Can 16-18-year-old elite ballet dancers improve their hip and ankle range of motion over a 12-month period?

Excessive Knee Internal Rotation during Grand Plié in Classical Ballet Female Dancers

Classical ballet dancers are exposed daily to physically demanding movements. Among these, the Grand Plié stands out for its biomechanical complexity, particularly the stress applied to the knee joint. This study investigates the knee kinematics of healthy professional classical ballet dancers performing the Grand Plié. Twenty dancers were evaluated with a motion analysis system using a marker-based protocol. Before measurements, the self-reported Global Knee Functional Assessment Scale was delivered for the knees' functional ability, and the passive range of knee motion was also assessed. The average score on the Global Knee Functional Assessment Scale was 94.65 ± 5.92. During a complete circle of the Grand Plié movement, executed from the upright position, the average maximum internal rotation of the knee joint was 30.28° ± 6.16°, with a simultaneous knee flexion of 134.98° ± 4.62°. This internal rotation observed during knee flexion exceeds the typical range of motion for the joint, suggesting a potential risk for knee injuries, such as meniscal tears. The findings provide an opportunity for future kinematic analysis research, focusing on the movement of the Grand Plié and other common ballet maneuvers. These data have the potential to yield valuable information about the knee kinematics concerning meniscus damage.

The Effectiveness of Classical Ballet Training on Health-Related Outcomes: A Systematic Review

BACKGROUND

Regular physical activity is of paramount importance to reduce chronic disease risk. Classical ballet training requires balance, strength, and range of motion. Participation in social ballet classes is increasing. Ballet training interventions may be an alternative method of regular, enjoyable activity. This review aimed to determine the effectiveness of classical ballet training interventions on physical and psychological health.

METHODS

Ten databases were searched until April 2019. The included studies investigated classical ballet training interventions of a ≥4-week duration, on any population (no restrictions on experience and clinical condition), measuring physical health or psychological outcomes.

RESULTS

Twenty-three studies (25 intervention groups) were included, comprising experienced (19 groups) and novice dancers (6 groups). In experienced populations, muscular strength was the most commonly reported outcome. However, only 25% of these studies reported improvements. With novice dancers, including clinical populations, balance showed the most positive change, improving in 75% of studies that reported this measure.

CONCLUSIONS

Classical ballet training may improve balance in novices and maintain physical activity across the life span. Experienced dancers showed no further improvement, perhaps due to an already greater ability. There was large heterogeneity between the included studies. A greater focus on classical ballet interventions for inexperienced populations is required.

Prevalence and unique patterns of lower limb hypermobility in elite ballet dancers

OBJECTIVES

Determine the prevalence of lower limb hypermobility in elite dancers and secondarily to describe the patterns of mobility.

DESIGN

Cross sectional.

SETTING

Self-report questionnaires and physical assessments were undertaken at a tertiary dance institution and a professional ballet company.

PARTICIPANTS

Fifty-seven pre-professional and 29 professional ballet dancers (21±4years, 64% female, mean 13.7years training) were recruited.

MAIN OUTCOME MEASURES

Lower Limb Assessment Score (LLAS) was used to assess hypermobility. Prevalence was determined by descriptive statistics, between-leg and -group comparisons were analysed using the chi-square statistic and the pattern of mobility by cluster analyses.

RESULTS

The right leg was significantly more hypermobile than the left for the whole cohort (44% vs 40% meeting ≥7/12 for the LLAS; LLAS mean/12(SD): right:5.0(2.4) and 7.6(1.9); left:4.8(2.1) and 6.7(2.0) in pre-professionals and professionals respectively (p = 0.02)). Subtalar pronation (p < 0.001) and hip abduction/external rotation (left:p = 0.01; right:p < 0.001) were significantly more hypermobile bilaterally in professionals. Three hypermobility profiles on the left and four on the right lower limb were identified.

CONCLUSIONS

This paper presents unique lower limb hypermobility profiles identified in elite dancers.

The association between menarche, intensity of training and passive joint ROM in young pre-professional female dancers: A longitudinal follow-up study

OBJECTIVES

To determine the association between the status of menarche (yes/no), the intensity of training and the potential to improve passive joint range of motion (ROM) over a 12-month period of dance training.

DESIGN

Prospective cohort study.

SETTING

Dance studio.

PARTICIPANTS

Fifty-nine female dancers aged 12.8 ± 0.5.

MAIN OUTCOME MEASURES

The dancers were asked about their dance intensity and screened for anthropometric parameters and passive joint ROM in Grades 7 and 8.

