Getting Knee Deep With Dr. Craig Westin

IMAGE Craig Westin, M.D., orthopedic surgeon for the Chicago Center for Orthopedics at Weiss Memorial Hospital and medical director of Chicago’s Joffrey Ballet. IMAGEI am very pleased to introduce you to Craig Westin, M.D., orthopedic surgeon for the Chicago Center for Orthopedics at Weiss Memorial Hospital and medical director of Chicago’s Joffrey Ballet. Dr. Westin received his orthopedic training at Harvard and after a sports medicine fellowship in Europe, ran the ski clinic at the Alta and Snowbird ski resorts in Utah. In addition to his role at Joffrey Ballet, he is a team physician with the U.S. Figure Skating Team and the personal orthopedic surgeon for Olympic Figure Skating Silver Medalist, Sasha Cohen.

Dr. Westin generously took time out of his busy schedule to talk with Dance Advantage about knee problems, proper alignment, pain, and injuries common to dancers.

Dance Advantage: We have readers who practice or compete in both figure skating and dance. These two disciplines share some patterns of injury I’m sure but, what are concerns unique to each?

Dr. Westin: Both disciplines have frequent problems with the foot and ankle, but for different reasons.

Dancers have unique problems with pointe. The extreme downward position of the ankle when dancing en pointe can pinch the normal structures in the back of the ankle producing pain. Dancers must also have very strong muscles to maintain proper alignment of the foot.

Skaters have many foot problems but most are caused by the very rigid boots of skating. Apart from proper fit (most elite skaters have custom boots) and careful break-in, the blade must be expertly mounted and an arch support may be built into the boot if needed.

DA: What is the number one knee injury you encounter in dancers?

Dr. Westin: The kneecap area is the most frequent site of trouble. When the knee bends deeply the pressure between the patella (kneecap) and the femur (thigh bone) is about seven times the body weight! The patella glides over the end of the femur in a groove that matches the back of the patella. Problems occur with the outward turn required of dance. This can pull the patella off-center and cause pain. Hip ‘turn-out’ must be good to reduce the outward twist on the knee.

DA: I’ve known of recreational and competitive dancers who have chronic knee problems, even those that require surgery in dancers younger than 18. How can dancers best avoid knee injury?

Dr. Westin: Proper alignment of the hip, knee and foot is important for good dance technique and for maintaining healthy knees. When the knee bends, the kneecap should be centered over the middle of the foot. This spreads the pressure [DA note: Again… 7 times your body weight!] in the knee evenly to reduce injury. When the kneecap is off center due to poor alignment, uneven pressure on the kneecap increases the risk of injury. The knee is capable of about 20 degrees of twist, but it doesn’t tolerate the twist well with full weight on the leg.

Alignment of the knee starts by checking the feet and hips!

The foot is the most common place where alignment is affected. Pronation is the term that refers to the rolling-in motion of the middle part of the foot. Pronation is normal and is a very important in absorbing the shock of a jump. The movement of pronation lowers the arch and twists the knee inward. It makes for “knock-kneed” alignment, when the knees are abnormally close together and the ankles are spread widely apart. If you bend the knee with the foot pronated, the kneecap passes over the big toe side of the foot rather than the center of the foot. Good strength of the muscles below the knee is necessary to control ankle position.

Sickling is a term for turning the foot the opposite way, which is also referred to as inversion. Sickling is a sign of poor technique. Dancers need good strength to pull the foot both inward and outward below the ankle. The key is to have balanced, equal strength.

Proper hip turnout is required for ballet. Complete turn out at the hip reduces twisting forces on the knee. Stretches and proper warm up improves motion of all joints including the hip. Muscles that help turn the leg out at the hip are called external rotators. They are in the back of the hip, deep in the buttocks. These may need to be strengthened to help turnout. Most exercise programs overlook them. An instructor, and athletic trainer or physical therapist can teach dancers some exercises to strengthen the hip external rotators. To some degree hip turnout is a gift not every dancer is blessed with.

