Welcome back to the Dance Blog! This week we’re going to be talking about what is perhaps one of the single most terrifying dance injuries out there: the meniscus tear. When it comes to the dancer population, meniscus tears are like the boogeyman. It’s something we’re always looking under our beds for and with good reason. Meniscus tears can be nasty, they can take a dancer out of the studio for long periods of time and for many, perhaps even most, there is a very real fear that tearing your meniscus can mean the end of your career as a dancer. So this week we’re going to dive into the anatomy, pathomechanics and treatment options for this injury to see if we can’t shine some light on this condition and maybe even change some of our outlook on it.
Ok anatomy first. This is basically a recapitulation of the knee anatomy discussed in my blog post on ACL tears so for more details make sure to check that post out. The knee is composed of three bones (the femur, tibia and patella), six ligaments (MCL, LCL, ACL and PCL) and two shock absorbers (the medial and lateral menisci). That’s right there are two menisci in each knee. Each menisci is crescent shaped and essentially forms around the medial and lateral sides of your knee joint. On the medial side, the MCL or Medial Collateral Ligament runs vertically from the tibia to the femur laying on the outside of the medial meniscus. On the lateral side, the LCL or Lateral Collateral Ligament does the same with the lateral meniscus. It’s important to note here that due to their proximity, meniscus tears often feature MCL or LCL damage as well.
Now the menisci are made up of cartilage and as such are predominantly avascular. This means that there isn’t much blood supply which in turn means that the menisci are not very good at healing and repair. Of course this depends widely on the age of the patient as the outermost portion of the meniscus, called the red zone, is vascularized and does heal moderately well. At least compared to the white, avascular, zone. The amount of red zone present is inversely proportional to the age of the patient meaning, younger people have more red zone and older people have less.
So how does a dancer tear their meniscus? Well functionally, the menisci serve as shock absorbers for the knee joint. They can endure a lot of compressive force and are really good at distributing that force across the knee. Rotational forces on the other hand are forces that the menisci are not so good at dealing with. The primary method by which a dancer tears a meniscus is therefore any movement that causes rapid or aggressive pivoting or rotation.
Wait a second, wasn’t that how dancers tear their ACL too? Well… yes. In a lot of ways these two injuries are very similar and as it relates to dancers this can actually be helpful in some ways. As we discussed in my ACL tear post (seriously go read it. It's practically the companion piece to this post) dancers have a built in defence when it comes to how susceptible we are to ACL tears. This defence being the nature of how we train. Because so much of dance is choreographed, dancers rarely pivot or rotate through their knees unexpectedly. When we do perform these kinds of movements, we know they’re coming and as a result can approach them properly thus reducing the likelihood of causing injury.
That’s good right?! I mean dancers are far less likely to tear their ACL compared to most other athletic populations, so this must mean the same of meniscal tears right?!.. Not really. You see, ACL tears do, like meniscus tears, occur due to sudden or aggressive pivoting. However, the ACL tear has the additional requirement of anterior translation of the tibia on the femur. Meniscus tears don’t have that additional requirement, rotation and pivoting alone are the main factors.
What's this mean for dancers? In short, DO NOT FORCE YOUR TURN OUT!!! Dancers, the
number one thing you can do to help prevent a meniscal tear is to swallow your pride and get honest with yourself about your turnout game! Ballet dancers are easily the biggest culprits here, but they're far from the only ones. I can speak from personal experience that as a student and professional I would crank my turnout at the barre and in center to try and look as good as possible. This is a terrible habit that has been sewn into dance culture for a LONG time and it is absolutely hurting dancers as a result.
When you force your turnout beyond what you're naturally capable of, it’s not the hips that are doing the extra work, it’s the knees. Your hips only externally rotate to their natural limits. Once there, your tibia begins to over rotate on the femur so as to create the illusion of extra turnout. The result is that your medial menisci are preloaded with all this extra rotation force. Now, every time you plié, you compound these forces even more.
And just think about all the times you move through plié in dance. Transitional movements,
exercises, poses, the list goes on. If you're forcing your turn out this means that every time you perform movement that puts force through the knee you are over stretching the medial menisci. Do this consistently enough and over a long period of time and you will begin to derange your menisci. Remember my post about why oversplits are so bad because they permanently derange the hip capsule. Well, the same rule applies here!
So, you’ve trained for weeks, months, years even, and all the while forcing your turn out and
causing micro injuries to your medial menisci. Now the day comes where you’re performing a
series of jumps or maybe just one big jump. All of that abuse and misuse of your menisci suddenly culminates in one traumatic moment. You land a jump, likely forcing your turnout, sending not just rotational forces but also compressive forces through your now destabilized shock absorbers and suddenly you can understand why they fail to absorb the shock. Boom! You’ve torn your meniscus.
