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®2015 Human Kinetics - IJATT 20(3), pp. 31-37


Patient Outcomes Utilizing the Selective

Functional Movement Assessment
and Mulligan Mobilizations With Movement
on Recreational Dancers With Sacroiliac
Joint Pain: A Case Series
Ryan Krzyzanowicz, MSEd, AT • Massachusetts College of Liberal Arts; Russell Baker,
DAT, AT, and Alan Nasypany, EdD, AT • University of Idaho; Frank Gargano, PT, DPT,
OCS, MCTA • Rehabilitex; and Jeff Seegmiller, EdD, AT • University of Idaho

Tthe sacroiliac joint (SIJ) has been identi­

fied as the origin of low back pain affecting
under tremendous amounts of stress.4 This
combination can place a dancer at more
13-25% of patients.1-3 risk of injury to the lumbar spine and SIJ.6
In the dance population, A dancer suffering from SIJ injury may pres­
K EY P O IN T S low back pain has been ent with a variety of symptoms that could
reported to account for include: pain with palpation to the SIJ, pain
Mulligan mobilizations with movement 12-23% of all injuries.4'5 with pelvic loading movements (e.g., hip
(MWM) and selective functional movement In the dance medicine external rotation combined with jumping,
assessment (SPMA) interventions can setting, many patients leaping, or twisting), and extension of the
► quickly decrease pain and improve function report to the clinic com­ lumbar spine.7 In addition to pain, SIJ injury
in patients suffering from sacroiliac joint plaining of low back and could result in decreased mobility of the SIJ
pain. SIJ pain of unknown and dysfunctional movement of the SIJ.7
etiology.4 The SIJ plays One potential treatment option for SIJ
Mulligan MWM and SFMA interventions
a vital role in the func­ pain is the utilization of Mulligan Concept
can produce clinically-significant changes
tional movement and Mobilizations with Movement (MWM). A
► across patient-oriented outcome instru­
ments that can be maintained through a
biomechanics of dance. MWM is a manual therapy intervention devel­
return to activity.
Turnout, or extreme oped by Brian Mulligan and couples acces­
external rotation of the sory mobilizations with physiological motion
Mulligan MWM and SFMA interventions can hip, combined with the to treat positional faults of joints.8 Mulligan
► be incorporated into a traditional clinical
examination to improve patient outcomes.
extreme range of hip
extension can place the
proposed that positional faults may result in
subtle joint mal-alignment, which produces
pelvis and lumbar spine altered joint function, pain, or decreased


range of motion.8 To date, the physiological process processing issue).10 Once a breakout has been classi­
by which positional faults may cause musculoskeletal fied, the clinician should perform treatment and cor­
pain or dysfunction has not been clearly identified.9 rective strategies based on the functional diagnosis.10
The MWMs used in this case series consisted of a pos­ Once a dysfunctional movement pattern is iden­
terior innominate, where the ilium is posteriorly rotated tified, the SFMA can also be used as an intervention
on the sacrum and an anterior innominate, where the using the paradigm of reset, reinforce, and reload.10
ilium is anteriorly rotated on the sacrum.8-9 To date, no Resetting includes using manual therapy techniques,
research has been published investigating the use of such as the Mulligan concept, to treat the dysfunction
MWMs for treatment of SIJ dysfunction. (e.g., JMD). Reinforce includes stretching exercises,
Another option for treating SIJ pain is to use the soft tissue mobilization, and forms of biofeedback
selective functional movement assessment (SFMA), an (e.g., kinesiology taping), and reload includes thera­
assessment instrument used to capture dysfunction peutic exercises to improve dynamic loading.10 The 4
from a regional interdependence model and identify x 4 matrix is a functional exercise progression that
appropriate intervention strategies based on those begins in nonweight bearing and no resistance, and
findings.10 The purpose of the SFMA is to provide a then progresses to standing and resistance (Table 1).
systematic approach to rank the quality of movement The 4 x 4 matrix can be used as a progression model
(e.g., full range of motion during movement) and the for increasing load and difficulty of exercises for the
provocation of symptoms during a movement.10 Once patient.
a top-tier assessment is completed, patients proceed The purpose of this investigation was to use the
through any breakouts that may be needed. SFMA and Mulligan mobilizations with movement
A breakout is performed any time a movement is (MWM) on recreational dance patients who complained
not classified as functional nonpainful and is completed of SIJ pain. Questions being investigated were: (a)
by the clinician using a movement pattern isolation Does SFMA intervention and Mulligan MWM decrease
map to identify potential causes for the dysfunction or the level of impairment in patients suffering from SIJ
faulty movement patterns. Breakouts are used to help pain as measured by the Disablement in the Physi­
guide the clinician to the area of dysfunction. Clinicians cally Active (DPA) scale? (b) Does SFMA intervention
should break down painful movements after dysfunc­ and Mulligan MWM decrease patients’ reported pain
tional movements to reduce unnecessary pain provoca­ on the Numeric Pain Rating Scale (NPRS)?11-12 (c) Do
tion.10 Each breakout ends with one, or a combination dancers with SIJ pain present with similar movement
of three, patient classifications: (1) tissue extensibility dysfunctions as determ ined by an SFMA exam?
dysfunction (TED), (2) joint mobility dysfunction (JMD), We documented the outcomes of three consecutive
or (3) stability or motor control dysfunction (SMCD). A patients who were diagnosed with SIJ pain and treated
TED could produce a dysfunctional nonpainful pattern with SFMA interventions and Mulligan MWM.
by having dysfunctional movement, usually of tissues
that span more than one joint (e.g., shortened tendons
M e th o d s
or scar tissue).10 A JMD could produce a dysfunctional
nonpainful pattern due to the articular surfaces and An a priori case series analysis was used for the design
contractile and noncontractile tissues that connect for this study. Three consecutive recreational dance
them having reduced mobility (e.g., facet syndrome).10 patients who presented to the Dance Medicine Clinic
A SMCD could result in a dysfunctional nonpainful pat­ complaining of SIJ pain were included in the study. The
tern in two ways, either due to a stability dysfunction or patient population was a sample of convenience. All
due to a motor control dysfunction (e.g., neurological patients were evaluated by an athletic trainer currently

