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Instep Dance Magazine Articles

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

March 1998

Knee Injuries - Part 2a - Trauma

By Rick Allen, DC

"Better health leads to better dancing."

This month, let's continue examining injuries to the knee. Because it is constructed as a hinge-like joint with the femur and tibia forming long lever arms, it can easily be subjected to enough stress in athletic activities, including dancing, to be traumatically injured. Because of its design, the stability of the knee joint depends entirely on soft tissues: muscles, tendons, ligaments, cartilage and a joint capsule. This is less sturdy than the hip joint, for instance, which is a strong ball and socket joint made of bone.

Common injuries to the soft tissues include strains of muscles and tendons and sprains of ligaments. They may also include dislocations of bone and injury to the cartilaginous menisci. A dancer may sustain such an injury by a misstep on an uneven surface (including, heaven forbid, their partner's foot!), going up or coming down from a lift improperly, or possibly by tripping and falling forward, forcing the knee into hyperextension. Let's examine four of these types of injury: collateral ligament sprains, patellar dislocations, sprain or tearing of the cruciate ligaments, and damage of the menisci.

[ Diagram of knee /collateral ligaments ]

Collateral ligament sprains: On each side of the knee are ligaments that allow the knee to flex and extend, but prevent sideways motion. A misstep with a sideways force may sprain one or both of these ligaments. As I explained in January, sprains are classified into three grades of severity. A first-degree, or mild, sprain is one in which only a few ligamentous fibers are damaged. There is pain, mild tenderness, minimal swelling and bleeding, and, above all, no abnormal instability or laxity of the joint. The medial collateral ligament is the most commonly injured. A minor sprain can be treated by ice initially and support by crutches if needed, with rapid advance to weight bearing, full range of motion, and return to dancing in a few weeks. Massage of the surrounding muscles and cross-fiber friction of the ligaments, as tolerated, help prevent adhesions from forming and promote complete recovery without residual problems. I also encourage use of vitamins, especially vitamin C with bioflavonoids, herbs, such as white willow, and the proteolytic enzyme bromelain to promote a speedier recovery.

A second-degree, or moderate, sprain is due to a greater ligament disruption, but one that is not yet a complete rupture. Pain, tenderness, swelling, and bleeding are more evident, but the key feature is the presence of some instability or laxity of the joint. The amount of laxity depends on the amount of ligament that has been torn. Treatment ranges from that for a first-degree sprain to cast immobilization for 4 to 5 weeks. You may be out of action for 8 weeks or more. During this time it is important to maintain aerobic fitness by doing activities which don't stress the leg and knee, such as upper body exercises and, perhaps, swimming.

A third-degree, or severe, sprain is due to a complete rupture of the ligament and is associated with marked disability. Often there is a tear in other ligaments and a meniscal injury as well. Such a combined injury usually demands surgical repair.

[ Diagram of knee /patellar area ]

Patellar dislocation: The patella, or kneecap, acts as a fulcrum by which the quadriceps, or thigh muscles, gain mechanical advantage when straightening the leg. The patella rides in a groove at the end of the femur. If the patella shifts to one side or comes out of this groove (ouch, yes, BIG ouch), it has become partially or fully dislocated. Typically, this happens when an athlete, such as a dancer, performs a twisting activity. Most commonly, the rear leg rotates inward and the patella shifts laterally, to the outside.

A professional should treat a dislocated patella. An x-ray is necessary because of the potential for bone fragmentation. Typically, the doctor will relocate the patella after injecting a local anesthetic. Thereafter, the knee is immobilized for several weeks, followed by rehabilitation exercises.

The patellar may chronically subluxate, or shift to one side without completely dislocating, following an acute dislocation or in the person whose patellar shape and alignment is such that the patella has a tendency to slide to the outside. This may cause pain when climbing stairs or when doing activity in which the knees twist. When examined, there is tenderness under the patella, and a positive apprehension sign. That is, when the kneecap is pushed to the outside by the examiner, pain is not necessarily experienced, but the person feels very anxious that the kneecap may shift out of place.

A patella that subluxates requires similar rehabilitation exercises that do not stress the kneecap. These are generally done with the knee in extension or in only slight flexion. Leg lifts, initially with light weights of only a few pounds, are used to strengthen the quadriceps, especially the inside muscle group, the vastus medialis oblique (VMO) fibers. Strengthening the quadriceps helps stabilize the knee and leg. Gentle closed chain exercises with buoyant support, such as partial leg bends in a pool, have been shown to be quite beneficial for speeding recovery. A brace may be valuable to stabilize the patella in place. If persistent symptoms occur despite an adequate trial of exercises and bracing, surgery may be necessary to repair damaged ligaments.

Next article: Oops! I'm out of space, so let's continue next month with two additional acute, traumatic knee injuries: sprain or tearing of the cruciate ligaments and damage of the menisci.

I know there are quite a few of you who have had a problem with your knees at some point. If you have had a knee injury and are willing to share your experience, please give me a call or an e-mail. It is always helpful for others to read about your personal experience.

Future article: I still 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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