, side step with resistance, SL bridge, qped leg ext with knee flexed and qped leg ext with knee extended Children’s Healthcare of Atlanta 19 Apophysitis/Avulsion Fractures • • • • • Ischial Tuberosity: Hamstrings AIIS: Rectus Femoris ASIS: Sartorious Lesser Trochanter: Iliopsoas Iliac Crest: TFL, Glutes, Obliques Children’s Healthcare of Atlanta 20 Apophysitis/Avulsion Fracture: Treatment • Avoid pain! • Progressive stretching • Progressive strengthening – – – – – Isometric Global strengthening Low load concentric High speed eccentric Sport specific • Check mechanics Children’s Healthcare of Atlanta 21 Femoroacetabular Impingement • CAM Impingement • Pincer Impingement Children’s Healthcare of Atlanta 22 FAI Treatment • Surgical – Femoroplasty/Acetabuloplasty – Labral Repair – Microfracture • Conservative – Physical Therapy – Activity Modification Children’s Healthcare of Atlanta 23 Conservative Treatment of FAI • Wall et al 2013 – Systematic lit review promoted initial non‐op treatment • Hunt et al 2012 – Subjects treated with conservative treatment alone or conservative treatment followed by surgery had favorable outcomes at one year follow up • Yabek et al 2013 – Case series of 4 patients with ALTs all demonstrated improvements in pain, function and strength following conservative care • Austin et al 2010 – Case study: controlling hip add and IR can decreased pain associated with ALT Children’s Healthcare of Atlanta 24 Conservative Treatment of FAI • Decrease stress on anterior joint structures • Avoid/Prevent “impingement” • Assess femur on pelvis motion and pelvis on femur motion http://www.hipandkneeadvice.com/index.php/hip-conditions/hip-impingement/ Children’s Healthcare of Atlanta 25 Hip Joint Biomechanics • Correa et al 2010 – Glutes and gastroc decrease anterior hip joint force during gait • Lewis and Sahrmann 2007 – Anterior hip joint force increases with increased hip extension, decreased gluteal force and decreased iliopsoas force Children’s Healthcare of Atlanta 26 Post op Management of FAI • Phase I: Acute Phase – Protect the healing tissue – Control Pain/Inflammation – Neutralize muscle atrophy • Phase II: Controlled Stability – Restore ROM – Normalize gait – Initiate proprioceptive exercises • Phase III: Strengthening – Increase muscle strength/endurance – Optimize neuromuscular/ proprioceptive control – Improve cardiovascular endurance • Phase IV: Return to Sport – Restore power – Progressive plyometric work – Sport specific activities Children’s Healthcare of Atlanta 27 FAI Post op precautions • Weight bearing restrictions – varies • ROM restrictions – ER – Flexion – Abduction • Progressive hip flexor strengthening Children’s Healthcare of Atlanta 28 Developmental Dysplasia of the Hip • Wide range of hip abnormalities – – – – Shallow acetabulum Non‐spherical femoral head Acetabular retroversion/anteversion Dislocated hip • Wide range of ages – Babies: Pavlik harness – Adults: Surgical • Periacetabular Osteotomy • Femoral Osteotomy • Hip Replacement Children’s Healthcare of Atlanta 29 Periacetabular Osteotomy • Re‐orientation of acetabulum • Cut through all 3 bones of pelvis Children’s Healthcare of Atlanta 30 PAO Post-op Rehab • Precautions – TDWB x 6‐8 weeks – Limit active hip flexion – Hip flexion ROM limited to 30‐80 deg • Considerations – Avoid SLR – Return to sport in 6‐7 months Children’s Healthcare of Atlanta 31 In Conclusion… • Assess muscle activation patterns in addition to strength • Progress to function as quickly as possible • Glutes! Glutes! Glutes! Children’s