Ta ble 1 4 x 4 Ma t r ix '0
1—Nonweight Bearing 1—No resistance (pattern assistance)
2— Quadruped 2—No resistance
3— Kneeling 3—Resistance (pattern assistance)
4— Standing_________ 4—Resistance


enrolled in a doctoral program, with seven years’ expe­ ination and treatm ent of each patient were provided
rience and one year of experience using the Mulligan by the sam e clinician. The institutional review board
concept. Patients were evaluated using a traditional com m ittee approved this study and each patient gave
orthopedic evaluation.13 Once the orthopedic evalua­ written consent before initial evaluation for inclusion
tion was completed, patients were then taken through in the study.
the SFMA. Patients were classified into one of four
Intervention. A Mulligan MWM utilizing the foun­
groups: (1) functional nonpainful, in which movem ent
dational principles described by Mulligan in his text
is nonpainful and of great quality as defined by having
were adm inistered by the sam e treating clinician in
m ovem ent that is of full ROM and no symptoms; (2)
each clinical case.8 The direction of the applied mobi­
functional painful, in which the patient can perform
lization was dependent on the innom inate rotation of
the m ovem ent with great quality but has pain with it;
each patient. Each MWM was performed in three sets
(3) dysfunctional painful, in which the patient has an
of 10 repetitions.8 The MWM technique applied was
abnormal movem ent pattern and associated pain with
based upon the recom m endations found in Mulligan
movement; or (4) dysfunctional nonpainful, in which
teachings and the “PILL” concept (i.e., pain free, imme­
the patient has a dysfunctional movem ent pattern, but
diate effects that are long-lasting) was followed with
does not have pain with the m ovem ent.10
each patient during examination and treatm ent.8-16"7
Clinical outcom es utilizing patient-oriented evi­
Patients were expected to be pain free and experience
dence to determ ine the effectiveness of MWM and the
immediate relief while the MWM was being performed.
SFMA as an intervention for SIJ pain are limited. There­
Exercises were selected for each patient based upon
fore, once the evaluations were completed, patients
the SFMA breakout findings, were based off of the 4 x
were then given patient-report outcome measures, the
4 matrix of the SFMA, and were performed before the
DPA scale, and the NPRS. The DPA scale is a patient-re­
Mulligan MWM intervention.10The top-tier of the SFMA
ported outcome instrum ent designed for the physically
was not reassessed at discharge; only those patterns
active. The DPA scale includes four outcomes measures,
that were dysfunctional were reassessed. All patients
measures of impairments (IMPs), functional limitations
were monitored for the rest of the academ ic semester.
(FLs), and disability (DIS), and includes questions
To assess patient-reported outcomes a NPRS and
regarding health-related quality-of-life (HRQOL).14
the DPA scale were used pre- and postintervention.
The DPA is scored from 0 (floor) to 64 (ceiling), with
Patients completed NPRS pre- and postintervention
16 points being subtracted from the final tally to pro­
at initial clinical examination and at each subsequent
duce the patient’s score at that tim e.15 A change of 6
treatm ent, including at discharge. The DPA scale was
points for acute injury and 9 points for chronic injury
completed as part of the initial clinical examination,
is considered a minimal clinically-important difference
at the end of each week, and at discharge. If a patient
(MCID).l5The NPRS is commonly used to measure pain
was discharged before the end of a week, the patient
intensity with patients being asked to rate their pain on
would complete the DPA scale during the discharge
a 0 (no pain) to 10 (worst possible pain) rating scale."
visit. All of the patients were instructed not to perform
A 2 point change on the NPRS is considered a MCID."
any other exercises or treatm ents during this time, but
were allowed to continue to participate in dance activ­
Case Descriptions
ities as normal. Patients were discharged upon being
History. A sum m ary of each patient’s history is pro­ pain free during dance activities and at rest, displaying
vided in Table 2. Each patient had a positive FABER negative special tests (i.e., FABER, lumbar quadrant,
(flexion, abduction, external rotation) test for pain over and long-sit tests), displaying functional nonpainful
the SIJ and positive lumbar quadrant test for pain over m ovem ent patterns in previously impaired patterns,
the SIJ while extending and rotating toward the side and reporting a clinically-relevant DPA scale score. A
that was bothersome. Each of the patients denied any clinically-relevant DPA scale score is a score that was
history of spinal trauma, hip, or thigh pathology. Active, within the established range of healthy people who
passive, and resistive range of motion assessm ent in have completed the DPA scale.15
trunk flexion and trunk extension did elicit pain in Based upon the physical exam ination (e.g., palpa­
each patient. Leg-length testing and the neurological tion, long-sit test), patient 1 was classified as having an
exam were unremarkable. All components of the exam­ anterior rotation of the left ilium. To address the ilial


