Turn-out, Injuries, Hips, Knees and Feet: The importance of not overtraining, crosstraining, and specifically strengthening the opposing sides….


Margaret Barr's "Strange Children" [...

Margaret Barr’s “Strange Children” [ballet], 1955 / photographer unknown (Photo credit: State Library of New South Wales collection)

Dancers are strange children. For what other persons would set out to achieve the impossible, inch by inch, seeking a kind of perfection and freedom which allows them to communicate to others more artfully, those existing ballets created for bodies conditioned for performing these unbelievable and frequently imperceptibly impossibly difficult steps and combinations of steps? To the untrained eye, this intentionally looks easier than it is. But as they attempt to achieve more and more of the masterpiece that remains in the dancer‘s brain, only the very successful are considered to be so, and no one but a consummate artist can detect many of the imperfections and flaws contained therein. Certainly, no one but ballet dancers understand this, or stand united on the subject. Modern dancers detest it. The public doesn’t get it. And the trick is after all of that, dancers are forbidden to let you see their hard work. It is truly an art only really appreciated, deeply, by the best. And only they can criticize it, develop it, or lay at our feet the secrets of it. For most dancers themselves, you will find, find it difficult, if not impossible to explain, not all of it, anyway. They try. Misogynists or mystics?

jose limon

That photo is of Jose Limon. Sometimes, my thinking (and writing) delves into deeper, or more technical, areas where I am not an expert, but have concerns on the subject. Problems and experiences we have had may help to serve other people similarly facing such issues. That is by no means stating that I am, or have become, and expert on the subjects noted. It is very possible that I am wrong in stating some things, but I am thinking it out as I go-is there any other way? It is merely a line of thinking that I have found, or measures, which may prove to be, helpful to others. So I think, in this instance, I will share this. My daughter, has for some time been dancing and she is a hard worker. Because she started later, and had to learn so much to be caught up and prepared for her age level of dancing, she has traversed, in instances, very quickly, the long-practiced maneuvers, steps and poses of other ballet students, who frequently do not understand WHY they do things, or WHAT they are doing, but they do it everyday. So this is good for them, too. In addition to speeding up her practicum to achieve her dancer-sylph, she had had to work on her various short-comings.

All dancers have them. Each one, each area of the body needs to be fit, balanced and prepared for the hard work to come. getting to that point is obviously frustrating for even the best dancers (and the keeping it of it is also a repeated task). All dancers find they have some shortcomings. As the years, or levels, pile up, the dancing becomes more difficult, requiring the basic ability to execute various steps, and combinations correctly, and then more ability, and ultimately-perfection. But even at the preliminary stages when working, quickly, or more rapidly than they are accustomed to, and throughout your dancing career-however long that may be-foundation is forgotten in the moment of dancing, and you just dance as fast or as well as you can. It would admittedly be, a very tedious process,  if one had to stop every minute or so, and correct oneself, be corrected, or think about it, but that is what needs to be done, and what should be done, but it is NOT what is done beyond the basic level for many dancers. This is how most injuries occur.

Over-training is another common way to injure oneself. In order to become better, faster, it is very easy to get hurt and when you add on to that any other frailties, anatomical differences, technical abilities or shortcomings, it is a recipe for injury of some kind, all kinds, and we are finding-most kinds. One injury, when working at so high a level of training, can spiral outward, on the mend, with less than active (not as active) muscles, and result in consequential injuries, either to the first, or new. You almost can’t stop, but then you HAVE to. Most injuries will get worse if you continue to dance on them making the recovery time inevitably  longer and the possible injury itself-worse. My daughter’s injuries nearly all fall into this category, for nothing is essentially wrong with her-thank God. She is not deformed, has straight legs and only some hyperextension issues, which believe it or not is becoming more noticable with stretching and straining to become a ballerina. When anything is overstretched, it is a problem. Always.

