The Next Level

Accentuated Stretch and Flexibility for Classical Dance Development and Martial Arts (Multi-Sport Olympic Development)

Stephen M. Apatow, Founder, Director of Research and Development, Sports Medicine & Science Institute and International Dancescience Development Program*

* Humanitarian Resource Institute, Humanitarian University Consortium Graduate Studies Center for Medicine, Veterinary Medicine and Law.


The study guide "
Classical Ballet Based Biomechanics: Orthopedics 101" covers the topic of correct postural alignment and the mechanical ideal.  The general rule is that any movement pattern outside of correct postural alignment, is stressed and has the capacity to result in injury.  This is a reference point for postural analysis in dance training and sports specific development programs. In the context of orthopedic diagnostics, postural analysis is the key to understanding the mechanism of stress and substantive course of therapeutic action.

Priority Focus Areas

Hip Range of Motion: Turnout

Many dance and sports injuries, related to the demands placed on the body and requirement for flexibility in concert with poor warm-up, can produce Achilles, posterior tibial, and patellar tendinitis.  Repeated jolts, with incorrect postural alignment, contribute to joint complex deformation and the mechanism of injury.

Rule: Correct alignment = non-stressed, Incorrect alignment = stressed.

In the turned out position, the weight should fall from the body to the thigh and directly through the knee and ankle.  This distribution of weight can be achieved if the external rotation of the lower extremities occurs at the hip.

As a rule, external rotation of the foot should only occur to (1) the mechanical ability to track the knee cap  over the center line of the ankle and foot and (2) the center of gravity (vertical axis) 2 inches behind navel, dropping between the heels (1st, 2nd, 4th, 5th).


If a child does not maintain correct knee, ankle, foot alignment, then the bone and articular level will stabilize into a permanent developmental deformity (knee, ankle, foot complex).

Understanding the Mechanism of Injury

To achieve increased external rotation of the lower extremity, students may increase their lumbar lordosis or "screw the knee."  Increasing lordosis decreases the tension on the iliofemoral ligament allowing increased external rotation of the hip.  However, it will put an excess strain on the lumbar spine, as much a the hyperextension in gymnastics does.  "Screwing the knee" is done by assuming a demiplie (half knee bend) position, allowing the 180 degree positioning of the feet to be achieved at the floor, then straightening the knees without moving the feet.  This puts a great deal of torque on the knees and can produce medial knee strain and patellar subluxation.  "Rolling the foot" can produce posterior tibial tendonitis and bunions.

Knee Problems

Medial knee strain is common in student dancers and presents as pain along the medial side of the knee with no history of specific injury.  Pain is usually worse after class and gradually decreases if there is a day or two hiatus between ballet classes.  There is no history of swelling or locking.  Physical examination often reveals some tenderness along the medial aspect of the knee but not specifically over the joint line or over the medial collateral ligament.  No effusion is present.  Ligamentous laxity, meniscal signs, and patellar tenderness are lacking.  Radiographs are not usually required in this situation.  If one finds tenderness specifically along the distal femoral epiphysis or along the tibial tubercle or patellar tendon, one is dealing with a different problem.  One can confirm the suspicion of medial knee strain by asking the child to do a plie.  An imaginary plumbline dropped from the knee should land over the second toe.  If the plumbline falls medial to the foot during plie, then the medial knee structures are seeing increased strain and will gradually respond with pain.  Beware the child who achieves "knees over feet" by assuming a increased lordotic position.

In the ballet class, approximately one half to two thirds of class is spent at barre exercises, most of which include plies in various positions.  In addition, plies are fundamental to initiating jumps and landing from them.  Hence, if one's plie technique is incorrect, musculoskeletal problems are quite likely.  These problems can be resolved by explaining the proper technique to the child.  The best way for finding a child's proper position using external rotation of the hip is to have the child stand with his or her legs straight and feet together.  Instruct the child to move his or her legs from parallel to a position of comfortable external rotation, keeping the back straight and head up. The "turnout" achieved will be a function of the child's femoral neck-shaft angle.  Keeping the knees straight will ensure that the rotation will occur at the hips.  Once in this position, the child can be instructed to keep his or her feet at this angle, but assume the various ballet positions.  While performing plies in these positions, the knees should fall directly over the feet.  Most good ballet instructors will accept this variation in positioning of their students and realize that not all students can achieve a 180 degree angle of their feet.  In addition, good instructors will teach the children to obtain more external rotation using the short external rotators of the hip rather then cheating with lordosis of the lumbar spine or twisting the knee.

