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Sports Medicine Advisory: Lower Extremity
Turnout - Accentuated Stretch and Flexibility Exercises for
Classical Ballet Training
By Stephen M. Apatow, Director of Research and Development,
Sports Medicine & Science Institute.
Dance
injuries secondary to trauma are rare and usually fractures sustained in
falls. Most problems are related to the demands placed on the body
in dance. Many of these demands and problems are similar to those
in gymnastics. The requirement for flexibility in concert with poor
warm-up can produce Achilles, posterior tibial, and patellar tendinitis.
Repeated jolts and soft slippers contribute to stress fractures as they
do in gymnastics.
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In the ideal turned out position, the weight should fall from
the body to the thigh and directly through the knee and ankle. This
distribution of weight can be achieved if the external rotation of the lower
extremities occurs at the hip.
Please note, S.M.Apatow began dance training
when at 22-23 years of age. It was via a concentrated stretch program
combined with excellent dance training that the range of motion demonstrated
in this photo was achieved.
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To achieve
increased external rotation of the lower extremity, students may increase
their lumbar lordosis or "screw the knee." Increasing lordosis decreases
the tension on the iliofemoral ligament allowing increased external rotation
of the hip. However, it will put an excess strain on the lumbar spine,
as much a the hyperextension in gymnastics does. "Screwing the knee"
is done by assuming a demiplie (half knee bend) position, allowing the
180 degree positioning of the feet to be achieved at the floor, then straightening
the knees without moving the feet. This puts a great deal of torque
on the knees and can produce medial knee strain and patellar subluxation.
"Rolling the foot" can produce posterior tibial tendonitis and bunions.
Knee
Problems
Medial
knee strain is common in student dancers and presents as pain along the
medial side of the knee with no history of specific injury. Pain is
usually worse after class and gradually decreases if there is a day or two
hiatus between ballet classes. There is no history of swelling or locking.
Physical examination often reveals some tenderness along the medial aspect
of the knee but not specifically over the joint line or over the medial
collateral ligament. No effusion is present. Ligamentous laxity,
meniscal signs, and patellar tenderness are lacking. Radiographs are
not usually required in this situation. If one finds tenderness specifically
along the distal femoral epiphysis or along the tibial tubercle or patellar
tendon, one is dealing with a different problem. One can confirm the
suspicion of medial knee strain by asking the child to do a plie.
An imaginary plumbline dropped from the knee should land over the second
toe. If the plumbline falls medial to the foot during plie, then the
medial knee structures are seeing increased strain and will gradually respond
with pain. Beware the child who achieves "knees over feet" by assuming
a increased lordotic position.
In the
ballet class, approximately one half to two thirds of class is spent at
barre exercises, most of which include plies in various positions.
In addition, plies are fundamental to initiating jumps and landing from
them. Hence, if one's plie technique is incorrect, musculoskeletal
problems are quite likely. These problems can be resolved by explaining
the proper technique to the child. The best way for finding a child's
proper position using external rotation of the hip is to have the child stand
with his or her legs straight and feet together. Instruct the child
to move his or her legs from parallel to a position of comfortable external
rotation, keeping the back straight and head up. The "turnout" achieved will
be a function of the child's femoral neck-shaft angle. Keeping the
knees straight will ensure that the rotation will occur at the hips.
Once in this position, the child can be instructed to keep his or her feet
at this angle, but assume the various ballet positions. While performing
plies in these positions, the knees should fall directly over the feet.
Most good ballet instructors will accept this variation in positioning of
their students and realize that not all students can achieve a 180 degree
angle of their feet. In addition, good instructors will teach the
children to obtain more external rotation using the short external rotators
of the hip rather then cheating with lordosis of the lumbar spine or twisting
the knee.
Patellar
Tendinitis
Patellar
tendonitis, often a part of the presentation of Osgood-Schlatter disease,
is seen in both the young dancer and gymnast. Patellar tendonitis
is also called "jumper's knee" because it is commonly seen in athletes who
jump often. These athletes have pain in the patellar tendon unit,
either at the distal pole or the patella, along the patellar tendon, or
on the tibial tubercle.
On physical
examination, one will find very specific point tenderness at the site of
inflammation. Often swelling will be present in the infrapatellar
bursa. The child also may have pain when extending the leg against
resistance. Usually jumping activities are the cause. In addition,
Micheli (Micheli, L.J., and Rosegrant, S.: Boston sports medicine:
Helping the young athlete. Phys. Sports med., 9:105-107, 1981) feels
that the "overgrowth" syndrome contributes to the prevalence of Osgood-Schlatter
disease in the 11- to 13-year-old age group. Although children are assumed
to be naturally flexible, poor flexibility and inadequate warm-up were factors
in over half the injuries seen in Micheli's clinic.
