Dance Anatomy and Kinesiology

Dance
Anatomy
and
Kinesiology
Karen Clippinger,
MSPE
Note: This e-book reproduces the text of the printed book, but it may not include images,
tables, or figures that have restrictions on electronic distribution.
Human Kinetics
Library of Congress Cataloging-in-Publication Data
Clippinger, Karen S.
Dance anatomy and kinesiology / Karen Clippinger.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-0-88011-531-5 (hard cover)
ISBN-10: 0-88011-531-9 (hard cover)
1. Dance--Physiological aspects. 2. Dancing injuries--Prevention. I. Title.
RC1220.D35C55 2007
617.1'02--dc22
2006012441
ISBN-10: 0-88011-531-9
ISBN-13: 978-0-88011-531-5
Copyright © 2007 by Karen Sue Clippinger
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and 2.6 by Jason M. McAlexander, MFA; Printer: Sheridan Books
Title/chapter-opening page montage photos courtesy of Keith Ian Polakoff (top and bottom) and Patrick Van Osta (middle). Dancers,
from top to bottom: Holly Clark, Jennifer Fitzgerald, and Dwayne Worthington.
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Dedicated to my parents, Delphine and Everett,
for instilling in me the love of learning;
my son, Shawn,
for keeping learning fresh and alive;
my many teachers and colleagues
for their generous sharing of their knowledge; and
dancers everywhere
for adding inspiration to my life.
Contents
Preface vii
Acknowledgments x
CHAPTER 1 The Skeletal System and Its Movements . . . . . . . . . . . . . . . . . . . . . . . 1

Primary Tissues of the Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Bone Composition and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Bone Development and Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Human Skeleton. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Joint Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Body Orientation Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Joint Movement Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Skeletal Considerations in Whole Body Movement. . . . . . . . . . . . . . . . . . . . . . 28
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Study Questions and Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
CHAPTER 2 The Muscular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Skeletal Muscle Structure and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Microstructure of Skeletal Muscle and Muscle Contraction . . . . . . . . . . . . . . . 37
Muscle Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Muscle Attachments to Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Muscles, Levers, and Rotary Motion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Types of Muscle Contraction (Tension) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Muscular Considerations in Whole Body Movement . . . . . . . . . . . . . . . . . . . . . 53
Learning Muscle Names and Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Study Questions and Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
CHAPTER 3 The Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Bones and Bony Landmarks of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Joint Structure and Movements of the Vertebral Column . . . . . . . . . . . . . . . . . 74
Description and Functions of Individual Muscles of the Spine. . . . . . . . . . . . . . 81
Ideal Spinal Alignment and Common Deviations . . . . . . . . . . . . . . . . . . . . . . . 81
Spinal Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Muscular Analysis of Fundamental Spinal Movements . . . . . . . . . . . . . . . . . . 108
Key Considerations for the Spine in Whole Body Movement . . . . . . . . . . . . . . . 112
Special Considerations for the Spine in Dance . . . . . . . . . . . . . . . . . . . . . . . 113
Conditioning Exercises for the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Back Injuries in Dancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Study Questions and Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
iv
Contents v
CHAPTER 4 The Pelvic Girdle and Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Bones and Bony Landmarks of the Hip Region . . . . . . . . . . . . . . . . . . . . . . . 158
Joint Structure and Movements of the Pelvic Girdle . . . . . . . . . . . . . . . . . . . . 159
Joint Structure and Movements of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Description and Functions of Individual Hip Muscles . . . . . . . . . . . . . . . . . . . 164
Alignment and Common Deviations of the Hip Region . . . . . . . . . . . . . . . . . . 164
Pelvic and Hip Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Muscular Analysis of Fundamental Hip Movements . . . . . . . . . . . . . . . . . . . . 186
Key Considerations for the Hip in Whole Body Movement. . . . . . . . . . . . . . . . 193
Special Considerations for the Hip in Dance . . . . . . . . . . . . . . . . . . . . . . . . . 194
Conditioning Exercises for the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Hip Injuries in Dancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
CHAPTER 5 The Knee and Patellofemoral Joints . . . . . . . . . . . . . . . . . . . . . . . . 237

Bones and Bony Landmarks of the Knee Region . . . . . . . . . . . . . . . . . . . . . . 238
Joint Structure and Movements of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . 239
Description and Functions of Individual Knee Muscles. . . . . . . . . . . . . . . . . . 244
Knee Alignment and Common Deviations . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Knee Mechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Structure and Movements of the Patellofemoral Joint . . . . . . . . . . . . . . . . . . 256
Patellofemoral Alignment and the Q Angle . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Patellofemoral Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Muscular Analysis of Fundamental Knee Movements. . . . . . . . . . . . . . . . . . . 261
Key Considerations for the Knee in Whole Body Movement . . . . . . . . . . . . . . 264
Special Considerations for the Knee in Dance. . . . . . . . . . . . . . . . . . . . . . . . 265
Conditioning Exercises for the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Knee Injuries in Dancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
CHAPTER 6 The Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Bones and Bony Landmarks of the Ankle and Foot . . . . . . . . . . . . . . . . . . . . 298
Joint Structure and Movements of the Ankle and Foot . . . . . . . . . . . . . . . . . . 300
Description and Functions of Individual Muscles of the Ankle and Foot . . . . . . 309
Alignment and Common Deviations of the Ankle and Foot . . . . . . . . . . . . . . . 324
Mechanics of the Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Muscular Analysis of Fundamental Movements of the Ankle and Foot . . . . . . . 331
Key Considerations for the Ankle and Foot in Whole Body Movement . . . . . . . . 333
Special Considerations for the Ankle and Foot in Dance . . . . . . . . . . . . . . . . 336
Conditioning Exercises for the Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . 340
Ankle and Foot Injuries in Dancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
vi Contents
CHAPTER 7 The Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Bones and Bony Landmarks of the Shoulder Complex . . . . . . . . . . . . . . . . . . 374
Joint Structure and Movements of the Shoulder Girdle. . . . . . . . . . . . . . . . . . 375
Joint Structure and Movements of the Shoulder . . . . . . . . . . . . . . . . . . . . . . 378
Description and Functions of Individual Muscles of the Shoulder Complex . . . 380
Alignment and Common Deviations of the Shoulder Complex . . . . . . . . . . . . . 395
Shoulder Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Muscular Analysis of Fundamental Shoulder Movements . . . . . . . . . . . . . . . . 401
Special Considerations for the Shoulder Complex in Dance . . . . . . . . . . . . . . 409
Other Joints of the Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Description and Functions of Selected Individual Muscles of the Elbow. . . . . . 415
Structure and Movements of the Radioulnar Joints . . . . . . . . . . . . . . . . . . . . 415
Key Considerations for the Upper Extremity in Whole Body Movement. . . . . . . 431
Conditioning Exercises for the Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . 432
Upper Extremity Injuries in Dancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
CHAPTER 8 Analysis of Human Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

Anatomical Movement Analysis of Whole Body Movements . . . . . . . . . . . . . . 466
Other Methods for Movement Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Research-Supported Movement Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Optimal Performance Models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Movement Cues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
References and Resources 503

Index 523
About the Author 533
muscular systems. Similarly, kinesiology can be con-
Preface sidered the science of human motion and tradition-

ally involves the study of the principles of anatomy
and mechanics in relation to human movement.
Even though the broader use of kinesiology includes
anatomical principles, anatomy is listed separately
in the title of this text because of the greater focus
given to anatomy than seen in some kinesiology
texts. Kinesiology is included in the title of this
text because of the more applied focus and inclu-
Dance is physically demanding and involves many sion of aspects of mechanics that generally exceed
styles of movement. The vocabulary of dance the scope of traditional anatomy texts. Mechanics
requires tremendous versatility, strength, range is a branch of physics concerned with energy and
of motion, balance, neuromuscular coordination, forces and their effect on bodies and motion. When
and kinesthetic awareness. To measure a successful mechanics is applied to the study of the anatomical
performance is difficult. It is not simply a matter structure and function of living organisms, such as
of how high a dancer jumps or how fast a dancer human beings, it is called biomechanics. This text
runs, but rather includes elusive qualities such as selectively includes aspects of biomechanics that
expressiveness, movement connectivity and phras- relate to movements of joints, dance technique, and
ing, aesthetic demands for specific body segment injury prevention.
positioning, dynamic versatility, and stage presence.
This is to say that the dancer is an artist as well as
Chapter Content
a technician. However, the human body is still the
instrument of expression, and some basic anatomi- This book contains eight chapters. The first two chap-
cal and biomechanical principles apply to optimal ters provide a foundation for the rest of the text by
performance. Hence, this text has been written to presenting anatomical and kinesiological concepts
provide scientific information that dancers can use and terminology that are particularly relevant for
to better understand their bodies and consequently dance and that are utilized in the remaining text.
reduce injury risk while they enhance longevity and Chapter 1 covers bones, joints, body orientation
performance. terminology, and joint movement terminology.
This book emerged from the difficulty that I and Chapter 2 focuses on muscle structure, levers, types
many colleagues had in finding a single text that of muscle contractions and their function in human
could be used to teach anatomy and kinesiology movement, and an approach to learning muscle
classes for dancers. Many dancers are visual learners names and actions.
and so often request texts that are rich in graphic Chapters 3 through 7 deal with the various regions
materials. However, there was also the desire for the of the body. The first of these chapters (chapter 3)
written material to be adequate in depth, as scientifi- focuses on the spine because of its central structural
cally accurate as possible, and specific for dancers. and functional role in movement. The next three
This text has been developed to meet these criteria chapters (chapters 4 through 6) cover the lower
and to provide many practical exercises to allow danc- extremity, moving proximally to distally from the hip
ers to apply the material on their own bodies. to the knee and then to the ankle and foot. A single
chapter (chapter 7) covers the upper extremity. The
lower extremity is discussed first and in more detail
Scope, Structure, because of the preponderance of injury in this area,
and Organization the important use of the lower extremity for weight
bearing and force generation in many dance forms,
The focus of this book is dance movement, so and the tendency to emphasize the spine and the
selected aspects of the broader disciplines of anatomy lower extremity in dance anatomy and kinesiology
and kinesiology that are most vital for developing an courses due to time constraints.
understanding of dance movement are included. Each of these five chapters addresses the pri-
For example, human anatomy is the science of the mary bones, joints, muscles, alignment deviations,
structure of the human body and traditionally covers and mechanics for the given region, with special
all of the systems of the body. However, the scope of considerations for dance. Sample strength and flex-
this text is narrowed to cover just the skeletal and ibility exercises are also presented. These exercises
vii
viii Preface
are included to help the reader better understand • Attachments tables provide the pronunciation,
the function and location of muscles as well as the proximal attachment(s), distal attachment(s),
purpose of classic strength or flexibility exercises and key action(s) of the primary muscles covered
for improving dance technique and helping prevent in this text. This special element is included in
common injuries. In the final section of each of these chapters 3 through 7, positioned closely to the
chapters, common dance injuries for the given region picture and verbal description of the given muscle
are described. The purpose of these injury sections is to aid the reader with deducing the line of pull
not for self-diagnosis and self-treatment. Rather, they and potential action(s) of the given muscle.
provide a better understanding of the anatomical • Study Questions and Applications are designed
basis of selected injuries so that teachers and danc- to aid with learning the material presented in the
ers have a sound basis for evaluating risk, deciding chapter and with checking that key concepts are
on temporary modification, or designing sequential understood.
class progressions that will allow execution of dance
repertoire with the desired aesthetic and lower injury
risk. Through the material in the injury sections the Dance Terminology
dancer can be better informed when seeking treat-
Throughout the text, dance movements are often
ment from a qualified medical professional should
described using terminology from ballet. This was
an injury occur.
done because of the greater standardization of this
The concluding chapter of this book provides a
terminology. However, simplified versions of this
schema that will help readers analyze full-body dance
terminology (e.g., front développé vs. développé
movements. The purpose of this chapter is to present
devant) without reference to the facing of the body
a tool that can be used to increase understanding of
are used to make the information more accessible
strength, flexibility, and technique issues that will
to dance medicine professionals and dancers from
influence optimal execution of a dance movement.
other dance forms, who often use ballet terminology
This understanding will allow the dancer and dance
less formally. But this common use of ballet termi-
instructor to be more specific in cueing and in the
nology is not meant to limit the application of the
use of supplemental exercises so that dance perfor-
information to ballet technique; dancers can make
mance is enhanced.
parallel applications to similar movements in the
dance form of their choice.
Special Elements
Various special elements appear throughout most How to Use This Book
chapters to provide practical applications of selected
key concepts covered in the given chapter. Some of
for Different Goals
these special elements can easily be utilized in a lab Although the original impetus for this book was to
format in academic settings. The special elements provide a text for university courses, it is also intended
include the following: for other dancers, for dance teachers, and for those
who provide health care for dancers. Potential benefits
• Concept Demonstrations select key concepts that
for the teacher include a clearer picture of anatomical
are often difficult to grasp and provide move-
and kinesiological factors that will help the teacher
ment experiences that the reader can perform
better communicate technique challenges, a better
to aid learning.
understanding of what to look for in students to iden-
• Tests and Measurements provide examples of tify potential technique problems, and exercises that
tests that are used for evaluation of areas such as can be given to students to help them better achieve
ligamental injury, muscular strength, or flexibility. technical success. Potential benefits for the dancer
Although many of these tests require specialized include a better understanding of technique chal-
training to perform and are not meant to be per- lenges such as proper turnout and alignment and
formed by the reader without such training, they a clearer understanding of individual strengths and
have been included because they clearly illustrate weaknesses, as well as of ways to improve the areas of
the function or constraint provided by a given weakness. Potential benefits for health care providers
structure. include a better understanding of how injury preven-
• Dance Cues reflect on the potential anatomical tion and treatment relate to dance technique.
basis of some cues that are commonly used when In an attempt to meet the disparate needs of
teaching dance technique. the potential readers just described, this book is
Preface ix
designed to allow for different levels and emphasis the sections of the chapters they want to emphasize in
as the book is used. For example, the student new to their courses while leaving other sections as optional
anatomy may focus on the illustrations and the sum- supplemental reading.
mary charts of primary muscles and their functions In summary, it is hoped that this book will become
while using the sections on strength exercises, flex- a valuable resource that can be used on different
ibility exercises, and injuries only for reference. In levels as knowledge and circumstances change. In the
contrast, the more knowledgeable reader may focus past, much of dance was taught by imitation of profi-
on details such as the secondary actions of muscles, cient dancers and teachers, with cueing often based
implications of joint mechanics for technique and on intuition and personally derived experiential
injury, and the many references provided for more assumptions. This text is designed to bring greater
in-depth study. scientific knowledge and understanding to dance
Similarly, in surveying colleagues teaching dance so that assumptions can be evaluated and honed to
anatomy and kinesiology courses in academic set- reflect an ideal blend of science and art. It is also
tings, I found that courses were taught in many dif- designed to show the value of the scientific perspec-
ferent ways. For example, some teachers gave little tive so that as new research and knowledge evolve in
or no coverage to the upper extremity while others dance, readers can have a framework within which to
included a basic survey of the area. Some teachers apply this information. Such a blend of science and
included primarily anatomy, while others provided art can allow teaching to become more effective and
greater emphasis on injuries and mechanics and empower dancers to realize their unique individual
still others on corrective exercises and cueing. So, potentials so that technical proficiency will less limit
again, the book is designed with consistent headings their artistic vision.
within chapters in order to allow teachers to select
Acknowledgments
I would like to thank the many colleagues who have interiors. Gratitude is also expressed to photogra-
provided valuable input to this book, and especially phers Keith Ian Polokoff and Patrick Van Osta for
Katherine Daniels (Cornish College of the Arts), use of their photos in the montage at the opening of
Scott E. Brown (Sinai Hospital of Baltimore and the book and each chapter, as well as their contribu-
Johns Hopkins University), Terese Freedman (Mount tion of other photos used within chapter interiors.
Holyoke College), and Ralph Rozenek (California Appreciation is also expressed to Alonzo King’s Lines
State University, Long Beach), for their review of Ballet and Robert Rosenwasser for their assistance
all or portions of this text. Deepest gratitude is with acquisition of photos.
expressed to D. Skip Clippinger and Mario Zemann I would also like to thank the dancers who are
for the countless hours they spent rendering illus- depicted in the photos and especially (1) the danc-
trations for this book, essential for enriching and ers of Pacific Northwest Ballet; (2) Maurya Kerr
clarifying the theoretical concepts presented in this (currently dancing with Alonzo King’s Lines Ballet)
text. Sincere thanks are also expressed to Francia and Jennifer Owen (currently dancing with Bal-
Russell (Director of Pacific Northwest Ballet School) letMet Columbus) for use of photos demonstrating
for her long support of my work, particularly in exercises and correct technique taken by me when
the early years, and the pivotal role she and Pacific they were students at Pacific Northwest Ballet School;
Northwest Ballet played in the evolution of my work and (3) Jennifer Fitzgerald (CSULB dancer), Merett
with dancers. Miller (Sacramento Ballet dancer), and Dwayne
I also greatly appreciate all the talented photogra- Worthington (CSULB MFA dancer) for modeling for
phers who provided inspiring images of dancers in strength, flexibility, and technique exercises. Appre-
motion, as well as other individuals who contributed ciation is also expressed to Shawn Robertson for his
photographs or helped me acquire the photographs assistance with editing and cataloging my photos.
used in this text. Particular appreciation is expressed Lastly, I would like to thank California State
to Francia Russell and Lia Chiarelli for their assis- University, Long Beach and particularly Judy Allen
tance with photo acquisition of Pacific Northwest (Dance Department Chair) and Donald Para (Dean,
Ballet dancers and Angela Sterling (photographer College of the Arts) for their support of this work, as
for Pacific Northwest Ballet) for providing the pho- well as the many individuals at Human Kinetics that
tographs of Pacific Northwest Ballet dancers used on helped to make this text become a reality.
the cover, each chapter opening, and some chapter
x
System and
The Skeletal
Its Movements
© Angela Sterling Photography. Pacific Northwest Ballet dancer Patricia Barker.

CHAPTER ONE
1
2 Dance Anatomy and Kinesiology
W e start our discussion of dance anatomy and

kinesiology in this book by looking at the skele-
tal system. The skeletal system provides the structural
sheets, or membranes, that cover and line surfaces of
the body or form glands. Connective tissues gener-
ally function to bind, support, insulate, and protect
framework of the human body, and its joints permit structures and can be further divided into connective
the varied movements we explore in dance vocabu- tissue proper, cartilage, bone, and blood.
lary. In movements such as the high kick shown in While the first three types of tissues are composed
the photo on page 1, bones function in both their mainly of cells, connective tissue is characterized by
support and movement functions. The bones and the presence of large quantities of nonliving material
associated joints of the gesture leg allow for the large in the space between connective tissue cells (extra-
movement occurring at the right hip, while those cellular matrix; L. extra, outside of), which contains
of the support leg are key for providing stability so different fibers and other constituents that dictate its
that the dancer can remain upright despite a very form and function. For example, bone has calcium
small base of support. The support function of bones salts within its extracellular matrix that provide it
requires that they be strong, and understanding of with the type of strength needed to support body
bone remodeling is key for preventing loss in bone weight. Some types of connective tissue proper have
strength commonly seen in female dancers. The closely packed bundles of protein fibers (collagen),
role of bones in joints is key for understanding and giving them the type of strength necessary for their
describing human movement. Topics covered in this function of binding bone to bone (ligaments) or
chapter will include the following: muscles to bones (tendons). Blood, the atypical con-
nective tissue, has plasma as its extracellular matrix;
• Primary tissues of the body its fibers become apparent only during the process
• Bone composition and structure of blood clotting.
• Bone development and growth These primary tissues of the body can be grouped
• The human skeleton together into anatomical or functional units called
organs. An organ is a structure that performs a spe-
• Joint architecture cific function for the body and is composed of two
• Body orientation terminology to four of the primary tissues. Examples of organs
• Joint movement terminology are the heart and brain. Furthermore, organs that
• Skeletal considerations in whole body move- work closely together for a common purpose can
ment be grouped according to a common function into
systems, including the skeletal system, muscular
The concepts and terminology provided in this system, and nervous system. The skeletal system will
chapter will be utilized and applied in more depth be addressed in this chapter, and the muscular system
in later chapters. Hence, this chapter can serve both will be addressed in chapter 2. The skeletal system
as an introduction and as a reference for when this is composed of all of the bones of the body, related
information is readdressed. cartilages and ligaments, and the joints that connect
these bones together.
Primary Tissues
of the Body Bone Composition
and Structure
The body is composed of four different primary tis-
sues, each with its own particular structure to help it In the average individual, bone makes up about 15%
carry out its required functions. These four primary to 20% of total body weight (Huwyler, 1999). Bone
tissues include muscle, nervous, epithelial, and con- is characterized by its strength and rigidity, and it is
nective tissues. Muscle tissue is characterized by its one of the strongest connective tissues in the body.
ability to contract and is found in the heart, in various Unlike that of other tissues, the extracellular matrix
organs (e.g., in the smooth muscle in the gastrointes- of bone contains calcium salts. These minerals com-
tinal tract), and in the many skeletal muscles of the pose about 60% to 70% of bone weight (Hall, 1999;
body. Nervous tissue is composed of cells (neurons) Rasch, 1989) and impart to bone its great compres-
that are able to generate and conduct electrical sive (L. pressus, to press together) strength, the ability
messages, as well as other cells (neuroglia) that help to resist a force that would tend to push together or
support these neurons. Epithelial tissue is composed crush a bone. This extracellular matrix also contains
of cells that fit closely together to form continuous collagen fibers (G. koila, glue + gen, producing).
The Skeletal System and Its Movements 3
Collagen imbues bone with its great tensile strength limbs, where they serve as levers to enhance move-
(the ability to resist a pulling force that would tend to ment. For example, the “thigh” bone, or femur, is a
pull a bone apart; L. tensio, to stretch) and flexibility. long bone (figure 1.1). Other examples include the
The composition of bone can be compared to that clavicles, humerus, radius, ulna, and metacarpals
of reinforced concrete, with the collagen playing the and phalanges of the upper limb or extremity and
role of the steel and the calcium crystals serving the the tibia, fibula, and metatarsals and phalanges of
role of the sand and rock. The compression strength the lower limb or extremity (figure 1.4). The long
of bone is actually greater than that of reinforced bones in the lower extremity are generally larger and
concrete (Guyton, 1976), and the tensile strength of stronger to meet their weight-bearing needs, while
very dense bone is estimated to be 230 times greater those in the upper extremity are generally smaller
than that of muscle of a similar cross section (Rasch and lighter to meet their role in reaching and in
and Burke, 1978). manipulation of objects.
• Short bones are cubical in shape and are found
Functions of Bone in the upper portion of the hand (carpals; see figure
1.4) and feet (tarsals; see figures 1.1 and 1.4). These
The composition of bone allows it to serve in the bones aid with shock absorption, transmission of
following key functions. forces, and small complex movements.
• Support: Bones provide an internal framework for

the body that is essential for stability and form.
• Protection: Some bones protect fragile structures
within. For example, the skull helps protect the
brain; the rib cage, the heart and lungs; and the
pelvic girdle, vital internal organs.
• Movement: Many bones serve as levers to enhance
movement capabilities (see Muscles, Levers, and
Rotary Motion in chapter 2 [p. 44] for more infor-
mation). Having long levers in our body allows
our limbs to move through a large distance, at a
fast speed, or both.
• Blood cell production: Some bones contain tissue
(red bone marrow) that is responsible for the
production of red blood cells. Red blood cells
are vital for the transport of oxygen and carbon
dioxide.
• Mineral storage: Various important minerals
such as calcium, phosphorus, and magnesium
are stored within the bones. When necessary,
hormones can stimulate release of some of these
minerals into the blood for the body to use. These
minerals are vital for important processes such
as blood clotting, nerve transmission, muscle
contraction, and energy metabolism.
Types of Bone
Bones come in a large variety of shapes and sizes.

They can be classified according to their shape
into the five types described next and illustrated in
figure 1.1.
• Long bones are tubular in shape and much

longer than they are wide. They are found in the FIGURE 1.1 Types of bones in the skeleton (anterior view).
• Flat bones are relatively thin and flat, but often figure 1.2. Learning these structures is key for under-
slightly curved in shape. These bones commonly standing bone growth and health. The shaftlike
protect important soft underlying structures (such as part, called the diaphysis (G. a growing between),
the brain), and their shape also allows for extensive has thick walls of compact bone and a hollow cavity
attachment of muscles. Examples include the upper called the medullary cavity (L. marrow). The layer
portion of the pelvis (ilium) seen in figure 1.1 and of compact bone thins toward the extremities of
the ribs, sternum, scapulae, and some of the bones the long bone. The enlarged ends of the bones are
of the skull shown in figure 1.4. called the epiphyses (G. epi, upon + physis, growth).
• Irregular bones do not fall into the preceding These broadened epiphyses provide extensive area
three classifications and exhibit complex and varied for muscle attachment. They also offer larger surface
shapes. Their shape is adapted to special purposes; areas for articulation with adjacent bones, enhanc-
and they serve a variety of functions including pro- ing joint stability. The surfaces of the epiphyses that
tecting the spinal cord, supporting body weight, actually come in contact with opposing bones are
transmitting loads, providing sites for muscle covered with a thin layer of specialized connective
attachment, and facilitating movement. Examples tissue called articular cartilage. Articular cartilage
include the vertebrae and lower portions of the pelvis helps lessen forces and allows joints to move more
(ischium and pubis) shown in figures 1.1 and 1.4. smoothly (see Synovial Joints on pp. 12 and 13 for
more information). Rather than housing a hollow
• Sesamoid bones (G. sesamoeides, like sesame) are
cavity, the epiphyses are filled with cancellous bone.
bones that form within a tendon. They help protect
The spaces of both the cancellous bone and the med-
the tendon from excessive wear due to rubbing against
ullary cavity are filled with a soft, fatty substance called
the underlying bone, and they change the angle of
bone marrow. Some of this marrow (red marrow) is
the tendon so that the muscle can produce more
the type that is vital for making red blood cells.
effective force. Examples include the “kneecap,” or
In bone that is still growing, there is a plate of car-
patella (figure 1.1), which is encased in the tendon of
tilage separating each epiphysis from the diaphysis.
the quadriceps femoris, and two small bones within the
tendon of the flexor hallucis brevis, located under the
base of the big toe and discussed in chapter 6. Because
these sesamoid bones are relatively flat, many texts
include them in the class of “flat bones” just described,
while other texts put them in a class of their own.
Structure of Bone
Bone does not have uniform composition. For exam-

ple, the relative percentage of mineralization varies
between bones, as well as within a given bone to help
it better serve its functions. In general, bones have an
outer layer of very dense bone called compact bone
and an inner layer of less dense bone called spongy,
trabecular, or cancellous bone. The compact bone
provides strength and stiffness. Cancellous bone (L. a
grating, lattice) contains many open spaces between
thin processes of bone (trabeculae). These trabecu-
lae (L. trabs, a beam) form a type of latticework that
corresponds to the lines of stress occurring within
the bone. This architecture provides bones with
additional strength and shock-absorbing capacity,
while allowing the bones to be much lighter than if
they were composed solely of compact bone.
Structure of a Typical Long Bone

The compact bone, cancellous bone, and other FIGURE 1.2 Structure of a typical long bone (longitudinal
structures present in a typical long bone are shown in section).
This is termed the epiphyseal plate (G. epi, upon + monly is turned into cartilage models of bones that are
physis, growth) or “growth plate” (see Bone Devel- then mostly replaced with bone as the child develops.
opment and Growth for more information). In the This latter type of ossification is termed endochondral
adult these epiphyseal plates have been replaced with ossification (G. endon, within + chondros, cartilage),
bone, and the diaphysis has fused with the epiphysis. and it is this type of ossification that is responsible for
The bone used in this fusion is very dense and is vis- the increase in length of long bones. Endochondral
ible as an epiphyseal line on X rays. ossification originates at a site near the center of the
With the exception of the portion of the epiphyses shaft of the cartilage model that is called the primary
covered with articular cartilage, the whole outside of ossification site. This ossification begins at the end of
the bone is covered by a fibrous membrane called the second month of intrauterine life (Hall-Craggs,
the periosteum (G. peri, around + osteon, bone). The 1985) and proceeds in both directions away from the
inner layer of the periosteum contains cells that are center to form the diaphysis. Shortly before or after
capable of laying down new bone (osteoblasts). The birth, one or more secondary ossification centers
periosteum is richly supplied with blood vessels, appear toward the extremities of the long bone,
which are essential for bone nutrition. It also pro- which ossify the epiphysis.
vides a site for attachment of muscles and ligaments As growth proceeds, a plate of cartilage remains
to the bone. Muscles generally do not attach right between the diaphysis and epiphyses: the epiphyseal
into the bone; rather their connective tissue exten- plate or “growth plate” previously described. This
sions, such as the tendon, attach to the periosteum, epiphyseal plate maintains its thickness by balancing
which in turn has small fibers that penetrate into the growth of cartilage on its epiphyseal side with the
the bone (Sharpey’s fibers). The periosteum can be replacement by bony tissue on its diaphyseal side.
readily injured, and due to its abundant nerve supply This process prevents fusion and allows growth in
may be responsible for much of the pain associated length of the bone to continue until the adult size
with shin splints, bone bruises, and fractures. of that particular bone is achieved. At this time,
The endosteum (G. endon, within + osteon, bone) the production of new cartilage declines; the carti-
is a membrane lining the internal bone surfaces laginous epiphyseal plates are replaced by bone; and
including the medullary cavity and the canals pass- the diaphysis fuses with the epiphyses. The “growth
ing through the compact bone. Like the periosteum, plates” are now considered “closed.” This closure of
it contains cells that can help with bone growth the epiphyseal plates generally occurs progressively
and repair. These cells, located in the endosteum from puberty to maturity. Although there is much
and periosteum of growing bones, are particularly individual variability, most of the long bones of the
important for growth of bones in terms of girth limbs achieve closure between approximately age
versus length (see Bone Development and Growth 15 and 25 (Goss, 1980); it occurs as much as four
for more information). years earlier in a female than a male (Kreighbaum
and Barthels, 1996).
Structure of Other Types of Bones In addition to growth in length, long bones also
undergo remodeling and growth in circumference,
Similar to long bones, the short bones, irregular
termed appositional growth. The osteoblasts in the
bones, and flat bones have an outer layer of compact
deep layer of the periosteum lay down new bone
bone covered by periosteum. Underneath this layer
(intramembranous ossification), while cells in the
of compact bone lies cancellous bone that is covered
endosteum (osteoclasts) resorb bone. This process
by endosteum. These types of bones are not cylin-
allows the bone to grow “outward,” increasing its
drical in shape and so have no epiphyses, diaphysis,
girth while slightly expanding the medullary cavity to
or medullary cavity. However, they do contain bone
make a thicker and stronger bone while preventing
marrow between their trabeculae. Some of the flat
the bone from becoming too heavy. Although this
bones contain red marrow, the type of marrow
expansion in girth occurs at the greatest rate before
capable of generating red blood cells.
maturity, it continues throughout adulthood. A sum-
mary of this growth of long bones in circumference
Bone Development and Growth and length appears in figure 1.3.
During fetal development, specialized connective Bone Remodeling

tissue (mesenchyme) can be directly turned into
bone, termed intramembranous ossification (L. within In addition to growing in length and width, bone is
a membrane; os, bone + facia, to make), but more com- also continually remodeling. Approximately 5% to
sion becomes electropositive, creating an electrical

A Growth in length B Growth
via endochondral in girth and potential that appears to stimulate bone deposition
ossification remodeling (Enoka, 2002; Mercier, 1995). Although Wolff’s law
has gone through some modifications in more recent
years to include additional factors, the concept is
still germane. Healthy bones remodel in response to
mechanical demands; they lay down new bone where
needed and resorb bone where it is not needed.
With Wolff’s law in mind, it is not surprising that
bone density is very much influenced by activity. The
mechanical stresses associated with walking, run-
ning, and dancing provide an important stimulus
to encourage maintenance of healthy bone density,
and bone density has been shown to be differen-
tially increased in relation to the associated stresses
of those activities. For example, some runners may
show increased bone density in the lower leg bones;
tennis players may show increased bone density of
the arm bones on their dominant side; and ballet
dancers may show thickening of the shaft of the
second metatarsal bone of the foot.
Although the most potent effect on bone density
appears to relate to high-impact weight-bearing
physical activity, forceful muscle contractions without
weight bearing can also positively influence bone
density; and greater bone density has also been
FIGURE 1.3 Bone growth in youth. (A) Growth in bone shown to be associated with stronger muscles and
length via endochondral ossification; (B) growth in bone greater muscle mass (Andreoli et al., 2001; Frost,
girth via appositional growth and maintenance of propor- 2000; Stewart and Hannan, 2000). Conversely, even
tions via remodeling. young children who are hospitalized, individuals of
any age whose limbs are immobilized in casts, and
7% of our bone mass is recycled in a week, and as healthy young individuals involved in space flight
much as a half a gram of calcium can enter or leave (Hall, 1999; Roy, Baldwin, and Edgerton, 1996;
the adult skeleton in a single day (Marieb, 1995). So, Zernicke, Vailas, and Salem, 1990) experience loss
although bone is very hard, it is very alive and is con- of bone density (osteopenia) that can lead to gross
tinually changing in response to many factors includ- structural weakening of bones (increased porosity
ing the mechanical stresses to which it is exposed. in bone termed osteoporosis), probably due to
This relationship of stress to bone development was inadequate forces borne by bone. For example,
actually expressed a long time ago (in 1892) by Julius bed rest of four to six weeks can result in signifi-
Wolff. Wolff’s law holds that changes in the internal cant bone density losses that are not fully reversed
architecture of bone and the external conformation with six months of normal weight-bearing activity;
of bone will occur in accordance with mathematical and astronauts may lose up to 19% of their weight-
laws and in response to the forces acting on bones. bearing bone on extended missions.
The primary forces acting on bones are believed to Bone remodeling and density are also influenced
relate to the contraction of muscles and the loading by race, age, calcium availability, hormones, and
of bones in weight-bearing activities. gender. For example, in terms of ethnicity, African
It appears that the longitudinal stresses (com- Americans tend to have greater bone density than
pression) related to weight bearing are particularly Caucasians, which is conjectured to be linked to
potent for instigating bone deposition and may be greater muscle mass in African Americans (Burr,
due to the piezoelectric effect (G. piez , to press + 1997; Hall, 1999). In terms of age, bone deposition
electricity). In the 1950s it was shown that when outweighs bone resorption in healthy children,
bone is placed under stress, an electrical gradient is resulting in net growth in bones. In younger adults,
generated. The side of the bone under compression bone resorption and bone deposition proceed
becomes electronegative while the side under ten- at similar rates. In older adults, bone resorption
predominates, resulting in loss in bone density and appears to be protective for bone density, and so
osteoporosis. However, for normal bone growth to dancers who are low in estrogen production or not
proceed in children, and for normal peak mineral menstruating (athletic amenorrhea) would be at risk
mass to develop in young adulthood, adequate for lower bone density. This risk for early bone loss
dietary intake of calcium and other nutrients is essen- is heightened by the common tendency for dancers
tial. Furthermore, even if there is adequate calcium to smoke cigarettes and ingest large quantities of caf-
available and normal peak bone density is achieved, feinated beverages, including soft drinks (Clippinger,
osteoporosis develops earlier, tends to be more 1999). This loss of bone density, part of the female
severe, and is four times more common in women athlete triad (American College of Sports Medicine,
than men (Dudek, 1997). In terms of gender, adult 1997), can occur with dancers as young as in their
females generally begin with about 30% less bone teens, resulting in losses in bone density normally
mass than men (Rasch, 1989), start decreasing bone not seen until after the fifth decade and markedly
density at an earlier age, and lose bone at a greater increasing susceptibility to stress fractures (Khan et
rate than males. Osteoporosis affects approximately al., 1999). Some of this loss in bone density may be
40% of women after the age of 50 (Hall, 1999); and irreversible, and loss of bone density in young danc-
in elderly females, spinal bone density is often 40% ers is particularly concerning when one realizes that
of that at 20 years of age (Abernethy et al., 2005). approximately 50% of bone mineralization and 15%
At age 80, women have one chance in five (Kenney, of adult height are normally established during the
1982) of sustaining a fracture of the hip (neck of the teenage years (Hall, 1999).
femur), and osteoporosis-related fractures and asso- Hence, dancers should be particularly conscien-
ciated complications are among the leading causes tious about eating a nutrient-dense diet with ade-
of death in the elderly population (Hall, 1999). quate caloric and calcium content. Recommended
Unfortunately, this vulnerability of women to daily calcium intakes vary, according to source,
osteoporosis is of particular concern to dancers, gender, and age, between 800 and 1,500 milligrams;
and not just in later life. Although moderate activity and a 1994 National Institutes of Health consensus
has been shown to increase bone density, strenuous panel recommends 1,200 to 1,500 milligrams daily
physical training combined with other factors still for young adults between the ages of 11 and 24
under investigation, such as low energy availability, years (Beck and Shoemaker, 2000; Clark, 1997).
extremely low percentage body fat, or failing to One of the easiest ways to obtain adequate levels of
menstruate normally, can result in loss of bone den- calcium is to regularly ingest three or four servings
sity rather than a gain in bone density (Myszkewycz of milk products per day. Any of the following foods
and Koutedakis, 1998; Williams, 1998). Estrogen provides about 300 milligrams of calcium: 8 ounces
TESTS AND MEASUREMENTS 1.1
Measurement of Bone Density
Various tests can be used for detecting osteoporosis through the measurement of bone density. In
the 1940s, plain X rays were used (Kaufman, 2000). However, since demineralization of bone is not
apparent until about 40% of the bone has been lost, other methods have been developed that are more
sensitive and can detect changes at a much earlier stage. One of the more precise tests currently used
is termed dual-energy X-ray absorptiometry (DXA). This method uses X-ray beams that have two distinct
energy peaks—one that will be absorbed more by soft tissue and the other by bone. This allows for
the soft tissue component to be subtracted and the bone mineral density to be determined. However,
many other tests are also available, some of which are less expensive and more accessible. In dancers,
testing of multiple sites is often recommended, as results from various sites may differ (Khan et al.,
1996). For example, due to the frequent loading of the lower extremity associated with dancing, the
bone density in the femur might appear normal while a site in the upper extremity may be low. Dancers
who have amenorrhea or have other reason for concern should discuss with their attending physicians
what their concerns are, whether testing is indicated, and what test would be best for them.
(0.2 liters) of milk, 1 cup of yogurt, or TABLE 1.1 Calcium Content of Selected Foods (Approximate)
1 ounce (28 grams) of Swiss cheese. So
one can easily achieve 1,200 milligrams Calcium
of calcium by having four of such dairy Serving content
options or three dairy options plus size (mg) Calories
other selections that add up to the Dairy products
needed additional 300 milligrams (see
Low-fat yogurt
table 1.1). To foster goals of staying
Plain 1 cup 415 145
lean, low or nonfat varieties of these
dairy products can be selected (for Fruit-flavored 1 cup 340 230
more specific recommendations, see Ricotta cheese (part skim) 1/2 cup 335 170
Nancy Clark’s Sports Nutrition Guidebook
Low-fat milk 1 cup 300 120
[1997]). For dancers who cannot toler-
ate or do not like dairy products, one Swiss cheese 1 oz 270 105
can see from looking at table 1.1 that Cheddar cheese 1 oz 205 110
it is difficult to meet recommended
American cheese 1 oz 175 105
values. In such cases, consultation with
a nutritionist and discussion of supple- Low-fat cottage cheese 1/2 cup 70 100
mentation with the dancer’s physician Cream cheese 2 tbsp 20 100
are recommended.
Protein foods
Stress Fractures Processed tofu with calcium sulfate 4 oz 145 70

Eggs 2 large 56 160
While exercise usually serves as a stimu-
Cooked lentils 1 cup 50 210
lus for increasing bone density, there
are times when the breakdown of bone Almonds 12-15 40 90
exceeds the repair and remodeling of Peanut butter 2 tbsp 20 190
bone and a stress fracture occurs. A
stress fracture is a microscopic fractur- Hamburger patty 3 oz 10 200
ing of the bone resulting in a thin crack Chicken 3 oz 10 140
that is so small, it is not even initially
Vegetables and fruits
apparent on an X ray. When a bone
undergoes excessive repetitive submax- Collard greens 1/2 cup 180 30
imal stress, it responds with increased Bok choy, cooked 1/2 cup 125 15
osteoclast activity. These osteoclasts
resorb bone as the first step before Broccoli 1/2 cup 70 20
laying down a stronger new matrix. In Orange 1 medium 55 70
the process, they temporarily leave the
Green beans 1/2 cup 30 15
bone weaker. If stress is too great, the
outer portion of the bone (cortex) may Orange juice 1 cup 27 110
crack, creating a stress fracture. Calcium fortified orange juice 1 cup 300 110
Theoretically, stress fracture risk can
be increased by factors that negatively Mashed potatoes 1/2 cup 25 100
impact bone health, and so all of the Carrots 1/2 cup 24 24
factors just discussed relating to bone
Lettuce 1/4 head 20 27
density, including being female, a his-
tory of menstrual disturbance, less lean Apple 1 medium 10 80
mass in the lower limb, inadequate Grains
calcium intake, a low-fat diet, and smok-
ing, can heighten stress fracture risk Whole-wheat bread 2 slices 40 130
(Bennell et al., 1996; Clarkson, 1998; Cooked rice 1/2 cup 10 80
Hershman and Mailly, 1990; Taube and
Bagel (water) 1 3 in. 8 165
Wadsworth, 1993). Female athletes have
Sources: Clark (1997) and U.S. Department of Agriculture (1981).
been reported to have a 1.5 to 3.5 times
greater risk of stress fractures than male athletes The Axial and Appendicular Skeleton
(Browning, 2001), and a study of ballet students
found that young females had about twice the risk The skeleton has two major divisions—the axial
of developing stress fractures as young males and skeleton (L. relating to an axis) and the appendicu-
that this risk is further heightened during adoles- lar skeleton. As its name implies, the axial portion
cence; 70% of the stress fractures in female dancers forms the central upright “axis” of the skeleton,
occurred during the late adolescent period of 15 to and includes the skull, vertebral column, sternum,
19 years of age (Lundon, Melcher, and Bray, 1999). and ribs (figure 1.4A). The skull contains 28 bones,
Furthermore, a study of female dancers found an which form the face (facial bones) and remainder
older age of onset of menstruation (menarche), and of the skull (cranial bones). This book will simplify
the incidence of menstruation stopping (secondary this area and simply refer to the bones of the skull
amenorrhea) was twice as high among dancers with as a unit. The skull provides an essential protective
stress fractures as compared to dancers without stress function for the vulnerable brain and plays an impor-
fractures (Warren et al., 1986). Even more dramatic, tant part in housing the senses of sight, smell, taste,
another study of professional ballet dancers found a and hearing. The sternum (commonly referred to
female dancer who had amenorrhea longer than 6 as the breastbone; G. sternon, the chest) and the
months had an estimated risk for stress fracture 93 12 ribs with their adjoining cartilages help form
times that of a dancer who did not have amenorrhea the thorax, which provides important protection
(Kadel, Teitz, and Kronmal, 1992). for the lungs and heart. Thirty-three vertebrae
Training errors, such as an increase in exercise form the vertebral column (commonly referred to
intensity or duration that is too great, can also be as the spine). The segmented property of the spine
important (Brukner, Bradshaw, and Bennell, 1998), allows it to be flexible and capable of a wide variety
and one study of runners with stress fractures found of movements. Consecutive vertebrae form a canal
27% of cases developed after rapid commencement that houses and protects the very important and
of training (Taunton, Clement, and Webber, 1981). fragile spinal cord.
Another study of runners found training errors in The appendicular skeleton is composed of the
22.4% of 320 stress fractures (Matheson et al., 1987). bones of the limbs (appendages), which are hung
Although not substantiated, in dance, a sudden upon or attached to the axial skeleton as seen in
increase in workload (especially pointe work or figure 1.4B. The appendicular skeleton contains two
jumps); rapid changes in dance style, technique, or additional subdivisions, the paired upper extremity
floor surfaces; and excessive fatigue may contribute and the paired lower extremity. The upper extrem-
to stress fracture risk. One study of professional ballet ity is composed of the bones of the shoulder girdle,
dancers showed a 16 times greater risk for those upper arm, lower arm, wrist, and hand. The shoulder
dancing more than 5 hours per day when compared girdle consists of the paired clavicles (commonly
with those dancing less than 5 hours (Kadel, Teitz, called collarbones) and scapulae (L. the shoulder
and Kronmal, 1992). blades). The upper arm bone is called the humerus
Stress fracture prevalence has been reported to (L. shoulder), while bones of the lower arm are the
be as high as 61% in professional ballet dancers radius (on the thumb side; L. rod, ray) and ulna
(Warren et al., 1986), and further research will be (L. arm). The upper part of the hand contains two
necessary to understand the relative significance rows of small bones called the carpals (eight bones);
of the various causative factors in dancers. In the followed by five rays of bone found in the “palm” of
interim, current study results suggest that application the hand, called the metacarpals; and the 14 digits
of sound training principles, swift medical referral of the fingers called the phalanges.
when amenorrhea is present, healthy nutritional The lower extremity is composed of the bones
practices including adequate calcium intake, and of the pelvic girdle, thigh, lower leg, and the ankle-
smoking cessation can aid in the prevention and foot. The pelvic girdle is composed of two paired
treatment of stress fractures. hip bones called os innominatum or os coxae that
connect to each other in the front and to the sacrum
The Human Skeleton behind. In the young child, each os coxae is made
up of three separate bones: the ilium (upper wing-
There are 206 bones in the adult human skeleton, like portion of the pelvis), ischium (lower portion),
177 that can engage in voluntary movement (Ham- and pubis (front portion). These bones later fuse
ilton and Luttgens, 2002). The major bones of the together. The thigh bone is called the femur, and the
skeleton are shown in figure 1.4. lower leg bones are the tibia and fibula. The tibia is
FIGURE 1.4 Major bones of the human skeleton. (A) Lateral view of axial skeleton and (B) anterior view of complete
skeleton.
the larger of the bones, and is the primary weight- Bony Markings
bearing bone of the lower leg. The fibula acts like a
strut, placed to the outside of the tibia. The patella, In addition to the names just mentioned for the
or kneecap, is located in front of the lower part of bones of the skeleton, names are often used for
the femur. The ankle-foot region has seven bones specific sites on a given bone. This labeling is helpful
located in the ankle and upper foot area called the for describing the specific location of blood vessels
tarsals; five rays of bone located in the main body of and nerves, or attachments of tendons, ligaments, or
the foot, called the metatarsals; and 14 digits located fascia. Such sites are commonly depressions, open-
in the toes, called the phalanges. Note the similarity ings, projections, or processes as described in table
of the arrangement of the foot and hand; the differ- 1.2. This terminology will be applied as individual
ence is that the hand has one more carpal than the joints are described more fully in following chapters
foot has tarsals. of this book.
TABLE 1.2 Bony Markings
Name Definition Example

Depressions and openings
Fossa A hollow or depression Iliac fossa
Foramen A hole or passage through a bone Obturator foramen of pelvis
Sinus A cavity or spongelike space in a bone Sinus tarsi in foot
Projections and processes that help form joints
Condyle Rounded projection at the end of a bone that enters into Condyles of tibia
formation of a joint
Facet Smooth, flat area where a bone comes in contact with Facets of vertebrae
another bone
Head Spherical projection beyond a narrow necklike portion Head of femur
located at the end of a bone that enters into formation
of a joint
Projections and processes to which muscles attach
Crest A large ridge Crest of ilium
Epicondyle Eminence located above a condyle Epicondyles of femur
Line A less prominent ridge Linea aspera of femur
Malleolus A rounded process Lateral malleolus of fibula
Spinous process A sharp spine-like projection Spine of scapula
or spine
Trochanter Very large projection Greater trochanter of femur
Tubercle A small rounded projection Lesser tubercle of humerus
Tuberosity A rounded projection Ischial tuberosity
Joint Architecture Fibrous Joints

Fibrous joints are held tightly together by either very
The human skeleton is composed of various bones short fibers (sutures), cords (ligaments), or sheets
joined together to form segments or links. The (interosseous membranes) of fibrous connective tissue.
connection between adjacent bones or cartilage is In each case, the fibrous connective tissue directly con-
termed a joint or, more technically, an articulation. nects the adjacent bones and there is no space between
These articulations have two primary but divergent the bones. Sutures allow no true movement, but only
functions: to bind the skeleton together and to “give,” while the other two types of fibrous joints allow a
provide mobility. There are many different kinds of variable amount of movement depending on the length
articulations, with varied types of connections and of their fibers. The type of connective tissue involved
motions present. (dense regular connective tissue) can withstand great
tensile stress. Examples of fibrous joints include the
Classification of Joints sutures of the skull, the middle joint between the
bones of the forearm (middle radioulnar), and two of
Joints can be classified according to the type of the joints between the bones of the lower leg (middle
connective tissue that binds them and the presence tibiofibular and distal tibiofibular joints).
or absence of a joint cavity (Marieb, 1995). In this
Cartilaginous Joints
structure-based classification system there are three
classes of joints—fibrous, cartilaginous, and synovial Cartilaginous joints are united directly by cartilage
(see table 1.3). (fibrocartilage or hyaline cartilage); and, similarly
TABLE 1.3 Types of Joints
Examples Description
Fibrous joints
In fibrous joints, articulating
bones are joined directly with
fibrous tissue and there is no
intervening joint space. Sutures
of the skull are examples of
fibrous joints utilizing very short
fibers such that almost no
movement is allowed. Interosseus
membranes are examples of
fibrous joints utilizing longer fibers
such that very slight movement
is allowed. In the case of the
middle tibiofibular joint, this slight
movement accompanies changes
in positioning of the ankle-foot
complex and is essential for
optimal biomechanics.
Cartilaginous joints
In cartilaginous joints,
articulating bones are joined
directly by either hyaline or
fibrocartilage. The epiphyseal
plates connecting the epiphyses
and diaphysis of long bones are
examples of cartilaginous joints
involving hyaline cartilage. This
arrangement allows “give” but no
real movement, and with maturity
these “growth plates” ossify
with cartilage being replaced by
bone. The intervertebral discs are
examples of cartilaginous joints
utilizing discs of fibrocartilage.
This design allows more movement
and essential shock absorption.
Synovial joints
In synovial joints, the articulating
bones are not directly joined, but
rather are separated by a joint
cavity that contains synovial fluid.
A joint capsule and ligaments
help hold the bones together.
This design facilitates movement,
and these joints are essential
for functional movements of the
limbs. There are six types of
synovial joints that differ in terms
of the movements they allow.
The knee joint is an example of a
synovial joint that is considered a
modified hinge joint and primarily
allows motion in one plane and
around one axis.
12
to the situation with fibrous joints, there is no space cell division is infrequent, and damage is generally
between the adjacent bones. Like bone, cartilage repaired by fibrous tissue.
cells are surrounded by an extracellular matrix con- Synovial joints are surrounded by a sleevelike
taining collagen fibers. However, unlike bone, this structure made of fibrous tissue called the articular
matrix is not calcified and is more like a firm gel in or joint capsule. This capsule varies markedly in thick-
consistency. This gives cartilage less rigidity and more ness and composition between joints to favor either
shock-absorbing capacity. Examples of cartilaginous mobility or stability. The fibrous tissue composing the
joints (fibrocartilage type) include the joints between capsule contains irregularly arranged collagen fibers
the bodies of the vertebrae (the intervertebral discs) and some elastic fibers in its matrix (dense irregular
and the pubes (pubic symphysis). This fibrocartilage connective tissue), which give it strength and allow it
type of joint involves a pad or disc of fibrocartilage, to withstand tension applied in many directions. The
a design that allows slight movement as well as capsule generally attaches to the bones, via the perios-
shock absorption. The epiphyseal plate, previously teum, at the margins of the articular cartilage.
discussed with long bones, is also a cartilaginous The capsule is lined on the inside with synovial
joint, only of the hyaline cartilage type. The latter membrane. This membrane is a vascular, fragile,
joint allows no true movement but adds a “give” to smooth tissue (loose connective tissue) that produces
the associated bones. synovial fluid. This synovial fluid (G. syn, together +
L. ovum, egg) has a consistency similar to egg white
Synovial Joints and helps to lubricate the joint and decrease wear
Synovial joints differ from fibrous and cartilaginous and tear. Studies indicate that synovial fluid will
joints in that adjacent bones are not directly con- change its characteristics (viscosity) such that when
nected to each other and there is actually a space either the temperature or the velocity of joint move-
between the articulating bones. This space is called ment is low, it will offer more resistance to movement
the joint cavity. Although this space is very small, it (Levangie and Norkin, 2001). Conversely, when the
generally allows a large degree of motion. Synovial temperature is higher (such as after warm-up) or
joints are the most common type of joint in the human the velocity of movement is higher, less resistance to
body, and almost all of the joints found in the limbs movement is provided. Synovial fluid also is important
are synovial in nature. Synovial joints are particularly for nourishment of articular cartilage, and it contains
important for the study of human movement, and cells that respond to the presence of a foreign object
thus are the focus of this book. Examples of synovial or infection. When injury or irritation occurs, an
joints include the shoulder, elbow, wrist, hip, knee, abundant secretion of synovial fluid follows, which can
and ankle. The typical structure of a synovial joint is produce noticeable swelling. It is the presence of the
described next and is depicted in figure 1.5.
A characteristic of synovial joints is that the ends
of the bones that come together to form the joint
are covered with articular cartilage. Articular carti-
lage is a thin layer of hyaline cartilage covering the
joint surfaces that helps decrease friction and aids
in shock absorbency. The extracellular matrix of
hyaline cartilage has characteristics between those
of a solid and a liquid and has the ability to adapt to
stress—actually exuding some of its fluid in response
to loading (Whiting and Zernicke, 1998), spread-
ing the load and reducing the stress at any contact
point by 50% or more (Hall, 1999). According to
one estimate, it also reduces friction at joints to only
approximately 17% to 33% of the friction of a skate
on ice under the same load. Articular cartilage does
not contain its own blood supply and is dependent on
nourishment from the synovial fluid and underlying
vascular bone. In some areas where this cartilage is
thick (such as the backside of the patella), nourish-
ment may not be adequate and degeneration can FIGURE 1.5 Structure of a typical synovial joint
occur. In general, once growth has ceased, cartilage (longitudinal section).
synovial membrane and synovial fluid that gives rise

to the name of this type of joint, “synovial” joint.
Synovial joints are generally reinforced by liga-
ments. Ligaments (L. ligamentum, a band) are strong
bands of fibrous tissue that bind the articulating
bones together. They contain abundant collagen
fibers arranged in a lengthwise manner (dense
regular connective tissue), which provide them with
good tensile strength. Ligaments serve as passive
constraints to prevent dislocations and add greater
stability to joints. They also tend to limit the direc-
tion and extent of motion allowed at a given joint.
These ligaments can be deep to (intracapsular),
part of (capsular), or outside of (extracapsular) the
joint capsule. The cruciate ligaments of the knee
are examples of intracapsular ligaments; and the
collateral ligaments of the knee (figure 5.3 on p. 240)
are examples of extracapsular ligaments. The gle-
nohumeral ligaments of the shoulder (figure 7.7 on
p. 380) are examples of capsular ligaments.
Some synovial joints contain another specialized
structure called a fibrocartilage disc (alternately
termed articular disc). As the name suggests, this
structure is composed of fibrous cartilage. Fibrous
cartilage has more collagen fibers in its extracellular
matrix and hence is stronger than hyaline cartilage.
In some joints this fibrocartilage structure is shaped
more like a circumferential ring than a disc and is
called a labrum. These fibrocartilage structures are FIGURE 1.6 Fibrocartilage structures associated with
located within the joint and function to enhance synovial joints. (A) Menisci of the knee (right knee,
superior view) and (B) glenoid labrum of shoulder (right
joint congruency, joint stability, and joint shock
scapula, anterior view).
absorbency. They are present only in select synovial
joints such as the knee (meniscus), shoulder (glenoid often found surrounding tendons that come into
labrum), and hip (acetabular labrum). Two examples close association with bones such as the long tendons
are shown in figure 1.6. of the hand and foot. A retinaculum (L. a band, a
Many synovial joints have other associated struc- halter) is a thickened band of connective tissue that
tures that aid in their function, such as fat pads, helps hold tendons in place. Retinacula are also
bursae, tendon sheaths, and retinacula. As their prevalent around the ankle and foot. Examples of
name suggests, fat pads are an accumulation of these structures associated with the foot are shown
somewhat encapsulated fatty tissue (adipose tissue). in figure 1.7.
They aid with cushioning and shock absorption and
can be found at various places such as the hip, knee, Subclassification of Synovial Joints
and under the heel. A bursa (L. a purse) is a con-
nective tissue sac lined with synovial membrane and Despite sharing the common structure just described,
containing a thin film of synovial fluid that functions synovial joints vary considerably in their shape and
to help reduce friction. Bursae often protect soft the movements they allow. Table 1.4 illustrates one
tissue such as tendons or skin from underlying hard commonly used classification system for basic types
bone, and there are approximately 150 present in the of synovial joints and their associated movements.
human body (McCarthy, 1989). For example, there is Here, the six types of synovial joints are described
a bursa between the back of your heel bone and the only in terms of their shape. However, their shape
overlying tendon, and one between the patella and has important implications for movement capacity
the overlying skin. Synovial tissue can also be used to (noted in parentheses in table 1.4) and will be dis-
protect tendons via a double-layered sac-like covering cussed after the necessary terminology is covered in
called a tendon sheath. These tendon sheaths are the next two sections of this chapter.
Body Orientation Terminology