Patellar Tendinitis

Patellar tendonitis, often a part of the presentation of Osgood-Schlatter disease, is seen in both the young dancer and gymnast.  Patellar tendonitis is also called "jumper's knee" because it is commonly seen in athletes who jump often.  These athletes have pain in the patellar tendon unit, either at the distal pole or the patella, along the patellar tendon, or on the tibial tubercle.

On physical examination, one will find very specific point tenderness at the site of inflammation.  Often swelling will be present in the infrapatellar bursa.  The child also may have pain when extending the leg against resistance.  Usually jumping activities are the cause.  In addition, Micheli  (Micheli, L.J., and Rosegrant, S.: Boston sports medicine: Helping the young athlete. Phys. Sports med., 9:105-107, 1981)  feels that the "overgrowth" syndrome contributes to the prevalence of Osgood-Schlatter disease in the 11- to 13-year-old age group.  Although children are assumed to be naturally flexible, poor flexibility and inadequate warm-up were factors in over half the injuries seen in Micheli's clinic.

The treatment for patellar tendonitis is rest.  The child may do any activities that do not aggravate the problem.  Generally, forceful kicks, jumps, and plies must be temporarily avoided.  Ice massage over the tendon area will often decrease the pain as well as the inflammation.  In resistant cases, a jumpers knee brace, a knee sleeve with a pad over the patellar tendon, will decrease the forces applied to the tendon by the quadriceps muscle and relieve the pain.  Exercising the quadriceps muscle is to be avoided initially because it will aggravate the problem.  However, when the pain has decreased, one should initiate stretching and strengthening of the quadriceps.  Symptoms generally resolve in three to four weeks.

Excerpts from  Sports Medicine Concerns in Dance and Gymnastics
Carol C. Tetz, M.D. Assistant Professor, Orthopedics, University of Washington, Seattle, Washington
Pediatric Clinics of North America, Vol. 29, No. 6, December 1982
Clinics in Sports Medicine, Vol 2, No. 3, November 1983

Part II: Accentuated Stretch and Flexibility Exercises to Increase Turnout

Most dancers and athletes don't know that a lack of turnout or hip range of motion could be caused by soft tissue restrictions, which can be addressed with an accentuated stretch and flexibility program.

I personally began dance training in my early 20's, as an athlete training for international competition in cycling, skiing and rowing.  Dance training was pursued to optimize balance, economy and leverage mechanics for skating techniques in cross-country skiing.  In conjunction with my sports specific training, my first 3 years encompassed intensive modern, jazz and ballet (Lee Lund: Jaime Rogers). In 1987, I progressed to the study of the Soviet System of ballet training at the Nutmeg Conservatory for the Arts.  

My background in studies in sports medicine, exercise physiology and biomechanics, helped with the analysis of the physical demands of the dance training, leading to the development of intensive spine and extremity flexibility programs.  In the context of turnout, by the time I reached Nutmeg Conservatory, I had more turnout that 95 percent of the students in the development program.

I had a chance to integrate this work with dancers preparing for international ballet competition, in an experiment that yielded immediate functional improvement of flexibility (turnout, shoulder complex, spine, extremity) and technical performance.  Shortly thereafter, a general stretch series was developed for all levels, pre-ballet through upper level.

Hip Turnout 101

Programs that do not operate with students from a one out of a thousand selection process, need to focus optimization of the correctable functional limitations.  The conventional approach is to throw all children into the same training, without regard for their lack of prerequisite flexibility, allowing them to advance (in many cases deform) to meet the physical demands.

During international summer programs, upwards of 90 percent of older students (14-17 years of age) could not parallel plie, with correct alignment of the kneecap over the centerline of the ankle and foot.  This was due to articular stabilization of the ankle/knee complex from poor training. The inability to maintain correct alignment in the parallel, meant that they were not capable of working in any turned out position without risk of injury.  The majority of these students work with perfect turnout of the feet in the technique classes, via complete disregard of the alignment problem by instructors.  

