Hear a Patient Power interview with Dr. Nancy Kadel, an orthopedic surgeon and former professional dancer. Tendonitis, shin splints and problems with ankles, feet, hips, knees and lower back are common injuries among dancers. Some of these injuries can end a dancer's career. Kadel discusses how treating the early signs of stress and strain can prevent debilitating injuries.

Interview Transcript

Andrew Schorr:

A high percentage of dancers, particularly professional dancers, have injuries that take them out of dancing as they recover and sometimes can even be career ending. Now at UCSF ,there’s a dancer who has become an orthopedic surgeon. We’ll hear all about diagnosis and treatment of dance injuries coming up on Patient Power.

Welcome to Patient Power. I'm Andrew Schorr. I have a daughter who dances. I've worked with a lot of women who took dance, and there was a woman, years ago at age five taking ballet classes in Idaho, and she went on to become not just a dancer for awhile, a professional dancer, but also ultimately a foot and ankle specialist and an orthopedic surgeon helping dancers, everyone else too, but particularly her dream was to help people with dance injuries get the right diagnosis and the right treatment, and she's doing that now at UCSF Medical Center. I'm talking about Dr. Nancy Kadel who joins us to talk about dance injury diagnosis and treatment and her specialty at UCSF.

Dr. Kadel, thanks for joining us. Did you ever imagine when you were five years old that you would be an orthopedic surgeon and then could combine your love of dance with helping other dancers have as great a career or just a love of dance and doing it as they could?

Dr. Kadel:

Thank you Andrew. No I never imagined being a surgeon. I just imagined being a dancer. I was so caught up with the music and the movement I just knew I had to do dance, and only later as I realized how much I loved science and as I cleaned my own fish; fishing with my father and my brothers, and they always thought that I was a bit odd that I would not be afraid of cleaning my fish; I realized that surgery and medicine was something that was interesting to me. It didn't frighten me. It seemed very intriguing, and I always wanted to see what things looked like inside, so it seemed a natural.

It is kind of funny that people say, "Well how can a dancer become a doctor?" but to me there were a lot of parallels. It took a lot of dedication, and it took a love and a passion for it, and I think both careers do that. You sort of have a limited social life for awhile, and you have to memorize a lot of things, and those were both really to me it seemed quite natural.

Andrew Schorr:

I think it's so cool that you are an associate professor on the faculty there at UCSF and there's a big dance community in the Bay area for sure. Tell us what do we know about the percentage of dancers, particularly professional dancers, who have injuries and what about that applying to their foot and ankle?

Dr. Kadel:

It's interesting. Different studies looking at professional dance companies have quoted injury incidence rates of 67% to up to 95% of dancers in one year sustain some type of injury that forces them to be out for at least a week. That’s a high percentage of injuries, and of those injuries almost 65% of them are of the foot and ankle. That's one reason why I chose to specialize in foot and ankle. In my own dance background I saw that the foot and ankle was something that was injured pretty frequently and really necessary as part of your instrument to do your job and to perform your art.

Healthy Dancers Clinic

Andrew Schorr:

It doesn't always mean surgery, and people have this fear well if I deal with it that will be the end of my career, but yet these problems can get worse, and that could lead to a career changing course. Tell us about how you work with the community. I know you have another title where you are Clinical Medical Director of a healthy dancer center. Tell us what that is and how you help people in just trying to, if you will, nip the problems in the bud.

Dr. Kadel:

That's exactly right. At our Healthy Dancers Clinic, which is actually located in the Oberlin Dance Commons, it's called the ODC dance commons, the Oberlin Dance Collective Commons, which is in the Mission area in San Francisco. We actually have a free clinic open to dancers of any age and any technique. It could be ballet, modern, Afro-Brazilian, and it's a screening clinic. We like to see dancers there when it's a small problem, and hopefully as you said we can nip it in the bud and prevent it from becoming a true injury that requires them to be out because most of the injuries that we see are really overuse injuries; strains and sprains and even stress fractures are an overuse-type injury; and often we find that they’re technically related. There may be some technical alignment issue or a flooring issue or just like any athlete, too much too soon. You suddenly decide you're going to train for a marathon or you're suddenly rehearsing for three performances coming up, and you rapidly increase the hours of participation in your activity, and that can lead to these overuse injuries.

So often when it's a small little ache or pain we can see the dancers, and we have a wonderful staff of volunteer physical therapists and physicians all of whom either were dancers, are dancers, or have an interest in dance, so they can also look at the dancer's technique and hopefully we can identify those problems, or sometimes it's an area of muscle weakness that we can give some specific exercises to, and by-and-large most of these dancers do not go on to needing surgery.

