Pilates for Ballet Dancers
Ballet training is rigorous on young bodies. Pilates can help strengthen teenage dancers and help avoid injury.
April 9, 2014
The rigorous physical training undertaken by the preteen or adolescent female ballet dancer can predispose her to unique but predictable injuries and dysfunctional performance patterns. A particularly vulnerable stage is during the time of the "adolescent growth spurt." Sudden growth changes in the limbs usually precede that of the spine. Adaptation of muscle coordination and strength in the torso may take 1 to 2 years to stabilize.4 Girls may not be able to balance as well or to lift their legs as high during this stage. They temporarily become weaker and less flexible.
Feelings of awkwardness during this transitional period may contribute to low self-esteem. Fluctuating hormonal changes can also exacerbate poor self-image and confidence in abilities. Without adaptations in dance training, didactic health-education and emotional support to accommodate for this predictable but time-limited phase, girls can make poor health choices that have life-long consequences.4,5
Studies show that more than 50% of dancers develop lifelong chronic pain syndromes and 85% develop serious eating disorders that put them at risk for early onset of osteoporosis.4,5 In fact, excessive jump training during periods of accelerated growth can lead to early degenerative disc disease, chronic tendonitis and stress fractures. During the adolescent growth spurt, it is suggested that impact jump training be limited with more focus placed on cardio conditioning, strength training and core stabilization.4
Paradoxically, this turbulent time also offers opportunities for important communication between the dancers, parents, dance instructors and physical therapists. More frequently, physicians and performance specialists urge new methodology in dance training for the preteen and adolescent girl. This article will present common injury patterns and performance dysfunctions of female dancers seen in my clinic as well as easy-to-implement and less expensive applications of Pilates training apparatus and props.
Back to Basics
Common patterns of musculoskeletal pain and dysfunction are typically reported at the hip, low back, ankle and knee.8 Healthy musculoskeletal development specific to the young ballet dancer ideally occurs between the ages of 11 to 14 years old. It is during this prepubescent and pubescent period that bone re-modeling in the pelvis, acetabulum, femoral head and neck are the most malleable to the increased femoral retroversion so important to proper "turnout."1 This is a crucial time to follow a healthy diet; to ingest enough calcium rich foods and enough healthy calories to build the strongest skeleton possible. Ideally, ballet classes should provide didactic health education that includes the rationale behind healthy training habits and a healthy diet (including consequences and long-term effects of osteoporosis).4,5
Although aerobic endurance is diminished in the dance population, studies show that even 1 hour of training per week can have significant positive effects on stamina, injury prevention and improved bone mass. Cross training for cardio- interval and strength training should be encouraged.7 Ballet groups might seek out reduced rates in local gyms since the dancers would likely visit just 1 to 2 times per week. Such symbiotic relationships offer advertising perks for businesses that promote positive health habits for teenage athletes.
Young dancers and their parents can be assured that strength training will not change the physique negatively but rather make muscles stronger and leaner.7 This, in turn, helps to decrease back injury risk, development of chronic tendinitis at the knee and ankle and stress fractures in the feet.6 Core strengthening can be done as Pilates mat work in class and at home using DVDs or approved books containing photographs or illustrations for proper form. These alternative training techniques are perfect to supplement technical skill and control. With proper education and psychological support, the maturing dancer has a better grasp of how to build the foundation that will ultimately support her longer arms and legs and artistically coordinate her growing muscles. Self-esteem grows as this awkward phase is better understood.4
Turnout: the Bottom Line
Proper turnout is the classic ballet dancer's foundational framework. Dancers who are not able to achieve maximum lower extremity external rotation at the hips, tibias and feet typically compensate with dysfunctional movement patterns that lead to overuse injuries and chronic pain.8 Since "perfect" turnout is considered to be 180 degrees, compensatory strategies are commonly seen in the dance population. Compensations include rolling the medial arches into pronation, torqueing the medial knee anteriorly (and out of alignment with the tibia), and hyperextending the lumbar spine into anterior tilt.1
Turnout represents a combination of femoral retroversion, hip external rotation and external rotation of the feet with the long axis of the proximal tibia bisecting the calcaneous between the second and third toes. An average value of turnout of pre-professional student dancers (combining the amount of external rotation of both feet) is about 135 degrees. Dancer students typically have about 50 degrees of passive external rotation of each hip (measured in prone with knee flexed to 90 degrees). Increased femoral retro-torsion is desirable. Common unilateral measures can vary between 17 to 19 degrees.
