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The following information is intended as a resource and should not
be used to self-diagnose or treat. Use of non-steroidal anti-inflammatory
drugs (NSAID’s) may be used to reduce inflammation and pain
associated with that inflammation. Dancers should be aware that
dancing while taking NSAID’s can mask pain, which can lead
to further tissue injury.
Structure
The knee is commonly referred to as a hinge joint, though it is
in fact more complex. The knee is the largest joint in the body.
With the support of bony surfaces, cartilage, muscles, tendons,
and strong ligaments it sometimes has to bear the weight of up to
four times a person’s body. The motions that the knee is capable
of consist of bending (flexion) and straightening (extension), with
a limited degree of rotation and sliding.
Anterior Knee Pain
Knee Hyperextension
Patellar Malalignment
Patellar Femoral Syndrome
Patellar Tendonitis
Plica Syndrome
Meniscus Tear
Medial Collateral Ligament Tear
Anterior Cruciate Ligament Tear
Osteoarthritis
Adolescent Anterior Knee
Pain
“I have pain in the front of my knee. My knee ‘cracks’
a lot.”
Chronic pain in the front and center of the knee is common among
active, healthy young athletes – especially girls. The pain
may develop gradually, with initial onset as a dull ache of the
patella (kneecap).
Causes
The structure of the knee joint is such that even small changes
to its alignment or distribution of weight can aggravate the joint.
Adolescent dancers may have a sudden increase in training frequency,
which can put excessive stress on the knee complex. Also, developing
dancers may notice a large growth spurt in a short period of time,
which can greatly decrease flexibility. This occurs when bones grow
more rapidly than muscles, which cannot acquire the same amount
of length at the same pace. This decreased flexibility, in the quadriceps
especially, can pull and place stress on the kneecap.
Symptoms:
Pain is commonly noticed in the anterior (front) aspect of the knee
accompanied by swelling and a general tenderness of the patella.
Many adolescents also experience popping or crackling as they climb
stairs or when standing after extended periods of sitting. The pain
may flare up with activities that involve repeated flexion (bending)
of the knee.
Treatment
Ice and rest are helpful to reduce the acute pain experienced with
anterior knee pain. A developing dancer who pushes through this
pain without seeking the advice of a physician or clinician can
aggravate this injury and potentially cause tendonitis or other
more serious injury. An assessment of the dancer’s mechanics
with plié and identification of strength and flexibility
deficits is crucial to preventing reoccurrence. Commonly, dancers
with this condition also present with weakness or inflexibility
in the hip or ankle, and those joints must be evaluated as well.
Once a dancer returns to class, they should perform a proper warm-up
beforehand. Dancers should also avoid training or performing on
very hard surfaces and should wear well-cushioned, supportive shoes
when possible to reduce the stress placed on the front of the knee.
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Genu Recurvatum (Hyperextension)
“My knees extend way back, and now they’re painful.”
The knee can sometimes extend “beyond straight”,
creating a convexity of the leg posteriorly (towards the back).
This hyperextension of the knees is thought by some to complement
the aesthetic of the leg with a pointed foot. In dancers, this often
indicates a general predisposition towards ligamentous laxity. The
dancer may notice other joints of the body with similar hyperextension.
Causes
Ballet dancers in general show more of a trend towards this hyperextension
of the knees. Trouble arises when the dancer “locks”
back in to his or her knees, or has an extreme amount of flexibility
in the knee joint (looser ligaments/significant amount of hyperextension)
and therefore places undue stress on the knee joint and lower leg
rather than employing muscle strength for stance.
Symptoms / Associated problems
Hyperextension of the knees can put excessive stress onto other
structures in and around the knee, which can become painful. Common
associated problems include:
• A muscle imbalance in the thigh, in which the quadriceps
muscles can be overactive and the hamstrings subsequently are not
as well developed.
• Patella displacement or subluxation can occur, due to poor
quadriceps development or general ligamentous laxity.
• The unusually high amount of loading placed on the lower
leg can result in “shin splints” or even, in more severe
cases, tibial stress fractures.
Treatment
The varied associated problems of hyperextended knees will require
an assessment by a physician or clinician to determine where weaknesses
may exist and which structures are consequently under stress. A
well designed home exercise program can be crucial in correcting
and preventing reoccurrence of pain.