She will have to watch out for these and many other injuries in the future, but for starters, these have been enough. In a nutshell, too soft pointe shoes (little support) resulted in an achilles injury (and a failure to really work her feet to make them stronger). While taking it easy on that (for months) and stretching to become able to do higher poses, achieve more turn-out and better grand jetes, she torqued her knee (and after 21 performances of Nutcracker, or something very close to that). Mind said, “turn-out” in plie, and knee refused. Overtraining and fatigue, I thought immediately. Then, while recuperating from that (80%) is about all I could rein her in-she experienced a deep groin pain preventing her from turning out at all, for no apparent reason. Many days had I suspiciously eyed her laying on the floor in the butterfly position, and thought,”too passive”, but….I was right, and wrong.

The hip injury is getting better, but for many weeks she has not been able to do much (involving turn-out) that does not cause pain. Oddly developpes do not hurt, while a simple ronde a terre-does, and a tendu! Movement of the whole leg in the hip joint. The hip. I came up with this after much research and found that most hip injuries in other dancers are down to five and we did want to rule-out the femoral fracture (Harkness/NYU). Whew! But all of them which did mention a pain, were on the outside or front of the hip and not deep inside it. The bad ones were deep, but, we knew it was

HTC modded keyboard running on my Samsung

HTC modded keyboard running on my Samsung (Photo credit: DanieVDM)

getting better and was not related to hip popping, so that ruled out all the rest except the femoral fracture-common to dancers, and she did not feel it was broken (she would deny it if it was!). They are very easy to break actually and require surgery…. Movements to the side hurt more and above the hip line in front???  Only certain positions means certain ligaments or muscles. Sometimes you can feel warmth (none), notice swelling (Ibuprofen), but she didn’t and neither ice nor heat were particularly effective. A warm bath might help, but it did not.

All of these things should be noted, and a journal should be kept following injuries so you can remember the activity associated with it that causes (caused) pain. My dancer cannot always recall what she was doing when it happened, especially if it becomes worse after class-could have been anything! A doctor will ask. The more you know, the better diagnosis they can give. Dancers do not like to think about their injuries, let alone, keep a journal of them. Morbid, but effective. Tell them to try recording it on their phones. Most Android phones have this capability and the recordings will show up in S Memo (or in Apps) and Media-they can find that; it is very handy for the lazy speakers. I did not say “lazy dancers.” These notes record by voice, too. Tell them to tell their phone to “record a memo.”

Her second injury, to the knee, I felt sure was related to her turn-out issues. I did not expect it was a turn-in issue. But is is. She has a great turn-out, but a poor turn-in. The doctor confirmed this, and we also ruled out hip or foot problems-basically they are perfect for life. We are still learning about dancing. Too much turn-out (stretching) has resulted in two injuries from weak turn-in-specifically the adductors and the hip muscles. If one is over turned out, and the body has to suddenly transition to a turn-in, and does not react quickly and forcefully enough-the counter-muscle strains-the one that helps you control turn-in and turn-out. Over turned-out-funny. In stretching, most dancers fail to realize strengthening has to be done in equal amounts as stretching, of the same muscles, for support and control. Teachers do not explain this. At all. And apparently, not effectively, especially for young students who have short attention spans.

For anyone involved in the serious study of dance, no doubt, the discussion of turn-out has arisen in class. You probably know by now if you have good or perfect turn-out because you will have heard it from teachers. It’s the next thing down from “feet.” Remarkably, many successful dancers have notably deficient turn-out. It is the actual foundation of all classical ballet. It is stated by doctors that the ease at which it is obtained (sometimes) appears to be correlated with the age at which dancing is begun. In short, turn-out is relative to ballet, therefore, it will be stated by some that it should be learned early. It is and it is not. Let me re-state that many professional dancers turn in all the time-they fail to remember to turn-out. It is perhaps the conditioning of it, not physiologically, but mentally, that makes it more well-remembered by the earlier you start, but in fact, that has to do with memory and not actual ability to turn-out. There is also functional turn-out and structural turn-out. Even those very rare students with “perfect (structural) turn-out,” turn-in (do not have good functional turn-out). It is not only one part of the hip that is actually responsible for how much turn-out one has, and actual deformity-again, popular in ballet (only), does occur, and is therefore deemed “perfect.” FURTHERMORE, it is just as important for dancers with this turn-out to remember, all the time, to turnout at the correct times-and they don’t! Children who do not want to work on turn-out are quick to notice this in professional dancers as “okay,” but it is not, necessarily. Everyone is different!

