Anterior Knee Pain in Dancers

Mar4th 2019

Looking Beyond Patellofemoral Pain Syndrome

Written by Carolina Rotondo, MPT, Hons BSc Kin

Reg. Physiotherapist 
Cert. McKenzie MDT Practitioner (MIC)
Cert. Complete Concussion Management Practitioner

Research has shown that single-sport athletes like gymnasts, figure skaters, and dancers are more susceptible to injury than their multi-sport counterparts.  When it comes to complaints of knee pain in dancers, our goal is to make an accurate clinical diagnosis that lends to favourable outcomes.  Here are some critical questions we try to answer:

knee pain in dancers, three ladies dancing ballet
  1. Is the knee pain being referred from the back? In as many as 50% of reported knee problems, the issue may not even be the knee itself.  An examination of the lower back (even though there may be no complaints in this area) and the nerve roots that ultimately extend to the knees are thoroughly screened using static or repeated back movements and assessing for a symptomatic and functional response in the knee.  These cases often resolve quite rapidly.
  2. Once the spine is cleared, is there an obstruction of the knee that is altering its mechanics and causing pain? Joint obstructions can rapidly change if the right movement is found (this is called a direction of preference).  Luckily, in the knee, there are not a lot of movements to explore.
  3. Not the spine, not a joint obstruction, so is this a soft tissue injury? Soft tissue injuries meet very specific criteria and often respond to optimal loading strategies: too much load can cause setbacks, while too little a load reduces tissue capacity.  There is good and bad news here  – soft tissue repair can take several months to fully recover; however, we can probably keep you participating in your activity provided that we manage the load appropriately.
  4. Not the spine, not a joint obstruction, not soft tissue, so what’s left?  In a majority of cases, we would have already made a diagnosis prior to reaching this step.  But let’s take a look at one option for those who have slipped through cracks: Patellofemoral pain syndrome (PFPS).
Holly Maher was our (Canadian-born) MSc Physiotherapy Student from Robert Gordon University in Scotland , from October to December 2018.  Additionally, Holly is an ADAPT Certified and Acrobatique Certified Dance Teacher.  From here, Holly will tell you everything you need to know about knee pain in dancers.
Growing up as a dancer myself, I suffered from this knee pain throughout my adolescent years. I never was able to get it to completely go away. I just got used to “dealing with it”. Eventually I went to university and stopped dancing so frequently. It was that tapering down in combination with finally learning to treat myself that allowed me to participate in activities pain-free!
Knee Pain in Dancers
  • The prevalence in dancers ages 11 – 16 is 30-36%.
  • Knee (and back) pain are found to be more common in dancers than any other athletes.
  • Knee pain is found more prevalent in dancers greater than 11 years old and increases relative to the start of puberty.
What is Patellofemoral Pain Syndrome?

According to the Patellofemoral Pain Consensus statement, the core criteria to define PFPS is:

  • Pain around or behind the patella (knee cap).
  • Aggravated by at least one activity that loads this joint (ex. Squatting, ascending/descending stairs, running, jumping).
  • Provocation during a squat is the best available test.
  • Affects both physically active and sedentary individuals.
  • Prevalent in 7 – 28% of young adolescents.
Why does this happen?
  1. Misalignment of the Patella
  • Normal knee tracking involves the patella moving straight up and down when the knee bends (2a).
  • In some research, it was found that in PFPS the patella gets pulled out to the side when the knee bends instead of straight (2b), known as  lateral patellar displacement and tilt).
  • Also some limited evidence showing an association of PFPS and patella Alta (knee cap sitting higher than usual)
** This, supposedly, leads to increased grinding underneath the patella causing pain.  However, current research tends to minimize the effects of anatomic and biomechanical variations on performance and injury prevalence in elite athletes, because they are now being found in athletes without pain. **
  1. Muscle Weakness: A consensus of which muscles are to blame is limited, however:
  • There is good evidence suggesting that quadriceps weakness plays a key role in PFPS.
  • There is some evidence that suggests weakness in the gluteus muscles that contributes to PFPS.

3. Influence of Physical Activity

  • Muscle imbalances and flexibility have been identified in sedentary individuals with PFPS.
  • A recent increase in activity or excessive activity may also contribute to PFPS.
But what about in dancers?
Factors Contributing to PFPS in Dancers
  1. Eccentric Loading and Repeated Landing.  Many dance movements involve a plié, which is the slow bending of the knees done in turnout. Additionally, the plié position is used to decelerate the body and absorb impact on landing a jump. Landing a jump requires eccentric contraction of the quadriceps muscle; which means that the muscle is lengthening around the knee joint while still maintaining tension.  Unfortunately, there is not enough time and effort spent in training the movement pattern and muscles necessary to withstand these demands repeatedly over time.
  2. Turned out position.  Many young dancers are not capable of producing the external rotation in the hips to produce the “ideal” turnout position. The turnout muscles are very small and deep within the structure of the hip.  In young dancers, it may be difficult to learn how to activate these muscles, and instead, they will often use the larger external rotator of the hip, the gluteus maximus. However, glute max extends the hip; when, ideally during a plié, the hip must flex.  As a result, compensatory patterns are developed, like tibial external rotation (rotating shins out) and pronation (feet rolling in), which places added physical stress on the knee that it is not capable of handling at a particular time.
  3. Range of Motion. In addition to hip range of motion, limited ankle mobility that affects the depth of pliés has been shown to contribute to knee pain.
  4. Adolescent Growth.  Young adolescent dancers, especially females, usually go through a substantial growth spurt.  During growth phases, bones will length faster than muscles. This may temporarily affect the muscles which will need to be retrained.

Patellofemoral Pain Research Retreat concluded these recommendations:

  1. Exercise therapy is the most effective treatment course for PFPS. Exercises should focus on hip and knee strengthening.
  2. Foot orthoses are recommended to reduce pain in the short term. IT was found that pre-fabricated (off the shelf) orthotics were just as effective as custom fabricated orthoses.  However orthotics should be used only in the immediate short term to alleviate pain with every day activities.
  3. Patellofemoral, knee and lumbar mobilisations are not recommended in isolation.
  4. Electrophysical agents are not recommended.
Take Home Message
  1. AN ACCURATE DIAGNOSIS IS KEY.  Let’s make sure your knee pain is coming from your knee.
  2. DO YOUR EXERCISES!!  A planned exercise program that focuses on key movement patterns and muscle development has proven to produce the most effective results for pain and performance in both the short and long term.
  3. CROSS TRAINING.  Incorporating strength exercises (or alternative sport/activity) that were not specifically dance related were beneficial to overall lower extremity strength, improving performance, and reducing risk of injury.
  4. DON’T FORCE TURN-OUT.  Proper technique in this instance goes hand in hand with proper joint movement. Your turnout will come as your flexibility improves and your muscles develop to hold this position. The compensatory strategies, previously noted, to increase turnout are the responsibility of both the dancer and the teachers to identify and correct.


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Carolina is a trained professional, certified in the McKenzie Method of Mechanical Diagnosis and Therapy. Her background in ballet coupled with a passion for promoting the healthy dancer rules her practice as a physiotherapist. If you have knee pain or another dance related injury and want to ask her a question, feel free to send her an email at If you would like to book an appointment with Carolina, give us a call at 905-847-5227, or book online here.

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