196 Dance Anatomy and Kinesiology
femur; and the awareness of neutral, flexed, and
hyperextended positions of the spine. However, the
principles previously discussed should be applied to
enhance technique and reduce spinal stress.Turnout
The use of external rotation of the hip is an impor-
tant element of classical ballet and many other dance
forms, and many dancers are concerned about how
much turnout their bodies possess. The extent of hip
external rotation, or turnout, possible for a dancer
is primarily determined by bony, ligamental, and
muscular factors. Bony factors include the depth
and shape of the hip socket (acetabulum). A more
shallow acetabulum that faces more laterally is gen-
erally considered to favor external rotation, while a
deeper socket that faces more anteriorly can lessen
the extent of external rotation permitted. The angle
of the shaft of the femur relative to the neck of the
femur also affects the extent of turnout possible. As
described earlier in this chapter, individuals with
less anteversion or more retroversion tend to have
greater external rotation. Curvature and length of
the femoral neck may also affect mobility. A neck
that is more concave and longer will tend to facilitate
abduction and lateral rotation, while a shorter, less
concave neck will lessen the potential end ranges of
these motions, due to contact with the edge of the
acetabulum.
The joint capsule and its associated ligaments
can also affect potential hip external rotation. The
capsule and certain ligaments, particularly the ilio-
femoral ligament, become taut with hip external
rotation. Hence, if they are more extensible they will
allow greater turnout. Similarly, adequate extensibil-
ity of key muscles, including the hip internal rotators
and adductors, will allow the range permitted by
the bony and ligamental constraints to be realized.
The relative contribution of, and the magnitude of
change possible in, each of these constraints is an
area of controversy. It has been theorized that early
training may be able to actually affect bony con-
straints, allowing for a molding of femoral torsion
up to about age 11 or 12 (Brown and Micheli, 1998;
Sammarco, 1983), but that after this age, improve-
ments in passive turnout would be due to stretch-
ing of soft tissue constraints (capsule, ligaments,
and muscles). Although an earlier study suggested
changes in femoral torsion in favor of retroversion
with elite ballet dancers who began training prior to
10 years of age (Miller et al., 1975), the failure in a
recent study to find greater retroversion in elite ballet
dancers (Bauman, Singson, and Hamilton, 1994)and the observation that measurement of passive
hip external rotation appeared to increase markedly
following participation in class (Garrick and Requa,
1994) suggest that the greater external hip rotation
seen in the average dancer may be due more to soft
tissue constraints than bony changes.
Various screening tests can be utilized to estimate
the passive hip external rotation present in a dancer,
and the results will vary markedly in accordance with
the measurement techniques used. However, studies
agree that ballet dancers exhibit significantly greater
passive and active hip external rotation than non-
dancers; and some studies also showed lower levels
of hip internal rotation, with even lower levels of
internal rotation in male versus female ballet danc-
ers (DiTullio et al., 1989; Garrick and Requa, 1994;
Hamilton et al., 1992; Khan et al., 1997).
Some orthopedic surgeons hold that a minimum
of 60° of hip external rotation should be present by
15 years of age in a dancer who wishes to pursue a
career in classical ballet (Brown and Micheli, 1998;
Thomasen, 1982). Measurements performed by the
author showed the average hip external rotation of
elite advanced/professional ballet dancers to be 59.9°.
The technique for measurement, used on dancers who
had just warmed up, involved a prone position with
moderate force applied while an assistant stabilized
the hip such that the endpoint was reached at which
any additional rotation was of the pelvis and not the
femur. Use of protocols with less manual assistance,
or with the knees touching (hip adduction) versus
hip-width apart (neutral), would reveal lower values.
Another study of elite professional ballet dancers
showed average hip external rotation of 52° for both
men and women (Hamilton et al., 1992).
While using an exact measure as a screening factor
is probably unwise due to diverse results, the com-
plex relationship between passive and active use of
turnout, and the controversy regarding the extent to
which turnout can change with training, the concept
is still germane that a ballet dancer with very limited
hip external rotation will likely have difficulty achiev-
ing the required aesthetic without undue stress and
injury (Garrick and Requa, 1994; Hamilton et al.,
1992) and will be more prone to dropout from pro-
fessional training (Hamilton et al., 1997). In many
other dance forms including modern, jazz, and tap,
the aesthetic does not dictate as extreme a lateral
facing of the feet, and there is likely more tolerance
for lower values of hip external rotation. One study
showed that when asked to adopt a comfortable
turned-out first position, modern dancers’ mean
position was 29° less turned out than the mean for
ballet dancers (Trepman et al., 1994).