Turnout specific stretch sequences are classical ballet specific and a fundamental prerequisite for a warmup progression. A stretch series that prepares the student for demands of the classical ballet training must be completed for a minimum of 30 minutes before every classical ballet technique class.

Note: Pilates and Yoga do not accomplish the joint rage of motion needed for the correct execution of classical ballet  specific training.  Stretches must be classical ballet alignment specific.

Postural Alignment of the Shoulder Complex and the Mechanism of Joint Stress and Injury

Postural alignment of the shoulder complex is one of the most neglected areas, second to hip turnout, in classical ballet training.

Port de bra demonstrating upper extremity alignment where (1) the shoulder complex is held back and down, (2) head of the humorous stabilized as far behind the clavicular head as possible, (3) major muscle groups include concurrent contracture of the pectoral and latissimus muscles to stabilize the shoulder complex and stercliedomastoid muscle for the cervical spine.

The flat back position (non-winged scapulas), encompasses optimal connection of the arms to the upper extremity.

Shoulder Stretch

Range of motion of the shoulder complex is crucial for correct alignment of the upper extremity.  Holding a rigid band, rope or pole, position the hands in a position wide enough (elbows rotated up in port de bra position), then progress to a smooth transition overhead.  As the range of motion opens, bring the hands closer together. Olympic swimmers possess close to the mechanical ideal, with hands at shoulder width.

Note: The arms must be held straight, with all movements executed below a threshold of discomfort.

Mechanism of Injury

The functional arc of elevation of the shoulder is forward with impingement occurring predominately against the anterior edge of the acromion and coracoclavicular ligament. 1  As the head of the humorous bone shifts anterior to the clavicular head, discomfort may be noted after the exercise and progress to pain during the exercise resulting in tenderness over the anterior acromion and greater tuberosity.  The dancer or athlete also has a painful or uncomfortable abduction arc and positive impingement signs.  If the bicipital tendon is involved, there will be (1) tenderness over the bicipital grove, (2) positive straight arm raising, (3) resistive forward flexion at 80 degrees with the elbow extended, and (4) positive resisted forearm suppuration.

The differential diagnosis of impingement syndrome includes (1) acute traumatic bursitis (caused by a direct blow) (2) primary acromioclavicular pathology (acute tenderness), or a (3) cervical disc (neck symptoms and nerve involvement beyond the elbow).

The complaints related to the shoulder complex and bicipital tendon are generally responsive to a restriction in activity accompanied by oral anti-inflammatory agents.

Ruptures of the bicipital tendon have been reported in gymnasts,  2  frequently occurring as a degenerative problem or as a consequence of sudden unexpected stress applied to the contracted biceps. Symptomatic bursa formation about the scapula raises the traditional question of osteochondroma and need for x-ray films to rule out this rare entity. 3

Thoracic Outlet Conditions

In thoracic outlet conditions, the neurologic examination is negative and radiographs normal with the structure involved difficult or impossible to identify.  It is assumed that the ligamentous support structure or the joints between the articular processes have been injured and occasionally, a symptomatic muscle may be indicated.

Treatment is tailored to the severity of the problem with analgesic, anti-inflammatory agents, and possibly a soft collar until there is full, spasm-free range of motion.  In some patients, a specific neck complaint is accompanied by intermittent numbness, tingling, heaviness, and fatigue of an upper extremity, which suggests a thoracic outlet syndrome. 

The outlet syndromes are related to lower elements of the brachial plexus from C-7 to T-1. X-ray films may reveal a cervical rib with greater suspicion attached to the incomplete or short cervical rib due to the congenital ligamentous bands coupling coupling the cervical rib to the first rib.

Brachial Plexus Injury

Upper extremity weakness as a consequence of participation in contact sports has been associated with injuries to the upper branch of the brachial plexus as a probable causative neurologic injury.  The is occasioned by downward force upon the shoulder and deviation of the head and neck backward or toward the opposite shoulder, suggestive of traction on the brachial plexus.  The distribution of nerves from the upper trunk includes (1) superscapular (supraspinatus and infraspinatus muscles), (2) upper and lower subscapular (subscapularus and teres major), musculocutaneous (coracobrachialis and biceps), (4) axillary (deltoid and teres minor).

