II. INJURIES, PREVENTION AND CURE

Chapter 3. The Knees

As has been said earlier, knees are second only to feet as a source of trouble. They have a tremendous amount of hard work from the very beginning. They are vulnerable and unforgiving joints. An ankle will recover from quite severe injury with no after-effects but the knee has a long memory and any real damage to it can be a major calamity.

Injuries or inflammatory conditions fall roughly into two classes, those which affect the ligaments and cartilages and those in which the patella is involved. The former are the most common and the earliest complaints come from the very junior children and are usually due to nothing more than an excess of zeal in pulling up the thighs, which action of course draws up the patella. The resulting pain may be well above the knee or just below (figure 27) and is caused by a slight stretch on the tendon of the muscle on the front of the thigh which pulls up the patella, or upon the ligament by which the patella is attached to the tibia below. It is as well to give the child a day or two off work, when the pain should disappear, and a warning to avoid any jerking in straightening the knees when back at the bane.

Apart from this small strain, others depend very largely on the formation of the knees in relation to the thigh and leg. A knee which is in good alignment rarely gives any trouble. By far the greater number of troubles occur amongst those pupils with any marked degree of knock-knee, those

Figure 27. Site of pain due to "Pulling Up' thigh muscles too forcibly.

with short hamstring muscles who there­fore do not straighten the joint without effort and definitely those with any hyperextension or sway-back at the knee joint. In the first of these, the knock-kneed, there is often some laxness in the joint, with resulting instability and a lack of a perfect balance in the working of muscles and ligaments on either side which control and produce movement. In addition, the tibia is slightly out-turned, rendering it easy for the child to turn out from below the knee instead of from the hip, a fruitful source both of foot and knee strain.

Most complaints may be given a day or two off work and perhaps strapped or bandaged before returning to the barre, but when a child points definitely to the inner or outer side of the knee as the pain-giving spot it is a signal for caution. The inner side especially is the most commonly met site of strain of the lateral ligament, and later of a nipping or displaced cartilage. Before thinking so far ahead, however, it is wise to make sure that the cause does not lie nearer at hand, in fact at the first exercise at the barre. Pliés are a tax on the knee even when perfectly performed, more especially in the upward movement. Any falling inwards of the knees at the moment of rising puts a great strain on the inner side of the joints and this is doubled when there is any relaxation or "sitting" at the lowest point. This fault is injurious to the feet, but much more so to the knees and, repeated continually, may easily be the source of strain on the ligaments. The immediate treatment for any complaint therefore in this region is a few days' rest and, as usual, correction of any mistakes in technique. Persistence in the pain calls for medical investigation.

In neither of these strains do we find swelling, but in a third condition the knee is puffy and stiff, due to inflammation in the bursa or sac of fluid which acts as a buffer between the patella and the tibia. It is more likely to be the result of a blow or prolonged kneeling than from straight work, and if it does not subside speedily with kaolin poultices or similar treatment advice should be obtained with­out further delay.

Any condition in which a knee locks should be regarded as needing immediate investigation, as also should that in which it gives way suddenly. Either may recover temporarily, but should never­theless be taken as warnings, and the possibility be eliminated of a cartilage nipping or a patella slipping. Pain which is felt either over or under the patella, more when the knee is flexed than when straight, needs an accurate diagnosis of the cause for fear of inflammation of the under surface of the patella, a condition which if it exists would be likely to put an end to further training. One cannot say why this arises, other than over-use of a joint predisposed to such a condition, perhaps by former injury which has not been divulged at the time of the audition. Parents and children are apt to forget the incidence of an accident in early years, or maybe have a reluctance to confess to such. Remember too that any infective illness may leave potential joint trouble, which might not become manifest under ordinary life conditions, but which will be awakened by the unusual demands of ballet. This is especially so in the case of the knee joint. These are rare eventualities in children, fortu­nately, but they do occasionally occur, again more often in the knee which is not in perfect alignment with the thigh.