Before we consider the specific movements allowed
by the synovial joints just described, it is helpful
to learn some basic anatomical terminology. This
terminology can be used to describe the location of
anatomical structures, body segments, or the body as
a whole. Key terminology includes the center of mass,
line of gravity, anatomical position, anatomical direc-
tions, anatomical planes, and anatomical axes.
The Center of Mass and Line of Gravity
The center of mass of the body is the single point

of a body about which every particle of its mass is
equally distributed. This can be thought of as the
point at which the body could be suspended or sup-
FIGURE 1.7 Associated structures of the foot. ported where the body would be totally balanced
in all directions. When studying bodies subject to
gravity (such as human movement on Earth), the
center of mass may also be termed the center of
• Gliding or plane joints contain joint surfaces gravity (CG). During upright standing with the arms
that are generally flat or slightly curved in shape. down by the sides, the center of mass or center of
Examples of gliding joints occur between some of gravity of the body is approximately located just in
the carpal bones (intercarpal joints), tarsal bones front of the second sacral vertebra and at about 55%
(intertarsal joints), and the articular processes of of a person’s height (Smith, Weiss, and Lehmkuhl,
the vertebrae (facet joints). 1996).
• Hinge joints are composed of a spool-shaped sur- The line of gravity is an imaginary line run-
face that fits into a concave surface. Examples of ning vertically from the center of mass of the body
hinge joints are the ankle, elbow, and knee (the toward the ground. Gravity is the attraction of the
latter is a modified hinge). mass of the earth for the mass of other objects, and
• Pivot joints are composed of an arch- or ring- due to the effect of gravity, every particle of the
shaped surface that rotates about a rounded or body has a vertical force vector. However, these
peg-like pivot. Examples of pivot joints occur in individual force vectors can be simplified into one
the upper forearm (upper radioulnar joint) and force vector for the entire body. This single force
between the first and second vertebrae of the vector acting on the whole body is termed the line
spine (atlantoaxial joint). of gravity of the body. Since the line of gravity of
the body must run through the center of mass of the
• Condyloid or ellipsoid joints consist of an oval-
body, its position in space constantly changes as the
shaped condyle that fits into an elliptical cavity.
body changes its position and configuration during
An example of a condyloid joint occurs at the
movement.
wrist (radiocarpal joint) and knuckles of the
These concepts of the center of mass and line of
hands (#2–#5 metacarpophalangeal joints) and
gravity can be applied to body segments, as well as
feet (metatarsophalangeal joints).
the body as a whole. For example, the center of mass
• Saddle joints are composed of a saddle-shaped of the trunk, thigh, leg, and foot segments can be
bone that fits into a socket, which is concave- derived. One can then establish the line of gravity
convex in the opposite direction. An example of of each of these segments by dropping a vertical
a saddle joint occurs at the thumb (first carpo- line from the center of mass of the given segment.
metacarpal joint). These concepts of the center of mass and line of
• Ball-and-socket joints consist of a ball-shaped gravity are key for the analysis of alignment, forces,
head that fits into a socket. Ball-and-socket joints and movement. They will be used in later chapters,
are the most freely movable type of joint in the including the calculation of resistance torque when
body. Examples of ball-and-socket joints occur at lifting a dumbbell or another dancer (see figure
the shoulder joint and hip joint. 2.12 on p. 48).
TABLE 1.4 Types of Synovial Joints
Uniaxial joints
Hinge In hinge joints, a spool-shaped surface fits into a concave
surface allowing motion in one plane (flexion-extension in
Humerus
the sagittal plane). Example: elbow joint.
Ulna
Pivot In pivot joints, an arch- or ring-shaped surface rotates about

a rounded pivot allowing motion in one plane (rotation in
the horizontal plane). Example: upper radioulnar joint.
Biaxial joints
Condyloid In condyloid joints, an oval-shaped condyle fits into an
elliptical cavity allowing motion in two planes (flexion-
extension in the sagittal plane and abduction-adduction in
the frontal plane). Example: knuckles (metacarpophalangeal
joints) in hands.
Saddle In saddle joints, a saddle-shaped bone fits into a socket that

is concave-convex in the opposite direction allowing motion
in two planes (generally involving specialized movement
terminology). Example: thumb (first carpometacarpal joint).
Triaxial joints
Ball-and-socket In ball-and-socket joints, a ball-shaped head fits into a
socket allowing motion in three planes (flexion-extension in
the sagittal plane, abduction-adduction in the frontal plane,
and external rotation-internal rotation in the horizontal
plane). Example: shoulder joint.
16
Triaxial joints (continued)
Gliding In gliding joints, flat or slightly curved surfaces come
together allowing slight sliding motions that do not occur
around an axis. Example: acromioclavicular joint.
Anatomical Position
Anatomical position is a reference position or start-
ing position that is used for movement terminology.
Anatomical position is an erect standing position; the
feet face front (either together or slightly separated),
and the arms are down by the sides with the palms
facing forward so that the thumbs face outward and
the fingers are extended. Anatomical position is
illustrated in figure 1.8. This position of the arms
allows movements such as bending and straighten-
ing (technically termed flexion-extension) of the
elbow, wrist, and fingers to occur in the same spatial
direction (plane) as other major joints of the body
such as the shoulder and hip. This makes learning
movements easier and more logical.
Two other terms are commonly used to describe
positions of the body—prone and supine. As seen
in table 1.5, prone refers to lying face downward on
the stomach, while supine refers to lying face upward
on the back. These two terms are particularly useful
when one is describing exercises.
Directional Terminology
The other key terms defined in table 1.5 and selec-
tively illustrated in figure 1.8 are used to describe the
relationship between parts of the body in anatomical
position, or the location of the given structure in refer-
ence to other structures. Note that these terms occur
in pairs with opposite meanings. So, superior means
closer to the head or “above” while inferior means
farther from the head or “below.” Anterior or ventral
means toward the front of the body while posterior
or dorsal means toward the back of the body. For
example, the bony projection used for evaluation of
pelvic alignment, found on the front and top portion
of the pelvis, is termed the anterior superior iliac spine FIGURE 1.8 Anatomical position and directional termi-
(ASIS); that found on the back of the pelvis is termed nology.
TABLE 1.5 Anatomical Position and Directional Terminology
Term Definition
Positional terminology
Anatomical position Standing with feet and palms facing front
Supine Lying on the back
Prone Lying face downward
Directional terminology
Superior (cranial) Above/toward head
Inferior (caudal) Below/toward feet
Anterior (ventral) Front side/in front of
Posterior (dorsal) Back side/in back of
Medial Closer to the median plane/toward midline
Lateral Farther from the median plane/toward side
Proximal Closer to root of limb, trunk, or center of body
Distal Farther from root of limb, trunk, or center of body
Superficial Closer to or on the surface of body
Deep Farther from the surface of body
Palmar Anterior aspect of hand in anatomical position
Dorsal Posterior aspect of hand in anatomical position; top aspect of foot when standing in
(for hands/feet) anatomical position
Plantar Bottom aspect of foot when standing in anatomical position
the posterior superior iliac spine (PSIS). Medial anterior side is termed the palmar aspect. For the lower
refers to closer to the midline while lateral refers to extremity, during standing in anatomical position the
farther from the midline. For example, the rounded top side of the foot is termed the dorsal aspect while
bony projection of the inferior femur, located on the bottom aspect is termed the plantar aspect.
the inside of the knee, is termed the medial con-
dyle; the projection located on the outside of the Anatomical Planes
knee is termed the lateral condyle. Proximal means
closer to the root of the limb or trunk, while distal The concept of planes is used to help describe basic
means farther from the root of the limb or trunk. movements of the body and its segments. In this
For example, the joint between the radius and the context, a plane can be thought of as an imaginary
ulna that is located close to the elbow is termed the flat surface such as a sheet of cardboard that passes
proximal or superior radioulnar joint, while the through the body in a given direction. In anatomical
joint located close to the wrist is termed the distal position there are three imaginary reference planes
or inferior radioulnar joint. Superficial refers to that are perpendicular to each other and divide the
closer to the surface of the body, while deep refers body in half by mass. These cardinal planes or prin-
to farther from the surface of the body. For example, cipal planes each pass through the center of mass of
the abdominal muscle called the rectus abdominis the body. These cardinal planes correspond to the
is superficial relative to the deep abdominal muscle three dimensions in space and are termed the sagit-
called the transverse abdominis. tal, frontal, and horizontal planes as illustrated in
Some additional specialized terminology is used figure 1.9. The cardinal sagittal plane is also termed
for clarification in some parts of the body such as the median or midsagittal plane, and it is a vertical
the hands and feet. For example, during standing in plane that divides the body into equal right and left
anatomical position, the posterior side of the hand is portions. The cardinal frontal, or coronal, plane is a
referred to as the dorsal aspect or surface while the vertical plane that runs perpendicular to the sagittal
plane and divides the body into anterior and poste-

rior portions of equal mass. The cardinal horizontal
or transverse plane runs transversely through the
body such that it is perpendicular to the sagittal and
frontal planes. During upright standing the horizontal
plane is parallel to the floor. It divides the body into
superior and inferior portions of equal mass.
In addition to these cardinal planes, there can be
other sagittal, frontal, or horizontal planes that run
parallel to their cardinal counterpart but differ in
that they do not pass through the center of mass of
the body and do not divide the body in half by mass.
These other planes are helpful for describing many
functional movements in which different segments
of the body are moving in planes parallel to a given
cardinal plane. While some texts term these noncar-
dinal planes secondary planes (Smith, Weiss, and
Lehmkuhl, 1996) or segmental planes (Kreighbaum
and Barthels, 1996), for purposes of simplicity this
text includes cardinal and noncardinal planes within
the terms sagittal, frontal, and horizontal planes as
described in table 1.6.
Anatomical Axes and Associated Movements

When movement occurs in a plane, it is always occur-
ring around an axis that is perpendicular to this FIGURE 1.9 The three cardinal planes of the body and
plane. Hence, there are three imaginary anatomical their axes.
reference axes, each associated with one of the three
basic planes—sagittal, frontal, and horizontal—pre- plane in which the movement occurs. To picture
viously described. When one is describing motion the relationship between an axis and the motion
about these axes in their respective planes, move- it allows, imagine a pencil running through your
ment can be of the whole body or of a body segment. joint in the direction associated with that given axis.
Examples of such movements in the sagittal plane are Then try to imagine what type of movement it would
shown in figure 1.10. With whole body movement the allow and in what plane this movement would occur
axis generally runs through the center of mass of the (table 1.7). Mediolateral axes for the wrist, elbow,
body, as with a forward somersault (figure 1.10A), or shoulder, hip, knee, and ankle joints are shown in
through a point of external support. Examples of a figure 1.10C that would allow movements at these
point of external support are the hands on a paral- joints in a sagittal plane.
lel bar during a swinging motion, the hands on the
floor in a walkover (figure 1.10B), and the feet on • Mediolateral axis (frontal axis). A mediolateral
the floor in the preparation phase of a jump. With (ML) axis runs in a side-to-side direction in a frontal
movement of body segments, the axis runs through plane, perpendicular to a sagittal plane and allowing
the joint, again in a direction perpendicular to the motion in a sagittal plane. An ML axis through the
TABLE 1.6 Basic Anatomical Planes
Name Definition
Sagittal plane(s) A vertical plane dividing body into right and left portions
Median plane The midsagittal plane dividing the body into equal right and left portions
Frontal plane(s) A vertical plane dividing the body into front and back portions
Horizontal plane(s) A transverse plane dividing the body into upper and lower portions
DANCE CUES 1.1
“Bend the Knees to the Side”
D uring work in turnout, some teachers use directional cues to help students try to maximize their
turnout. During standing in parallel position with the feet, the knees will bend or flex “forward”
in a sagittal plane. However, with ideal turnout, the hips would be externally rotated sufficiently to
allow the knees to bend “sideward” so that this movement would occur in a plane closer to the frontal.
Sometimes using this spatial cue of “reaching the knees to the side” or “bending the knees to the side”
can help dancers use more turnout and find muscles that can help with maximizing turnout. However,
as discussed later (chapters 4 and 5), it is important that the positioning of the knee be appropriate for
the individual dancer’s turnout and be achieved through emphasis on external rotation of the femur
at the hip joint versus excessive rotation of the tibia at the knee joint.
FIGURE 1.10 Movement of the body in a sagittal plane about a mediolateral axis through (A) the center of mass of
the whole body, (B) an external point of support, and (C) a joint.
20
TABLE 1.7 Basic Anatomical Axes
Plane Movement example

Name Definition of motion (axis running through hip joint)
Mediolateral (ML) Passes through body from side to side Sagittal Parallel dégagé (front)
Anteroposterior (AP) Passes through body from front to back Frontal Parallel dégagé (side)
Vertical Passes through body from top to bottom Horizontal Turning out while standing in first
position
knee would allow the motion of bending the knee are a parallel brush (dégagé) to the side, a lateral
(knee flexion) in a sagittal plane such as used in a bend of the torso (figure 1.11B), a jumping jack, a
first-position parallel plié. Examples of dance move- cartwheel, and a Russian split. These can be thought
ments occurring primarily in sagittal (L. sagitta, an of as movements of body segments or the whole body
arrow, in the line of an arrow shot from a bow; e.g., in a side-to-side or lateral direction.
in an anteroposterior direction) planes are a parallel • Vertical axis (longitudinal axis). A vertical axis
brush (dégagé) to the front; torso “contractions”; runs in a superior-inferior direction, perpendicular
raising the arm from a position down by the side, to a horizontal plane and allowing motion in a hori-
forward, to an overhead position (shoulder flex- zontal plane. For example, the vertical axis running
ion); a forward roll; a forward leap; and performing through the spine (from top to bottom) allows the
a triplet moving forward. These can be thought of movement of trunk rotation in the horizontal plane.
as movements of body segments (an example for the Examples of dance movements occurring primarily
torso is provided in figure 1.11A) or the whole body in horizontal planes are a torso twist (figure 1.11C),
in primarily a forward and backward direction. turnout (hip external rotation), a turn (pirouette),
• Anteroposterior axis (sagittal axis). An antero- and a turning jump. These can be thought of as
posterior (AP) axis runs in a front-to-back direction movements of body segments or the whole body in
in a sagittal plane, perpendicular to a frontal plane a twisting or turning manner.
and allowing motion in a frontal plane. For example,
the AP axis running through the shoulder allows the Students new to anatomical terminology often do
movement of raising the arm to the side (shoulder well at picturing these planes relative to anatomical
abduction) in a frontal plane. Examples of dance position as shown in figure 1.9, but have difficulty under-
movements occurring primarily in a frontal plane standing how these planes correlate with functional
A B C
FIGURE 1.11 Dance vocabulary showing movement of the trunk in the (A) sagittal, (B) frontal, and (C) horizontal plane.
movement. To aid with this understanding, it is first the exception of gliding joints, all synovial joints
important to remember that these planes are in ref- can permit two or more of the following six basic
erence to the body. So, if you turn the entire body, joint movements: flexion, extension, abduction,
these planes shift without any consideration for the adduction, external rotation, and internal rota-
space in which you are standing. Hence, a parallel tion. The logic of these terms is best seen relative
back attitude would be in the sagittal plane whether to anatomical position. As with position terminol-
you were facing the front of the room, the side of the ogy, these terms occur in pairs that have opposite
room, or the front diagonal of the room. Second, it meanings. The pairings for movement terminology
is important to realize that with most joints key to are flexion-extension, abduction-adduction, and
the study of human movement, motion involves rota- external rotation-internal rotation. Each of these
tion of one bone relative to another bone (angular pairs reflects movement that occurs in the same
motion). Because bones are secured relative to other plane and about the same axis, but in the opposite
bones at joints, the bones rotate about this joint direction. For example, flexion-extension could be
when they receive force (see Muscles, Levers, and reflected by bringing the arm to the front (shoulder
Rotary Motion on p. 44 for more information). So, flexion) or bringing the arm back (shoulder exten-
to establish the plane of motion, picture the imagi- sion), with both movements occurring in the sagit-
nary surface that the entire rotating bone segment is tal plane about an ML axis. A description of these
sweeping along. It sometimes helps to imagine that fundamental movements follows, and a summary is
you had chalk on that segment and then imagine provided in table 1.8.
what plane the segment would “draw.” For example,
when you are standing in anatomical position and • Flexion (L. flecto, to bend) involves bringing
lifting the thigh to the front and then back down, anterior surfaces toward adjacent anterior surfaces,
the thigh segment “draws” a sagittal plane as seen in or posterior surfaces toward adjacent posterior sur-
figure 1.13. In contrast, when you are lifting the leg
to the side and then back down, the thigh segment
“draws” a frontal plane as seen in figure 1.14. Lastly,
when you are rotating the leg along the long axis of
the femur, the end of the leg (e.g., the foot) “draws”
a horizontal plane as seen in figure 1.16.
Planes and Axes in Complex Movement

Understanding these three reference planes and associ-
ated axes is very helpful for analyzing movement. How-
ever, it is important to realize that joint axes are often
complex and involve subtle shifts in different ranges of
motions. Therefore, the concept of reference axes is
not exact but rather provides a useful approximation
helpful for picturing movement. Furthermore, many
complex dance movements utilize several planes with
different body segments and often involve planes
between the sagittal, frontal, and horizontal planes.
For example, aesthetics are often enhanced through
addition of rotation to the trunk when it is arched or
tilted rather than vertically positioned (figure 1.12).
Planes other than the basic sagittal, frontal, and
horizontal planes are termed diagonal, or oblique,
planes. In such cases the axis is perpendicular to the
particular diagonal plane and different from the
three reference axes previously described.
Joint Movement Terminology FIGURE 1.12 Dance vocabulary showing movement of

the trunk that does not occur in the basic planes, but
The movements at joints about the axes and in the rather in diagonal planes.
planes just described have specific names. With CSULB dancer Jennifer Fitzgerald.
TABLE 1.8 Joint Movement Terminology
Name Definition
Basic movements
Flexion Bringing the anterior or posterior surface of a body segment toward the anterior or posterior surface
of an adjacent body segment (bending)
Extension Moving from a flexed position toward the anatomical position (straightening)
(Hyperextension) Moving in extension past the anatomical position
Abduction Moving away from the midline of the body
Adduction Moving toward the midline of the body
(Circumduction) Describing a cone with the apex at the joint; combines flexion, abduction, extension, and adduction
External rotation Turning anterior surface outward
Internal rotation Turning anterior surface inward
Specialized movements
Right lateral flexion Side-bending of the trunk to the right or moving from a position of left lateral flexion toward
(spine) anatomical position
Left lateral flexion Side-bending of the trunk to the left or moving from a position of right lateral flexion toward
(spine) anatomical position
Right rotation (spine) Turning the anterior surface of the head or trunk to the right
Left rotation (spine) Turning the anterior surface of the head or trunk to the left
Pronation (forearm) Turning the palm backward
Supination (forearm) Turning the palm forward
Horizontal abduction Movement of the limb away from the midline in a horizontal plane when the limb is flexed to a 90°
(shoulder and hip) position
Horizontal adduction Movement of the limb toward the midline in a horizontal plane when the limb is flexed to a 90°
(shoulder and hip) position
Dorsiflexion Bringing the toes and top of the foot up toward the shin (flexing the foot)
(ankle-foot)
Plantar flexion Bringing the toes and bottom of the foot downward (pointing the foot)
(ankle-foot)
Inversion (foot) Lifting the medial portion of the foot upward
Eversion (foot) Lifting the lateral portion of the foot upward
faces. In most joints, such as the spine, hip, elbow, • Extension (L. extensio, to stretch out) is the
wrist, or joints between the digits of the fingers opposite motion to flexion, although occurring in
(interphalangeal joints), it is the anterior surfaces the same sagittal plane and around an ML axis as
of the segments that are brought closer together or seen in figure 1.13. Extension can be described as
“approximated” with flexion. For example, bring- bringing anterior surfaces away from adjacent ante-
ing the front of the forearm toward the front of the rior surfaces, or posterior surfaces away from adjacent
upper arm is elbow flexion. However, with selected posterior surfaces, back toward anatomical position. It
joints, such as the knee, it is the posterior surfaces can also be thought of as increasing the angle between
of the segments that are approximated with flexion. adjacent bones or, colloquially, as “straightening” the
Flexion is also sometimes described as decreasing the joint from a bent position. Straightening the knee
angle between two bones or, colloquially, as “bend- from a bent position during rising from a plié or exe-
ing” the joint. Flexion occurs in the sagittal plane cuting a développé is an example of knee extension.
around an ML axis as seen in figure 1.13. Straightening a joint beyond anatomical position is
FIGURE 1.13 Joint movements in the sagittal plane about a mediolateral (ML) axis: flexion-extension and plantar
flexion-dorsiflexion.
termed hyperextension. For some joints (such as the as seen in figure 1.14. Adduction can be described as
knee, elbow, or fingers), extension from anatomical returning the body segment back toward anatomical
position (hyperextension) is not possible except in position and the midline of the body. For example,
very flexible individuals. Hyperextension is not a new adduction would involve bringing the arm down to
movement but rather just a continuation of extension the side from an overhead position. To remember
beyond anatomical position, and in movement analy- this terminology it is helpful to associate adduction
sis the term extension encompasses hyperextension. with “add”ing that body part into the midline, while
Flexion-extension occurs in some uniaxial (hinge) to abduct someone means to unlawfully carry the
joints, all biaxial (condyloid and saddle) joints, and person “away.” So, to abduct a body segment is to take
all triaxial (ball-and-socket) joints. it “away” from the midline. Abduction-adduction
• Abduction (L. abducens, drawing away) involves occurs in all biaxial (condyloid and saddle) and
moving a segment of the body away from the median triaxial (ball-and-socket) joints but is not possible
plane or midline of the body. This movement is still in any uniaxial joint. Abduction-adduction occurs
considered abduction throughout its full range, even at such joints as the shoulder and hip.
if it seems to be coming back toward the midline in • Circumduction (L. circium, around + ductus,
its excursion beyond 90° (e.g., raising the arm to the to draw) is not a new movement per se, but rather
side and continuing to an overhead position when a compound movement that simply combines the
bringing the arms to a high fifth position). Abduc- four basic movements just described while utiliz-
tion occurs in the frontal plane around an AP axis ing multiple planes. Circumduction is a sequential
as seen in figure 1.14. combination of flexion, abduction, extension, and
• Adduction (L. ductus, to bring toward) is the adduction (in that order or in the reverse order). In
opposite motion to abduction, although it still circumduction, the body segment describes a cone,
occurs in the same frontal plane around an AP axis with one end of the segment making a circle (base
FIGURE 1.14 Joint movements in the frontal plane about an anteroposterior (AP) axis: abduction-adduction and right
lateral flexion-left lateral flexion.
of the cone) while the other end stays stationary

(apex of the cone). For example, circumduction of
the shoulder occurs when you trace a circle with your
middle finger as seen in figure 1.15B.
• External rotation involves moving the anterior
surface of a limb outward or away from the midline of
the body. It is also termed lateral rotation or outward
rotation and is the primary motion used at the hip to
establish turnout. External rotation occurs in a horizon-
tal plane around a vertical (longitudinal) axis through
the body segment as seen in figure 1.16. The fact that
a longitudinal axis is involved is important for under-
standing rotation, as well as the difference between
rotation and circumduction. For rotation, both ends
of the segment stay at the same point in space and the
segment just twists along the long axis. For example,
rotation of the shoulder occurs when the entire arm is
twisted while the middle finger stays at the same place FIGURE 1.15 Distinguishing between shoulder rotation
rather than making a circle (circumduction), as shown and circumduction. (A) Rotation involves twisting along the
in figure 1.15A. In dance, external rotation of the hip longitudinal axis of the limb with the middle finger rotating
occurs during turning out from a parallel first position. in place, while (B) circumduction involves a cone-shaped
In contrast, circumduction of the hip is utilized when movement path with the middle finger tracing a circle.
FIGURE 1.16 Joint movements in the horizontal plane about a vertical axis: internal rotation-external rotation, pronation-
supination, right rotation-left rotation, and horizontal abduction-adduction.
the dancer performs a circling motion with the foot on usually used for certain joints in an effort to clarify
the floor (circular portion of rond de jambe à terre). the direction of movement or to describe movement
• Internal rotation is the opposite motion to exter- that is slightly different from the six basic movements
nal rotation, although still in the horizontal plane and just discussed. For example, since the midline runs
about a longitudinal axis through the body segment as through the head and trunk segments, much of the
seen in figure 1.16. Internal rotation involves bringing basic terminology does not work well for describing
the anterior surface of the limb inward, toward the movements of the spine. Hence, during bending
midline of the body, such as is used in jazz dance when the torso to the side in the frontal plane, abduction-
the thigh is rotated inward so that the knee faces medi- adduction does not clearly describe what is occur-
ally. It is also termed medial or inward rotation. Unlike ring, and right or left lateral flexion is alternatively
what occurs with some of the other movement pairs used. So, right lateral flexion is the movement of
discussed, the limb can readily be either internally bending the torso to the right, while returning from
or externally rotated from anatomical position, and this position to anatomical position or bending to
anatomical position is often regarded as the neutral the left is termed left lateral flexion as seen in figure
position. External-internal rotation occurs in some 1.14. Similarly, external and internal rotation in the
uniaxial (pivot) joints and all triaxial (ball-and-socket) transverse plane are not adequate characterizations
joints. External rotation-internal rotation occurs at for the spine or head, and rotation is described as
such joints as the shoulder and hip. right or left rotation from the perspective of the
dancer who is moving. So, right rotation is movement
Specialized Joint Movement Terminology of the anterior surface of the head or trunk so that
it faces right, while left rotation is movement of the
At some joints, additional terminology is used to anterior surface of the head or trunk so that it faces
describe motions. This specialized terminology is left as seen in figure 1.16.
CONCEPT DEMONSTRATION 1.1
Fundamental Joint Movements
While standing in anatomical position, perform the following movements.

• Movements in the sagittal plane. Perform flexion of the fingers, wrist, elbow, shoulder, and hip
joints in which the distal segment is the moving segment. Note that this involves forward movement of
the distal segment of the joint from anatomical position in a sagittal plane such that anterior surfaces
of the joint segments are approximating. Then, extend these joints, returning to anatomical position.
Note that this occurs in a backward direction in a sagittal plane. Can these joints be extended from
anatomical position? Now flex the knee joint. Note that although movement occurs in a sagittal plane,
flexion of the knee involves a backward movement of the distal segment with posterior surfaces of the
segments approximating, while extension involves a forward motion. In some cases, such as when the
hand or foot is weight bearing and fixed, the proximal segment moves alone or simultaneously with
the distal segment. Perform flexion of the hip in which the proximal segment moves and the distal
segment remains stationary.
• Movements in the frontal plane. Perform abduction of the shoulder and hip joints in which the
distal segment of the limb (hand and foot) is allowed to move. Note that these movements involve
movement from anatomical position away from the midline of the body in a frontal plane. Then,
adduct these joints, returning to anatomical position. Note that adduction of these joints involves
a movement toward the midline of the body in the frontal plane. Can these joints be adducted from
anatomical position? Now perform abduction and adduction of the hip joint in which the foot is fixed
and the pelvis is the moving segment. How do these movements relate to the dance terminology
“sitting in your hip”?
• Movements in the horizontal plane. Perform internal rotation of the shoulder and hip joint in
which the distal segment (hand and foot) is free to move. Note that this involves movement of the
anterior surface of the limb toward the midline in a horizontal plane. Then, perform external rotation
of the shoulder and hip, returning back to anatomical position. Can external rotation be performed
from anatomical position? Note how similar amounts of internal and external rotation can occur from
anatomical position, in contrast to the other movement pairs. How do these movements relate to the
dance terminology “turnout”? Now perform rotation at the hip joint in which the pelvis moves while
the foot remains fixed.
In the upper extremity, two specialized move- extension. Movement in the opposite direction from
ment pairs are used to describe movements in the a lateral position anteriorly (toward the midline of
horizontal plane about a vertical axis: pronation- the body) is termed horizontal adduction or hori-
supination and horizontal abduction-adduction (see zontal flexion.
figure 1.16). Pronation refers to internal rotation of In the lower extremity, this same terminology
the forearm so that the palm faces backward while of horizontal abduction-adduction can be used for
supination refers to external rotation of the forearm movements of the thigh in the horizontal plane
so that the palm faces forward. Anatomical position from a position of 90° of hip flexion. With the foot,
utilizes a position of forearm supination. Horizontal terminology of plantar flexion and dorsiflexion is
abduction-adduction is terminology that has been used in place of flexion-extension due to the con-
developed because of the common use of the arms troversy regarding which side of the foot should be
at shoulder height during functional movement. If considered “anterior.” Plantar flexion of the foot at
the arm is flexed to a 90° position at the shoulder the ankle joint corresponds to what dancers term
joint, movement of the arm laterally in the horizontal “pointing” the foot, while dorsiflexion corresponds
plane is termed horizontal abduction or horizontal to what dancers term “flexing” the foot. So, remember
that “P” in pointing goes with “P” in plantar flexion. saddle joints are biaxial joints allowing movement in
These movements occur in the sagittal plane around two planes (2df). Condyloid joints generally allow
an ML axis as seen in figure 1.13. Additional spe- flexion-extension in the sagittal plane and abduction-
cialized terminology for both the upper and lower adduction in the frontal plane (although specialized
extremity is addressed in chapters covering the terminology is used for some of these movements).
respective joints. For the saddle joint (first carpometacarpal joint),
specialized movement terminology is used that will
Joint Movements Associated be addressed in chapter 7. The ball-and-socket joint
With Specific Types of Synovial Joints is the only type of triaxial joint, allowing move-
ment in three planes (3df). Movements allowed
Now that planes, axes, and joint movement termi- are flexion-extension in the sagittal plane, abduc-
nology have been covered, the movement capacity tion-adduction in the frontal plane, and external
of synovial joints can be added to their shape-based rotation-internal rotation in the horizontal plane.
description. Synovial joints can be subclassified Notice that triaxial joints differ from biaxial joints
according to whether they have one, two, three, or through the addition of rotation. The association of
no axes—uniaxial, biaxial, triaxial, and nonaxial, movement capacity and joint type is summarized in
respectively. The number of axes a joint has also table 1.4 (p. 16).
parallels the number of planes in which that joint
allows motion, which is termed degrees of freedom Skeletal Considerations
(df) and determines the types of movement allowed
from anatomical position. in Whole Body Movement
Gliding joints are considered nonaxial joints as Additional concepts come into play when one
they allow only slight gliding or sliding motion that examines the contribution of bones and joints to
does not occur about an axis. Hinge and pivot joints functional movements such as those used in danc-
are uniaxial joints allowing movement in one plane ing. Three particularly key considerations are joint
(1df). Hinge joints allow the movements of flexion- stability and mobility, close-packed and loose-packed
extension in the sagittal plane, while pivot joints positions of joints, and closed and open kinematic
allow rotation in the horizontal plane. Condyloid and chain movements.
Types of Synovial Joints and Their Movements
While standing in anatomical position, identify the following joints and perform their movements. Refer
to figure 1.9 as needed.
• Uniaxial joints. Perform the movements of the forearm that are allowed by the elbow joint. What
type of synovial joint is it? In what plane and about what axis does movement of this joint occur? Now,
perform movements of the forearm that are allowed by the upper radioulnar joint. In what plane and
about what axis does movement of this joint occur?
• Biaxial joints. Perform the movements of the hand that are allowed by the wrist joint. What type
of synovial joint is it? In what two planes and about what two axes does movement of this joint occur?
Now, perform movements of the thumb and note similarities and differences from the wrist joint. Can
either of these joints be actively rotated?
• Triaxial joints. Perform the movements of the upper arm that are allowed by the shoulder joint.
What type of synovial joint is it? In what three planes and about what three axes does movement
of this joint occur? How does rotation differ from circumduction? What plane is utilized with triaxial
joints that is missing with biaxial joints? How does this combination of uniaxial, biaxial, and triaxial
joints further the stability and mobility demands of the upper extremity in gestural movements and
weight-bearing movements in dance?
Close- and Loose-Packed Joint Positions
• Loose-packed position of the fingers. While sitting, bend your elbows to 90° with your palms
facing upward and the fingers in line with the metacarpals. Spread the fingers and then bring them
back in. Note the degree of abduction and adduction of the fingers that can occur in this loose-packed
position of the metacarpophalangeal joint.
• Close-packed position of the fingers. Bring the fingers up to face the ceiling while keeping the
rest of the hand in place (90° of metacarpophalangeal joint flexion). Now, try to spread the fingers
and notice how limited abduction and adduction of the fingers are in this close-packed position of
the metacarpophalangeal joints. What advantages could the change in mobility present in different
positions offer functions performed by the hand?
Joint Stability and Mobility Close-Packed and

Loose-Packed Positions of Joints
Joint stability can be defined as the ability of a
joint to withstand forces and avoid being separated Joint stability is also influenced by the specific posi-
(disarticulated) without injury. This is a very impor- tion of a given joint, and articulating surfaces of
tant property of joints, from a perspective of both synovial joints have a position that offers the great-
defining movement capacity and promoting safety. est mechanical stability. This position is termed
When forces exceed the stability of a joint, injury to the close-packed position and often occurs at the
the various tissues can occur. Two common types of extreme in the range of motion, such as full exten-
injury are injury to the ligament, termed a sprain, sion of the elbow, knee, wrist, or fingers (interpha-
and injury to the muscle, termed a strain. langeal joints); flexion of the metacarpophalangeal
In contrast to joint stability, joint mobility can joints; and dorsiflexion of the ankle. In this close-
be defined as the range of motion allowed prior to packed position the following conditions generally
tissue restraints. The functional capacity of joints to occur: (1) The joint surfaces have the greatest con-
move through a full range of motion, also termed tact area and fit (congruency); (2) a majority of key
flexibility, is an important aspect of physical fitness ligaments are under tension; (3) the capsule is taut;
and essential for allowing the achievement of dance and (4) the joint is under compression and difficult
aesthetics. Key factors that influence relative joint to separate (Smith, Weiss, and Lehmkuhl, 1996).
stability versus mobility include the joint architec- In close-packed positions stability is facilitated, and
ture (type of joint, shape and depth of articulation); often little or no muscular contraction is required
arrangement of the ligaments and capsule; vacuum to maintain the position during weight bearing. This
created in the joint due to the negative atmospheric offers advantages in terms of energy expenditure
pressure; extensibility of the muscles, tendons, and that can be very valuable in positions such as upright
fascia crossing the joint; neural factors that influence standing. In all other positions, the joint surfaces
the resistance to movement; effects of gravity; and, have less contact and are termed loose-packed. In
in some cases, occlusion of adjacent soft body parts loose-packed positions key capsular and ligamental
or impingement of bone against bone. These factors structures are slack, and motion, rather than joint
are discussed in more detail and as they relate to spe- stability, is facilitated.
cific key joints in subsequent chapters. However, it is
important to note that although dancers often imag- Closed and Open
ine that continuing to increase joint mobility should Kinematic Chain Movements
be their goal, excessive mobility can be associated
with decreased stability and increased injury risk. In the human body many joints occur in series and
Instead, the goal should be a balance of joint stability often their movements occur together, rather than
and mobility, which will allow for protection of joints in isolation. This has led to the use of the engineer-
while still meeting desired dance aesthetics. ing term “closed kinematic chain,” in which a series
DANCE CUES 1.2
“Stand So That Your Bones Support Your Weight”
S ome forms of modern dance encourage students to achieve standing alignment emphasizing
support by bones and minimizing muscle contraction to maintain an upright position. Although
standing involves many joints, for simplicity we focus on the knee at this point. During standing with
the knees straight, a close-packed position of the knee is present, allowing the bones and passive con-
straints to primarily create stability. However, if the knees are bent either in a standing position or to
begin a movement, muscle contraction is immediately required to prevent the knees from buckling.
While some schools of dance that emphasize efficiency favor this cue and a more passive approach
with standing, other schools prefer a more active stance (“pulling up on the knees”) utilizing slight
levels of muscle contraction as discussed in chapter 5.
of rigid links are interconnected by a series of pin- performing weight-supported positions like a hand-
center joints such that motion of one link will pro- stand. In dance, the lower extremity is commonly
duce predictable motion in the other joints of the used both as a closed and as an open kinematic
system (Levangie and Norkin, 2001). In the human system, often changing in different phases of the
body, a kinematic chain (G. kinēmatica, things that movement or between sides of the body. An example
move) is represented by a series of joints that link of the former is in a stag leap: Prior to the takeoff the
successive body segments or bones. The concept of lower extremity is working in a closed manner, while
a closed kinematic chain, or closed kinetic chain, is in the air the legs are acting as an open kinematic
operative when the distal segment is fixed while the chain. An example of the latter occurs at the barre;
proximal segments move, such as when one is in an the support leg is working in a closed manner, while
erect weight-bearing position. In this case, when the gesture leg is often working as an open kinematic
the knee bends, simultaneous motion in the ankle chain as seen in figure 1.17.
and hip also occurs. In contrast, when the distal seg- The concept of kinematic chains has important
ment moves in space, such as in performing brushes implications for understanding movement, injury,
(dégagés), motion at the hip can occur in isolation, and rehabilitation. In terms of movement, one
without necessarily involving motion of the knee. This important implication has to do with the potential
is termed an open kinematic chain, or open kinetic movement allowed by the whole limb. The total
chain, movement. With this type of movement, the degrees of freedom available for the performance of
motion of adjacent joints is not predictable, as they a multijoint movement is considered the summation
may move either independently or together. of the degrees of freedom derived from all adjacent
In dance, the upper extremity is more commonly joints in the chain. So, for example, kicking a ball
used in an open kinematic chain manner such as could be considered to involve an 11-degree-of-
when the dancer is making gestural movements. freedom system relative to the trunk, with 3df derived
However, when used in an open manner, there is from the hip, 2df from the knee, 1df from the ankle,
often a required linking of segments to achieve the 3df from the tarsals, and 2df from the toes (Hamill
desired aesthetic for use of the arms. This aesthetic and Knutzen, 1995). This summation concept is
often varies markedly between different dance forms essential to allow for the complex movements and
and even different choreography within the same adjustments required by dance. Implications for
dance form. Less frequently the arms are used in injury and injury rehabilitation is addressed in fol-
a closed kinematic manner, such as when one is lowing chapters.
Closed and Open Kinematic Chain Movements
Begin standing in fifth position with the arms in low fifth, and perform the following movements, dis-
tinguishing between open and closed kinematic chains.
• Lower extremity movement. Plié and then bring the left foot up to touch the right knee (retiré).
The right leg is working as a closed kinematic chain. How is the left leg working? How does the con-
cept of open and closed kinematic chains relate to the terminology of the support and gesture leg
used in dance?
• Upper extremity movement. Bring the arms overhead, from low to high fifth position. What type
of kinematic chain does the arm movement represent? How could arm movement be changed in dance
to create a condition in which the distal segment is fixed?
Summary
The skeletal system is composed of the bones of the
body, the related cartilages and ligaments, and the
joints that connect these bones together. Bones can
be classified according to their shape as long, short,
flat, and irregular bones. Their shape is in accor-
dance with their functions of providing support,
protection, sites for muscle attachments, and levers
for movement. Although bones have great compres-
sive and tensile strength, they are constantly being
remodeled in accordance with applied stresses and
the availability of calcium and other key nutrients.
A total of 206 bones come together to form the
skeleton. The skeleton can be divided into the axial
skeleton and the appendicular skeleton (upper
extremity and lower extremity), and adjacent bones
within these divisions are connected by fibrous, carti-
laginous, or synovial joints. Synovial joints contain a
joint cavity and primarily give rise to the movements
we associate with the limbs. These synovial joints can
be further classified according to their shape and
the number of axes and planes of movements they
allow. Standardized terminology has been developed
to clearly describe the planes, axes, and associated
movements of joints. In functional movement, joints
serve dual functions of stability and mobility. The
demands of these opposite functions can in part be
met by the change in stability offered by close- and
FIGURE 1.17 Open and closed kinematic chain move- loose-packed positions. In functional movement,
ments. The foot of the support leg is fixed on the joints often work in conjunction with other joints,
ground, and the right leg is functioning as a closed kine- rather than in isolation. The concepts of open and
matic chain. In contrast, the left foot and the left hand closed kinematic chains help describe the potential
are free to move, and hence these limbs are functioning linkings of adjacent joints.
as open kinematic chains.
Maurya Kerr as a student at Pacific Northwest Ballet School.
Study Questions and Applications

1. Describe how long bones grow in width and in length.
2. List and locate, on your own body, the bones that constitute the (a) axial skeleton, (b) upper
extremity, and (c) lower extremity.
3. Classify each of the bones that constitute the lower extremity as long, short, flat, or irregu-
lar.
4. Standing in anatomical position, demonstrate three dance movements that occur in each of
the following planes: sagittal, frontal, and horizontal.
5. Review the joint movements described in table 1.8 and select two movements from dance that
exemplify each of these joint movements.
6. Draw a typical synovial joint and label its components. Then, describe the function of each
of these components.
7. Contrast and compare the types of joints found in the upper extremity and lower extrem-
ity.
8. Describe how the presence of loose- and close-packed positions of the joints could be helpful
to meet differing movement demands of joints required by dance.
9. Design a movement sequence that incorporates both open and closed kinematic chain move-
ments for the hip, knee, and ankle. Identify when these joints are working in an open and a
closed kinematic chain.
10. A dancer has been having a difficult time performing a pushing movement of the arm with
the desired aesthetic. Her teacher has noted that her movement looks “jerky” and lacks the
desired smooth coordination.
a. Describe what joint motions should be occurring at the shoulder, elbow, and wrist.
b. Describe how the idea of a kinematic chain relates to this movement.
c. Describe how the movement aesthetic would be different under the following conditions:
1. Sequential movement starting from the distal and proceeding to the proximal joint
2. Sequential movement starting from the proximal joint and proceeding to the distal
joint
3. Movement beginning at the elbow, followed by movement at the other two joints
4. Simultaneous movement at all three joints so that the end position of each joint is
reached at the same moment
d. Identify appropriate cues that could be utilized to try to implement the desired technique
adjustments.
System
The Muscular
CHAPTER TWO
33
© Angela Sterling Photography. Pacific Northwest Ballet dancer Carrie Imler.
I n this chapter we examine the muscular system. It

is the muscular system that produces movements
of the skeletal system. We could not walk or dance
light microscope, smooth muscle cells appear long,
narrow, and spindle shaped, with a single central
nucleus. The cells are very closely aligned to form
without the motive force provided by our muscles. sheets, and as their name suggests, lacking in cross-
Muscles have a unique ability to produce tension that striations. Smooth muscle contraction is not under
is translated to bones to produce joint movement. voluntary control; hence this type of muscle is termed
In addition, muscles can offer constraints to motion involuntary muscle. It also has the ability to maintain
when the limits of their extensibility are approached. tone and contract automatically, without stimulation
Hence, adequate flexibility, as well as strength, is from the nervous system.
essential for the expansive movements encompassed Cardiac muscle is the type of muscle found in the
in dance. The large leap (grand jeté en avant) shown walls of the heart. The contraction of cardiac muscle
in the photo on page 33 exemplifies these demands helps pump blood via blood vessels to the lungs and
for both muscular strength and flexibility to project other parts of the body. Under the light microscope,
the body through space and achieve the desired lines cardiac muscle fibers have bands, termed striations,
of the body segments. Learning about how muscles that run across the width of the cell. Cardiac muscle
work is key for understanding and describing human fibers are also short and branched with unique junc-
movement. Topics covered in this chapter include tions, termed intercalated discs, at the abutment
the following: of the ends of adjacent cells. Cardiac muscle cells
generally contain a single nucleus (uninucleate)
• Skeletal muscle structure and function but sometimes two (binucleate). Similar to smooth
• Microstructure of skeletal muscle and muscle muscle, cardiac muscle is not under voluntary
contraction control (involuntary), and due to specialized cells
• Muscle architecture (pacemaker cells) is able to contract automatically,
without stimulation from the nervous system.
• Muscle attachments to bone
Skeletal muscle is the type of muscle that attaches
• Muscles, levers, and rotary motion to the bones of the skeleton and gives rise to move-
• Types of muscle contraction (tension) ments at joints. Although influenced by gender, body
• Muscular considerations in whole body movement type, and activity, these muscles make up approxi-
mately 40% to 45% of an average adult’s body weight
• Learning muscle names and actions
(Hall, 1999). Under the light microscope, a skeletal
muscle cell is very long, narrow, and cylindrical, with
Skeletal Muscle Structure many cross-striations and many nuclei (multinucle-
ate). Unlike smooth and cardiac muscles, which
and Function generally work with little conscious control, skeletal
Muscle cells are the only cells capable of producing muscles are called voluntary because many can be
active tension and contracting. Contractility is the controlled at will. Unlike smooth and cardiac mus-
unique ability of muscle tissue to shorten. Some cles, they cannot contract automatically and instead
recent texts substitute “the ability to produce ten- rely on stimulation from a nerve. Skeletal muscles
sion” for “contractility,” since tension produced by are also important for the maintenance of posture
muscles does not always result in a shortening of and positions, stability of joints, shock absorption,
muscles (see Types of Muscle Contraction [Tension] support and protection of internal tissues, control of
on p. 50 for more information). It is this property of pressures within cavities, and production of body heat.
contractility that generates movement of the human Greater than 75% of the energy utilized with muscle
body, as well as allows for movements in the heart contraction is released as heat (McGinnis, 2005).
and other internal organs. There are three types of Because of its importance for human movement, this
muscle tissue—smooth muscle, cardiac muscle, and book focuses on skeletal muscle, and any further refer-
skeletal muscle—shown in table 2.1. Smooth muscle ence to muscle will be to skeletal muscle only.
forms part of the walls of hollow organs (e.g., blad-
der, uterus, stomach) and various systems of tubes Properties of Skeletal Muscle Tissue
(e.g., within the circulatory, digestive, respiratory,
and reproductive systems). Contraction of smooth In addition to contractility, skeletal muscle is char-
muscles helps move substances through organs acterized by the following properties: irritability,
(such as food through the stomach) and through extensibility, and elasticity. Irritability is the ability to
tubes (such as blood through arteries). Under a receive and respond to a stimulus, commonly from
TABLE 2.1 Three Types of Muscle Tissue
A. Smooth muscle B. Cardiac muscle C. Skeletal muscle

Appearance Closely aligned, long, spindle-shaped cells with Short, branching, generally uninucleate cells Very long, cylindrical, multinucleate cells
central nuclei that interdigitate at intercalated discs
Nonstriated Striated Striated
Location Walls of hollow organs and tubes Walls of heart Primarily attaches to bones and occasionally
to skin
Function Propels substances or objects through organs Propels blood through blood vessels Movement, posture, joint stability, shock
or tubes absorption, facial expressions
Control Involuntary Involuntary Voluntary
Automatic contractions Automatic contractions Requires nerve stimulation to contract
35
an associated nerve. The classic response of muscle These elastic components can be modeled as a
to this stimulus is to produce tension or contract. spring (figure 2.2), and mechanical energy that is
The properties of extensibility and elasticity can be stored in the elastic component of muscle when a
better understood if we look at a mechanical model stretch is applied can be recovered when the stretch
of muscle. is released (recoverable deformation), just as a spring
will quickly recoil to its unextended position when
The Mechanical Model of Muscle the tension is removed. These elastic components
give rise to muscle’s property of elasticity. Elasticity is
A three-component mechanical model has been the ability of a muscle to return to its resting length
developed to explain the behavior of muscle (figure after being stretched. In addition, the connective
2.1). The ability of muscle to contract resides within tissue associated with muscle has another property,
very small protein structures found within the muscle termed viscosity. Viscous or plastic properties are
cell that are further discussed in the next section of usually modeled by a hydraulic cylinder (dash pot)
this chapter. These structures are termed the contrac- as shown in figure 2.2 and reflect puttylike behavior,
tile component (CC) or active component of muscle. in which the elongation produced by a force remains
However, muscle also contains two elastic compo- after the force is removed (permanent deformation).
nents—the parallel elastic component and the series Together, the elastic and viscous properties of con-
elastic component. The contribution of these elastic nective tissue are termed viscoelastic, and it is this
components does not require active contraction, and viscoelastic response that gives rise to muscle’s prop-
hence they are also termed passive components. As erty of extensibility as seen in figure 2.3. Extensibility
its name suggests, the parallel elastic component or distensibility is the ability of muscle to be stretched
(PEC) lies parallel to the contractile component and or to increase in length beyond resting length. The
is composed of many structures including the con- average muscle fiber can be stretched 1.5 times its
nective tissue in muscle, the muscle cell membrane resting length (Hamilton and Luttgens, 2002). The
(sarcolemma), and an elastic protein closely associ-
ated with the contractile proteins of muscle (titin).
Conversely, the series elastic component (SEC) lies
in series with the contractile component and consists
primarily of the tendon (about 85%), with a much
smaller contribution from some of the structures
of the contractile component (Alter, 2004; Enoka,
2002; Kreighbaum and Barthels, 1996; Levangie and
Norkin, 2001).
FIGURE 2.1 Three-component mechanical model of FIGURE 2.2 Viscoelastic properties of connective
muscle. tissue.
The Muscular System 37
muscle cannot lengthen on its own; rather a force up to even 24 or 28 inches (60 or 70 centimeters)
such as gravity or the contraction of another muscle in length (Hamilton and Luttgens, 2002; Rasch and
is required to create this elongation. This character- Burke, 1978; Smith, Weiss, and Lehmkuhl, 1996).
istic of extensibility is key for allowing the dancer to Skeletal muscle fibers grow in both length and diame-
improve the range of motion permitted at a given ter from birth to adulthood, with a five times increase
joint—that is, flexibility. in diameter possible during this period (Hall, 1999).
The study of this viscoelastic characteristic of Strength training using heavy resistance and low
muscle has been instrumental in developing current repetitions can also result in substantial increases in
theories of muscle behavior and recommendations muscle cell diameter, termed hypertrophy (G. hyper,
for effective muscle conditioning programs such as over + trophy, nourishment).
those for improving flexibility. When a muscle and To understand how muscle cells are capable
its related connective tissue are stretched, elonga- of causing a contraction, it is necessary to look at
tion of both the elastic and viscous elements occurs. a single muscle cell on a microscopic level. Each
However, when the stretch is discontinued the elastic muscle fiber contains specialized protoplasm termed
elongation recovers, and only the plastic elongation the sarcoplasm, within which is embedded very thin
remains (Taylor et al., 1990). While the elastic ele- fibers called myofibrils (G. mys, muscle) that run
ments are influenced only by the magnitude of the the length of the muscle cell but are only about
applied force, the viscous elements are influenced four-millionths of an inch (1-2 micrometers) wide
by temperature, as well as the rate and duration of (Hamill and Knutzen, 1995). These myofibrils are
the applied forces. The behavior of this component arranged in a parallel formation within the muscle
can be compared to that of Silly Putty or stiff taffy. A cell and consist of still finer threads called myofila-
force (i.e., pulling the taffy apart) that is applied slowly ments (G. mys, muscle + L. filamentum, thread) that
and for a long duration, with the taffy warm, produces can be either thick (primarily containing the protein
greater elongation and less tendency for breaking. myosin) or thin (primarily containing the protein
Thus, to emphasize increases in flexibility that persist actin). These myosin and actin filaments exhibit dif-
over time, the goal is to maximize plastic elongation. ferent light properties under the view of a polarizing
This can be achieved by the use of a slow, lower-force, microscope and interdigitate in a manner that gives
longer-duration stretch applied to warmed muscles. rise to alternating dark and light bands, imparting
In terms of duration, three repetitions of a 30-second to skeletal muscle fibers their characteristic striated
stretch appear to provide most of the potential length appearance. As can be seen in figure 2.3, the lighter
changes associated with a given stretch (Garrett, I band contains only thin filaments (actin), while the
1991). Conversely, to emphasize greater force pro- darker A band contains thick filaments throughout,
duction of a muscle, the goal is to maximize elastic with thin filaments extending as far as the H zone.
elongation. This can be achieved through applica- The H zone of the A band contains only thick fila-
tion of a rapid, higher-force stretch, immediately ments (myosin) and is lighter than the other portion
preceding a shortening (concentric) contraction of of the A band. Each I band is bisected transversely by
the same muscle (see Stretch-Shortening Cycle on a Z line, and one end of each actin filament within
p. 54 for more information). this I band is attached to this Z line. These actin
and myosin filaments are organized in repeating
segments longitudinally that are termed sarcomeres.
Microstructure The sarcomere (G. sarco, muscular substance + meros,
of Skeletal Muscle part) is a compartment between consecutive Z lines
and is the functional unit of muscle contraction.
and Muscle Contraction
The structural unit of a muscle is the muscle cell. It The Sliding Filament Theory
has been estimated that the human body contains
approximately 270 million muscle cells (Wells and The most widely held theory of muscle contraction is
Luttgens, 1976). Because these muscle cells are long called the sliding filament theory (Huxley, 1969). As
and very thin, they are often called muscle fibers. An its name implies, this theory holds that the filaments
individual muscle cell generally has a diameter rang- just discussed are the mechanism by which muscles
ing from approximately 0.0004 to 0.004 inches (0.01 contract. Each myosin filament is surrounded by
to 0.1 millimeters). In contrast, many muscle cells six actin filaments. Myosin filaments contain cross-
range between 1 and 3 inches (approximately 2.5-7.6 bridges, and actin filaments contain active sites as
centimeters) in length, and select muscles may be shown in figure 2.3. When the muscle is not activated,
Thin (actin) filament
Thick (myosin) filament

Cross-bridge
Sarcomere
Z line H zone Z line
Thick (myosin) filament

Thin (actin) filament
I band A band I band
FIGURE 2.3 Microstructure of a skeletal muscle fiber.