Perhaps they can exhibit better turn-out, which is nagged about in the studio, but face it, when they get on stage-they forget. Any dancer is only trying to remember 6,000 things on stage, and as you watch most of them, particularly soloists, you will notice they turn in, frequently, or you will notice that they do not exhibit their perfect turn-out, except when at the barre in first position or in plies, in second. Ligaments change, and dancers have to not only stretch to initially achieve turn-out, and exercises to strengthen it-do not stop at the barre (I’ll tell you why), but most dancers have to maintain their own degree of turn-out by stretching daily and remembering to reinforce turn-out in the studio and while dancing, all the time, for the rest of their lives.

As people get older, much older, all of their ligaments and muscles begin to deteriorate, so not exhibit the same elasticity as when they were younger, but dancers continue to dance, turned-out, or turned-in, and they continue to get nagged about it, until it is second nature, for the most part, for them to remember to turn-out or they get beyond the point professionally when any teachers complain about it anymore. That is one indication of a professional-not having to be taught anymore. It is up to the dancer to work on it, keep it and nurture it. Holding turn-out is how you refer to it in class and that is exactly what it means. Therefore, it is not the degree of turn-out which is extremely important in all dancers, but their ability to control it; that requires strength! And the lack of control causes injuries. Wait and see or get on it now, to prevent  injuries.

Dancers with perfect turn-out also turn-in, because of strength issues-not just memory loss or forgetfulness. It is the body’s natural inclination to do so, and the mind of a dancer must think about so many other things, occasionally (LOL), that sometimes it can just go-that is why you train to control it, so it goes where you want it to, and how far you want it to.

There are many exercises in ballet, poses in variations, and most importantly, but never mentioned,transitions in classical ballet, which cannot be accomplished without injury to a dancer who does not possess adequate turn-out to do them. Perhaps more importantly, not turning-out first and then failing to hold the required degree of turn-out can be dangerous if not life threatening, then dance threatening (and this is the worse of the two-for dancers!). This is anatomy and physiology, and fact. It is fairly safe to say, then, and I do, that all dancers turn-out excessively, whether good schools tell them to or not, they learn to, it is conditioned in other ways, even if teachers tell you they do not force turn-out. They teach turn out, refer to turn-out and yell, “TURN OUT,” and they have to if they teach Ballet.

English: First Position of the feet in Ballet

English: First Position of the feet in Ballet (Photo credit: Wikipedia)

Notice the “over turn-out” in first position? Slightly? What is too much for many persons is simply put, too much without control. I always releve (turned-out) in every position, just to check that my alignment is correct and that the right muscles are engaged, and that I can releve from that position. It is evident when doing this, if you feel awkward, or forced, that you are! Fix it-turn a little tiny bit in and gain control from that position before you open further. Practice making transitions and moving from these positions, think of variables, so that when the time comes, it is no sweat-you have done that before, and the body remembers it. Sometimes, I also attempt a plie from whatever position this happens to be, all of them, to make sure there is nothing wrong, to see what I can do, and to strengthen infrequently used muscles that may contribute to a better position in the end, by cautious means. What a lot of teachers mean by teaching turn-out young is that they can put dancers in over turned-out position and due to the laxity of the muscles at that age they do not readily see injury-that does not mean that it is not occurring, only that you can’t see it. Ask Mikhail Baryshnikov about his knees and forced turn-out and I am sure you will get an earful. I have found, over the years, that my habit, hard to instill or demand in others, fixes almost any turn-out problem, assures that I can execute the position(s) correctly (with the correct amount of turn-out), in transitions, or quickly, without hurting myself, and that after years of doing it, I have no issues or injuries! It’s like falling, with practice, you can learn to fall without injury, or with substantial reduction of injury. Falls happen-practice. After years of doing this, and I am much, much older than any of you reading this, it helps strengthen those muscles directly associated with each position, the best. How do you learn to surf? You surf. Is there exercise for learning to surf or be a better surfer? Yeah, surfing. How do you build up the muscles used in surfing? Surfing. Practice, practice, practice-not repeat, repeat, repeat! Also, holding these positions is easier after many repetitions, and many years. I have good balance from it in most ballet positions, and I haven’t really danced as hard as you are for 30 years! But I still do the exercises….