DA: Dancers often feel the need to work through pain. What are the risks of this philosophy and when should a student see a doctor about pain or discomfort?

Dr. Westin: We should pay attention to pain, not ignore it. Pain is a signal that something is wrong. We need to look for the cause, but the answers may not be medical.

Good technique and sufficient strength are needed for optimal function. Pain can be the result of poor technique OR weakness can lead to a breakdown of good technique.

Have your instructor watch you do your painful movement. If your foot, knee, hip and spine positions are correct the impact stresses of dance are absorbed and distributed evenly to reduce injury. You should see a doctor if you have a breakdown in technique and can’t correct it, or if your instructor sees nothing wrong.

IMAGE A woman sitting holds her knee. Only her legs are shown. IMAGEThe site of pain is not always the origin of the problem. For example, Achilles tendon pain can result from ankle muscle weakness or from loss of ankle motion. A physical therapist can correct most dancing problems.

Keep in mind the three- day rule: If a pain persists for three days, you should tell your instructor. You can’t report every little thing, but if pain is prolonged, it will lead to weakness and further trouble.

In addition, take note of new choreography or layoffs. Unfamiliar movements will put unfamiliar stresses on your body that can lead to injury. New movements may require additional out-of-studio exercises to build strength. After a period of complete rest (vacation or illness), work back to a regular schedule over a week or so.

It’s best to remain physically active when you are away from dance. “Cross training” (doing other activities) helps the mind as well as the body refresh itself.

Having touched on some of these topics and concerns on Dance Advantage in the past, I have to say it’s great to have a medical doctor and sports medicine specialist as experienced as Dr. Westin corroborate what we try to consistently communicate to our readers and students. I hope many of you teachers out there are feeling the same way!

Thanks so very much, Dr. Westin, for giving your time here on the site and for all you do in the dance world. You can find out more about Dr. Westin at the Chicago Center for Orthopedics website.

We want to hear from you!

What are YOUR questions about knees, orthopedic surgery, and dancer injuries?

Write them in the comments below. Your question may be selected and addressed by Dr. Westin or another expert contributor on Dance Advantage.

Nichelle (owner/editor)
Nichelle Suzanne is a writer specializing in dance and online content. She is also a dance instructor with over 20 years experience teaching in dance studios, community programs, and colleges. She began Dance Advantage in 2008, equipped with a passion for movement education and an intuitive sense that a blog could bring dancers together. As a Houston-based dance writer, Nichelle covers dance performance for Dance Source Houston, Arts+Culture Texas, and other publications. She is a leader in social media within the dance community and has presented on blogging for dance organizations, including Dance/USA. Nichelle provides web consulting and writing services for dancers, dance schools and studios, and those beyond the dance world.
Nichelle (owner/editor)
Nichelle (owner/editor)
Nichelle (owner/editor)
Nichelle (owner/editor)

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  1. Thanks for this informative post Nichelle and Dr. Westin!

    I think many young dancers, teens, athletes don’t listen to the pain cues enough as the fear is in losing a role, status, position. This was a lesson I learned the hard way myself, suffering a torn ACL (full reconstruction) and double neurectomy in my left foot in my early twenties after years of playing through pain, doing whatever it took to participate.

    Education and awareness are so key in keeping our dancers, who are wonderful athletes, strong and healthy. I’ll be sure to share this post with others.


  2. Summer DTC says:

    I’m a modern dancer with a very strong ballet background. I have recently damaged my vastus medialis and am having a hard time finding a physical therapist who can help. My turnout muscles are significantly stronger than the muscles which stabilize the inside of my knee. When I developpe en avant or a la second, sometimes I am unable to fully straighten my knee. I’ve been put on a bike and given exercises going up and down stairs, but I am not really feeling much improvement. Feelings of weakness/pain are mild, but constant.
    How can I strengthen the interior muscles of my knee in a manner that will actually be useful for dance and not just a normal athlete?