Andrew Schorr:

I think this is so cool. I've interviewed a lot of orthopedic surgeons, typically men, maybe former baseball players, football players, rugby players, etc., but again having a daughter and working with a lot of women, all of them have done or do dance, and they love it, and all of them I think have had some injuries, fortunately slight ones, along the way, so it would seem that UCSF offering this and working with a team devoted to dance is, well, it's about time. It's really cool.

Injuries Associated with Dancing

Andrew Schorr:

So let's talk a little bit about the specific injuries. What are some of these things? Is it usually the Achilles? What are the things that come up and how do you assess how serious they are?

Dr. Kadel:

It is also specific on what kind of dance that they're doing. So some of the modern dancers who are barefoot, roll around on the floor, do a lot of lifts with each other, sometimes the women lift the men or the men lift the women, we see shoulder, hip, knee, but in the foot and ankle for those dancers we often see tendonitis; again such as Achilles tendonitis, and we really want to watch that especially in the male dancers who do lots of jumping. If they start to get tendonitis we want them to avoid a rupture if at all possible.

Sometimes it could be that they have some weakness elsewhere. We often find weakness around their hip that we work on and also looking at their alignment. Sometimes if they have a lot of pronation or tend toward flat feet their Achilles can be quite tight, and so we work with them not only on just stretching but also looking at their placement of the foot on the floor and their overall alignment when they’re doing moves such as a plie or landing from a jump.

So we try and look at the whole person and not just the isolated Achilles tendon. For ballet dancers who dance on point or on the tips of their toes, you know those pink satin shoes with the ribbons, so the ballet dancers often get what we call posterior impingement. So they can have a tight Achilles too, but often the tissues in the back of the ankle can get pinched and swollen from being on the tip of your toes, and also the tendon to your big toe, which goes right back there in your ankle called the flexor hallucis longus tendon, can get swollen and cause some popping and snapping and pain in the back of the ankle.

Certainly any of the tendons around the ankle can get tendinitis, but it's more common that we see either the impingement in the back of the ankle, the Achilles tendon both in men and women, and also we get some patients with impingement in the front, and those are people who land hard from jumps, and we often can find some pinching in the front.

It isn't just working with the ankle. Sometimes we realize that the reason they're landing so hard is that they’re not controlling their landing with their core or their pelvic floor, they’re whole body isn’t aligned up correctly when they're landing, and that’s contributing. So I think that’s the benefit of having this clinic in the studio setting. If we need to we can step inside the studio and have them jump on the studio floor where we can watch them do these moves, which I think it’s important to not just be focused on their foot because they're using their whole body when they're dancing, but the foot sometimes takes the brunt of it, and when you have other areas that are weak it all ends up in the kinetic chain running down to the foot, and that's where they feel the pain.

Andrew Schorr:

Now this is a fairly unique place. I imagine there are other specialists maybe in New York, but on the West Coast you must be fairly unique.

Dr. Kadel:

There are other specialists, other orthopedists that are sort of the company doctor for some of the major dance companies. I'm certainly not the only person in San Francisco that can treat dancers, but I'm probably unique in that of all of those orthopedic surgeons I'm probably the only one who has been a dancer.

Andrew Schorr:

Right, you seem very, I think you'd be very comfortable to say okay, do a plie for me. Let's start that way rather than saying ah, you know. No I think it's terrific. Now let's talk a little bit about other kinds of things. For instance one of our producers was mentioning her mother was a dancer for years, and she's now in her 50s and she still teaches dance, but the women as they age have been finding that they're also getting some knee problems as well.

Dr. Kadel:

Knee and hip. There have been quite a few hip replacements in famous dancers, and certainly that extreme of the turned out position, where they're, ideally there's a 180-degree turnout, you're toes are pointed to the side, and that turnout is coming from your hip. We've found in both male and female dancers that hip replacements are not unheard of. What's been difficult is in large population studies it's been difficult to capture all these dancers and really do a good epidemiological study to say is this really higher than the general population for their age. Once they leave New York City Ballet and they end up in Ohio it's sometimes hard to find all of these people to then find out, but certainly the knee as well and some groups have suggested that as we get older we shouldn't do grand plies anymore because that's a lot more stress on the knee, and also foot and ankle arthritis as well because of the extremes of motion that dancers, just like soccer players, soccer players also actually point their foot quite a bit, and they've found some question of whether there might be slightly increased focal arthritis whether it's knee, hip, or ankle, in dancers as in other athletes who have very specific movements that the general population doesn't do on a daily basis.