RESULTS

Along the 12 months of dance training, we found significantly increased ankle-foot en-pointe, hip abduction, and hip external rotation (ER); significantly decreased hip internal rotation (IR); and significant increased hip ER:IR ratio. In Grade 7, 26 dancers (44.1%) reached menarche (Yes menarche); in Grade 8 an additional 23 dancers (39.0%) reached menarche (No/Yes menarche); and 10 dancers (16.9%) had not reached menarche (No menarche). MANOVA (mixed models) with repeated measures to compare joint ROM between the three menarche groups (Yes; No/Yes; No), with h/week dance practice as a co-variant, showed that hip ER, ankle-foot en-pointe, and ER:IR were significantly correlated with h/week in all three menarche groups.

CONCLUSIONS

Most passive joint ROM can be improved over 12 months of dancing around the age onset of menarche. H/week of dance practice is a main factor contributing to improved hip ER, ankle-foot en-pointe and ER/IR ratio.

Lower leg and foot contributions to turnout in female pre-professional dancers: A 3D kinematic analysis

Turnout is a central element of classical ballet which involves sustained external rotation of the lower limbs during dance movements. Lower leg and foot compensation mechanisms which are often used to increase turnout have been attributed to the high incidence of lower limb injury in dancers. Evaluation of dancers' leg posture is needed to provide insight into the lower limb kinematic strategies used to achieve turnout. The primary purpose of this study was to use 3D kinematic analyses to determine the lower leg and foot compensations that are incorporated by female university dancers to accentuate their turnout. Active and passive external tibiofemoral rotation (TFR) was also measured. A moderate-strong negative relationship was observed between hip external rotation (HER) and foot abduction in the three first position conditions. A moderate negative relationship was found between passive TFR and foot abduction in all first position conditions. Our findings suggest dancers are more likely to pronate, than rotate the knee to compensate for limited HER. Dancers with a limited capacity to pronate may force additional rotation via the knee. Ongoing research would benefit from more in-depth analyses of the foot/ankle complex using a multi-segment foot model.

Métodos usados para avaliar o en dehors ou turnout de dançarinos e bailarinos clássicos: revisão da literatura

RESUMO A técnica do ballet clássico exige a realização máxima do en dehors ou turnout, caracterizado pela rotação externa de membros inferiores. Considerando a sua importância, diversos protocolos para a sua avaliação e mensuração têm sido propostos. O objetivo desta revisão foi investigar sistematicamente quais os métodos utilizados para avaliar o turnout de bailarinos clássicos e/ou praticantes de ballet clássico existentes atualmente. A busca foi feita nas bases de dados Scopus, Science Direct e PubMed, no mês de fevereiro de 2016, e os artigos encontrados deveriam: estar redigidos na língua inglesa, avaliar bailarinos clássicos ou dançarinos que praticassem ballet clássico e mensurar o en dehors ou turnout. Foram encontrados 593 artigos, dos quais 25 foram pré-selecionados para esta revisão, apresentando quinze diferentes métodos e instrumentos de mensuração do turnout: cinemetria; inclinômetro; turnout protactor ou transferidor para medir o turnout; goniômetro; Dupuis Tropometer; transferidor original; fotos dos sujeitos; discos rotacionais; teste de flexibilidade de Nicholas; flexímetro; desenho clínico dos pés; sujeito sobre um pedaço de papel ou solo ou quadro branco; ressonância magnética; filmagem do sujeito executando sequência de passos; Dasco Pro Angle Finder. Esta revisão apresenta forte evidência para afirmar que não há, até o presente momento, um método ou instrumento padrão-ouro para mensuração do turnout de bailarinos, de modo que esta costuma ser adaptada e escolhida de acordo com o objetivo de cada estudo.

Is goniometry suitable for measuring ankle range of motion in female ballet dancers? An initial comparison with radiographic measurement

Female ballet dancers require extreme ankle motion to attain the demi-plié (weight-bearing full dorsiflexion [DF]) and en pointe (weight-bearing full plantar flexion [PF]) positions of ballet. However, techniques for assessing this amount of motion have not yet received sufficient scientific scrutiny. Therefore, the purpose of this study was to examine possible differences between weight-bearing goniometric and radiographic ankle range of motion measurements in female ballet dancers. Ankle range of motion in 8 experienced female ballet dancers was assessed by goniometry and 2 radiographic measurement methods. The latter were performed on 3 mediolateral x-rays, in demi-plié, neutral, and en pointe positions; one of them used the same landmarks as goniometry. DF values were not significantly different among the methods, but PF values were (P < .05). Not only was PF of the talocrural joint significantly less than the other 2 measurements (P < .001), PF from the goniometric method applied to the x-rays was significantly less than PF obtained from clinical goniometry (P < .05). These data provide insight into the extreme ankle and foot motion, particularly PF, required in female ballet dancers and suggest that goniometry may not be ideal for assessing ankle range of motion in these individuals. Therefore, further research is needed to standardize how DF and PF are measured in ballet dancers.