  3. Dr Westin says:

    Dear “injured VMO”,
    The VMO is the lowest member of the quadriceps group and is crucial in centering the kneecap as the knee bends. The quad has to pull twice as hard to lock your knee fully straight as it does to hold your knee at 30 degrees of bend. If the quad is weak it can be hard to fully extend the knee. You must be sure that there is not a different problem keeping it from going straight. Check with your doctor about this.

    The VMO pulls the kneecap toward the inside of the knee so the cap tracks properly.
    Physical therapists can show you some good VMO exercises, usually done with the knee fairly straight. Stairs are not a good idea for building strength if your knee is sore. Remember fatigue builds strength, pain steals it! Get tired not sore with strength exercises.

    What is sometimes overlooked is the tissue on the outside of the kneecap, the “lateral retinaculum” (LR). If the knee is injured, the LR can tighten and can keep the kneecap off center. Even a strong VMO can not overcome a kneecap that is off center due to a tight lateral retinaculum.

    Have your therapist show you “patellar mobility” exercises. These should include lifting the outer(lateral) side of the kneecap up with your fingers. Many people find this creepy at first. Do it with your knee fully straight and the thigh (quad)completely relaxed. You need to rest your heel on something so the quad reales. You should have equal tilt to both kneecaps. The amount of kneecap tilt varies between people. Do these “kneecap tips” until your have equal mobility in both kneecaps. Also be sure your hamstrings aren’t too tight. This is usually not a problem with dancers due to routine stretching, but tight hamstrings put increased demands on the kneecap and quad muscle too
    Good Luck!

  4. Michele Troutman says:

    My 14 year old daughter has danced for 5 years and is hoping to go on point. Her teacher noticed some issues with her foot. An orthopedic consult in Grand Rapids Michigan near us revealed bunion (big toe) she does have some pain with this and hammer toes (three middle toes). The tendons on her middle toes are shortened and her toes are crunched up. This condition runs in her dads side of the family. The doctor said she could have surgery to fix these issues and possibly continue to dance. I have read in “The Pointe Book” that surgery isn’t for dancers. Is there a Doctor that specializes in dancers I could take her to for an opinion?

  5. I’m glad you posted this informative Q&A. Serious dance injuries, and their prevention, should be seriously addressed! On a less serious note, I recently posted a blog on called “Dancing to the Right,” a light hearted snippet on the physical difficulties encountered by the older dancer – despite our aches, pains and stiffness, the mature dancer finds ways to compensate – we continue to take class because of love for the art.

    • “The important thing is that we’re there, in ballet class, doing what we love and striving to be our best. That’s what I do, and I feel like I still belong.”

      You definitely belong! When you love it, you make it happen. Regardless of level or ambition, this is what a dancer does! Thanks for sharing 🙂

  6. i’m 15 years old and have been dancing for 4 years. Last week i did a center leap (i’m not very good at them) and when i landed on my left leg i felt my knee pop out and pop back in or something. i fell to the ground and i couldnt get up anymore. the docter doesnt really know what happened to me. but just yesterday i started walking without the crutches and i can straighten my legs without any pain. But my knee is still very swollen and nobody knows why. I’ve started to do basic ballet stretches and barre exercises but it hurts my knee really bad. Any advise to what i may have??

  7. Laurie Etchells says:

    My daughter a 13 yr old ballerina (in her eight year of ballet) has your #1 knee
    problem with the knee cap and patella. We have had her to physical therapy, an orthopedic surgeon and she wears a knee brace when doing lots of walking etc..The problem is it doesn’t seem to be going away that much. It’s been 1 year now and she is just dealing with it but she fell this spring at a performance where she was in the front of the stage. She stretches ALOT and does all the physical therapy exercises still at home. Our question is what’s next?

    • Hugh Churchward says:

      Hi Laurie
      I don’t know if your daughter’s problem is sorted but I have been to a physical therapist who does something called Ortho-Bionomy which helped my knee and hip problems out of sight. As she explained to me, and which was my experience also, was that they help to reduce the tension and help to re-educate the tissues so that they work with the surrounding areas more coherently. I don’t know if there is one in your area but it really is a cracking technique. Good luck with it all.

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