A dancer should also consider an analysis of technique and alignment
during training, as poor mechanics can aggravate injury. In particular,
many instructors have developed different syntax and imagery to
appropriately cue dancers with natural hyperextension to work in
a more anatomically sound way – encouraging dancers not to
“lock their knees” or “find the breath behind
the knee” are common choices. It is also important that younger
dancers with naturally hyperextended knees should be taught how
to avoid “sitting into” their hyperextension. They should
work in first position with the heels together, and should learn
to feel the knees “pull up”, and not lock back. In this
position the knees will not feel straight, however the dancer will
learn to feel the correct alignment.
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Patellar Malalignment
/ dislocation
“My kneecap will come out of joint.”
A displaced patella occurs when the kneecap (patella)
slips out of its groove on the thigh bone (femur). Often the kneecap
will slip out of its groove momentarily, and then relocate. This
is known as a patellar subluxation and can happen repeatedly. A
patellar dislocation is when the kneecap slips out of its groove
and will not relocate. This is a very painful condition which usually
requires the assistance of a physician to assist with relocation.
Causes
Injuries generally occur during athletic activities and are common
in running, jumping or during sudden changes of direction. A sharp
blow to the knee may also dislocate the patella. With a subluxation,
the dancer will notice momentary pain, followed by a feeling of
unsteadiness or the tendency for the knee to “give way”.
With a dislocation, the pain is significant and disabling and a
visible deformity can be seen. Both conditions will result in immediate
swelling of the knee. In severe cases, there may be numbness or
partial paralysis below the dislocation as a result of pressure
pinching or cutting blood vessels and nerves.
Treatment
Both patellar subluxations and dislocations require a physician
consult. With a dislocation, the physician can usually reposition
the joint with a physical manipulation. X-rays may be required to
rule out any fracture to the bony surfaces. Following relocation
or with repeated subluxations, the knee may need to be immobilized
or placed in a brace for several weeks. Rehabilitation with a physical
therapist or athletic trainer following patella subluxation injuries
is essential to restore strength and range of motion of the knee
and to help with reoccurrence. Severe conditions may require surgery
to stabilize the kneecap within its groove and assist with repeated
subluxations.
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Patellar-Femoral Syndrome
(Chondromalacia)
“I have pain on the front of my knee. It gets worse with stairs,
and sitting for a long time.”
Patella-Femoral Syndrome (PFS) is a general term to
describe pain affecting the joint surface between the patella and
the femur underneath. Behind the patella is a cartilage lining which
provides for a smooth gliding surface between these two structures.
Chondromalacia is a softening or wearing away of this articular
cartilage under the patella, resulting in pain and inflammation.
Causes
Typically, pain with PFS and chondromalacia will present over a
period of time. Dancers will notice pain during class, especially
with jumps and/or grande plié. The knee may begin to swell
at the kneecap and may start to become painful with stairs and sometimes
sitting for a long time. Overuse during training and technique or
mechanical faults employed by the dancer can aggravate this condition.
Very often, dancers will present with iliotibial band tightness
along the outside of the thigh or weakness in the medial quadriceps
muscle. If the condition persists over time, the cartilage behind
the kneecap can begin to soften and become damaged due to the repeated
compression on the femur.
Treatment
If chondromalacia patella is identified in the early stages of inflammation,
conservative treatment can be effective. Ice and anti-inflammatory
medications can be helpful in reducing acute inflammation and pain.
Dancers should modify their training activities when possible to
reduce stress from jumping and excessive knee flexion (grande plié).
A physician, athletic trainer and/or physical therapist consult
is essential to determine which structures in the knee exhibit excessive
tightness or weakness. An examination of the foot, ankle, and hip
should also take place as those joints transfer stresses to the
knee. Dancers may be presented with various surgical options for
patella-femoral stabilization. Surgical correction should only be
attempted once all conservative treatment options have been exhausted.
Technical Tip:
Dancers should make sure that the knees are fully ‘pulled
up’ especially working in 5th position. Some dancers ‘cheat’
the 5th position and aim to get more turn-out by standing with the
front leg slightly bent. Some will also complain that they cannot
get the leg straight in 5th position, therefore allowing the knee
to relax. This results in weakness in the vastus medialis oblique
muscle (VMO), and tightness in vastus lateralis and the iliotibial
band (ITB) which can cause uneven pull on the patella.
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Patellar tendonitis/“Jumper’s
Knee”
“The front of my knee hurts when I jump.”
At the base of the kneecap (patella) is a thick patellar
tendon, connecting the patella to the tibia bone below. This tendon
is part of the 'extensor mechanism' of the knee, and together with
the quadriceps muscle and the quadriceps tendon, these structures
allow your knee to straighten out, and provide strength for this
motion.
Causes
Patellar tendonitis is the condition that arises when the tendon
and the tissues that surround it, become inflamed and irritated.
