Let's be sure to recognize that the knee cap is not the knee. The knee is the large joint formed by the meeting of the upper and lower leg bones and includes the knee cap (patella) and all the soft tissue structures which line, move, support, and protect the bony anatomy. The patella provides a protective plate to safeguard the joint but it's primary function is to maximize the force production of the quadriceps ( the thigh muscles in the front of the leg ), acting as a pulley to increase mechanical production and to distribute tendon forces during stress and weight bearing.
Misalignment can throw off the physics of the entire leg structure and cause pain. Therefore the first issue we will look at is alignment.
The Knee in Relation to the Foot:
Because the knee is a visual reference for where the joint is we can monitor our alignment by looking to see its relationship to the foot bones. In time we can learn to sense this alignment which will be necessary in order to move easily and without concern.
Healthy movement of the knee in dance and sports is dependent on our awareness of how the weight is distributed through the foot and the ease of joint mobilization through the hip, knee, ankle, and foot. Of course it seems that natural movement should come naturally but we do much more extreme range of motion in advanced sports and dance. With muscle imbalance from lack of activity or overuse of particular muscles even walking and climbing stairs can result in pain over time. Therefore a little education can help us to function more efficiently in all activities!
When we bend the knee should generally align with the second metatarsal, easily referenced as the second toe but as movement is initiated there will be a natural tendency for some desirable pronation to take place. The knee alignment over the second toe is a very stable position and maintains a more rigid foot which would be preferred for strength activity such as heavy lifting and squatting. However for dancing we require a reactive and soft foot which is adaptive and mobile and responsive to the floor and the kinetic activity of the entire human structure. This slight pronation or movement of the knee in the direction of the big toe activates the muscles of the entire leg and allows motion throughout the foot. The foot and ankle contain 26 bones, 33 joints, and over 100 muscle and tendon structures and all of these structures need to be available to the dancer as lively and activated movers! The more rigid foot where the second toe and knee align is a place to begin but we cannot dance without releasing into natural pronation which mobilizes joints and muscles. Excessive pronation can present a problem but a healthy amount will help protect the knee as it turns on supporting structures.
This natural pronation occurs as turn is initiated in the feet which demands a broader discussion of the technique.
Especially For Ladies:
That being said the female dancer presents with excessive pronation frequently because of the body structure and weaker hamstrings seen in testing female dancers and athletes. Ballet dancers may pronate to a dangerous degree if the turnout muscles are weak and they force turnout in the knee and foot causing them to roll into the arch. Our more natural walking actions in ballroom should allow for the diagonal transfer of weight through the foot so the weight moves across the big toe joint toward the push off phase. Lady dancers also weaken the hamstrings by wearing high heels so they need to be sure to stretch and strengthen those muscles as well as the large hip muscles to avoid the knee moving too far inward.
Here the feet are open and receptive to the floor. The Latin shoe poises the lady's weight more to the front of the foot and can easily encourage a tense and gripped foot. Spread the toes and feel that you are creating a suction cup towards the floor and not pulling the toes into a type of fist.
Dr. Amelia Wiggins presents information on knee pain and injury in female dancers at the Mercy health Symposium for Dancers.
Photos and illustrations by Bonita Brockert
The Oversway as a Dance Application
Here the alignment is marked along the second metatarsal. The two small arrows show the map of where the knee would line up for a more rigid foot required for protecting the knee in a squat or other strength type stationery activity.
The larger arrow pointing toward the big toe illustrates the desirable pronation taking place in moving forward or laterally which activates the muscles and joints of the leg, hip, and foot.
This short video shows the neutral position of the foot in weight bearing but static and then the pronation taking place as the body weight moves forward and the knee flexes into a dance movement.
The Knee is the largest joint in the body and the most frequently injured. It is capable of flexing and extending with limited ability to rotate and slide. The knee is fragile in athletics as the structures that hold it can easily be overstretched with physical demands. Through proper alignment we can lessen injury which can result from the rapid directional changes and wide range of movements required of dancers. Perfect technique does not insure you will never be injured as there is always the possibility of a fall, overuse, hard or sticky floors, etc. but it will certainly protect you from the many problems which manifest if you repeat a movement with poor technique enough times.
Of course if you already have an injury or significant cartilage wear you will still have pain when you move no matter how good your technique may be . We are assuming that we are looking at a healthy knee. Muscle imbalances, weakness, and tight areas in the lower extremities will cause alignment problems and pain. Also many individuals may have structural problems and need orthodics to help balance the feet. No discussion of the knee is complete without attention to the foot as they directly affect one another.
