Patellar Femoral Syndrome Part 2

          My last post discussed the chronic condition known as patellar femoral syndrome, the related symptoms, and possible treatments.  Since it is always better to bypass injuries than figure out how to recover from them, this post will address some causes of this condition and how to avoid them.

      This condition occurs when the patella, or knee cap, is misaligned. When it is misaligned, it cannot slide along the groove in the femur when it moves. The patella can move out of this position as a result of an acute injury from a fall or a sudden movement, but one of the main causes is a misalignment that develops over a period of time.  This misalignment occurs when the muscles that are meant to stabilize this joint and hold the knee cap in position begin pulling on the knee joint unevenly.  

          Muscle groups work in pairs. The pairs work opposite each other - one group extending while the other flexes, or bends the joint. In order to create stability, both groups need to pull on the joint evenly, creating equal tension in all directions. When one muscle group is tighter than its partner group, the tension is unequal and the patella is pulled out of position.   

        This condition can be the result of tight quadriceps, which are the four muscles along the front of the thigh, or tight hamstrings, which are the muscles that run along the back of the thigh. These muscular imbalances can be avoided by making sure that all of the muscles are worked and stretched evenly. 
        Dancers tend to use certain muscle groups more than others and need to be aware of what muscles may not be worked as often. Cross training in other activities like yoga, Pilates, biking, swimming or walking can help ensure that all muscles are worked evenly.  Dancers also need to be aware of the iliotibial band, also called the IT band for short - this tendon connects the gluteus maximus muscle and the tensor fascial lata muscle to the skeleton.  Dancers use the gluteus maximus a lot since it is responsible for returning the leg to its original position after it has been lifted to the front, lifting the leg in arabesque, and is one of the main muscles involved in turning the leg out.  

            The tensor fascia lata is constantly relied upon by dancers as it is responsible for lifting the leg to the front and the side and rotating it inward. 

        The constant use of these two muscles causes the IT band to grow tight. Dancers need to stretch out the IT band often so it does not pull the knee joint out of position.

        By simply being aware of which muscles might need some extra work and being sure to stretch every muscle equally, most chronic conditions relating to poor skeletal alignment can be avoided.  It is extremely important for dancers to learn about muscular imbalances, to know their own bodies and to cross train to be healthy, strong dancers.

Patellar Femoral Syndrome - Part I

“When there is alignment and understanding, it is much easier to navigate forward together, ” - Karen Kimsey-House

          The knee is one of the most relied upon joints of the human body and is subjected to a great deal of force every day. During a simple activity like walking, the amount of force placed upon this joint is equal to anywhere from one-third to one-half an individual's body weight. When a person is climbing stairs the force placed upon the joint is equivalent to 3 times the individual's body weight, and when squatting, the knee must manage a force equal to 7 times the individual's body weight. When considering these facts, it is easy to understand that there must be a great amount of stress placed upon the knee in all kinds of dance. When the knee joint is functioning correctly, it is usually able to cope with this stress, however, when something is misaligned, and the knee joint is not functioning efficiently, the stress can be detrimental.

        Patellar femoral syndrome is a chronic condition in which the patella, or knee cap, is not correctly aligned. The patella is a triangular shaped bone that lies on top of the femur, or thigh bone. There is a groove in the femur which allows the patella to slide back and forth as the knee bends and extends. When the patella is not in alignment, it does not fit well into this groove, and the friction of the patella against the femur begins to wear away the cartilage found in the joint.

          When the knee joint is at rest, the patella is held in place by the capsule surrounding the joint, the ligaments on either side of the patella (the retinaculum), and the patellofemoral ligament, which connects the femur to the patella.

When the knee is actively bending or extending, the joint's stability is provided by the quadriceps (the four muscles located on the front of the thigh), the vastus medialis (which is a muscle that is found on the inner side of the thigh), the vastus lateralis (which is a muscle that runs along the outside of the thigh), and the iliotibial band, which runs from the gluteal muscle of the buttocks down the outside of the thigh.

          Dancers with patellar femoral syndrome will experience pain behind and around the kneecap during activities that require the knee to bend like squatting, jumping or climbing stairs. Occasionally, the dancer will also experience the knee buckling, or "giving way" when walking and may also complain of stiffness in the knee after sitting for a while.