LEVEL OF EVIDENCE

Diagnostic, Level I.

Measurement of the extreme ankle range of motion required by female ballet dancers

Female ballet dancers require extreme ankle motion, especially plantar flexion, but research about measuring such motion is lacking. The purposes of this study were to determine in a sample of ballet dancers whether non-weight-bearing ankle range of motion is significantly different from the weight-bearing equivalent and whether inclinometric plantar flexion measurement is a suitable substitute for standard plantar flexion goniometry. Fifteen female ballet dancers (5 university, 5 vocational, and 5 professional dancers; age 21 ± 3.0 years) volunteered. Subjects received 5 assessments on 1 ankle: non-weight-bearing goniometry dorsiflexion (NDF) and plantar flexion (NPF), weight-bearing goniometry in the ballet positions demi-plié (WDF) and en pointe (WPF), and non-weight-bearing plantar flexion inclinometry (IPF). Mean NDF was significantly lower than WDF (17° ± 1.3° vs 30° ± 1.8°, P < .001). NPF (77° ± 2.5°) was significantly lower than both WPF (83° ± 2.2°, P = .01) and IPF (89° ± 1.6°, P < .001), and WPF was significantly lower than IPF (P = .013). Dorsiflexion tended to decrease and plantar flexion tended to increase with increasing ballet proficiency. The authors conclude that assessment of extreme ankle motion in female ballet dancers is challenging, and goniometry and inclinometry appear to measure plantar flexion differently.

Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial

BACKGROUND

Plantar heel pain is one of the most common musculoskeletal disorders of the foot and ankle. Treatment of the condition is usually conservative, however the effectiveness of many treatments frequently used in clinical practice, including supportive taping of the foot, has not been established. We performed a participant-blinded randomised trial to assess the effectiveness of low-Dye taping, a commonly used short-term treatment for plantar heel pain.

METHODS

Ninety-two participants with plantar heel pain (mean age 50 +/- 14 years; mean body mass index 30 +/- 6; and median self-reported duration of symptoms 10 months, range of 2 to 240 months) were recruited from the general public between February and June 2005. Participants were randomly allocated to (i) low-Dye taping and sham ultrasound or (ii) sham ultrasound alone. The duration of follow-up for each participant was one week. No participants were lost to follow-up. Outcome measures included 'first-step' pain (measured on a 100 mm Visual Analogue Scale) and the Foot Health Status Questionnaire domains of foot pain, foot function and general foot health.

RESULTS

Participants treated with low-Dye taping reported a small improvement in 'first-step' pain after one week of treatment compared to those who did not receive taping. The estimate of effect on 'first-step' pain favoured the low-Dye tape (ANCOVA adjusted mean difference -12.3 mm; 95% CI -22.4 to -2.2; P = 0.017). There were no other statistically significant differences between groups. Thirteen participants in the taping group experienced an adverse event however most were mild to moderate and short-lived.

CONCLUSION

When used for the short-term treatment of plantar heel pain, low-Dye taping provides a small improvement in 'first-step' pain compared with a sham intervention after a one-week period.

Dance-Related Injury

Although dance medicine has derived extensive knowledge from sports medicine, some aspects covered in the practice of dance medicine are unique to this field. Acute and overuse injuries must be analyzed within the scope of associated mechanisms of injury, mainly related to the practice of specific dance techniques. Even though most available medical literature concerning dance medicine is specific to ballet-related conditions, many of the concepts covered here and in other articles can be helpful in the treatment and diagnosis of participants in other dance disciplines. Continued research is expanding the knowledge on injury patterns of different dance disciplines. It is the experience of dance practitioners that dancers are quite in touch with their bodies; thus, when their ailments are systematically analyzed, and underlying cause can usually be identified. In this sense, it is evident that the principles of dance medicine and rehabilitation allow the practitioner to arrive at a diagnosis and treat the underlying causes to prevent reinjury, ameliorate sequelae from injury, and minimize residual deficits after injury.