One common source of knee pain results from poor tracking of the patella (knee cap) along the patellar tendon which is the tendon of the quadriceps muscle. This tendon attaches to the tibia (lower leg bone) right below the knee. The posterior groove of the patella allows it to move along this band. Tracking injuries can occur through a blow or fall, attempting to turn on a sticky floor, turning in sneakers, etc. These are examples of an acute injury caused by a moment of trauma. Frequently the knee will begin to hurt without any such incident and this is often a result of muscular imbalance and/or poor technique and alignment. perfect practice makes perfect but pain and injury result from repetition with incorrect technique.
Kelly Jo Trimble, Cincinnati Ballet Athletic Trainer, demonstrates how the dance medicine team assesses dancers for injury prone areas. As weak or tight areas are identified the dancer's wellness plan can be personalized. (Mercy Health Dance Medicine Symposium)
Men students often have difficulty in movements like the oversway. particularly the throwaway oversway, or similar rotational entries to movements like the left whisk. The big muscles of the hips and thighs must be trained to maintain proper alignment and safe movement over the supporting leg and foot as the right hip and thigh rotate into the left leg. Hip flexion is often compromised in adult students and they may resist the strong crease needed in the left hip joint which allows a full and free movement and the flexibility throughout the leg joints which helps maintain a safe relationship of shin and knee to foot. Without an awareness of toning and resistance in the standing leg muscles combined with flexibility in the hip and ankle the knee will swing outside the foot and stability will be lost. Restrictions in the hip and untoned legs increase stress load and opportunity for injury if repeated often enough. Sometimes one good overturn will result in an acute injury. As always this weakness is not only damaging to the lower extremities but is also a disaster for the lady and produces an ugly line (usually combined with a wobble!)
"Lowering" Too Much of A "Good" Thing?
One more common fault in ballroom dancers is over bending/lowering excessively. This can be seen everywhere but particularly in waltz, tango, bolero and samba. Many times the lowering phase in waltz is technically wrong and the student will lower on one instead of commencing to rise at the end of one. Whether a result of falling out of balance on three, misunderstanding the rise and fall, undertoned legs, or the idea that more is always better, the weight taken heavily into the knee and beyond the foot is ugly, dangerous, and prevents the natural rebound of weight through the legs. In samba and bolero it is also unattractive and creates a loose and flimsy leg as well as an injury prone situation.
If you are dancing with correct technique and tone and have well balanced muscle strength and flexibility your knees should not be painful while dancing. If so there is something going on in your mechanics of dancing or the mechanical balance of the body an assessment should be made with a good dance medicine therapist and dance coach. Don't just assume that it should hurt to dance and rely on a knee brace and a bag of ice. Get a good evaluation of your physical condition and your dance technique.
Look familiar? How many entertainers do you see in media who can barely stand let alone dance in those stilettos? You may see yourself here, recalling early attempts to dance in a Latin sandal. There is ample fodder for judges as we see these legs and feet so often on the competitive floor. Taking the time to train the proper technique is absolutely essential for both beauty and security as well as support for hip and rib cage actions.
It is an undertaking to shape the feet, ankles, and knees even without the added challenge of a high heel . Ladies need to develop strong technique to control the base action AND the shoe!
Protecting the Knee Part two Revised
(originally published in Dance Week)
by Bonita Brockert
The body weight should be felt fully through the foot with the foot "open" and not tense and with awareness of the four corners of the foot. Sometimes this is described as a tripod made up of the large heel bone (two corners of the back of the tripod) and the metatarsal heads of the big and little toes. The surface area, the pads of the metatarsals or ball of the foot rest into the floor and the toes which are levers for foot action should be open and sensitive to the floor, ready to respond to the direction of weight moving around in the foot. The "four corners' gives a better picture mentally of the width of the heel bone and it's support balanced with the other points of the forefoot. This can be a new way of thinking for the lady dancer who is poised atop a high and tiny heel in her pump or sandal. She may visualize her heel as having the same shape and not allow herself to move around the bone as she sees it as such a tiny point.
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Poise and Awareness in the Foot
Here the toes are more "gripped" inwardly and there is less foot to floor connection and intrinsic muscles are tense.
Here the dancer is unaware of the excess supination (rolling to the outside) taking place in his foot and knee while dancing a throwaway. The knee should remain inside the shoe within the first three metatarsal bones and weight should be distributed through the foot rather than mostly to the outside edge. Pressing the big toe into the floor can be a good reminder and helps to stabilize the placement. (This is a movement which requires a more stable foot as there is additional loading and forces are different than those encountered in moving actions. Therefore the "knee over second toe" rule is more applicable here). This requires keen awareness as the turning of the hips will force the knee outside the base of the body unless the dancer disciplines the angles of the lower extremities.