“Turn out” is the amount of outward rotation that can be achieved from the legs.
For a ballet dancer, the ideal amount of turn out is 90° from each leg.1 If that motion is not possible from the hip joints, the motion must come from other parts of the body.2 While the ideal amount of hip external rotation of each leg is 90°, no need to toss your pointe shoes in the trash if you don’t have that much hip mobility. Even elite professional ballerinas rely on compensations to produce the desired level of turn out.3
On average, only 60% of turn out is produced from hip external rotation. The knee contributes 10-20% and the ankle-foot complex contributes 20-30% to achieve 180° overall turn out.4 Female ballerinas from the American Ballet Theatre and New York City Ballet only have an average of 52° hip external rotation available within each hip joint!3 Greater amounts of turn out from the hip will allow your extensions to be higher and allow you to move faster side-to-side, but mainly it is for aesthetics.5 In fact, the ideal amount of turn out in the 17th century was only 45° from each leg…wouldn’t that be nice?5
“Forcing turn out” is the phrase commonly used to describe excessive compensations at other parts of the body to achieve the appearance of more turn out. It has been reported that 70-100% of dancers demonstrate greater turn out when standing in 1st position compared to the amount of available hip external rotation, indicating compensations from other parts of the body.6-7 While some level of compensation is acceptable, excessive compensation has been associated with injury.6-7 In college-level ballet dancers, those who reported at least one previous injury that impacted their ability to participate in dance, had an average of 32° compensated turn out. Dancers who reported no history of injuries only had 17.3° compensated turn out.6 In college-level modern dancers, those who reported 2+ injuries in the past 2 years had an average of 43° compensated turn out and dancers who reported no history of injuries in the past 2 years only had 26° compensated turn out.7 Therefore, greater levels of compensated turn out may increase risk for injury.
There is some debate among researchers regarding turn out and various injuries. Decreased total turn out has been associated with increased risk of non-traumatic injuries and increased compensated turn out has been associated with increased risk of traumatic injuries.7-8 The most common compensations to allow for the appearance of 180° of turn out occur at the back, knee, and ankle-foot complex.
BACK: excessive lumbar lordosis (increased sway or arch of the back) à associated with low back pain, lumbar stress fractures9
KNEE: excessive twisting (lower leg external rotation with thigh internal rotation) à associated with excessive stress to knee ligaments and cartilage, and patellofemoral pain syndrome9
ANKLE-FOOT: excessive pronation (dropping inside of foot to the ground) à associated with shin splints, plantar fasciitis, cuboid syndrome, sesamoid problems, and Achilles tendon injury9
Many studies agree that the amount of external rotation available in the hip joint is set by 10-12 years old.10-11 Any gains in turn out after 12 years of age, are likely due to greater compensations, increased soft tissue flexibility, and improved hip strength. 10-12 Decreased soft tissue and joint flexibility is natural with increasing age.11-12 However, this phenomenon appears to be delayed in dancers due to frequent and extensive stretching of the muscles.11-12 After 10-12 years old, dancers must focus on maintaining the amount of available motion in the hip rather than trying to improve it.11-12 Turn out is mainly produced by six deep external rotator muscles in the hip: piriformis, superior and inferior gemelli, obturator internus and externus, and quadratus femoris.4 However, the gluteus maximus/medius/minimus, psoas major/minor, adductors, and sartorius muscles can contribute depending on the position of the hip.4 By improving the strength of these muscles, a dancer can better utilize the available motion within the hip.
Each dancer will have different combinations of neuromuscular control deficits, muscle tightness, and muscle weakness that contribute to excessive compensations during turn out. It is important to have an individualized and well-balanced program that addresses each impairment rather than trying to forcefully gain more motion within the hip joint.11 If you have concerns regarding your alignment during dance, please contact your physician or set up a screen with a performing arts physical therapist at a convenient Athletico Physical Therapy location!
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