Medical Knee Pain: Dancers vs General Populations
Non specific medial knee pain is a fairly common ailment experienced by a wide variety of clientele. We find that there are a few distinct differences when dealing with knee pain in general populations compared to when dealing with dancers. In general populations we find that medial knee pain is more likely to be related to muscle tightness due to poor joint stability and poor movement mechanics.
In contrast, we find that in dancers the pain is more likely to be caused by their excessive range of motion and lack of strength at end ranges of motion so as a result the treatment plan is quite different. Not to mention that in most cases the dancer needs to be able to resume training and performances so the rehab program needs to address the underlying cause of the knee pain whilst maintaining flexibility, joint mobility and balance.
SYMPTOMS:
– Medial knee pain – particularly in single stance or at depth
– Decreased stability – especially when standing on the affected leg.
– Decreased range of motion due to pain inhibition.
– Decreased strength and impaired ability to perform large compound movements
CAUSES & RISK FACTORS FOR MEDIAL KNEE PAIN:
General Populations:
– Muscle tightness (adductors, sartorius, gracilis etc)
– Muscle imbalances
– Poor Force Dynamics
– Lifestyle (occupational postures etc)
Dancers:
– Hypermobility
– Decreased muscle strength at end ranges of motion
– Postural issues conditioned by dance
Style-dependant differences:
– Ballet: rotation and being on pointe puts more load through the medial knee
– Contemporary: increased floor work and work at depth
EXERCISE INTERVENTION PROGRESSION PLAN:
With dancers there is almost a ‘split’ program with half of the program focusing correcting the underlying causes of the knee pain as well as addressing proprioceptive and stability work; whilst the other half of the program needs to be style-related general strength and conditioning.
PART 1: Dancer-specific Knee Rehab Program:
1. Muscle Activation – focused on knee stabilising muscles
2. Strength – Compound muscle strength
– Weight-bearing, bilateral and unilateral, single plane strength
– Weight-bearing – unilateral, single plane strength at extreme ranges
– Multi-directional complex dynamic work with the introduction of rotational movement
PART 2: Dance Style Specific Conditioning Program:
Below is a general overview of the main components that we address in the conditioning side of the program however this part of the program needs to be very specifically tailored to the individual:
– Conditioning program focused on relevant physiological adaptions
– Flexibility and mobility work
– Muscular endurance related conditioning
– Upper body postural and strength related work
CONSIDERATIONS:
General considerations
– Severity and mechanism of injury
– Strength of knee and hip stabilising muscles
– Strength at end ranges and strength out of depth.
– Patellar tracking – VM Strength
– Pelvic control – in all planes and direction
– Static posture vs performance in dynamic movement
– Hip and ankle mobility
– Ankle proprioception
Specific and personal considerations
– Mechanism of injury and timeframe of onset of pain (acute vs progressive onset)
– Injury history – acute vs chronic problem
– Injury history – injuries to other joints and/or structures.
– Jumping and landing mechanics
– Technique – pirouettes etc
– Realistic ability to reduce volume or rest
CASE STUDY – MEDIAL KNEE PAIN
18 yr old elite dancer
• Subluxed knee during contemporary dance piece during the performance week for her full time dance program.
• Had been experiencing knee pain and signs of instability prior to incident.
• Cause was increased hip mobility and lack of strength at end range as well as poor patellar tracking and knee instability due to decreased VM (Vastus medialis) strength.
Program outline
1. Manual Therapy
• Used to help promote healing and encourage mobility during the acute stages of injury.
• Incorporated hands on soft tissue release work and dry needling
• This was performed over the first month of her rehab and progressed towards exercise based intervention as pain reduced.
Case Study: Special Considerations
This client had a limited training history where resistance training was concerned despite being a very technically sound dancer. The progression plan had to prepare the client for the introduction of single stance exercises as her strength and stability on both the affected and non-affected side was inadequate initially. For this reason the program took slightly longer to progress to unilateral compound exercises in normal ranges and at depth than what we may find in clients with a more extensive training history.
For a ballerina we would have even more focus on exercises with rotational movement, proprioception as well as multi-directional dynamic stability exercises so that they were able to cope with the high volume of piroutte, foutté and pivot work. For this client this type of work was certainly important hence the inclusion of these types of exercises but given the nature of the floor work and transition work in contemporary dance, strength at depth took priority.
Dance specific conditioning phase was run in conjunction with this and sought to improve whole body endurance. Upper body exercises focused on developing scapular setting and overhead stability as well as support strength to prepare the dancer for all of the falls, partner work and floor work in contemporary pieces. Lower body exercise selected centred around a mix of double stance compound exercises appropriate to the current level of progression in the rehab progression at the time. The lower body exercises needed to reinforce what was being targeted in the rehab program however needed to be at a slightly easier level of progression as they were performed under fatigue.
2. Exercise Intervention – Phase 1: Muscle Activation
• Focus was initially on predominantly isolative work on knee then also hip stabilising muscles.
• Progressed from non weight-bearing to weight-bearing exercises as pain and associated muscle inhibition reduced.
Example of exercises used in this phase of training:
• VM Activation with foam roller
• Single leg extensions
• Hamstring curl and lift
• Banded clams
Then progressing on to exercises such as the following later in the phase:
• Leg press 1 and 1/4’s
• Wall ball sprinters
• Monster walks
• 1 and 1/4 box squats
• Supported pistol squats
3. Exercise Intervention – Phase 2: Strength – Compound Muscle Strength
Progression plan was as follows:
i. Weight-bearing, bilateral & unilateral single plane exercises.
Example of exercises used in this phase of training:
• Front squats
• Sumo squats
• DB step ups
• DB static lunges
ii. Weight-bearing unilateral and single plane exercises at depth and extreme ranges of motion.
Example of exercises used in this phase of training:
• Pulse deadlifts & deficit deadlifts
• Deep box squats
• High box step ups & high box step downs
• Full range supported pistols
iii. Multi-directional complex dynamic work with the introduction of rotational movement.
Example of exercises used in this phase of training:
• Kettlebell single leg deadlift resisting against band pulling knee medially
• Single leg ‘star’ pendlums
• Multi-directional lunges
• BOSU lateral jumps/ hops