The treatment
for patellar tendonitis is rest. The child may do any activities
that do not aggravate the problem. Generally, forceful kicks, jumps,
and plies must be temporarily avoided. Ice massage over the tendon
area will often decrease the pain as well as the inflammation. In
resistant cases, a jumpers knee brace, a knee sleeve with a pad over the
patellar tendon, will decrease the forces applied to the tendon by the quadracepts
muscle and relieve the pain. Exercising the quadracepts muscle is to
be avoided initially because it will aggravate the problem. However,
when the pain has decreased, one should initiate stretching and strengthening
of the quadracepts. Symptoms generally resolve in three to four weeks.
Excerpts
from Sports Medicine Concerns in Dance and Gymnastics
Carol
C. Tetz, M.D. Assistant Professor, Orthopedics, University of Washington,
Seattle, Washington
Pediatric
Clinics of North America, Vol. 29, No. 6, December 1982
Clinics
in Sports Medicine, Vol 2, No. 3, November 1983
Part
II: Accentuated Stretch and Flexibility Exercises to Increase Turnout
Most
dancers or athletes do not know that a lack of turnout or hip range of
motion could be caused by soft tissue restrictions which can be addressed
with an accentuated stretch and flexibility program.
As an
athlete training for international competition in skiing and rowing (in
my early 20's), I began an intensive modern, jazz and ballet program
with very limited flexibility. In 1987, I progressed to the study of the
Soviet System of Ballet Training at the Nutmeg Ballet/Conservatory for the
Arts. During these 6 years of intensive training, my background
in sports medicine, biomechanics and exercise physiology combined
with top instruction led to my personal development of close to 180 degree
functional hip turnout.
The following
stretch exercises were adapted from a test for internal and external femoral
rotation in the flexed position, Hoppenfeld: Physical Examination
of the Spine and Extremities:
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In a seated position, both lower legs are brought to 90 degrees.
Place the ankle of the upper leg onto the knee of the lower leg (be sure
not to sickle the foot). The objective of the stretch is to bring the upper
knee to the lower heel. The ideal range of motion is attained when
both legs freely align in a parallel position.
The degree of restriction that exists in the hip directly relates
to mechanical factors which limit the dancer or athlete's capacity to achieve
their potential turnout with correct knee, ankle and foot alignment.
Note: All stretches must be executed slowly and below the threshold
of pain or discomfort.
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Advanced
Stretch and Flexibility Exercises to Increase Turnout
Once a
student has developed the capacity to freely align both legs in a parallel
position they can gradually enhance the stretch by using a towel or pad
beneath the ankle of the upper leg.
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| When the knee of the upper leg can easily contact the ankle of
the lower leg, the dancer or athlete may desire to stabilize the leg with
cloth strapping material or a velcro band. |
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Next, slowly, lay back . The range of motion developed in
this stretch will help develop the flexibility needed to work with external
rotation of the hip with the leg at 90 degrees (turnout stretch seated
) and standing (turnout stretch laying). |
The ideal
alignment for turnout in classical ballet training relates to the capacity
of the dancer to accommodate correct tracking of the knee over the center
of the ankle and foot in parallel, 1st, 2nd, 3rd, 4th or 5th positions.
This standard should be applied in all technique classes and choreographed
movement.
As a
student integrates accentuated hip stretches into their overall development
program, external rotation of the hip will increase and enable the student
to safely increase the degree of turnout of the feet in technique classes.
Selected
Bibliography
Agrippina
Vaganova, Basic Principles of Classical Ballet, Dover, 1969
Alfred
A Knopf, The Classic Ballet, New York, 1984
Clinics
In Sports Medicine, Injuries to Dancers ,Saunders 1983
Beryl
Dunn, Dance! Therapy for Dancers, London, 1994
Donald
F.Featherstone, Dancing Without Danger, 1970
L.M.
Vincent, The Dancers Book of Health, Andrews and McMeel, 1978
White-Panjabi,
Clinical Biomechanics of the Spine, J.B. Lippincott, 1978
Rosse-Clawson,
The Musculo-Skeletal System in Health and Disease, Harper & Row, 1970
Stanley
Hoppenfeld, Physical Examination of the Spine and Extremities, Appleton,
1976
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