Diagnosis and Treatment

Andrew Schorr:

Now I know a lot of the diagnosis can be on physical exam and seeing their alignment and looking for soreness and tenderness and hopefully giving them strategies to correct that. Sometimes surgery might be indicated. How do you evaluate that, and if somebody does have surgery, and I know it will vary by the type, can they have a hope of getting back to where they were rather than giving up something they love?

Dr. Kadel:

Let me answer the first part about the diagnosis. Certainly at our screening clinic we don't have access to x-ray, but if we see someone that we think has a more serious injury we certainly might put someone on crutches or give them a removable boot cast, a walking cast, if we feel that they need it, but if there are people that we think have a more serious injury we try to refer them. If they have no insurance we try to send them to the county hospital where we could arrange for them to get radiographs, that would be x-ray, or an MRI at times, and a bone scan could also be used when we're worried about stress fracture for example. I typically do an MRI because it can also tell you about soft tissue, and it's more specific than a bone scan, although the bone scan is quite sensitive for stress fracture. Regarding the surgery, again it depends. If they tear their ACL like a skier could tear their ACL, dancers can tear their ACL, but because of their very specific maneuvers that are required when they return, and they certainly can't wear a brace on stage; it doesn't go with most of the costumes; it often takes them over six months to a year to fully return. Often some of the ankle surgery if they have impingement in the back and we do a surgery I still tell the dancers it's unlikely that they would be at performance level after surgery until six months. That doesn't mean they're not taking class and they're not doing therapy or Pilates or pool class, but as far as actually being on stage it really takes a large amount of time for the dancer. It takes six months to a year before they can really be back to their level. They usually can get back, and they're quite motivated as patients certainly to do all they can to get back, but it really takes a long time, so I try to avoid surgery if I can because that's going to take six months out of a dancer's career if we can help it.

Andrew Schorr:

I understand how when someone has problems or symptoms they're fearful about telling anybody, and they want to see can they just bull through it for a concern that they can't perform, they can't rehearse, maybe their status in a dance company will be changed, but I also know that if they can consult with someone like yourself or your team it may be that it can be dealt with simply too.

Dr. Kadel:

Exactly, and it's such a competitive world for the dancers, and if you're having an off day someone else may get your part, and you may not be considered for it again even though you originally had that role, so I can understand why they try and push through injuries, but we're hoping with our clinic being embedded at the studio the people can just drop in, nobody has to know that they dropped in, and when it's early and hopefully we can say well let's show you this taping technique and try a few of these exercises and come back next week to see how you’re doing, often we can prevent it from becoming the larger injury that actually takes them out.

So it's a culture that we have to work to change, but they have to trust the healthcare providers, and I think it's hard when they go to someone who maybe has little experience and doesn't really understand what those demands are. It's easy to say well if it hurts don't do it and stay off of it for three weeks, but three weeks of no dance class is pretty hard for any dancer to swallow.

Andrew Schorr:

Dr. Nancy Kadel, I think it is so cool that you've been able, you know, it's what we all want to do in life is take your loves if you have more than one; you have dance starting at age five and medicine; and put them together and then help a specific community, and obviously this applies to people, you see patients who are not dancers as well, but certainly for the dancers I think it's great that you're at UCSF and sort of on their side. I think that is really cool.

Dr. Kadel:

Thank you. I've been very fortunate, and this was really my dream for many years to be able to still practice orthopedic surgery but help dancers even if that means often I don't get to do surgery on them, I have plenty of other patients that need surgery.

Andrew Schorr:

Right.

Dr. Kadel:

So I've been quite lucky.

Andrew Schorr:

Okay, so you're alongside all those other former athletes and other scientists and researchers in the orthopedic department, but what a great addition to UCSF Medical Center. Thank you so much for being with us, and congratulations on the work you're doing in San Francisco.

Dr. Kadel:

Thank you so much Andrew.

Andrew Schorr:

This is what we do on Patient Power. I want to mention for our listeners that if you want more information about Dr. Nancy Kadel and all the physicians and services at UCSF, just call the UCSF Physician Referral Service. Here’s the number: 888-689- UCSF (888-689-8273). I'm Andrew Schorr. You've been listening to Patient Power brought to you by UCSF Medical Center. Remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you'll get care that's most appropriate for you.

Recorded February 2009

 

Reviewed by health care specialists at UCSF Medical Center.
Last updated April 30, 2012

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.