Unspecific Knee Pain

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What is unspecific knee pain?

Unspecific knee pain is a condition characterized by regular episodes of knee pain that are hard to explain. You might experience knee pain during or after training that eases if you take some time off. Typically, though, the pain will instantly return when you start dancing again. Clinical examination, X-rays or MRI scans may not identify any obvious problem, inside or around your knee.
Such symptoms are often rooted in complex muscle dysfunction. Elevated myofascial tension in an affected extremity will put a lot of pressure on joints and lead to high levels of tension in the tendons and muscles involved. This can therefore be the cause of joint pain or any kind of ligament inflammation (insertional tendinopathies). While you rest, myofascial tension will decrease and symptoms will get better, but the underlying problem will persist and even worsen as soon as you resume physical activity.

How can it occur?

Unspecific knee pain in dancers is an overuse issue that results from intense ballet training, and is most often related to a number of different functional problems. As well as the underlying myofascial dysfunction, joint dysfunction of the spine and pelvis is also highly likely. You may therefore feel “blocked” in your back or hip or experience limited range of motion in different areas of your body. Unspcific knee pain is almost always rooted to a dysfunction of the quadriceps muscle.

Symptoms arising from muscle dysfunction usually follow two simple mechanisms:

  • elevated tension of the muscles and the fascia will put high traction and compression forces on joints and tendons. This can limit tendon flexibility and joint range of motion and can directly lead to overuse and pain.
  • dysfunctional muscles will not be able to work at their full strength and may therefore not fulfill all their functions properly. This can lead to instability and malalignment of the whole leg. Malalignment is a common cause of tendon and joint overuse and pain.

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 the piriformis (one of the smaller pelvic muscles inserting on the sacrum). This causes pelvic torsion and functional leg length discrepancy.
The increased amount of stabilization work needed to compensate for leg length discrepancy will overcharge different groups of muscles. The peroneals – a group of two active foot stabilizers on the lower leg – are often affected. With impaired function of the peroneals, both active leg and foot stabilization will be affected and overuse symptoms can arise in different areas of the knee.

What are the typical symptoms of unspecific knee pain?

Unspecific knee pain can show different pain qualities. You may have a dull pain around your kneecap that is difficult to localize or perhaps just experience an achy stiffness of your knee. However, intermittently occurring sharp pain in different localizations is also possible.

How can unspecific knee pain be diagnosed?

Your doctor will examine your knee and review your symptoms as well as your current training activities. He will especially check for specific pain in and around the knee. He will also put a focus on joint range of motion, leg alignment and knee stability.
Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of patellar subluxation is sometimes challenging and your doctor may ask a specialist in manual medicine for his opinion.
Typically MRI Scans or X-rays do not help finding a correct diagnosis. MRI scans may reveal local inflammation in the soft tissue involved with the problem but usually do not explain the whole range of symptoms.

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This SPECT scan is a very sophisticated diagnostic tool to visualize the level of biological activity in a specific area. In this case it shows an overuse in the tibia plateau of a dancer’s knee that could not be seen in a conventional MRI scan. It was the desperate attempt to understand a functional overuse problem but definitely didn´t contribute to solve it. This picture is shown for illustration purposes only. SPECT scans are not a standard procedure to diagnose unspecific knee pain.

What are the treatment options?

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.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. 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. Dysfunction 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.

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.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.

  • Find a specialist in manual medicine

Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.

  • Start working on your problem

There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:

Flexibility trainingITB release, Rectus femoris release, Hamstrings release, Adduktor release, Psoas stretch, Lumbar spine releasePiriformis release,

Strength training: Core training – resistance band workout, Core training – Abs crunches, “The clamshell” – Piriformis training, “The monster walk” – Piriformis training

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.


 

 


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