Ta b l e 2 Summary of I n it ia l P h y s ic a l E x a m s
Age (Years) Years
P atient and Sex Dancing Exam
1 18/F 12 P a t i e n t 1, a r e c r e a t i o n a l d a n c e r , r e p o r t e d t o t h e D a n c e M e d i c i n e C l i n i c c o m p l a i n i n g
o f lo w b a c k p a in th a t h a d p e r s is te d fo r a m o n t h . T h e s p e c ific d a n c e m o v e m e n t th a t
c a u s e d t h e m o s t p a i n w a s w h e n s h e l a i d s u p i n e f o r a b o u t 1 0 s, t h e n j u m p e d u p i n t o a
P lie p o s itio n . S h e r e p o r t e d h e r p a i n a s a 3 /1 0 o n th e N R P S w h ile d a n c i n g a n d a 3 /1 0
a t r e s t. C lin ic a l e v a l u a t i o n r e v e a l e d p a i n ( 5 /1 0 ) u p o n p a l p a t i o n o f t h e le f t Slj f r o m t h e
P SIS to t h e in f e r io r s a c ra l a n g le . T h e FA BER a n d l u m b a r q u a d r a n t t e s t s w e r e p o s itiv e
f o r Slj p a i n . P a l p a t i o n o f p e l v i c l a n d m a r k s a n d a p o s i t i v e lo n g - s i t t e s t i n d i c a t e d a n t e ­
r i o r r o t a t i o n o f t h e l e f t i n n o m i n a t e . H e r S F M A r e s u l t e d in a D N c l a s s i f i c a t i o n f o r t h e
th ir d c e r v ic a l p a t t e r n to th e rig h t, m u l t i s e g m e n t a l f le x io n , m u l t i s e g m e n t a l r o t a ti o n to
t h e rig h t, s in g le -le g s t a n c e (b ila te ra l), a n d o v e r h e a d s q u a t. H e r SFM A b r e a k o u t s in d i­
c a te d a SM C D ; th e in c o r p o r a tio n o f a M W M in to th e e v a lu a tio n in d ic a te d a n a n te r io r
p o s i t i o n a l f a u l t o f t h e S lj, w h i c h s i g n i f i e d t h e M W M w a s a n a p p r o p r i a t e i n t e r v e n t i o n .
T h e re m a in d e r o f th e o rth o p e d ic ev a lu a tio n w a s u n re m a rk a b le a n d sh e re p o rte d an
in itial D P A s c a l e s c o r e o f 3 1 .