If, as a dancer, you attend a new class, and the teacher has you do something for which you are not physically prepared to do, you will fall out of it. That is the best sign, this muscle is not trained. Train it by doing the exercise over and over. Do not think to use the fail-safe quadriceps for anything except stability and pumping-force. The Amish say, there is always another way, and there is almost always another muscle that needs work when your quadriceps engage to protect you-they do not jump into action unless it is to protect you from a major tumble-from everything. The finer muscles responsible for controller finer movements-are ignoring you, not engaging, not working, because you haven’t trained them to listen. Most dancers think they have no faults, are not lazy, but mentally, there are things we just do not bother to do. We ALL do this. We also rely on routines and it is virtually impossible to do all of the exercises you need to do in one routine, so make list and rotate them-less chance for injury! It is hard, harder than 64 small jumps in center, all of them a foot or more off the ground, and then again, because it seems so easy we just take it for granted, but I bet you can do those jumps. Working and strengthening the finer muscles is hard, because these muscles are hard to find, hard to visualize, and they all work together at times, making the isolation of them very difficult to sort out, or the use of them fathomable. They are truly not as complicated as they seem, but you have to take the time and think about them, research them, practice using and finding them-or try to-and prevent injury.

Adequate turn-out for dancers is that degree of turn-out required for that dancer, based on his/her body structure, bone shape (especially the femur, acetabulum and pubis) which determine the range of movement of the hip, and also the ilio-femoral ligament, obturator externus (front-see picture below), and piriformus, gemellus inferior, obturator internus and externus (front), which in addition are responsible for the strength of the hip movements. Overstretching in the butterfly, for example, which virtually no teacher will tell you is harmful (“do it 3x a day!”), but it is. It is when you do not strengthen the hip, or stretch the hip sufficiently in the opposite direction. But enough is said about this to beginning or ambitious dancers who

OBTURATOR EXTERNUS MUSCLE

must stretch to attain a better degree of turn-out and they need to be particularly watchful, especially if they are teenagers. No exercises are specifically given for it in ballet class. Repeated 2x per day, these stretching exercises can overstretch the adductors, resulting in serious groin pain in the student, usually deep in the tissue, where ice and heat may have little impact. Ibuprofen can help, but must not be relied upon for daily use. The pain can be so severe the dancer cannot turn-out-that is actually the key to the cause of this pain, for most other injuries to the hip result in different kinds of pain inside or outside the hip, but not affecting the turn-out per se.

Piriformis - Muscles of the Lower Extremity An...

Piriformis – Muscles of the Lower Extremity Anatomy Visual Atlas, page 8 (Photo credit: Rob Swatski)

From all of the material I have read about possible hip injuries, it is my own conclusion, and that of a venerable dance doctor, that without sufficient strength in the adductors, and overstretching present, a sudden twisting or turning can result in a straining of the muscles of the groin and on the inside of the upper thigh if they lack the tone to prevent overstretching. The pain in the upper thigh is frequently called “rider’s strain,” and is caused by too much stretch of the adductors when doing movement a la seconde (Dancer’s Book of Health, L. M. Vincent). It is said that some dancers, with ligament laxity, may even feel the thighbone “go out of joint.” This continual dislocating may lead to joint degeneration, so the importance of good muscle conditioning and avoidance of over stretching cannot be ignored! He says to “always seek control more than height”, and when warming up, do not risk strain by caving in to the temptation of placing the leg on the barre for the first stretch. Check with your dance teacher/physical therapist before performing these exercises to make sure they do not interfere with your goals.

