Chronic Conditions of the Knee

         "There are three steps you have to complete to become a professional dancer: learn to dance, learn to perform, and learn how to cope with injuries." -D. Gere

         

      The knee is the largest joint in the body and is constantly supporting the body’s weight.  Dancers depend upon their knees to support their bodies while turning, jumping, and performing extensions.  Since the knee joint is found between sets of muscles that dancers use repeatedly, and dancers often have muscular imbalances in the leg that cause misalignments, it is not surprising that knee injuries account for 14-20% of complaints among dancers.

            This week’s post will discuss some chronic dance injuries that affect dancers.  These injuries develop over time and increase in severity until the cause is determined and eliminated.

            A condition that occurs in children and adolescents who are involved in activities like dance that involve quick turns or jumping is Osgood Schlatter’s Disease.  One in five adolescent athletes is diagnosed with this condition, and it occurs when quick movement demands are placed upon the body during the growth spurt.  During the growth spurt, bones grow quicker than muscles placing a strain on the body.  When this strain is exacerbated by activities that stress the body, this condition develops.  It manifests itself as a painful lump on the leg right below the kneecap.  Dancers may experience swelling, tenderness around the knee, tightness in the quadriceps and/or hamstrings, and/or pain with exercise.  It can involve inflammation of bone, cartilage, the patellar tendon, or any combination of the three.  It should be treated using the PRICE method (protection, rest, ice, compression, elevation) and anti-inflammatories.  It usually resolves itself in 12-24 months when the growth spurt is completed.  A physical therapist can help the dancer find ways to navigate through classes and rehearsals.  In extreme cases, a dancer may be forced to take a break from dance until the pain begins to subside.

            Patellar femoral syndrome occurs due to a misalignment in the leg.  Muscular imbalances or forcing the body into unnatural positions that are unhealthy for the body, like forcing turnout from the knee, can cause the patella, or kneecap, out of position.  Instead of sliding back and forth in the groove on the femur, or thighbone, the kneecap is “derailed”.

          As the back of the kneecap rubs against the femur, the cartilage under the kneecap wears away causing chondromalacia.  It is characterized by pain around the kneecap during jumps, during pliés, and after sitting for a long period of time.  The dancer may also experience some swelling around the knee and/or hear a “crunching” sound when moving it.  Rest and ice may help, and a physical therapist should be consulted to determine the underlying cause.  The dancer’s technique can be examined to determine what alignment issues may be present, and the dancer can be evaluated for muscular imbalances that may be the cause.  A physical therapist who works with dancers will be able to help correct technical problems and/or provide strengthening and stretching exercises to fix any imbalances that are present.

            Another knee problem that can be caused by alignment issues and/or muscular imbalances is patellar tendonitis.  In this condition, the patellar tendon, which connects the quadriceps to the kneecap, becomes inflamed.  When the tendon is pulled on excessively due to tight quadriceps muscles, it becomes swollen and painful.  Rest, ice, and anti-inflammatories will help alleviate swelling and pain, and a physical therapist can provide exercises to eliminate the tightness in the quadriceps.

            Prepatellar bursitis is a condition found mostly in modern and jazz dancers because of the knee work involved in these techniques.  Bursae are tiny fluid-filled sacs found in the joints of the body that act as cushioning.  When repeated friction occurs in a joint, the bursae become inflamed and painful.  When executing knee work, the constant friction between the knee and the floor becomes a source of irritation.  Rest, ice, anti-inflammatories, compression, and physical therapy can alleviate the swelling.  In more severe cases, cortisone shots or surgery may be necessary.

            My next post will cover acute knee injuries that are the direct result of trauma and tend to be more serious in nature.

Forcing Turnout: Is It Really That Bad For You?

            "Dance, an art form; the body, an instrument. Learn to play the instrument so you can master the art form."-Debbie Dee

       Turnout is an integral part of ballet technique.  It involves externally rotating each leg 90° so that the inside of the leg is visible from the front.  Turnout originated in the 1600’s during the reign of the French king, Louis XIV.  Ballet was performed on a proscenium stage, which necessitated sideways movement while displaying as much of the body as possible.  The shoes that were used were elaborately adorned, and it is believed that part of the reason for turnout was to display the beauty of the shoes while performing.

     

              When the “rules of dance” were written down by Pierre Beauchamp, they included the five positions that are the basis for ballet today and the concept of turnout.  Today’s turnout is much more exaggerated and extreme than it was originally, and perfect 180° turnout is the ideal to which today’s ballet dancers aspire.

           

            Unfortunately, not everyone’s body structure allows for perfect turnout.  The rotation must originate from the hip since it is the only ball and socket joint in the leg.  The ability to turnout is predetermined by the shape of the head of the femur, or thighbone, the angle that is formed where it inserts into the pelvis and the flexibility of the muscles and ligaments surrounding the hip.  While the actual skeletal structure cannot be changed, the flexibility of the hip can be increased through specific stretches to allow for a greater range of motion.

            Since few dancers are born with an ideal body structure for turnout, ballet dancers often feel the need to force their legs to rotate more than is anatomically feasible.  Dancers bend their knees, outwardly rotate their feet and then force the body to hold that position while they straighten their legs.  It is quite easy to spot the dancer who is forcing turnout.  Teachers need to check to see if the dancers’ kneecaps, or patellas, are facing the same direction as their toes.  If they are not, the rotation is being forced and the dancer is probably struggling to hold the position.

            It is the struggle to maintain forced turnout, which can lead to a variety of problems.  In an attempt to hold forced turnout and remain balanced, the dancer begins to grip the floor with the toes, which keeps the plantar tendon in a contracted state which inflames the tendon and eventually results in plantar fasciitis.  The dancer may also begin to pronate, or roll forward at the ankle.  Pronation causes the dancer to use the inside of the foot when pushing off the floor for relevés and jumps instead of using the bottom of the foot.  In addition to making the movement less efficient, this action puts pressure on the big toe joint, which will become inflamed and irritated, and eventually a bunion will develop.

            Forcing turnout from the ankle also causes the tibia, the large shinbone, to twist.  This twisting irritates the tibialis posterior muscle, which attaches to the tibia, and can result in shin splints.

            All of the unnatural twisting weakens the ligaments that are responsible for the stability of the ankle and the knee and disturbs the natural line of the Achilles tendon, causing tendonitis.  Tendonitis can also develop in the patellar tendon, which attaches the quadricep muscles of the thigh to the tibia.

            Lastly, in order to balance while forcing turnout and pronating, the body compensates by tipping the pelvis forward.  As this happens, the curve in the lumbar spine increases, causing swayback, or lordosis.  Lordosis stretches the hamstrings, puts a strain on the lower back and decreases the shock absorption quality of the spine.

            The feet are the body’s foundation.  Just like any change in a foundation causes detrimental shifts in a building, when the feet are placed in an unstable position, the other body parts must shift to compensate for the instability.  It is imperative that turnout originate at the hip joint and not be forced from the ankle or knee.  An efficient, healthy dancer is one who learns to make the most of his or her body, respecting and working with its strengths and within its limitations.