This is usually due to overuse, especially from jumping activities.
This is the reason patellar tendonitis is often called "jumper's
knee." Patellar tendonitis usually causes pain directly over
the patellar tendon. A physician or clinician may be able to recreate
your symptoms by placing pressure directly on the tendon. The tendon
will often become visibly swollen as well.
Treatment
The most important first step in treatment is to avoid activities
that aggravate the problem. With patellar tendonitis this typically
includes stair climbing and jumping activities. Dancers may need
to restrict their class and rehearsals to limit these activities
until symptoms improve. During the acute injury stage ice and anti-inflammatory
medications may be helpful for pain relief. Stretching of the quadriceps,
hamstring, and calf muscles prior to activity is very important
to relieve stress on the patella tendon. A consult with a physician
or physical therapist can be very helpful to evaluate strength,
flexibility, or technique deficits that may be contributory factors
in patellar tendonitis.
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Plica Syndrome
“My knee ‘catches’ when I sit for a long time.
It’s painful with stairs.”
Often called "Synovial Plica Syndrome",
this is a condition that is the result of a remnant of fetal tissue
in the knee. The synovial plica are membranes that separate the
knee into compartments during fetal development. These plica normally
diminish in size during the second trimester of fetal development
and in adults, they exist as sleeves of tissue called "synovial
folds," or plica. In some individuals, the synovial plica is
more prominent and prone to irritation.
Causes
The plica on the inside of the knee, called the medial shelf plica,
is the synovial tissue most prone to irritation and injury. When
the knee is flexed, the plica is exposed to direct trauma, but it
also may be injured in overuse syndromes. Plica syndrome is often
misdiagnosed as a meniscal tear or patellar tendonitis. Dancers
may complain of pseudo-locking of the knee when sitting for a period
of time. Pain is typically experienced on the anterior-medial aspect
of the knee (front and middle), however, unlike meniscal injuries,
there is usually little or no swelling.
Treatment
Symptomatic plica syndromes are best treated by resting the knee
joint and using ice and anti-inflammatory medications. These measures
are usually sufficient to allow the inflammation to settle down.
Occasionally, a physician may recommend an injection of cortisone
into the knee, which can be helpful. An assessment with an athletic
trainer or physical therapist is useful to identify any secondary
factors to the dancer’s knee pain, such as tightness or weakness
in surrounding muscle groups, or technique deficits. If these measures
do not alleviate the symptoms, then surgical removal of the plica
may be indicated. Surgical resection of the plica has good results
assuming the plica is the cause of the symptoms.
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Meniscus Tears
“I have pain in my knee and it ‘locks up’ on me.”
Inside the knee joint, there are two “C”
shaped pieces of cartilage which protect the joint surfaces of the
femur and tibia from grinding against each other.
Causes
Injuries to the meniscus usually occur as a result of some type
of trauma (landing a jump, twisting a knee, etc). Tears to the meniscus
will vary in severity. Minor tears may not become painful for the
dancer until some time has passed after the injury itself. Severe
tears will be immediately painful and swollen. The dancer will notice
impairments with knee range of motion, walking, and may even complain
of the joint ‘locking up’.
Treatment
Dancers with a small meniscal tear may be able to return to activity
with only conservative treatment, including ice, anti-inflammatory
medications, and physical therapy to help strengthen the knee. More
significant tears usually require arthroscopic surgery to prevent
further damage to the whole joint and its stability. Rehabilitation
following surgery will vary depending on the extent of meniscal
damage. However, most dancers return to a full class and rehearsal
schedule within 6-8 weeks following surgery.
Technical Tip:
“Screwing home” turnout by planting the feet at the
desired angle of turnout and subsequently straightening knees is
perhaps the number one offender for injuries to the menisci. Working
correctly by turning out “from the hip” can prevent
many unwanted injuries including tears and disruptions to this protective
cartilage of the knee.
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Medial Collateral Ligament
(MCL) Tear
“I landed a jump badly and felt pain on the inside of my knee.”
The medial collateral ligament (MCL)is a key stabilizing
ligament of the knee that prevents movement of the joint from side
to side by attaching the femur to the tibia on the inside, or medial,
portion of the leg. An MCL injury is one of the most common ligamentous
injuries occurring around the knee.
Causes
Commonly, dancers sustain an MCL injury as a result of some trauma
to the knee, such as repeated jumping or sudden twisting, turning,
or stopping movements. Dancers will notice immediate pain on the
inside of the knee. The pain will generally last for few hours or
more. The dancer may also notice a lack of full range of motion
in the knee, and often a feeling of ‘instability’. MCL
tears can be painful to touch on the inside part of the joint surface.