Interestingly, students who feel that they do not possess enough turn-out can fall prey to this type of injury if their leg is inclined to drop “backward,” so they will often find that their turn-out is not lacking, but rather their ability to control it is. These types of exercises will help, but for specific muscle attention (there are six sets- count them- of muscles and ligaments responsible for turn-out, and a few other muscles besides) it would do to look up and verify which muscles to strengthen, what each set does, and the individual ones, and to go over where they are, when they are used and what to do to strengthen each one and each group, just to prevent injury and to be aware of this rather complicated area of the body, prone to injury in female dancers with a high level of ballet classes, training or just plain dancing. There are classes, sometimes, led by physical therapists (and dancers) to integrate whole body strengthening and conditioning to prevent injury in the different parts of the body that ballet dancers are susceptible to. These injuries are particularly a problem for adolescent students for growth and hormone reasons. Look no further than the Nureyev Foundation in Switzerland, to locate a dance doctor (a real one-not a quack) in your area, or a dance-trained physical therapist, who can help you discover more about your dancing body and its limits, as well as its possibilities!

http://www.noureev-medical.org/content/contact-information

Deep muscles of the medial femoral region.

Deep muscles of the medial femoral region. (Photo credit: Wikipedia)

Your hip adductors (left) are all responsible for moving your leg in toward the midline of your body–a movement called adduction. Located on the inside of your thigh, your adductors stretch from the inside of your knee to the bottom of your pelvis. Strong adductors are important in knee and hip stability, and if they become weakened, you may find your knees are prone to dropping outward. Additionally, performing exercises for your adductors will tone the area of your inner thigh. There are a variety of exercises you can perform for this important muscle group.
Medicine Ball Squats

Stand with your feet hip-width apart. Place a light medicine ball or soccer ball between your knees. Keeping the ball in place by squeezing your knees together, squat until your knees are bent to 90 degrees and your thighs are parallel to the floor. Push your hips forward and straighten your knees to stand up. Make sure that you concentrate on pushing your knees in against the ball throughout this exercise.

Lying Side Inner Thigh Lift
Lie on the floor on your left side with your body straight and your head resting on your outstretched left arm. Cross your right leg over your left and place your right foot on the floor, creating a figure-4 shape and allowing space to lift your lower leg. Raise your left leg inward by using your adductor muscles. Lift your foot 8 to 12 inches off the ground. Slowly lower your foot back to the floor and repeat before rolling over and changing sides. Make this exercise harder by wearing ankle weights-no more than 1 lb, and work up to that!
Hip Adductor Machine

Sit on the machine with the leg pads against your knees and your legs as far apart as comfortable. Press against the pads and push your legs together until the machine arms touch. Pause for one to two seconds before slowly returning to the starting position and repeating. This machine can strain your muscles if you are weak here, as most dancers are, it is advised to put it on its lowest setting and do no more than 12 reps the first several times, working up to three sets of 10 or twelve. Dancers also have to be careful not to bulk up-so many of these exercises have to be done in moderation, compared to general athletes, or those trying to get into shape. Dancers have a preferred shape, and need to remember to work the opposing side EQUALLY. In this case, that means, to put the pads on the outside of the leg and reverse the exercise. Most dancers will find it is easier to press the pads out (a no-brainer), than in. That is where you need work!

Lying Pillow Squeeze

This one is easy, so you will really feel “the pee” muscles working. My daughter hates it when I say this. Lie on your back with your legs bent and your feet flat on the floor (also on the bed or while you are waiting for lights to change to green in the car-anywhere and from any position). Place a large pillow between your knees. Keeping your head on the floor and your arms by your side, press your knees together and squeeze the cushion as hard as you can for five seconds. Relax slightly, but keep the cushion in place. Push your knees together again and continue repeating for the desired number of repetitions. Only a few will be possible at first, so do not overdo it. It is more important to hold it for 5-10 seconds than to repeat it often. It is also more challenging. Work up!

Many dancers experience imbalance between the hip adductors or inner thighs and abductors, the hip and gluteus muscles. To counter this muscular imbalance, here is a stretch which needs to be held at least 30 seconds. Personally, I do not recommend “adjustments” like pulling the leg (performed by some over-zealous chiropractic offices, and  frequently, without any warning!).

Preparation:

1) On floor or mat, lie face up with arms extended at sides

2) Lift one leg straight up then bend knee and hip to 90 degrees flexion

Execution:

1) Lower bent knee leg to opposite side toward hand.

2) Hold stretch for 30 seconds, maintaining 90° flexion in hip with both shoulders flat on the floor.

3) Repeat with opposite side.