Reprinted, by permission, from R.S. Behnke, 2006, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), p. 14.
the active sites on the actin are blocked. The sliding

filament theory holds that activation of a muscle
causes a release of calcium from within the muscle
fiber. This calcium release changes the configuration
of protein molecules (troponin and tropomyosin) so
that the active sites on actin are exposed and become
available for the myosin cross-bridges to attach to.
This attachment, termed coupling, triggers a split-
ting of the energy molecule adenosine triphosphate
(ATP), producing rapid “flexion” of the myosin
cross-bridge, which pulls the actin filaments a short
distance toward the center of the sarcomere. The
cross-bridge then uncouples, and retracts, and the
myosin is recharged with another molecule of ATP.
It is now ready to react with another active actin site.
In this process of cross-bridge coupling, flexion, and
uncoupling, the Z lines are drawn in toward the A
bands, and the H zone narrows or even disappears
as seen in figure 2.4.
Although the amount of shortening of each sar-
comere unit is small, the cumulative effect of short-
ening of the many sarcomere units in series can be
marked. For example, a muscle fiber similar in length
to that of the biceps brachii has been estimated to have
about 40,000 sarcomere units in series; and the sum
effect of their shortening would be approximately
1.6 inches (4 centimeters), equivalent to about
40% of the length of the muscle from its position at
rest (Smith, Weiss, and Lehmkuhl, 1996). These cou- FIGURE 2.4 Schema of muscle contraction. (A) Resting
pling, flexion, uncoupling, retraction, and recharg- state, (B) slight contraction, (C) greater contraction.
ing processes, known as cross-bridge cycling, are
repeated hundreds of times in a second to produce In contrast, Type IIb fibers favor energy systems
the shortening of the sarcomere associated with that do not depend on oxygen (anaerobic pathways)
muscle contraction. And the amount of tension and are characterized by having the fastest contrac-
generated by a muscle depends on the average tion time, the largest diameter, and the greatest force
number of links between actin and myosin at a given production, but the greatest fatigability of all fiber
moment. types. These fibers are particularly important for
As soon as activation of the muscle fiber ends, carrying out short-duration, high-intensity muscle
calcium is rapidly pumped from the vicinity of the contractions such as used with weight training or
myofilaments. This drop in calcium concentration with sprint or power events such as the 100 m dash.
restores the blocking of the sites on actin, returning Lastly, Type IIa fiber properties lie between those of
the filaments to their relaxed, “resting” state. Type I and Type IIb fibers, with generally a slightly
slower contraction time, smaller diameter, and less
Muscle Fiber Type force production, but a higher resistance to fatigue
than Type IIb fibers. Type IIb fibers become key when
Although all muscle fibers are capable of contract- a limited endurance element is added to activities,
ing as just described, there are some important dif- such as with running a mile. Because the character-
ferences in their contractile properties and energy istics of Type IIa fibers are in between those of Type
use that are reflected by their classification into two I and Type IIb fibers, some texts list their charac-
basic types—slow-twitch (Type I) and fast-twitch teristics as intermediate. However, because many of
(Type II) (American College of Sports Medicine these characteristics are still closer to those of Type
[ACSM], 2001). Type II fibers can be further divided IIb than Type I fibers, other texts list many of their
into two major subtypes: Type IIa and Type IIb. characteristics as the same as those of Type II. This
A third subtype has been identified but appears to text combines these approaches to reflect character-
occur infrequently, and its characteristics are still istics more closely aligned to Type IIb (hence their
under investigation (Wilmore and Costill, 2004). name) but different in the direction of Type I fibers
Hence, it will not be further addressed in this text. as seen in table 2.2.
Type I fibers emphasize energy systems that utilize Although most human muscles contain both
oxygen (aerobic metabolism), allowing them to slow-twitch and fast-twitch fibers, different propor-
remain active for prolonged periods. Type I fibers tions exist in line with functional demands. For
have a slower contraction time and smaller cross- example, the gastrocnemius is used predominantly
sectional area, and produce less tension, but have for powerful activity such as jumping and has about
a higher resistance to fatigue than Type II fibers. 50% fast-twitch and 50% slow-twitch fibers in the
These fibers are particularly important for carrying average individual. In contrast, in the soleus muscle,
out sustained contractions or repetitive low-intensity which is used in more sustained activity and serves
muscle contractions such as those used with pos- key postural functions, the proportion of slow-twitch
ture, walking, or endurance events (e.g., running fibers may be as great as 85% (Smith, Weiss, and
a marathon). Lehmkuhl, 1996). The difference in the role of
TABLE 2.2 Skeletal Muscle Fiber Characteristics
Muscle fiber type

Characteristics Type I Type IIa Type IIb
Muscle fiber diameter Small Intermediate/large Large
Color Red (dark) Red White (pale)
Contractile speed Slow Fast Fast
Force production Low Intermediate/high High
Fatigue resistance High Moderate Low
Energy efficiency High Intermediate/low Low
Aerobic capacity High Moderate Low
Anaerobic capacity Low High Highest
such muscles has led to the use of the terms tonic or Muscle Cross-Sectional Area
postural to describe muscles that have a greater pres-
ence of slow-twitch fibers and phasic or nonpostural Basically, a muscle with more muscle fibers will be
to describe muscles that have a greater presence of capable of producing more force than one with fewer
fast-twitch fibers. fibers. Muscle fibers usually lie parallel to each other,
In addition to varying between muscles, percent- and so the cross-sectional area reflects to some degree
ages of slow-twitch fibers and fast-twitch fibers differ the number of fibers and relates to force production.
between individuals. Most sedentary individuals have Although this idea of a direct relationship between
a similar proportion of fast-twitch and slow-twitch cross-sectional area and the number of muscle fibers
fibers in many muscles. However, since fast-twitch is complicated by different fiber arrangements and the
fibers are important for generating fast, powerful fact that different fibers have different diameters due
muscle contractions, athletes like sprinters gen- to fiber types and hypertrophy, the concept still holds
erally have high proportions of fast-twitch fibers that a larger muscle with a greater cross-sectional
(55-75%). In contrast, since slow-twitch fibers are area can produce more force than a smaller muscle
important for producing repetitive contractions with a smaller cross-sectional area. So, for example,
without fatigue, endurance athletes such as distance the gluteus maximus can produce more force than
runners have high proportions (60-90%) of slow- one of the hamstring muscles, in part due to a greater
twitch fibers (Powers and Howley, 1990; Takashi, cross-sectional area. Furthermore, strength training
Kumagai, and Brechue, 2000). For example, the will generally cause an increase in the cross-sectional
gastrocnemius muscle in some elite sprint runners area within the same muscle (hypertrophy) and will
has been shown to be composed of 73% fast-twitch allow for greater force production.
fibers while the gastrocnemius in elite female dis-
tance runners contained 69% slow-twitch fibers
Fiber Arrangement
(Wilmore and Costill, 2004). Ethnicity may also be a
factor. For example, individuals of African American Muscle fibers in a whole muscle occur in two primary
descent have been shown to have a higher percent- arrangements—fusiform and penniform—with many
age of fast-twitch fibers than individuals of Caucasian variations within each of these types. With fusiform
descent (ACSM, 2001). (L. fusus, spindle + forma, form), also termed longitu-
How much of this composition of fibers is geneti- dinal arrangements, muscle fibers run close to paral-
cally determined and how much of it can be changed lel with the muscle’s long axis as seen in figure 2.5A.
by training is still an area of controversy. At this point This structure allows for relatively few fibers per unit
it appears that genetics is the most fundamental area, and so offers a disadvantage in terms of force
determinant of quantity and distribution of fibers, production capacity. However, in this arrangement
but heavy training may alter some of the proper- muscle fibers are generally longer, and so there is an
ties of given fibers to allow them to better meet the advantage in terms of how much shortening of the
demands produced by the specific training regime muscle can occur. When sarcomeres are fully con-
(Gordon and Pattullo, 1993; Nieman, 1999; Wilmore tracted, they can reduce the length of a muscle fiber
and Costill, 2004). So, for example, dancers who by 30% to 70% of its original resting length, with the
genetically have a higher percentage of fast-twitch average muscle fiber shortening about 50% (Hamill
fibers may be able to naturally generate more force and Knutzen, 1995; Levangie and Norkin, 2001; Pitt-
and potentially jump higher, while dancers with Brooke, 1998). So, for example, a 50% shortening
higher percentages of slow-twitch fibers may have of a muscle fiber of the sartorius, which is about
advantages in adagio or repetitive movements such 17.6 inches (448 millimeters) long (Enoka, 2002),
as relevés. However, with appropriate training, all would represent about 8.8 inches (224 millimeters)
dancers can improve their ability to some degree to of shortening; 50% shortening of the vasti muscle
meet specific dance demands. fibers (penniform muscles), which are about 2.8
inches (72 millimeters) long, would only represent
Muscle Architecture a decrease in length of about 1.4 inches (36 millime-
ters). Furthermore, due to the lengthwise arrange-
In addition to fiber type, the architecture of a given ment of fibers, shortening of fibers translates into
muscle is important for meeting specific demands. almost equivalent shortening of fusiform muscles as
Two architectural characteristics that are particularly a whole. Hence, muscles with such an arrangement
important are muscle cross-sectional area and fiber favor moving the limbs through space with greater
arrangement. range or speed. Examples of fusiform muscles are
FIGURE 2.5 Muscle fiber arrangement. (A) Fusiform, (B) penniform.
the biceps brachii, pectineus, adductor brevis, and muscle tissue and is key for providing form and for
the very long and thin sartorius muscle. attaching muscles to their respective bones. As shown
In contrast, with penniform (L. penna, feather + in figure 2.6, individual muscle cells are covered by a
forma, form) or pennate muscles, fibers run at an very fine sheath termed the endomysium (G. endon,
angle relative to the muscle’s longitudinal axis as within + mys, muscle), while bundles of about 100 to
seen in figure 2.5B. This diagonal arrangement, 200 muscle fibers (fascicles) are covered by a dense
similar to the design of a feather, allows more fibers connective sheath termed the perimysium (G. peri,
in a given volume of muscle (greater physiological around + mys, muscle) and the whole muscle itself is
cross-sectional area) and hence the ability to produce covered by another membrane called the epimysium
greater force. However, since these fibers tend to be (G. epi, upon + mys, muscle). The central part of a
shorter and are also at an angle to the long axis of the muscle, which tends to be thicker and in which the
muscle, a 50% shortening of a fiber in these muscles contractile cells predominate, is called the muscle
results in less shortening of the muscle as a whole. belly. Toward the ends of the muscle belly, the
So greater force production is gained at the cost of muscle cells end; but the connective tissue cover-
reduced speed and range of motion. Approximately ings continue to attach the muscle to one or more
three-fourths of the muscles in the human body bones: directly (e.g., trapezius, figure 2.7A), via a
follow this penniform arrangement, including many cordlike or flat band called a tendon (e.g., biceps
muscles of the limbs such as the gluteus maximus, brachii, figure 2.7B), or via a sheetlike structure of
quadriceps femoris, deltoid, tibialis posterior, and fibrous tissue called an aponeurosis (e.g., latissimus
gastrocnemius. dorsi, figure 2.7C). Tendons (L. tendo, to stretch out,
extend) are the most common form of attachment
and serve to concentrate the pull of the muscle to
Muscle Attachments to Bone a small area on the bone. Tendons are very strong.
Connective tissue, including the endomysium, peri- Their tensile strength has been estimated to be 4,169
mysium, and epimysium, is intimately related to pounds (1,891 kilograms) per square inch in an adult
Muscle fiber
Sarcolemma
Myofibril
Periosteum
Nucleus
Sarcoplasm
Endomysium
Striations
Perimysium
Epimysium
Skeletal muscle
Fascia
Thick (myosin)
filament
Tendon Myofilaments
Thin (actin)
filament
FIGURE 2.6 Structure of skeletal muscle and related connective tissue.

Reprinted, by permission, from R.S. Behnke, 2006, Kinetic anatomy, 2nd ed. (Champaign, IL: Human Kinetics), p. 14.
FIGURE 2.7 Attachments of muscles onto bones (A) directly, or indirectly through a (B) tendon or (C) aponeurosis.
(Rasch and Burke, 1978), and the Achilles tendon Origin and Insertion
can resist tensile loads equal to or greater than steel
of similar dimensions (Hamill and Knutzen, 1995). These connective tissue attachments of muscles
Due to the large forces transmitted by tendons and to bones have historically been termed the origin
aponeuroses (G. apon, from + neuron, sinew), the and insertion of a muscle; the origin generally stays
attachment of a tendon often gives rise to a raised stationary as the segment containing the insertion
tubercle, and an aponeurosis to a line or ridge on moves. However, more recent texts, including this
the bone to which it attaches. text, have elected to substitute the terms proximal
attachment and distal attachment. While this termi- reversal of customary action of the iliopsoas muscle
nology works well for the extremities, it is sometimes (figure 2.8B).
necessary to use additional terminology for the
head, neck, and trunk, such as superior attach- Line of Pull of a Muscle
ment/inferior attachment or medial attachment/
lateral attachment. The use of these alternative The location of the proximal and distal attachments
terms to origin and insertion better reflect the con- of a muscle relative to the axis of the joint is funda-
cept that when a muscle contracts, it exerts equal mental in determining the type of joint movement
force on each attachment and tends to pull both that will occur. Although technically the line of action
attachments toward each other. Which end actually or line of pull of a muscle is the net effect (resultant)
moves depends on the other forces that come into of applied forces on a common point of attach-
play, such as the relative mass of the adjacent segment of every fiber contained within a given muscle
ments or the stabilizing action of adjacent muscles, (Levangie and Norkin, 2001), one can roughly
and whether the distal segment of the limb is fixed or approximate this resultant force, or “pull,” by draw-
moving. For example, when flexing the elbow as you ing an imaginary double-headed arrow with its base
lift a weight (biceps curl), the proximal attachment at each attachment and pointing toward the center
stays stationary, and it is the forearm and distal attach- of the muscle as seen in figure 2.9A. In instances in
ment of the biceps brachii
that move. In many everyday
movements of the limbs (espe-
cially of the upper extremity),
this pattern occurs where the
distal segment moves while
proximal segments are readily
stabilized due to greater mass.
It is also generally the easiest
way to think about learning the
actions of a given muscle and
can be termed the customary
action of a muscle. However,
there are cases in functional
movement where the distal
segment is stationary and the
proximal segment moves, or A
where both segments simul-
taneously move. When the
proximal segment moves, it
can be termed a reversal of
customary action of a muscle.
A pull-up offers an example of
a reversal of customary action
for the biceps brachii, where
the proximal segments and
attachments (humerus and
trunk) move, while the distal
segment (forearm) stays sta-
tionary with the hands fixed
on the pull-up bar. Similarly,
lifting the thigh to the front
while the trunk stays station-
B
ary (figure 2.8A) would reflect
customary action, whereas lift-
ing the trunk while the thigh FIGURE 2.8 Customary and reverse muscle actions of the iliopsoas. (A) Raising
stays stationary would reflect the thigh and (B) raising the trunk.
Sacramento Ballet dancer Merett Miller.
pull, this is an effective tool for deducing the actions

of a given muscle in the tradition of Platzer (1978)
and Kreighbaum and Barthels (1996). Readers are
encouraged to approach learning muscle actions in
this manner rather than by rote memorization to
make the learning process easier, to provide a self-
check procedure, and to promote retention. If just
the location and line of pull of a muscle are learned,
the actions can be figured out logically, or conjec-
tured actions can be evaluated. To facilitate this
process, summary figures showing the approximate
line of pull of primary muscles of their respective
joints are provided in chapters 3 through 7.
When applying this line of pull analysis to a spe-
cific movement, rather than a specific muscle, the
double-headed arrow is replaced by an arrow with
one head. The direction of this arrow reflects the pull
of the muscle on the body segment that is moving in
the given movement.
It is also important to realize that the line of
pull of a muscle may change its relation to the axis
of rotation of a given joint in different ranges of
motion, causing the muscle to change its action. For
example, the upper (clavicular) portion of the pecto-
ralis major acts as an adductor of the shoulder when
the arm is low as seen in figure 2.9B; but when the
arm is brought above shoulder height (90° shoulder
abduction), the line of pull shifts to above the axis
of rotation of the shoulder and the clavicular por-
tion of the pectoralis major becomes an abductor
of the shoulder as seen in figure 2.9C. In dance, the
same change in the line of pull occurs when raising
the arms to the side from low to high fifth, and the
dancer can palpate contraction of the pectoralis
major in the upper ranges of the movement.
FIGURE 2.9 Change in line of pull and action of the Muscles, Levers,
pectoralis major with different angles of shoulder abduc-
tion.
and Rotary Motion
When force is applied to a system that is not restricted
which muscles have broad attachments, the arrow at some point, motion occurs along a straight line;
would be drawn to bisect the broad attachment. In that is, linear motion occurs. However, as previously
some cases with very broad or multiple proximal or described, in the human body, bones are restricted at
distal attachments, multiple arrows may need to be joints; therefore when a muscle contracts, its attach-
used, and different portions of the muscle may have ments produce rotation of the associated bone or
different actions due to different lines of pull rela- body segments about its joint axis or axes. This form
tive to the axes of movement. In such instances, the of motion is called rotary or angular motion, and it
usual way of reflecting this difference in action is to occurs in all types of synovial joints except gliding
divide the muscle into portions such as the upper joints. Learning about angular motion and levers is
(clavicular) and lower (sternal) portions of the important for appreciating how changing the body
pectoralis major (figure 2.9A). Although simplistic, configuration, such as having the knee bent versus
and not inclusive of all of the factors involved in an straight, profoundly influences the forces required
accurate mathematical analysis of a muscle’s line of to execute a movement.
Different Actions of Pectoralis Major
The differing functions of the clavicular and sternal portions of the pectoralis major can be demon-
strated with the following exercise.
• Shoulder flexion and extension. Sit with your hands clasped at shoulder height with both elbows
extended. Pull down with the right arm (shoulder extension) and up with the left arm (shoulder flexion)
simultaneously such that no net movement of the shoulders occurs. Note the lower sternal portion
of the pectoralis major contracting on the right side of your chest and the upper clavicular portion of
the pectoralis major contracting on the left side of your chest.
• Shoulder horizontal adduction. Press both your hands and arms toward each other so that no
net movement of the shoulder occurs (isometric horizontal adduction). Note the clavicular and sternal
portions of the pectoralis major contracting on both the right and left sides of your chest.
It is easier to understand rotary motion if we look ness of the effort, allowing for less force to be used
at how a lever works. Put simply, a lever is a rigid to overcome a given resistance. The wheelbarrow,
bar revolving about a fixed point called the axis, nutcracker, and lug nut wrench can all function
pivot, or fulcrum. In the human body, bones serve as second-class levers. This type of lever probably
as levers, and the interposed joint serves as the axis does not exist in its pure form in the human body.
(A). Muscles attach to the levers or bones, and when However, there are cases in closed kinematic chain
they contract they generally produce rotary motion movements in which the muscle acts on the proxi-
about the fixed or relatively fixed axis of the joint (in mal segment while the distal segment (e.g., foot or
reality, the axis of joints tends to shift slightly with dif- hand) is fixed, so that the distal portion of the body
ferent ranges of motion). This tendency of muscles acts like a third-class lever. For example, in a relevé,
to produce rotation in one direction, termed effort the dancer rises on the toes (metatarsophalangeal
(E), is countered by the tendency of the resistance joints—A) when the weight of the body (R) is over-
to produce rotation in the opposite direction (R). come by contraction of the calf muscles (E).
Which of these three components—effort, axis, or In the third-class lever, the effort lies between
resistance—is between the other two determines the resistance and the axis, making the distance of
which of the three classes a lever belongs to as shown the resistance from the axis always greater than the
in figure 2.10. It is easier to remember the difference distance of the effort. This arrangement favors range
between levers if you remember that the middle com- of motion and speed, at the expense of the effective-
ponents spell “ARE” when you proceed from first- to ness of the force. Tweezers and many sport imple-
third-class levers. So, with a first-class lever the axis ments (bats, rackets, paddles) are used as third-class
is in the middle, and effort and resistance are on levers. Most muscles of the human body when they
opposite sides of this axis. This arrangement can be act in open kinematic chain movements function as
used for balance or to gain either effective force or third-class levers. An example is the deltoid muscle
range of motion, depending on the relative distances (E) acting to produce abduction of the arm (R) at
of effort and resistance from the axis. Seesaws, scis- the glenohumeral joint (A).
sors, and crowbars can function as first-class levers.
In the body, the atlanto-occipital joint (A) functions Torque (Moment of Force)
in a first-class lever system, where the weight of the
head (R) is balanced by the extensor muscles of the Adding a little more detail to this concept, the capac-
head/neck (E). ity or effectiveness of a force to produce rotation
With a second-class lever, the resistance is between is termed torque (L. torqueo, to twist) or moment
the axis and effort, making the distance of the effort of force. The amount of torque acting to rotate a
from the axis always greater than the distance of the given system can be calculated by multiplying the
resistance. This arrangement magnifies the effective- amount of force times the perpendicular distance
FIGURE 2.10 Three classes of lever systems used in human movement.
from the line of action of the force to the axis of effort (E) × effort arm (EA). However, this torque
rotation or potential rotation. This latter quantity related to contraction of the muscles trying to effect
(perpendicular distance from the line of force to the a given motion is countered by the torque related
axis of rotation) is termed the force arm or moment to the resistance to this motion. When the torque of
arm. The key point here is that it is not just the the resistance is due to external forces such as the
magnitude of the force but also how far away from effect of gravity on a dumbbell or a body segment,
the axis (e.g., the joint) that this force is acting that then the torque of the resistance = resistance (R) ×
is vital in determining its effect. So, when analyzing resistance arm (RA).
joint movement, the force resulting from muscle
contraction can be termed the effort (E); the line Mechanical Advantage
of this force would be the line of pull of the muscle,
and the point of application of this force would The relation of the moment arm of the effort to the
be the muscle attachment to the bone. So, as can moment arm of the resistance has important conse-
be seen in figure 2.11, torque of the muscle (T) = quences for the potential to overcome resistance and
is called the mechanical advantage (EA/RA). If the

effort arm and resistance arm were of equal length,
then this would yield a mechanical advantage of 1
and would mean that if you wanted to hold a 15-
pound (6.8-kilogram) weight, it would take about 15
pounds of muscle force to counterbalance this weight.
However, throughout most human limbs, third-class
levers predominate, where EA is much smaller than
RA as shown in figure 2.11A. Since in third-class levers
the effort is located between the axis and resistance,
RA always must be greater than EA and the mechani-
cal advantage must always be less than 1 (figure
2.11B). Furthermore, muscle attachments are usually
very close to the joint (axis), making EA very small
relative to RA with mechanical advantages often 0.1 or
even lower (Smith, Weiss, and Lehmkuhl, 1996).
This gives the limbs very low mechanical advan-
tage where very large forces have to be generated to
overcome relatively small resistances. For example,
as shown in figure 2.11C, about 79 pounds (351 N)
of force must be exerted by the biceps brachii to
counterbalance holding a 10-pound (4.5-kilogram)
weight in the hand. This calculation, in contrast to
the calculation shown in figure 2.11A, takes into
account the contribution of the weight of the fore-
arm, as well as the weight of the dumbbell. When
doing a calculation where the external weight is
large (e.g., lifting another dancer), the weight of
the arm may be excluded for purposes of simplicity
and because its contribution to the torque produced
by the resistance is relatively small. However, in
other instances, such as when lifting a lower limb in
dance class (e.g., side extension), consideration of
the weight of this limb is vital, and it is primarily the
torque produced by the weight of the leg that must
be overcome by the muscles of the hip in order to
effect the desired movement.
However, whether the weight of the limb is key
or not, the point remains that large forces have to
be generated by muscles to overcome much smaller
resistances, and the triceps brachii must exert about
222 pounds (987 N) of force in order for the hand
to press down with 20 pounds (89 N) of force on a
scale. In cases in which the elbow is extended and
the resistance arm is greater, the torque produced
by a 10-pound weight would be approximately 20
foot-pounds at shoulder height as shown in figure
2.12A, and about 300 pounds (1,335 N) of tension in
the deltoid may be necessary to raise the arm to this
height (Rasch and Burke, 1978). So, in human limbs
FIGURE 2.11 Levers and torque. (A) Biceps force this prevalence of third-class levers represents a grave
required to counter dumbbell torque; (B) mechanical disadvantage in terms of mechanical advantage and
advantage; (C) biceps force required to counter forearm has important implications for injury predisposition.
and dumbbell torque. However, this arrangement does foster a large range
of motion of the end of the lever and a potential

advantage in terms of speed of movement of this
distal segment. So, although a large amount of force
of the deltoid would be required to overcome the
10-pound dumbbell, a small amount of shortening of
the deltoid would result in a much greater excursion
of the hand. This ability to move the hand or foot
through a very large range of motion, and if desired,
at a very high velocity, is commonly utilized in dance
and many other human movements.
Equilibrium Versus Movement

Lastly, the relationship of the net torque of the
muscle relative to the resistance has important impli-
cations for joint movement. In essence, if the torque
of the muscle is exactly equal to the torque of the
resistance, the system is in equilibrium (Fr. aequus,
equal + libra, a balance) and no net movement will
occur. If the torque of the muscle (effort) is greater
than the torque of the resistance, joint rotation will
occur in the direction of the muscle’s pull. And, if
torque of the resistance is greater than that of the
muscle, joint rotation will occur in the direction of
the resistance (table 2.3).
Applying these concepts to dance, when you hold
another dancer at shoulder height, the torque of the
muscles must be equal to the torque of the dancer
(e.g., weight of dancer × perpendicular distance to
shoulder joint axis). When you lift the dancer, muscle
torque is greater than resistance (dancer) torque;
and when you lower the dancer, muscle torque is less
than the torque produced by the dancer. Further-
more, as illustrated in figure 2.12B, if you imagine
the 120-pound weight is a dancer, moving the dancer
closer to you when you lift would dramatically reduce
the torque produced by the dancer and the amount
of muscle force needed to lift the dancer. Conversely,
moving the dancer farther away when you lift would
dramatically increase the muscle force required to
carry out the movement. Taking this concept into
consideration, it is easy to understand how functional
human movement often incorporates bending the
limbs (elbows, knees) to shorten the lever arms when
reducing resistance torque would be advantageous.
It also explains why a very long-limbed person would
have to exert significantly greater muscular effort
than one with shorter limbs to lift a dance partner
of a given weight.
Angle of Muscle Attachment

FIGURE 2.12 Change in resistance torque with (A) While the moment arm of the resistance is key in
change in shoulder joint angle and (B) change in shoul- determining resistance torque, the effectiveness of
der and elbow joint angle.
Concept Demonstration 2.2
The Influence of Moment Arms on Torque
Perform the following movements while sitting or standing.

•â•‡ Use of a long moment arm. Hold your dance bag or another heavy object at shoulder height with
your elbows extended. Think about the distance your bag is from your shoulder, that is, the moment arm
of the resistance, and the large torque that this bag would exert. Note the amount of muscular effort that
is required to hold the bag in place.
•â•‡ Shortening the moment arm. Bend your elbows, bringing your bag close to your chest at shoulder
height. Notice the change in the moment arm of the resistance. Why does your bag feel lighter, and why
is less muscular effort required to hold it at shoulder height?
•â•‡ Application to other dance movements. Now consider the weight of your leg as the resistance.
How would bending your knee for a développé versus lifting the leg with your knee straight make it easier
to lift the leg higher?
Note: Due to rights limitations, this item has been removed.
RAl = moment arm of leg

RAf = moment arm of foot
49
TABLE 2.3 Relationship of Net Torque, Joint Movement, and Type of Muscle Contraction
the muscle force in producing desired rotation is this reason, a joint that is loaded in extreme flexion,
greatly influenced by the angle of the muscle’s attach- such as during dance floorwork, is at heightened
ment relative to the bone. The muscle force or effort risk for injury. However, careful simultaneous use
has a direction determined by its angle of attach- of muscles that tend to dislocate the joint in the
ment and a magnitude determined by how hard the opposite direction can be used to help protect and
muscle is contracting, and hence is a vector. A basic stabilize the joint.
property of vectors is that they can be resolved into
vertical or perpendicular and horizontal or parallel
components. In the human body, the perpendicular Types of Muscle Contraction
component of the muscle effort will tend to produce (Tension)
rotation of the joint and hence is termed the rotary
component, as shown in figure 2.13. At all angles of The relationship of net torque of the muscle relative
pull other than 90°, the parallel component (running to the net resistance previously discussed can also
parallel to the distal bone and through the axis of the be associated with types of muscle contraction or
joint) of the muscle effort will tend to pull the distal tension. Before looking at possible types of muscle
bone toward the joint (stabilizing) or away from the contraction, it is important to remember the sliding-
joint (dislocating), depending on the joint angle. So, filament theory and to recall that this muscle tension
at angles less than 90°, only part of the muscle effort can only pull the ends of the muscles toward each
will produce rotation (rotary component), while part other (termed the law of approximation) and not
contributes to joint stability (parallel component), push them away. This gives rise to the commonly
as seen in figure 2.13A. This offers a disadvantage used statement that “muscles can only pull and not
for movement but an advantage for joint stability push.” However, although the same internal pro-
that can be particularly useful when the limbs are cess of cross-bridge formation is occurring within
weightbearing. When a muscle’s angle of pull is per- a muscle cell, the muscle as a whole may shorten,
pendicular (90°) to the bone on which it is pulling, lengthen, or stay the same length, depending on
virtually all of the muscle’s effort will contribute to whether the torque resulting from the contraction
joint rotation (figure 2.13B), an optimal situation of the muscle is more than, less than, or the same
in favor of movement. Lastly, when the muscle’s as the resistance torque. These differences have
angle of pull is greater than 90°, again only part of traditionally been described as types of muscle
the muscle effort will produce joint rotation (rotary contractions. However, because contraction implies
component), while part acts to dislocate the joint “shortening,” some authors prefer the terminology
(parallel component), as seen in figure 2.13C. For “types of muscle tension.”
Dynamic Muscle Contraction

Dynamic muscle contraction or tension occurs when
there is a change in length of the involved muscle and
accompanying observable joint movement. There are
two types of dynamic (historically termed isotonic)
contractions—concentric and eccentric.
Concentric Contraction
A concentric muscle contraction or tension involves
a shortening of the muscle and resultant visible joint
movement (e.g., flexion, abduction) in the direction
of the action of the primary muscle. Concentric (G.
con, with + kentron, center) loosely means “toward
the center”; and with this type of contraction, both
attachments of the muscle will tend to be pulled
toward each other as the muscle shortens. On the
sarcomere level, actin is being pulled toward the
center of the sarcomere with each successive cross-
bridge formation. This is the classic way we think of
muscle contraction, and the concentric contraction
is the basis for charts that list the action or actions
of a given muscle. With concentric contractions the
torque from the muscle or muscle group is greater
than that of the resistance, and joint movement is in
the same direction as the torque generated by the
muscle or muscle group. For example, a concentric
contraction occurs in a biceps curl exercise on the
up-phase of the movement (table 2.3A) because the
torque of the elbow flexors (including the biceps bra-
chii) is greater than the resistance torque produced
by the weight of the dumbbell and forearm.
Concentric contractions are commonly used on
the up-phase of movements in dance such as rising
from a plié, the takeoff phase of a jump, or raising
the arms overhead.
Eccentric Contraction
An eccentric contraction or tension involves a
“lengthening” of the muscle (i.e., the distance
between origin and insertion gets greater) as vis-
ible joint motion is occurring. Eccentric (G. ek, out
+ kentron, center) loosely means “away from the
center,” and with eccentric contractions the resis-
tance is “lengthening” the muscle while the muscle
is contracting to control the effect of the resistance.
On the sarcomere level, the actin go away from
the center of the sarcomere, and cross-bridges are
broken and then reformed as the muscle lengthens
(Levangie and Norkin, 2001). In most cases, the
muscle is not actually “lengthening” beyond resting
length, but rather gradually decreasing the degree of
contraction from its shortened (contracted position)
FIGURE 2.13 Influence of angle of muscle attachment toward its resting length. With eccentric contractions,
on rotary and parallel components of muscle force.
DANCE CUES 2.1
“Pull Up Your Knees”
W hile some schools prefer a more relaxed stance, other schools of dance encourage students to
“pull up the knees” on the support leg when working at the barre or center floor. This cue is
often further elaborated by encouraging students to not let the thigh muscles be “relaxed,” the knee-
caps be “loose,” or the support knee bend or “wobble.” From an anatomical perspective, tightening
the quadriceps femoris muscle can pull the patella upward, add the desired tension to the thigh, offer
joint stability (large parallel stabilizing component), and prevent the knee from bending. Although
a maximum contraction of the quadriceps is not recommended due to the aesthetic in many dance
forms to avoid overdevelopment of the thighs and from a perspective of desired movement efficiency,
a slight contraction of the quadriceps can help stabilize the support knee and prepare the muscles for
necessary rapid slight adjustments as the gesture leg is moving. Tensing muscles around a joint can
enhance some of the muscle receptors’ sensitivity to stretch and markedly enhance proprioception at
that joint (Irrgang and Neri, 2000). It can also help counter the tendency that some dancers have of
relying too much on passive constraints such as the ligaments for stability.
Some dancers, however, tend to create a hyperextended position of the knee when they contract the
quadriceps. In these cases, cueing to “lightly pull the kneecap up versus back,” or cueing to “gently pull
up both the front and back of your knees” may be helpful. In the latter case the desire is to generate a
slight co-contraction of the quadriceps and hamstrings that can create a balanced stability and readiness
with the hamstrings (knee flexors) acting to prevent potential knee hyperextension that is sometimes
associated with excessive contraction of the quadriceps femoris. Some examples of electromyography
recordings from the quadriceps femoris, hamstrings, and adductors from selected dancers are shown
later in the chapter to demonstrate the individual differences in muscle activation associated with
standing “in preparation” in turned-out first position (see Tests and Measurements 2.1 on p. 64).
the torque produced by the resistance is greater commonly used on the down-phase of movements
than the torque produced by the muscle, and the in dance, such as the descent of a plié, landing from
direction of movement is opposite to that of the a jump, or lowering the arms from overhead to the
muscle torque and in the same direction as that of sides of the body.
the resistance.
In human movement, this type of contraction is Static (Isometric) Muscle Contraction
commonly used to control the effects of gravity, to
decelerate body segments, and to help absorb shock A static or isometric contraction (G. iso, same +
loads (Dye and Vaupel, 2000). For example, in the metron, measure) loosely means “equal length” and
down-phase of the biceps curl (table 2.3C), gravity is involves a partial or complete contraction of a muscle
the external force that is producing the movement, where no visible joint movement occurs. On a sar-
and the elbow flexors are working eccentrically to comere level, there is a small initial pulling of the
help control the movement. If the elbow flexors were actin toward the center of the sarcomere until the
not used, gravity would make the weight drop very slack is taken out of the muscle-tendon complex as
rapidly, potentially causing joint injury. In this case a whole, and then cross-bridge formation cyclically
the resistance torque is greater than that of the mus- occurs at the same sites. So, although there is active
cles. It is important to notice that even though elbow tension being generated by the involved muscle,
extension is occurring (due to the effects of gravity), the torque generated by the muscle is being exactly
it is the elbow flexors and not the elbow extensors counterbalanced by that of the resistance such that
that are being used to control this extension. So, the no net movement occurs. The resistance can be from
same muscle group is working on the up-phase as on internal forces generated from contracting muscles
the down-phase, only with a concentric and eccentric with oppposite actions or the result of an external
contraction, respectively. Eccentric contractions are force such as another person, a weight, or gravity.
Concentric, Eccentric, and Isometric Muscle Contractions
Perform a very slow développé to the front.

• Analysis of contraction type. Analyze whether an isometric, concentric, or eccentric contraction
of the hip flexors would be used on the following phases of the movement:
– Up-phase
– Hold-phase
– Down-phase
• Influence of tempo. Perform this same movement more quickly and speculate on any changes
in muscle action that might occur, particularly on the down-phase.
DANCE CUES 2.2
“Release and Recover”
S ome styles of choreography encourage dancers to “drop” or “release” their body weight and then
“catch” or “recover” the weight to create a pause or change in the direction of the movement.
When the center of mass of a body segment such as the head, arm, or upper torso is moved out of
equilibrium, such as by bringing the segment forward, gravity will tend to make it fall toward the
floor. In dance, this dilemma can be dealt with in many ways. One approach is to use the muscles that
oppose the influence of gravity eccentrically in a constant, controlled manner so that the movement
can be stopped at any instant. Another approach is to momentarily let the body segments “fall” under
the influence of gravity, and then rapidly use the muscles that oppose gravity eccentrically to deceler-
ate the segments in accordance with the desired movement path. Although the look and feel of the
movements are quite different, it is important to realize that muscles are still required to shape the
movement and oppose gravity. So, care should be taken to avoid cues suggesting that muscles are not
used, or that you can move from your bones alone. If we did not use our muscles we would collapse
to the floor and would be unable to get up.
For example, an isometric contraction of the elbow commonly used to maintain desired positions of the
flexors would be operative when one is holding the support leg, torso, and the arm on the barre.
dumbbell at a given angle and not letting that joint
angle change (table 2.3B). Isometric contractions are
also used posturally to maintain a position of parts of Muscular Considerations
the body or the whole body. For example, in upright in Whole Body Movement
standing, the soleus muscle generally contracts iso-
metrically to prevent the body from falling forward. Much of this chapter has focused on principles
In dance, isometric contractions play a vital role in related to a single muscle. However, in most func-
preventing undesired compensations of the body, tional movement there is well-orchestrated contribu-
as well as maintaining desired positions of the body tion of many muscles at many joints. When trying
and its segments. For example, when the dancer to understand such whole body movements, some
is working at the barre, isometric contractions are additional important considerations include use
of the stretch-shortening cycle, the different roles body 8-12 inches [20-30 centimeters] in the plié),
muscles can play when they are acting simultane- rapidly applied, with minimal delay (less than 0.4-
ously, how muscles can work as force couples, and 1.0 second), and without a pause or relaxation of
the unique challenges that arise with muscles that the muscle at the end of the stretch (e.g., at the
cross multiple joints. bottom of the plié) between the eccentric and con-
centric contraction. While some dancers appear to
Stretch-Shortening Cycle naturally utilize a timing that facilitates enhanced
force from the SSC, other dancers could benefit
In some movements, a muscle is used eccentrically by small changes in their preparatory movements.
immediately preceding use of the same muscle Common errors include hesitating rather than uti-
concentrically. This is termed the stretch-shorten- lizing a quick reversal of directions at the bottom of
ing cycle (SSC), or prestretch. When an active the plié and suboptimal depth of the preparatory
muscle is stretched, mechanical energy is stored plié. Training regimes that focus on this response
in the elastic component of the muscle, which is of muscle (e.g., plyometrics) have been shown to
then released during the immediately following enhance performance and may reduce injury inci-
shortening contraction, resulting in greater force dence in muscles such as the hamstrings that are
production (Asmussen and Bonde-Petersen, 1974; required to perform rapid stretch-shortening phases
Bosco and Komi, 1979; Komi, 1979). Recall that in movements like jumping and sprinting (Smith,
the elastic components of muscle can be modeled Weiss, and Lehmkuhl, 1996).
as a spring. So, you can envision this phenomenon
by imagining stretching a spring. When you let go, Muscle Roles
the spring will recoil and pull back together. Addi-
tional factors, including neural considerations and When muscles work together at the same time, there
chemical energy from preloading the muscle, also are four primary potential roles they can play—mover
probably contribute to enhanced force output; and (agonist), antagonist, synergist, or stabilizer. These
the relative potential contribution of these and other roles are specific to a given movement and not a
factors is still under investigation (Cronin, McNair, given muscle. Hence, the same muscle can serve in
and Marshall, 2000; Enoka, 2002; Smith, Weiss, and a different role with different movements.
Lehmkuhl, 1996). Whatever the mechanism, this
enhanced force can be marked; and in very rapid, Mover (Agonist)
small jumps from both feet, it was calculated that
only 40% of the force was due to the concentric A mover, or agonist (G. agon, contest), is a muscle
contraction of the muscle while approximately 60% or muscles whose contraction actually produces the
of the force was due to these elastic and other factors desired joint movement. There may be many muscles
(Thys, Cavagna, and Margaria, 1975). In addition, that are capable of producing this desired movement.
release velocity and jump height have been shown Traditionally the term prime mover(s) or primary
to improve 12% to 18%, and mean power output in muscle(s) is reserved for those muscles that are
a strength training exercise improved 8% to 16% most important or effective in producing the move-
with the use of SSC (Cronin, McNair, and Marshall, ment, and the terms assistant mover(s) or secondary
2000). Furthermore, use of SSC has been shown to muscle(s) are used for those muscles that are less effec-
allow for lower energy requirements (e.g., greater tive or that are called into play in specialized circum-
efficiency) in a given movement. stances such as when more force is needed. However,
An example of use of the SSC in dance is the use these distinctions often are controversial and complex,
of a quick demi-plié prior to a jump. The gluteus and so which agonists are considered primary or
maximus, hamstrings, quadriceps femoris, and calf secondary may differ between different sources. In
muscles would work eccentrically on the down-phase raising the leg to the back (e.g., parallel attitude), the
of the plié and then concentrically on the up-phase. agonists are the hip extensors including the hamstrings
This principle is used frequently in dance, allowing as seen in figure 2.14.
for greater movement efficiency and potentially
Antagonist
contributing to the “effortless” aesthetic desired
in some dance forms, as well as greater force pro- An antagonist (G. anti, against + agon, contest) is a
duction for explosive movements. To optimize muscle or muscles with an action opposite to the
use of this property, the prestretch should be of action of the prime mover. Antagonists are often
a relatively small magnitude (e.g., lowering the positioned on the side of the joint opposite to the
hamstrings (semimembranosus and semitendinosus)

have actions of hip internal rotation as well as hip
extension. To achieve the desired parallel position of
the leg, the lateral hamstring (biceps femoris) can act
as a synergist, with its secondary action of hip external
rotation neutralizing the undesired internal rotation
of the other hamstrings as shown in figure 2.14.
A further useful distinction is between a true and a
helping synergist. If the synergist only neutralizes the
undesired action and does not help with the desired
action, it is called a true synergist. However, if it helps
with the desired action and neutralizes the undesired
action, it is called a helping synergist. The back atti-
tude synergy just described is an example involving
a helping synergist, since the lateral hamstring aids
with the desired action of hip extension while it neu-
tralizes the undesired hip internal rotation.
Stabilizer (Fixator)
A stabilizer, or fixator, is a muscle that contracts iso-
metrically to support or steady a body part against
forces related to muscle contraction, gravity, soft
tissue constraints, momentum, or recoil from the
movement. The first of these potential functions,
stabilization against the forces related to muscle con-
traction, occurs with most movements. Remember
that when a muscle contracts, it tends to pull both of
FIGURE 2.14 Muscle roles in whole body movement its ends toward its center. However, often the desire
(lateral view). is to have movement occur only at one end of the
muscle, and stabilizers can work to anchor the neces-
sary bone or body part to allow that to happen. For
agonists. In raising the leg to the back, the antagonists example, in a kick to the front (grand battement),
are the hip flexors including the rectus femoris as stabilizers (abdominal muscles) work to prevent the
seen in figure 2.14. Generally, antagonists relax while proximal attachment of the iliopsoas muscle (a hip
the prime movers contract. However, antagonists flexor that attaches to the lower spine proximally)
sometimes work together with agonists—termed co- from arching the low back, as the iliopsoas’ distal
contraction—when a part must be held rigid, when attachment on the femur effects the desired action
very precise movement is required, and during decel- of lifting the thigh (hip flexion).
eration of body parts. An example of the latter occurs An example in which gravity is the primary factor
during running, where the antagonist (hip extensors) occurs with push-ups. Abdominal muscles must be
would initially relax to allow the prime movers (hip contracted to stabilize the pelvis and spine and pre-
flexors) to bring the thigh forward in the swing phase vent the tendency for the low back to arch and the
but then would contract eccentrically to decelerate the body to sag due to the effect of gravity. An example
thigh before it reaches its full height to the front. in which soft tissue constraints are instrumental occurs
during raising of the leg to the back in a parallel atti-
Synergist (Neutralizer) tude. As the leg is raised backward, the hip flexors
A synergist (G. syn, together + ergon, work) is a muscle offer passive resistance as they are being stretched and
that works together with the agonist(s) to help tend to pull the pelvis into an anterior tilt and pro-
achieve the movement goal. The role of the synergist duce an arching of the low back unless the abdomi-
is described differently in different texts. This text nal muscles are used to stabilize the pelvis as seen
will confine the meaning of synergist to a muscle in figure 2.14. Appropriate timing and magnitude
whose action serves to neutralize an undesired sec- of stabilization are an important element of skilled
ondary action of the prime mover(s). When raising dance performance, and very specific positioning
the leg to the back in a parallel attitude, the medial and movement of many joints are often desired.
Muscles as Force Couples couples used whenever the arms are raised overhead
are shown in figure 2.15B. The upper trapezius and
The technical definition of a force couple is two serratus anterior muscles as well as the upper trape-
forces that are equal in magnitude and opposite in zius and lower trapezius can work as force couples
direction and are located at a distance from the axis to produce upward rotation of the scapula necessary
such that they produce rotation. An example of a for raising the arms overhead (see Scapulohumeral
force couple is the use of the hands on the steer- Rhythm on p. 397 for a more detailed discussion on
ing wheel of an automobile to produce rotation of the function of these particular muscles).
the wheel as seen in figure 2.15A. In dance, a force
couple is formed by the feet to produce rotation of Special Considerations
the body for turns such as a pirouette. When refer- With Multijoint Muscles
ring to muscles in the body, “force couples” can be
more loosely used to describe muscles located at Muscles can cross one or multiple joints, and the
different positions relative to a joint axis but that act number of joints crossed dramatically influences the
together to produce rotation in the same direction. muscle’s contribution to movement. As their names
In such anatomical force couples, the lines of pull
of muscles are not necessarily directly opposite in
direction and equal in magnitude. Examples of force
FIGURE 2.15 Force couples. (A) Hands on steering FIGURE 2.16 Number of joints crossed by muscles.
wheel and (B) muscles of scapula (posterior view). (A) Single-joint (posterolateral view), (B) two-joint (anterior
view), and (C) multijoint muscles (posterior view).
suggest and as illustrated in figure 2.16, a single-joint over the knee while shortening is occurring across
(uniarticulate) muscle crosses only one joint, while the hip. In essence, this enhances the efficiency of
a two-joint (biarticulate) muscle crosses two joints the rectus femoris by keeping the whole muscle at a
and a multijoint (multiarticulate) muscle crosses two length where it can generate more muscle tension,
or more joints. A single-joint muscle can produce as well as allowing for greater force due to the use
motion only at the one joint it crosses. For example, of the stretch-shortening cycle. Other examples
the gluteus minimus shown in figure 2.16A crosses of muscles that cross two or more joints—that is,
only the hip joint and so can produce movement multijoint muscles—are the sartorius, tensor fascia
only at the hip joint. In contrast, a multijoint muscle latae (figure 2.16B), hamstrings, gastrocnemius,
can produce motion at all the joints that it crosses. biceps brachii, the long head of the triceps brachii,
With a two-joint muscle, both of its tendons are pulled and many muscles of the hands and feet, such as the
nonselectively toward the belly of the muscle, result- flexor digitorum longus shown in figure 2.16C.
ing in the tendency to cause movement at both of its
joints. This can be advantageous from a perspective Active and Passive Insufficiency
of efficiency when both actions are simultaneously However, despite this advantage in terms of efficiency,
desired, such as when both functions (hip flexion multijoint muscles hold a disadvantage in terms of
and knee extension) of the two-joint rectus femoris allowing either fully active or fully passive range of
(figure 2.16B) are used when kicking. motion at two or more joints simultaneously. Regard-
Using one function of the muscle concentrically ing the former, active insufficiency occurs when
and the other eccentrically at the same time can active contraction of the muscle is unable to produce
also offer an advantage for two-joint muscles. For as much range of motion as could be produced if
example, in locomotion, when the leg is initially swung an external force (e.g., gravity, momentum, another
forward (concentric hip flexion), the knee is often in body part, or another person) was responsible for
a flexed position (knee extensors working eccentri- the movement. This limitation is due to the fact that
cally). This combination stretches the rectus femoris the average muscle fiber can shorten only about half
Active Insufficiency
• Establishing active insufficiency.