Stretching for performance enhancement

Stretching exercises have been considered an essential component of physical training programs for decades. Cross-sectional studies have demonstrated that flexibility measures are related to performance in many sports, suggesting that using stretching to enhance flexibility may indirectly improve performance. However, observations by athletes and coaches have called into question the universal prescription of stretching for the purpose of enhancing sport performance, and this skepticism is being supported by a growing body of empirical data. Whereas the tissue responses and adaptations to stretching have been the most widely studied area of stretching research, comparatively little is understood regarding the neural influences on range of motion, which may have more applicability when the range of motion needs are related to skilled movements as in sport.

Range of joint movement in female dancers and nondancers aged 8 to 16 years: anatomical and clinical implications

BACKGROUND

Little data are available on changes that occur with age in joint range of motion in dancers and nondancers.

HYPOTHESIS

In dancers, joint range of motion will increase with age, whereas it will decrease in nondancers, independent of the joint studied.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The study population included 1320 female dancers, aged 8 to 16 years, who participated in different types of dancing classes (classical ballet, modern dance, jazz, etc) and 226 nondancers of similar age. Range of motion was measured for the hip, knee, ankle, foot, and spinal joints.

RESULTS

The pattern of differences in range of motion with age varied in different joints and types of movement. (1) For combined ankle and foot plantar flexion (pointe), ankle plantar flexion, and hip external rotation, there was no change in range of motion in dancers, whereas range of motion diminished with age in the nondancers. (2) For ankle dorsiflexion, neither group showed any change with age, and range of motion was significantly greater in the nondancer group. (3) For knee flexion, hip flexion, and hip internal rotation, range of motion decreased with age in both groups. (4) For hip abduction, range of motion decreased with age in dancers and remained constant in the nondancers. (5) For hip extension, range of motion increased in both groups. (6) For lower back and hamstrings, range of motion increased among dancers with age and remained constant among nondancers.

CONCLUSION

Dancers and teachers should realize that passive joint range of motion is unlikely to improve with age. Therefore, the major goal of a dancing program should focus on exercises that retain the natural flexibility of the dancers' joints rather than trying to improve them.

An evaluation of differences in hip external rotation strength and range of motion between female dancers and non-dancers

OBJECTIVES

To evaluate the differences in hip external rotation (ER) strength and inner, outer, and total hip ER range of motion (ROM) between dancers and non-dancers and between left and right sides in each group.

METHODS

Seventy one subjects (34 dancers and 37 non-dancers) volunteered for this study. The strength (truncated range average torque (TRAT), work, and angle specific torque (AST)) of the hip external rotator muscle group, through the full available active hip ER ROM, was evaluated using concentric isokinetic (30 degrees /s) testing on a KinCom dynamometer. Adjustment for lean body mass (LBM) was made for comparison of strength between groups. A two way repeated analysis of covariance was used to compare strength between groups. A two way repeated analysis of variance was used to compare strength between sides and ROM between groups and sides. Bonferroni correction was made for multiple analyses, and significance was accepted at p<or=0.05.

RESULTS

AST at 0 degrees , 20 degrees , 30 degrees , and 40 degrees of hip ER was greater in the dancers than the non-dancers (p<or=0.022). TRAT, work, AST(0 degrees ), AST(20 degrees ), and AST(30 degrees ) of hip ER were all greater on the right side than the left (p = 0.007) in both groups. Dancers had greater inner ER ROM (p = 0.013) and less outer ER ROM than non-dancers (p<or=0.001). There was no difference in total ER ROM between groups (p = 0.133). The right side had greater inner ER (p<or=0.001) and total ER ROM (p<or=0.001) than the left in both groups.

CONCLUSIONS

Ballet dancers have greater inner range, angle specific strength and inner range ER ROM, demonstrated by a shift in the dancers' strength curves. This shift in the strength curve towards the inner range of hip ER may be an adaptive training response.

The effect of pre-season dance training on physical indices and back pain in elite cross-country skiers: a prospective controlled intervention study

OBJECTIVE

To evaluate the effect of pre-season dance training on back pain, joint mobility, and muscle flexibility, and on speed and agility in elite cross-country skiers.

METHODS

26 skiers participated (mean (SD) age, 19 (3.9) years). An intervention group (n = 16) had 12 weeks of dance training; a control group (n = 10) did not dance; otherwise both groups followed a similar pre-season physical training programme. Joint mobility and muscle flexibility of the spine, hip, and ankle were measured. Two sports related functional tests (slalom and hurdle) were also done. All measurements/tests were carried out before and after the dancing period.