          Any dancer experiencing these symptoms should rest the joint and use ice and anti-inflammatories to control the discomfort. The dancer should also contact a sports or dance medicine doctor to get a complete diagnosis. In most cases, once the cause is determined, physical therapy can help alleviate the symptoms and help realign the kneecap.

          Since an ounce of prevention is worth a pound of cure, my next post will focus upon the causes of patellar femoral syndrome and how to prevent this condition from occurring.

Exercises to Improve the Arch of Your Foot

         "The human foot is a masterpiece of engineering and a work of art." - Leonardo da Vinci

        All dancers strive to achieve the perfect foot. My last two posts detailed the anatomy of the arches of the foot and explained why a passive foot stretcher is not the most effective or healthy way to achieve that goal. 

         This post will provide you with healthy ways to work on strengthening and improving the arches. 

 * Slow, controlled elevés and relevés - Working the 
     muscles of the calf, the gastrocnemius and the soleus, 
     will help contribute to arch strength. Simple relevés and 
     elevés will work, but you can also vary the timing for an 
     extra challenge - going up on one count and taking three
    counts to gradually lower your heels or taking three counts 
     to rise and lowering the heels in one count.

* Forced arches  - In a parallel first position, bend your 
   knees. While keeping them bent, slowly begin to raise up 
   onto the ball of your foot to a forced arch position and then 
   slowly your heels to the floor. Repeat 8 times.


* Seated pointing and flexing  - Seated with your legs
   straight out in front of you. Point and flex your feet using a 
   theraband for resistance. You can wrap the theraband  
   around the ball of your foot and hold the ends in your 
   hands to provide resistance when pointing your foot, or
   loop the theraband around a chair leg and across the top of 
   your foot to provide resistance when flexing the foot.

* Domes - This exercise will work of muscles and tendons
   underneath the foot. Seated on a chair with your feet flat on
   the floor, keep your toes flat and do not allow them to curl 
   while trying to slide the ball of your foot toward your heel. 
   This movement is a small, subtle one but a slight dome 
   will form underneath your foot. Do 5-8 repetitions on each

* Towel gathering - Lay a small towel or scarf flat on the
    floor. Seated in a chair, place your foot flat on the towel and
   do not move your heel as you begin to slowly use your toes
   and the ball of your foot to gather and pull the towel toward
   your heel. The towel will only move a little each time. Be
   sure that both sides of the foot are working evenly, trying 
   not to use one side more than the other. Do 5 repetitions on 
   each foot.

Using these exercises will strengthen and improve your arches in a healthy way to achieve the aesthetic that dancers strive for while decreasing the risk of injury.

Improving the Dancer's Arch: Do Foot Stretchers Work?

"The human foot is a masterpiece of engineering and a work of art." - Leonardo da Vinci

Dancers spend hours in the studio critiquing their bodies and comparing them to those of other dancers. One body part that receives considerable attention for obvious reasons is the dancer's foot. My last post spoke of the anatomy of the arches of the foot and the three most common types of feet - those with a high arch, those with a medium arch, and those with a flat foot and the implications that each of these have for dancers.

As each dancer works to create aesthetically pleasing lines, he or she often tries to find ways to stretch or increase the arch of the foot. A foot stretcher is a device that stretches a dancer's foot. The dancer places his or her foot inside the device which holds the foot in an arched position while stretching the ligaments of the foot to increase range of motion and presumably increase the dancer's arch.

There are some dancers who have a limited range of motion in their feet because of the bone structure. These dancers will not benefit from a foot stretcher since, no matter how much the foot is stretched, the bone structure cannot be changed.

For those who have a limited range of motion due to tight ligaments, it would seem that this type of device would be ideal. Unfortunately, foot stretchers work in a passive manner. Although range of motion may be increased, strength is not being developed at the same time. An increased range of motion may allow the foot to be placed in a new position, but if the dancer does not have the corresponding strength to move the foot into or hold it in such a position, it will be of no use.

It is important to remember two things about ligaments - their jobs are to hold bones together and to limit certain movements, and they are non-elastic; once they are stretched out, they will not return to their original lengths. If feet are overstretched with the use of a device like a foot stretcher, ligaments will become lax and will not be able to do their jobs effectively, and the dancer will no longer have the same joint stability that he or she once did. Overstretching the ligaments of the foot could lead to a greater chance of injury in the foot and ankle joints when the dancer's foot needs to bear weight in balances or when landing from jumps.