Ok, theatrics aside, of course the planets can align even without years or repetitive forced turnout. One bad movement can cause the meniscus to tear simply due to a poorly executed step under the right circumstances. However, I really want to nail home how much improper biomechanics such as forced turn out can greatly increase your chance for injuries like meniscus tears. I call out healthcare providers a lot on this blog for being prideful and refusing to acknowledge what they don’t know but here I’m calling out the dance industry. Forced turnout is not pretty, it’s not beneficial. It’s damaging and incredibly unnecessary in the modern dance setting and shame on any teacher, choreographer or director who pushes such a harmful and antiquated approach to dance training.
Ok I’m putting my soap box away now I promise. Let’s move onto signs and symptoms. For the reasons discussed above, the most common meniscus tear in the dancer population is a tear in the medial meniscus. With this injury some of the most common signs include painful popping deep in the knee joint. This is different from painless popping of the joint which is common and not generally concerning with dancers. Additionally, swelling, stiffness, trouble or inability to walk or stand on the affected leg are all common with meniscus tears. A tell tale sign that there may be a problem with the meniscus is difficulty or inability to extend the knee completely. This can occur only sometimes when trying to extend the knee or every time and is a result of a torn piece of meniscus tissue getting stuck in the joint space.
So what can you expect for treatment with a meniscus tear. Like I’ve said before, more invasive injuries such as ACL and meniscus tears really require a case by case approach. There is no one size fits all. Depending on the patient’s age, where the tear has occurred, if the tear is partial or complete and the degree to which the patient can or can’t walk on and utilize their knee all play into the decision making process when it comes to treatment.
That said, the two forms of care we’re looking at here are surgical and conservative. With surgical care we’re talking about arthroscopic surgery most of the time. Here the surgeon will make three small incisions in the knee and using tools cut away the damaged parts of the meniscus and possibly sew together the torn ends. Following surgery, heavy rehab will be required to get back into dancing shape. With the conservative approach you’re basically going straight to rehab. Note that the goal with meniscus tears, whether it's treated surgically or conservatively, is not necessarily to fix the tear but rather simply to return the knee to full functionality. Also shout out for my Plasma Rich Platelet injections post, go read it! PRP can be used in conjunction with both the surgical and non-surgical options here to help speed up the healing process. And as always, it's absolutely vital that you find a healthcare provider that understands dance and the stresses that dance puts on the body. Rehabilitation for meniscus tears should be custom built with dance in mind or else reinjury can readily occur.
Regardless of which treatment you ultimately receive, it’s important to go into recovery with a
realistic mindset. Meniscus tears are nasty injuries for dancers. Recovery is not measured in
weeks, it's measured in months. Especially if we’re talking about getting back to dancing shape in a responsible and effective manner. That said, if we’re serious about our rehab and we don't try to go back too early or do too much before the knee is truly rehabilitated then we should understand that meniscus tears do not need to be the career ending events we fear them to be. Life after tears can look pretty similar to life before the tear in many cases. It all comes down to the nature of the injury and the earnestness with which we approach our recovery.
Alright, heavy topic this week! Next week we’re going to be talking about labral tears of the hip. In the meantime, this week's dancer shout out goes to Jessica Nikić. Jessica began dancing when she was 2 years old and danced competitively until she was 18. She attended the University of the Arts in Philadelphia studying Fine Arts and minoring in Dance. Most recently Jessica has worked as a gallery director with several cruise ships. Jessica is another hometown hero outta Rochester, NY where she lives with her husband (who she met while sailing the world), her son Theo and newborn daughter Luna. I’ve known Jessica since we were little dancing together at the same studio. She’s the nicest person you’ll ever meet and an even better artist. Seriously, following dance, Jessica transitioned to painting as her artistic form of expression. Utilizing a contemporary realistic style, Jessica’s work is amazing and can be seen on Instagram here:
https://www.instagram.com/jessnikic_art/?hl=en. In her words she is an “avid traveller whose
colorful paintings pay homage to all the places she has been.” Bonus fact: Jessica does
commissions! Make sure to check her out and if you like what you see, private message her and get a piece of her art for yourself! You can see one of her recent pieces below!
And remember, if you have any questions or topics you would like me to address here on the
Dancer Blog comment below and let me know! Also if you want to help this community grow
faster, please like and share this blog on Facebook, Instagram, and Twitter. Until next time!
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