This month I’m offering you some thoughts on turn-out, that often-debated subject in dance (especially ballet) that we all worry over / strive for / get obsessed with.  I am especially indebted to long-time dance medicine colleague and researcher, Dr. James Garrick, MD, for his insightful comments on this article–and a special “thank you” also to Dr. Matthew Wyon, PhD – Research Centre for Sport Exercise and Performance @ University of Wolverhampton (UK) / Vice President of IADMS, for his input as well.

Enjoy–and Pass It On! 

– Jan Dunn, MS, Dance Wellness Editor

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OK, so let’s talk about turn-out…that elusive external rotation of the legs in the hip socket that dancers (especially ballet dancers) all strive for.

This post is going to be just a brief foray into that (often thorny) discussion. I’m not going to give you detailed anatomical information–there are various online resources (as well as books) especially written for dancers that can give you excellent, very specific anatomical detail (I’ve provided a partial resource list at the end).

What I do want is to share with you what I feel is important for every dancer / teacher (and parent) to know–gleaned from 40 years of teaching dance / 35 years in the dance medicine field / 32 years of teaching Anatomy, Kinesiology, and Injury Prevention to dancers in university dance departments.

Just the Basic Facts, Ma’am

Turn–out, as every dancer and teacher knows, involves rotating the legs outward from the hip socket. It enables us to be able to have full range of movement in dance, especially in sideways directions.

A Brief History of Turnout

Turn-out has historical beginnings going back to the French and Italian courts, evolving from a combination of different things–such as fencing / having to move sideways or back your way out of the king’s presence (so that you wouldn’t ever turn your back on him) / and (my particular favorite) – in court, turning one’s leg out to show the intricate designs on the heels of one’s shoes (France’s King Louis XIV – “The Sun King”, who founded the Royal Academy of Dance in 1661 – was actually one of the first to do this, to show off his elaborately decorated shoes to the court!).

For many years, the desired “perfect” turn-out meant (especially in ballet) that you had your feet completely turned out, straight side to side, in a 180 degree straight line. But unfortunately…

Very few people have a hip socket that is capable of rotating the femur (thigh bone) completely out to the side–so the extra slack instead gets transferred to the knee joint and foot (for a full detailed analysis of how this all works, see some of the resource articles mentioned at the end). This is called, as you probably know, “forcing” your turn-out–which means that you are using compensatory movements at the knee, foot (rotation / twisting), or lumbar spine (hyperextension, or “swayback”) to increase the apparent range of your turn-out.

The problem is–if dancers “force” their turn-out from the knees / ankles / lumbar spine, not-nice things can result, especially over time.

More Basics

The structure of our hip joint is something we are born with—different factors determine how much / how little turn-out we have at the actual joint. For example:

• The shape of the bones
• How deeply set into the hip socket the femur (thigh bone) is
• How tight or loose the ligaments are

You will find some online sites that say you can possibly change your structural, inherited turn-out with early training (between ages 8-12), but this is still very much debated in the dance medicine and science field, and some of the people who are most knowledgeable about this, from a research perspective, do not think it is really possible.

What can be changed, however, is muscle imbalance–both strength and flexibility–around the hip joint, which can limit hip external rotation.

Interested? Read on!

The average person on the street usually has turn-out in the range of 40-45 degrees. We know that dancers usually average around 55 degrees, and occasionally slightly more–but very few people have that 90 degree turn-out in the hip socket that equals 180, when the heels are together in 1^st position.

So when you see dancers standing at the barre in 180-degree first position, the chances are pretty good that they are “forcing” it, and taking the extra stress in the knees and feet.

Why Forcing Turnout Is Not Good

Over time, forcing turn-out puts undesirable force and pressure on joints / body parts that were not designed to do that–in particular, the feet / knees / lower back.

Be aware that there are some dance blogs that will tell you that’s it OK to do this (force at the knee / foot / lumbar spine), but those sites are ignoring the majority of the dance medicine research–which tells us that it is potentially detrimental and injurious to those body parts, over time. To quote well-known dance science researcher / author, Karen Clippinger, MS, in her textbook “Dance Anatomy and Kinesiology” (Human Kinetics, 2007):

“Failure to maintain turnout at the hip and excessive twisting from the knee down are believed to be a contributing factor to many injuries of the knee, shin, ankle, and foot”.

Other prominent researchers in this area will all tell you the same thing–and add injuries of the lower back to the list as well.

Interesting Things To Know About Turnout

Turn-out Tests

Testing how much turn-out you actually have at the hip socket should ideally be done by a dance-familiar physical therapist or trainer (or physician).

There is one prone (lying on your stomach) “eyeball” test that I like to use, which can give you / your teacher a fair idea of where your range falls–and while physical therapists would use a goniometer (the instrument used to measure joint angles) to give an exact reading, it is possible to use this same test to give an approximate estimate of the dancer’s hip external rotation.

Muscular Imbalance Issues

I mentioned above how muscle imbalance can affect your turn-out (remember our article on Causes of Injuries? – the importance of muscle balance….?). If the muscles on one side of the joint are stronger (or less flexible) than the other, it will limit full range-of-motion for that leg, in all directions–including turn-out.

It’s important to note that the hip internal rotator muscles are weak and tight in many dancers (especially ballet)—and that this will limit the amount of external rotation that can happen. Dancers can sometimes increase their measured degree of turn-out by as much as 20 degrees when they do have this imbalance situation and are put on a program for stretching and strengthening the internal rotators.

And sometimes, you aren’t actually using all the natural turn-out that you do have, simply because the external rotator muscles aren’t strong enough to hold it. So that principle of equal muscle strength and stretch is really important here…and remember that weak muscles = tight muscles.

