APA Sport Physiotherapist Brad Fernihough reviews Hip & Back Pain in Dancers


Over the last 15 years, Physioworks Health Group’s Brad Fernihough has extensive experience providing his physiotherapy expertise to dancers and performers at elite level, including with Cirque de Soleil and the Birmingham Royal Ballet.

Of regular occurrence as an issue in his consultation and injury treatment of dancers is the Psoas Muscle, which has become an area of interest and focus for Brad; and he presents the following review.

Snapping Hip Syndrome and Lower Back Pain – the Psoas (IP) Muscle in Dancers.

By Brad Fernihough, February 2018.

Psoas (IP) from the Greek spoas, means, “two muscles, one on each side of the loin extending internally from the sides of the spinal column to the upper end of the femur which assists in flexing and rotating the thigh and flexing the trunk on the pelvis” (Prather 2000)

In 2003, as part of my post graduate studies, I undertook anatomical investigation of the muscle structure, orientation and origin that elucidate the ability of the IP to perform a stabilising role at the lumbar spine, with a dual function as the prime mover for hip movement of flexion.

The iliopsoas (IP) muscle has been implicated as a cause of lower back and hip injuries, as it plays a vital role in the controlling movement of both regions. These anatomical relationships are of particular relevance to gymnasts/dancers as they force back into extension and hip rotation, altering the muscle’s ability to function optimally.

Lumbar Spine:

Increased turnout and resultant hyperlordosis cause the centre of gravity of a gymnast/dancer to move posteriorly, increasing the extension of the lumbar spine and increasing Psoas Muscle (PM) activity to overcome this posterior weight shift. This forces an increase compressive loads at the upper lumbar segments and shear forces at the lower lumbar. It is proposed that maximal PM contraction does lead to large shear forces at the junction between the Sacrum and lumbar spine.

Functionally, the gymnast/dancer may be categorised as having an ‘extension pattern’ whereby injury may occur at the lumbar spine due to this hinging at one level/motion segment of the lumbar spine (O’Sullivan 2000). This increase in the net movement of the centre of gravity posterior to the vertebral column, places increased stress specifically at the small bony bridges at each spinal level. It may lead to spondylolysis or spondylolisthesis, as commonly experienced in many gymnasts/dancers (Gelabert, 1986; Khan et al., 1995; Micheli, 1983).

Snapping Hip Syndrome (SHS):

Firstly the “snapping” is not a breaking of tissue, but rather a rubbing of the PM muscle /tendon over a groove in the bone on the front of the hip, making a clicking or clunking feeling and even an audible noise. This altered line of pull of the IP tendon, common in gymnasts/ballet dancers, is due to forced rotation of the hip. A 6 year survey of dance injuries reported 44% hip injuries as SHS, and that the tendon rubbing caused bursitis in 23% of hip injuries (D. C. Reid, 1988)

(Image: Penning 2002)

Further to the snapping hip, the IP tendon is susceptible to compression injury in sustained postures where the leg is elevated and externally rotated (such as Ballet movement Passe or Grand Jete). This is due to the IP tendon passing under the inguinal ligament and forming a ‘U’ as the lower limb is taken into this position (Khan et al., 1995). In this case, structures noted as potential sources of pain are:

  • the IP tendon
  • the spermatic cord in males (round ligament in females),
  • ilioinguinal nerve
  • the femoral nerve

(Image: Moore, 1992)

Dissection also revealed that the fascial connection of the Iliacus and Psoas Muscles are intertwined with the femoral nerve bundle, inguinal ligament and adductor/flexor muscles of the hip.

This continuum shown in Anatomical dissection of the IP muscle and surrounding structures elucidates the complex nature and role that it has within the lumbopelvic (LBP) region. In reference to gymnasts/dancers, their ‘Changed’ anatomical alignment may implicate the incidence of LBP due to the increased tone of Iliospoas (IP). and/or SHS due to the approximation of the IP tendon to the anterior hip joint.

Consideration of the functional implications of the IP complex is vital to the role of therapists when managing gymnasts/dancers that experience these debilitating conditions. Regular soft tissue release of the psoas muscle, as well as learning Muscle Activation techniques are key to optimum function and thus injury prevention of the lumbar spine and hip complex.



Gupta, A., Fernihough, B., Bailey, G., Bombeck, P. (2004). An Evaluation of Differences of Hip External Rotation Strength and Range of Motion between Female Dancers and Non-dancers. British Journal of Sports Medicine, 38, 778 – 783.

Khan, K., Brown, J., Way, S., Vass, N., Crichton, K., Alexander, R., et al. (1995). Overuse injuries in classical ballet. Sports Medicine, 19(5), 341-357.

Micheli, I. J. (1983). Back injuries in dancers. Clinics in Sports Medicine, 2(3), 473-484.

Moore, K. L. (1992). The lower limb (3 ed.). Sydney: Williams and Wilkins.

O’Sullivan, P. B. (2000). Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual Therapy, 5(1), 2-12.

Penning, L. (2000). Psoas muscle and lumbar spine stability: a concept uniting existing controversies. Critical review and hypothesis. European Spine Journal, 9(6), 577-585.

Penning, L. (2002). Spine stabilization by psoas muscle during walking and running. European Spine Journal, 11, 89-90.

Prather, H. (2000). Pelvis and sacral dysfunction and exercise. Physical Medicine and Rehabilitation Clinics of North America, 11(4), 805-836.

Reid, D. C. (1987). Preventing injuries to the young ballet dancer. Physiotherapy Canada, 39(4), 231-235.

Reid, D. C. (1988). Prevention of hip and knee injuries in ballet dancers. Sports Medicine, 6, 295-307.

About the Author: APA Sports Physiotherapist Brad Fernihough consults at Physioworks Health Group Camberwell. Please call reception 9889 6611 to book a consultation with Brad.