Create active insufficiency with the ham-
string muscles by performing both of its joint
actions (knee flexion and hip extension)
together. Stand on your left foot and lift the
right foot off the ground and flex the right
knee as fully as possible. Then, with the
knee fully flexed, try to lift the leg as high
as possible to the back (hip hyperextension)
as if doing a parallel back attitude.
• Angle of knee flexion.
– You will find that either the ham-
string starts to cramp or the knee
starts to decrease its degree
of flexion as the thigh is raised
higher toward the ceiling. Why?
– Holding the end position, use
your hand to bring your right heel
toward your buttocks. Why can you bend the knee further when you use your hand?
Passive Insufficiency
• Establishing passive insufficiency. Create passive insufficiency with the hamstring muscles by
establishing a position opposite to the actions the hamstrings produce (e.g., hip flexion and knee
extension) by lying on your back and using your arms to bring one leg up toward your shoulder while
your knee is maintained in an extended position until a mild stretch is felt at the back of the leg (see
figure 2.23B on p. 67). Note this endpoint.
• Adding knee flexion. Then bend your knee slightly and note that the leg can be brought
higher.
– Why can you bring the leg higher with your knee bent?
• Application to other dance movements.
– Noting the degree of passive range that your body exhibits with your knee straight, how could
this affect your ability to perform high kicks to the front or split leaps?
– If a dancer has less than 90° of hip flexion possible due to passive insufficiency, how would
this influence the dancer’s ability to stretch the hamstrings while sitting with the legs straight
to the front or in second position?
of its resting length, and this limit of shortening can no resultant movement would occur. However, this
readily be reached when a muscle is shortening across is not the case. The explanation for this apparent
two or more joints simultaneously. In addition, muscle paradox is that multijoint muscles often have a more
has difficulty producing high contractile force when pronounced effect, due to having better leverage
in a very shortened position (length–tension relation- and producing greater torque, at one of the joints
ship), and so strength of that muscle will influence that they cross as shown in figure 2.18. In the case
how much range of movement can be achieved. Active of the hamstrings, this muscle has a longer moment
insufficiency can be demonstrated by simultaneous arm and so creates a greater torque at the hip than
performance of both actions of a two-joint muscle, the knee, with its action of hip extension predomi-
such as hip flexion and knee extension for the rectus nating. Conversely, the rectus femoris has a longer
femoris as seen in figure 2.17A. moment arm and so creates a greater torque at the
knee than the hip, with its action of knee extension
Lombard’s Paradox predominating. Hence, their co-contraction can
Another special consideration with a two-joint result in the desired motion rather than either no
muscle comes into play when the required motion motion or undesired motions. So, a two-joint muscle
at one joint is in the opposite direction to that can be utilized that has its primary action coincident
produced by that muscle. This condition is termed with the desired action at one joint, while another
Lombard’s paradox (Rasch, 1989). The classic muscle works synergistically to overcome the unde-
example used with Lombard’s paradox is co-con- sired motion and create the desired action at the
traction of the hamstrings and the quadriceps femo- second joint.
ris, such as during rising from a plié or standing up
from sitting in a chair. The hamstrings can produce
the desired action of hip extension but the unde- Learning Muscle
sired action of knee flexion. On the other hand, the Names and Actions
rectus femoris produces the desired action of knee
extension but the undesired action of hip flexion. Now that some key principles of how muscles func-
So how can the desired action of hip extension and tion have been covered, the next step in understand-
knee extension occur from their co-contraction? ing movement is to learn the names, locations, and
One would think that if they were used together actions of specific muscles. There are approximately
they would just neutralize each other’s action and 434 muscles in the human body, with about 75 pairs
A B
FIGURE 2.17 Active and passive insufficiency of two-joint muscles. (A) Active insufficiency of the rectus femoris; (B)
passive insufficiency of the hamstrings.
responsible for movements of the body and posture of these muscles that are more commonly known is
(Hall, 1999). An overview of selected primary muscles provided in figures 2.19 and 2.20. These and other
and the one or two most important actions for some muscles are then presented in more detail by region
with a drawing, description of their attachments, and
a more detailed description of their actions in chap-
ters 3 through 7. Chapter 8 provides more in-depth
figures and summary charts of major muscles, useful
for movement analysis. Although the process of learn-
ing muscles can seem overwhelming for someone new
to anatomy, it is made easier if logic rather than just
pure rote memorization is used. A recommended
approach to learning individual muscles follows.
1. Use Latin and Greek roots to provide informa-

tion. Note that many of the words used in anatomy,
including the names of muscles, have their roots
in Latin or Greek. When learning about specific
muscles it is often helpful to understand the meaning
of these roots. The meaning of selected word roots
is provided in table 2.4 and included for key muscles
in chapters 3 through 7. If one understands the
meaning of these roots, the name of a muscle often
provides useful information about that muscle’s
FIGURE 2.18 Lombard’s paradox. characteristics.
Tibialis anterior
(ankle-foot dorsiflexion,
foot inversion)
FIGURE 2.19 Selected major muscles and key actions—anterior view.
60
(ankle-foot plantar flexion)
(ankle-foot plantar flexion)
(ankle-foot plantar flexion,

foot eversion)
FIGURE 2.20 Selected major muscles and key actions—posterior view.
61
Latin and Greek roots provide the fol- TABLE 2.4 Word Roots and Muscle Names
lowing clues about a muscle:
Word root Meaning Sample muscle
• Action: adductor longus (adductor
= to adduct or bring toward the abducens leading away from abductor hallucis
midline), levator scapulae (levator biceps two-headed biceps femoris
= to lift)
brachium upper arm brachialis
• Direction of fibers: rectus abdomi-
nis (rectus = straight), obliquus brevis short adductor brevis
internus abdominis (obliquus = delta triangle deltoid
slanting or oblique)
gracilio slender gracilis
• Location: triceps brachii (brachium
= arm), pectoralis major (pectoris latissimus the broadest latissimus dorsi
= chest) levator lifter levator scapulae
• Number of divisions/proximal longissimus the longest longissimus of erector spinae
attachments (heads): quadriceps
longus long adductor longus
femoris (quadriceps = having four
heads), triceps brachii (triceps = magnus larger adductor magnus
having three heads), biceps brachii major the larger teres major
(biceps = having two heads)
maximus the largest gluteus maximus
• Shape: deltoid (delta = shaped like
the letter delta, triangular) minimus the smallest gluteus minimus
• Size/relative size: gluteus maximus minor the smaller pectoralis minor

(maximus = largest), adductor obliquus oblique, slanting obliquus internus abdominis
brevis (brevis = short)
pectoris chest pectoralis major
2. Learn the muscle name and location.
While keeping the meaning of useful word peroneus belonging to fibula peroneus longus
roots in mind, learn the name and location piriformis pear-shaped piriformis
of the specific muscle.
quadriceps having four heads quadriceps femoris
3. Estimate the muscle’s line of pull,
rectus straight rectus abdominis
and deduce its action(s). From knowing
the muscle’s location and approximate rhomboids rhomboid rhomboideus major
attachments, estimate its line of pull. Then, serratus serrated serratus anterior
note where this line of pull is relative to
the axis of the joint to deduce what type of sterno sternum sternocleidomastoid
movement would be produced at that joint tensor stretcher tensor fasciae latae
when the muscle shortens (e.g., concentric
teres round teres minor
contraction). Try to understand the logic,
rather than just memorize the actions. For triceps three-headed triceps brachii
example, in many cases, muscles located vastus large vastus medialis
anterior to the joint produce flexion;
muscles located posterior to the joint pro-
duce extension; muscles lateral to biaxial or triaxial deductions with the actions listed in figures 2.19 and
joints produce abduction; and muscles medial to 2.20. However, a more in-depth understanding of
these types of joints produce adduction (exceptions muscles requires an appreciation of their secondary
include muscles at the knee joint and scapulae). Mus- actions and use in functional movements. Knowledge
cles producing external rotation are often located regarding many of these more complex actions of
posteriorly, and those producing internal rotation muscles has been derived from various methods
are often located anteriorly; but this relationship is of research including electromyography (EMG).
less consistent. Electromyography (G. electron, amber [electricity]
Initially it is helpful to try to deduce just the pri- + mys, muscle + grapho, to write) utilizes electrodes
mary one or two actions some of the more commonly inserted into the muscle (e.g., needle electrodes) or
known muscles would have and cross-check these applied to the skin over a given muscle (e.g., surface
Deducing Muscle Actions From Their Attachments
Use figures 2.19 and 2.20 for reference.

• Action of the middle deltoid muscle. Find the middle deltoid in figure 2.20, and use this to
locate the muscle on your body or a skeleton. Place your thumb on the estimated midpoint of the
proximal attachment and your little finger of the same hand on the estimated midpoint of the distal
attachment to establish the line of pull of the muscle. Now bring the distal attachment toward the
proximal attachment and see what shoulder joint movement occurs. Check this action with that listed
on figure 2.20.
• Action of the anterior deltoid and posterior deltoid. Repeat this procedure with the anterior
deltoid (figure 2.19) and posterior deltoid (figure 2.20).
• Reversal of customary action. This procedure demonstrates the customary actions of muscles
(with concentric contractions) in which the distal segment is the moving end. This is the easiest way
to learn muscle actions. However, keep in mind that in instances such as when the hand is fixed
(closed kinematic chain), these muscles can produce movement of the proximal segment (reversal of
customary action) or both segments simultaneously (e.g., push-up, pull-up, dips).
Attachments and Primary Actions of the Deltoid Muscle
Proximal Distal
Muscle attachment(s) attachment(s) Primary action(s)
Deltoid Anterior: clavicle Humerus (deltoid Anterior: Shoulder flexion
(DEL-toid) (lateral aspect) tuberosity) Shoulder horizontal adduction
Middle: scapula Shoulder internal rotation
(acromion process) Middle: Shoulder abduction
Posterior: scapula Shoulder horizontal abduction
(spine)
Posterior: Shoulder extension
Shoulder horizontal abduction
Shoulder external rotation
electrodes) to help record the electrical activity of process, for now focus on just the prime movers. A
muscles during various movements or conditions more detailed analysis can take into account second-
(see Basmajian and DeLuca, 1985). The greater the ary muscles, synergists, and stabilizers; this more
contraction of the muscle, the greater the frequency detailed approach will be reserved for chapter 8.
and amplitude of the recorded potentials. Results of Furthermore, simplify this process of analysis by
some of these studies will be referred to in ensuing first identifying the functional group of muscles that
chapters, and additional research methods helpful for would perform the movement (e.g., hip flexors, hip
movement analysis will be addressed in chapter 8. extensors, hip abductors) as seen in table 2.5, and
4. Determine the muscles that could produce then selecting one to three specific primary muscles
a given joint movement. In addition to learning that perform this desired joint movement.
the action(s) of a given muscle, it is important to 5. Take into account the influence of gravity
reverse that process and learn which muscles could and the type of muscle contraction. When one is
produce a given joint movement. This is impor- practicing this process of analyzing a movement, it is
tant for movement analysis. A summary table for important to remember that the influence of gravity
each region is provided in chapters 3 through 7 must be taken into account. In many phases of dance
to help with this process. A cumulative summary movements, gravity is fundamental in producing
is also provided in chapter 8. When performing this the movement, and muscles are used to control this
Electromyography
Examples of EMG records of three muscle groups for danc- FIRST POSITION–BALLET
ers directed to stand in first position, “prepared,” as if they S7 S3
were in class, is shown. Records from two professional ballet A
dancers and two advanced modern dancers were selected to
show the range in response with the same position. With this
version of testing, the magnitude of the tracing of a muscle Q
during a given movement is compared to that of a maximum
voluntary contraction of the same muscle with the same
electrode application.
H
Key:
FIRST POSITION–MODERN
A = hip adductor (adductor longus)
S13 S9
Q = quadriceps femoris (vastus medialis) A
H = hamstrings (biceps femoris)
TABLE 2.5 Simplified Movement Analysis of Demi-Plié in Parallel First Position
Type of Type of
contraction Knee contraction
Hip joint Hip muscle (sample Knee joint muscle (sample
Phase motion group muscles) motion group muscles)
Up-phase Hip Hip Concentric Knee Knee Concentric
extension extensors (gluteus extension extensors (quadriceps
maximus, femoris)
hamstrings)
Down-phase Hip flexion Hip Eccentric Knee flexion Knee Eccentric
extensors (gluteus extensors (quadriceps
maximus, femoris)
hamstrings)
Selected key joints: Hip, knee
movement set into play by gravity. For students new to the direction of movement, while movements in the
anatomy, this is a difficult concept to grasp. It is help- same direction as gravity will be produced by gravity
ful to consider whether the movement of the body or and controlled by eccentric contraction of muscles
its segments is primarily (1) opposite to the direction whose action is in the opposite direction to the joint
of gravity (upward) or (2) in the same direction as movement occurring.
gravitational forces (downward). For slow, controlled For example, in a plié in first position (figure
movements, movements opposite to the direction of 2.21), the up-phase would be going against gravity,
gravity are generally produced by concentric muscle and the knee extensors (quadriceps femoris) would
contraction of muscles whose action is the same as be working concentrically to produce knee exten-
FIGURE 2.21 Types of muscle contraction in which gravity plays a primary role.
sion. In contrast, the down-phase would be produced tal plane in both directions of the movement (e.g.,
by gravity, and the knee extensors would be working horizontal abduction and adduction). In fast move-
eccentrically to control knee flexion and prevent ments, the interplay of muscles and gravity becomes
the dancer from collapsing to the floor. So, even more complex; and concentric use of muscles to
though opposite motion is occurring at the joint accelerate segments, co-contraction of antagonists
(knee extension on the up-phase and knee flexion to control movement, and eccentric contractions to
on the down-phase), the same muscle group is decelerate body segments combined with gravita-
being used for both phases (concentrically on the tional forces often come into play. Understanding
up-phase to produce the movement and eccentri- the importance of gravity on muscle function is
cally on the down-phase to control and resist the essential for accurate movement analysis and will be
flexion tendency produced by gravity). So, one further discussed in chapter 8.
approach to movement analysis is to determine 6. Application to exercise design. Another way to
what muscle group is working on the concentric reinforce the understanding of a muscle’s action(s)
phase of the movement; this will tell you the muscle and location is to design exercises for strengthening
group responsible for the movement both on the a given muscle, stretching a given muscle, or prevent-
up-phase (concentrically) and on the down-phase ing injury to that muscle or a related structure. Chap-
(eccentrically). A basic schema for this approach is ters 3 to 7 contain samples of such exercises. When
provided in table 2.5 with the plié performed in a one is designing a strength exercise, at least one of
parallel position and analysis limited to the hip and the primary actions of the muscle must be opposed
knee joints for purposes of simplicity. Another way by the resistance. In order for the exercise to be effec-
of thinking of this is to note that when eccentric con- tive, this muscle must be challenged (overloaded)
tractions are involved, muscles are working that have sufficiently such that muscle failure is approached
the opposite action to the direction of movement within relatively few repetitions but muscle injury is
that is actually occurring. Also remember that when avoided. The American College of Sports Medicine
gravity would tend to produce a given movement recommendations (1998) are to perform 8 to 12
and no movement is occurring, isometric muscle repetitions of a variety of exercises. Some of the more
contractions are generally in play. difficult examples of strength exercises provided in
In slow movements of body segments that are the following chapters may initially require that fewer
perpendicular to gravity (horizontal or parallel to repetitions be performed (four to six repetitions) so
the floor), gravity does not have the same effect, and that excessive muscle stress is avoided.
muscles are often used concentrically to produce The resistance utilized in strength exercises can
movements and to maintain the limb in the horizon- take many forms, such as body weight, ankle weights,
dumbbells, springs, elastic bands, or guided weight moment arm working against gravity, but less back
apparatus. In the case of the first three forms of stress, hip extensor strengthening can be performed
resistance, an effective exercise also depends on with the torso leaning forward (such as with forearms
appropriate positioning of the body so that the action resting on a barre) or kneeling with the hands on
of the muscle is opposed by gravity. For example, the floor as seen in figure 2.22C.
when one is performing shoulder external rotation
with the elbows by the sides, an upright position of In the design of strength exercises for two-joint
the torso will allow effective opposition if a band is muscles, the exercise may incorporate movement at
being used for resistance, but not if a dumbbell is the just one of the joints or may combine the movements
resistance. Instead, using a side-lying position of the at both joints. In the latter case, the positioning
body would allow gravity to better resist the action of used at one joint can influence which muscle of a
shoulder external rotation. Similarly if one is trying functional group is being emphasized. For example,
to strengthen the hip extensors, lowering the leg the hamstrings can be strengthened by an exercise
from 90° would be hip extension but not effective using only knee flexion such as knee curls, an exer-
for strengthening the hip extensors. As seen in figure cise using only hip extension such as back leg lifts,
2.22A, this movement is going in the same direc- or an exercise that combines both actions such as
tion as gravity and would actually require eccentric seen in figure 2.22C. In this latter exercise, the knee
contraction of the opposite muscle group, the hip is just bent slightly to try to help the dancer “find”
flexors, to control the lowering of the legs. To make the hamstring muscle. Then, the leg is lifted higher
the hip extensors the prime movers, the leg would (hip extension), focusing on using this same muscle
have to be lifted to the back in order to be working group to lift the leg. This approach can be used to
against gravity as seen in figure 2.22B. However, in help the dancer emphasize use of the hamstrings
the standing position the range of motion is quite versus the gluteus maximus. In contrast, if the knee
limited without necessitating a marked anterior tilt is bent to an extreme range as seen in figure 2.22D,
of the pelvis and hyperextension of the lumbar spine, the hamstring will be so shortened across the knee
which could be of concern if a heavy resistance was joint that it will be difficult for it to be effective in
being used. Furthermore, greater challenge to the generating force for hip extension. This intentional
hip extensors will be provided when the leg lifts production of active insufficiency for the hamstrings
higher such that the moment arm for the resistance can be used to perform hip extension with a greater
is longer. To allow more range of motion with a long use of the gluteus maximus.
FIGURE 2.22 Influence of body position on hip extensor strengthening. (A) Ineffective relationship to gravity, (B) effec-
tive relationship to gravity but small range of motion, (C) effective positioning with hamstring emphasis, and (D) effec-
tive positioning with gluteus maximus emphasis.
When one is designing a stretching exercise for With two-joint muscles, the desired position of
a given muscle, the approach is different. Here a stretch is often achieved by incorporating elonga-
position is utilized that is opposite to, versus the tion of the muscle across both joints, at least to some
same as, at least one of the primary actions of the degree. For example, when stretching the hamstring
muscle such that the given muscle is put in a posi- muscle, a more flexible dancer would likely use a
tion of elongation. As previously described, three position of hip flexion and knee extension to pro-
repetitions of a 30-second slowly applied stretch of duce an effective intensity of stretch on the ham-
low to moderate intensity appear to be an effective strings such as seen in figure 2.23A. However, this
approach for improving flexibility. This method of combined use might create too great an intensity of
stretching, where a position is maintained, is termed a stretch or not allow appropriate positioning of the
static stretching. Another effective approach, termed body for a less flexible individual. In such a case, the
PNF contract-relax (proprioceptive neuromuscular knee can be slightly bent to allow correct position-
facilitation), utilizes a 5- to 10-second contraction of ing and an appropriate intensity of stretch either in
the target muscle immediately followed by a 10- to a sitting position or in a supine position as shown in
20-second stretch, with this sequence repeated three figure 2.23B. Gravity can be utilized in many ways
times (Shrier and Gossal, 2000; Tanigawa, 1972; during stretching of muscles. However, positions will
Wallin et al., 1985). While this is frequently used often be used in which gravity tends to approximate
for stretching outside of class, fewer repetitions and either the proximal or the distal body segment such
shorter-duration stretches are commonly employed that stretch intensity is increased. In the sitting ham-
within the dance class for a majority of muscle groups string stretch shown in figure 2.23A, gravity will tend
due to other programming considerations such as to bring the trunk (proximal segment) closer to the
class flow, maintenance of the elevated temperature thigh to increase hip flexion and stretch intensity. In
of the body, and time constraints because of the many the supine hamstring stretch shown in figure 2.23B,
other essential class objectives. gravity will tend to bring the thigh (distal segment)
FIGURE 2.23 Influence of body position on hamstring stretching. (A) Sitting, (B) supine, and (C) standing.
toward the trunk to increase hip flexion and stretch components. The elastic components play an impor-
intensity. In the advanced standing hamstring stretch tant role in stretching muscle and in the passive
shown in figure 2.23C (performed with the foot of contribution to muscle force. The contractile com-
the upper leg resting on a wall), gravity will intensify ponents are the active elements of muscle. According
the stretch (hip flexion) when the trunk is leaned to the sliding-filament theory, a coupling of small
forward. However, as flexibility progresses and the filaments within the muscle produces muscle tension
dancer gets closer to the wall, gravity plays less of a or contraction. The skeletal muscles are attached
role and the arms are classically used to pull the torso to bones via tendons or aponeurosis, and so muscle
further forward. contraction can be translated into rotary motions at
When one is considering appropriate exercises joints. Depending on the balance of torque related
for injury prevention and treatment, it is essential to to muscle effort and torque related to resistance at
understand the underlying mechanics or principles a given joint, muscle contractions can be dynamic
that are associated with a given injury. For example, (concentric or eccentric) or static (isometric). These
as will be discussed in chapter 5, improper movement different types of muscle contractions help muscles
(tracking) of the patella is believed to underscore serve their varied roles as prime movers, antagonists,
some injuries involving the kneecap. The quadriceps synergists, and stabilizers.
femoris muscle, and specifically the vastus medialis, is Individual muscles vary in their relative per-
vital for correct movement of the patella, and hence centage of slow-twitch and fast-twitch fibers, cross-
specific strengthening of the quadriceps femoris is sectional area, and fusiform or penniform fiber
one recommendation for prevention of such prob- arrangement in accordance with functional demands
lems. The addition of the sections on injuries to for greater force production, greater speed/range of
chapters 3 through 7 is not to suggest that readers motion, or greater postural control. When learning
who are not medical professionals diagnose and treat individual muscles it is helpful to take into account
their own injuries or those of their students/associ- the meaning of Latin or Greek word roots utilized in
ates. Diagnosis and treatment of injuries should be their names and locations. The location of the proxi-
performed only by qualified medical professionals. mal and distal attachments of a muscle creates a “line
Rather, the intent of these sections is to elucidate of pull,” and from the relationship of this line to the
some of the theorized relationships between injuries axis of the joint one can deduce the possible actions
and the anatomy and mechanics discussed in the of a muscle. Knowledge of the actions of muscles can
given chapter so that dancers can be more effective in also be used to analyze movements and predict the
preventing injuries and have a better understanding muscles that would function as prime movers in a
of why certain exercises might be recommended in given movement. To be accurate, such an analysis must
medically prescribed rehabilitation programs. take into account the role of gravity and the types of
muscle contractions occurring in different phases of
the movement. Knowledge of muscle actions can also
Summary be used to design effective strength exercises and
flexibility exercises, and to better understand why
Skeletal muscle gives rise to movements at joints. certain exercises would be valuable for prevention
Skeletal muscle contains both elastic and contractile and treatment of common dance injuries.

1. List the four properties of skeletal muscle and explain their practical significance for
dance.
2. Make a diagram of the contractile mechanism of a muscle cell and label and define the fol-
lowing structures: A band, I band, H zone, Z line, actin, myosin, and sarcomere.
3. Describe the sliding-filament theory and how it relates to concentric, eccentric, and isometric
muscle contractions.
4. Examine a pirouette, and describe when the calf muscles (gastrocnemius and soleus) would
be working concentrically, isometrically, and eccentrically.
5. What difference in muscle fiber types would you expect to see in a world-class marathon
runner versus a high jumper?
6. If the EA for a given muscle is 1.5 inches (3.8 centimeters) and the RA is 15 inches (38 centi-
meters), what would the mechanical advantage be? What is the significance of this mechanical
advantage in terms of the muscle force needed to effect movement against the resistance?
7. Describe how the relationship of the torque associated with muscle effort and the torque asso-
ciated with the resistance changes with concentric, eccentric, and isometric contractions.
8. Distinguish between a synergist and stabilizer, and provide two examples from dance.
9. Using figures 2.19 and 2.20 for reference, identify a muscle that can serve as an antagonist
to the following muscles: pectoralis major, gluteus maximus, erector spinae, biceps brachii,
and quadriceps femoris.
10. Describe how the serratus anterior and trapezius work as a force couple.
11. Using figure 2.14 for reference, locate the proximal and distal attachments of the rectus
femoris on the skeleton. Use these attachments to mentally construct the line of pull of the
rectus femoris, and deduce the actions the rectus femoris could have at the hip joint and
knee joint. Use figure 2.19 to check your deductions.
12. Apply the concept of active and passive insufficiency to the rectus femoris. Provide two examples
of movements in dance in which these phenomena would be operative and what you could
do to lessen the constraints.
13. Using the schema provided in table 2.5, perform a simplified movement analysis for raising
the arms to the front from low fifth to high fifth.
14. A dancer wants to improve her form in a grand jeté. Her teacher notes that her back knee
tends to bend and both legs do not reach adequate height to give the desired line in the
jump.
a. Describe what joint motions are occurring at the hip and knee of the front leg and the
back leg.
b. Describe how raising the front leg straight versus with a developing movement would affect
the moment arm of the leg and potential height of the front leg.
c. Taking into account the concept of active insufficiency, identify muscles that should be
strengthened to help increase the height the front leg can be raised. Taking into account
the desired hip joint motion of the back leg, identify muscles that should be strengthened
to help increase the height to which the back leg can be raised. Which of these muscles
would also tend to bend the knee of the back leg, and what muscle group could serve as
a synergist to neutralize this undesired knee flexion? Looking at the desired position at
the height of the leap, identify the muscles that would need very high levels of flexibility.
Provide a cue to help the dancer achieve the desired line of the back leg.
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The Spine
© Angela Sterling Photography. Pacific Northwest Ballet dancers Lisa Apple and Christophe Maraval.
CHAPTER THREE
71
T he spine, or vertebral column, is the central

organizing structure of the skeleton and the
most fundamental element of the axial skeleton.
is commonly called the spinal column or vertebral
column. These vertebrae are arranged in five con-
tiguous regions and are numbered consecutively
For this reason it is the first anatomical region dis- by region as seen in figure 3.1. Seven vertebrae are
cussed in this text. The vertebral column as a whole located in the neck region and are called cervical
articulates with the head, ribs, and pelvis, whereas vertebrae (C1-C7) (L. cervix, neck); 12 are in the
individual vertebrae articulate with each other. region of the chest or thorax and are called thoracic
These various articulations allow for movements vertebrae (T1-T12) (G. thorax, chest); five are in the
of the head, trunk, and pelvis. Due to its central low back region and are called lumbar vertebrae
location, the spine also functions to provide vital (L1-L5) (L. lumbus, loin); five form the sacrum
support for upright posture, and to transmit forces (L. sacred bone) at the back of the pelvis; and the
to and from the upper and lower extremities. In lowest four (three to five) are only partially formed
dance, great demands are placed on the spine to and make up the coccyx, or tailbone. Since in the
maintain the desired positioning of the torso and adult the five sacral vertebrae are fused to form the
help support another dancer during partnering sacrum and the four coccygeal vertebrae fused to
as shown in the photo on page 71. In addition to form the coccyx, only the upper 24 (7 cervical, 12
strength, dance movements such as arabesques or thoracic, and 5 lumbar) are movable. Although the
jazz layouts require exceptional spinal flexibility and number of cervical vertebrae tends to be constant,
complex neuromuscular coordination to achieve the numerical variations of thoracic, lumbar, and sacral
desired aesthetics of the movement. With dance, in vertebrae occur in approximately 5% of otherwise
contrast to many sports, great attention is also paid to normal people (Moore and Agur, 1995).
positioning or alignment of the spine whenever the The vertebrae found in each of these regions
limbs are in movement. Hence, better understanding differ in both shape and size in accordance with
of both how to move and how to stabilize the spine function. For example, the vertebral column as a
can enhance dance skill. whole is shaped like an extended pyramid such that
This chapter will present basic anatomy and the vertebrae get progressively larger from cervical
mechanics of the spine that influence optimal per- to lumbar regions. This arrangement has functional
formance and injury vulnerability. Topics covered significance since each vertebra must bear the weight
will include the following: of all the body parts above it, until the spine rests on
the sacrum, where the weight of the body is trans-
• Bones and bony landmarks of the spine
ferred. Since the weight of the body is transferred
• Joint structure and movements of the vertebral to the pelvic girdle via the sacrum, the bones of the
column coccyx do not have to support the weight of the
• Description and functions of individual muscles upper body and are much smaller.
of the spine Although there is variance in structure by region, a
• Ideal spinal alignment and common deviations typical vertebra consists of a vertebral body, vertebral
arch, and seven processes as shown in figure 3.2A.
• Spinal mechanics
The vertebral body is the large, cylindrical anterior
• Muscular analysis of fundamental spinal move- portion of the vertebra, through which most of the
ments weight of the body is transmitted. Extending posteri-
• Key considerations for the spine in whole body orly from the body is a hollow partial ring termed the
movement neural arch or vertebral arch, formed by two pedicles
• Special considerations for the spine in dance and two laminae. The pedicles (L. pes, foot) are short,
• Conditioning exercises for the spine broad processes that extend back from the body of
the vertebra to attach to the broad, flat plates of bone
• Back injuries in dancers called laminae (L. a thin plate). This vertebral arch
and the posterior surface of the body of the vertebra
form the walls of the very important opening, the
Bones and Bony Landmarks vertebral foramen (L. an aperture). The vertebral
of the Spine foramen from successive vertebrae of the vertebral
column form the vertebral canal or spinal canal,
The spine extends from the skull to the tip of the which houses and provides protection for the spinal
tailbone (coccyx). It is composed of 33 consecutive cord and its related membranes, vessels, and nerve
small bones called vertebrae (L. joint) and hence roots. Small indentations located on the upper (supe-
The Spine 73
FIGURE 3.1 Regions and curvatures of the vertebral column (lateral view) (A) at birth and (B) during adulthood.
FIGURE 3.2 Typical lumbar vertebra. (A) Superior view, (B) lateral view.
rior vertebral notch) and lower (inferior vertebral articular, and two inferior articular. The spinous pro-
notch) portions of the pedicles of adjacent vertebrae cess projects backward and downward from the junc-
form smaller openings called intervertebral foram- tion of the paired laminae. The spinous processes
ina as seen in figure 3.2B, which provide passageways are the projections you can feel, or palpate, when
for the nerves to leave the spinal cord. you run your finger down the back of your neck and
The vertebral arch also gives rise to seven pro- trunk. The spinous process that is particularly large
cesses—one spinous, two transverse, two superior at the base of the neck belongs to C7, and due to its
distinctive shape is termed the vertebra prominens be pushed out of the disc by the compression associ-
(L. prominent). The paired transverse processes ated with weight bearing. However, with repetitive
project posterolaterally from the junction of the loading, a small amount of water is lost from the
pedicles and the laminae. The spinous and transverse disc such that the spine undergoes up to an 0.8-inch
processes form important sites for the attachment of (2-centimeter) loss in height during the day (Hall,
ligaments and muscles of the vertebral column, and 1999), which is restored when pressures are relieved
they function to increase the mechanical advantage such as during sleep and recumbency. Conversely,
of these structures by allowing for an attachment when compression is decreased due to the loss of
farther away from the axis of rotation. The paired gravity during space flight, astronauts can undergo
superior and inferior articular processes are located a temporary increase in the height of the spine of
at the junctions of the pedicles and laminae. As their approximately 2 inches (5 centimeters).
name suggests, these processes form joints with the Each end of the disc is centrally closed by a thin
vertebrae immediately above and below. cartilaginous plate (vertebral endplate) that is firmly
adhered to the body of the adjacent vertebrae (figure
3.3). The inner zone of the annulus fibers is attached
Joint Structure and Movements to this endplate, while the outer peripheral zone
of the Vertebral Column attaches directly into the bony tissue of the vertebral
body (epiphyseal ring). When the spine is subjected
The vertebrae are generally joined to adjacent ver- to very large compression forces, these vertebral
tebrae both at the vertebral bodies and at the verte- endplates can sometimes fracture (Panjabi, Tech,
bral arches. These joints are collectively termed the and White III, 1980).
intervertebral joints. There are also some additional The intervertebral disc constitutes 20% to 33% of
specialized joints that occur in specific regions of the total height of the vertebral column (White III
the vertebral column and serve to help connect the and Panjabi, 1978), with disc thickness varying in dif-
skull, ribs, and pelvis to the spine.
Joints Between the Vertebral Bodies

The bodies of adjacent vertebrae from the second cer-
vical vertebra to the first sacral vertebra are connected
by cartilaginous joints, and the interposed cartilage
is termed the intervertebral disc. Each intervertebral
disc consists of an outer ring, termed the annulus A
fibrosus, and an inner gelatinous mass, termed the
nucleus pulposus as shown in figure 3.3. The annulus
(L. annulus, ring) fibrosus is composed of concentric
sheets or lamellae of fibrocartilage. The fibers run in
approximately the same direction in a given band but
in the opposite direction in any two adjacent bands
as shown in figure 3.3A. This structural arrangement
provides strength to the disc to help it withstand forces
and limit excessive motion in many directions. The
nucleus pulposus (L. the inside of a thing + fleshy)
is a deformable gel-like core that is about 80% water
in a healthy disc (Deckey and Weidenbaum, 1997)
and allows for rocking and rotating motion between
adjacent vertebrae, as well as essential absorption of
B
compression forces for the vertebrae.
During weight bearing, the nucleus pulposus
is compressed and exerts a large centrifugal force
on the fibers of the annulus as seen in figure 3.3B.
The nucleus pulposus contains charged molecules
(proteoglycans) that tend to pull water into the FIGURE 3.3 The intervertebral disc. (A) Transverse sec-
disc—important to counter the tendency for water to tion, (B) sagittal section.
The Spine 75
ferent regions from about 0.1 inch (3 millimeters) in is poorly covered and represents a weak area where
the cervical region to about 0.3 inches (9 millimeters) disc protrusion frequently occurs.
in the lumbar region (Levangie and Norkin, 2001). In
the cervical and lumbar regions the discs are thicker Joints Between the Vertebral Arches
anteriorly and help form the anteriorly convex curva-
tures found in these regions. In the thoracic region the The superior articular process of one vertebra
discs are more even in thickness, and the posteriorly articulates with the inferior articular process of the
convex curvature in this region is more due to the vertebra above to form the facet joints, more tech-
wedge shape of the vertebral bodies. nically termed zygoapophyseal or apophyseal joints
The bodies of the vertebrae and intervertebral (figures 3.2 and 3.5A). These facet joints are synovial
discs are further connected by ligaments—the ante- joints of the gliding variety. Hence, they allow small
rior longitudinal ligament and the posterior longi- gliding movements in various directions. The shape
tudinal ligament as seen in figure 3.4. The anterior and facing of the given articular processes are key in
longitudinal ligament is a strong, broad fibrous band determining the extent and direction of movement
that extends from the inner (pelvic) surface of the
sacrum up to the skull. This ligament covers and
connects the anterior aspects of the vertebral bodies
and the intervertebral discs. It functions to help
limit the extent of spinal hyperextension, maintain
stability, and prevent forward bulging of the annulus
of the intervertebral disc as seen in figure 3.5A. The
posterior longitudinal ligament is a narrower fibrous
band, having about half the strength of the anterior
longitudinal ligament (Levangie and Norkin, 2001).
This ligament runs along the posterior aspect of
the vertebral bodies, within the vertebral canal. It
is attached to the intervertebral discs and the pos-
terior edges of the vertebral bodies from C2 to the
sacrum. The posterior longitudinal ligament helps
limit extreme spinal flexion and posterior protru-
sion of the intervertebral discs as seen in figure 3.5B.
However, the posterolateral corner of the annulus
FIGURE 3.4 Primary ligaments of the spine (intertrans- FIGURE 3.5 Influence of (A) hyperextension and (B)
verse ligament not visible in this section). flexion on key spinal structures.
greater forces with hyperextension, lateral flexion,

and rotation; they have been shown to provide about
40% of the spine’s ability to resist rotational torsion
and must withstand 30% of the compression forces
accompanying hyperextension (Hall, 1999).
The facet joints are given further support by a
thin articular capsule and by more distant ligaments
of varying width and strength as seen in figure 3.4.
These ligaments span between adjacent transverse
processes (intertransverse ligaments [L. inter,
between]), laminae (ligamentum flavum), deeper
portions of the spinous processes (interspinous
ligaments), and tips of the spinous processes (supra-
spinous ligament [L. supra, above]). In the neck
region, the supraspinous ligament merges with the
ligamentum nuchae (L. nucha, back of the neck)
and actually provides a site for muscle attachment
(Moore and Agur, 1995). The ligamentum flavum
(L. flavus, yellow) also is unique in that its relatively
high elastic content (giving rise to its yellowish color)
allows it to aid with straightening the spine after it
has been flexed.
The various ligaments of the spine, including those
between the bodies and vertebral arches, have been
shown to be under tension during erect positions
and are very important for helping provide stability
to the vertebral column as a whole. The pre-tension
of these ligaments, in conjunction with the presence
of the intervertebral discs, helps resist the tendency
for the vertebral column to collapse. In addition,
the muscles, discussed shortly, are fundamental for
integrity as well as movements of the spine.
Specialized Vertebral Joints

There are some specialized joints associated with the
FIGURE 3.6 The role of the facet joints in spinal move- vertebral column. These joints help link the head,
ment (lateral view). Orientation of facets in (A) cervical ribs, and pelvis to the spine.
and (B) thoracic regions allows for more free rotation,
while (C) orientation in the lumbar region limits rotation. Craniovertebral Joints
The craniovertebral joints (G. kranion, skull)—the
possible between adjacent vertebrae and tend to vary atlanto-occipital and atlantoaxial joints—involve the
significantly in different regions of the spine as seen skull and the two most superior cervical vertebrae
in figure 3.6. For example, in the lumbar region, the (C1 and C2). These two uppermost vertebrae lack
more vertical alignment of the facet joints limits an interposed intervertebral disc, are not typical in
the degree of possible rotation (figure 3.6C), while shape, and are specialized to meet their function of
in the thoracic (figure 3.6B) and cervical regions helping support and move the head. The first cervi-
(figure 3.6A) the facet orientation allows more free cal vertebra is ringlike, without a body or spinous
rotation. While the forces on the facet joints are rela- process, as seen in figure 3.7A. Because it receives
tively small in standing and sitting, during bending the weight of the head, C1 is called the atlas (after
and lifting the lumbar facets take on a greater role in the mythical giant who is said to have supported the
spinal stability by helping prevent one vertebra from pillars of heaven). Its superior concave, oval articular
sliding forward on another (Fiorini and McCam- facets join with two rockerlike projections located
mond, 1976). These facet joints can also undergo on the lower skull (occipital condyles) to form the
The Spine 77
the axis, and the joint between C1 and C2 is called

the atlantoaxial joint (figure 3.7C). It is classified as
a pivot joint, allowing about 45° to 50° rotation and
giving rise to the “no” movement of the head (Hay
and Reid, 1982; Magee, 1997).
The extent of movement allowed at both of the
craniovertebral joints is much greater than allowed
at the other intervertebral articulations, permit-
ting freer movements of the head but leaving the
cervical spine vulnerable for injury. These motions
are normally constrained by various ligaments of
these craniovertebral joints. However, in trauma
or combat, the large ligament of the atlas, which
normally separates the dens from the spinal cord,
can be ruptured, allowing the dens to be driven into
the upper spinal cord or lower brainstem, often
resulting in paralysis or death (Moore and Agur,
1995).
Joints Between
Thoracic Vertebrae and Ribs
In addition to the intervertebral discs and facet joints
between adjacent vertebrae, most thoracic vertebrae
join with a rib via two gliding joints termed the cos-
tovertebral joint and the costotransverse joint. The
costovertebral joint (L. costa, rib) is formed between
the head of a rib and flattened areas (called facets
or demi-facets) on the side of the body of the corre-
sponding vertebrae or two adjacent vertebrae and the
interposed disc. The costotransverse joint is formed
between another facet on the distal portion of the
transverse processes and a small projection (tuber-
cle) found on each of the first 10 ribs (figure 3.8).
These 10 upper ribs progress from their attachment
onto the spine laterally and then course anteriorly to
attach to the sternum either directly (“true ribs”) or
indirectly (“false ribs”) via a segment of cartilage (the
FIGURE 3.7 Specialized cervical vertebrae: (A) The
atlas and (B) the axis articulate to form (C) the atlanto-
costal cartilages) as seen in figure 3.8A. The lower
axial joint. two rib pairs are shorter—they do not join onto the
sternum—and because their lateral ends are free,
they are called “floating ribs.”
paired atlanto-occipital joints. Although these are The 12 thoracic vertebrae, 12 ribs (and associated
condyloid joints, their parallel arrangement limits costal cartilage), and sternum make up the thoracic
their motion to primarily give rise to the “yes” move- cage, or rib cage. This arrangement provides an
ment, or nodding movement of the head, allowing important protective “cage” for vital structures
about 10° to 20° of flexion and 25° of hyperextension such as the lungs and heart, as well as stability for
(Hay and Reid, 1982; Magee, 1997). Moderate lateral upright stance and movement, yet allows for small
flexion and very limited rotation are also allowed at but important motions of the ribs that accompany
this joint (Levangie and Norkin, 2001). breathing. During vigorous inhalation, the ribs are
The second cervical vertebra has a unique large, elevated, while during exhalation the ribs return to
peg-like projection, termed the dens (L. tooth) or their normal position. This motion of the lower ribs
odontoid process, as seen in figure 3.7B. This process is referred to as the “bucket handle motion” of the
projects superiorly from its body to form a pivot for ribs (figure 3.8C), since it is like the motion in which
C1 (upon which the skull sits). Hence C2 is called a bucket handle is slightly lifted and lowered. Due
FIGURE 3.8 The thoracic cage and selected key joints. (A) Anterior view of key joints, (B) lateral view, and (C) superior
view of joints between ribs and vertebrae.
to the shape and orientation of the ribs, elevation further stability from two paired ligaments that span
creates more of an anterior increase in diameter in between the transverse processes of the lower lumbar
the upper ribs and a lateral increase in diameter in vertebrae and the crest of the ilium (iliolumbar liga-
the lower ribs. ment) or sacrum (lumbosacral ligament). However,
despite additional ligamental support, due to greater
Lumbosacral Joint disc thickness and joint surface area there is much
The lower portion of the spine is specialized for greater motion possible at the lumbosacral joint than
transference of weight through the pelvis. The joint between the initial lumbar vertebrae. Furthermore,
between the body of the last lumbar vertebra and unlike the gradual transitions seen between the
rigid sacrum (L5-S1), called the lumbosacral joint, other regions of the spine, a sharp angle termed the
is very important for movements of the spine and for lumbosacral angle occurs at the lumbosacral joint
the movements of the pelvis relative to the spine (the as seen in figure 3.9. This sharp angle increases the
latter are described in chapter 4). In addition to the tendency for the upper vertebrae to slide forward on
regular intervertebral ligaments, this joint receives the lower vertebrae (shear forces). The greater shear
The Spine 79
FIGURE 3.9 The lumbosacral angle (lateral view). (A) Normal, (B) increased, (C) decreased.
and greater motion associated with the lumbosacral lumbar region due to the more vertical orientation
joint and lower lumbar spine markedly increase the of the facet joints that resist such motion. It is help-
risk for injury, and approximately 75% (Grabiner, ful to keep these movement ranges in mind when
1989) of all serious back injuries occur at the L4-L5 one is analyzing and teaching the desired execution
and L5-S1 levels. of dance movements. For example, given the large
The lateral portions of the sacrum join with the potential extension in the lower lumbar vertebrae
pelvis via the paired sacroiliac joints. These joints and the relatively low amount of extension in the
will be discussed in chapter 4. thoracic region, it is easy to see why many dancers
excessively arch the low back and do not achieve the
Movements of the Vertebral Column desired extension higher in the spine in movements
such as port de bras to the back.
Movements of the vertebral column can be described While describing movements at individual motion
relative to the spine as a whole or relative to a given segments is key for research, injury prevention, and
motion segment (segmental movement). A motion rehabilitation, description of movements of the ver-
segment is composed of two adjacent vertebrae and tebral column as a whole is important for movement
their related soft tissue, including the interposed analysis and description of the actions of muscles.
intervertebral disc. Segmental movement varies And although movements between individual ver-
markedly by region (figure 3.10) (White III and Pan- tebrae are relatively small and include only gliding
jabi, 1978), but in general, movements of the verte- and cartilaginous joints, the summation of all of these
bral column are more free in the cervical and lumbar small movements produces a considerable range of
region. In contrast, they are more limited (except for motion of the spine as a whole, more comparable to
rotation) in the thoracic region due to their struc- that seen with a triaxial joint. Movements of the spine
tural linking to the relatively rigid rib cage. (also termed trunk) include flexion-extension in the
In terms of specific joint movements, flexion is sagittal plane, right lateral flexion-left lateral flexion
greatest in the cervical region followed by the lumbar primarily in the frontal plane, and right rotation-left
region. It is more limited in the thoracic region due rotation primarily in the transverse plane as seen in
to the presence of the ribs. Extension is most free in figure 3.11.
the cervical and lumbar regions. It is more limited in However, in functional movement, due to various
the thoracic region due to the longer, vertical spinous factors, including the presence of the anteroposte-
processes and the orientation of the thoracic curve rior curves of the spine and the facings of the facet
(convex posteriorly). Lateral flexion is greatest in the joints, movements of the spine often involve small
cervical and lumbar regions. It is more limited in the subtle movements in planes in addition to the plane
thoracic region due to the ribs. Rotation is free in of the primary movement. For example, rotation is
the upper cervical region (atlantoaxial joint) and generally associated with slight lateral flexion at the
the thoracic region. Rotation is more limited in the segmental level. This consistent linking of motion
FIGURE 3.10 Composite of segmental movements in different regions of the vertebral column.
Adapted, by permission, from A.A. White and M.M. Panjabi, 1978, “The basic kinematics of the lumbar spine,” Spine 3: 12-20.
FIGURE 3.11 Movements of the vertebral column. (A) Flexion-extension, (B) right lateral flexion-left lateral flexion, (C)
right rotation-left rotation.
80
The Spine 81
around one axis with motion around a different axis 3.1B. The cervical and lumbar curvatures are convex
is termed coupling (Levangie and Norkin, 2001). anteriorly, and the thoracic and sacrococcygeal
Skilled dancers often develop a complex array of curvatures are convex posteriorly. The thoracic and
muscle activation patterns to limit some of this cou- sacral curvatures are primary curvatures that develop
pling when the dance aesthetics require the look of during the fetal period and are present at birth (Hall-
motion of the spine as a whole in a single plane. For Craggs, 1985) as seen in figure 3.1A. The thoracic
example, some floor work in modern dance utilizes curve is due primarily to the wedged shape of the
rotation with a “long and lifted spine,” with minimal vertebrae in this region. In contrast, the cervical and
accompanying visible lateral shift or side-bending of lumbar curvatures do not fully develop until after
portions of the spine. birth and thus are termed secondary curvatures.
The cervical curve has been conjectured to develop
Muscles in response to the pull of the neck extensors as the
infant begins lifting the head up with sitting and
In addition to the many strong ligaments and joint crawling. The lumbar curve is further formed when
capsules of the vertebral column, many muscles act the child starts standing and walking. When the child
on the spine. These muscles range from small slips stands, the tightness of the iliofemoral ligament and
vital for local stabilization to large muscles capable hip flexors (see chapter 4) will tend to tilt the top
of generating large forces. Given the tremendous of the pelvis anteriorly, and the lumbar spine must
number of joints and the complexity of the spine, be extended to keep the torso upright. Unlike the
heightened by the presence of the normal sagittal other curves, the lumbar curve also tends to increase
curvatures, these muscles are vital for moving the during the growth years; an approximate 10° increase
spine, stabilizing the spine, and preventing injuries occurs between the ages of 7 and 17 (Hall, 1999).
that occur so readily in this region of the body. The lumbar curve is unique to the human species
and is believed to be a specialized adaptation to
upright stance and gait (Napier, 1967). The lumbar
Description and Functions and sacrococcygeal curvatures tend to be more pro-
of Individual Muscles nounced in females than in males. In contrast, the
thoracic curvature tends to be higher in males than
of the Spine females prior to age 40, and then similar, or in some
The back region contains approximately 200 muscles cases much greater, in females in later years (White
(Rasch and Burke, 1978), including muscles for res- III and Panjabi, 1978).
piration, moving the upper extremity, and moving When these sagittal curves are of normal mag-
the vertebral column. This text will simplify coverage nitude, their balanced presence contributes to the
to key muscles for stabilization and movements of springlike characteristics of the spine and allows it
the spine, and it will exclude many of the muscles to withstand greater forces and move more freely
that move the neck and head. The location of these than if it were a straight column. However, in some
selected spinal muscles has a logical relationship instances, one or more of these curves is excessive,
to their actions, with anterior muscles other than disrupting this balance and placing undue stress on
the iliopsoas producing spinal flexion, posterior some segments of the spine. Exaggerations of the
muscles producing spinal extension, and lateral normal curves in the sagittal plane include cervi-
muscles producing lateral flexion. Most anterior cal lordosis, kyphosis, and lumbar lordosis, while
and posterior muscles also have secondary actions a decrease in the lumbar curve is termed flat back
of spinal rotation and lateral flexion. Many of these (figure 3.23, p. 94). An abnormal curve occurring
muscles attach onto the pelvis and thorax rather than primarily in the frontal plane is termed scoliosis.
the vertebrae themselves, making their influence on Milder forms of these alignment problems may
the spine indirect. (See Individual Muscles of the relate to muscular imbalances and habitual move-
Spine, pp. 82-93.) ment patterns, but it is also important to realize that
these alignment conditions may be related to more
serious underlying pathology and may have a strong
Ideal Spinal Alignment genetic basis or psychological basis. Therefore, it is
and Common Deviations important that the dancer procure a good medical
evaluation if any of these conditions are accompa-
When one looks from the side, the spine is not a nied by pain, appear to be progressing, or are severe
straight column but has four curves as seen in figure in magnitude.
(Text continues on p. 93.)
Individual Muscles of the Spine

Anterior Muscles of the Spine
The anterior muscles of the spine include various muscles that primarily act on the head and neck
(sternocleidomastoid, three scaleni, prevertebral group), the abdominal muscles, and the iliopsoas. The
abdominal muscles are composed of the paired rectus abdominis, external oblique, internal oblique,
and transverse abdominis. The iliopsoas crosses the hip joint, as well as the spine, and only its func-
tion relative to the spine will be addressed in this chapter.
Attachments and Primary Actions of Rectus Abdominis
Muscle Inferior attachment(s) Superior attachment(s) Primary action(s)

Rectus abdominis Crest of pubis of pelvis, pubic Cartilages of ribs 5-7 Spinal flexion
(REK-tus ab-DOM-i-nis) symphysis Spinal lateral flexion (same)
Rectus Abdominis
As its name suggests, the rectus abdominis (rectus,
straight + abdom, abdomen) runs up and down, verti-
cally, in the central portion of the abdomen as seen
in figure 3.12. The rectus abdominis is a relatively
narrow muscle but prominent, and the right and left
recti are separated by a tendinous band called the
linea alba (linea, line + alba, white). The muscle fibers
are parallel in arrangement and are crossed by three
approximately horizontal fibrous bands termed tendi-
nous inscriptions, giving rise to the term “six pack”
used to describe highly developed abdominal muscles.
The rectus abdominis is located superficially and is
encased within a sheath formed by the aponeuroses
of the other abdominal muscles as seen in figure
3.21C. The primary action of the rectus abdominis is
spinal flexion, and the rectus abdominis is considered
the most powerful flexor of the spine. This action of
the rectus is used when one curls the torso up from FIGURE 3.12 The rectus abdominis (anterior view).
a supine position in floor work or performs “contrac-
tions” of the torso in modern or jazz dance. When one
side of the rectus abdominis contracts alone (unilateral contraction), the rectus abdominis can also
assist with spinal lateral flexion to the same side. Posturally, the rectus can also work to pull downward
on the rib cage, depressing the lower ribs and preventing “rib leading,” or to pull upward on the pubic
bone, creating a tucked position of the pelvis (posterior pelvic tilt).
Palpation: Lying on your back with your knees bent and feet flat on the floor, curl up so that your
head and shoulders rise off the floor. The rectus abdominis can be palpated just to the sides of the
midline of the abdomen running from the bottom of the sternum (xiphoid process) to the pubic bone
(symphysis pubis). Also, run your fingertips along the midline of the abdomen. Dancers who have
borne children may occasionally find a crevice between the paired recti abdominis. This separation in
the connective tissue—termed diastasis recti—can occur from the extreme stresses associated with
pregnancy and labor.
The Spine 83
Attachments and Primary Actions of External Oblique Abdominal Muscle
Muscle Lateral attachment(s) Medial attachment(s) Primary action(s)