RESULTS

Four (of six) subjects from the intervention group who initially complained of ski related back pain did not report back pain after the dance training; the three subjects with back pain from the control group were unchanged. At study onset the intervention group had a slightly impaired range of motion in the spine compared with the control group. After dance training, there was a better relation between kyphosis of the thoracic spine and lordosis of the lumbar spine, and a 7.1 degrees increase in hip flexion with the knee extended (p = 0.02). In the control group hip extension decreased by 0.08 m on average (p = 0.01). No positive effects of dance training on sports related functional tests were observed.

CONCLUSIONS

Preseason dance training improved the range of hip motion and joint mobility and the flexibility of the spine. These improvements might explain the reduction in ski related back pain in the intervention group.

Ballet dancer's turnout and its relationship to self-reported injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To compare the relationship between the degrees of turnout, passive hip external rotation range of motion, and self-reported history of low back and lower extremity injury in ballet dancers.

BACKGROUND

Ballet dancers are encouraged to externally rotate their lower extremities (turnout) as far as possible. This may cause stress on the dancers' low back and lower extremities, putting them at risk for injury.

METHODS AND MEASURES

Thirty college-level ballet dancers and instructors were evaluated. Each participant completed an injury questionnaire that placed the participant either in a group with a self-reported history of low back and lower extremity injury or in a group without a self-reported history of low back and lower extremity injury. Each dancer's first-position turnout and passive external rotation range of motion for both hips were measured. The comparison between each dancer's first-position turnout and the measured hip external rotation range of motion was called "compensated turnout." A 2-sample test was used to determine if the average compensated turnout was significantly different in the injured and noninjured groups.

RESULTS

The mean (+/- SD) compensated turnout values for the injured and noninjured groups were 25.40 degrees (+/- 21.3 degrees) and 4.7 degrees (+/- 16.3 degrees), respectively. This difference was significant at P = 0.006.

CONCLUSION

Based on a self-reported history of low back and lower extremity injuries, ballet dancers have a greater risk of injury if they reach a turnout position that is greater than their available bilateral passive hip external rotation range of motion.

Medical and rehabilitation issues in classical ballet

Classical ballet is a demanding professional occupation, with participants who are often underserved in terms of accurate diagnosis and appropriate comprehensive medical care. The view that follows is designed to be as global and insightful as published to date. Specific rehabilitation considerations, dance mechanics, idiosyncratic differential diagnosis, and personality and equipment issues are discussed, and a rational view of dogma is presented.

Changes in hip and ankle range of motion and hip muscle strength in 8-11 year old novice female ballet dancers and controls: a 12 month follow up study

OBJECTIVES

To evaluate in a 12 month longitudinal study changes in hip and ankle range of motion and hip muscle strength in young female novice ballet dancers.

METHODS

Fifty three of the original 77 (69%) female dancers aged 8-11 years and 40 of the original 49 (82%) controls returned for follow up measurements one year later. Supine right active hip external (ER) and internal (IR) rotation were measured using an inclinometer. A turnout protractor was used to assess standing active turnout range. Range of right weight bearing ankle dorsiflexion and calf muscle length were measured in a standing lunge position using an inclinometer. A manual muscle tester was used to assess right hip flexor, IR, ER, abductor and adductor strength.

RESULTS

The mean (SD) 12 month change in hip ER did not differ between dancers (11.7 (11.3)degrees) and controls (8.1 (17.6)degrees). Dancers gained 12.5 (13.5)degrees hip IR which was significantly greater than controls (0.5 (13.9)degrees). Greater IR change was associated with improved IR strength (r = 0.34, p<0.001). Dancers increased total turnout (12.0 (16.7)degrees) significantly more than controls (2.2 (20.0)degrees). There was no significant change in ankle dorsiflexion range in either group. Dancers and controls increased in all measures of hip muscle strength (p<0.001) and dancers achieved significantly greater gains in three out of five muscle groups (all, p<0.05).

CONCLUSIONS

Total hip range of motion increased in both ballet students and controls at this young age. However, ankle dorsiflexion did not, which is probably due to this movement being blocked by bony apposition, rather than soft tissue stretch. This has implications for ballet teachers, as it has long been accepted that this movement could be improved with training. Dancers had greater increases in hip strength after 12 months compared with controls in muscles specific for ballet, suggesting that hip strength can be trained at this young age. Whether these gains are permanent requires further study.