Healthcare of Atlanta 32 Thank You! • [email protected] Children’s Healthcare of Atlanta 33 References • • • • • • • • • Reiman MA, Bogla L, Loudon J. A Literature Review of Studies Evaluating Gluteus Maximus and Gluteus Medius Activation During Rehabilitation Exercises. Physiotherapy Theory and Practice 2012; 28(4): 257‐268. Lewis CL, Sahrmann SA, Moran DW. Anterior Hip Joint Force Increases with Hip Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force. J Biomech 2007; 40(16): 3725‐3731. McKinney BI, Nelson C, Carrion W. Apophyseal Avulsion Fractures of the Hip and Pelvis. Orthpaedics January 2009; 32(1): 42‐48. Freeman S, Mascia A, McGill S. Arthrogenic Neuromuscular Inhibition: A Foundational Investigation of Existence in the Hip Joint. Clin Biomech Feb 2013; 28(2): 171‐177. Correa TA, Crossley KM, Kim HJ, Pandy MG. Contributions of Individual Muscles to Hip Joint Contact Force in Normal Walking. J Biomech 2010; 43(8): 1618‐1622. Agricola et al. The Development of CAM‐Type deformity in Adolescent and Young Male Soccer Players. AJSM 2012; 40(5): 1099‐1106. Lewis CL ,Sahrmann SA, Moran DW. Effect of Hip Angle on Anterior Hip Joint Force During Gait. Gait Posture 2010 October; 32(4): 603‐607. Lewis CL. Extra‐articular Snapping Hip: A Literature Review. Sports Health 2010; 2(3): 186‐ 190. Austin AB et al. Identification of Abnormal Hip Joint Motion Associated with Acetabular Labral Tear. JOSPT Sept 2008; 38(9): 558‐565. Children’s Healthcare of Atlanta 34 References • • • • • • • • Schmitz MR et al. Identification of Acetabular Labral Pathological Changes in Asymptomatic Volunteers Using Optimized Non‐contrast 1.5T Magnetic Resonance Imaging. AJSM June 2012; 40(6): 1337‐1341. Millis MB, Lewis CL, et al. Legg‐Calve‐Perthes Disease and Slipped Capital Femoral Epiphysis: Major Developmental Causes of Femoroacetabular Impingement. J Am Orthop Surg. 2013; 21: Suppl 1: S59‐63. Selkowitz DM, Beneck GJ, Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Latae? Electromyographic Assessment Using Fine Wire Electrodes. JOSPT Feb 2013; 43(2): 54‐65. McCarthy JC et al. The Role of Labral Lesions to Development of Early Degenerative Hip Disease. Clin Orthop and Rel Res. Dec 2001; 393: 25‐37. Yabek et al. Non‐Operative Treatment of Acetabular Labrum Tears: A Case Series. JOSPT May 2011; 41(5): 346‐353. Hunt et al. Clinical Outcomes Analysis of Conservative and Surgical Treatment of Patients With Clinical Indications of Prearthritic, Intra‐articular Hip Disorders. PMR July 2012; 4(7): 479‐487. Vicenzino et al. Foot Orthoses and Physiotherapy in the Treatment of Patellofemoral Pain Syndrome: A Randomized Clinical Trial. BMC Musculoskeletal Disorders 2008 9:27 Lenhart et al. Hip Muscle Loads During Running at Various Step Rates. JOSPT Oct 2014; 44(10): 766‐773. Children’s Healthcare of Atlanta 35 References • • • • Willy R, Scholz J, Davis I. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clinical Biomechanics Dec 2012; 27(10): 1045‐1051. Duthon et al. Correlation of clinical and magnetic resonance imaging findings in elite female ballet dancers. Arthroscopy March 2013; 29 (3): 411‐419. Hamilton D, Aronsen P, Loken JH et el. Dance training intensity at 11‐14 years is associated with femoral torsion in classical ballet dancers. Br J Sports Med. 2006; 40: 299‐303. Turner R, O’Sullivan E, Edelstein J. Hip dysplasia and the performing arts: is there a correlation? March 2012; 5(1): 39‐45. Children’s Healthcare of Atlanta 36
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