External oblique Anterolateral aspect of lower Anterior crest of ilium, crest of Spinal flexion
(o-BLEEK) 8 ribs pubis, and linea alba Spinal lateral flexion (same)
Spinal rotation (opposite)
External Oblique Abdominal Muscle

(Obliquus Externus Abdominis)
As its name suggests, the external oblique (L. obliquus,
slanting, deviation from the vertical or the horizontal) is the
more superficial of the oblique muscles and runs diagonally
downward from its lateral attachments toward its more medial
attachments. The line of pull of the fibers of this paired muscle
can be pictured as forming the letter “V” on the front of the
abdomen, with each oblique forming one side of the “V.” It’s
a thin and flat but relatively expansive muscle, covering the
abdomen from the rectus abdominis to the latissimus dorsi
(figure 3.13). Due to its lateral location and its diagonal line
of pull, the external oblique tends to produce spinal lateral
flexion to the same side or rotation to the opposite side. With
rotation of the spine with the pelvis stationary, it pulls the
lateral side of the rib cage downward and medially toward the
midline of the trunk such as in twisting the torso. However,
when the right and left external obliques contract together
(bilateral contraction), they produce spinal flexion and the
same type of movements as the rectus abdominis. With their FIGURE 3.13 The external oblique abdomi-
curved position around the side of the abdomen, these muscles nal muscle (lateral view).
are also effectively positioned to help flatten the abdomen,
depress the lower rib cage, and maintain appropriate postural positioning of the torso and the pelvis.
Palpation: Curl up about 20° as just described for palpating the rectus abdominis, and then rotate
toward the left. You can palpate the contraction of the right external oblique by placing your fingertips
below the ribs and about 4 inches (10 centimeters) lateral to the navel (umbilicus).
Attachments and Primary Actions of Internal Oblique Abdominal Muscle

Internal oblique Thoracolumbar fascia, anterior Ribs 9-12, cartilages of ribs Spinal flexion
(o-BLEEK) 2/3 of iliac crest, lateral 7-9, and linea alba Spinal lateral flexion (same)
inguinal ligament Spinal rotation (same)
Internal Oblique Abdominal Muscle (Obliquus Internus Abdominis)

As indicated by its name, the internal oblique is situated more deeply beneath the external oblique.
Like the external oblique it is a very flat muscle, and it forms the intermediate layer of the abdomi-
nal muscles. Its upper fibers run diagonally upward in a medial direction from its more lateral lower
attachments at approximately a 90° angle to the external oblique muscles as seen in figure 3.14 (its
lower fibers run more horizontally). When the internal oblique contracts it can produce lateral flexion
to the same side and rotation to the same side such as with side-bending, off-center facings, or spi-
raling movements of the torso in dance. With rotation with the pelvis stationary, it pulls the medial
abdominal area laterally toward the iliac crest and

has been shown to demonstrate greater activity in
rotation than the external oblique (Ng et al., 2002).
In contrast, the external oblique has been shown to
exhibit greater activity in lateral flexion than the inter-
nal oblique. Bilateral contraction of the right and left
internal obliques can produce spinal or trunk flexion
and movements like those of the rectus abdominis.
Similar to the external obliques, the internal obliques
can also help flatten the abdominal wall, pull the lower
rib cage down, posteriorly tilt the pelvis, and maintain
spinal stability.
Palpation: Because the obliques and transverse
abdominis are thin layers of muscle running just
superficial or deep to one another, their individual
actions cannot be well differentiated. However, when
one performs the curl-up with rotation to the left (just
described for palpating the external oblique), the ten-
sion palpated on the left side of the abdomen, just
medial to the front of the crest of the pelvis, is in part
FIGURE 3.14 The internal oblique abdominal muscle
due to contraction of the left internal oblique.
(lateral view).
Attachments and Primary Actions of Transverse Abdominis

Transversus abdominis Thoracolumbar fascia, Linea alba, pubis Constriction of abdominal
(trans-VER-sus ab-DOM-i-nis) anterior 3/4 of iliac crest, wall and contents
lateral inguinal ligament, ribs Assists with spinal
7-12 (costal cartilages) stabilization
Transverse Abdominis
(Transversus Abdominis)
As its name suggests, the transverse abdominis (L.
trans, across + versus, to turn + abdom, abdomen)
runs across the abdominal area in an approximately
horizontal manner (figure 3.15). It forms the deepest
layer of the abdominal muscles, lying just beneath
the internal oblique muscles. Similar to the internal
and external obliques, it is a flat muscle, and its
muscular fibers are primarily situated at the sides of
the abdomen. The anterior aponeuroses of the trans-
verse abdominis fuse with the anterior aponeuroses
of the internal and external oblique muscles to form
a single tendon (linea alba) that splits centrally to
form a sheath, in which the rectus abdominis runs
vertically.
In contrast to the other abdominal muscles, the
transverse abdominis is considered primarily a
postural muscle and a muscle of respiration. With
its horizontally directed fibers, it is not capable of FIGURE 3.15 The transverse abdominis (anterolat-
producing spinal flexion. Instead, when its muscle eral view).
The Spine 85
fibers contract, the transverse abdominis compresses the abdominal contents. Hence, it is sometimes
referred to as the “corset muscle” because it encloses the abdominal cavity similarly to the way a corset
would. The transverse abdominis is used in such actions as forced expiration, coughing, sneezing,
speech, laughing, straining, and pulling the abdominal wall in toward the spine. Although in the case
of breathing, it appears that the transverse abdominis can be preferentially recruited, the other move-
ments just listed are not effected by the transverse abdominis alone but rather usually also include
contraction of the rectus abdominis to a lesser extent and obliques to a greater extent (De Troyer et
al., 1990; Floyd and Silver, 1950). The transverse abdominis has also been shown to be particularly
important for stabilization of the spine when the arms or legs move and for helping protect the spine
during lifting. In dance, the function of the transverse abdominis of “pulling the abdominal wall inward”
to help produce the aesthetically desired “flat abdomen” is often emphasized.
Palpation: Place your hand flat against your abdomen, with the heel of the hand below the ribs and
above the side of the ilium and the fingers pointing toward the umbilicus. Then, forcibly exhale. Part of
the tension felt under your hand is due to contraction of the transverse abdominis.
Attachments and Primary Action of Iliopsoas
Muscle Proximal attachment(s) Distal attachment(s) Primary action(s)

Iliopsoas (il-ee-o-SO-us)
Psoas major Transverse processes, bodies, Lesser trochanter of femur Hip flexion
(SO-us) and intervertebral discs of T12-L5 Posture (maintenance of
normal lumbar curve)
Iliacus Iliac fossa, crest of ilium, sacrum Lesser trochanter of femur Hip flexion
(il-ee-AK-us)
Iliopsoas
The iliopsoas—composed of the psoas major and
iliacus—is a powerful flexor of the hip, and this func-
tion will be further discussed in chapter 4. However,
it is important to note that due to its attachment
onto the anterior portion of the bodies, discs, and
transverse processes of the last thoracic vertebra
and entire lumbar spine (T12-L5), the psoas major
(G. psoa, muscles of the loin + great) also can
directly influence the lumbar spine, under most
conditions producing lumbar extension and lateral
flexion during upright standing (see Psoas Paradox
on p. 108 for more information). In contrast, the
iliacus (iliac, relating to the ilium) can indirectly
affect the curvature of the spine through its exten-
sive attachment on the pelvis (figure 3.16), since
pulling the top of the pelvis forward (anterior pelvic
tilt) is accompanied by an increase in lumbar exten-
sion. Hence, the iliopsoas is believed to be a key
FIGURE 3.16 The iliopsoas (anterior view).
for maintaining the normal lumbar curve (Hamilton
and Luttgens, 2002; Michele, 1960) during upright
sitting and standing (Basmajian and DeLuca, 1985; Nachemson, 1966), and bilateral tightness can
contribute to an excessive lumbar curvature (lumbar hyperlordosis), while excess length and weakness
can contribute to an inadequate lumbar curve (flat back posture). Unilateral iliopsoas tightness can
produce a lateral curvature of the spine (functional scoliosis) or slight rotations of the spine or pelvis
commonly seen in dancers.
Palpation: Sitting on the floor or in a chair, lean forward to relax the abdominal muscles and carefully
press your index and middle fingertips deep into the abdomen about 1 inch (2.5 centimeters) medial
to the front portion of the top of the iliac crest. Then lift the knee toward the chest (hip flexion) on
the same side without leaning back, and you should feel a tightening of the iliopsoas under the more
superficial abdominal wall.
Posterior Muscles of the Spine
The muscles located posterior to the spine (the postvertebral muscles) include muscles that primarily
act on the neck and head (splenius and suboccipital group) and a large number of paired muscles with
the common action of spinal extension. Although many classification schemas exist, this text will use
the classification of these spinal extensors into three groups—the erector spinae, semispinalis, and
deep posterior spinal group. Within these groups, the muscles are arranged from small slips spanning
adjacent vertebrae on the deepest level (deep posterior spinal group) to progressively larger slips with
the semispinalis and erector spinae. This arrangement allows for complex fine coordination with the
smaller slips and yet large force production with the longer slips.
Attachments and Primary Actions of Erector Spinae

Spinalis
Spinalis cervicis Spinous processes of C7 Spinous processes Spinal extension
(spi-NA-lis ser-VIS-us) (sometimes T1-2) of C2-C4 Spinal lateral flexion (same)
Spinalis thoracis Spinous processes Spinous processes Spinal extension
(spi-NA-lis tho-RA-sis) T11-L2 of upper thoracic Spinal lateral flexion (same)
vertebrae (T1-4 or T8)
Longissimus
Longissimus capitis Transverse processes Inferior, lateral skull Extension of head
(lon-JIS-i-mus kah-PIT-us) of T1-4 or T5, articular (mastoid process) Lateral flexion of head and
processes of C4 or C5-7 C spine (same)
Rotation of head (same)
Longissimus cervicis Transverse processes Transverse processes C spinal extension
(lon-JIS-i-mus ser-VIS-us) of T1-4 or T6 of C2-6 C spinal lateral flexion
(same)
C spinal rotation (same)
Longissimus thoracis Lumbar spinous Transverse processes Spinal extension
(lon-JIS-i-mus tho-RA-sis) processes, of T1-L5, posteromedial Spinal lateral flexion (same)
thoracolumbar fascia portion of lower 10 ribs Spinal rotation (same)
Iliocostalis
Iliocostalis cervicis 3rd-6th rib angles Transverse processes Spinal extension
(il-ee-o-kos-TA-lis ser-VIS-us) of C4-6 Spinal lateral flexion (same)
Spinal rotation (same)
Iliocostalis thoracis Upper borders of angles Angles of upper 6 ribs, Spinal extension
(il-ee-o-kos-TA-lis tho-RA-sis) of lower 6 ribs transverse process of C7 Spinal lateral flexion (same)
Iliocostalis lumborum Spinous processes Inferior border of angles Spinal extension
(il-ee-o-kos-TA-lis lum-BOR-um) of T11-L5, posterior of lower 6 or 7 ribs Spinal lateral flexion (same)
sacrum, iliac crest Spinal rotation (same)
The Spine 87
Erector Spinae
The erector spinae (L. erector, to raise or make erect
+ spina, spine) is a paired massive muscle that is
the most powerful extensor of the spine. It lies in
the trough on each side of the vertebral column. The
muscle begins inferiorly as a large mass but soon
divides into three approximately vertical columns of
muscle. The medial column is called the spinalis
(spina, vertebral column, spine); the intermediate
column is called the longissimus (longissimus, lon-
gest); and the lateral column is called the iliocostalis
(ilio, ilium + cost, rib). Each column can be further
divided into three parts in accordance with its superior
attachments as shown in figure 3.17. As can be seen
from viewing the attachments of these muscles, they
span different regions of the spine and are composed
of slips that generally span six to eight vertebral seg-
ments. Both the iliocostalis (thoracis and lumborum)
and longissimus (thoracis) have attachments onto
the ribs in the thoracic region, while the spinalis is
more centrally located and spans between vertebrae
and associated ligaments only.
Although different components and regions of
the erector spinae have slightly different actions,
their combined bilateral contraction can produce
extension of the spine, the head, or both such as
is used when raising the trunk back to vertical from FIGURE 3.17 The erector spinae (posterior view).
a forward-bent position. When one side contracts,
they all can produce lateral flexion to the same side, especially when used in combination with the
abdominal muscles. In addition, the longissimus and iliocostalis can produce rotation to the same
side for the spine or head such as is used to help twist the torso so that the shoulders face front in
an arabesque. The erector spinae also contribute to stability and protection of the spine.
Palpation: While standing, place your fingers flat against the low back with your right fingers just to
the right of the low lumbar spinous processes and your left fingers just to the left of the same spinous
processes. Slowly flex the trunk forward about 40° and then slowly raise the torso back to vertical. The
tension you feel under your fingers when the torso rises is due to contraction of the erector spinae. You
can also feel the erector spinae contracting on alternate sides when you walk slowly with your hands
in the same position as just described.
Attachments and Primary Actions of Semispinalis

Semispinalis (sem-ee-spi-NA-lis)
Semispinalis capitas Transverse processes of Occipital bone of skull Extension of head and C spine
(kah-PIT-us) C7-T7 Spinous processes 4-6 Lateral flexion of head and C spine (same)
Articular processes Segments above in cervical Rotation of head and C spine (opposite)
of C4-6 and upper thoracic regions
Semispinalis cervicis Transverse processes Spinous processes of C2-5 C and upper T spinal extension
(ser-VIS-us) of T1-6 C and upper T spinal lateral flexion (same)
C and upper T spinal rotation (opposite)
Semispinalis thoracis Transverse processes Spinous processes of C6- C and T spinal extension
(tho-RA-sis) of T6-10 T4 C and T spinal lateral flexion (same)
C and T spinal rotation (opposite)
Semispinalis
The semispinalis (semi, half + spina, spine) lies close to
the vertebrae beneath the erector spinae. It is divided into
three parts in accordance with its superior attachments
as seen in figure 3.18. As suggested by their name, these
three paired muscles are only located in the thoracic and
cervical regions of the spine. Except in the upper region,
the muscle fibers span from transverse process to spinous
process several vertebrae above, and so their line of pull
goes inward and upward from their inferior attachment. In
accordance with this line of pull, when one side contracts
the action is spinal lateral flexion and rotation to the
opposite side. When both sides contract together they can
produce extension of the thoracic spine, cervical spine,
or the head and are some of the muscles emphasized
when trying to strengthen the “upper back.” In dance,
the semispinalis is used with other spinal extensors to
achieve the desired arching of the upper back and a “long
and lifted” spine when the torso is vertical.
Palpation: Place the fingers of your right hand flat against FIGURE 3.18 The semispinalis (posterior view).
the lower neck just to the right of the low cervical spinous
processes, and the palm of your left hand against your
left temple. Slowly rotate your head to the left. The tension you feel under your fingers when the head
rotates is due in part to contraction of the semispinalis (capitis).
Attachments and Primary Actions of Deep Posterior Spinal Group

Interspinales Spinous processes of C and L Spinous process of vertebra Stabilization
vertebrae above Local spinal extension
Intertransversales Primarily transverse processes Primarily transverse process Stabilization
of C and L vertebrae of vertebra above Local spinal extension
Local spinal lateral flexion (same)
Rotatores Transverse processes of one Junction of laminae and Stabilization
vertebra, most developed in spinous process or transverse Local spinal extension
thoracic region process 1-2 vertebrae above Local spinal lateral flexion (same)
Local spinal rotation (opposite)
Multifidus Sacrum, ilium, transverse Spinous processes 2-4 Stabilization
processes of T1-T3 and vertebrae above from C2-L5 Local spinal extension
articular processes of C4-C7, Local spinal lateral flexion (same)
most developed in lumbar
Local spinal rotation (opposite)
region
Deep Posterior Spinal Group

The deep posterior spinal group includes the intertransversales, interspinales, rotatores, and multifi-
dus. These muscles are composed of a series of paired small slips that span one to four vertebrae in
various regions of the spine as seen in figure 3.19. In general, the intertransversales (inter, between)
span between transverse processes of adjacent vertebrae, the interspinales (inter, between) between
spinous processes of adjacent vertebrae, and the rotatores (L. rotatio, to revolve or rotate) and multifi-
The Spine 89
dus (L. divided into many clefts or segments) between

transverse and spinous processes. All of these muscles
share the common action of spinal extension when
both sides contract. In addition, unilateral contraction
of the intertransversales and multifidus can produce
small amounts of lateral flexion, while the rotatores
and multifidus can produce small amounts of rotation
to the opposite side. However, many of these deep
muscles have poor mechanical advantage and are
believed to be more important for helping stabilize the
spine, and helping to control segmental movement,
rather than producing the large forces associated with
movements of the spine as a whole (Basmajian and
DeLuca, 1985; Donisch and Basmajian, 1972; McGill,
2001; Panjabi et al., 1989). These muscles also have
higher densities of receptors (muscle spindles); these
provide feedback that can be used to detect and moni-
tor precise positions of vertebrae (Moore and Dalley,
1999; Smith, Weiss, and Lehmkuhl, 1996). Due to their
deep location, the deep posterior spinal group cannot
be readily palpated.
Lateral Muscles of the Spine
There is one paired muscle, the quadratus lumborum,

that is located posterolaterally versus anteriorly or
posteriorly. This lateral location gives it the unique FIGURE 3.19 The deep posterior spinal muscles
capacity to produce lateral flexion of the spine without (posterior view).
additional movements. The other muscles that can
produce lateral flexion are located either anteriorly, and so tend to also cause flexion (the abdominal
muscles), or posteriorly, and so tend to also produce extension (spinal extensors).
Attachments and Primary Actions of the Quadratus Lumborum Muscle

Quadratus lumborum Posterior iliac crest, 12th rib, tips of transverse Fixes or depresses lower rib
(kwod-RA-tus lum-BOR-um) iliolumbar ligament processes L1-4 Spinal lateral flexion (same)
Stabilizes spine and pelvis
Quadratus Lumborum
The quadratus lumborum (quad, four sided + lumb, lumbar region) is a flat muscle located on either
side of the spine behind the abdominal cavity in the low back area as shown in figure 3.20. Its fibers
run upward from the iliac crest to the lowest rib, with side slips running medially to attach to the top
four lumbar vertebrae. When one side of this muscle contracts it can produce lateral flexion of the
spine to the same side. Posturally, the quadratus lumborum can help depress the last ribs, stabilize
the spine, and keep the pelvis level. This latter function of not allowing one side of the pelvis to drop
relative to the rib cage is very crucial on the swing side during walking gait and on the gesture leg
during upright dance movements.
Palpation: Sitting in a chair with the upper torso hanging forward, place your fingertips below the last
rib and toward the spine (under some of the erector spinae if possible) on the right side. Then, hike
the right hip (bring the right iliac crest toward the ribs). The tension you feel is partly due to contraction
of the quadratus lumborum.
Summary of Spinal
Muscle Attachments and Actions
A summary of the attachments of the spinal muscles
is provided in table 3.1, and selected muscles and
attachments are shown in figures 3.21, A and B, and
3.22, A and B. From these resources, deduce the line
of pull and resultant possible actions of the primary
muscles of the spine; check your results by looking
at figure 3.21D and figure 3.22C.
FIGURE 3.20 The quadratus lumborum (posterior

view).
TABLE 3.1 Summary of Spinal Muscle Attachments and Primary Actions
Muscle Origin* Insertion** Primary action

Anterior muscles
Rectus abdominis Crest of pubis Cartilages of ribs Spinal flexion
(REK-tus ab-DOM-i-nis) of pelvis, pubic 5-7 Spinal lateral flexion (same)
symphysis
External oblique Anterolateral aspect Anterior crest of Spinal flexion

(o-BLEEK) of lower 8 ribs ilium, crest of Spinal lateral flexion (same)
pubis, and linea Spinal rotation (opposite)
alba
Internal oblique Thoracolumbar fascia, Ribs 9-12, Spinal flexion
(o-BLEEK) anterior 2/3 of iliac cartilages of ribs 7- Spinal lateral flexion (same)
crest, lateral inguinal 9, and linea alba Spinal rotation (same)
ligament
Transversus abdominis Thoracolumbar fascia, Linea alba, pubis Constriction of abdominal wall and
(trans-VER-sus ab-DOM-i-nis) anterior 3/4 of iliac contents
crest, lateral inguinal Assists with spinal stabilization
ligament, ribs 7-12
Psoas major Transverse Lesser trochanter Hip flexion
(S0-us) processes, bodies, of femur Posture (maintenance of normal lumbar
and intervertebral curve)
discs of T12-L5
Iliacus Iliac fossa, crest of Lesser trochanter Hip flexion
(il-ee-AK-us) ilium, sacrum of femur
Muscle Origin* Insertion** Primary action
Posterior muscles
Erector spinae (e-REK-tor SPEE-nuh): Spinalis
Spinalis cervicis Spinous processes of Spinous processes Spinal extension
(spi-NA-lis ser-VIS-us) C7 (sometimes T1-2) of C2-C4 Spinal lateral flexion (same)
Spinalis thoracis Spinous processes Spinous processes Spinal extension
(spi-NA-lis tho-RA-sis) T11-L2 of upper thoracic Spinal lateral flexion (same)
vertebrae (T1-4 or T8)
Erector spinae: Longissimus
Longissimus capitis Transverse processes Inferior, lateral skull Extension of head
(lon-JIS-i-mus kah-PIT-us) of T1-4 or T5, (mastoid process) Lateral flexion of head and C spine (same)
articular processes of Rotation of head (same)
C4 or C5-7
Longissimus cervicis Transverse processes Transverse C spinal extension
(lon-JIS-i-mus ser-VIS-us) of T1-4 or T6 processes of C2-6 C spinal lateral flexion (same)
C spinal rotation (same)
Longissimus thoracis Lumbar spinous Transverse pro- Spinal extension
(lon-JIS-i-mus tho-RA-sis) processes, cesses of T1-L5, Spinal lateral flexion (same)
thoracolumbar fascia posteromedial portion Spinal rotation (same)
of lower 10 ribs
Erector spinae: Iliocostalis
Iliocostalis cervicis 3rd-6th rib angles Transverse Spinal extension
(il-ee-o-kos-TA-lis ser-VIS-us) processes of C4-6 Spinal lateral flexion (same)
Iliocostalis thoracis Upper borders of Angles of upper Spinal extension
(il-ee-o-kos-TA-lis tho-RA-sis) angles of lower 6 ribs 6 ribs, transverse Spinal lateral flexion (same)
process of C7 Spinal rotation (same)
Iliocostalis lumborum Spinous processes Inferior border of Spinal extension
(il-ee-o-kos-TA-lis lum-BOR-um) of T11-L5, posterior angles of lower 6 or Spinal lateral flexion (same)
sacrum, iliac crest 7 ribs Spinal rotation (same)
Semispinalis Slips of muscles spanning several vertebrae Extension of head and C spine
(sem-ee-spi-NA-lis) from the transverse processes of C4-T10 to Lateral flexion of head and C spine (same)
the posterior skull or spinous processes of Rotation of head and C spine (opposite)
C2-T4
Deep posterior spinal group 1. Spinous process to spinous process Stabilization
(interspinales) Local spinal extension
2. Transverse process to transverse process Local spinal lateral flexion (same)
(intertransversales) Local spinal rotation (opposite)
3. Transverse process to laminae of
vertebra above (rotatores)
4. Generally transverse process to spinous
processes above (multifidus)
Lateral muscles
Quadratus lumborum Posterior iliac crest, 12th rib, tips Fixes or depresses lower rib
(kwod-RA-tus lum-BOR-um) iliolumbar ligament of transverse Spinal lateral flexion (same)
processes L1-4 Stabilizes spine and pelvis
*Inferior, lateral, or proximal attachment for anterior muscles; inferior attachment for posterior and lateral spinal muscles.
**Superior, medial, or distal attachment for anterior muscles; superior attachment for posterior and lateral spinal muscles.
91
FIGURE 3.21 Anterior view of primary muscles acting on the spine. (A) Muscles, (B) attachments, (C) sheath formed
by the aponeuroses of abdominal muscles, (D) line of pull and actions.
92
The Spine 93
FIGURE 3.22 Posterior view of primary muscles acting on the spine. (A) Muscles and attachments, (B) deep posterior
spinal group, (C) line of pull and actions.
Ideal Standing Postural Alignment centers of key weightbearing joints so that undue joint
stress is avoided and minimal muscular contraction is
Although controversial, this text will consider ideal required to maintain the desired positioning.
posture to encompass a balance of these sagittal More specifically, positioning of the line of gravity
curves and a positioning of joints so that the body’s allows much of the necessary support for the spine
line of gravity is located in the median plane and runs to be provided by intervertebral disc pressures and
in front of the thoracic vertebrae and just anterior to constraints offered by ligaments, fascia, and capsules
or through S2 as seen in figure 3.23A (Hamilton and of the facet joints (Caillet, 1996). Slight additional
Luttgens, 2002; Levangie and Norkin, 2001). This active support is often provided by low levels of activ-
gravity line would ideally pass through or close to the ity of the spinal extensors (particularly the thoracic
FIGURE 3.23 Curvatures of the spine. (A) Normal; (B) lumbar lordosis, thoracic kyphosis, and cervical lordosis;
(C) flat back; (D) scoliosis.
extensors and deep posterior spinal group) and the Provance, 1993). A plumb line is a cord with a weight
abdominals (particularly the internal obliques). As (plumb bob) attached to its distal end so that when
the gravity line continues downward, it runs slightly hung it will provide an absolute vertical line as a
posterior to the axis of the hip joint with the result- reference for measuring deviations. If one viewed
ing tendency for hip extension (extensor moment) a dancer from the side, the plumb line would be
limited by the iliofemoral ligaments (LaBan, Raptou, aligned with the ankle/foot (just in front of the lat-
and Johnson, 1965), and in some cases, slight activ- eral malleolus, which is the distal end of the fibula).
ity of the iliopsoas muscle (Basmajian and DeLuca, This would serve as the fixed point. Then, with ideal
1985); just anterior to the axis of the knee, with the alignment the following external landmarks would
resulting tendency for the knees to extend (extensor all be located right along the plumb line: the lobe
moment) limited by passive constraints (posterior of the ear, middle of the tip of the shoulder, middle
knee capsule and knee ligaments); and just anterior of the thorax, greater trochanter (projection on
to the ankle axis, generally requiring low levels of lateral femur), just in front of the middle of the
activity in the calf muscles (particularly the soleus) knee, and just in front of the lateral malleolus. Any
to prevent the body from falling forward (Basmajian of these landmarks that do not fall upon the plumb
and DeLuca, 1985; Floyd and Silver, 1950; Nachem- line would reflect deviations from ideal alignment.
son, 1966; Ortengren and Andersson, 1977). Assuming that the shoulders are not “rolled,” having
To utilize the concept of ideal postural alignment all of these landmarks aligned along the plumb line
practically, the vertical gravity line is reflected by a generally indicates a very basic correct balance of
plumb line, and surface landmarks on the body are the sagittal spinal curves.
used to reflect where this gravity line would actu- From this lateral view, the positioning of the
ally run inside the body (Kendall, McCreary, and pelvis should also be noted. With ideal alignment
The Spine 95
the pelvis is vertical (ASIS in a vertical plane with the many spinal structures, including the portion of the
pubic symphysis; see chapter 4) rather than tilted vertebrae (pars interarticularis) commonly involved
forward or backward. This positioning of the pelvis in stress fractures (spondylolysis). In addition to
will directly affect spinal alignment, as an anterior increased shear, fixed hyperlordosis is associated with
pelvic tilt tends to increase the lumbar curve while greater contraction of the erector spinae (Frankel
a posterior pelvic tilt tends to decrease the lumbar and Nordin, 1980; Wolf et al., 1979), which may allow
curve. Positioning of the spine and pelvis also affects low back muscle fatigue and strain to occur more
alignment of the lower extremity and can contribute readily. Furthermore, fixed lordosis can interfere
to such alignment deviations as hyperextended knees with the cyclic loading and unloading of the facet
(genu recurvatum) and rolling in of the feet (prona- joints necessary for proper cartilage nutrition, which
tion), discussed in later chapters of this text. may precipitate early breakdown of this cartilage
The body can also be viewed relative to a vertical (Stanish, 1979).
plumb line from the front or the back. When one Lumbar hyperlordosis is often prevalent in young
views the dancer from behind, the gravity line should dancers and is sometimes exaggerated in an effort to
bisect the distance between the heels and ideally be achieve greater turnout. However, at least in ballet,
in line with the spinous processes of the vertebrae. lordosis may decrease with years of training. Dance
When viewing from the front, the gravity line should training encompasses alignment directives that
again bisect the distance between the feet and ideally may tend to create straighter cervical, thoracic, and
be in line with midline structures such as the pubic lumbar curvatures. One study of young ballet danc-
symphysis, umbilicus, and nose. These anterior and ers showed that although lumbar range of motion in
posterior views provide the opportunity to see asym- extension was higher, the depth of lumbar lordosis was
metries between right and left sides of the body such significantly lower in dancers than in age-matched
as is associated with scoliosis. non-dancers (Livanelioglu et al., 1998). Similarly, in
another study of ballet dancers, lumbar hyperlordosis
Lumbar Hyperlordosis was very prevalent in Level 1 dancers but not in Level
6 or advanced/company dancers (Clippinger-Rob-
In the normal upright stance the sacrum tilts anteri- ertson, 1991). In contrast, in higher levels of dance,
orly and inferiorly an average of about 30° (normal fatigue posture was prevalent. So, it is important for
lumbosacral angle). This tilt necessitates that the dancers to realize that having hyperlordosis at one
lumbar spine extend (termed lordosis) in order to point in training does not mean that this will always
bring the torso upright (figure 3.23A), giving rise to be a problem, and care must be taken not to overcor-
the normal lumbar curve. However, in some individu- rect and excessively reduce the lumbar curve.
als there is an abnormally large lumbar curvature. When lumbar hyperlordosis is present, strength-
This postural condition is termed lumbar lordosis ening the abdominal muscles (figure 3.25A and
(G. lordosis, a bending backward), or more accu- table 3.4 [p. 134]) can often help improve the
rately lumbar hyperlordosis (figure 3.23B). Lumbar condition. Posteriorly, the spine forms a bony con-
hyperlordosis is often accompanied by an increased nection between the rib cage and pelvis. However,
inclination of the sacrum (increased lumbosacral in the front, this connection is effected purely by
angle), an anterior pelvic tilt, and sometimes a for- the abdominal musculature. Because of this struc-
ward displacement of the torso relative to the ideal ture, the strength, resting length, and activation
posture plumb line. of the abdominal musculature are very critical in
Lumbar hyperlordosis not only is undesirable determining the distance between the rib cage and
from a perspective of the aesthetics of many dance pelvis. That distance, in turn, affects the curvature of
forms but also may increase the risk for low back the lower spine and hence ideal alignment as seen
injury (Goldberg and Boiardo, 1984; Ohlen, Wred- in figure 3.24.
mark, and Spangfort, 1989). First, lumbar lordosis In addition to inadequate abdominal strength,
increases the tendency for the lower vertebrae to lumbar lordosis may also involve low back and hip
slide forward on the underlying vertebrae (shear flexor (especially the iliopsoas) tightness as seen
forces). For example, inclining the sacrum forward in figure 3.24A. Excessive lordosis associated with
10° or 20° is associated with an increase in the shear muscle tightness is particularly common during
force acting across the lumbosacral joint from 50% adolescent growth spurts (Micheli, 1983). If this is
of body weight to 65% or 75% of the body weight the case, stretching of the hip flexors (figure 3.25B
above this joint, respectively (Hamill and Knutzen, and table 4.7A [p. 224]) and low back (figure 3.25C
1995). This increased shear produces extra stress on and table 3.7, A and B [p. 144]) will also be necessary
FIGURE 3.24 (A) Lumbar hyperlordosis, (B) contraction of the abdominal muscles to establish the desired neutral
position of the pelvis and normal curve of the lumbar spine.
to improve the condition, and little improvement muscles) so that it is in line with the ASIS can help
will be seen with just strengthening the abdominal achieve neutral alignment. Overexaggeration of
muscles. Testing for range of motion of the hip flex- incorrect positions (anterior tilt and posterior tilt),
ors is recommended (see chapter 4) so that it can be visual cues, and tactile cues are often helpful for
determined whether these muscles are a contributing “relearning” neutral pelvis and ideal spinal align-
factor and need to be stretched. ment, as the lumbar hyperlordosis posture will feel
Unfortunately, improving strength and flexibil- “normal” and corrections foreign.
ity in key muscles is often not sufficient to correct Some dancers who have a greater degree of
lumbar hyperlordosis, and working with changing lumbar lordosis or who excessively extend the spine
movement patterns is also necessary. Studies sug- higher up also will tend to displace the lower ribs
gest that some individuals tend to maintain posture forward (sometimes termed “rib leading”) and may
more with the spinal extensors versus the abdomi- also need to focus on bringing the lower rib cage
nals (Klausen, Nielsen, and Madsen, 1981) and also “down and back.” In essence this involves a con-
show more prevalent use of the spinal extensors in traction of the abdominal muscles whereby both supe-
movement (Hamliton and Luttgens, 2002). Many rior and inferior attachments move and are brought
dancers with hyperlordosis appear to exhibit exces- closer together, shortening the distance between the
sive back extensor activation, and successful change front of the rib cage and pubic bone. Cueing to knit
in this posture for standing and dynamic movement the front of the pelvis and rib cage closer together while
often involves greater co-activation of the abdomi- still maintaining a lift along the central plumb line or
nal muscles and upper back extensors for correct lift of the upper back can sometimes be effective.
positioning and spinal stabilization. In an effort to Rehearsal of muscle activation patterns resulting
achieve this, cueing dancers to “pull the pubic bone in desired alignment should gradually progress from
up” (inferior attachment of some of the abdominal simple isolation exercises to simple dance skills such
A
D1 D2
FIGURE 3.25 Correcting functional lumbar lordosis. (A) Strengthening abdominal muscles; (B) stretching hip flexors;
(C) stretching low back; and (D) technique: activation of abdominal muscles to maintain neutral lumbopelvic alignment
in pliés.
97
DANCE CUES 3.1
“Pull Up With Your Abs”
T he cue to “pull up” or “lift” is often used in conjunction with the abdominal muscles (e.g., “pull
up or lift with your abdominals”) in response to seeing a dancer that is excessively arching the
low back and anteriorly tilting the pelvis. A desired anatomical interpretation of this cue is to contract
the abdominal muscles such that the inferior attachment onto the pelvis is the moving end, rotating
the pelvis posteriorly and decreasing lumbar hyperlordosis to achieve the desired neutral position
of the pelvis and normal curvature of the lumbar spine. However, some dancers misinterpret this cue
as one directing them to pull up the superior attachment of the abdominal muscles onto the rib cage,
requiring contraction of the thoracic spinal extensors versus abdominal muscles and resulting in “rib
leading,” or undesired backward movement of the upper back. Dancers can be assisted in achieving
the desired intent of “pulling up” by standing with one side to the mirror for visual feedback and using
one hand to maintain the lower anterior rib cage in its desired neutral position while the other hand
is placed on the low abdomen to encourage the use of the abdominal muscles to lift the pelvis to a
neutral position as shown in figure 3.24B.
as pliés (figure 3.25D) and rises to more complex perform abdominal work in a small range of motion
dance movement such as turning and jumping. (tending to create tightness) without stretching the
As strength, flexibility, and kinesthetic awareness abdominal muscles or balancing abdominal exercises
improve, the conscious effort required to maintain with back extension exercises utilizing a full range of
ideal alignment should decline or disappear. There motion. As with lumbar lordosis, postural kyphosis is
is evidence that shortened muscles may be more common in young children and adolescents; about
readily recruited in movement patterns (Pitt-Brooke, 25% of adolescents have kyphosis-related difficulties
1998); so restoring balanced strength and flexibility (Hall, 1999).
between the abdominal muscles, spinal extensors, In terms of correction, in normal standing and
and hip flexors should allow neutral alignment to sitting the gravity line falls in front of the thoracic
be achieved more easily. curve, tending to produce flexion of the thoracic
spine (particularly in females with larger breasts).
Kyphosis This tendency must be countered by consistent low
level activity in the thoracic extensors, such as the
Kyphosis (G. humpback) is characterized by an longissimus and multifidus muscles of this region
abnormal increase in the thoracic curvature as seen (Levangie and Norkin, 2001). Hence, strengthen-
in figure 3.23B. This excessive curvature can be ing the upper back extensors and using cues such
rigid in nature as a consequence of various diseases as “lift the upper back up toward the ceiling” to
or structural abnormalities, while in other cases encourage activation of these muscles are keys for
it is more flexible and functional in nature. The prevention and improvement of kyphosis. However,
latter more functional version is commonly seen in considering the range of extension is so much lower
sedentary individuals who sit with slumped posture, in the thoracic region than in the lumbar region, the
adolescents who carry heavy school backpacks, and challenge with upper back exercises is to stabilize the
athletes such as swimmers and weightlifters who have low back by firmly pulling up the inferior attachment
a strength or flexibility imbalance (or both) between of the abdominal muscles, while the focus is on the
anterior and posterior shoulder muscles (discussed relatively small movement in the upper back. The
in chapter 7) or spinal muscles. Dancers also some- exercises in figure 3.26 use the back of the chair to
times exhibit mild kyphosis that is associated with help the dancer focus on isolating movement to this
weak upper back extensors or inadequate thoracic upper back region for strengthening (figure 3.26A
extensor activation and the tendency to let the upper and table 3.4H [p. 137]), stretching (figure 3.26B),
back collapse and rest on passive constraints (fatigue and practicing correct alignment (figure 3.26C).
posture). This also sometimes occurs in dancers who When kyphosis is accompanied by a forward position
The Spine 99
A1 A2
B C1 C2
FIGURE 3.26 Improving kyphosis. (A) Strengthening upper back extensors; (B) stretching abdominal muscles and increasing upper
back range in extension; (C) technique: thoracic extension while maintaining neutral lumbopelvic alignment.
of the shoulder termed “rolled shoulders,” this must out Scheuermann’s disease or other medical condi-
also be addressed (chapter 7). tions. Scheuermann’s disease classically develops
However, if kyphosis is painful or pronounced, around puberty and actually involves a wedging of
it is important to seek a medical evaluation to rule one or more thoracic vertebrae related to abnormal
behavior of the epiphyseal plate. The pronounced This high incidence of fatigue posture in dancers
kyphosis (Dowager’s hump) seen with aging (and may relate in part to the tendency for many danc-
particularly in postmenopausal women) involves ero- ers to dramatically increase flexibility in the hip
sion and collapse of the anterior portion of one or flexors and other soft tissues to allow sufficient hip
more thoracic vertebrae due to osteoporosis. These hyperextension to achieve the desired aesthetic in
and other medical conditions produce a structural movements to the back such as arabesques. Since
versus functional kyphosis that requires specific with normal alignment the gravity line falls slightly
medical treatment. posterior to the axis of the hip joint, gravity would
Kyphosis is often seen in association with other tend to produce hip hyperextension. However, in the
spinal or pelvic deviations. When combined with dancer with increased range in this area, the normal
lumbar lordosis, the resultant postural deviation passive constraints that would limit this motion would
is termed kypholordosis. When combined with a not be operative until much later, allowing excessive
forward displacement of the pelvis, the resultant posterior tilting of the pelvis and hip hyperextension
condition is termed fatigue posture. (e.g., the fatigue posture) unless (a) the iliopsoas is
actively used to prevent this, (b) the center of mass
Fatigue Posture of the torso is moved slightly forward to lessen this
extension tendency (extension moment), or (c) both
Fatigue posture involves a forward displacement forms of correction are used. Another possible expla-
of the pelvis relative to the ankle and “plumb line” nation is that the lumbar flexion and posterior tilt of
(Tests and Measurements 3.1) and backward dis-
placement of the torso relative to the pelvis and
“plumb line” as seen in figure 3.27A. The posterior
torso is frequently kyphotic, and the lumbar curve
varies according to the level and degree of posterior
displacement of the torso. In contrast to lumbar
lordosis posture, fatigue posture classically involves
hip joint extension or hyperextension rather than
flexion, and generally a posterior rather than ante-
rior tilt of the pelvis. This posture gets its name of
fatigue posture from the fact that it involves resting
on the ligaments (especially the iliofemoral ligament
discussed in chapter 4) for support and thus requires
almost no muscular effort for maintenance. Hence,
it actually requires less energy to stand with fatigue
posture than with ideal posture.
However, sustained use of ligaments for support
can be detrimental, while the associated posterior
shift of the weight of the trunk alters force transmis-
sion in the low back area such that sacroiliac pain may
occur. The posterior position of the torso also distorts
the normal transfer of weight of the arms and head
to the spine and can be associated with upper back
and neck fatigue or pain, and a compensatory forward
position of the head. The fatigue posture occurs very
frequently in mature individuals and in highly trained
dancers. For example, in a study of university dance
students and another study of adult non-dancers,
the average hip marker was found to be anterior to
the knee in standing posture (Woodhull, Maltrud,
and Mello, 1985; Woodhull-McNeal et al., 1990).
A B
Similarly, in a study of young ballet dancers, about
half of Level 6 and almost all of the advanced/profes-
sional dancers studied displayed fatigue posture with FIGURE 3.27 (A) Fatigue posture; (B) activation of
relaxed standing (Clippinger-Robertson, 1991). thoracic spinal extensors and hip flexors.
The Spine 101
Evaluation of Standing Postural Alignment
Perform the following observations on another dancer or on yourself (with your side to a mirror) using
figures 3.23 and 3.27 for reference. Observation will be easier if a bathing suit or leotard and tights
are worn. One can devise a plumb line by attaching a piece of string overhead and hanging a plumb
bob or some other small weight from this piece of string. The piece of string should be long enough
that the weight just clears the floor.
General Observation
Have your partner stand upright with the legs parallel and feet under the hip joints. Apply markers
(adhesive dots, small pieces of masking or colored tape) to the landmarks shown in figure 3.27.
Situate your partner with her or his side to the plumb line so that it runs through the ankle marker.
Note the relationships of the landmarks and the curves of the spine to each other and the plumb
line. Attempt to classify this standing alignment, noting the presence of ideal, lumbar hyperlordosis,
kyphosis, flat back, or fatigue posture.
Replicate Common Postural Deviations
To help train your eye and understand the differences, have your partner perform the following maneu-
vers, and note the changes in the spinal curves; changes in the relative positioning of the head, torso,
and pelvis; and changes relative to the plumb line.
1. Round and sink backward into his or her upper back to simulate kyphosis.
2. Tilt the top of the pelvis forward and arch the low back to simulate lumbar hyperlordosis.
3. Press the bottom of the pelvis forward and let the upper back relax backward to simulate fatigue
posture.
4. Tuck the pelvis slightly, pull the abdominal muscles back against the lumbar spine, and lift the
spine upward as much as possible to simulate flat back posture.
Apply to Simple Movement
Repeat the same alignment observation with your partner performing a first position plié and rise
(parallel and then turned out). Note if the general postural pattern observed with standing remains
or changes.
the pelvis may reflect an effort to stabilize the lumbar are too tight or strong (or both) relative to the back
spine (McMeeken et al., 2002), which is known to extensors. This overcorrection can readily be avoided
have marked increased mobility in dancers. by including stretches for the abdominal muscles
The fatigue posture can often be improved with or full range of motion abdominal exercises, such
strengthening of the upper back extensors (figure as seen in figure 3.28C (and table 3.4C, variation 1
3.28A and table 3.4H [p. 137]), and sometimes the [p. 134]), and spinal extension exercises (table 3.4,
hip flexors (figure 3.28B and table 4.5, A-C [pp. 213- I and J [p. 138]), which will dynamically stretch the
214]). In some cases abdominal tightness is also a abdominal muscles, in one’s regular routine.
factor, and stretching is advised. When rolled shoul- However, as with other postural problems, success-
ders are involved, this must also be addressed. With ful correction of the fatigue posture often requires
some dancers, fatigue posture can actually relate to changing muscle activation patterns and breaking
overcorrection of lumbar lordosis. Performing lots habitual patterns. Since the fatigue posture is a pas-
of abdominal exercises in short ranges of motion sive posture involving hanging on the ligaments,
(e.g., curl-ups) in an effort to correct lumbar lordosis muscles need to be activated to avoid this posture.
over a long period of time can sometimes lead to the Use of the upper back extensors will tend to decrease
opposite imbalance in which the abdominal muscles the exaggerated thoracic curve (kyphosis), while a
A
C1
C2
FIGURE 3.28 Improving fatigue posture. (A) Strengthening upper back extensors; (B) strengthening hip flexors if indicated;
(C) performing abdominal strengthening incorporating a range in which the abdominals are dynamically stretched.
102
The Spine 103
small co-contraction of the abdominal muscles can the natural curve (lordosis) in their cervical spines,
be used to bring the torso forward (so that it is more and so working with a qualified physical therapist is
directly over the pelvis) and into alignment along advisable if this condition is marked.
the plumb line. This repositioning of the torso will
also lessen the forces (extensor moment) tending to Flat Back
cause the hip hyperextension and posterior tilting
of the pelvis associated with the fatigue posture. Flat back posture involves a decreased lumbar curve
Cueing to “lift the upper back up and forward,” as such that the low back looks flat as seen in figure
though there was a string attached to the spine (at 3.23C. The flat back posture reduces the normal
a level between the shoulder blades) that is being shock absorbency of the spine and is hypothesized
pulled up on a slight forward diagonal, can often to contribute to disc degeneration. Interestingly,
be used to find correct positioning. If slight hip having decreased curvatures of the spine is thought
hyperextension is still present, slight activation of the to increase the risk for low back injury (Klausen,
hip flexors (iliopsoas) by cueing to bring the front Nielsen, and Madsen, 1981; McMeeken et al., 2002),
of the pelvis slightly forward toward the thigh can just as having excessive curvatures can increase
be used to establish the desired neutral position of injury risk. The flat back posture is sometimes seen
the pelvis and hip joint (figure 3.27B). in dancers who have worked so hard to decrease
their excessive lumbar lordosis that they have actu-
Cervical Lordosis and Forward Head ally overcorrected and taken out the desired curve
in their lumbar spines. It is also likely that the
An increased curve in the upper back (often associ- cueing and alignment encouraged in many forms
ated with kyphosis) can bring the head forward and of dance, focusing on “lengthening the spine,“
the eye level down. To reach a horizontal eye level, tend to decrease the cervical, thoracic, and lumbar
the upper neck is then brought into extension, curvatures. Whether the extent of curve reduction
resulting in cervical lordosis and an undesired
forward positioning of the chin termed forward
head (Palmer and Epler, 1990) as seen in figure
3.29A. This forward position also moves the center
of gravity of the head in front of the line of grav-
ity of the body; and Caillet (1996) estimates that
when the head is 3 inches (7.6 centimeters) for-
ward, the weight of the head (approximately 10
pounds or 4.5 kilograms) exerts about 30 pounds
(13.6 kilograms) of torque on the cervical spine.
This places excessive demands upon the spinal
extensors and facet joints.
Over time, this position tends to create a short- A B
ening of the cervical extensors; and neck presses
(figure 3.29B), in which the chin is brought down
and the head is gently pressed back against the
hand for 5 seconds, are often recommended for
relief. The neck extensors can also be stretched
using the hand to gently lengthen the neck by
bringing the head “out and forward” on a slight
diagonal (figure 3.29C). However, when kyphosis
is involved, correcting the kyphosis is essential
for correct head positioning. Use of images such
as bringing the chin slightly back and imagining
“being suspended from just behind the ears” can
C D
sometimes help get the desired length in the neck
and avoid the tendency for the chin to jut forward
(figure 3.29D). However, care must be taken not to FIGURE 3.29 Improving forward head. (A) Forward head posture;
excessively stretch or straighten the neck. When X (B) strengthening neck flexors with neck press; (C) stretching neck
rays are taken, many dancers find that they have lost extensors; (D) technique: chin back with neck lifting up.
associated with such dance training has long-term different orientation of the transverse processes, or a
negative health consequences and whether greater spinous process that is not centrally located. Surpris-
curvatures automatically return when training stops ingly, about 90% of structural scoliosis occurs with
will require investigation. no known cause (Mercier, 1995); this type of scoliosis
Correction of flat back posture is controversial, with no known cause is termed idiopathic scoliosis
but in some cases may be aided by strengthening (G. idios, one’s own + pathos, suffering).
the low back extensors as well as the hip flexors Although the causes of idiopathic scoliosis are
(iliopsoas). In other cases this posture is more related poorly understood, there is strong evidence that
to repetitively standing in a passive posture (such as familial factors play a role; the risk of having scoliosis
fatigue posture) in which the pelvis is tucked (poste- increases about 10 times if someone in your immedi-
rior pelvic tilt), thereby decreasing the lumbar curve. ate family has it. Gender also plays a role in terms
In this case, successful correction will require the use of incidence and severity; females are 8 times more
of lumbar supports and a re-education of static and likely than males to require treatment for scoliosis
dynamic alignment focusing on restoring a neutral (Liederbach, Spivak, and Rose, 1997). Activity also can
pelvis and associated normal lumbar curve. influence scoliosis incidence. Although this influence
was originally believed to be linked to muscle imbal-
Scoliosis ances associated with asymmetrical occupations and
sports, the elevated incidence of scoliosis in activities
Scoliosis (G. skoliosis, crookedness) is characterized considered more symmetrical (e.g., swimming and
by a lateral curvature of the vertebral column in an ballet) suggests this association is more complex than
approximately frontal plane. When one looks from initially believed (Becker, 1986; Sward, 1992).
behind the vertebral column, the spine ideally runs While the incidence of scoliosis for the general
approximately straight up and down. It is common to U.S. adolescent population has been estimated to be
have a very slight right thoracic curve, which has been between 10% and 16% (Akella et al., 1991; Trepman,
conjectured to be due to the position of the aorta or Walaszek, and Micheli, 1990), studies of female ballet
handedness (White III and Panjabi, 1978). However, dancers have reported incidences of 24% (Warren
the presence of an appreciable lateral curve or curves et al., 1986), 33% (Hamilton et al., 1997), 40.7%
of the spine as seen in figure 3.23D is termed scolio- (Akella et al., 1991), and 65% (Molnar and Esterson,
sis. Scoliosis can involve a single lateral curve, termed 1997). The higher incidence of scoliosis found in
a “C” curve, or multiple curves. When two alternating dancers may relate to a higher familial incidence;
curves are present the curve is termed an “S” curve as the common recommendation for children with
seen in figure 3.30B. The vertebrae involved with the scoliosis to take ballet; a greater prevalence of a taller,
lateral curves also frequently rotate, generally with more ectomorphic body type; a greater prevalence
the spinous processes turning toward the concavity of increased flexibility or actual hypermobility;
of the abnormal curvature (figure 3.30D). This gives the tendency for prolonged growth spurts due to
rise to the prominent raised portion of the posterior delayed maturation; low estrogen levels associated
rib cage (“rib hump”) to one side of the spine, often with delayed maturation and disrupted menstrual
evident in dancers with scoliosis, as shown in figure cycles (amenorrhea); and inadequate nutrition
3.30C. This rotation also appears to have a very nega- with suboptimal calcium and vitamin D. Further
tive impact on spinal mechanics, and current models investigation of causative factors is important so that
of scoliosis suggest that scoliosis be visualized as a prevention can be better addressed. Prevalence of
complex three-dimensional deformity with torsion(s) scoliosis in dance forms other than ballet warrants
similar to an elongated helix. further investigation.
Scoliosis can be divided into two types—nonstruc- Given its high incidence, it is important that danc-
tural scoliosis and structural scoliosis. Nonstructural ers and their teachers have a basic understanding of
scoliosis is reversible and will generally improve when the detection and treatment of scoliosis. Although it
the underlying condition is treated. Examples of may be seen at any age, scoliosis is usually detected
underlying conditions include leg length difference, clinically between the ages of 10 and 13. Detection
muscle spasms, asymmetrical muscle development, often relates to noticing apparent asymmetries or
and handedness patterns. In contrast, structural sco- results of screening tests such as the forward bend
liosis is generally considered irreversible and involves test (described in Tests and Measurements 3.2) com-
structural changes both within and between the ver- monly used in schools. Early detection is important
tebrae. For example, a vertebra may be asymmetrical because the combination of bracing, therapeutic
as a consequence of having different length pedicles, exercise, and other therapeutic treatments may be
The Spine 105
able to halt or slow further progression in moderate single strap over one shoulder, to regularly switch
curves (>25°). Unfortunately, if curves are allowed the side on which it is carried. In some cases, using a
to progress to about 40° (see figure 3.30A for one small bag on wheels that can be pulled with alternate
method of measurement), very drastic surgery involv- arms may be a better option. Dancers should also
ing spinal fusion along the length of the abnormal regularly perform exercises for trunk stabilization
curve and various forms of instrumentation to try to and abdominal and back extensor strength that
stabilize the spine may be recommended (Warren emphasize rotation (Mooney, Gulick, and Pozos,
et al., 1986). So, dancers should watch for asym- 2000), while taking extra care to work for symmetry
metries and seek medical evaluation if scoliosis is in their stretching exercises, strengthening exercises,
suspected. and dance technique. If teaching dance, care must be
In terms of prevention, dancers should also be taken to avoid demonstrating on the same side and
careful to carry their dance bags and books in a to avoid consistent one-sided biases in choreography
backpack worn over both shoulders, or if using a (e.g., always turning one way).
FIGURE 3.30 Scoliosis (posterior view except superior view on D). (A) Cobb method of measuring curvatures, (B) struc-
tural scoliosis with widened rib space on convex side and narrowed rib space on concave side of thoracic curvature,
(C) visible rib hump with forward bend test, (D) rotation of vertebrae and effect on thoracic cage.
Detection of Scoliosis
Perform the observations and forward bend test on another dancer as described next, using figure
3.30 as a reference. Observation will be easier if female dancers wear a swimsuit top, a halter top,
or a backless leotard and if male dancers remove their shirts.
General Observation
Have your partner stand upright with the legs parallel and feet under the hip joints. Viewing your partner
from both the front and back, note any apparent asymmetries such as a difference in shoulder height,
scapular prominence, unequal height of hands or distance of arms from sides of body, difference in
height of one side of the pelvis versus the other, one side of the pelvis rotated farther forward than
the other, unequal waistline, or leg length discrepancy. Standing from behind, palpate the spinous pro-
cesses from the top of the neck to the sacrum and note any apparent lateral curvature or rotation.
Forward Bend Test
Then, observing from directly behind, have your partner very slowly bend forward (“roll down”), start-
ing from the top of the head, and progress downward while the arms hang free by the sides. Look
for symmetry of the sides of the trunk at each level of the spine and note whether one side is higher
and if there is a “rib hump.”
Note: Although helpful, it is important to realize that many factors such as leg length difference and
handedness patterns can create asymmetries. However, young dancers with apparent scoliosis are best
referred for medical evaluation to determine the basis and magnitude of apparent asymmetries.
Although a well-balanced “S” scoliosis, even if Abdominal Contraction for Spinal Protection
involving large curvatures, does not necessarily pre-
clude a professional dance career, it is associated The spine can be subjected to tremendous forces
with an increased risk for stress fractures (Warren et during dance and other athletic endeavors. It has
al., 1986) and low back injury. In the experience of been calculated that 2,071 pounds (939 kilograms) of
the author, even many dancers with low curvatures force is imposed on the lumbosacral disc as a person
(especially when accompanied by larger rotations) leans forward and lifts a 170-pound (77-kilogram)
experience asymmetry in their work. Hence, par- weight off the ground (Morris, Lucas, and Bresler,
ticular attention should be directed toward avoiding 1961). Similarly, a study of selected aerobic dance hip
further development of asymmetries, with assistance extension exercises (involving motions similar to those
procured from a qualified physical therapist if utilized in dance) showed that torque values occur-
needed. Furthermore, attention should be paid to ring at the lumbar spine were greater than those that
preventative measures for stress factors (including are estimated to accompany lifting a 100-pound (45-
nutritional and hormonal) discussed in chapter 1. kilogram) load (Hall and Lindoo, 1985). Such large
forces approach or even exceed the forces found to
damage discs (Bartelink, 1957) or the bony vertebrae
Spinal Mechanics themselves (Eie, 1966) when they are removed from
cadavers and studied in a laboratory setting. The fact
The fact that the normal spine is comprised of many that apparent damage to the spine does not occur
consecutive segments with alternating curves influ- during such rigorous functional activities (despite
ences its vulnerability to injury and the actions that meeting or exceeding experimental loads that pro-
muscles can have on it. The abdominals appear to duced damage) suggests that in the living organism,
play a particularly key role in protecting the spine via something must serve to protect the spine.
mechanisms still under investigation. One example One of the mechanisms that may provide protec-
of how changes in spinal curvature can affect mus- tion for the spine is intra-abdominal (L. within the
cles’ action is illustrated with the psoas paradox. abdomen) pressure (IAP). Intra-abdominal pressure
The Spine 107
is described as the pressure that can be generated if muscles including the transverse abdominis, internal
the muscle walls around the abdominal cavity are con- obliques, erector spinae, multifidus, quadratus lum-
tracted (abdominal muscles, diaphragm, pelvic floor borum, latissimus dorsi, and gluteus maximus. Due to
muscles). The function of IAP was originally described its posterior attachments onto the spine, this thoraco-
by Bartelink (1957) as that of acting like a fluid ball lumbar fascia tensioning theory holds that when the
that resists deformation as soon as the pressure within thoracolumbar fascia is tightened it tends to produce
is raised as seen in figure 3.31A. This was theorized to extension that could assist in movements such as lift-
provide an additional route to help transfer forces from ing, or at least in stabilizing the spine (Richardson,
the torso to the pelvis such that an unloading effect Hodges, and Hides, 2004), thus decreasing the load
estimated to be as high as 30% to 50% is offered to the on the lumbar spine (Levangie and Norkin, 2001).
spine (Morris, Lucas, and Bresler, 1961). Still another theory (muscle fusion) holds that con-
Although this original model has been challenged traction of the abdominal muscles has the opposite
by recent studies, there is still support for the concept effect, that is, that it tends to pull the lumbodorsal
that the abdominal muscles play a role in protecting fascia laterally and to lessen lumbar lordosis, reduc-
the spine. One alternate explanation is that the con- ing shear and allowing more efficient support of the
traction of the abdominal muscles (particularly the spine (Plowman, 1992; Saal, 1988b).
transverse abdominis) reduces shear forces by push- Whether IAP, shear reduction, thoracolumbar
ing back against the front of the lower spine, resisting tensioning, or a combination of these mechanisms
lumbar hyperextension and anterior sliding of the is operative, strengthening the abdominals and
vertebrae as seen in figure 3.31B. Another theory is focusing on using them prior to rigorous move-
that contraction of the abdominal muscles may help ments (such as lifting a partner) should theoretically
increase stiffness of the trunk so that the spine does increase their protective effect for the spine. Studies
not buckle when loads are applied (Hall, 1999). A of IAP have shown the amount of IAP that can be
related theory is that contraction of the abdomi- generated is much greater in athletic individuals and
nal muscles (specifically the transverse abdominis elite weightlifters than in slight, nonathletic individu-
and internal oblique abdominal muscles) and the als (Bartelink, 1957; Eie and Wehn, 1962; Grieve,
resultant IAP act by tensioning the thoracolumbar 1978). Studies suggest that the transverse abdominis
fascia as seen in figure 3.31C. The thoracolumbar most importantly, and obliques secondarily, are vital
fascia is a complex structure that can be divided into for the generation of IAP (Bartelink, 1957; De Troyer
three layers (Smith, Weiss, and Lehmkuhl, 1996). et al., 1990; Grillner, Nilsson, and Thorstensson,
It has connections to the ribs, vertebrae, sacrum, 1978; Kumar and Davis, 1978). It appears that the
select posterior ligaments of the spine, and various rectus abdominis does not play much of a role in
FIGURE 3.31 Potential roles of abdominal muscles in protecting the low back. (A) Original intra-abdominal pressure
(IAP) theory, (B) shear reduction theory, (C) thoracolumbar tensioning theory.
intra-abdominal pressure generation, and its role is To understand what muscles are producing a
probably more that of control of movements of the given movement of the spine, it is essential to appre-
spine. Hence, abdominal strengthening exercises ciate the role of gravity when standing upright. In this
should be selected and cued to emphasize strengthen- upright position, the spine is in a potentially precari-
ing the transverse and oblique abdominal muscles. ous position, and if it is moved in any direction “off
center,” gravity will tend to make it fall in that direc-
Psoas Paradox tion. Often a slight voluntary concentric contraction
is used to initiate movement in a desired direction.
Although the iliopsoas is primarily considered a hip Then gravity becomes the primary mover, and
flexor, it can also produce movements of the spine muscles with actions opposite to the movement pro-
that are influenced by the position of the body. When duced by gravity are used to control that movement.
the spine is in a flexed position, the line of pull of the To visualize these movements, it is helpful to think of
iliopsoas is generally anterior to the axis of rotation the spine as a flexible column with the muscles acting
of the lumbar intervertebral joints, and it will tend to like guy ropes relative to the spine (Smith, Weiss, and
produce flexion of the lumbar spine (Levangie and Lehmkuhl, 1996). When the vertebral column is verti-
Norkin, 2001). The iliopsoas acts in this function cal, little or no tension in the guy ropes is required.
during rope climbing, Graham contractions, and However, when the vertebral column leans off the
various dance warm-ups performed on the floor that vertical, the guy ropes (e.g., muscles) opposite to the
involve swinging the leg forward (hip flexion) with direction in which the spine is leaning must contract
the lumbar spine in flexion. However, in most cases to control or prevent the falling of the spine in that
(such as with normal standing) when the lumbar direction. Muscles of the spine are also often used
spine is in extension, the line of pull of many of the together (co-contraction) in a coordinated manner
fibers of the iliopsoas runs posterior to the lumbar to create a stable desired position of the spine. A
intervertebral joints and tends to produce extension summary of the muscles capable of producing the
(hyperextension) of the lumbar spine. This appar- fundamental movements of the spine is provided
ent role reversal from its usual tendency to produce in table 3.2, and an illustration of the fundamental
extension of the lumbar spine to being a flexor of movements of the spine was given in figure 3.11.
the lumbar spine is termed the psoas paradox. This
general tendency to produce lumbar hyperexten- Spinal Flexion
sion may be desirable in some instances, such as to
help maintain the lumbar curve with upright stand- Spinal flexion is forward bending in the sagittal
ing. However, there are many other cases, such as plane, tending to bring anterior surfaces of the
when lifting the gesture leg to the front in dance vertebrae and trunk together. However, because the
or in double-leg lift abdominal exercises, when it is cervical and lumbar regions curve in the direction
undesirable, and firm contraction of the abdominal of hyperextension (concave posteriorly), flexion of
muscles is required to stabilize the proximal attach- these regions may represent a decrease in extension
ments of the iliopsoas and prevent the undesired or a flattening of the curve, without actually neces-
anterior pelvic tilt and spinal hyperextension. sarily producing a position of flexion of the adjacent
vertebrae. It is common in the cervical curve for
flexion to reduce the curve to a straight line; and in
Muscular Analysis flexible individuals, the lumbar curve may actually
of Fundamental be reversed.
The classic concentric use of the abdominal mus-
Spinal Movements cles and other spinal flexors occurs when the spine
In analyzing movements of the spine, it is important flexes or the pelvis posteriorly tilts against gravity or
to realize that they are often linked with movements another external resistance. When gravity offers the
of the pelvis. This relationship will be discussed in resistance, a supine position of the body allows for
chapter 4. It is also important to realize that the effective resistance. For example, in the isometric
segmental structure of the spine allows different curl-up (see table 3.4B [p. 134]), the spinal flexors
movement capacities in different regions of the spine work concentrically on the up-phase to curl the torso.
and allows one part of the spine to move in one direc- The rectus abdominis and right and left external and
tion while another part moves in another direction. internal obliques all act together to produce spinal
However, for purposes of simplicity, it is helpful to flexion, while the transverse abdominis ideally aids
first learn movement of the spine as a whole. with pulling the abdominal wall inward. With slow
The Spine 109
TABLE 3.2 Fundamental Spinal Movements and the Muscles That Can Produce Them
Spinal movement Primary muscles Secondary muscles

