Turnout in Ballet Dancers

Original Editor - Lania-Schane Smith

Top Contributors - Lania-Schane Smith  

Introduction

Ballet dancer's are both artists and athletes. They perform aesthetically pleasing movements which require a tremendous amount of strength and athletic abilities. Turnout (TO) is a position of the lower limbs used in many dance forms, but especially in ballet. During TO the lower limbs are externally rotated away from each other and away from the midline with the aim of increasing range of motion in the lower limb; as well as for stability in static and dynamic balance. TO is considered to be the most important aesthetic aspect of classical ballet. Active aspects of TO require high levels of inter- and intra-muscular coordination, precise proprioception, strength, and endurance to achieve functional dynamic alignment.

Anatomy

Bones of the hip joint

The Pelvis is made up of two halves, the innominate bones, which is a fusion of three bones namely the Pubis, Ilium and Ischium. Each of these bones contribute to form the Acetabulum (or hip socket). The pubic bones connect in front to form the symphysis pubis, which is a joint containing a small piece of cartilage. The Femur is another bone that forms part of the hip joint. The femur consists of the round head, the neck, the shaft and two condyles (lateral and medial). This is known to be the longest bone in the body.

All of these bones come together to form the ball-and-socket joint better known as the hip joint or the femoroacetabular joint. The hip socket (also known as the Acetabulum) is deepened by the labrum which is a cartilage like structure.

The Pelvis and Femoroacetabular joint.

Capsule and ligaments

The hip joint capsule is a sleeve of fibrous connective tissue that surrounds the joint. The function of the capsule is to hold the femoral head in the socket and to stabilise it. It also provides some restriction of movement. The capsule is lined with a synovial membrane which secretes synovial fluid, which acts a lubricator for the joint. Three major ligaments play a role in stabilising the capsule. These are the: iliofemoral ligament, ischiofemoral ligament, and the pubofemoral ligament. These ligaments contribute to stability when standing especially.

Ligaments of the hip joint.

Muscles responsible for TO

TO originates in the hip joint. There are several muscles around the hip joint that are responsible for creating this external rotation. Some of the muscles are primary external rotators and others are secondary external rotators.

The primary external rotators of the hip are:

• Gluteus maximus
• Piriformis
• Obturator internus
• Gemellus superior
• Gemellus inferior
• Quadratus femoris

Secondary external rotators of the hip are:

• Posterior fibers of the Gluteus medius
• Posterior fibers of the Gluteus minimus
• Obturator externus
• Sartorius
• Long head of the Biceps femoris

Factors affecting TO

TO is a complex movement that involves multiple joints, including hip external rotation, tibiofemoral rotation, tibial torsion, and out-toeing, along with dorsiflexion. It is a very interesting concept unique to various dance styles, especially ballet dancing. Normal hip passive external rotation ranges from (0-45) degrees in the average human body. Professional ballet dancer's often strive for the "perfect" 180 degree TO as this is the most aesthetically acceptable in the art form. It is; however, known that professional ballet dancers have a functional TO range of about 133.6 degrees with a passive external rotation capability of 50.2 degrees and active external rotation of 35.2 degrees. TO occurs primarily in the Femoroacetabular joint if it is executed properly.

Five main factors exist that can affect the range of TO available to the dancer:

1. Angle of femoral anteversion - An increase in anteversion can cause the toes to turn inward, while retroversion tends to result in a greater turnout of the toes.
2. Orientation of the Acetabulum - An Acetabulum that faces more laterally, ensures for greater TO.
3. Shape of the Femoral neck - A longer and more concave neck results in increased range of motion in the hip.
4. Elasticity of the Iliofemoral or Y ligament
5. Flexibility and strength of the muscle tendon unit

Assessment of TO

It has been suggested that hip external rotation should be measured (with a goniometer) while the dancer is in a prone position, with hips extended and knees bent at 90 degrees. It's important to also document the dancer's warm-up status during the measurement.

Various non-hip components, like tibial version, are important for Total Turnout (TTO) measurements. Tibial version can add up to 20° to TTO. By including tibial version and other factors in TTO evaluations, we can better understand TO, which can improve dancer performance and help prevent injuries.

Several methods have been proposed in the literature for measuring Total Turnout (TTO).

1. Standing in First Position:
   • Subjects stand in first position on an original protractor.
2. Foot Tracings:
   • Lines are constructed on tracings of feet in various ballet positions (e.g., first, demi-plié, second, third, fourth, and fifth positions).
3. Photographic Assessment:
   • TTO is measured from photographs of subjects standing on friction-free foot pedals.
4. Nicholas Lower Extremity Torque Flexibility Test:
   • This test assesses externally rotated stance in the ballet first position by measuring the angle between the feet.
5. Leighton Flexometer:
   • Subjects are seated, and hip external rotation is assessed using a Leighton Flexometer.

Injuries related to TO

Injury rates among dancers are notably high, ranging from approximately 0.62 to 5.6 per 1,000 dance hours. While ballet dancers aim for an ideal TO of 180 degrees, this level of TO is anatomically unfeasible for most individuals due to their inherent range of passive TO. Consequently, many dancers resort to forcing their TO to achieve their goals, which can ultimately lead to injury. When forcing TO, three main compensatory mechanisms may present:

• Lumbar hyperlordosis
• Forced Tibial external rotation
• Hyperpronation/abduction of the feet

To achieve optimal TO, dancers need at least 70 degrees of hip external rotation on both sides, 5 degrees of tibial external rotation on both sides, and 15 degrees of foot external rotation on both sides. However, very few dancers can reach this ideal TO without making compensatory adjustments in the pelvis, lumbar spine, knee, ankle, and foot joints.

Efficient movement in dance involves optimal motions that require minimal force; when this is not achieved, the risk of overexertion and injury increases. High occurrences of low back pain, along with injuries to the knees, lower legs, feet, and ankles, are frequently associated with compensatory movements and excessive forcing of TO.