In middle school, senior Ellie Kim was dancing 15 to 16 hours a week at Dance Academy USA, a competitive dance studio in Cupertino. When she began feeling discomfort in her knee in sixth grade, she ignored the pain, believing that it would’ve been too taxing to deal with the injury. But as her injury progressed, the pain started impacting her daily life, not just when she was dancing.

“I [would] come home from practice and go to sleep and hope that anything that was bothering [me] the night before with [my] body would go away in the morning,” Kim said. “For a good month or so I would wake up and feel the pain in the bottom half of my knee immediately as soon as I’d wake up. That was really shocking to me, because I never had pain occur from not moving or not dancing, rather just stationary movement. And that was kind of worrisome. It got to a point where after some competitions, I couldn’t walk the next day.”

Her dance teacher told her to see her doctor, who referred Kim to a physical therapist to treat her patellar tendonitis: inflammation of the tendon that connects the knee to the shin. Since Kim’s injury developed because of overuse and weak muscles around the knee, she worked on squats and stretches for strength. Because she did not enjoy going to physical therapy, Kim ultimately decided to do her therapy program at home, for five to six months.

“The way that they did [therapy] made me feel, maybe it was necessary, but it made me feel as though my injury was really limiting,” Kim said. “It felt as though I was looked at like a patient or that I was sick in some way. And I don’t understand that feeling. But I felt that way. [Doing the exercises at home] was a lot more comfortable for me. I could do it at my own pace.”

Adan Ramirez, physical therapist assistant and certified athletic trainer (ATC) at BEST Physical Therapy, recommends that athletes recovering at home do their exercises in front of a mirror or camera to make sure they’re doing them correctly. Additionally, Ramirez says that a benefit to recovering at a clinic is receiving immediate verbal feedback, as well as doing modified exercises that cater to athletes’ respective sports. 

“Some of [these exercises], I’ll be honest, can be boring,” Ramirez said. “I used to be an athlete myself and so I can only do this for so long. But if a soccer player comes in, I’ll have them move the ball with the leg that’s on the ground, do some passes, some volleys. Basketball players will dribble, do some passing and catching as they’re standing on one leg.”

Basketball player sophomore Emi Kosakura found that going to a physical therapist during the season of her freshman year improved her performance, as she had ignored knee pain for a couple years until it became too bothersome in her freshman year. Her doctor said her injury wasn’t severe and was a result of slight bruising and weak knees.

When Kosakura went to physical therapy for a couple months, she was instructed to strengthen the muscles around her knee. 

Ramirez finds that athletes, while focusing on playing the game, tend to neglect strengthening the right muscles. His therapy program consists of exercises for muscles that support the knee, including hamstrings, glutes and hips, feet, core and quadriceps. One exercise, called the single leg RDL, works on single leg strength, hamstring activity and glute strength, activating the whole posterior chain.

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“Just imagine a 300-pound football player running,” Ramirez said. “During the running cycle, you’re landing on one leg. So [with] all your weight, all those gravitational forces coming down on that one leg, it’s really important the muscles around there are nice and strong to provide stability … You have to move properly and efficiently and really take the time to really feel how you’re moving and make sure you’re not doing an exercise improperly.” 

For Kim, the weaker muscles around her hamstring, quadricep and calf caused her to use her knee to carry her weight incorrectly, wearing it out over time. 

“For my whole life, I did not know that the way that I was dancing was really damaging my leg, but it was,” Kim said. “So it was hard for me to restructure my habits in the way that I was used to. It made me feel really weak at times, because skills that I could do before, when I actually do them correctly, I couldn’t do as well … But then I just realized that if I could do it incorrectly, I could definitely do it correctly.”

To break old movement patterns, Ramirez emphasizes starting slow before building up speed, especially in agility exercises. In an exercise like a ladder drill, he places a resistance band around the athletes’ knees to cue them to push their knees outwards, setting up the knee and the hip in a neutral position. This makes sure the athlete moves with intent — not focusing on rep count or time, but prioritizing proper, efficient movement.

“The way [the body] works [is that] when you go fast with something, it’s going to refer to movement patterns that it already knows. And most of the time those movement patterns are incorrect,” Ramirez said. “When you go slow and you do it repetitively in a slow fashion, the brain starts to remember that movement pattern. And so when you go quickly, it’s going to refer to that proper movement pattern.”

After years of ignoring her knee pain, Kim wishes she investigated the cause of her pain earlier, as her delayed response caused more challenges. She says she would tell her middle-school self to stop thinking her pain is OK and to recognize when something is wrong. 

“You’ve been alive for long enough to know your own body and to be able to listen to it and not be scared of what other people will think of you,” Kim said. “It’s important to not put your expectations of your body in front of what you’re actually physically capable of. That doesn’t make you weak, that makes you self aware.”

Kim believes that since dancers commonly hurt their knees, aching knees and cracking joints are accepted as natural, often diminishing the scope of the injury. 

“I don’t like that approach to dealing with any injury,” Kim said. “I think it can cause a lot of people to not speak about their injuries, if you’re telling them that they should be able to deal with it.” 

According to Kosakura, this normalization is common in basketball too. While Kosakura perceived her knee discomfort as a minor injury, she had to familiarize herself with the level of movement she could handle. 

“[My] coach was really understanding, so she didn’t make me do as much,” Kosakura said. “I only had to do what I could do. Other than that, sometimes I would push myself too much, and then I had to sit out because I did more than I actually could.”

Ramirez did the same as a high school athletic trainer, trusting athletes to gauge their pain and whether they can stay in a game. He says athletes usually are honest with themselves but reminds them not to let the pain get out of control.

“If you’re in pain already, your body’s going to feel that, you’re going to be moving differently because of it,” Ramirez said. “So you could cause yourself even more injury. The thing I [tell] athletes is to get on top of it right away before it gets even worse … I know it’s hard for athletes to admit that because they’re gonna lose playing time, they might lose their spot. But, in the long run it’s really going to help them out. If they wait too long [they could be risking further injury with longer recovery times], and if you get on top of it right away you can limit that time that you’re off the field.”