Knee and Thigh
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.
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.
Adolescent Anterior Knee Pain
Patellar Femoral Syndrome
Medial Collateral Ligament Tear
Anterior Cruciate Ligament Tear
"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).
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.
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.
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.
" 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.
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.
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.
" 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.
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.
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.
"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.
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.
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.
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.
" 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.
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.
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.
" 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.
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.
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.
" 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.
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'.
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.
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.
" 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.
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.
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.
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.
" 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.
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.
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.
" 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.
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.
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.
- Strengthening the knee and hip muscles are critical to preventing overuse injuries. Strong, balanced muscles will help take strain away from the knee.
- 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.
- Give your body time to rest and heal itself, otherwise damage can build up and cause chronic pain conditions.
- 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.
- 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.
- 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.