What is a meniscal tear?
The two menisci are c-shaped structures inside the knee joint: the lateral meniscus on the outside of the knee, and the medial meniscus on the inside. The most important function of the menisci is to distribute the pressure from weight-bearing activities across a large surface area of the cartilage covered joint, to reduce the impact overall. The menisci move back and forth, allowing the thighbone (femur) to glide and rotate on the shinbone (tibia). A meniscal tear is a rupture of the meniscus. This is the most common injury of the knee joint but can be particularly serious for dancers. The menisci contribute to rotational stability of the knee, especially in very mobile joints. Rotational stability is crucial in dance and a loss of stability may cause severe overuse issues; it may lead to high mechanical wear of the cartilage, with the risk of early onset arthritis of the knee.
How can it occur?
Meniscal tears in young dancers are usually traumatic. They can occur when the knee is forcefully twisted with the foot in a fixed position. In older dancers they can also be degenerative and occur with a minor trauma or just an uncontrolled movement. If a meniscus is degenerative, this means that the tissue of the meniscus has lost its flexibility and stability due to permanent overload. It therefore may become prone to injury.
Muscle dysfunction can seriously affect leg alignment and stabilization and is an important contributing factor to knee injury and overuse issues concerning the lower extremities. Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with dance injuries. Psoas dysfunction leads to tightness of the rectus femoris muscle (a part of the quadriceps) and causes anterior rotation of the pelvic bone (ilium/innominate). As a result, the hamstrings on the back of the thigh will be loaded and a dysbalance between the hamstrings and the quadriceps will build up. Active knee stabilization thus will be seriously affected and the risk of a meniscus injury will rise.
What are the typical symptoms of a meniscal tear?
Typical symptoms of an acute meniscal tear include a sharp pain either on the inside or on the outside of the knee, a swelling of the joint and often a limited range of motion. You may not be able to fully bend or straighten your knee or it may even get stuck in a position. Whenever this happens, you should consult a doctor immediately.
How can a meniscal tear be diagnosed?
Your doctor will examine your knee and perform some specific tests to find out if a meniscus tear is present. These tests may provoke a sharp pain if the meniscus is torn. However, it is important to relax your knee and focus on the location of the pain during examination. If a meniscal tear is suspected, an MRI scan is usually necessary to verify a tear and determine the type and severity of the lesion. It will also be able to show other problems inside the knee like cartilage defects or lesions of the cruciate ligaments.
This MRI scan of the knee shows a tear in the medial meniscus portrayed as a white gap in the triangle-shaped meniscus. Fluids appear white in this picture. Due to the tear there is a substantial amount of liquid in the joint labeled as “joint effusion”.
What treatment options are there?
If you have severe or constant knee pain, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers. The results of the MRI scan will determine further treatment. Most of the detected meniscal tears will have to be operated on.
Depending on the type of the meniscal lesion, the torn part of the meniscus will have to be removed or can sometimes be fixed with a suture. Arthroscopic surgery can be performed to treat most meniscal tears. The advantage over traditional open surgery is that the joint does not have to be opened up fully. For knee arthroscopy only two small incisions are made: one for the arthroscope and one for the surgical instruments. It is therefore referred to as a minimal invasive technique.
In order to handle a given overuse situation in the course of rehabilitation, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine.
Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
You had a knee accident or suspect a problem with your meniscus? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis. If surgery is recommended, finding a doctor who is familiar with dancers’ knees is sometimes challenging and you may want to see different specialists. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Start working on the underlying problems after an operation
As far as rehabilitation allows, there is a lot that you can do to work on the problems that may have contributed to the accident. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients (most of them can be performed wearing a brace):
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.