2 19/F 16 P a tie n t 2, a r e c r e a ti o n a l d a n c e r , r e p o r t e d to th e D a n c e M e d ic in e C lin ic c o m p l a i n i n g o f

lo w b a c k p a in th a t h a d p e r s is te d for 12 m o n t h s . S h e h a d s o u g h t o u t o t h e r t r e a t m e n t
(e.g ., e le c t r i c s t i m u l a t i o n , t h e r a p e u t i c e x e r c i s e s ) p r e v i o u s l y f r o m o t h e r c l i n i c i a n s w i t h ­
o u t a n i m p r o v e m e n t i n h e r r e p o r t e d p a i n l e v e l . T h e p a t i e n t r e p o r t e d t h a t all s i n g l e - l e g
f u n c tio n a l m o v e m e n t s , s u c h a s t u r n i n g o r s q u a t t i n g , p r o d u c e d p a i n (7 /1 0 ) o n t h e left
s id e d u r in g d a n c e a c tiv itie s. W h ile a t re st, h e r p a in w a s r e p o r te d a s a 6 /1 0 o n th e
N P R S . C l i n i c a l e v a l u a t i o n r e v e a l e d p a i n w i t h p a l p a t i o n ( 5 / 1 0 ) o f t h e l e f t SIJ f r o m t h e
P SIS to th e in f e r io r s a c r a l a n g le . T h e FABER a n d l u m b a r q u a d r a n t te s ts w e r e p o s itiv e
f o r SIJ p a i n . P a l p a t i o n o f p e l v i c l a n d m a r k s a n d a p o s i t i v e l o n g - s i t t e s t i n d i c a t e d p o s ­
t e r i o r r o t a t i o n o f t h e left i n n o m i n a t e . H e r S F M A r e s u l t s i n c l u d e d D P p a t t e r n s d u r i n g
m u ltis e g m e n ta l flex io n a n d e x te n s io n a n d o v e r h e a d sq u a t. S h e h a d DN p a tte r n s
d u r i n g m u l t i s e g m e n t a l r o t a t i o n to t h e r i g h t a n d s in g le - l e g s t a n c e (b ila te ra l). H e r S F M A
b r e a k o u t s in d ic a te d a n e x te n s io n JM D a n d a SM C D . T h is led u s to c h o o s e M W M a s a n
i n t e r v e n t i o n to a d d r e s s t h e p o s t e r i o r p o s i t i o n a l fau lt. T h e r e m a i n d e r o f t h e o r t h o p e d i c
e v a l u a t i o n w a s u n r e m a r k a b l e a n d s h e r e p o r t e d a n in itial D PA s c a l e s c o r e o f 4 9 .