Flexion Rectus abdominis Iliopsoas*
External oblique abdominals
Internal oblique abdominals
Extension Erector spinae Semispinalis
Deep posterior spinal group
Iliopsoas
Lateral flexion Quadratus lumborum Semispinalis
External oblique abdominals Deep posterior spinal group (intertransversarii and
Internal oblique abdominals multifidus)
Erector spinae Iliopsoas (lumbar lateral flexion)
Rotation External oblique abdominals Semispinalis

Internal oblique abdominals Deep posterior spinal group (rotatores and multifidus)
Erector spinae
*In select circumstances due to the psoas paradox.
movements, the rectus acts alone when the head lifts,

and the obliques join in when the shoulders begin to
rise. In dance, this type of movement occurs when the
dancer is rising from a supine position such as in con-
tractions commonly used in modern and jazz dance.
When standing in an erect position the situation
gets more complex. In the standing contraction
shown in figure 3.32, the abdominals would still be
used rigorously to posteriorly tilt the pelvis, flex the
spine, and pull the abdominal wall inward. In addi-
tion, a slight co-contraction of the spinal extensors
would be required to achieve the desired “lift” of
the movement and prevent the upper back from
collapsing too far forward. However, if the torso were
allowed to round forward such as in a roll-down,
the spinal extensors would be the primary muscles
working (eccentrically) to control the spinal flexion
produced by gravity. In dance, a slight co-contraction
of the abdominals is often encouraged to shape the
movement, with the head and shoulders staying close
to the lower body as the roll-down proceeds.
Spinal Extension
Extension is the return from a position of flexion
toward anatomical position or backward bending,
in the sagittal plane. When the spine is extended
beyond anatomical position the movement can be
termed hyperextension. In analysis or description of
a movement, we often simply continue to use the term
FIGURE 3.32 Sample dance movement showing spinal
“extension” because the goal is to describe the direc-
flexion.
tion of movement (extension) rather than a position. Photo: Roy Blakey. Dancer: Douglas Nielsen in Anna Sokolow’s “The Cage The
However, at times, such as in description of a position Pond,” with Batsheva Dance Company, Tel-Aviv.
The Role of Gravity in Standing Movements of the Spine
Perform the following movements from a standing position with your feet parallel and about hip-width
apart, using figure 3.11 as a reference.
• Gravity and forward flexion. Place one hand with the palm on the side of the lumbar spine.
Place the other hand on your abdomen. Then, slowly roll down (as if you were going to touch the floor)
about halfway. Think about the effect gravity would have during this movement. Explain why you are
feeling the muscle contraction you are feeling, and how the abdominal and spinal extensors would
operate in this movement.
• Gravity and spinal extension. Keeping your hands placed as before, slowly come back up from
this position of forward flexion to a vertical position of the spine. What muscles do you feel working?
Again, explain the role of the abdominal and spinal extensors in this movement and whether eccentric,
concentric, or both types of contractions would be involved. Now, let your torso carefully arch slightly
beyond vertical (hyperextension). Explain the influence of gravity with this movement and how it would
affect muscle use.
• Gravity and spinal lateral flexion. With your hands hanging by your sides, slowly bend the torso
to the side. Again, think about the influence of gravity and try to feel and explain what muscles are
working on both the down-phase and up-phase of the movement. Include the quadratus lumborum,
as well as the abdominal muscles and spinal extensors. Now vary the position of your torso slightly
as you bend to the side (torso slightly forward of and then back of a directly side position). How does
this influence muscle use?
• Gravity and spinal rotation. Lastly, with your hands hanging by your sides, rotate your torso to one
side. How is the influence of gravity different in this motion than in the previous motions? How will this
influence the contribution and contraction type of the abdominal muscles and spinal extensors?
or a mechanism of injury, it can be helpful to use the to a vertical or a flat back position in port de bras or
term “hyperextension.” center floor warm-ups in modern and jazz dance. The
The classic concentric use of the spinal extensors spinal extensors also work very hard to prevent the
occurs when the spine extends or hyperextends torso from tilting too far forward and to attempt to
against gravity or another external resistance such maintain a more upright position of the torso when a
as in the prone single-arm spine arch (table 3.4I leg is lifted to the back in an arabesque, back attitude
[p. 138]). The erector spinae muscles have been (figure 3.33), or leap.
shown to be particularly active during prone exten-
sion, with greatest activity in the spinalis, followed by Spinal Lateral Flexion
the longissimus, and with the least in the iliocostalis
(Basmajian and DeLuca, 1985). The semispinalis and Spinal lateral flexion is side-bending in the frontal
deep posterior spinal group are also active to some plane and is termed either right lateral flexion or
degree during prone extension. The latter muscle left lateral flexion. Spinal lateral flexion is named in
group is believed to primarily act to help stabilize the accordance with the way the side of the upper spine
spine and adjust motion between individual vertebrae, bends with reference to the lower part. So, approxi-
while the erector spinae provides the primary force mation of the right sides of the vertebrae such as
for full spine extension. when bending the torso to your right during standing
The spinal extensors are also commonly used would be termed right lateral flexion. Conversely,
concentrically to bring the torso back up toward a approximation of the lateral surfaces of the vertebrae
vertical position from a position of forward flexion. to the left would be termed left lateral flexion. To
In dance this use of the extensors is common, such be consistent with the custom of using a term that
as when the torso is brought from a flexed position describes the direction of the motion, the return to
The Spine 111
pure lateral flexion occurs there appears to be little

action of the rectus abdominis, but when it is com-
bined with slight flexion of the torso, the rectus and
oblique co-contract to help produce the motion.
During upright standing, the spinal lateral flexors
work whenever the torso is bent to the side. This
motion is commonly used in modern and jazz move-
ments and second-position floor or barre stretches in
which the torso is bending or reaching to the side as
seen in figure 3.34. In the pictured movement, the
right lateral flexors initiate the movement. Then
once the spine is off center, the left lateral flexors
would primarily work to control the motion eccentri-
cally, motivated primarily by gravity once the spine is
off center. As with side-lying movements, the specific
contribution of the spinal lateral flexors appears to
be affected by position of the trunk. However, the
oblique muscles appear to be particularly impor-
tant, with the contribution of the spinal extensors
more variable (Basmajian and DeLuca, 1985). For
example, one study found greater activity in the
FIGURE 3.33 Sample dance movement showing spinal

extension.
© Angela Sterling Photography. Pacific Northwest Ballet dancer Melanie Skinner.
anatomical position from left lateral flexion would

be termed right lateral flexion, and vice versa.
The classic concentric use of the spinal lateral
flexors occurs when the spine laterally flexes against
gravity or resistance such as in side-ups (see table
3.4K [p. 139]). The quadratus lumborum, oblique
abdominal muscles, and erector spinae are considered
the primary lateral flexors. Note that the external
and internal obliques on the same side of the body
would be working to produce the same motion (e.g.,
when lying on your right side, the left external and
left internal oblique would both produce the desired
left lateral flexion). In some cases, the semispinalis,
deep posterior spinal extensors, rectus abdominis,
and iliopsoas also assist with the movement. Which
muscles contribute to the movement is influenced by FIGURE 3.34 Sample dance movement showing spinal lateral
the amount of resistance, speed of the motion, and flexion.
specific positioning of the trunk. For example, when Photo courtesy of Bill Evans. Photographer: Jack Mitchell. Dancer: Bill Evans in “Five Songs.”
spinal extensors on the opposite side in the lumbar rotation. Performing rotation around the long axis of
region but greater activity in the spinal extensors the spine would be affected primarily by the abdominal
on the same side in the thoracic region (Andersson, obliques and spinal extensor muscles. Theoretically
Ortengren, and Nachemson, 1977). when rotating the torso to the right, the right internal
oblique, right longissimus, right iliocostalis, left exter-
Spinal Rotation nal oblique, left multifidus, left rotatores, and left semi-
spinalis thoracis muscles would contract to produce the
Spinal rotation is twisting around the long axis of the movement. Note that unlike what happens in lateral
spine and, similar to the situation with lateral flexion, flexion, the internal and external obliques from oppo-
is also designated as right or left in accordance with site sides work together to produce rotation.
the way the front of the upper spine turns with refer- While some EMG studies have confirmed this
ence to the lower part. Right rotation is defined as expected activity in the lumbar region (Ortengren
movement of the head or shoulders to the right with and Andersson, 1977), other studies have shown
respect to a fixed pelvis, or movement of the pelvis to a more complex contribution of muscles than
the left with respect to a fixed head or fixed shoulders expected, possibly due to the complex interaction
or upper spine. Return from these positions would of agonists, synergists, antagonists, and stabilizers
be termed left rotation. and the complex lines of pull and multitude of
Concentric contraction of the spinal rotators is joints crossed by spinal musculature (Basmajian and
used whenever the head, torso, or pelvis is twisted DeLuca, 1985). Also, as with lateral flexion, position-
such as in jazz isolations, spiral movements in ing of the torso and the relationship of gravity will
modern dance (figure 3.35), and facings in ballet affect which muscles contribute, as well as the pri-
where the front of the torso is rotated relative to the mary site of rotation. For example, when spinal rota-
front of the pelvis. For purposes of simplicity, this tion is performed from a vertical standing position,
discussion will be limited to thoracic and lumbar greater rotation tends to occur in the thoracic region.
However, when it is performed from a posi-
tion of hyperextension, a greater amount
of rotation tends to occur in the lumbar
spine, and the spinal extensors tend to
make a larger contribution to the desired
rotation. Conversely, when spinal rotation
is performed from a position of spinal
flexion, greater rotation occurs higher
in the spine, and the oblique abdominals
tend to be utilized more to produce the
rotation. These same concepts apply to
strengthening exercises with rotation in a
prone position.
Key Considerations
for the Spine
in Whole Body Movement
Due to its central location, coordinated
movement between the trunk and limbs is
vital to meet movement goals and for injury
prevention. Core stability is one important
mechanism for protecting the spine and
enhancing centered movement.
Core Stability
Core stability (also referred to as trunk sta-
FIGURE 3.35 Sample dance movement showing spinal rotation. bility, lumbopelvic stabilization, and spinal
© Angela Sterling Photography. Pacific Northwest Ballet dancer Christophe Maraval.
The Spine 113
stabilization) can be defined as the development or muscles can be used to lessen or eliminate unde-
restoration of neuromuscular aspects of lumbopelvic sired compensatory trunk movement occurring in
control vital for protecting the spine from injury response to movements of the limbs and could lessen
or reinjury (Hodges, 2003). Strategies to develop potentially injurious forces borne by the spine.
core stability generally utilize two components. One
component emphasizes utilizing exercises to improve Centered Movement
the muscular strength and endurance of key trunk
muscles (muscle capacity). The second component Core stability is also one important aspect of highly
has gained great attention in recent years and focuses skilled movement used by dancers and athletes. In
on the training of the coordinated use of these key movement forms such as dance, martial arts, and
trunk muscles during functional movements (motor Pilates, use of core stability is one part of desired
control). movement patterns that are often termed “cen-
As described earlier in this chapter, the vertebral tered” movement. In these movement forms, core
column is very dependent on a balance of the spinal stability is often used in a very refined manner to
muscles for stability. Unlike some joints such as meet aesthetic goals as well as biomechanical goals.
the hip and knee, which can be “locked” in slight For example, in some dance movements, the torso
hyperextension to allow the ligaments to provide and pelvis are held relatively upright while the arms
the primary support, the spine cannot be locked and or legs are used in a variety of movements. Many
the anterior-posterior curves of the spine will tend to beginning dancers have difficulty with this coordina-
collapse or buckle due to the effect of gravity if not tion, and many visible compensations of the torso
counterbalanced by appropriate muscles. In fact, an leaning front, side, or back are seen. However, as
isolated ligamentous spine without muscular support skill progresses, such compensations are minimized
will collapse when less than 5 pounds (2 kilograms) such that large range limb movements occur without
is applied to it (Nachemson, 1966). The torso can distorting the desired positioning of the torso. This
be pictured as a cylinder (Nachemson and Morris, skill is made more complex in cases where the torso
1964), where with ideal alignment muscles located is moved through desired positions off the verti-
on all sides of the cylinder are balanced so that the cal while the limbs move. For example, the spinal
torso is “stable,” the curves are not exaggerated, and hyperextension accompanying a cambré to the back
the spine is protected from excessive stress. in ballet, the presentation of the torso in flamenco,
Many muscles of the trunk likely play a role in a jazz layout, or a spiral arching motion of the torso
core stabilization, but due to their location the used in modern all require slightly different use of
abdominals and back extensors are particularly key. the abdominals, back extensors, and other trunk
For example, automatic abdominal contraction muscles to create the desired line and avoid exces-
(transverse abdominis followed by oblique abdomi- sive movement of one vertebra relative to another.
nals) prior to quick movements of the arms, and Achieving and maintaining such desired positions of
legs, peak vertical forces in walking and running, the torso not only requires strong trunk muscles but
and landing from jumping has been demonstrated also appropriate timing and magnitude of activation
(Grillner, Nilsson, and Thorstensson, 1978; Hodges of these muscles.
and Richardson, 1996, 1997). Studies suggest that the
central nervous system activates components of the
abdominals without our conscious awareness prior Special Considerations
to movement of the limbs. This precontraction of for the Spine in Dance
the abdominals is believed to aid with trunk stability
through the resultant generation of IAP or thoraco- Various aspects of dance place great demands on the
lumbar fascia tensioning. Similarly, muscles such as spine. Some areas that are of particular importance
the multifidus of the deep posterior spinal group in terms of technique and injury prevention are
appear to be vital for core stability at the segmental spinal alignment, spinal hyperextension, standing
level of the spine. So, well-timed and coordinated forward flexion, and partnering.
contraction of such deep muscles of the spine is
believed to be particularly key for stabilizing the Spinal Alignment in Dance
spine on a segmental level, while the more superficial
trunk muscles that can generate larger forces work The standing alignment used at center floor or at the
to stabilize and control movements of the spine as barre in some dance styles is quite similar to the ideal
a whole. Together, these deep and superficial trunk standing alignment previously described. However,
DANCE CUES 3.2
“Lift and Lengthen Your Spine”
T he cue to “lift and lengthen your spine” can

be interpreted from an anatomical perspec-
tive as referring to the use of muscles to counter
the tendency of gravity to slightly “collapse” the
normal sagittal curves of the spine (A). With well-
coordinated contraction of the spinal muscles,
the curves can be slightly decreased and the
length of the spine very slightly increased. How-
ever, the challenge of this cue is that because the
curves of the spine go in different directions, a
complex co-contraction of muscles in different
regions of the spine is necessary to achieve the
desired effects. For example, if too much con-
traction of the abdominal muscles occurs, it will
decrease the lumbar curve but increase the tho-
racic curve, pulling the front of the rib cage too
far down and creating a “collapsed” versus “lifted”
look. In contrast, if excessive thoracic extension
is used, it will tend to bring the shoulders and
upper back behind the gravity line and again fail
to create the desired “lifted” look.
Sometimes it can be helpful to use supplemen-
tal cues, for example the cue of imagining a line
of energy starting with the front of the bottom of
the pelvis, going under the rib cage (along the
front of the spine), and out the top of the head
(just behind the middle of the top of the head)
as seen in the figure (B). For dancers that still
appear “collapsed” in the chest, thinking of lifting the top of the sternum up toward the ceiling can
facilitate desired positioning. For dancers who still tend to shorten the low back (lumbar hyperlordo-
sis), thinking about letting the low back “lengthen” and reach down toward the floor, or imagining
having a small weight hanging from the coccyx or having fingertips on the back of the sacrum that
pull the sacrum slightly down toward the floor, while still maintaining the “lift” on the front of the
body, can be helpful.
because the goal is preparation for movement and When one is actually dancing, the spine is dynami-
an aesthetic of “energy” or “presence” versus relaxed cally changing its position—often in multiple planes
standing, this alignment generally involves more that encompass combinations of flexion, lateral flex-
muscle activation. Such greater muscle activation is ion, extension, and rotation; but the skilled dancer
consistent with many different directives commonly should be able to quickly reestablish this neutral base
given by dance teachers such as “reach the head up alignment when the choreography utilizes an erect
toward the ceiling,” “lift the spine toward the ceiling,” position of the torso.
or “lift and lengthen the spine.” But this positioning However, some styles of dance may also involve
would still ideally entail spinal curves of appropriate slight differences from this “neutral” base align-
magnitude that are balanced in the sagittal plane ment. For example, the aesthetics of some schools
and can be thought of as a neutral base alignment. of flamenco and ballet may involve greater “lift and
The Spine 115
arching” of the upper back, while some schools of this positioning in individuals with tight hamstrings
modern dance prefer slightly anterior positioning (see chapter 4).
of the rib cage. Skilled dancers can learn to achieve In more complex dance movements, spinal align-
these aesthetics while still protecting their low backs ment becomes much more complicated. However,
with abdominal co-contraction. And as with the neu- even though changes in positions are very dynamic,
tral base alignment, skilled dancers should be able to there is still the desire to achieve a given movement
quickly reestablish the base alignment of their dance without undesired distortion of the spinal curves,
style when demanded by the choreography. or in accordance with the specific positioning
When sitting on the floor as is common in modern dictated by the choreography. For example, when
and jazz dance, a different challenge for spinal align- one is performing a side reach, pure lateral flexion
ment comes into play. Sitting in a relaxed/slumped involves the torso moving almost directly to the side
position as seen in figure 3.36B tends to be associ- (figure 3.37A) without the ribs going forward or the
ated with as much as 40° of posterior tilting of the bottom of the pelvis going back (figure 3.37B). Such
pelvis, with a consequent decrease in lumbar lordosis, positioning involves a subtle co-contraction of many
increase in thoracic kyphosis, and associated increase muscles with appropriate timing and magnitude of
in intradiscal pressure. It is very easy to assume this force such that both appropriate spinal stabilization
position, as it relies on passive support from back and movement are effected in accordance with the
ligaments and other soft tissues with little spinal goal movement. Such coordination of muscles is one
extensor activity. However, using a more erect posi- marker of skill in the professional dancer.
tion during sitting so that a more neutral position of
the pelvis is maintained and the weight of the upper Spinal Hyperextension
body is felt directly over the bottom of the pelvis
(“sitz bones” or ischial tuberosities) versus behind, Hyperextension of the spine tends to make the front
and so that the spinal extensors are used to “lift” the part of consecutive vertebrae pull away from each
spine and prevent excessive flexion of the lumbar other and the back part of consecutive vertebrae
and thoracic regions, will reduce lumbar stress and press together. More specifically, hyperextension pro-
better achieve the desired dance aesthetic (figure duces tension on the front of the disc, compression
3.36C). When one is performing floor work in which at the back of the disc, and increased pressure within
the knees are extended, it is important to realize that the disc. Hyperextension also creates increased
adequate hamstring flexibility will be necessary to stresses in the posterior portion of the vertebrae; and
allow this more neutral position of the pelvis, and it when it is very forceful or repetitive, the facet joints
may be necessary to slightly bend the knees to allow can become injured or stress fractures to the bone
FIGURE 3.36 Changes in the low back with standing and sitting. (A) Normal lumbar curvature with standing, (B) unde-
sired excessive posterior tilt of pelvis and decreased lumbar lordosis with sitting, (C) desired neutral pelvic alignment
and less loss of normal lumbar lordosis with sitting.
than the thoracic spine, this technique

requires the development of high levels of
abdominal and upper back strength, upper
back flexibility, and subtle neuromuscular
coordination that can take years to develop.
Technique cues that can be used to help
obtain this arch include (1) imagine arching
up and back over a barrel; (2) imagine that
someone is lifting you up and back from just
below the shoulder blades, and the scapulae
become a shelf to support the upper back;
(3) think of the spine as a flexible column
with the goal to create a continuous long
arc rather than allowing the lower portion
to collapse and crimp.
Spinal Forward Flexion

Movements involving forward flexion of
the spine are very common in modern
and jazz dance forms and may relate to
the disc injuries more commonly seen in
older modern dancers. In contrast to what
A B occurs with hyperextension, with forward
flexion the anterior portions of the vertebrae
press toward one another and the posterior
FIGURE 3.37 Spinal alignment during lateral flexion. (A) Balanced structures of the spine tend to pull away from
muscle co-contraction resulting in desired spinal alignment, (B) inad- one another. This creates compression at the
equate abdominal contraction resulting in undesired spinal align- front of the disc and tension at the back of the
ment. disc and increases intradiscal pressure. It also
creates large stresses on the ligaments that
itself can occur (spondylolysis). Activities such as span between adjacent vertebrae posteriorly. Further-
dance that utilize repetitive hyperextension tend to more, during flexion the top vertebrae tends to slide
display increased incidence of low back injury, and so forward as it tilts due to the weight of the trunk. This
an understanding of this movement is important. sliding tendency creates large shear forces. Lastly,
Undesired hyperextension can occur statically muscle activity influences spinal stresses.
as part of standing posture (lumbar hyperlordosis) In terms of the influence of muscles, the activity
or dynamically in dance movements such as when of the back extensors initially increases the further
one is rising from a plié, laterally flexing the spine, the spine bends until about 40 to 50° of spinal
jumping, or turning. As just described, an important flexion (Andersson, Ortengren, and Nachemson,
part of dance training is to develop the desired spinal 1977). This is the case because the head and torso
alignment such that this undesired hyperextension is are moving farther away from the axis of rotation
avoided. However, in other cases such as an arabesque of the spine (increasing the moment arm of the
jazz layout or various porte de bras movements involv- resistance), and so greater force must be generated
ing arching to the back, spinal hyperextension is a by the spinal extensors to eccentrically counter this
necessary component of the dance movement. In torque and prevent uncontrolled falling of the torso.
such cases, the potential for associated injury can This greater force is of concern in terms of straining
be reduced with appropriate co-contraction of the the back extensors, and muscle endurance has been
abdominal muscles and back extensors, so that the shown to be adversely affected by greater degrees of
amount of hyperextension and shear stress in the flexion. For example, the length of time in which
low lumbar spine is limited and greater emphasis is workers were able to maintain a position was reduced
placed on arching higher and throughout more of from 13 minutes with 20° of forward flexion to 4
the back (figure 3.38). Since tremendously more minutes with 30° of forward flexion (Soderberg,
hyperextension is naturally allowed in the lumbar 1986). The greater force of the back extensors is also
The Spine 117
A B
FIGURE 3.38 Specific co-contraction of the abdominal muscles and spinal extensors to limit hyperextension in the
low lumbar spine and emphasize upper back extension. (A) Incorrect technique, (B) correct technique.
of concern because of the increased stress it creates have led to recommendations to use full flexion with
within the discs. One study reported that intradiscal care and that adding large forces to this vulnerable
pressure at L3 doubled in magnitude with 40° of position such as those associated with percussive toe
forward bending (Nachemson, 1981). touching or bounce stretching is not advisable in
A different concern becomes operative with recreational athletes.
extreme degrees of forward bending. After about However, many dancers find roll-downs and such
50° of forward bending, the activity of the spinal inverted positions helpful for developing flexibility,
extensors actually decreases instead of increasing, reducing excessive low back tightness, and finding
until at full flexion these muscles are inactive; this certain neuromuscular connections. One approach
is termed the flexion relaxation phenomenon (Hall, is to use such spinal flexion in dance populations
1999). In this position of full flexion, the spine is prudently (avoiding excessive use in terms of dura-
devoid of the stability and protection provided by tion of holds or number of consecutive repetitions)
muscular contraction and relies on passive support when the body is adequately warmed and with careful
from the joint capsules and ligaments, discs, thora- attention to technique. In terms of technique, poten-
columbar fascia, and the passive elastic components tial risks can theoretically be lessened by emphasizing
of the back extensors. This is potentially dangerous keeping the head close to the torso as the dancer
for these passive constraints, particularly given that flexes the spine (decreasing the moment arm of
they are susceptible to fatigue. For example, with the resistance) and by emphasizing tightening the
repetitive loading, discs appear to lessen their ability abdominals and pulling them in toward the spine to
to absorb shock or withstand forces, and injury can help reduce shear forces and protect the spine via
then result from relatively small forces. In addition, intra-abdominal pressure or thoracolumbar fascia
the tension in the interspinous ligament associated tensioning. Also, inadequate hamstring flexibility
with full flexion can increase facet joint loading and will not allow adequate forward rotation of the pelvis,
anterior shear force (Hall, 1999). These observations which occurs after about 45° of spinal flexion (see
DANCE CUES 3.3
“Lift the Upper Spine Up and Back”
T he cue to “lift the upper spine up and back” can be interpreted anatomically as focusing on extend-
ing the thoracic spine backward without letting the rib cage go forward. Focusing on “pulling up”
with the inferior attachment of the abdominal muscles onto the pelvis will help limit anterior tilting
of the pelvis and resultant undesired excessive hyperextension in the lower lumbar vertebrae. Then,
focusing on arching the mid and upper thoracic spine such that the sternum lifts up and back will
help achieve the desired distribution of some of the arch to higher regions of the spine. However,
achievement of this desired arch requires very subtle co-contraction of the abdominal muscles and
back extensors in very specific regions of the spine.
For example, excessive use of the spinal extensors in the lower thoracic and upper lumbar region
will tend to create undesired forward movement of the anterior rib cage. In contrast, excessive
stabilization of the rib cage by the abdominal muscles and holding the ribs down will not allow the
thoracic spine to hyperextend. Thus, while a consistent “pulling up” of the lower attachment of the
abdominal muscles onto the pelvis is maintained, the upper attachment of the rectus abdominis and
obliques onto the rib cage must be allowed to move away as the sternum lifts up and back, so that the
abdominal muscles are used eccentrically to help control backward movement of the trunk while the
spinal extensors (particularly the thoracic) are used concentrically to cooperatively create the desired
positioning of the spine as seen in figure 3.38B.
Lumbar-Pelvic Rhythm on p. 183 for more informa- very meaningful. Similarly, the degree of rotation can
tion) and can result in increased stress to the lumbar markedly influence spinal stresses. Some structures
spine (Hamill and Knutzen, 1995; Plowman, 1992). of the spine such as the discs are vulnerable to rota-
Dancers with tight hamstrings can modify such a position, and most back injuries involve a combination of
tion to reduce back stress by slightly bending the knees flexion and rotation or hyperextension and rotation.
or supporting the torso with forearms on the thighs During lifting of that same 22-pound weight, rotating
until adequate hamstring flexibility is developed. 20° with the spine flexed 20° increases intradiscal
pressure to 472 pounds (214 kilograms) of force. Fur-
Partnering thermore, asymmetrical positioning has been shown
to negatively affect the ability to lift heavy loads, with
Partnering other dancers is associated with very large losses of 12%, 21%, and 31% at 30°, 60°, and 90° of
forces, but the potential risk to the spine can be asymmetry, respectively (Caillet, 1996).
lessened by appropriate spinal and pelvic alignment Even more dramatic in determining stresses to the
of the lifter, specific muscle emphasis during lifting, spine is the distance the partner is from the spine.
appropriate positioning of the partner, and adequate Having a dancer farther away from your body will
strength and flexibility in key muscles. In terms of greatly increase the resistance torque that must be
alignment, emphasis on lifting with the legs with the overcome by the shoulder muscles and the bending
torso more vertical is associated with lower forces torque that must be met by the trunk muscles to
borne by the spine than bending the spine forward maintain a stable position. Studies have shown that
and “lifting with the back.” The intradiscal pressure whether one is lifting with the torso erect or bent
at L3 has been estimated to be about 382 pounds forward, the farther the weight is from the body the
(173 kilograms) of force when one is picking up a greater the activity of the spinal extensors and the
22-pound (10-kilogram) weight with the back straight greater the pressure borne by the discs (White III
and knees bent, versus 427 pounds (194 kilograms) and Panjabi, 1978). The calculation in one study was
when bending forward with the back (Nachemson, that lifting a 100-pound (45-kilogram) weight with
1981). Considering that another dancer is likely to the weight about 30 inches (76 centimeters) in front
weigh five or six times more than the weight used in of the fulcrum (L-S disc) and the legs straight would
that study, such a change in load to the discs could be require 1,500 pounds (680 kilograms) of muscle
The Spine 119
pull and produce 1,600 pounds (726 kilograms) performing trunk stabilization exercises can improve
of pressure on the lumbosacral disc (Bradford and this aspect of lifting. However, in some cases, exces-
Spurling, 1945). sive arching of the low back and leaning the torso
So, to reduce the potential forces borne by the back during lifting are a compensation due to inad-
spine, dancers should directly face their partner, equate shoulder flexibility (necessary to allow an
bring the partner close to them, keep the torso as overhead position) or inadequate upper extremity
vertical as possible, and emphasize lifting by extend- strength. In such cases, strengthening and stretching
ing the hips and knees rather than the back whenever key upper extremity muscles used in partnering can
the choreography allows. One can encourage the also help protect the back (chapter 7).
latter desired mechanics by suggesting that danc- While applying the principles just discussed can
ers think of pushing down into the ground with help reduce the stress to the spine, there are many
the feet, knees, and hips as they straighten, rather cases in which the choreography will not allow
than lifting the back. Also, it is helpful to emphasize application of all of them. For example, often chore-
looking straight ahead versus down to encourage ography requires that the partner be lifted with the
a more upright position of the
spine. Strengthening the hips
and knees with exercises such
as squats, lunges, or leg presses
(chapter 4) will allow a dancer to
lift a partner more readily using
this upright body alignment.
The dancer should also avoid
excessive lumbar lordosis and
utilize adequate trunk stabiliza-
tion when lifting another dancer
as shown in figure 3.39. Focusing
on firmly tightening the abdomi-
nal muscles, pulling the abdomi-
nal wall in toward the spine and
the ribs down toward the pelvis so
that the torso is directly over the
pelvis just prior to and during the
lift, will help utilize the protective
effects of IAP and prevent the
large shear forces associated with
excessive arching of the back. In
addition, balanced co-contrac-
tion of the spinal extensors is key
for stabilizing the spine and pre-
venting the weight of the partner
from pulling the trunk forward.
Although the ideal desired posi-
tion of the lumbar spine at the
beginning of a lift is still an area
of great controversy (Gracovetsky
et al., 1989; Hall, 1999; LaFre-
niere, 1985; McGill, 2001), there
is generally agreement that it
should be neutral or just momen-
tarily slightly flexed, with both
hyperextension or exaggerated
or sustained flexion avoided. FIGURE 3.39 Maintaining proper spinal alignment and adequate stabilization is key for
Strengthening the abdominal reducing injury risk during partnering.
muscles and back extensors and © Angela Sterling Photography. Pacific Northwest Ballet dancers Patricia Barker, Stanko Milov, and Casey Herd.
spine bent forward, with the torso twisted, or with the formatting of exercises can help achieve greater
partner moving away from the body. Nevertheless, abdominal strength and the development of abdomi-
if the dancer develops adequate strength, utilizes nal use that can more readily be applied to dancing.
good core stabilization, and applies whichever other The following is a discussion of these and other
principles are relevant, partnering can be performed principles that can be used to make many abdominal
without injury to the back. In addition, when lifting exercises more effective.
from a forward flexed position is required, it is desir-
Emphasizing Flexing Spine Versus Hip Remember
able not only to emphasize abdominal stabilization
that the abdominal muscles work to flex the spine
but also to focus on keeping the knees slightly bent
while the hip flexors work to bring the torso closer
and using the hip extensors to bring the pelvis under
to the thighs (e.g., hip flexion). Hence, emphasiz-
first before extending the knees and spine.
ing sequentially curling (flexing) the torso and
keeping the torso as rounded forward as possible
Conditioning Exercises (figure 3.40A), versus lifting the torso with a flat back
(figure 3.40B), in exercises such as curl-ups can help
for the Spine achieve the desired abdominal emphasis. Cues such
as “maintaining a ‘C’ curve” or “imagining hugging
Adequate and balanced muscular strength and flex-
a large ball” can sometimes help achieve this desired
ibility of the spine are essential for correct mechan-
use of the abdominal muscles. Excessive use of the
ics, optimal movement, and injury prevention. How-
hip flexors not only decreases desired overload to the
ever, there is tremendous controversy regarding the
abdominal muscles but also can place undue stress
relative benefit and risk of various trunk exercises,
on the spine if the spine is not sufficiently stabilized.
and many of the exercises commonly performed by
For individuals with excessive lumbar lordosis, per-
dancers would be considered contraindicated for
forming “abdominal” exercises with excessive use of
recreational athletes or individuals with a history
the hip flexors can actually worsen rather than help
of back problems. Hence, a discussion of general
correct this postural condition.
principles related to spinal exercises precedes the
discussion of specific conditioning exercises. Keeping Head and Neck in Line Focus on continu-
ing flexion of the spine through the cervical region,
General Guidelines thinking of the head and neck continuing the “C”
for Abdominal Strengthening curve of the lower spine. If one is having difficulty
achieving this alignment or is experiencing neck
Many dancers and other athletes perform abdominal discomfort when performing supine abdominal
exercises regularly and yet show marked weakness exercises, it is helpful to try focusing on “softening
when tested for abdominal strength. In testing of the chest” (making it slightly concave) and bringing
pre-professional ballet dancers using Kendall and the sternum slightly back and down as if hugging
McCreary’s leg-lowering test, 68% could not maintain someone, while bringing the chin slightly in toward
a stable pelvis when their legs were lowered beyond the chest (as if holding an orange between the
60°, and only 4% could lower their legs all the way chin and chest). If the neck muscles are not strong
to the table while maintaining desired positioning enough, it may also be necessary to initially use one
(Molnar and Esterson, 1997). Similarly, the author has hand to support the neck. One should avoid pulling
found inadequate abdominal strength as evidenced on the neck, alternate the arm used for support, and
by the curl-up height test, and inability to maintain gradually increase the number of repetitions that can
pelvic stabilization with leg lowering, when testing pre- be performed without support. It can also be helpful
professional ballet students, performing arts high to perform exercises starting from sitting (such as
school dance majors, and university dance majors. the curl-back shown in table 3.4C [p. 134]), which
This frequent occurrence of low abdominal strength involves less stress for the neck flexors because the
levels is likely due in part to the use of ineffective weight of the head is closer to the axis of rotation
exercises and formatting. Recommendations follow (shorter moment arm).
for improving the gains obtained from abdominal Keeping Feet Unrestrained Keeping the feet free
work while keeping injury risk relatively low. will generally make the abdominal muscles work
more and hip flexors work less (Godfrey, Kindig,
Enhancing Abdominal Exercise Effectiveness
and Windell, 1977; Guimaraes et al., 1991; Hall,
Selection of appropriate exercises, meticulous Lee, and Wood, 1990; Lipetz and Gutin, 1970), and
technique, adequate muscle overload, and proper so most abdominal work should be done with the
Abdominal Strength and Endurance Tests
Perform the following two tests on another dancer to estimate the strength and endurance of the
abdominal muscles.
Curl-Up Height Test (Muscular Strength)
Start with your partner supine with the knees bent to about 90° and the feet resting on the ground
(not held down). The elbows are bent with the fingers spread and the tips of the thumbs in contact
with the top of the head. Then, keeping the elbows back and in line with the ears, your partner should
very slowly curl up as high as possible without using momentum, without letting the elbows come for-
ward, and without letting the feet lift. Cue your partner to round the spine as much as possible (spinal
flexion) rather than raise with a flat back. Measure the perpendicular distance from the prominent
vertebra at the base of the neck (C7—vertebra prominens) to the ground using a tape measure, as
shown in A. The goal is to be able to come all the way up to a sitting position.
Note: Due to differences in spine length and flexibility, the same measured distance will not reflect
the exact same angle of trunk flexion from individual to individual. However, this measure will give you
an approximate indication of strength (with stronger individuals able to come up higher) and provides
a useful tool to monitor improvement in strength within the same individual.
Curl-Up Repetition Test (Muscular Endurance)
Start with your partner supine with the hips and knees bent to 90° and the feet against a wall (B1).
The elbows are bent and face forward, and the fingers surround the ears. Cue your partner to curl up
B1 B2
(continued)
121
TESTS AND MEASUREMENTS 3.3 (continued)
and touch the elbows to the mid-thighs in cadence with a metronome or count set at 25 curl-ups per
minute for a maximum of 4 minutes (B2) (Sparling, 1997). Count the number of proper curl-ups your
partner completes. The count stops as soon as the elbows no longer touch the knees or the dancer
is not able to keep up with the count. The dancer may not rest and then begin again. The maximum
goal would be 100 repetitions in 4 minutes, but the mean for professional hockey players tested was
50, with 11% of players meeting the endpoint (Quinney, Smith, and Wenger, 1984). Based on some
preliminary tests with dancers, this author considers 40 to 59 repetitions “good” and greater than or
equal to 60 repetitions “excellent.”
Note: Dancers with inadequate strength to touch the elbows to the thighs can cross their arms
in front of their chest and touch their forearms to their thighs. Or they can bring their arms down to
their sides and place a strip of masking tape just in front of their middle finger and a second strip
of masking tape 3 inches (7.6 centimeters) in front of the first strip. With each curl the hands must
move forward to touch the second strip of tape (Robertson et al., 1988; Sparling, 1997).
feet free. Dancers who develop high levels of

abdominal strength and excellent technique
may want to perform one set of an advanced
variation with the feet restrained (e.g., under
the strap of an incline bench, Reformer, or
Cadillac) if spinal flexion can be effectively
maintained. However, several sets of exercises
should also be done with the feet free.
Pulling Abdominal Wall Inward When one
is performing abdominal exercises, emphasis
on pulling the abdominal wall inward toward
A the spine will help recruit the obliques and
transverse abdominis. Remember that the
transverse abdominis is not capable of pro-
ducing spinal flexion and so will not neces-
sarily be recruited with abdominal exercises
unless its function of pulling the abdominal
wall inward (often termed “hollowing” in
dance) is emphasized. One study showed
that by using multisensory cueing including
verbal cues that emphasized pulling the navel
up and against the spine, subjects were able
to recruit more transverse abdominis and
internal obliques and less hip flexors (ilio-
psoas) on the down-phase of a curl-up (Miller
and Medeiros, 1987). An exaggerated, slow
B
exhalation or quick, forced exhalation can
also serve to emphasize greater use of the
FIGURE 3.40 Technique for abdominal exercises. (A) Correct— transverse abdominis (De Troyer et al., 1990).
emphasis on rounded spine (spinal flexion) with abdominal wall Emphasizing this inward pull of the abdomi-
pulled inward; (B) incorrect—flat back with emphasis on using hip nal muscles is also important for helping
flexors to raise torso. develop the aesthetically desired use of the
The Spine 123
Creating a “C” Curve
Start lying supine with the knees bent to about 90° and the feet resting on the floor. For the first
three of the following, place one hand on the back of each thigh and use the hands to help bring the
spine into about 20° of flexion.
• Emphasizing spinal flexion. While maintaining the back of the sacrum fully in contact with the
floor, use your hands to pull the spine into further flexion. First, focus on pulling the bottom of the
sternum down and back, and then focus on pulling the bottom of the anterolateral rib cage down and
back to further increase spinal flexion, while the hands slightly assist the motion. Then, let go with
the hands and focus on keeping the low ribs back and the same angle of spinal flexion without help
from the hands.
• Emphasizing the low abdominal muscles. While maintaining the upper spine at the same degree
of flexion, gently pull the pubic symphysis toward the navel, creating a small “tuck” (posterior pelvic
tilt). Let go with the hands, and attempt to maintain the same positioning of the trunk, with the pubic
bone and ribs pulling toward each other.
• Emphasizing the transverse abdominis. Slowly breathe into the abdomen and push the abdomi-
nal wall outward. Then, slowly exhale and pull the abdominal wall inward toward the spine, from the
pubic bone to the sternum. Make the whole abdominal surface concave, as if you were wrapping it
around a large ball; let go with the hands, and maintain this concave position without hand support.
Now, dissociate the muscle contraction from the breathing, focusing on alternately pushing the wall
out and pulling it back in while natural, unlinked breathing occurs.
• Putting it all together. Beginning from a supine position, pull the pubic bone and ribs toward each
other and scoop the abdomen inward as the torso curls up as shown in the figure. If there is difficulty
with one element, practice that element alone and then try to put all three elements back together.
abdominal muscles to aid in keeping the abdomen will produce greater overload to the abdominal muscles
flatter versus protruding while dancing. by causing shortening of the muscle from both direc-
tions. Furthermore, adding a posterior tilt to various
Posterior Pelvic Tilt and Lower Abdominal Empha- abdominal exercises and including other exercises
sis Slightly tilting the top of the pelvis backward so that emphasize moving the inferior attachment of the
that the pubic bone comes up into a slightly “tucked” abdominals on the pelvis, such as the hip lift (Sarti et al.,
position (posterior pelvic tilt), while bringing the 1996) (table 3.4E [p. 135]) and hanging leg lift (figure
bottom of the anterior rib cage slightly down and in, 3.44 [p. 130]), can help develop the motor patterns
important for correcting lumbar lordosis and creat- concentric contraction, strength can be developed at a
ing a neutral pelvis during functional movement and range higher than could be reached with a concentric
may involve more activation of muscle fibers located contraction alone. One can apply this same principle
lower in some of the abdominal muscle groups. by starting from a sitting position and curling back
toward the floor (eccentric contraction) as seen in
Adequate Range of Motion Full sit-ups with the figure 3.41C and table 3.4C (p. 134). Lower ranges
legs straight have been shown to only recruit various can be held isometrically (to add more overload) and
abdominal muscles from 20% to 34% of the time then, initially, the hands can be used to pull on the
(Halpern and Bleck, 1979) and are associated with legs to assist with coming back up to sitting (concentric
greater use of the hip flexors (Ricci, Marchetti, and contraction). As strength increases, use of the hands
Figura, 1981) and greater stresses to the spine (Axler can be lessened and then discontinued.
and McGill, 1997) than curl-ups. Hence, the trend
for abdominal work has been to substitute smaller Spinal Rotation Adding rotation to relevant
range curl-ups where various abdominal muscles are abdominal exercises such as a curl-up will cause
active 90% to 93% of the time, and there is probably greater challenge to the oblique abdominal muscles.
less lumbar stress. However, this trend can be taken When one is performing a straight curl-up, both
too far, such that inadequate range is utilized to sides of the external oblique and internal oblique
provide necessary abdominal overload. In the very muscles can act with the rectus abdominis. However,
beginning phase of the curl-up, the neck flexors when rotation is added, some of the obliques are
and rectus abdominis are primarily working. As antagonists to the movement, and only the internal
the torso curls higher (up to about 40 to 50°) the oblique on the same side (ipsilateral) as the direc-
obliques are recruited and the abdominals work tion of movement and the external oblique on the
harder (length–tension principle), achieving about opposite side (contralateral) of the direction of the
50% of a maximum voluntary contraction with 45° movement can aid with the movement.
of flexion (Floyd and Silver, 1950; Sheffield, 1962; Use of Adequate Overload To produce desired
Soderberg, 1986). After about 50° of spinal flexion, improvements in muscular strength, the abdominal
the hip flexors become more primary and activation exercises should be difficult enough that one can
of the abdominals decreases. Hence, an effort should perform about 12 repetitions at the most. If more
be made to keep the back of the sacrum in contact repetitions can be performed, the difficulty should be
with the floor and fully flex the spine (30 to 45°) increased, for example by working in a higher range
rather than the common error of either only flex- (up to about 40° or 50°), adding trunk rotation, bring-
ing the spine slightly and barely raising the torso off ing the feet closer toward the buttocks when they are
the ground in the exercise or only flexing the spine on the floor (Hall, Lee, and Wood, 1990), bringing the
slightly and then primarily using the hip flexors to legs up (90° hip and knee flexion) with the lower legs
raise the torso further. Using a larger range of spinal in the air or supported by the seat of a chair or bench
flexion is also important for dancers because some (Gutin and Lipetz, 1971), bringing the arms farther
dance movements (such as getting up and down away from the navel to increase the moment arm of
from the floor in modern and jazz) incorporate a the resistance (e.g., from by the sides to across the
full range of motion, and strength gains are specific chest, supporting the head, or reaching overhead), or
to the range worked, declining markedly the farther adding external resistance such as dumbbells held in
away the angle is from that used for strengthening. the hands. Furthermore, remember that the effect of
Type of Muscle Contraction One way of working gravity on the body is primarily creating the resistance
a fuller range of motion in dancers who do not have in these exercises. Therefore the body must be appro-
adequate strength to curl up very high (concentric priately positioned so that the abdominal muscles are
contraction), as seen in figure 3.41A, is to use isomet- having to work against gravity, such as when one is
ric or eccentric contractions. For example, after one performing a curl-up from a supine position or a side-
curls up concentrically, the hands can be used to pull up from a side-lying position. In contrast, exercises
the shoulders up slightly higher (e.g., to flex the spine that neglect this principle related to gravity, such as
further). The hands are then released, and either standing full-waist circles or standing reaches, are so
the position is held (isometric contraction) as seen ineffective in terms of overload that they are virtually
in figure 3.41B and table 3.4B (p. 134) or the torso useless for abdominal strengthening.
is slowly lowered back down to the floor (eccentric Recovery After 6 to 12 repetitions of an appropriate
contraction). Since greater force can be generated exercise, one should allow recovery of the abdomi-
with an eccentric or isometric contraction than with a nal muscles for 2 to 3 minutes before performing
The Spine 125
first three sets of abdominal muscle exercises