Treatment
There are varying severities of MCL tears, ranging from stretching
of the tissue to a complete rupture of the ligament. Most MCL tears
can be treated conservatively, including rest from activity, ice,
and anti-inflammatory medications. Treatment by a physical therapist
or athletic trainer is indicated to strengthen the knee and prepare
the dancer for return to class and rehearsals. On rare occasion
a complete rupture of the MCL may require surgery to repair the
ligament or reattaching the ligament to the bone.
Technical Tip:
Poor or improper turnout puts the MCL at particular risk, stressing
this outer connective tissue of the knee between the thigh and lower
leg. Proper turnout from the hip joint cannot be emphasized enough.
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Anterior Cruciate Ligament
(ACL) Tears
“I landed a jump and heard a pop in my knee.”
The anterior cruciate ligament (ACL) is a deep ligament
primarily responsible for maintaining the stability and integrity
of the knee, connecting the femur to the tibia within the joint,
behind the kneecap (patella). Injuries to the ACL can vary in severity
– minor sprains to complete ruptures. The ACL unravels like
a braided rope when it’s torn and does not heal on its own.
Causes
ACL injuries are experienced by all types of athletes and dancers.
Injuries typically occur when a dancer lands a jump or performs
a sudden movement where the knee is forced side-to-side or unnaturally
twisted. With complete ACL tears, dancers will usually hear an audible
“pop” sound and notice immediate instability and pain.
The dancer may not be able to bear weight on the injured leg.
Treatment
Without the proper diagnosis and treatment, an ACL injury can place
the entire knee joint in danger. Extra wear and tear of the joint,
especially damage to the cushioning cartilage in the knee (menisci),
can complicate the injury and subsequently the rehabilitation and
recovery. A torn ACL most often requires surgical reconstruction.
The new ligament is often replaced by using a section of tendon
below the kneecap (patellar tendon) or hamstring tendons. Surgery
is followed by intensive rehabilitation of the joint and surrounding
muscles. Typically, dancers can expect to return to class within
3-4 months after surgery, and begin rehearsals and performances
approximately 6-8 months after surgical repair.
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Osteoarthritis
“I have been dancing all my life and now have a constant knee
pain.”
Osteoarthritis involves inflammation and degenerative
breakdown of the cartilage lining the ends of the bones within a
joint. Healthy cartilage normally protects the joint, allowing for
smooth movement and shock absorption. Without the usual amount of
cartilage, the bones rub together, causing pain, swelling and stiffness.
Causes
The most common causes of osteoarthritis are previous injuries,
joint overuse and aging. It is also suspected that there is a genetic
component to the disease. Dancers may have little or no complaints
of knee pain until the disease has progressed significantly. With
significant arthritis, dancers will start to notice pain with many
activities, including walking, ascending stairs, and even at rest.
Treatment
A physician can confirm a diagnosis of osteoarthritis with an X-ray.
Osteoarthritis is a degenerative condition and there is presently
no cure. The dancer should maintain existing flexibility in the
knee joint to help prevent injuries caused by friction. A physician
may recommend anti-inflammatory medication to assist with pain relief.
A consult with a physical therapist or athletic trainer is also
helpful to determine if strength deficits or imbalances exist and
help to correct them. Severe conditions may require total knee replacement
surgery once pain becomes no longer tolerable.
Knee Injuries: Prevention tips for dancers:
1. Strengthening the knee and hip muscles are critical to preventing
overuse injuries. Strong, balanced muscles will help take strain
away from the knee.
2. Stretching the knee and hip muscles are equally important in
preventing overuse injuries. Stretching the quadriceps, hamstring,
and hip muscles will help to make your muscles long and lean, and
will reduce pull on the different knee structures.
3. Give your body time to rest and heal itself, otherwise damage
can build up and cause chronic pain conditions.
4. Listen to your body! If it hurts after class, rehearsal or performance,
the chances are you’ve irritated something by over-use. Ease
off it, and give it time to heal, otherwise you may end up with
an ‘–itis’ type overuse injury.
5. Fatigue sets in at the end of a long day of class and rehearsal.
Continued strengthening of the knee and hip muscles is of the utmost
importance to prevent injury when the body gets tired.
6. Use proper technique. Alignment in a plié should always
be maintained such that the knee goes directly over the second toe.
When the knee falls inside the second toe, it can put increased
stress on structures in the ankle, knee, and hip.
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