To measure femoral torsion, the dancer is positioned in prone with the knee flexed 90 degrees. Femoral retro-torsion can be ascertained without external imaging by positioning the neck of the femor in the horizontal plane using "Nelaton's Line." This is the line that connects the anterior superior iliac spine with the ischial tuberosity. When the axis of the femoral neck is positioned horizontally, the proximal tip of the greater trochanter crosses Nelaton's line during hip joint rotation.1
The proper combination of femoral retroversion and passive hip external rotation should allow a dancer the best chance of optimal turnout without the need for dysfunctional compensatory strategies that lack aesthetic appeal and put the dancer at higher risk for repetitive overuse injury.8 Studies show training for optimal turnout is between the ages of 11 to 14 with ballet practice more than 6 hours per week (a minimum of 3 classes per week but optimally 4).1
The emphasis on turnout and back extension sets the dancer up for weak abdominals. Early in his career, Joseph Pilates noted the characteristic of weak abdominals among the ballet dancers of the New York City Ballet. He didn't feel that the traditional standing barre routine addressed (but rather contributed to) this deficit. He built the "Reformer" as his "superior" supine version of barre exercise to allow better strengthening of core abdominal and lower extremity musculature. Regardless of access to more expensive Pilates equipment, the physical therapist can easily use aspects of Pilates floor/mat work and incorporate Pilates props to activate weakness in the abs, pelvic and shoulder girdle. Futhermore, Dynamic Myofascial Cupping (a variation of traditional myofascial release) can be an excellent method to release tight back muscles and fascia or to relieve localized muscle spasms brought on by excessive seasonal performances.
Functional Hip Screening for Weakness & Dysfunction:2
1. Unilateral Stance Crossover Test- This is a reliable functional screen for femoro-acetabular impingement. The test provokes/ re-creates medial groin pain. It is performed in unilateral stance on the involved leg while reaching over and across the body as far as possible without loss of balance.
2. Medial Triple Hop Test: Both a reliable and valid screening test that demonstrates objective difference between the leg function of the involved vs. the non-involved hip.
The test measures total excursion with 3 consecutive medial hops. That measurement is compared to that of the opposite leg. This is an excellent screening tool that can demonstrate objective improvement in performance before and after PT intervention. Certainly this kind of objective data is most relevant in today's competitive health market.
Other Screening Assessments:
1. Flexibility measures of ankles, hamstrings, quads and hip flexors
2. Patellar femoral tracking and patellar mobility
3. Knee and ankle alignment and stability with hops, landings, plies, and rising into demi-pointe (3)
4. Segmental spine mobility and stability testing
5. Scoliosis screening
6. Screening for signs of spondylolisthesis
7. Scapular alignment and strength assessment
8. Coordination and strength testing for oblique, rectus and transverse abdominals
9. Medial and lateral ankle strength
10. Big toe flexibility
11. Turnout flexibility and control (include measurement of prone femoral torsion and prone hip external rotation described previously)1,3
12. Alignment between tarsal bones of foot and tibia in full plantar-flexion as screening for advancement to training on-pointe3
1. D. Hamilton, P. Aronsen, J.H. Loken, I.M. Berg, R. Skotheim, D. Hopper, A. Clarke and N.K. Briffa, "Dance training intensity at 11-14 years is associated with retro-femoral torsion in classic ballet dancers" British J. Sports Med 2006 April: 40(4): 299-303.
2. Benjamin R Kivlan, PT, MS, OSC, SCS, Christopher R Carcia, PT, PhD, OCS, SCS, et al. "Reliability and Validity of Functional Performance Tests in Dancers with Hip Dysfunction" Int. J Sports Phys Ther: 2013 August; 8(4): 360-369.
3. David Weiss, MD, Rachel Anne Rist. MA, Gayanne Crossman, PT, EdM. "When Can I Start Pointe Work? Guidelines for Initiating Pointe Training" J Dance Med Sci 2009: vol.13(3), 90-92.
4. IADMS Education Committee (Kathryn Daniels, Chair), "The Challenge of the Adolescent Dancer" Int. Assoc Dance Med Sci., c 2000.
5. R. Ringham MS, K. Klump PhD, W. Kaye M.D., D.Stone, MD, et al. "Eating Disorder Symptomatology Among Ballet Dancers" Int. J. of Eat. Disorder,2006 Sept, (29): 503-508.
6. Twetchett EA, Koutedakis Y, Wyon MA. "Physiological Fitness and Professional Classical Ballet Performance: a Brief Review" J Strength Cond Res. 2009 Dec;23(9):2732-40.
7. Twetchett EA, Angioi M, Koutedakis Y, Wyon M. "Do Increases in Selected fitness parameters affect the Aesthetic Aspects of Classical Ballet Performance?" Med Probl Perform Art. 2011 Mar,26(1):35-8
8. Coplan JA, "Ballet Dancers' Turnout and Its Relationship to Self-Reported Injury". J Ortho Sports Phys Ther. 2002 Nov:32(11): 579-84.
Susan King is a senior outpatient physical therapist at East Cooper Medical Center in Mt. Pleasant, SC. For more information, visit www.eastcooperrehab.com