3 18/F 2 P a ti e n t 3 , a r e c r e a ti o n a l d a n c e r , p r e s e n t e d to t h e D a n c e M e d ic in e C lin ic c o m p l a i n ­
i n g o f r i g h t SIJ p a i n w h i l e p a r t i c i p a t i n g in d a n c e a c t i v i t i e s . T h e d a n c e m a n e u v e r t h a t
p r o d u c e d th e m o s t p a in (8 /1 0 ) w a s g o in g f r o m a sin g le -le g s t a n c e to a s q u a t w h e r e
s h e m o v e d h e r h a n d a c r o s s t h e fl o o r a n d t h e n r e t u r n e d to a fu lly e r e c t p o s i t i o n . S h e
r e p o r t e d t h a t h e r c u r r e n t p a i n h a d p e r s i s t e d fo r t h r e e d a y s b e f o r e r e p o r t i n g to th e
c lin ic fo r e v a lu a tio n . C lin ical e v a lu a tio n r e v e a l e d p a in (7 /1 0 ) w ith p a l p a t i o n o v e r th e
r i g h t SIJ t h a t r e f e r r e d i n t o h e r g l u t e u s m a x i m u s . T h e F A B E R a n d l u m b a r q u a d r a n t
t e s t s w e r e p o s i t i v e f o r SIJ p a i n . P a l p a t i o n o f p e l v i c l a n d m a r k s a n d a p o s i t i v e l o n g - s i t
te s t in d ic a te d a n a n te r io r ro ta tio n o f th e rig h t in n o m in a te . H e r SFM A re s u lts in c lu d e d
a FP p a t t e r n d u r i n g th e first c e r v ic a l p a t t e r n a n d m u l t i s e g m e n t a l r o t a ti o n to t h e rig h t.
S h e h a d a DN p a tt e r n w ith m u l ti s e g m e n ta l fle x io n a n d a D P p a tt e r n w ith sin g le -le g
s t a n c e (rig h t s id e o n ly ) a n d o v e r h e a d s q u a t. H e r S F M A b r e a k o u t s in d i c a t e d a h ip JM D ;
th e in c o r p o r a tio n o f a M W M in to th e e v a lu a tio n in d ic a te d a n a n te r io r p o s itio n a l fault
o f t h e SIJ, w h i c h s i g n i f i e d t h e M W M w a s a n a p p r o p r i a t e i n t e r v e n t i o n . T h e r e m a i n d e r
o f t h e o r t h o p e d i c e v a l u a t i o n w a s u n r e m a r k a b l e a n d s h e r e p o r t e d a n in itial D PA s c a l e
s c o r e o f 15.
Note. NRPS = Numeric Pain Rating Scale; SIJ = sacroiliac joint; PSIS = posterior superior iliac spine; FABER = flexion, abduction, external rotation: SFMA =
selective functional movement assessment: DN = dysfunctional nonpainful; SMCD = stability motor control dysfunction; MWM = mobilizations with movement;
DPA = Disablement in the Physically Active; DP = dysfunctional painful; JMD = joint mobility dysfunction; FP = functional painful.


rotation, an anterior MWM was applied. The MWM was Changes in DPA Scale Scores
performed by grasping and rotating the effected ilium
posteriorly while stabilizing the sacrum and having
the patient perform a prone press-up. The MWM was
applied nonweight bearing for three sets of 10 repeti­
tions during each treatment session. Rolling techniques
were performed to address the core SMCD identified
during the SFMA. The technique involved the patient
rolling from prone to supine on both sides, while using
the lower extremities and lumbar spine to initiate the
movement. Rolling patterns were performed to assist
with resetting foundational core stability and motor
control patterns.10 Figure I Disablement in the Physically Active (DPA) scale scores. *Note
during initial evaluation all DPA scale scores were obtained. Patient 1
Based upon physical examination (e.g., palpation, completed the DPA scale at 7 days (discharge). Patient 2 completed the
long-sit test), patient 2 was classified as having a DPA scale at 7 days and 18 days (discharge). Patient 3 completed the DPA
scale at 5 days (discharge).
posterior rotation to the left ilium. To address the ilial
rotation, a posterior MWM was applied. The MWM
was performed with clinician mobilization of the SiJ Changes in NPRS Scores
anterolaterally through the thenar eminence on the
posterior superior iliac spine and counter pressure on
the other ilium to prevent the patient from rolling.8
The patient also performed prone press-ups during
the MWM. The MWM was applied for three sets of 10
repetitions during each treatment session. The SFMA
breakouts led to stability exercises starting with pelvic
tilts, progressing into a quadruped pattern, and finally
finishing with double knee to single knee stability
exercises to address the identified SMCD.
Based upon physical examination (e.g., palpation, Figure 2 Numeric Pain Rating Scale (NPRS) scores from initial evaluation
long-sit test), patient 3 was classified as having an to discharge.
anterior rotation to the left ilium. To address the ilial
rotation, an anterior MWM was applied in the same
manner as described for patient 1. The MWM was dysfunctional movement in the multisegmental flexion,
applied in nonweight bearing for three sets of 10 single-leg stance, and overhead squat patterns using
repetitions during each treatment session. The SFMA the SFMA. Two of the three patients (patients 1 and
breakouts led to the identification of a JMD of the hip. 2) also had a core stability or motor control dysfunc­
Pelvic tilts and opposite arm-leg motion in a quadru­ tion using the SFMA. All three patients’ dysfunctional
ped position were performed to address the JMD. The individual SFMA movement patterns improved from
exercises were also meant to assist with the stability dysfunctional to functional postintervention.
of the pelvic girdle.

