Knee Pain in Dancers & Performers: Hyperextension, Hypermobility and Anterior Knee Pain

Knee pain is one of the most common reasons dancers and performers come to clinic, and it’s rarely caused by just one thing.

We've been seeing many performers struggling with anterior knee pain (pain at the front of the knee) that is often linked to repeated loading in deep flexion, landing mechanics, turnout demands, and, very commonly, knee hyperextension in hypermobile individuals.

Anterior knee pain in dancers doesn’t usually come from one structure alone. Several highly sensitive tissues sit at the front of the joint, including the knee’s fat pads, mainly Hoffa’s fat pad and the quadriceps fat pad, and the cartilage underneath the kneecap, known clinically as the patellofemoral cartilage.The fat pads are richly vascularised and innervated with nociceptive nerve endings, meaning even low-grade irritation can produce moderate to significant amounts of pain. These can become irritated through repeated micro-trauma resulting from twisting forces, end-range loading (particularly uncontrolled!), or direct compression; these can trigger inflammatory processes that lead to thickening and reduced elasticity of the pad, allowing these tissues to become mechanically impinged during movement.

Similarly, chondromalacia patella refers to softening or irritation of the cartilage on the underside of the patella, which can develop when tracking of the kneecap is altered or when compressive loads are repeatedly driven through the joint, something we commonly see in hypermobile performers who habitually rest into hyperextension or train at extreme ranges.

Both can present separately or coexist with overlapping symptoms such as:

• Pain at the front of the knee

• Discomfort in full extension/hyperextension

• Pain in deep knee bend/squats and when kneeling

• A feeling of blocking or catching in the knee

• Swelling at the front of the knee

Why Is Anterior Knee Pain So Common in Performers?

The front of the knee is exposed to a lot of forces in dance and performance:

• Repeated pliés and deep knee bends

• Jumping, tucks and landing 

• Rapid changes of direction

• Sustained turnout positions

• Aesthetic demands for long, straight (often hyperextended) legs..relevé.. Think about all the time you have spent in relevé!

When these loads combine with hypermobility, particularly into end-range knee ranges, tissues at the front of the knee can become irritated over time.

Pain doesn’t always appear suddenly. More often, it builds gradually: stiffness after class, discomfort in warm-ups, or pain at the bottom of squats and lunges that slowly becomes harder to ignore.

Why Strength and Intentional Stability Matters:

For hypermobile performers, stability is all about active control, especially in the final degrees of knee extension where passive structures are otherwise doing most of the work.Intentional stability training focuses on teaching the body to:

• Control the last few degrees of extension with specific strength work so the knee doesn’t repeatedly fall into a locked position

• Share load across the quadriceps, hamstrings, glutes, and calves, helping off-load sensitive structures at the front of the joint rather than relying on the joint completely

• Support patellar tracking, which can be influenced by how well the surrounding musculature is coordinating during movement

• Manage rotation through the hip and foot by strengthening deep hip stabilisers and rotators, so the knee is not asked to compensate for poor proximal or distal control

• Absorb force more efficiently during landings, including retraining how the tibia rotates under load and progressively introducing plyometrics once sufficient strength is established

• Avoid collapsing into joint end-ranges, while still respecting the aesthetic demands of dance

In clinic, this often means deliberately training dancers at their available end-ranges rather than trying to avoid them altogether. 

Hypermobility itself isn’t the problem, many elite performers are highly mobile and remain relatively pain-free. Difficulties tend to arise when strength, coordination, and neuromuscular control don’t keep pace with the extreme ranges being used, and while hypermobility can’t be reversed, it can be supported through targeted strength work, coordination training, and improved proprioceptive awareness at end-ranges, giving performers far greater control, resilience, and confidence in the positions they depend on every day.