For definition and reaffirmation:
Think that some dancers use the outer thigh more than they ought to, when it is the inner thigh which is typically responsible for turn-out.  Working the turn-out muscles require isolating them and using them-nothing else will work. The adductors are the frequently forgotten five muscles of the inner thigh that connect to the pelvis—the Pectineus, the Adductor Magnus, the Gracilis, the Adductor Brevis, and the Adductor Longus. Look those up and write down their meanings, then locate them in yourself and work on them. When a dancer has had an injury to the knee, for example, these muscles will have atrophied while the dancer was resting from the knee injury. The tendency for the dancer to resume the level of previous training that his/her body was accustomed to is presumed, since most dancers who have not had a previous injury will not be aware of or expect these initial limitations so they just jump right back into class “to get back to where I was”! Right? NO.WRONG!!!!!!!!!!!!
Even a few days off, literally, can lead to some scary loss of muscle tone and requires s-l-o-w and steady passive and active stretching to get back to ground zero. I also recommend the warm-up exercises of Ballet for Dummies (Evelyn Cisneros is one of the authors-and certainly NO Dummie!) In it, they well discuss passive and active stretching and the importance of EACH for dancers. Too much passive stretching before dance class can also lead to injury in dance class. Best to do moderate exercises (warm up) before class, and stretching OUT after class, for up to 45 minutes.
Yoga and Pilates demand strong inner thigh muscles — fortunately, routine practice of both strengthens the inner thighs.The Pilates Reformer is also said to produce amazing results, but work with a trained professional. Don’t do any stretch to the point of discomfort and don’t force any stretch. Work up!
A good stretching program is key to maintaining muscular balance. Hip and adductor muscles are focused on in CORE workouts, but prior to this, which can result in overworking some muscles and under working others that dancers use, dancers had to rely on themselves to diagnose and usually fix what was wrong, and in good ballet classes, teachers address this, usually through modern dance techniques and other exercises. There are many modern dance exercises which I believe prevent any issues in these areas through dancing. On The Count of One and The Dancer Prepares give some really good advice, and there is no end of information available on the subject. You will not hear this through an orthopedic doctor, who relies on personal links with general physical therapists to practice exercises, get patients “back”, which might be good for octogenarians or football players, but are not fulfilling for a dancer beyond an early stage of injury recovery. Dancers demand more-faster.

Although some of the same muscles come into play with athletes and the general population, dancers refine their use, and rely on a good deal many more muscles than does a football player, and also work at a higher level of training each one for specific uses not understandable to most orthopedic doctors unless they are also dance professionals. A dancer also uses them a lot more and a lot more turn-out stretches, means a lot more and tougher turning-in exercises. My argument here is that most of these types of injuries are turn-in injuries, rather than turn-out injuries, actually. A good modern (basic, then intermediate) technique class-Graham or Horton is best and can also work absolute wonders to this balancing act; it can act as the antithesis to ballet, thus working all of the needed muscles in a dancer’s range, while being easy on the body, when exactly properly performed, and done at least four days per week for any significant results. Since this is not available or possible for all professional dancers (who do not have the time to become modern dancers), many of them rely on yoga. Yoga is everywhere and gets you in places nothing else does, but is not as active as modern, and not dancing.

The important points here are to listen to your own body, and do not readily accept the physical therapy or medical advice of a medical professional untrained in the dance profession. Dancers are different and require the patience themselves to identify areas of concern, underwork, overwork and injury. All bound together, usually. Any pain in executing any position might indicate the dancer is doing something wrong, and the sooner this is diagnosed and corrected, usually through re-teaching and strengthening the affected part, ASAP, the better. You might say that dancers are continually pushing the limits and need to train smartly. They hold their fate in their own hands and how they approach such injuries can be the end of one or most connected injuries as well, or the beginning of several more related ones. Therefore, it is important to sort it out, when you can’t dance it out.
Keep on Dancing!
About these ads

One thought on “Turn-out, Injuries, Hips, Knees and Feet: The importance of not overtraining, crosstraining, and specifically strengthening the opposing sides….

  1. Pingback: More Pliés to Practice! | Millicent Mouse's Blog

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s