can be performed in a strength format with
adequate overload and recovery and the final
set performed in an endurance format with
lower overload and higher reps.
Stabilization Exercises Because the abdomi-
nal muscles play a very important role as pos-
tural stabilizers as well as spinal flexors, some
exercise specialists advocate that strengthen-
A ing the abdominal muscles is not sufficient in
itself and recommend the inclusion of exer-
cises that emphasize the abdominal muscles
working in an isometric manner to help sta-
bilize the trunk while the upper limbs, lower
limbs, or whole body moves. Stabilization exer-
cises generally emphasize co-contraction of
trunk muscles including the spinal flexors and
extensors while a neutral position of the pelvis
(not tucked) and spine (with a normal lumbar
lordosis) is maintained. These exercises are
designed to emphasize the motor control
B aspect of developing core stability. Although
this is currently a very popular notion, what
exercises best develop core stabilization is
controversial and will require sound scien-
tific investigation. Furthermore, some of the
exercises advocated for stabilization are low in
effectiveness for building abdominal strength,
and so, in the opinion of the author, should
be done in addition to, rather than in place
of, traditional abdominal exercises.
An example of a stabilization exercise is
the leg reach shown in table 3.4G (p. 136). As
skill improves, learning to stabilize the torso
while the torso changes its position in space
C and relationship to gravity is a way to try to
foster transfer to more complex movement.
FIGURE 3.41 Using different types of muscle contraction to For example, side support positions can be
develop abdominal strength in a greater range of motion. (A) This performed on the elbows or hands, focusing
is the height that can be reached with a concentric contraction. on keeping the spine and pelvis stable as the
(B) Hands are used to pull up slightly higher; then hands are body shifts from side, to facedown, to opposite
released, and this higher range is isometrically maintained. side (figure 3.42A). Similarly, the abdominals
(C) Start from sitting and curl back to use an eccentric can be used to posteriorly tilt the pelvis as the
contraction in a higher range than can be obtained concentrically.
ball is brought toward the shoulders and then
to stabilize the spine and pelvis as the ball
another set of 6 to 12 repetitions of abdominal work. moves away and the body moves into an extended
During this recovery time, other muscle groups could plank position (kneeling abs, figure 3.42B). This
be strengthened or stretched. The common practice ball exercise can be made more challenging by
of performing multiple sets of abdominal exercises starting with the feet on the ball and lifting the body
immediately following one another generally results with the knees straight to an inverted “V” position
in little if any improvement in strength and makes (table 3.4F [p. 136]) as the ball moves toward the
the exercises primarily beneficial for muscular shoulders. Adding a push-up in either the inverted
endurance. For the dancer who wants to maximize (figure 3.42C) or plank position can also be useful
improvement in both strength and endurance, the for developing stabilization skills. Electromyographic
A1
A2 C
B1
B2
FIGURE 3.42 Sample stabilization exercises. (A) Side support, (B) kneeling abs, (C) inverted “V” and push-up, (D) inverted
arabesque.
126
The Spine 127
Maintaining a Neutral Lumbar Spine
Start lying supine with the knees bent to about 90° and the feet resting on the floor while one hand
rests on the front of the abdomen and the fingertips of the other hand are under the side of the low
back region.
• Emphasizing isometric contraction of the abdominal muscles. While maintaining the back of
the sacrum and thoracic spine in contact with the floor, pull the abdominal wall in toward the front
of your spine without letting your pelvis or rib cage move. Your hand should feel the abdominal wall
pulling inward without the anterior rib cage and pubic symphysis coming closer together.
• Emphasizing maintaining a lumbar curve. When the abdominal muscles contract they will tend
to produce lumbar flexion. One approach to maintaining a normal lumbar curve is to try to isolate
muscle contraction to the transverse abdominis, whose function is stabilization without trunk flexion.
Another approach is to maintain the lumbar curve with co-contraction of the lumbar spinal extensors.
Thinking of pulling the front and back of the spine toward each other, or pulling evenly up with the front
and back of the pelvis, can encourage co-contraction of the abdominal muscles and spinal extensors.
Your fingertips should feel the lumbar area stay lifted versus flattening out.
• Comparison to a “C” curve. Contrast this sensation and positioning to that associated with a
“C” curve. When creating a “C” curve, note that the lumbar area comes closer to the fingertips, and
the contact of the sacrum on the floor shifts upward as the pelvis and ribs come closer together.
studies indicate that moderate abdominal activity is not only to improve specific abdominal strength,
required in push-ups to maintain trunk alignment but also to develop a better kinesthetic awareness of
(Flint and Gudgell, 1965) and that combining two trunk positioning and appropriate muscle activation
skills requiring abdominal contraction (kneeling for stabilization as well as movement. To aid with
abs or inverted “V” and push-up) may help train development of kinesthetic awareness, it is often
stabilization in a more functional manner that can helpful to utilize external feedback such as that from
more readily transfer to dancers’ movements (Lange a mirror, that from a partner, contact of the back
et al., 2000). As skill increases, one can develop relative to the ground, or to use the hand to feel
asymmetrical stabilization by adding lifting one leg the position of the ribs, pelvis, or protrusion of the
in the inverted position (figure 3.42D). Due to the abdomen. In time, a new kinesthetic awareness can
associated decrease in stability of the base of sup- be developed and utilized in motor programs that
port, performing other types of abdominal exercises will allow for the desired neutral position of the spine
such as shown in figure 3.41 may also offer greater with static alignment and appropriate contraction
stabilization benefits than performing exercises on of the abdominal muscles in dynamic movement
the floor (Stanforth et al., 1998). to protect the spine and achieve the desired dance
aesthetic. A summary of the principles just discussed
Technique and Kinesthetic Awareness Essential for making abdominal strengthening exercises effec-
to an effective abdominal strengthening program is tive is provided in table 3.3.
that proper form not be jeopardized in an attempt
to do more repetitions or to do a variation that is too Limiting Abdominal Exercise Risk
difficult for current levels of strength or skill. One
aspect of good form is that exercises should be done Many of the principles just discussed for increas-
in a slow and controlled manner, without undue use ing the effectiveness of abdominal exercises also
of momentum. Another aspect of good form is that increase the stresses applied to the spine. So, while
the desired specific sequencing of spinal and pelvic appropriate for many highly skilled dancers with no
movements occurs, with an appropriate magnitude back injury history, a less-skilled, less-conditioned, or
and without undesired compensations. The goal is injured dancer may need to take a more conservative
TABLE 3.3 Summary Guidelines for Effective Abdominal Strengthening
Form Adequate overload/progression Format

Pull abdominal wall inward Increase range of motion Perform 6-12 repetitions of each
exercise (1 set)
Generally utilize a posterior pelvic Bring arms further overhead Perform 3-5 sets (generally perform
tilt and pull the front of the lower rib 1 set each of different abdominal
cage down and back exercises)
Emphasize rounding whole spine Bring feet closer to buttocks Use variations of sufficient difficulty
and softening chest that muscle failure is approached
but correct form is maintained
Use adequate range of motion Add spinal rotation or lateral flexion Allow 2-3 minutes recovery between
sets of abdominal exercises
Keep feet unrestrained Add dumbbells in the hands
Perform slowly with control
approach such as initially using a smaller range of the spine that accompanies many daily activities
motion, avoiding rotation, and not using dumbbells. such as leaning forward, the approach generally
Three other controversial considerations for injury used by the author for dancers without back pain is
risk include the use of long-lying positions, flexed to incorporate a slight posterior tilt (with associated
versus neutral lumbar spine, and long lever arms. lumbar flexion) for greater overload and greater low
abdominal activation, as well as to help dancers gain
Long-Lying Position Some exercises in modern better control of tilting the pelvis, when exercises are
and jazz dance floor work, as well as Pilates (e.g., being performed for abdominal strength—and gen-
roll-up), involve abdominal work performed supine erally a neutral position for stabilization exercises.
with the knees straight versus bent—termed the long- However, there is theoretical support and there are
lying position. Dancers who have tight hip flexors or advantages to both approaches.
marked lumbar lordosis may not be able to assume a
long-lying position without excessive arching of the Long Lever Arms Exercises in which the legs pro-
low back and anterior tilting of the pelvis, or at least vide the resistance, such as those in which both legs
will be unable to effect the desired posterior pelvic are raised and lowered while one is lying on the back
tilt prior to the curl-up or the necessary flattening or supported on the forearms, can produce strain
of the lumbar curve during the curl-up. Bending the and arching of the low back if inadequate abdomi-
knees causes flexion at the hip that slackens the hip nal strength is present as seen in figure 3.43A. Such
flexors and iliofemoral ligament and decreases the exercises have regained popularity in recent years
lumbar curve. Hence, dancers with these conditions because of their inclusion in Pilates mat work and
should perform abdominal work with the knees at apparatus work. However, it is important to realize
least slightly bent until adequate hip and low back that the prime mover for such exercises is actually
flexibility is achieved. the hip flexors, while the abdominal muscles act
as stabilizers to prevent undesired anterior tilting
Flexed Versus Neutral Lumbar Spine Flexion of of the pelvis and further extension in the lumbar
the lumbar spine is associated with an increase in spine. Given that several studies have shown these
disc pressure. Hence, maintaining the curve in the exercises to be relatively low in effectiveness for
lumbar spine (neutral spine) is often recommended abdominal strengthening (Flint and Gudgell, 1965;
for patients with disc injury. Due to the associated Guimaraes et al., 1991; Lipetz and Gutin, 1970) and
increase in disc pressure and the desire to dance that they are considered contraindicated for indi-
with a neutral versus tucked position, some exercise viduals with weak abdominal muscles (Hamill and
specialists also advocate using a neutral versus tucked Knutzen, 1995), these exercises are better viewed as
position during abdominal work in general. How- stabilization exercises that should be used only with
ever, since the elevation in disc pressure is much less appropriate individuals, and they often require modi-
than that occurring with rigorous dance movements, fication and a gradual progression. For example,
and since lumbar flexion is a natural movement of in contrast to many other stabilization exercises in
The Spine 129
muscles facilitates the ability to stabilize

the pelvis.
Similarly, if leg lifts are advanced for
highly conditioned dancers to variations
where the torso is vertical (at a gym
or with the Pilates Cadillac as seen in
figure 3.44A), one or both knees should
be initially bent to reduce the torque
produced by the legs while adequate
abdominal stabilization strength and
skill are developed. Then, over time,
one or both legs can be partially and
eventually fully extended, only as long
as adequate stabilization of the lumbar
spine can be maintained (figure 3.44B).
Changing the relationship to gravity such
A that the moment arm of the resistance
(represented by the legs) gets longer as
the legs are lifted to 90° (versus shorter
as occurs with the supine version) makes
the abdominals have to work much harder.
Hence, the hanging leg lift (in contrast to
supine variations) has been shown to be
one of the most effective abdominal exer-
cises for recruiting the obliques as well as
the rectus abdominis (Axler and McGill,
1997; Flint and Gudgell, 1965; Guimaraes
et al., 1991; Gutin and Lipetz, 1971).
General Guidelines
for Back Extensor Strengthening
In the past it was believed that lumbar
hyperlordosis posture and much of back
injury were due to a strength imbalance,
with the abdominal muscles being weaker
B
than the back extensors. Hence, the
emphasis was primarily on strengthen-
FIGURE 3.43 Long lever arms. (A) Inadequate abdominal stabilization ing the abdominal muscles. However, in
resulting in the iliopsoas pulling the lumbar spine into hyperextension and recent years this theory has been chal-
undesired low back stress, (B) adequate abdominal stabilization with a slight lenged. There is increasing evidence
posterior pelvic tilt.
that many individuals are weak in their
back muscles as well as their abdominal
which use of a neutral pelvis is advocated, use of a muscles (Graves et al., 1990; Pollock et al., 1989;
slight posterior pelvic tilt when one is first learning Smidt et al., 1983; Suzuki and Endo, 1983), and
long lever arm exercises can help ensure that lumbar the tightness of the low back commonly seen with
hyperextension is avoided (figure 3.43B). To further lumbar hyperlordosis is not necessarily indicative
reduce risk, such exercises can initially be performed of high strength levels. Furthermore, it has been
on the forearms with only one leg extended (table shown that inadequate spinal extensor strength and
3.4G [p. 136], leg reach), with the legs pointing up endurance can increase the risk for low back injury
more toward the ceiling or with the knees bent such (Caillet, 1996; Parnianpour et al., 1988) and that
that the torque produced by the legs will be less, or both inadequate extensor strength and, particu-
with the hands or a pillow under the pelvis so that larly, inadequate endurance are commonly present
a better angle of attachment for the abdominal in individuals with low back pain (Chaffin, 1974;
A B
FIGURE 3.44 Hanging leg lift. (A) Modified with knees bent, (B) advanced with knees straight.
CSULB dancer Dwayne Worthington.
Hides et al., 1994; Levangie and Norkin, 2001; Pollock Enhancing Back Extensor
et al., 1989; Roy, DeLuca, and Casavant, 1989). Strengthening Effectiveness
Conversely, a high level of physical activity has As with abdominal exercises, careful selection and
correlated with greater strength of the vertebrae performance of back extensor exercises are keys for
and discs (Porter, Adams, and Hutton, 1989), and obtaining potential strength benefits. Many of the
several studies have also shown that individuals with principles discussed with the abdominals are also
good back extensor endurance and better general relevant for the back.
conditioning have fewer incidences of back problems
and less risk of osteoporosis than deconditioned Feet Unrestrained and Restrained. As with abdomi-
individuals. Similarly, a recent study with university nal exercises, when the feet are restrained the hip
dancers showed a decrease in the number of classes muscles can assist the spinal muscles with the move-
missed due to back pain after participation in a ment. Therefore, it is important that some exercises
back strengthening program (Welsh et al., 1998). for the spinal extensors be performed without the
So, there is sufficient basis to indicate that dancers feet stabilized. However, when the feet are held down
should include strengthening for their back exten- by a partner, strap, or bar, most dancers are able to
sors as well as their abdominal muscles. However, a arch the back much higher, and so it provides a way
balance with abdominal strengthening is important, that strength in a higher range of motion can be
as strengthening the back extensors alone has been carefully developed. In addition, when the feet are
shown to actually have a negative effect on postural restrained, the dancer can often more readily focus
stability (Kollmitzer et al., 2000). on using the hip extensors to pull the bottom of the
The Spine 131
Back Extensor Strength Test
Perform the following test on another dancer to estimate the strength of the back extensors. This
test should be performed slowly, carefully, after the back is fully warmed up, and only if it is pain
free. Dancers with a history of back injury or pain should not perform this test unless approved and
supervised by their medical provider.
Back Extension Height Test (Muscular Strength)
Start with your partner prone on a mat with the knees extended and the feet together and resting on
the ground. The elbows are bent with the fingers spread and lightly resting on the back of the head.
Then, have your partner, with the elbows back behind the ears, very slowly arch up as high as possible
without using momentum, without letting the elbows come forward, and without letting the feet lift off
the ground. Cue your partner to arch the spine starting from the top of the spine and continuing to
the bottom. Measure the perpendicular distance from the indentation at the base of the neck (sternal
notch) to the ground using a tape measure as shown in the figure. The goal is to be able to come up
to the same height with this active test as the dancer can achieve passively (when using the arms
to press against the floor to arch the back). Average back extension test results for performing arts
high school dance majors tested by the author were 13 inches (33 centimeters) for female and 12
inches (30 centimeters) for male dancers.
Note: Due to differences in spine length and flexibility, the same measured distance will not reflect
the exact same angle of spinal extension from individual to individual. However, this measure will
give you an approximate indication of strength (with stronger individuals able to come up higher) and
provides a useful tool to monitor improvement in strength within the same individual.
pelvis down to help prevent excessive anterior tilting upper back. One way to achieve this is to select posi-
of the pelvis and reduce excessive hyperextension in tions such as sitting (e.g., scarecrow, table 3.4H [p.
the low lumbar area. 137]) or kneeling over a ball (e.g., kneeling scare-
crow, table 7.10H [p. 439]) where the abdominals
Upper Back Emphasis. Given the markedly greater
can be used to more readily keep the lumbar spine
range of hyperextension possible in the lumbar
in slight flexion, as extension higher in the spine is
region and the larger cross-sectional area of the
emphasized. However, because the thoracic curve is
spinal extensors in this region, it is easy for back
concave anteriorly, it is important to note that the
extension exercises to primarily challenge and
range of extension will be very small compared to
strengthen the low back region. However, since there
that which occurs in the lumbar spine.
are actually different muscles (e.g., the semispinalis)
and different slips of muscles in the thoracic region Type of Muscle Contraction. As with the abdominals,
than in the lumbar region, it is important to also the arms can be used (in this case to press down on
include exercises that emphasize strengthening the the ground when prone) to achieve a slightly greater
height of the torso (e.g., greater spinal extension) kinesthetic awareness must be developed to achieve
than can be achieved with a concentric contraction. the desired sequential extension of spinal vertebrae
This higher position can be held for several counts rather than having large segments of the spine move
(isometric contraction) or followed immediately with as a whole or almost all of the movement occur in
a controlled lowering (eccentric contraction) to the the low lumbar spine. Lack of adequate stabilization
prone starting position. However, particular care must can make many back exercises potentially injurious
be taken not to strain the back extensors by only going rather than therapeutic.
a few degrees higher than can be reached concentri-
cally, and starting by only sliding one arm out as the Limiting Back Extensor Exercise Risk
other arm still offers support. Unfortunately, applying many of the principles that
Spinal Rotation. Adding rotation to back extension increase effectiveness, such as the addition of rota-
exercises can add greater overload to the muscles tion and resistance, will also increase the stresses
that produce rotation in the desired direction. Fur- borne by the discs and other spinal structures. So a
thermore, because there are actually different spinal more conservative approach is often recommended,
extensor muscles and slips of muscles in different with particular attention paid to range of motion
regions of the spine, rotation in different regions and and stabilization.
positions of the spine can actually produce greater Range of Motion. Using a greater range of motion
challenge to different muscles. For example, pure produces more overload through shortening of the
rotation was found to elicit a marked response in the muscles and allows for development of strength
multifidus and rotatores while the iliocostalis showed through a full range of motion. However, greater
greater activity when forward flexion (from standing) range of motion will generally require marked spinal
was combined with rotation (Basmajian and DeLuca, hyperextension, which is of concern in terms of injury.
1985). In prone or kneeling positions, subtle rotations Hence, there is still controversy as to how much range
and stabilizations, similar to those used in dance, can of motion should be used in back extension exercises.
be effected by lifting one arm, one leg, or an arm and For dancers with access to a gym (roman chair),
a leg at the same time (e.g., prone arabesque, table exercise ball, bench, or Pilates barrel, this controversy
3.4N [p. 140]. When on the hands and knees, lifting can be avoided by performing back extensions from
the opposite arm when one leg is lifted increases the a position of flexion to just a straight (neutral) spine.
upper erector spinae activity by about 30% (Levangie And one study showed marked gains in back extensor
and Norkin, 2001). strength in a flexed to neutral position when train-
ing on exercise equipment in a relatively small arc of
Adequate Overload and Recovery. As with the 36° flexion (Graves et al., 1990). However, because
abdominals, to produce desired improvements in of the prevalent use of marked spinal hyperexten-
muscular strength, the exercises that are performed sion in dance, there is a theoretical basis in terms of
should be difficult enough that only about 12 or functional issues to support using a range of motion
fewer repetitions can be performed, and a 2- to 3- in strength training for dances that includes hyper-
minute recovery of the spinal extensors should be extension. And only studies that have linked back
allowed between sets of back extension exercises. strength to the demands of the job have shown the
Difficulty can be increased by using a larger range ability to predict future back injuries (Parnianpour
of motion, adding rotation, bringing the arms to et al., 1988). But to reduce injury risk, hyperexten-
the side or overhead versus down by the sides, and sion should only be performed (without medical
adding dumbbells in the hands for resistance. Since supervision) if no back discomfort is present, there
the effect of gravity on the body is primarily creat- is no history of back pain or medical contraindica-
ing the resistance in many back extensor exercises, tion, range is gradually developed over time, and
appropriate body positioning should be used so sound technique is employed. One approach is to
that the torso or pelvis is moving against gravity to initially limit hyperextension to about 10 or 20° while
produce spinal extension, such as when performing focusing on developing abdominal co-contraction/
prone back extensions (e.g., table 3.4I [p. 138]). stabilization skills. Then range can be gradually
Technique and Kinesthetic Awareness. Performing increased as long as appropriate stabilization is used
back extensor exercises in a smooth and controlled and the movement remains pain free.
versus jerky manner with precise spinal articulation Abdominal Co-Contraction. One important aspect of
and positioning of the pelvis is essential for effec- these stabilization skills is utilizing a co-contraction
tiveness and safety. Subtle stabilization skills and of the abdominals, as discussed under Spinal Hyper-
The Spine 133
the pubic symphysis into the

ball or floor while the navel
stays lifted, can make it easier
to achieve the desired form as
shown in figure 3.45.
Strength Exercises
for the Spine
Specific sample strength and
stabilization exercises for the
spine are provided in table
3.4. The principles just dis-
cussed should be applied to
A performance of these exercises.
Exercises should be carefully
selected to match each dancer’s
current level of strength and
skill, and a variety of exercises
should be used to capture the
unique benefits each has to
offer. In general, start with pure
spinal flexion and spinal exten-
sion exercises (in the sagittal
plane) with less conditioned
dancers, and then add rotation
and lateral flexion as strength
and stabilization skill develop.
An example of a progression for
B abdominal exercises is provided
in table 3.5 on page 142.
In terms of the ratio of
FIGURE 3.45 Upper back extension with co-contraction of abdominal muscles. (A) Ade- abdominal and back extensor
quate stabilization of low lumbar spine, (B) inadequate stabilization of low lumbar spine. exercises that should be used,
multiple factors should be con-
extension (p. 115), to decrease the magnitude of sidered. Several studies showed that the back exten-
extension and shear in the lowest lumbar vertebral sors made greater improvements in strength (tested
segments. For example, when arching from a prone isometrically) than other muscles with just one work-
position, focus on pulling the pubic symphysis up out per week (Carpenter et al., 1990; Graves et al.,
with the lower attachment of the abdominals moving 1990; Pollock et al., 1989), suggesting that abdominal
so that the waist is lifted a half inch (1.2 centimeters) exercises should be performed with greater frequency
from the floor versus pushing into the floor, and or more sets than extensor exercises.
maintain this position of the pelvis as the back slightly However, this may change with aging, and per-
arches in the thoracic region. If this exercise is pro- formance of more back extension exercises may be
gressed to higher ranges of spinal extension, lumbar necessary to counter the tendency for kyphosis and
hyperextension will be necessary, but “pulling up the decrease in spinal extensor size noted to gradually
and in” with the lower attachment of the abdominals occur in men over 30 years of age and the decrease
onto the pelvis (as you allow the upper attachment in spinal extensor density noted in women in the 40
of the abdominals onto the rib cage to move away) to 49 age range (Imamura et al., 1983). In addition,
can still help limit anterior pelvic tilting and low back static and dynamic alignment should be taken into
stress. If difficulty in maintaining desired positioning account, and dancers with excessive hyperlordosis
is experienced, performing this exercise with a towel often benefit from greater abdominal work and back
roll under the front of the top of the pelvis, or kneel- extensor exercises that use very low range while empha-
ing with the hips on a ball while focusing on pressing sizing abdominal co-contraction and stabilization.
TABLE 3.4 Selected Strength Exercises for the Spine
Exercise name Description

(Resistance) (Technique cues) Progression
Muscle group: Spinal flexors
Muscles emphasized: Abdominals/technique
Joint movement: Spinal flexion with posterior pelvic tilting
A. Pelvic tilt Lie supine with knees bent to 1. Increase range.
about 90° with the feet flat on the 2. Increase symmetry of upper and
ground. Pull pubic bones and lower lower movement.
ribs toward each other, focusing
on tilting the top of the pelvis
posteriorly so that the lumbar spine
flattens against the floor. Hold 8
counts, then return pelvis and ribs
to starting position.
(Pull whole abdominal wall
inward so that it is concave, not
protruding.)
Muscles emphasized: Abdominals/isometric
Joint movement: Spinal flexion with posterior pelvic tilting
B. Isometric curl-up Lie supine with knees bent to 1. Bring feet closer toward
(Body weight) about 90°, feet flat on the floor buttocks.
and arms down by sides. Perform 2. Increase hold to 8 counts.
a slight posterior pelvic tilt, bring 3. Bring arms slowly back overhead
the chin toward the chest, and (high fifth) and then forward
curl up sequentially until shoulder again during the hold.
blades are off the floor. Then, place
4. Perform on a diagonal with both
hands on the outside of the thighs
hands on the outside of the
and use them to pull the torso up
same distal thigh.
slightly higher. Release hands, hold
for 4 counts, and return torso to
starting position.
(Keep abdominal wall pulled inward,
and avoid letting torso drop down
when hands release.)
Muscles emphasized: Abdominals/eccentric
Joint movement: Spinal flexion with posterior pelvic tilting and hip flexion
C. Curl-back Sit with your knees bent about 90° 1. Increase hold to 8 counts.
(Body weight) and feet flat on the floor. Perform a 2. Bring hands behind head and
slight posterior pelvic tilt and then then forward during hold.
curl the torso back down toward the 3. Start with the arms in high fifth.
floor. Begin by bringing the sacrum in
4. Bring knee to chest during hold.
contact with the floor, then proceed
until the back of the waist is in 5. Bring knee to chest and then
contact with the floor. Hold 4 counts, extend knee (développé) during
and slowly curl back up to starting hold.
position, using the hands on the
thighs to assist on the way up if
needed.
(Keep spine as flexed as possible
throughout the movement.)
Variation 1: Perform sitting on an
exercise ball, starting with the knees
bent about 90° and the feet flat on
the floor.
134
Muscles emphasized: Abdominals/stabilization and latissimus dorsi
Joint movement: Spinal flexion with shoulder extension
D. Reformer curl-up Lie supine with knees flexed just 1. Curl torso higher.
(Reformer) over hip joints, and lower legs 2. Increase springs.
parallel to the carriage while the 3. Extend knees with feet pointing
hands are overhead holding straps. toward ceiling as arms go
Bring arms forward and down overhead.
(shoulder extension), curl torso up
while keeping elbows extended so
that straps provide resistance to
spinal flexion, pause, bring arms
back overhead while torso remains
up, and then slowly lower torso to
starting position.
(Curl torso up as high as strength
will allow while still maintaining
back of waist in contact with
carriage, and avoid letting torso
lower down as arms go overhead.)
Muscles emphasized: “Lower” abdominals
Joint movement: Lumbar spinal flexion with posterior pelvic tilting
E. Hip lift Lie supine with knees slightly bent 1. Lift pelvis higher.
(Elastic band) and directly over the hips while the 2. Use a heavier band.
hands hold a band stretched across 3. Lift the pelvis on a diagonal.
the front of the thigh to resist
the motion. Perform a posterior
pelvic tilt and then continue that
movement until the sacrum slowly
lifts off the ground and the thighs
come closer to the shoulders. Hold
4 counts, and slowly lower the hips
back to the starting position.
(Emphasize the abdominals by
posteriorly tilting the pelvis to
produce the lift rather than flexing
the hip, and avoid the use of
momentum.)
(continued)
135
TABLE 3.4 Selected Strength Exercises for the Spine (continued)

Muscles emphasized: “Lower” abdominals/stabilization
Joint movement: Lumbar spinal flexion with posterior pelvic tilting and hip flexion
F. Inverted “V” Support the body weight with the 1. Lift pelvis higher.
(Exercise ball and body weight) hands on the floor and feet on an 2. Add a push-up in plank position.
exercise ball (plank position) with 3. Add a push-up in inverted “V”
the pelvis and spine in a neutral position.
position. Perform a posterior
4. Add lifting one leg up toward the
pelvic tilt and then lift the hips up
ceiling in inverted “V” position
toward the ceiling as the feet pull
(arabesque).
the ball closer toward the hands.
Pause, and slowly lower to starting
position.
(Emphasize keeping abdominal wall
pulled inward as hips lift up, and
avoid letting the pelvis anteriorly
tilt or the low back excessively arch
when returning to starting position.)

Muscles emphasized: Abdominal stabilization
Joint movement: Lumbar spinal flexion with posterior pelvic tilt maintained
G. Leg reach Lean back on elbows with knees 1. Begin to straighten second knee
bent about 90° and feet flat on floor. while the first knee is extended,
(Body weight)
Perform a slight posterior pelvic tilt, but only in a range where the
and bring knees to chest one at a pelvis can be kept stationary and
time. Then slowly straighten one leg the low back does not arch.
to a height where the foot is about 2. Fully straighten second knee.
2 feet (61 centimeters) off the 3. Perform with spine slightly flexed
ground while the other knee stays and no arm support.
above the hip with the lower leg
4. Perform with a neutral pelvis.
parallel to the floor. Hold 4 counts,
then bring the first knee back in
toward the chest. Alternate legs.
(Maintain a stable pelvis with
abdominals pulled in firmly toward
the spine throughout the exercise.)
136
Muscle group: Spinal extensors
Muscles emphasized: Upper back extensors
Joint movement: Cervical and thoracic spinal extension
H. Scarecrow Sit on the carriage with the knees 1. Increase range of motion of arch
(Reformer) bent and the feet flat on the in the upper back.
headrest while the arms are at 2. Increase spring resistance from
shoulder height with the elbows very light to light.
extended. Hold the straps in the 3. Add slight rotation of the torso
hands with the palms facing down. as the arms reach overhead.
Pull the elbows back slightly behind
the shoulders, externally rotate at
the shoulder so that the palms face
front, hyperextend the upper back
as the arms reach overhead, pause,
and reverse the pattern to slowly
return to the starting position.
(Keep the pelvis and low lumbar
spine stationary, emphasizing
movement and muscular work in
the upper back. Keep elbows at
shoulder height and maintain about
90° of elbow flexion during the
shoulder rotation phase.)
(continued)
137

Muscles emphasized: Upper and lower back extensors/stabilization
Joint movement: Spinal extension with shoulder flexion
I. Prone single-arm spine arch Lie prone on forearms with legs 1. Increase range of motion of
(Body weight) straight and feet together. Use the thoracic spinal extension while
abdominals to lift the front of the still maintaining ASIS off the
pelvis (ASIS) until a straight line floor.
could be drawn through the sides 2. Add a small dumbbell in the
of the shoulder, torso, and pelvis. hands.
Then reach one arm forward and 3. Add slight rotation of the torso
upward as the back arches, pause, toward the raised arm.
and return to the starting position.
(Keep “pulling up” from the low
attachments of the abdominals to
limit the degree of anterior tilting of
the pelvis as the back arches. Bring
the arm to or behind the ear, and
focus on “lifting” and arching the
upper back first.)
Muscle groups: Spinal extensors and shoulder flexors

Muscles emphasized: Back extensors/sequential
Joint movement: Spinal extension with shoulder flexion maintained
J. Spine arch with overhead press Lie prone with the hips at the edge 1. Gradually increase bar
(Reformer and bar) of the box and heels on the footbar, resistance from 1 pound to 5
with the knees bent and a weighted pounds (0.5-2.25 kilograms).
bar in the hands behind the head
with the elbows bent. Extend the
elbows to reach the bar overhead,
extend the knees and hyperextend
the spine, pause, and slowly return
to the starting position.
(Keep “pulling up” with low
attachment of abdominals to limit
anterior tilting of the pelvis and
sequentially extend the spine from
upper to lower, working only in a
pain-free range.)
138
Muscle group: Spinal lateral flexors
Muscles emphasized: Oblique abdominals
Joint movement: Spinal lateral flexion
K. Side-up Lie on one side with the knees 1. Increase range of motion.
(Body weight) and hips slightly flexed, then rock 2. Bring arms overhead and then
the whole body back as a unit back when torso is raised.
such that the knees are about 8 3. Add dumbbells in hands.
inches (20 centimeters) off the
floor. Slightly flex the spine, then
sequentially raise head, shoulders,
and torso toward the ceiling. Hold 4
counts, then slowly lower to starting
position.
(Keep abdominal wall pulled inward,
and lead with the lower arm such
that the spine slightly flexes and
rotates as it laterally flexes.)
Variation 1: Perform on the Pilates
Cadillac with the feet under the
restraining strap.
Variation 2: Perform with a “short
box” on the Pilates Reformer with
the feet under the restraining strap,
and increase range of motion by
beginning with the torso laterally
flexed toward the floor.
Muscles emphasized: Oblique abdominals/stabilization
Joint movement: Spinal lateral flexion with shoulder abduction
L. Side reach Begin on one side with weight 1. Increase range of lowering and
(Body weight) supported on forearm of bottom raising of hips.
arm and feet, with top foot in front 2. Support weight on the hand
of bottom foot. Top arm is in line of the bottom arm (with elbow
with shoulder. Slowly lower hips extended).
toward floor as the arm goes down 3. Perform one time, shift to face-
by the side, and then raise hips down with two-arm support and
toward the ceiling as top arm raises do push-up, shift to perform one
overhead, pause, and return to time on the other side. Repeat
starting position. series 2-6 times.
(Keep spine/pelvis neutral in the
sagittal plane and avoid sticking
ribs forward, reach from feet to
fingertips when arm goes overhead
while maintaining stability of the
support shoulder.)
(continued)
139

Muscle group: Spinal rotators
Muscles emphasized: Oblique abdominals
Joint movement: Spinal rotation with flexion
M. Curl-up with rotation Lie supine with knees bent to about 1. Rotate right, center, left, center.
(Body weight) 90° and the feet flat on the floor 2. Bring the arms back behind the
and the hands behind the head. head and then forward again
Then bring the chin to the chest, when in the rotated position.
and sequentially curl up the torso
as high as strength allows without
letting the back of the waist leave
the floor. Bring arms forward, slowly
rotate right and then center, then
bring hands back behind head, and
curl back down to starting position.
(Keep the spine flexed as you
rotate, and think of bringing the
shoulder higher as you rotate.)
Muscles emphasized: Spinal extensors
Joint movement: Spinal rotation with extension
N. Prone arabesque Lie prone with legs extended 1. Raise the torso slightly higher
(Body weight) and arms out to sides. Contract as the arm returns to second
abdominals to lift waist off floor, position.
and raise both arms off the floor 2. Add a 1-pound (0.5-kilogram)
in second position as head and dumbbell to the hands.
upper back lift. Then raise one leg 3. Gradually increase the dumbbell
about 6 inches (15.2 centimeters) from 1 pound to 3 pounds (0.5-
off the floor, bring the opposite arm 1.4 kilograms).
overhead, rotate the torso toward the
overhead arm, pause, and lower the
arm and torso to the starting position.
(Keep “pulling up” with lower attachment
of the abdominals to limit anterior tilting
of the pelvis, and lift the torso slightly
higher as the torso rotates.)
For all abdominal exercises, focus on pulling the abdominal wall inward toward the spine to help strengthen the transverse abdominis. For assymetrical exercises, perform
4-6 repetitions on one side and then 4-6 repetitions on the other side.
In contrast, dancers with fatigue posture or flat back and for chest lifts used to rise from supine to sit-
posture need adequate inclusion of back extension ting in jazz dance. The stabilization function of the
exercises with an emphasis on extension in the abdominal muscles is essential for achieving the
appropriate spinal region. desired aesthetic in many dance movements.
The first exercise listed in table 3.4, the pelvic tilt,
Spinal Flexor (Abdominal) Strengthening is not very effective for strengthening the abdominal
As previously described, strong abdominal muscles muscles but is included to develop the technique of
are believed to be important for preventing lumbar posteriorly tilting the pelvis that is used as part of
lordosis, generating IAP, stabilizing the spine, and many other abdominal exercises. As skill develops, it
preventing low back injury. In dance, strong abdomi- is no longer necessary to perform the pelvic tilt as a
nal muscles are important for floor work in modern separate exercise; rather it can be included in other,
dance such as Graham contractions or “hollowing,” more effective abdominal exercises. The isometric
The Spine 141
curl-up (table 3.4B) and the curl-back (table 3.4C) lower back extensors while focusing on abdominal
are meant to emphasize developing strength in a co-contraction.
range higher than one can reach in the up-phase of
the curl-up, so that in time the ability to concentri- Spinal Lateral Flexor Strengthening
cally curl up higher is enhanced. Some examples of
progressions are provided, but keep in mind that Strong spinal lateral flexors are important for floor
any of the procedures for increasing overload pre- movements involving rising from a position of lying
viously discussed can be used with these exercises. on the side. They are also used in the side-bending
The Reformer curl-up (table 3.4D) uses the straps movements of the torso commonly performed in
to provide greater overload and effectiveness. The modern and jazz dance. Often when bending the
hip lift (table 3.4E), kneeling abs (figure 3.42B), and torso to the side, dancers allow the lumbar spine to
inverted “V” (table 3.4F) emphasize lower abdominal excessively arch, due to inadequate co-contraction of
use and control of the pelvis essential for correcting the abdominal muscles. Hence, side-ups (table 3.4K)
lumbar lordosis. The side support (figure 3.42A, are provided that emphasize slight trunk flexion
p. 126) and leg reach (table 3.4G) emphasize devel- and rotation as the spine is laterally flexing, placing
oping strength and skill in spinal stabilization. In all greater emphasis on the obliques. One can also add
of these exercises it is important to emphasize pulling difficulty to this exercise by focusing on keeping the
the abdominal wall in and up toward the spine to pelvis stable as the torso laterally rises as high as cur-
challenge the vital transverse abdominis muscles. rent strength will allow. Stabilization exercises using
side positions such as the side reach (table 3.4L) can
Spinal Extensor Strengthening also provide challenge to the spinal lateral flexors.
Strong spinal extensors are very important for sta- Spinal Rotator Strengthening
bilizing the spine, bending the torso forward and
back when upright, and arching the back. Strong Strong spinal rotators are necessary for both stabiliza-
back extensors are also important for preventing tion and movement of the spine. Many injuries to the
undesired forward movement of the torso in move- back involve rotation, so it is particularly important
ments such as in an arabesque, split jumps, or lifting to strengthen the muscles involved in rotation and
a dancer overhead. As with the abdominal muscles, to practice proper mechanics during rotation. Subtle
a variety of exercises is recommended to provide use of the spinal rotator muscles is also involved in
a wider range of benefits—for example, including asymmetrical movements that include lifting of one
exercises that emphasize arching the upper back, leg or arm such as in an arabesque. Grosser use of
the full spine, rotation, and stabilization. the rotators is involved in movements in which the
The scarecrow performed sitting on the Reformer torso is twisting relative to the pelvis or the pelvis
(table 3.4H) or sitting in a chair (figure 3.26A, p. 99) is twisting relative to the torso, such as in jazz isola-
emphasize challenging the upper back extensors in tions or many warm-up combinations and movement
a position where it is easier to stabilize the lumbar phrases in jazz and modern dance.
spine. The thoracic extensors are important pos- Most of the spinal flexors and extensors are also
turally to prevent kyphosis and prevent the upper capable of producing rotation. The curl-up with
back from falling forward. Furthermore, one study rotation (table 3.4M) challenges the spinal flexors
showed that as back extensor fatigue occurs the (oblique abdominal muscles) capable of rotation.
contribution of the thoracic extensors becomes For effective challenge and to practice sound mechan-
more prominent (Klausen, Nielsen, and Madsen, ics, it is important to keep the spine flexed as the
1981). However, in order to target these upper torso rotates, rather than let one shoulder drop and
back extensors, the lower attachment of the pelvis the low back flatten or arch. The prone arabesque
must be actively “pulled up” so that the top of the (table 3.4N) emphasizes strengthening the spinal
pelvis is not allowed to tilt forward and the lumbar extensors capable of rotation. Adding lifting one leg
spine is not allowed to excessively hyperextend, to any spinal extension exercise will also produce
while the upper back arches with a very small range slight spinal rotation. Adding such rotation increases
of movement (figure 3.45). This is a difficult coor- the challenge and more specifically recruits some of
dination, and it often requires practice and help the spinal extensors believed to be commonly injured
from a partner or the use of a mirror to monitor in lumbosacral strains. Remember that the amount of
technique. The prone single-arm spine arch (table spinal extension present when rotation is added will
3.4I) and spine arch with overhead press (table influence the region of the spine involved in the rota-
3.4J) are designed to combine use of the upper and tion and the specific components of the spinal extensors
stressed. So, using varied positions will provide more dance. And, for example, while 20° to 30° of spinal
comprehensive strengthening. However, to help pro- hyperextension is considered normal for the general
tect the spine, it is important that there be a small adult population (table 3.6), elite female ballet danc-
co-contraction of the abdominal muscles to prevent ers were found to have an average of 79° (range 60° to
excessive hyperextension in the low lumbar spine. 124°) (see figure 3.46) and elite male ballet dancers an
average of 65° (range 45° to 93°) of spinal hyperexten-
Sample Abdominal Exercise Progression sion (Clippinger-Robertson, 1991). A study of flamenco
A sample routine for abdominal strength and stability dancers showed significantly larger range of lumbar
with progressions is provided in table 3.5. However, extension, lateral flexion (lumbar and thoracic), and
progressions should only be performed after excellent rotation (thoracic) than in controls (Bejjani, Halpern,
form has been mastered in easier variations. When and Pavlidis, 1990). So, stretches in all three planes of
harder variations are added, it is often necessary to motion are recommended for the spine. A discussion
initially use smaller ranges of motion and lower repeti- of specific selected stretches for the spine follows,
tions so that proper technique can be maintained. and many of these exercises are pictured and further
described in table 3.7. For purposes of time economy,
Stretches for the Spine stretches for the spine are also commonly com-
bined with stretches for the hip performed standing,
Very large ranges of motion of the spine are required sitting on the floor, or at the barre (see chapter 4).
to achieve the desired aesthetic in many dance forms However, as shown in table 3.6, many struc-
including ballet, modern, jazz, flamenco, and African tures other than muscles offer constraints to spinal
TABLE 3.5 Sample Abdominal Exercise Progression
Exercise name
(from table 3.4) Version of exercise Repetitions
Level I
Pelvic tilt Basic form 6 times
Isometric curl-up Basic form 6 times . . . 12 times
Curl-back Basic form 6 times . . . 12 times
Hip lift Basic form 6 times . . . 12 times
Level II
Isometric curl-up Bring feet closer to buttocks 6 times . . . 12 times
Curl-back Bring arms from low fifth to high fifth, then progress to 6 times . . . 10 times
adding weights in hands
Hip lift Lift pelvis on diagonal toward one shoulder 6 times . . . 10 times
Curl-up with rotation Basic form 4 times . . . 6 times/side
Leg reach Basic form 4 times . . . 6 times/side
Level III
Curl-up with rotation Rotate right, center, left, center, down 6 times . . . 12 times
Curl-back With arms in high fifth with weights, bring knee to chest and 4 times . . . 6 times/side
extend knee
Side-up Basic form, then progress to adding weights held across 4 times . . . 8 times/side
chest
Inverted “V” Basic form, then progress to lifting one leg (arabesque) 4 times . . . 4 times/side
Side reach Basic form, then progress to performing only 1 rep each 4 times/side . . . 12 total
direction and adding a push-up in the transition
TABLE 3.6 Normal Range of Motion and Constraints for Fundamental Movements of the Spine
Spine movement Average ranges

