How much turnout is enough?

James G. Garrick, M.D., a pioneer in dance medicine, has published many studies on the physical aspects of dance. Now he goes into the classroom to track the progession or lack of turnout in younger dancers for his next paper. Marin Dance Theatre students gain unique benefits as Garrick evaluates and identifies weak areas that need attention as their training continues.

Medical papers are difficult for laymen to understand. They contain technical descriptions of examinations and apologies for insufficent time to conduct long studies, as well as contradictions. However, in a paper, "Turnout and Training in Ballet," by James G. Garrick, M.D. and Ralph K. Requa, M.S.P.H., published in 1994, the findings are loud and clear. Their conclusion, which included other studies as well, was that none were able to identify a group of ballet dancers with "aberrant excessive external hip rotation." Most of the measurements fell well within the normal or high-normal turnout range, "but surely not the `pathologic' values many in the ballet community think are required for a successful dance career."

Papers on turnout from the several previous studies included in their findings admit flaws in the examination methods and other factors. Basically, the conclusions drawn from all these sources are that training begun during ages six to twelve develops turnout while altering the angle of the long thighbone at the hip by stretching the iliofemoral ligament, a possibility that is not well documented. If turnout does not increase as a result of ballet training at this age, the only way it can be achieved is by stretching the ligament. Examination of older dancers, however, would suggest that they have not stretched the ligament to the extent that they have unstable hips. Garrick's and Requa's article states that the primary reason that those older, more proficient dancers seem to have better turnout is that those with inadquate turnout have fallen along the way; and while turnout seems to be within normal range, although at the upper limits, dance education sorts out those whose external rotation is a standard deviation or more above the average. However, by virtue of the fact that these people also seem to have more internal rotation, and consequently more flexible hips, there may indeed be something to stretching the iliofemoral ligament. After the age of eleven, the femoral neck can no longer be altered; and after the age of fifteen, it is not possible to improve the rotation. (Bones are sufficiently ossified at the age of eight to bear body weight for serious ballet study. Most major European academies select their students to begin study with daily classes at the age of ten.) One authority concludes that if the young dancer at the age of fifteen does not have sufficient external rotation (60-70 degrees), she or he must be advised to stop dancing classical ballet. The dangers are in low back complaints, external rotator tendinitis at the hip, and problems of the patella, foot, and ankle associated with forced pronation (rolling in at the arch).

There are exceptions. Some dancers and nondancers are anatomically constructed with a high degree of natural turnout. Among the most highly selected and proficient dancers, Garrick and Requa found that external hip rotation measurements fall well within the normal range for the general population, suggesting that the rather substantial turnout seen in the lower extremities is the result of more than external rotation of the hips. (They have found no clue as to what caused that lower extremity turnout.)

Should the over-forty dancer or the late bloomer stop dancing? No. Careful teaching and realistic expectations can challenge the student to safe accomplishment and enjoyment at any age.

Combining science with early training, Garrick has been medical advisor and weekly consultant at the Marin Dance Theatre in San Rafael, California, since the new school opened in November. Director Margaret Swarthout, a former Royal Ballet member, has assembled a faculty of seven teachers who give classes in ballet, jazz, or modern dance.

At the school, Garrick measures height, weight, turnout, strength, and balance capabilities for documentation of students younger than those in his former studies. His purpose is to record whether or not training changes those physical characteristics or if only those dancers who have the right equipment sustain and continue to dance. In the meantime, the school's faculty and Swarthout have the benefit of the renown orthopedist's caring eye.

Garrick hopes his new research will allow him to identify residuals of previous problems that might compromise dance activities unless they are more thoroughly rehabilitated. With medical personnel readily available to Marin Dance Theatre students, their recommendations of enhanced stretching or focused strengthening programs will identify little problems before they become injuries.