Spontaneous serratus anterior paralysis is a relatively rare condition.  A common cause is backpacking 4 or a brachial neuritis.  The nerve is the most prominent over the second rib and may be injured by the undersurface of the scapula with forceful pulling of the arm.  It has also been suggested that injury is due to traction between the point of proximal fixation, the scalenus medius, and its point of distal fixation, the superior serratus anterior. 5

Neck Injury

Barre described a syndrome with symptoms of headache; retro-orbital pain; vasomotor disturbance of the face ; recurrent disturbances of vision, swallowing, and pronation due to alterations of the blood flow within the vertebral arteries; and associated disturbance of the periarterial nerve plexus.  The syndrome is one not frequently expressed in "whiplash" injuries. 

Cervical spondylosis in the middle and distal thirds of the neck is thought to be the usual provocative cause of irritation of the vertebral arteries. Limousin has pointed out that in young individuals, congenital abnormalities of the posterior arch of the atlas, the arcuate foramen, man produce the symptoms. 6 The possibility can be tested for by placing the head in a slightly extended position and firmly gripping the chin.  Firm pressure is then exerted between the thumb and finger, in a gripping action just below and lateral to the occipital protuberance, at the level of the lateral masses of the atlas.  Pain may be produced by the pressure accompanied by conjunctival injection and the shedding of tears.  In some cases there will be a feeling of vague faintness.

Since many of the patients are young anxious and impressionable, assurance and conservative therapy are generally all that is necessary.  Many of the symptoms are somewhat confusing and suggest a supratentorial origin,  nevertheless, they should be investigated.  Occasionally, more particularly with additional complaints of dizziness or staggering, some disturbance in the vestibular aspect may be established by nystagmography. 7


1. Neer, C.S., and Welch, R.P.: The shoulder in Sports. Orthop. Clin. North. Am., 3:583-591, 1977.
2. Del Pizzo, W., Norwood, L.A., Jobe, F.W., et al.: Rupture of the biceps tendon in gymnastics. Am. J. Sports Med., 6:283-285, 1978.
3. McWilliams, C.A.: Subscapular extosis with advetitious bursa. J.A.M.A., 63: 1473-1474, 1914.
4. Ilfeld, F.W., and Holder, H.G.: Winged scapula: case occurring in soldier from knapsack. J.A.M.A.., 120:448-449, 1942.
5. Gregg, J.R., Labosky, D., harty, M., et al.: Serratus anterior paralysis in the young athlete. J. Bone Joint Surg., 61A: 825-832, 1979.
6. Limousin, C.A.: Foramen arculae and syndrome of Barre-Lieou. Int. Othop., 4:19-23, 1980.
7. Toglia, J.U., and Ronis, M.L.: Electronytagmograhpy in clinical and medical legal uses. trans. Pa. Acad. Ophthalmol. Otolaryngol., 22-23-27, 1969.

Selected Bibliography

Agrippina Vaganova, Basic Principles of Classical Ballet, Dover, 1969 
Alfred A Knopf, The Classic Ballet, New York, 1984
Clinics In Sports Medicine, Injuries to Dancers ,Saunders 1983 
White-Panjabi, Clinical Biomechanics of the Spine, J.B. Lippincott, 1978 
Rosse-Clawson, The Musculo-Skeletal System in Health and Disease, Harper & Row, 1970 
Stanley Hoppenfeld, Physical Examination of the Spine and Extremities, Appleton, 1976 

Martial Arts Specific
JudoSport International

"Kokoro" is a martial arts training system, developed by Stephen M. Apatow, that integrate classical biomechanics into judo, ju_jitsu and mixed martial arts disciplines.  

Classical choreographic training used for Olympic development programs in skating and gymnastics, provides the foundation for skill development.  Martial arts provides a pathway for teaching classical alignment training for sports and Olympic development programs.  


  Aspirations to achieve top level performance requires detailed attention given to each aspect of the training program.  Every day, our diet, strength, speed, flexibility, postural alignment, mental preparation and technical training all relate to the factors upon which our bodies will adapt, to yield our potential performance. -- Stephen M. Apatow

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Classical Ballet Based Biomechanical Analysis and Orthopedics 101
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