Knee pain in young dancers seems to be a trend among my patients, and I am sure I am not the only therapist seeing this. Is this related to growing? Poor technique? I don't think that answer is the same for every dancer, but here are a few things to consider...
One of the most common reasons that dancers suffer from knee pain comes from improper body mechanics and dance technique. This is not the fault of dance teachers or bad training, it is the fact that children have not yet developed good muscle control or stability. We see this across the board in any sport because when kids are growing they have not quite figured out how to use their bodies and are still developing. Especially in dance, which is meant to be a very controlled activity, a lack of body awareness can be quite problematic. The good news: dance teaches excellent body awareness and coordination from a young age, we just need to make sure dancers don't get injured as they are learning!
The first order of importance is learning how to properly align the lower extremity during the 5 different dance positions. If dancers can learn how to perfect their technique here from an early age, the risk of pain and injury goes down.
So how do we go about correcting alignment from a proper anatomical position? We work on something all dancers love- TURNOUT! I find the number one reason my dancers are having alignment issues and subsequent knee pain is from not knowing how to properly engage the turnout muscles.
Specifically with the knees, a lack of hip turn out means that the movement is likely coming from other areas like the feet, ankles, and the knees. It may be that the dancer has weak turnout or they may just not know how to properly engage the muscle.
A closer look at the knee joint:
The lower leg (tibia) and thigh bone (femur) sit stacked on top of eachother. It is known as a "hinge"joint, and therefore is only capable of moving in 2 directions- bent and straight. There isn't much ability for the knee joint to twist, unless it is forced into that position. Think of a door hinge- its set up allows it to only move into 2 directions, open and closed. What would happen if you came along and tried to move it in another direction? It probably wouldn't go very far and if it did it would have to come from a forceful movement that would more than likely break the hinge. That is essentially what happens at the knee when you twist it in a way it is not made to go. Combine the twisting that is occuring from the knees with other movements, like a demi plie, and you have a recipie for disaster. It may not "break"the first time like a door hinge would, but if you did it over and over every dance class you would eventually wind up having a problem or two.
What types of knee joint problems can occur?
When the leg is in poor alignment, most of the stress is directed toward the medial knee. Excessive stress in this area can lead to sprains of the ligament (medial collateral ligament or MCL), tears in the meniscus, or even contribute to arthritis later in life. Learning to use the turn out muscles young helps combat this "screwing"motion. It allows the thigh and lower leg bone to move together as a unit, thus reducing the less than ideal twisting motion and subsequent injuries.
The other place it is common to feel knee pain is on the front side near the knee cap. This typically comes from the repetative bending (plie's) or jumping causing too much stress across the patellar tendon. The repetition can lead to irritation/inflammation of the tendon, known as patellar tendonitis (often referred to as jumpers knee). Unfortunately a plie is one of the reasons for anterior knee pain because of the amount the knee has to move forward over the toes. In a typical squat position, you are taught to stick your butt out so the knees do not go over the toes. The purpose behind this is to reduce the amount of stress that occurs over the quad and patellar tendons which can cause problems. In dance, you can imagine the teacher nor the audience would be pleased to see a dancer with their rear stuck out behind them. But a plie is a plie, and the knee must move forward over the toe without question. Who ever said all dance moves could be modified just to make the knees happy? If that was the case, I would be out of a job. What will help, is learning to use those turnout muscles more. The more control you have from the hips, the less stress you will get on your knees.
So now you know a thing or two about why the knee pain can occur, but how can we help dancers to fix it? Something to consider is that often the language used by dance teachers does not make sense to a dancer. The use of imagery for corrections can be helpful but not always fully descriptive in how to do a movement correctly to reduce injury. Where one image can help one girl, it may sound like gibberish to the next. In a perfect world, individualized training from a teacher or dance medicine specialist would be ideal to help improve their coordination, movement awareness and more importantly overuse pain. The more awareness for movement you have, the better.
I always recommend that dancers spend time practicing outside of dance class to better build strength and body awareness. In a previous blog post, I talked about finding your turnout muscles. Once you learn to properly locate your turnout muscles, you have to practice using them in a functional way. Only knowing how to utilize the muscles during an exercise will not tranfer over into knowing how to use it when you are dancing. You have to practice A LOT to build up muscle memory so that your brain knows how to activate the muscle no matter what position or peice of choreography you are working on. A dance class is not always the most effective place to practice these techniques. It is relatively fast paced and has distractions. The presence of other dancers can also create a bit of competition making it less likely that a dancer will want to correct and use their true turnout. Remember, using the hip muscles properly makes it appear that you are less turned out, at least initially while you are learning to become more aware of how to use them. This can be embarressing to be in a less turned out position than everyone else. Sure, you are actually being smarter and safer, but its hard to see it that way when you are in a room full of 13 year old girls. Solution? Simple, practice your barre work at home. This way you take out all the distraction and competition of class and are left to your own devices. This can be much more beneficial for building awareness at your own pace with all the foundational movements of choreography. The more time and techniques you practice, the faster your body learns.
This blog really only skims the surface of knee pain. Hopefully it will provide you with a few things to start thinking about. And then, stay tuned because there will certainly be more information to come in future blogs!