D is c u s s io n
R e s u lts
Based on clinically-significant improvements on the
From initial treatment to patient discharge, patients 1 NPRS, DPA scale, and SFMA classification, the com­
and 2 experienced a MC1D on the DPA scale (9 points) bination of SFMA and MWM intervention was an
for chronic pain, while patient 3 experienced a MCID effective intervention for the three patients in this case
for acute pain (6 points) (Figure 1).I4J5 Patient 3 was series. All improvements were maintained until the
the only patient who was classified as being in acute end of the semester, an average of 52 days following
pain. All three patients also experienced a MCID on the intervention. The lack of a MCID for patient 3 on the
NPRS (2 points) (Figure 2).n-12 All three patients had DPA scale may have been the result of her presenting


with an initial score that would be considered low for lizing the anterior superior iliac spine of the opposite
persistent injury and within the range of scores of an side, the clinician brings the torso up and performs a
uninjured population based on previous research.14 m anipulation.19 He concluded that manipulation could
While the treatm ent intervention resulted in clini- be an effective manual therapy for patients with SIJ
cally-significant results for each patient, variance was pain.19 Erhard et al.20 exam ined patients with low back
present regarding the num ber of treatm en ts until pain and classified them into an extension exercise
discharge (Table 3). In this case series, it was noted group and a mobilization group.20 The exercise group
that patients with a longer duration of sym ptom s was treated with the McKenzie philosophy, while the
(i.e., patients 1 and 2) required more treatm ents until mobilization group was treated using the sam e tech­
discharge. All three patients were able to continue to nique as described by Cibulka.19'20 Erhard et al.20 found
participate in dance activities without restriction, while that mobilization followed by general lumbar range of
also completing the full dance season without a return motion exercises improved patients’ Oswestry Disabil­
of their original complaint. Following her discharge, ity scores more rapidly than exercise alone. Visser et
patient 3 did later report pain (rated 1/10 on the NPRS), al.21 dem onstrated a 72% success rate in decreasing
but continued to participate in her dance activities pain with two treatm ents over the course of two weeks
without further treatm ent or exacerbation of pain. in patients with SIJ pain receiving high-velocity low
Another interesting result of the case series was amplitude (HVLA) thrust manipulations.21
the identification of a consistent pattern during the In comparison, our results suggest even though
perform ance of the SFMA. In each case, the patient different outcome m easures were assessed than other
presented with dysfunctional multisegmental flexion, studies, that a combined intervention aimed at treat­
single-leg stance, and overhead squat m ovem ent pat­ ing m ovem ent dysfunction and positional faults in
terns. While the exact cause of this is unknown, pain an individualized fashion may be effective (i.e., fewer
and joint centration issues are possible explanations. treatments, improved patient- and clinician-outcomes)
Multisegmental flexion dysfunction may have resulted in treating SIJ pain. Despite the fact that dancers are
from pain10or altered biomechanics at the pelvic girdle, perceived to be more hypermobile com pared with the
limiting flexion.18 The overhead squat and single-leg average patient,22 the use of the SFMA was still able
stance movem ent patterns may have resulted from to identify m ovem ent dysfunction in this population.
pelvic girdle dysfunction limiting m otion18 or pain Using a m ovement assessm ent tool, such as the SFMA,
inhibiting appropriate motor control during the move­ may be valuable in helping clinicians detect movement
m ent pattern.10 Further research should be conducted dysfunction that may be related to SIJ pain. In addition,
to determ ine if these m ovem ent pattern dysfunctions MWM may be able to be com bined with SFMA-based
are commonly present in dancers with SIJ pain. interventions to immediately result in a decrease of
Previous research investigations have examined pain and improved movement.
the effect of manual therapy on treating SIJ pain.19-21
L im ita tio n s
Cibulka19 exam ined a manipulative technique in a
case study of a patient with SIJ pain. The technique The lack of a comparison group of patients with similar
involved the patient lying supine with their hands inter­ clinical presentation used to confirm therapeutic bene­
connected behind their head; with the clinician stabi­ fit is a primary limitation in this study; however, as this


was an a priori designed case series, the results can be 5. Micheli LJ. Back injuries in dancers. Clin Sports Med. 1983;2(3):473-
484. PubMed
valued with greater strength than a retrospective case
6. Reid DC. Prevention of hip and knee injuries in ballet dancers. Sports
series. Only having three patients in the case series was Med. 1988;6:295-307. PubMed doi:10.2165/00007256-198806050-
a limitation, as having access to more patients possibly 00005

allows for better identification of trends present when 7. Bronner S, Ojofeitimi S. Pelvis and hip three-dimensional kinematics
in grand battement m o v em en ts./Dance Med Sci. 2011 ;15(1 ):23—30.
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