Knee pain is common in Irish dancers, second only to pain and injury at the foot and ankle, and accounts for 20% of all injuries in Irish dance. There can be many factors that contribute to a knee injury, but what every dancer must know in regards to the knee is that: Where the pain is, is not always where the problem is. Here are three common problems that can lead to pain and injury at the knee: 1. HIP WEAKNESS To understand the connection between the hip and the knee let’s do a brief anatomy review. The mechanics of the knee is largely controlled by muscles at the hip, specifically the gluteus medius muscle. The gluteus medius muscle lies at the side of the hip and functions to lift the leg to the side (hip abduction). It also helps to rotate the hip, and keeps your pelvis level while walking or standing/landing on one leg (prevents “sinking into” the hip). When gluteus medius is weak it causes the knees to fall inward relative to the hip and foot especially when landing from jumps. We call this medial knee displacement. If you want to check to see if you have a weak gluteus medius, watch your knees in the mirror as you squat on one or both legs, or when you land from a jump. If you’re weak, you’ll notice that one or both knees falls inward towards midline of the body.
(medial knee displacement and lack of ankle dorsiflexion vs correct alignment)
The gluteus medius should ideally be 4x more active at the hip than the inner thigh muscles (adductors) are. This means that when the inner thigh is either tight or too strong, and the outer thigh isn’t strong enough, it puts excessive stress and strain on the nee joint. This can lead to knee injuries such as patellofemoral pain syndrome (tracking dysfunction), patellar tendonitis, IT Band syndrome, medial ligament sprains, and even meniscus tears. To address this risk, dancers should work on targeted strengthening of the gluteus medius muscle. Also, try stretching or inhibiting the adductor muscle group in the inner thighs with either passive inner thigh stretches, and by rolling on a foam roller.
Hip Abduction
(keep leg in line with spine)
Hip Abduction + Extension
(kick up and back leading with the heel, use the hip and don’t arch the back)
Inverted Clam + Kick Back
(keep hip rotated in, start with knees together, use the hip to kick up and back lead with the heel)
Banded squats
(focus on hips going backward instead of down, and watch knee alignment in the mirror)
Banded Fire Hydrants
(practice with the knee and hips slightly bent, and again in a deep bend for different challenges, watch the alignment of the supporting leg so knee doesn’t fall inward; working leg lifts up and towards the back)
Single Leg Step Outs
(focus is on proper alignment of hip, knee, foot) bend hip/knee and tap the heel and watch in the mirror
2. ANKLE STIFFNESS A stiff ankle, especially one that doesn’t bend adequately into dorsiflexion (flexing the ankle so the toes point up) will also cause medial knee displacement. Stiff ankles are consistently linked to poor alignment of the knee and can increase wear and tear at the knee over time. Loss of dorsiflexion is common in dancers who have tight calf muscles, as is often the case with Irish dancers who spend so much time up on their toes. A tight calf pulls on the ankle joint and limits the ankle’s ability to flex upward. Limited dorsiflexion motion is also common in dancers who previously have experienced an ankle sprain but did not adequately restore full range of motion or strength as part of their recovery. Up to 50% of total energy from impact is absorbed in the ankle as the it flexes when landing from a typical jump. But, because in Irish dance the ankle stays quite stiff and the heels elevated, less energy is absorbed at the ankle. This means that more total energy must be absorbed at other joints, including at the knee. One way dancers should address this risk is to work daily on maintaining proper muscle flexibility in the calf muscles. The healthiest muscles are both strong and flexible. A stiff, inflexible calf or ankle does not absorb much energy from impact with the floor. Calf stretches should be done with the knee both straight and the knee bent and be held for minimum 30 seconds each. I recommend stretching the calf 3x/day for most dancers. Dancers can also benefit from a manual therapist or physician who can mobilize the ankle joint and assist with providing an even deeper stretch to the muscles.
(Straight and bent knee calf stretching. Can use incline board or just base of the wall with shoes on. Heel should be resting on floor instead of off a step) The second way to address this risk is to improve eccentric calf strength. The calf is a significant factor in absorbing energy when landing from jumps. Eccentric strength is strength while lengthening. In the case of the calf, eccentric strength is the ability of the calf to control the heel as it descends during a landing from a jump. While Irish dancers are traditionally very strong in getting up and staying up on their toes, eccentric weakness, ie. weakness in controlling the landing of jumps, can be common. Dancers should be able to perform 25 single leg heel raises off the edge of a step without fatigue. They should be able to do this both with the knee straight, and with the knee slightly bent to target both the gastrocnemius and the soleus calf muscles. For an eccentric focus, raise the heel all the way up quickly on 1 count, then slowly lower the heel down into a full stretch off the step, taking 5 counts to do so in a smooth controlled manner. Complete 25 reps with the knee straight, and 25 reps with knee bent, once daily.
Eccentric Heel Raises (straight knee)
Eccentric Heel Raises (bent knee)
3. FORCED TURN OUT
Dancers consistently strive for that perfect turn-out, but sometimes at a cost. When the turn-out muscles of the hip are weak or the hip joints lack mobility, it’s common for dancers to force their turn out by overly rotating at the foot and ankle to create the appearance of improved turn out. This creates a rotational stress at the knee joint, leaving the knee susceptible to injury. Focusing on strengthening turn-out muscles at the hip instead of forcing turn out at the foot and ankle can help reduce the risk for knee injury. You can check for forced turn out by watching your knee caps (patellas) while you dance turned out. Kneecaps should ideally point in the same direction as your toes. If they don’t, you may be forcing your turn-out from your foot.
Exercises like clamshells are a great place to start to improve hip turn out. Make sure you open the hip to your full range and don’t compensate by rotating through the back. Dancers should be able to confidently complete 3 sets of 20 reps on each side before adding resistance with a band. Using rotational discs is also one of my favorite ways to help dancers identify if they might be forcing turn out. Rotational discs are frictionless and help a dancer to really see and feel true turn out from the hip. They can also be used as a training tool for turn-out.
Clamshells
There are numerous safe and effective exercises to optimize strength, mobility, and performance at the hip, foot and ankle for the Irish dancer. Targeted stretching, strengthening, and learning how to jump and land correctly with proper hip, knee, foot alignment is critical to success in preventing knee injuries in Irish dancers. The vast majority of dance injuries can be prevented with proper training and care. Thus, I highly recommend working with a qualified teacher, strength coach, or dance medicine professional to identify these risk factors, and learn how to prevent dance injuries.
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Dr. Carrie Skony is a Certified Chiropractic Sports Physician®, dance medicine specialist, and owner of PERFORM Active Wellness + Dance Medicine in Lisle, IL where she enjoys working with dancers from all over the Chicago area. You can learn more about Dr. Skony at www.drcarrieskony.com or follow her on Instagram and Facebook, @drcarrieskony, for more dance related tips.