The Knee and Patellofemoral Joints 269hip, the less rotation will be required from the knee
downward. The need to emphasize fully develop-
ing external rotation from the hip is given further
support by findings that (1) ballet students exhibit
increased active range of hip external rotation but
not increased external rotation below the hip when
compared to nondancing university students (Khan
et al., 1997); (2) elite female ballet dancers with
more total injuries had lower values of total turnout
(Hamilton et al., 1992); and (3) in personal clinical
experience, many dancers with patellofemoral pain
syndrome experienced relief of symptoms by improv-
ing turnout technique.
To lessen knee stress, emphasize utilizing the
hip external rotators to help direct the knee over
the foot during movements such as pliés, and avoid
shifting the heel forward when the knee is flexed.
Furthermore, maintain as much external rotation as
possible at the proximal end of the femur (hip joint),
and avoid exaggerating the slight internal rotation
of the femur relative to the tibia (associated with
the locking mechanism of the knee) when extend-
ing the knees in movements such as rising from
a plié. When the foot is free, such as in brushes,
emphasis should be on rotating the hip and car-
rying the external rotation down the leg such that
the “heel comes forward,” rather than “bringing the
heel forward” from excessive tibial rotation. In the
author’s experience, most dancers do not fully utilize
or maintain the potential hip external rotation that
their bodies possess.
Valgus Stress in Dance
Floor work in jazz and modern often includes posi-
tions that incorporate internally rotating the back
leg, with the lower leg and foot facing back as seen
in figure 5.26. Although performance of such posi-
tions is often not recommended for sedentary or
recreational athletes, it is an important element of
some dance forms; and many dancers have adequate
hip range of motion to allow performance of such
positions without undue knee stress. However, if
inadequate hip or quadriceps flexibility is present
(particularly in men with limited hip internal rota-
tion), such positions might cause excessive valgus
knee stress and knee discomfort.
If dancers do experience knee discomfort, they
should perform supplemental stretching daily;
and the position can be temporarily modified as
shown in figure 5.26 as adequate hip flexibility is
developed.
Valgus, varus, and rotational stresses also occur at
the knee in dynamic movement as when the dancer
changes direction, moves side to side, or moves
on a diagonal. Studies looking at sidestepping and
crossover cutting maneuvers suggest that such move-
ments can place large stresses on the anterior cruci-
ate and collateral ligaments of the knee that are of
sufficient magnitude to cause ligament injury if the
muscles of the knee do not provide adequate stability
(Besier, Lloyd, Cochrane, and Ackland, 2001). These
stresses are markedly higher in situations in which
changes are unanticipated and the muscles do not“Bring the Heel Forward”
T
he instruction to “bring the heel forward” or “present the heel” is sometimes used by teachers in
an effort to maximize turnout in open kinematic chain movements in which the foot is moving
on the floor or coming off the floor, such as with a tendu or dégagé.
A desired anatomical interpretation is to think of the upper leg and lower leg as one continuous unit
in which rotation that started at the proximal end (the hip joint) will result in rotation at the bottom
end—such that the back of the heel will rotate from its original position of facing backward (when
the leg is parallel) medially and forward. To reinforce this concept, the image is sometimes used of
reaching the leg out and spiraling it around the axis running lengthwise through the middle of the
limb. This movement can be thought of as like that of a screwdriver, where rotation of the proximal
end by the hand results in rotation at the distal end. In contrast to this desired initiation, some danc-
ers respond to this cue by bringing the heel forward from externally rotating the tibia relative to the
femur at the knee joint. Hence it can be helpful to incorporate the hip into this cue, such as by cueing
to start the rotation by bringing the trochanter back and continuing the rotation down the leg such
that the heel rotates “in and forward.”