Blank

KNEE and THIGH

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.

Common Injuries

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.