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Instep Dance Magazine Articles

Reprints of monthly column as first appearing in Instep Dance Magazine.

February 1998

Knee Injuries - Part One - Overuse

By Rick Allen, DC

"Better health leads to better dancing."

This month, let's move up the leg to the knee. This large, hinge-like joint is subjected to a great deal of stress in athletic activities, including dancing, and is frequently injured. Because there is so much information to cover, I'm going to split the article into three parts: overuse injuries, acute traumatic injuries, and osteoarthritis. I hope to interview dancers who have had knee injuries, so if you would like to help, give me a call or e-mail. I know there are quite a few of you who have had a problem with your knees at some point.

As I mentioned last month, chronic injuries result from low-grade overuse and poor biomechanics over long periods of time, such as dancing for hours on end in poor shoes. In fact, overuse injuries of the knee are sometimes caused by improper biomechanics of the feet, so ask your doctor to also check your feet and shoes for proper fit and support. In particular, check for excessive flattening or pronation of the feet as you stand and walk.

[ Diagram of knee / Q-Angle ]

Another biomechanical cause of chronic knee injuries is excessive Q-angle, associated with knock-knees, or genu valgus. This angle is measured by drawing one line from the center of the patella to the anterior-superior iliac spine (ASIS) of the pelvis, and another line bisecting the patellar tendon. The angle formed by these two lines is the Q-angle. Optimum measurement for males is 8 to 12 degrees; for females, 12 to 15 degrees. Q-angles higher than 15 degrees for men and 20 degrees for women are considered clinically abnormal.

A combination of such biomechanical imbalances predisposes a person to injury by putting excessive forces on the knee. If you have chronic or repetitive knee injuries, see a sports specialist for a thorough examination.

Three tendons are typical sites of overuse injury to the knee: (1) the patellar tendon connecting the patella, or kneecap, to the lower leg, or tibia; (2) the iliotibial band along the lateral (outside) of the leg and knee; and (3) the popliteal tendon situated on the posterolateral aspect of the knee. Oftentimes the catchall term "runner's knee" is given to all three injuries. Let me distinguish their origin and treatment.

[ Diagram of knee / Pateller tendon]

Patellar tendinitis, sometimes called "jumper's knee," is typically painful just below the patella. The pain is often insidious in nature, and there is rarely an acute injury noted. A dancer might note this pain following a lot of bending of the knees, as in Russian folk dancing, or leaping, as in ballet. The athlete (remember, dancers are athletes) with patellar tendinitis frequently has point tenderness and some swelling just below the kneecap. There may be pain when the tendon is stressed. Bending the knee to approximately 90 degrees and straightening the leg against resistance can reproduce the pain. If the pain seems to be located more directly under the patella, have your doctor check for chondromalacia patella, which is an inflammation and eventual softening of the cartilage under the patella.

Treatment starts by avoiding the vigorous athletic activity that puts stress on this area. More specifically, a patellar tendon brace, an orthotic device that places pressure over the patella, can be quite helpful. As mentioned above, check the biomechanics of the foot, too. Often it is helpful to apply heat to the area just before exercising and ice afterward. Anti-inflammatory medications, such as ibuprofen, may be helpful on a short-term basis, but can actually be harmful in the long run because they block prostaglandin pathways that promote healing of cartilage and connective tissue, as well as those that mediate painful swelling and inflammation. This can set you up for a vicious cycle of using anti-inflammatory medication. Remember, too, that these medications are the number one cause of hospital admissions for gastrointestinal bleeding.

[ Diagram of knee / Iliotibal band ]

Iliotibial band friction syndrome (ITBFS) is a leading cause of lateral knee pain. The iliotibial band is a superficial thickening of tissue on the outside of the thigh and leg. The band begins on the outside of the pelvis and runs over the outside of the hip and knee, inserting on the tibia, just below the lateral femoral epicondyle of the knee. Running, cycling, and, perhaps, dancing can all produce sufficient friction of the band over the lateral femoral epicondyle to cause painful inflammation.

Treatment again starts by avoiding the aggravating activity. If the area is not too inflamed a massage therapist or chiropractor may be able to release the fascia (connective tissue) and stretch the iliotibial band. You can help by stretching in a giant "C" shape. Stand with the affected leg crossed behind the other. Bending sideways at the waist, lean your upper body as far as possible toward the unaffected side, lifting the arm on the affected side over the top of you head. Hold for 15 to 20 seconds. Repeat five times. Anti-inflammatory medications may be used, bearing in mind the warnings previously mentioned. Better yet is to rub the area with ice for five to ten minutes following activity. In rare instances, your last resort may be partial surgical release of the tight band.

[ Diagram of knee / Popliteus tendon ]

A less common cause of knee pain is irritation of the popliteus muscle and tendon. The popliteus is a relatively small muscle at the back of the tibia. Its tendon winds gradually upward around the lateral side of the knee to attach to the femur just above the outside of the knee on the lateral epicondyle. The popliteus tendon comes into immediate contact with the joint capsule, a number of ligaments and tendons, and the bones of the knee. With each movement of the knee, the popliteus tendon slides past these parts, which may irritate the tendon. Chronic irritation leads to inflammation of the tendon and the surrounding structures, with the gradual development of popliteal tendinitis. I suffered from this injury following a day of learning water starts on a windsurf board in the Columbia Gorge.

When the knee is examined, tenderness is found in the area below the lateral epicondyle and above the line of the knee joint. The pain seems located deep in the knee. Bending the knee to a right angle and resting the ankle of the affected leg on the opposite shin can reproduce the pain.

Treatment again starts by (surprise!) avoiding the aggravating activity. If the area is not too inflamed, release the muscle and adjacent fascia may be possible. Alternating ice and heat, as described for other overuse injuries, may help bring healing blood flow and remove excess inflammatory fluids. If local treatment and rest do not resolve the tendinitis, professional help may be necessary. In my case, conservative care (avoiding the aggravating activity, massage, release of the fascia and ice) brought me around in a couple of weeks.

If you have an overuse injury such as I have described, hopefully conservative care will help you keep on dancing! Better yet, with care and preventative stretches and exercises, hopefully you will keep on dancing and not experience any of these debilitating injuries.

Next article: Let's continue by discussing acute, traumatic knee injuries. If you have had a knee injury and are willing to share your experience, please give me a call or an e-mail.

Future article: I want to do an article on foot supports, technically called "orthotics". If you have had experience with orthotics (good, bad or indifferent), I would appreciate hearing from you.

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