Another concern with foot stretchers is that they force the foot into an exaggerated pointed position. This position can lead to posterior impingement of the ankle. In this position the calcaneus, or heel bone, is forced against the tibia, or large shine bone, and pinches all of the soft tissue at the back of the ankle. Posterior impingement syndrome results in pain and irritation when doing almost anything. This irritation can also lead to tendonitis.

Avoiding exercises and devices that passively stretch the foot will contribute to healthy dancing. There are ways to actively stretch the arch of the foot while simultaneously strengthening the foot that will create an aesthetically pleasing line without sacrificing ankle stability or injuring soft tissue. My next post will offer examples of those exercises so that dancers can improve their arches in a healthy way.

The Ideal Dancer's Arch

"The human foot is a masterpiece of engineering and a work of art." - Leonardo da Vinci

Dancers use their entire bodies, but their feet are what ground them, move them through space, allow them to rise up toward the heavens, and complete the lines of energy that extend out from their bodies through their legs. Having a "good"arch is often a discussion among dancers - it is believed that higher arches are the best arches because of the way they look, but what is most important is that the arches provide necessary support for weight bearing and effective landings, as well as aesthetically pleasing lines.

This series of posts will discuss the anatomy of the foot, the "ideal dancer's foot", the determinants of a dancer's arch, the best ways for dancers to improve their arches, and what methods should be avoided and why.

Basic Anatomy of the Foot and the Arches

The bones of the foot fit together to form the ankle joint, the arches of the foot and the toe, or phalangeal, joints. 

The primary ankle joint is formed where the tibia and and the fibula meet the talus.   The tibia is the large bone of the lower leg that is located on the inside of the shin while the fibula is the narrow bone that is found on the outside of the shin.  The talus is the bone located on the top of the arch of the foot where the lower leg and foot meet.  This joint is a hinge joint that is responsible for the ability to plantar flex (point) and dorsiflex (flex) the foot.

The bone beneath the talus is the calcaneus, or heel bone. The meeting of the talus and the calcaneus form the secondary ankle joint, a sliding joint, which allows the foot to move from side to side.

The bones that make up the arch of the foot are the talus, the navicular, the cuboid and the cuneiforms and those that make up the toes are the metatarsals and phalanges.

There are three arches in the foot. The arch that can be see on the inside of the foot is the medial longitudinal arch, the arch that runs along the outside of the foot is the lateral
longitudinal arch, and the arch that runs across the top of the foot from one side to the other is the transverse arch. All arches are important since they provide stability.

Everyone's body is different and no two people have the same foot structure. The height of the arches of the foot are determined largely by bone structure and also influenced by muscles and the flexibility of ligaments. There are three types of arches: 

 - the high arch This arch is characterized by its bony structure and strong ligaments that keep the bones held firmly in place. These type of feet are often rigid and inflexible, and do not absorb impact very well since only the ball of the foot and the heel touch the ground - about 20% of the general population.

- the medium arch This arch is ideal in that it provides for better shock absorption, and although the ligaments are not as tight, they do a great job of holding the bones in place while allowing for flexibility - about 60% of the general population.

 - the flat foot  While there is an arch apparent when a dancer is pointing his or her foot in the air, the arch disappears when the foot must bear weight because of the laxity in the ligaments - about 20% of the general population.



The ideal foot for a dancer is the medium arch since its natural bone structure provides an aesthetically pleasing image when the foot is pointed, and the strong  ligaments provide the stability and flexibility a dancer needs when dancing, balancing, and landing from jumps and lifts. These dancers excel at ballet, do well when dancing en pointe and are less apt to sprain an ankle.

Although they do not have "ideal dancer feet", those with high arches and flat feet can still excel at dance but would need to spend some time stretching and/or strengthening the arches for both aesthetic and stability reasons. 

Next week's post will provide some insight as to what dancers should and should not do to improve their arches in a healthy manner.


A Workshop for Dancers, Dance Educators & Parents

The Healthy Dancer

invites you to a

Summer Workshop 
Body Awareness
Injury Prevention & Care

Come learn how to…

Understand anatomy
Train efficient dancers
Train strong, technically sound dancers
Work with dancers' strengths & limitations
Train intelligent dancers
Prevent & care for injuries
Cross-train dancers effectively

Join us 
Saturday, July 25
1 PM - 4 PM
in Guilford, Connecticut
lectures & participatory workshops

(Space is limited, so reserve your spot soon)