We usually have one leg that naturally has more turn-out than the other–but be aware that muscle imbalance can also make that happen as well (here is where you need a PT to do some analysis / muscle testing). Assuming that there actually is a structural difference between R and L (there is with me, as with many dancers), you should never try to force the lesser-turned out leg to match the greater one. That will only lead to more problems down the road. Determine which of your legs is less–for example, R is 55 degrees, and L is 50–and then always match your legs to that lesser angle, to avoid stress and potential long-term injury.

Turnout In Performance?

Research in dance medicine has shown that in performance, we don’t use the same amount of turn-out as we do in class–we use less. This begs the question: If this is indeed the case, why do we insist on emphasizing extreme turn-out in class, when it does not transfer to performance?

Tibial Torsion Issues

We are often told that in a well-aligned turn-out position (i.e not forcing), we should aim our “knees over toes” – specifically, the 2^nd toe (or the joint space between the 2^nd/3^rd toe, which is the center of the forefoot).

This is indeed correct for a leg that has a straight tibia (shinbone) – but if you are among the dancers who have tibial torsion (where the tibia rotates inward slightly, with a slight curve to the outside of the leg), that knee / 2^nd toe alignment doesn’t quite match up.

There is nothing wrong with tibial torsion–it is just a different structure than a straight-line tibia–but it is important to know about, as both a teacher and dancer. (In dance screenings that I’ve participated in, as many as 40-50% of students had this type of leg structure).

Dancers with this type of anatomy often need to line the knee up with the great toe, as opposed to the 2^nd, or between 1^st / 2^nd toe joint–as opposed to 2^nd / 3^rd. Forcing the knee over to the 2^nd toe can cause supination (rolling outwards) in the foot, and additional problems at the knee joint.

It’s best to work with a knowledgeable dance teacher / trainer / physical therapist, if you have this type of leg alignment so that you can find the optimum position for your own individual structure.

Last, But Not Least, Turn-In!

Having a lifetime in dance and preventing injury is what it’s all about, and in that light, listen up, folks:

Turning in is equally important for dancers–maybe more so than turning out. It’s the imbalance around the joint that leads to injury, remember? So if you’re only always turning out (as many ballet dancers do) and never doing exercises in parallel, or more importantly, turn-in, you aren’t really using some of the important muscles around both the hip and knee joints…and that pre-sets us up for injuries down the road.

Plus, an important thing to realize is that those turn-in movements are keeping our actual hip joint healthy, over long years of use. It is full range of motion in any joint that keeps it healthy, and works to avoid arthritis. By only doing turn-out movements, and never / rarely doing parallel / turn-in, we are ignoring a good segment of the joint capsule…and joints that don’t move fully develop arthritis way faster than joints that move all through their natural range of motion!

So if your dance environment doesn’t provide good opportunities to use turn-in, find outside activities like Pilates, that will help keep your body in good overall balanced strength and flexibility.

And Remember–Turn-Out Doesn’t Make or Break You As A Dancer

There are so many things that all come together to make a good dancer. It’s not only the body we are born with, but the training, the artistry, the personality, the musicality…the list could go on and on.

Dr. James Garrick, MD, one of the pioneers of dance medicine, long-time physician for the San Francisco Ballet (among other companies), and researcher on turn-out, always counsels dancers to not get hung up on how much turn-out they do or don’t have. He reminds them that some of the world’s greatest dancers do not have that magical 180 degrees, and that working within your own natural turn-out, and focusing instead on all the many things that make us beautiful dancers–is what’s really important.

So – dance on – and don’t force your turn-out!

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Resources for further reading

There are many sites that discuss turn-out online–here are some that I like:

The Truth About Turnout | Dance Spirit

www.dancespirit.com/2010/10/the_truth_about_turnout/

Understanding True Turnout In Dance | Dance Advantage

Centerwork: Understanding Turnout – Dance Magazine – If …

Turnout for Dancers: Hip Anatomy and Factors Affecting …

(Editors Note: this is an extremely detailed anatomical description)

Books:

“Dance Anatomy and Kinesiology” – Karen Clippinger –Human Kinetics, 2007

“Dance Medicine Head to Toe: A Dancer’s Guide to Health” – Judith R. Peterson, MD – Princeton Book Company, 2011

“Finding Balance” Fitness, Training, and Health for a Lifetime in Dance” (2^nd Edition) – Gigi Berardi – Routledge, 2005

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Editor Jan Dunn is a dance medicine specialist currently based on the island of Kauai, Hawaii, where she is owner of Pilates Plus Kauai Wellness Center and co-founder of Kauai Dance Medicine. She is also a Pilates rehabilitation specialist and Franklin Educator. A lifelong dancer / choreographer, she spent many years as university dance faculty, most recently as Adjunct Faculty, University of Colorado Dept. of Theatre and Dance.  Her 28 year background in dance medicine includes 23 years with the International Association of Dance Medicine and Science (IADMS) – as Board member / President / Executive Director – founding Denver Dance Medicine Associates, and establishing two university Dance Wellness Programs

Jan served as organizer and Co-Chair, International Dance Medicine Conference, Taiwan 2004, and was founding chair of the National Dance Association’s (USA) Committee on Dance Science and Medicine, 1989-1993. She originated The Dance Medicine/Science Resource Guide; and was co-founder of the Journal of Dance Medicine & Science.  She has taught dance medicine, Pilates, and Franklin workshops for medical / dance and academic institutions in the USA / Europe / Middle East / and Asia, authored numerous articles in the field, and presented at many national and international conferences.

Ms. Dunn writes about dance wellness for 4dancers and also brings in voices from the dance wellness/dance medicine field to share their expertise with readers.