(thoracic and lumbar) of joint motion* Normal passive limiting factors
Flexion 0-80° Ligaments: posterior spinal ligaments
Discs: compression of anterior aspect and tension of posterior
aspect
Joint capsules: capsules and ligaments of facet joints
Muscles: spinal extensors and associated thoracolumbar fascia
Extension 0-30° Ligament: anterior longitudinal ligament
Discs: compression of posterior aspect and tension of anterior
aspect
Muscles: abdominals
Bony constraints: overlapping of spinous processes in thoracic
region, approximation of facet joints in lumbar region
Lateral flexion 0-35° Ligaments: contralateral spinal ligaments
Discs: compression of ipsilateral portion of disc and tension of
contralateral portion of disc
Muscles: contralateral quadratus lumborum and varying amounts of
oblique abdominals and spinal extensors, depending on position of
torso
Bony constraints: approximation of lower ribs and iliac crest
Rotation 0-45° Ligaments: costovertebral and perhaps posterior ligaments
Discs: tension in annulus fibrosus
Joint capsules: capsules of facet joints
Muscles: oblique abdominals and spinal extensors, varying with
position of torso
Bony constraints: facet joints in lumbar region
*From American Academy of Orthopaedic Surgeons (1965).
FIGURE 3.46 High range of spinal hyperextension present in some dancers.
143
TABLE 3.7 Selected Stretches for the Spine
Description
Exercise name (Technique cues) Progression
Muscles emphasized: Lumbar extensors
Joint position: Lumbar spinal flexion
A. Double knee to chest Lie supine with the knees bent and 1. Bring knees further toward
feet flat on the floor. Then use a armpits to increase lumbar
hand to gently pull one knee and flexion.
then the other knee toward the
chest until a stretch is felt in the
low back.
(Pull abdominal wall inward, and
focus on rounding the lumbar
spine.)
Variation 1: Perform kneeling with
the torso resting on thighs and arms
overhead (figure 3.25C, p. 97).
Muscle groups: Spinal extensors and hip extensors
Muscles emphasized: Lumbar extensors and hamstrings (for less flexible dancers)
Joint position: Lumbar flexion with hip flexion and knee extension
B. Sitting forward bend Sit with both legs forward and feet 1. Wrap hands around outside of
about 2 feet apart (knees may lower legs, and use hands to
be bent if hamstrings are tight). pull rounded torso closer toward
While keeping pelvis posteriorly floor.
tilted, bring head toward floor until
stretch is felt in low back.
(Emphasize keeping low back
rounded—i.e., flexing lumbar
spine—vs. flexing at hip joint.)
Variation 1: Perform sitting in chair
with feet on floor and forearms on
thighs.
Muscle group: Abdominals
Muscles emphasized: Rectus abdominis and oblique abdominals
Joint position: Spinal hyperextension
C. Prone press-up Lie prone, resting on forearms. 1. Bring elbows toward each other
Then press down with the forearms until shoulder width apart.
and sequentially arch spine from 2. Bring elbows back toward waist,
head to sacrum. and carefully arch higher.
(Keep neck in line with thoracic 3. Straighten elbows, press with
spine, and “reach” spine out hands, and carefully arch higher.
and up using a pain-free range of
motion.)
Variation 1: Perform on exercise
ball with hips supported by ball
and forearms pressing down on
ball (figure 3.47A, p. 148).
144
Description
Muscle groups: Abdominals and shoulder extensors
Muscles emphasized: Rectus abdominis, oblique abdominals, and latissimus dorsi
Joint position: Thoracic spinal extension with shoulder flexion
D. Upper back drape Sit on the floor with knees 1. Bring sitz bones back, closer to
bent, feet flat on the floor, and the ball.
the midback resting against an 2. Extend elbows with hands in
exercise ball. Lace fingertips line with ears (figure 3.47C, p.
behind head with elbows bent. 148).
Then pull the shoulder blades
together and the elbows back,
and sequentially arch the thoracic
spine from T12 upward.
(Pull “low abdominals” in and up to
prevent the top of the pelvis from
tilting forward, and emphasize arch
occurring in upper back with head
in line with this arch.)
Variation 1: Perform sitting in a
high-backed chair, and carefully arch
the upper back up and over the top
of the chair (figure 3.26B, p. 99).
Muscles emphasized: Quadratus lumborum and oblique abdominals
Joint position: Spinal lateral flexion
E. Side bend Sit with one knee bent with its side 1. Reach the hand that was on
resting on the floor and the other the floor across the front of
leg extended to the side. Then the body, and bend the torso
bend the torso to the side with the further.
lower arm resting on the ground
and the top arm reaching toward
the outstretched leg.
(Reach spine out long as you
laterally flex it, and keep both sitz
bones firmly in contact with the
floor.)
Variation 1: Perform sitting on the
floor with both legs outstretched
(second position).
Variation 2: Perform standing turned
out, facing the barre with one leg
up on the barre to the side.
(continued)
145
TABLE 3.7 Selected Stretches for the Spine (continued)
Description
Muscles emphasized: Lumbar and thoracic spinal extensors and oblique abdominals
Joint position: Spinal rotation
F. Supine spine twist Lie supine with one leg 1. Bring the knee and upper side
outstretched and the other knee of the pelvis further toward the
bent directly above the hip with floor without letting the shoulder
the lower leg parallel to the floor. lift off the floor.
Rotate the spine by using the
opposite hand to pull the knee
toward the floor while keeping the
upper back in place.
(Focus on rotating the spine along
its length while contracting the
abdominals to keep the pelvis
slightly tucked and the lower ribs in
good alignment with the pelvis.)
movements, including ligaments, discs, and bony pro- 3.7A) provides a gentle stretch for the lower back,
cesses. Hence, when one is performing stretches for creating a posterior tilting of the pelvis and a decrease
the back, particular care must be taken that the body in the lordosis in the lumbar spine. Although it may be
is adequately warmed, the stretch is slowly applied too mild for the more flexible dancer to feel a stretch,
without excessive momentum or force, and close it offers a position in which the pressure within the
attention is paid to proper positioning of the body. It intervertebral discs is low and is commonly recom-
is also important to realize that there is extreme indi- mended with low back pain. Similarly, performing
vidual variability in spinal motions, some of which is this stretch in a kneeling position (figure 3.25C,
structural in nature. For example, in the elite athletes p. 97), sometimes termed the rest position, can pro-
tested by the author, the range of spinal hyperexten- vide relief for tight or fatigued low back extensors.
sion has ranged between 8° (elite male race walker) The sitting forward bend stretch (table 3.7B) pro-
and 124° (elite female ballet dancer). Thus, it is vides a more rigorous variation, and a similar position
important to work carefully to increase or maintain of the spine can also be readily added to stretches for
the range afforded by one’s particular structure rather the hamstrings or hip adductors (see chapter 4). How-
than trying to forcibly match someone who may have ever, when performing any of these types of stretches,
a markedly different structure. Furthermore, when because the thoracic spine is concave anteriorly and
extreme range of motion is present, supplemental often very flexible, many dancers end up primarily
stretching outside of class is generally not necessary. stretching the upper back versus the desired low
Instead, strengthening exercises that work to dynami- back area. Maintaining the upper back in extension
cally maintain range while building strength to sup- and pulling the abdominal muscles back toward the
port the increased mobility are recommended. spine and keeping a more vertical pelvis while the
torso rounds forward can be used as an alternative to
Spinal Extensor (Spinal Flexion) Stretches achieve a more isolated stretch in the lumbar area.
Adequate flexibility of the spinal extensors is impor-
Spinal Flexor (Spinal Hyperextension) Stretches
tant for allowing full forward bending of the spine
(spinal flexion), for posterior tilting of the pelvis Adequate flexibility in the spinal flexors (abdominal
needed for lifting the leg very high to the front, and muscles) is necessary to allow for the full arching
for prevention of lumbar hyperlordosis posture. The of the back (spinal hyperextension) used in vari-
spinal extensors are postural muscles and so often ous dance movements. It also appears that having
become fatigued and “tight” with dance training, and adequate spinal hyperextension range is important
stretching can help relieve associated soreness and for a healthy back, particularly in males (Burton,
tightness. The double knee to chest stretch (table Tillotson, and Troup, 1989a, 1989b; Klausen, Nielsen,
The Spine 147
and Madsen, 1981); and a decrease in range in spinal pelvis relative to the torso. Dancers are often asymmet-
extension has been shown to generally accompany ric in this motion, and stretching more to the side with
aging in men, but not necessarily in women. How- less range can help improve symmetry. However, if the
ever, extreme range (hypermobility) as well as low genesis of this asymmetry is scoliosis, any stretching or
value (hypomobility) appears to increase the risk for strengthening should be performed under the direc-
low back trouble. So although spinal flexor stretches tion of a qualified physical therapist. The supine spine
are not recommended for dancers who already have twist (table 3.7F) is a stretch for the spinal rotators.
high values, they can be useful for dancers who are When performing this stretch, focus on keeping the
trying to develop their range or older dancers who spine extended and trying to rotate around a central
are finding a decrease in range. axis without letting the ribs shift to the side.
However, since hyperextension is a classic mecha-
nism for spinal injury, these stretches should be
done only if there is no history of lumbar lordosis Back Injuries in Dancers
or low back pain and with particular care, starting Because of inherent structural weakness and the great
with a mild stretch and gradually increasing range forces it is subjected to from body weight, externally
over time, always staying in a pain-free range. The applied forces, and contraction of muscles, the lumbar
prone press-up shown in table 3.7C was selected spine is particularly susceptible to injury. Back injuries
because arm support will allow for easy control of
appear to have a particularly high incidence in athlet-
stretch intensity. As range improves, support can
ics involving 1) weight loading and high compression
progress to using the hands (with elbows extended)
forces, 2) forceful twists, and 3) activities involving
in front of the shoulders, and then further progress
spinal hyperextension, such as competitive swimming
through gradually bringing the hands closer toward
(60%), track and field (48%), and weighlifting (40%)
the shoulders. Range in spine hyperextension can
(Aggrawal, Kaur, and Kumar, 1979; Mutoh, 1978).
also be improved if one performs this exercise with
Since dance contains all of these elements, it is not
the hips on an exercise ball (starting with pressing
surprising that back injury is prevalent. One study of
with the elbows and progressing to pressing with the
Broadway dancers found 26% of them sustained an
hands against the ball), as seen in figure 3.47A, or
injury to the back or neck during rehearsals while
uses a gravity-assisted position by lying supine with
45% sustained injuries to these areas during the pro-
the back arched over the ball (figure 3.47B).
duction season (Evans, Evans, and Carvajal, 1996). A
The upper back drape (table 3.7D) offers a stretch study of professional ballet dancers in Sweden found
that focuses on improving range in the upper back. 69% in 1989 and 82% of surveyed dancers in 1995
One can also add a strength component to the exer- reported low back pain some time in the previous 12
cise by pressing down with the hands and arching the months (Ramel, Moritz, and Jarnlo, 1999). Another
upper back while attempting to keep the pelvis in a study reports 60% to 80% of ballet and modern
neutral position in a supine rather than sitting posi- dancers had a history of back injuries, while two
tion (supine upper back arch, figure 3.47D). Hold this other surveys involving longer time frames reported
position for 5 seconds, starting with two and gradually incidences of 86% (Clippinger-Robertson, 1985) or
progressing over time to six repetitions. Precede and higher (Seitsalo et al., 1997). Probably because many
follow this active component with the passive stretch dancers sustain multiple injuries and some do not
(figure 3.47C) held for 20 to 30 seconds. seek medical help for low back pain, the reported
percentage of total injuries to the spine is lower than
Spinal Lateral Flexor Stretches
one might suspect from prevalence surveys, often
Adequate flexibility of the lateral flexors is important being second only to the ankle-foot region. Some
to allow the spine to bend fully to the side. The side reported percentages of total injuries to the spine
bend (table 3.7E) is an effective stretch that can be were 31% for professional ballet dancers (Garrick
performed sitting on the floor or standing with one leg and Requa, 1993), 17% for modern dancers (Bron-
up on the barre. To get full benefits from your stretch, ner, Ojofeitimi, and Rose, 2003), 18% for university
focus on keeping the pelvis level and stationary as the dance students (Rovere et al., 1983), 20% to 50% for
spine arches “up and away” with the ribs lifting “up flamenco dancers (Salter-Pedersen and Wilmerding,
and over” rather than shifting to the side. 1998), and 18% to 34% in Broadway dancers (Evans,
Evans, and Carvajal, 1996).
Spinal Rotator Stretches It is also noteworthy that back injuries may require
Adequate flexibility of the spinal rotators is necessary more time off from dancing than some other types
to allow the torso to twist relative to the pelvis, or the of injuries, in some cases requiring dancers to be out
A
FIGURE 3.47 Increasing range in spinal hyperextension. (A) Torso press-up, (B) back drape emphasizing full spinal
passive hyperextension, (C) upper back drape emphasizing increasing range in the upper back, (D) supine upper back
arch.
148
The Spine 149
for weeks, months, or even a whole year (Micheli, twisting in an asymmetrical manner (Caillet, 1996).
1983). Furthermore, spinal injury can often result in During lifting of heavy weights, or another dancer,
chronic or recurrent back pain. One survey of adult small spinal muscles (e.g., deep posterior spinal
dancers from various styles found that 17% of all group) with small moment arms must counterbal-
dancers and 23% of dancers with scoliosis reported ance very large external forces with large moment
a history of chronic or recurrent low back pain (Lie- arms, and injury can readily occur. Lumbosacral
derbach, Spivak, and Rose, 1997). strains may follow a single trauma, and the dancer
may describe the back as “locked” and say that he or
Prevention of Back Injuries she was “unable to move.” In other cases, the onset is
insidious and results from repetitive stresses of dance
Considering the relatively high injury incidence training that exceed healing capacity.
and the potential for a more serious or recurring Lumbosacral strains are characterized by localized
condition, dancers should take aggressive measures back pain that is relieved by rest and aggravated by
to prevent back injuries. The dancer can reduce activity. Muscle spasm on one or both sides of the
injury risk by being adequately warmed up prior to spine is often present. Symptoms tend to resolve rela-
stressful movement; focusing on correct abdominal tively quickly if there is not more serious underlying
stabilization and spinal alignment; developing bio- pathology such as injury to the disc or bone (Mercier,
mechanically sound partnering techniques; develop- 1995). Approximately two-thirds of individuals will be
ing adequate abdominal, spinal extensor, and upper relatively symptom free and able to function in work
extremity strength; and developing or maintaining or sport by two weeks (Harvey and Tanner, 1991);
adequate spinal, hip, and shoulder flexibility. 90% of such injuries resolve within two months
(Deckey and Weidenbaum, 1997).
Common Types Mechanical Low Back Pain

of Low Back Injuries in Dancers
Mechanical low back pain involves a localized aching
A few common back injuries will be described here. in the low back region without any well-defined ana-
However, it is important to realize that the same tomical cause. It is typically associated with lumbar
symptom of low back pain can come from numerous hyperlordosis. Mechanical low back pain commonly
very different sources including infections, tumors, occurs in young dancers and is believed to be asso-
rheumatologic conditions such as rheumatoid ciated with rapid growth spurts in which tight low
arthritis, congenital abnormalities, Scheuermann’s back musculature and lumbodorsal fascia, tight
disease, and chronic and acute injury (Gerbino and hamstrings, tight hip flexors, and weak abdominal
Micheli, 1995; Weiker, 1982). Hence, it is emphasized muscles often create a temporary imbalance lead-
that any dancer who experiences persistent or severe ing to an excessive lumbar curve (Micheli et al.,
back pain should seek medical help to evaluate and 1999). This hyperlordosis may be present in stand-
provide appropriate treatment. Self-treatment is ing posture or may manifest itself only in dynamic
particularly ill advised with the back because there movement such as jumping or partnering. In a study
are so many causes of low back pain, treatments for comparing back pain in active teens to that in adults,
one type of injury may aggravate another, and some 26% of teens were diagnosed with mechanical back
conditions can have very dire consequences if not pain while no adults received this diagnosis (Micheli
properly diagnosed and treated at an early stage. and Wood, 1995).
Lumbosacral Strain or Sprain Spondylolysis and Spondylolisthesis

Lumbosacral strains or sprains involve excessive Spondylolysis (G. spondylos, vertebra + lysis, loosen-
stretching and injury to the spinal extensor muscles, ing) involves a defect in the weakest region of the
ligaments of the spine, or both. Lumbosacral strains lamina located between the superior and inferior
often result from extreme movements of the spine articular facets (the pars interarticularis) of the
involving very forceful concentric contraction, force- vertebrae, most commonly occurring in the lower
ful eccentric contraction used to decelerate the torso, lumbar spine (figure 3.48A). Although this condition
mis-timing of a particular movement, or a sudden may be congenital, in many cases the defect is due to
unexpected exertion during carrying of a heavy a stress fracture. Although other factors come into
object. In the workplace, such injuries often involve play, the mechanism for injury is often hyperexten-
muscular overexertion associated with bending and sion (particularly combined with rotation or axial
FIGURE 3.48 Spondylolysis and spondylolisthesis (lateral view). (A) Spondylolysis, (B) spondylolisthesis, (C) spondylo-
listhesis with amount of slippage graded 1 to 4.
loading), and a much higher incidence is found body below as seen in figure 3.48C: 1 reflects up to
in athletes who are involved in activities requiring 25% slippage; 2 indicates greater than 25% and up
repetitive use of such hyperextension such as danc- to 50%; 3 reflects greater than 50% and up to 75%;
ers, gymnasts, weightlifters, football linemen, divers, and 4 reflects greater than 75% slippage (Mercier,
and figure skaters (Eck and Riley, 2004; Fehlandt and 1995). Logically, greater slippage is of greater con-
Micheli, 1993; Kotani et al., 1970; Seitsalo et al., 1997; cern in terms of spinal stability, symptoms, prognosis
Trepman, Walaszek, and Micheli, 1990). For example, for return to dance, and potential need to stabilize
while the incidence of spondylolysis in the general the spine with a surgical procedure.
U.S. population is about 5% (Deckey and Weiden- Symptoms of spondylolysis or spondylolisthesis
baum, 1997), incidence of spondylolysis was found include low back pain that is often exacerbated by
to be about six times greater (32%) in one study of hyperextension, particularly during standing on one
professional ballet dancers (Seitsalo et al., 1997). leg (such as an arabesque). Tenderness directly on
Spondylolysis is of particular concern with young the spine (in contrast to the muscles on the sides of
dancers. One study comparing athletic teens to adults the spine) is often present, and in some cases there
with low back pain showed an incidence of spondyloly- may also be radiating pain down the buttocks and leg
sis of 47% in teens as compared to only 5% in adults (sciatica), and tightness in one hamstring. With spon-
(Micheli and Wood, 1995). Some other studies have dylolisthesis, a “step-off” or “ledge” can sometimes be
shown less dramatic, but still markedly increased, felt due to the forward displacement of the lumbar
incidences of spondylolysis in young athletes and spinous process where the vertebra has slid forward.
particularly in athletes who participate in sport for Although the prevalence of spondylolysis in dancers
more than 15 hours per week (Hall, 1999). is high, it is important to be aware that many dancers
A closely aligned condition to spondylolysis is with spondylolysis or lower grades of spondylolisthesis
spondylolisthesis. Spondylolisthesis (G. spondylo, are able to continue successful dance careers, and
vertebra + olisthesis, slipping) involves an actual slid- some may not even have pain (Deckey and Weiden-
ing forward of one vertebra on the vertebra below, baum, 1997; Seitsalo et al., 1997). When traumatic
usually secondary to having spondylolysis on both spondylolysis is detected soon after its occurrence,
sides (figure 3.48B). It most commonly occurs in the medical treatment including immobilization with anti-
lumbar spine, with L5 slipping on S1 being the most lordotic bracing will often allow healing (Herman,
common, followed by L4 slipping on L5 (Weiker, Pizzutillo, and Cavalier, 2003; Micheli, 1983). In other
1982). Spondylolisthesis can be classified according cases, dancers are able to use abdominal co-contrac-
to the amount of forward displacement of the supe- tion (Moeller and Rifat, 2001) and technique modifi-
rior vertebra relative to the width of the vertebral cation sufficiently to limit shear and symptoms.
The Spine 151
Facet Syndrome in this region can readily compress the spinal nerve.
Compression of the spinal nerve can lead to pain,
While complaints of low back pain with hyperex- numbness, and weakness in areas related to those
tension (such as the arabesque position) are often served by the nerve that is being compressed.
associated with spondylolisthesis in the younger Disc herniation occurs most frequently in the
dancer, in the older dancer these complaints may lower lumbar region; 95% of lumbar lesions occur
be associated with the facet syndrome (Drezner and in the discs located between L4 and L5 or L5 and S1
Herring, 2001). The same mechanism of forceful or (Mercier, 1995). The mechanism of injury is contro-
repetitive hyperextension and rotation places stresses versial, but it often involves flexion or hyperextension
on the facet joint as well as the pars interarticularis. combined with rotation. As with spondylolysis, sports
In response, the facet joints and associated structures associated with these mechanisms appear to have a
can become inflamed and undergo degenerative higher incidence of disc degeneration; 75% of retired
changes (Trepman, Walaszek, and Micheli, 1990). world-class gymnasts showed signs of disc degenera-
Pain may be localized to the involved side of the low tion (Sward et al., 1991). The intensity of training at
back or may radiate down the lower extremity. a young age may also be a factor, and in gymnasts the
incidence of degenerative disc disease rose from 9%
Disc Herniation
to 43% to 63% in pre-elite, elite, and Olympic-level
The intervertebral disc tends to degenerate with female gymnasts (Gerbino and Micheli, 1995). Early
aging and exhibits decreased water content, height, rigorous training, the common use of hyperextension,
ability to absorb shock, ability to return to normal partnering, and the repetitive use of flexion combined
shape after being deformed, and thickness of the with rotation in modern dance could all potentially
annulus fibrosus (Deckey and Weidenbaum, 1997; increase risk for disc injury in dancers.
Panjabi, Tech, and White III, 1980). These factors The onset of symptoms can be sudden or more
all make the annulus fibrosus more vulnerable to vague. One of the primary classic complaints of
damage that can allow the nucleus pulposus to actually lumbar disc injury is pain radiating from the back or
extrude out through the annulus fibrosus and into the buttock down the posterior or posterolateral aspect
neural canal, termed disc herniation, as seen in figure of the thigh, termed sciatica, which may be accompa-
3.49. Such disc herniation occurs most frequently in nied by weakness or numbness in select areas of the
the third or fourth decade of life, when the disc is lower extremity (depending on the nerves involved).
undergoing the structural changes associated with this This pain tends to be exacerbated by coughing,
marked dehydration (approximately 35% reduction sneezing, the Valsalva maneuver, or prolonged sit-
in water content), and the resilient disc under age ting; all of which increase the pressure within the
30 and the dry, scarred disc over age 50 may be less disc. Sitting reduces the lordosis in the lumbar spine,
likely to fragment and displace (Hall, 1999; White III which creates a relative forward shift of the center of
and Panjabi, 1978). Disc herniation most commonly gravity (increased moment arm), thus increasing the
occurs in the posterolateral region of the disc, where pressure in the intervertebral discs (figure 3.36 on
the annulus fibrosus is thinner and the posterior p. 115). The dancer may lean toward or away from the
longitudinal ligament is weak. Spinal nerves traverse affected side, a tactic that can increase the space in
the posterolateral part of the disc, and so herniation the appropriate intervertebral foramen and reduce
pressure on the compressed nerve root. Tenderness
is generally present in the midline of the low back,
and spinal muscle spasm is often evident. However,
adolescents with disc herniations may sometimes
present with back pain and hamstring tightness, but
with little of the classic radiating pain or neurologic
signs (Deckey and Weidenbaum, 1997).
As with spondylolysis, disc injury does not neces-
sarily mean long-term pain and the inability to dance.
First, approximately 25% of healthy adults with no
low back pain have evidence of disc herniation (Cail-
let, 1996); the site of the herniation in relation to
FIGURE 3.49 Herniated intervertebral disc: L4 disc the size of the spinal canal and effect on stability of
herniation compressing L5 nerve (posterior view with the motion segment may be critical in determining if
vertebral arch removed). there is associated pain (Levangie and Norkin, 2001).
Second, there is increased evidence of the ability of and Herring, 2001). Flexion tends to stretch the tho-
the disc to heal, albeit with greater scar tissue and racolumbar fascia, reduce lumbar lordosis, and lessen
sometimes over as long a time as 12 to 18 months. anterior shear forces, which can provide relief in cases
It appears that disc collagen has a slow turnover, so of mechanical low back pain or spondylolisthesis. Flex-
repair is very slow (Adams and Hutton, 1982). And ion also increases the separation of the pedicles in the
even some dancers who initially have very debilitating lumbar region and decreases compression forces in
symptoms are able to return to professional dance the facet joints, potentially reducing symptoms when
at a later time. Lastly, it is important to realize that these structures are sources of pain (spondylolysis
some conditions may mimic disc herniation, such as and facet syndrome). Furthermore, flexion causes a
the piriformis syndrome discussed in chapter 4. marked increase in the capacity of the spinal canal
(Liyang et al., 1989), as well as an increase in the
Rehabilitation of Low Back Injuries intervertebral foramen width of about 30% (Soder-
berg, 1986), which can provide relief when pres-
Treatment approaches vary and will depend on many sure to the nerve root is involved. Flexion exercises
factors including the type of injury, severity of symp- generally include gentle abdominal strengthening
toms, age of the dancer, and preferred approach of exercises kept in a low range to limit intervertebral
the medical professional. Studies suggest that low disc pressure (e.g., pelvic tilts and small curl-ups), as
back pain will improve in 70% of patients in three well as gentle stretches for the spinal extensors (e.g.,
weeks and 90% in two months regardless of the type double knee to chest stretch performed in a supine
of treatment utilized (White III and Panjabi, 1978). position) and hamstrings in pain-free ranges. Other
However, in dancers, time is of the essence, and suf- anti-lordotic procedures include bracing, placing
ficient rehabilitation to prevent further occurrences one foot on a step when standing for extended time,
is vital for professional survival. Hence, working with keeping the knees at or slightly higher than hip height
a skilled physical therapist knowledgeable in the when sitting, using the abdominals to help maintain a
demands of dance is highly recommended. neutral spinal alignment, avoidance of sleeping on the
Initial treatment often involves relative rest, anti- stomach (sleeping on the side with a pillow between
inflammatory medications, modalities, and thera- the knees is often recommended for many types of
peutic exercise (Weiker, 1982). Note that the term back injury), and avoidance of wearing high-heeled
“relative rest” is used, as there has been a shift away shoes. In terms of dance, when return is permitted,
from prescribing total bed rest for low back pain overhead lifting, jumping, and hyperextension are
(except in the early days with more severe injuries) often initially avoided.
so that undesired substantial losses in muscle mass, Unlike the injuries just discussed, acute disc
strength, flexibility, and bone density are avoided herniations often respond in an opposite manner
(Saal, 1988a, 1988b). One study showed about 50% and are often aggravated by flexion and given relief
reduction from normal in the size of the sacrospinalis with extension exercises (Harvey and Tanner, 1991;
in patients who had been confined to bed for longer Saal, 1988a). Intradiscal pressure increases with
than three weeks (Imamura et al., 1983). Modalities spinal flexion, and so curl-up type exercises are often
such as ice, heat, ultrasound, electrical stimulation, avoided and isometric abdominal or stabilization
or massage may sometimes be prescribed in an effort exercises substituted during initial stages of treat-
to reduce muscle spasm and pain. In some types of ment. Passive hyperextension (such as the prone
injuries, joint mobilization techniques may be uti- press-up, table 3.7C) often provides reduction in
lized to restore normal movement between segments pain or centralization of pain, and McKenzie exten-
of the spine (Caillet, 1996; Saal, 1988a). Mild activity sion exercises (McKenzie, 1981) gradually progress
such as aquatic exercise or walking is also sometimes from passive to active extension exercises. However,
useful for diminishing pain and muscle spasm and it is important to realize that active hyperextension
restoring normal physiologic function. exercises also cause elevation in disc pressure and
In terms of therapeutic exercise, the controversies should be performed with medical guidance and
and protocols are beyond the scope of this book, but in a pain-free range. Lying on the back with the
a brief overview of some common principles follows. legs elevated by pillows or resting on the seat of
Many types of low back injury including mechanical the chair (figure 3.50) is also often recommended
low back pain, facet syndrome, spondylolysis and for temporary relief of disc-related back pain (and
spondylolisthesis, and some types of lumbosacral many other forms of back pain as well). The supine
strains initially emphasize flexion exercises and may position reduces pressure in the disc, while flexion
be aggravated by adding extension exercises (Drezner of the hips and knees reduces potential tension due
The Spine 153
been reported to be about 40% to 60% (Roy and

Irvin, 1983).
Upper Back and Neck Injuries in Dancers

While injuries to the spine occur much more fre-
quently in the lumbosacral area in the general popu-
lation and in ballet, in some dance forms injuries
to the upper back and neck can be quite prevalent.
A study of professional ballet dancers found that
only 9% of injuries to the spine were to the thoracic
FIGURE 3.50 Rest position often recommended for spine and 16% were to the cervical spine (Garrick
relief of low back pain. and Requa, 1993), while a study of performing arts
dance students found that 21% were to the thoracic
to the iliopsoas and potential stretch on the sciatic spine and 10% to the cervical spine but noted that
nerve. Recommendations are also often provided cervical and upper back strains occurred roughly
for activities of daily living that will tend to preserve twice as often in modern dancers as they did in ballet
the lumbar curve, such as using lumbar supports dancers (Rovere et al., 1983). An even greater occur-
and avoiding prolonged sitting or flexed postures. In rence of upper back and neck injuries was reported
terms of dance, when return is permitted, jumping, in Broadway dancers during the performance season;
lifting, full spinal flexion, flexion with rotation, and 29.4% of injuries to the spine involved the upper
extreme hyperextension are often initially avoided back and 35.3% the neck (Evans, Evans, and Car-
and then gradually reintroduced as healing and vajal, 1996). So, it appears that the different use of
symptoms allow. the head and neck associated with modern and jazz
As pain subsides and healing occurs, treatments dance may increase the risk of injury to the upper
for different types of injuries become more simi- portion of the spine.
lar and incorporate the development of balanced A strain of the neck generally involves injuries
strength and flexibility in all of the spinal muscula- to the ligaments, tendons, and musculature of the
ture, development or restoration of adequate flexibil- neck. However, many of the injuries that occur in
ity in the spine and hip (particularly in the low back, the lumbar region can also occur in the cervical
hip flexors, and hamstrings), correction of any spinal region, including disc herniation, spondylolysis, and
alignment or technique problems, and reestablish- spondylolisthesis. With the relatively small vertebrae
ment of normal core stabilization. Studies of individu- supporting the relatively large weight of the head, it
als with chronic low back pain have revealed a delay is not surprising that injuries occur in this region. In
and disruption of the normal firing pattern of the a large sample of individuals, cervical disc degenera-
abdominals prior to movement of the limbs (Hodges tion was documented in 12% of women and 17% of
and Richardson, 1996), a disruption in the timing and men in their 20s, and in 89% of women and 86% of
amount of firing of the different sides of the spinal men over 60 years of age, often without accompany-
muscles (Grabiner, Koh, and Ghazawi, 1992), very ing pain (Levangie and Norkin, 2001). As with the
localized wasting of the multifidus thought to be due lumbar spine, the cervical spine is vulnerable to
to neural inhibition (Hides et al., 1994), type II fiber forceful hyperextension or flexion, particularly when
atrophy of the spinal extensors, increased postural combined with rotation. Examples of these motions
sway, and decreased ability to balance in challenging occur with head isolations and head rolls in jazz
positions (Laskowski, Newcomer-Aney, and Smith, and African dance. Dancers training in these dance
1997). So, successful rehabilitation appears to require forms should begin executing such movements with
not only adequate strengthening (of sufficient inten- a smaller range of motion until adequate strength
sity to recruit type II fibers) of the trunk muscles but and skill are developed.
also restoring of normal stabilization functions and Another vulnerability for the neck occurs with
neuromuscular coordination (Richardson, Hodges, weighted flexion such as that utilized in the plow or
and Hides, 2004). It is very important that dancers shoulder rolls (back somersaults rolling over one
participate in long-term conditioning that addresses shoulder). Although a controversial area, other low
these issues and the specific demands of their dance back stretches can be easily substituted for the plow
form and not just stop their exercises when the pain that do not place such large stresses on the neck.
diminishes, as recurrence rates of back pain have Regarding shoulder rolls, such moves should be
reserved for more advanced dancers with adequate allow relatively large ranges of motion of the spine
skill and flexibility so that the weight of the body as a whole, termed flexion, extension, lateral flexion,
can be borne primarily on one shoulder and not the and rotation. The vertebrae and discs are spanned by
neck. Lastly, injury to this area may relate to lifting numerous strong ligaments that provide stability, and
and overhead use of the arms, and it may involve posteriorly by three layers of spinal extensors—the
muscles that stabilize and move the scapulae (chap- deep posterior spinal group, semispinalis, and erec-
ter 7) as well as muscles that stabilize and move the tor spinae—which can produce spinal extension,
head and upper spine. lateral flexion, and rotation. Anteriorly, three of the
Treatment will vary according to the structures abdominal muscle groups—rectus abdominis, exter-
involved and the severity of the injury but often nal obliques, and internal obliques—are capable of
includes anti-inflammatory medications and modali- producing spinal flexion, lateral flexion, and rotation
ties such as ice massage and mechanical massage indirectly through their attachments on the pelvis
(Micheli, 1988). Gentle stretching and movements and thorax. Laterally, the quadratus lumborum gives
to maintain range and, later, addition of strengthen- rise to pure lateral flexion of the spine. In addition
ing exercises (often beginning with isometric and to their role in movement, the muscles of the spine
progressing to isotonic) for the upper back exten- are important for posture and provide important
sors and muscles of the shoulder region are often stabilization and protection for the spine.
recommended. However, it is important to realize When one analyzes movement of the spine, it is
that persistent upper back pain in adolescents may be important to take into account the effect of gravity.
indicative of Scheuermann’s disease, and a prompt In the erect position, gravity quickly becomes the
medical evaluation is essential. primary motive force for many movements, and the
muscles with opposite actions to that movement are
used eccentrically to control that movement and
Summary concentrically to return the trunk back to an upright
The vertebral column houses the vulnerable spinal position. When the position is not erect, the relation-
cord and provides sites for attachments of muscles ship to gravity will again influence what muscles pro-
and ligaments. Its central location makes it par- duce and control desired movements. This concept
ticularly important for movement and vulnerable to is important for designing effective strengthening
injury. In an upright position, the vertebral column exercises for the spine as well as understanding
supports and allows movements of the head, helps some of the risks inherent in dance and other move-
support the upper extremity, and provides an impor- ments. Unfortunately, back injury is quite prevalent
tant link to the lower extremity via the pelvic girdle. in dance. However, the dancer can markedly reduce
The vertebral column itself consists of 33 vertebrae injury risk through strengthening the abdominal
that are linked (between C2 and S1) by an interver- muscles and spinal extensors, maintaining adequate
tebral disc between their bodies and gliding joints range of motion in the spine, and utilizing careful
between their articular processes. Although move- technique while still achieving movement aesthetics
ment is limited at each joint, together the joints to minimize inherent risks.
The Spine 155

1. Draw and describe the basic parts of a typical vertebra. How do these parts relate to the spinal
cord, spinal nerves, and intervertebral disc?
2. Describe the location of the anterior and posterior longitudinal ligaments and what move-
ments of the spine they primarily limit.
3. Discuss why the lumbosacral joint is particularly vulnerable to injury. Taking these factors into
account, list three movements from dance that would put this joint at risk, and state why. How
could this risk be diminished?
4. Locate the following muscles or muscle groups on yourself or a partner, and perform actions
that these muscles produce as you palpate their contraction: (a) Rectus abdominis, (b) external
oblique abdominal muscles, (c) internal oblique abdominal muscles, (d) erector spinae.
5. Observe the normal curves of the spine in the sagittal plane on a skeleton or on an illustra-
tion. Describe the direction of these curves at birth and in an adult. Provide the name given
when these curves are abnormal, and provide one strength exercise that would be helpful in
improving this condition.
6. Define intra-abdominal pressure. How could you maximize its potential protective effects?
7. Perform spinal flexion, extension, and lateral flexion from a standing position. Keeping
the influence of gravity in mind, describe which muscle groups would be primarily working
with each of these movements on both the up-phase and the down-phase. Then, perform
spinal rotation from a standing position. How is the influence of gravity different with this
motion?
8. Select a combination used in the warm-up section of a class you teach or take that is oriented
toward “warming up the spine.” Evaluate it in terms of effectiveness and risk. Is there anything
that could be done to improve this warm-up exercise from an anatomical perspective?
9. Describe four things you could do to enhance safety for your low back when partnering
another dancer.
10. Carefully perform a flat back position commonly used in jazz and some forms of modern
dance. Analyze the torque borne by the lower spine with this position (torque of the resis-
tance) and discuss why “rolling down” with the head close to the spine would alter this torque.
If the choreography called for use of a flat back position, what could the dancer do to help
decrease the stress to the low back?
11. Do a movement analysis of a double-leg raise, and describe the role of the abdominal muscles,
spinal extensors, and hip flexors in this exercise as compared to a curl-up. Discuss the relative
benefit and risk of this exercise and how it could be modified to reduce risk. How does the
psoas paradox relate to this exercise?
12. Using the curl-up as your basic exercise, provide five variations that would apply the principles
discussed for making abdominal strengthening exercises effective. How could these exercises
be cued to minimize exercise risk?
13. Perform one exercise for strengthening and one exercise for stretching the spinal extensors.
How could a strength exercise be modified to emphasize the upper back versus the lower back?
What cues could be used to enhance the safety of back extensor strengthening exercises?
14. Discuss why some common injuries to the spine initially respond better to flexion-based
rehabilitation and others more to extension-based rehabilitation.
15. In less trained dancers, jumps are commonly accompanied by a “pumping” motion in which
the torso goes back in the up-phase of the jump and forward in the down-phase of the jump.
Describe what muscles and cues could be used to try to prevent these undesired movements
of the trunk.
Hip Joint
The Pelvic
Girdle and
© Angela Sterling Photography. Pacific Northwest Ballet dancer Noelani Pantastico.

CHAPTER FOUR
157
I n this chapter we turn to structures and movements

within the hip region. The two halves of the pelvis
form the pelvic girdle. The pelvic girdle provides
• Joint structure and movements of the hip
• Description and functions of individual hip
muscles
the very important role of linking the lower limbs
• Alignment and common deviations of the hip
to the axial skeleton. The hip joint proper, formed
region
between the femur and pelvis, can be characterized
by its exceptional stability essential for withstanding • Pelvic and hip mechanics
the large forces associated with upright standing and • Muscular analysis of fundamental hip move-
locomotion. However, despite its structural predispo- ments
sitions for stability, the hip joint allows a surprising • Key considerations for the hip in whole body move-
degree of motion that dancers strive to enhance to ment
a degree rarely seen in other sports. Hip passive and
• Special considerations for the hip in dance
dynamic range of motion is one of the distinguishing
landmarks of the elite dancer as exemplified by the • Conditioning exercises for the hip
movement shown in the photo on page 157. To maxi- • Hip injuries in dancers
mize this potential range without creating injuries,
it is particularly important that dancers understand
the structure and function of the hip region. Bones and Bony Landmarks
This chapter will present basic anatomy and of the Hip Region
mechanics of the pelvic girdle and hip joints that
influence optimal performance and the vulnerability The sides of the pelvis are termed the os coxae or
of this joint to injury. Topics covered will include os innominatum, and each side is actually made up
the following: of three bones—the ilium (L. groin, flank), ischium
(G. ischion, hip), and pubis (L. pubes, the genitals) as
• Bones and bony landmarks of the hip region seen in figure 4.1—which become fused into a single
• Joint structure and movements of the pelvic girdle bone at about 15 or 16 years of age. The ilium is a flat
FIGURE 4.1 Bones and bony landmarks of the pelvis. (A) Posterior view, (B) lateral view, (C) anterior view.
The Pelvic Girdle and Hip Joint 159
bone that is the largest of the three bones. It forms Each os coxae also contains a horseshoe-shaped
the upper and side “winged” portion of the pelvis. Its cavity, composed of elements of the ilium, ischium,
internal surface, which is large, smooth, and concave, and pubis, called the acetabulum (L. a shallow vessel
is termed the iliac fossa (L. fossa, a trench or ditch) or cup), which can be seen in figure 4.1B. Its lower
as seen in figure 4.1C. The superior convex border margin is incomplete, and the gap is called the
of the ilium is termed the iliac crest (L. crista, bony acetabular notch. The spherical proximal end of
ridge) and can be easily palpated below the waist the femur, called the head of the femur (L. femur,
on the sides of the body, running both forward and thigh) and seen in figure 4.2, fits into this hip socket
backward. The top of the iliac crest is generally level or acetabulum. Distal to the head, the femur tapers
with the space between the spines of the fourth and to form the neck of the femur, which is a common
fifth lumbar vertebrae (L4-L5). If the crests are fol- fracture site in older women. This neck angles to join
lowed in an anterior direction, they begin to curve with the long shaft of the femur. At this junction,
downward, and the bony prominences that can be two large bony projections are located. The largest
felt on the front of the pelvis are called the anterior projection faces laterally and is appropriately termed
superior iliac spines (L. spina, short, sharp process of the greater trochanter (L. major bony prominence).
bone). If the crests are followed in a posterior direc- The smaller projection, located on the medial aspect
tion, a rough, broader prominence can be felt—the of the upper femur, is termed the lesser trochanter
posterior superior iliac spines as seen in figure 4.1A. (L. minor bony prominence). The line running
These landmarks are often abbreviated the ASIS and between these projections on the front of the femur
PSIS, respectively, and are key for evaluating pelvic is termed the intertrochanteric line (L. line between
symmetry and alignment. trochanters), while the prominent ridge located
The ischium is an irregular bone that is the stron- on the back of the shaft of the femur is termed the
gest of the three bones. It is located in the lower, linea aspera (L. linea, line + asper, rough), as seen in
posterior portion of the pelvis. The most inferior figure 4.2B.
portion of this bone has roughened eminences, upon You can locate the greater trochanter of the femur
which we sit, that are termed the ischial tuberosities by placing your thumb on the lateral aspect of the
(L. tuber, a knob) (figure 4.1B) or “sitz bones.” You crest of the ilium and reaching down on the thigh
can easily palpate the tuberosities of the ischium with the middle finger. When you internally and
while sitting on a chair by leaning forward and plac- externally rotate the leg, you should feel the greater
ing the fingers under the bottom of the pelvis from trochanter move beneath the skin. This landmark
behind. Then, slowly begin to rock your weight back is useful for evaluating hip mechanics and body
to sit upright, and the tuberosities can be felt press- alignment. During standing, the tip of the greater
ing down on the fingers. You can also palpate them trochanter is approximately level with the center of
in a standing position by placing the fingertips at the the head of the femur.
bottom of the buttocks and slowly leaning the trunk When studying the bones that make up the pelvis,
slightly backward and forward. This landmark is key it is interesting to note that this is one area of the
for teaching turnout and pelvic alignment. The ischial skeleton where there are marked gender-linked differ-
tuberosities lie in approximately the same horizontal ences necessary to meet the demands of childbearing.
plane as the lesser trochanters of the femurs. The female pelvis is generally broader, roomier, and
A thin, flattened portion of the ischium, called the less vertical than that of a male and has a wider inlet
ramus (L. a branch), ascends upward and forward to (superior pelvic aperture) and larger outlet (inferior
join with the inferior ramus of the pubis as seen in pelvic aperture). The coccyx and sacrum are also situ-
figure 4.1B. The pubis is also an irregular bone, and ated more posteriorly in women than in men (Mercier,
it is located in the anterior and inferior portion of the 1995; Moore and Dalley, 1999). In contrast, the pelvis
pelvis. The thin and flattened superior ramus of the of the male is narrower and deeper.
pubis ascends to join with the ilium. These rami, as well
as other portions of the pubis and ischium, form a large
opening in the pelvis termed the obturator foramen Joint Structure and Movements
(L. foramen, an aperture). This is the largest foramen of the Pelvic Girdle
in the body. The obturator (L. obturo, to occlude an
opening) foramen is covered by a membrane, and this The os coxae are firmly joined to the sacrum posteri-
membrane and the surrounding bones form attach- orly at the sacroiliac joints and anteriorly to each other
ments for muscles that are key for effecting turnout in at the pubic symphysis to form one solid structure, the
dance (the deep outward rotator muscles). pelvic girdle. The pelvic girdle provides a link between
FIGURE 4.2 Bony landmarks of the femur (right femur). (A) Anterior view, (B) posterior view.
the lower limbs and axial skeleton, and the lumbosa- Sacroiliac Joints
cral joint is key for describing the movements of the
pelvis relative to the axial skeleton. The pelvic girdle The sacroiliac joints (L. sacrum, sacred) are formed
also protects and supports vital lower abdominal between paired lateral C-shaped concave articular
organs and, in females, the developing fetus. surfaces of the sacrum and slightly convex articular
surfaces of the right and left ilium (figure 4.1A). The
Pubic Symphysis paired sacroiliac joints can be palpated just adjacent
to each posterior superior iliac spine. The PSIS are
The pubic symphysis (G. symphysis, a growing at the level of the spine of the second sacral vertebra
together) is a cartilaginous joint (figure 4.1C) (S2). These strong joints are complex and evade easy
that is heavily reinforced by ligaments on all sides. classification, demonstrating characteristics in dif-
Normally this joint only allows slight movement ferent regions of cartilaginous, fibrous, and synovial
that is important for shock absorbency. However, joints (Bechtel, 2001; Chen, Fredericson, and Smuck,
during pregnancy the width of the cartilage mark- 2002; Papadopoulos and Khan, 2004).
edly increases and the ligaments become more lax The sacroiliac joints are generally quite stable
to allow the slight spreading of the os coxae that is due to the restraints offered by the fibrocartilage
associated with pregnancy. and fibrous tissue within the joints, the presence
of very strong ligaments that tether the bones joint architecture with its unique arrangement of
together, expansions from surrounding muscles, ligaments and multijoint muscles helps the hip meet
and the shape of the involved bones (Dujardin et the bias toward stability, while still allowing adequate
al., 2002; Levangie and Norkin, 2001). Regarding mobility.
shape, the sacrum sits like a wedge between the two
ilia. Because it is wider at the top than the bottom, Hip Joint Classification
it will resist the tendency to slide downward pro-
and Associated Movements
duced by the weight of the body from above. In
addition, there are interlocking convolutions on The hip joint, or acetabularfemoral joint, is a ball-
the articulating surfaces of the sacrum and ilium that and-socket joint formed between the acetabulum
add stability and limit movement in certain direc- and the head of the femur. The acetabulum faces
tions. However, very small (0.5 to 1.6 millimeters) anterolaterally and slightly inferiorly. The head of
movements of the sacroiliac joints can occur and the femur forms about two-thirds of a sphere and is
are important for normal pelvic mechanics (Chen, fully covered by articular cartilage except for a small
Fredericson, and Smuck, 2002). These movements pit at the top of the head of the femur called the
involve a combination of rotation and translation fovea. The head of the femur faces upward and for-
about complex and unclear axes. Unfortunately, as ward relative to its neck, with its convex surface fitting
discussed later in this chapter, the sacroiliac joints well with the concave surface of the acetabulum. Due
are a very common site of injury and chronic pain to the depth of the socket and the broad surface areas
in dancers, particularly older dancers. of contact between the articulating bones, joint stabil-
ity is favored. Approximately 70% of the head of the
Movements of the Pelvic Girdle femur articulates with the acetabulum, in contrast to
only 25% contact of the head of the humerus in its
The limited movement permitted at the pubic sym- socket with the shoulder joint (Hamill and Knutzen,
physis and sacroiliac joints allows the pelvic girdle to 1995). The hip joint is considered the best example
essentially function as a single unit. This arrangement of a ball-and-socket joint in the body.
is advantageous in terms of stability and of protective As with other classic ball-and-socket joints, the
and support functions of the pelvis. However, it is hip joint has three degrees of freedom of motion:
limiting in terms of movement and hence the lower flexion-extension in the sagittal plane, abduction-
spine, particularly the lumbosacral joint discussed adduction in the frontal plane, and external-internal
in chapter 3, becomes very important for facilitating rotation in the transverse plane as seen in figure 4.3.
positional changes of the pelvis. The movements In many dance movements, combinations of these
of the pelvis are termed anterior tilt, posterior tilt, three movement pairs occur. The true axis of motion
lateral tilt, and rotation. They will be discussed later for the hip joint goes through the center of the femo-
in the chapter in connection with alignment and are ral head, which can be visually estimated from locat-
shown in figure 4.15 on page 178. ing the greater trochanter. However, the neck of the
femur serves an important function of increasing the
lever arm for the muscles that attach onto the greater
Joint Structure trochanter (gluteus maximus, gluteus medius, glu-
and Movements of the Hip teus minimus, deep outward rotators) so that these
muscles can produce markedly greater torque.
In upright posture and movements such as walking or
running, the weight of the upper body is transmitted Hip Joint Capsule and Key Ligaments
down through the spine and pelvis through one or
both rotary hip joints to be supported by the limb or A strong, dense joint capsule encloses the entire hip
limbs. In addition to withstanding these downward joint. It attaches from the margin of the acetabulum
forces of gravity, the hip joint also transmits forces and runs distally, encasing the neck of the femur
from the ground to the pelvis in these same move- like a tube, to attach posteriorly to the distal neck
ments. These important force transmission functions of the femur and anteriorly to the intertrochanteric
of the hip joint make joint stability and strength a line. The capsule also has thickened ligamental
priority. However, while stability is favored, sufficient bands, as shown in figure 4.4, that spiral around the
mobility must be present to facilitate economical neck of the femur and are named according to the
locomotor movement and allow for desired posi- bone from which they originate—the iliofemoral,
tioning of the foot and lower limb in space. The pubofemoral, and ischiofemoral ligaments. Due to
FIGURE 4.3 Movements of the hip joint. (A) Flexion-extension, (B) abduction-adduction, (C) external rotation-internal
rotation.
their spiral arrangement, all three ligaments and from falling backward or the head of the femur from
the capsule become tight with hip extension or pos- displacing anteriorly with little hip muscular activity
terior tilting of the pelvis, important for providing required.
stability with upright standing (Smith, Weiss, and As well as its postural role, the iliofemoral liga-
Lehmkuhl, 1996). Full extension during weight ment also serves as a powerful constraint for any
bearing can be considered the close-packed posi- movement that involves bringing the leg behind the
tion for the hip joint (Hamill and Knutzen, 1995) body such as in a tendu back or an arabesque. Most
in terms of ligamental stability, despite there being anatomy texts hold that the iliofemoral ligament
greater bony congruence at 90° of hip flexion with limits hip hyperextension to 10° to 20° in the average
slight abduction and external rotation (such as with individual, but many dancers apparently markedly
sitting in a chair). Conversely, all three ligaments stretch this ligament and the capsule in order to
become slack with hip flexion, allowing the dancer obtain a range of hyperextension as great as 40°. The
to have greater range of motion when the hip is not lateral fibers of the iliofemoral ligament also limit
extended. Some additional information about these hip external rotation and hip adduction. Due to this
ligaments follows. restraint to external rotation, some dancers adopt the
undesired tactic of anteriorly tilting the pelvis when
The Iliofemoral Ligament trying to achieve greater turnout at the hip.
The iliofemoral ligament is located on the front of The Pubofemoral Ligament
the hip joint, spiraling inferiorly from the anterior
inferior iliac spine of the pelvis to diverge into two The pubofemoral ligament is located on the anterior
bands that attach to the upper and lower portions and lower portion of the capsule as seen in figure
of the intertrochanteric line, as seen in figure 4.4A. 4.4A. It runs between the pubic bone and an area
The iliofemoral ligament is sometimes called the near the lesser trochanter. Its inferior location makes
“Y” ligament because its appearance resembles an it particularly effective for limiting hip abduction. It
inverted “Y.” This ligament is one of the strongest also assists the iliofemoral ligament in limiting hip
ligaments in the body and plays a very important extension and external rotation.
role in standing posture. In erect stance, the center
of gravity generally passes behind the center of The Ischiofemoral Ligament
rotation of the hip joint and so tends to extend the The ischiofemoral ligament is located on the poste-
joint. Because the iliofemoral ligament becomes rior side of the hip joint as seen in figure 4.4B and
taut with hip extension, this ligament can passively provides protection from posterior displacement of
allow stance to be maintained and prevents the trunk the femur. It spans between a portion of the ischium
FIGURE 4.4 Key hip joint ligaments (right hip). (A) Anterior view, (B) posterior view.
located just below the acetabulum and the back of that pulls the head of the femur into the socket. With
the femoral neck. This ligament prevents hip internal the depth of the acetabulum, the presence of the
rotation and horizontal adduction. acetabular labrum, and the extensive congruency of
this joint, suction plays a more prominent role at the
Specialized Structures of the Hip hip joint. Even if all the ligaments and muscles are
cut, the joint will stay together, and relatively large
Various specialized structures and factors are asso- forces are required to separate the bones as long as
ciated with the hip that provide additional joint the capsule is intact. In adult cadavers, 45 pounds
stability or aid with joint function. These structures (20 kilograms) of force was required to separate the
include the glenoid labrum and bursae, while suction joint 0.1 inch (3 millimeters), and in healthy adults,
also makes a significant contribution. 90 pounds (41 kilograms) of force was required to
separate the joint even when it was in a loose-packed
Acetabular Labrum position (Smith, Weiss, and Lehmkuhl, 1996).
In addition to the normal articular cartilage pres- Bursae
ent at the hip joint, there is a specialized ring of
fibrocartilage situated along the margin of the Numerous bursae are associated with the hip joint.
acetabulum. This rim of fibrocartilage, called the There are two that more commonly become inflamed
acetabular labrum (L. labrum, a lip-shaped struc- in dancers. One is a bursa located over the greater
ture), is considerably thicker at the circumference trochanter as seen in figure 4.42 on page 233, which
than at the center, thus increasing the effective depth helps protect the soft tissues that cross the back por-
of the acetabulum and helping to hold the femoral tion of this projection. The other is located between
head in place. In addition, by being thicker above the iliopsoas and the underlying articular capsule.
and behind, it helps provide cushioning for the
top and back of the acetabulum against the large Muscles
compression forces of the head of the femur during In addition to the strong capsule and ligaments of
erect stance and movements. Thus, this labrum helps the hip, there are many strong muscles that cross the
improve joint stability and protects the bone. hip joint and have a significant stabilizing effect on
the joint. Because of their importance in support-
Suction ing the weight of the body and generating the large
The hip joint has another factor facilitating joint forces associated with locomotor movements, these
stability. There is a difference in atmospheric pres- muscles are more massive and stronger than those
sure in the hip joint such that a vacuum is created associated with the upper extremity.
Description and Functions produces hip extension. Due to this complexity, it

is not surprising that many of the secondary actions
of Individual Hip Muscles of hip muscles are still under debate. Many of the
controversial secondary actions have been purposely
Twenty-two muscles cross the hip joint. However, excluded from this text. (See Individual Muscles of
despite the large number of muscles involved, they the Hip, pp. 165-177.)
are arranged in a logical way that makes remember-
ing their actions easier—the anterior group are all
hip flexors, the posterior group are generally hip Alignment and Common
extensors (except for the deep outward rotators), the Deviations of the Hip Region
lateral group are all hip abductors, and the medial
group are all hip adductors. However, although their Alignment of the bony segments in the hip region
primary actions are the same, members of these is important in itself and also influences the bony
groups may have different secondary actions. segments above and below the pelvis and hip joint.
In terms of deducing primary and secondary For example, alignment of the pelvis will influence
actions, it is important to keep in mind that since the the spine above and the knee, ankle, and foot below.
hip joint has three degrees of freedom of motion, Three alignment considerations in the hip region
many hip muscles will exert action about all three that are particularly important are pelvic inclina-
axes simultaneously. However, one or two actions tions or tilts, the angle of femoral inclination, and
will often predominate, due to better leverage of the angle of femoral torsion.
the muscle with respect to that axis. For example,
the actions of hip flexion and hip adduction pre- Pelvic Alignment and Movements
dominate with the pectineus, and its contribution to
rotation is generally not considered very significant. The position of the pelvis can be described as neu-
In addition, some muscles are extensive enough that tral or as having the following deviations: anterior-
different portions may have different relationships to posterior pelvic tilts, right-left lateral tilts, or right-
a given axis and hence may be capable of a different left rotations. These deviations from neutral can be
action. For example, many texts list the upper fibers temporary movements that accompany movements of
of the adductor magnus as a flexor and the lower the spine or femur as described later in this chapter
fibers as an extensor. Lastly, remember that as dis- (see Pelvic and Hip Mechanics, p. 181). They can
cussed in chapter 2, the action of a muscle may differ also be small deviations that tend to persist and to
with changes in the joint angle due to the shift in be habitual in standing posture or movement, as
the line of pull relative to the axis. For example, the will be described now. When identifying pelvic align-
adductor longus aids with early flexion, but its effec- ment or movement, the relative position of bony
tiveness decreases continuously until it no longer aids landmarks such as the iliac crests, ASIS, PSIS, and
with flexion; and after approximately 70° it actually pubic symphysis are used. (Text continues on p. 177.)
DANCE CUES 4.1
“Think of Your Pelvis as a Basin and Avoid Spilling the Contents”
T he instruction to “imagine your pelvis is a basin and avoid having the contents spill out by letting
it tip” is sometimes used by teachers in an effort to maintain desired alignment of the pelvis. From
an anatomical perspective, the directive parallels the concept of a neutral pelvis and avoiding letting
the pelvis tilt, particularly in an anterior direction. The problem with this image is that the pelvis is not
horizontal but has an angle of inclination. Furthermore, a student who is accustomed to dancing with
an anterior pelvic tilt will generally feel that the pelvis is “level.” So it is frequently necessary to use tactile
or visual cues such as placing the hands on the ASIS and noting when they are vertically aligned relative
to the pubic symphysis to identify a neutral position (see Tests and Measurements 4.1, p. 179). Then, the
basin or bowl image can often be successfully used to achieve the desired pelvic alignment.
Individual Muscles of the Hip

Anterior Muscles of the Hip
The anterior muscles of the hip include the iliopsoas, rectus femoris, and sartorius. These muscles
cross anterior to the axis of the hip joint for flexion-extension and so share the common action of hip
flexion used in movements such as walking, running, or leaping.
Attachments and Primary Action of Iliopsoas

Psoas major Transverse processes, bodies, and Lesser trochanter of Hip flexion
(SO-us) intervertebral discs of T12-L5 femur Hip abduction (higher ranges)
Posture
Iliacus Iliac fossa, crest of ilium, inner Lesser trochanter of Hip flexion
(il-ee-AK-us) lateral sacrum femur Hip abduction (higher ranges)
Iliopsoas
The iliopsoas is actually composed of the psoas
major (G. psoa, the loins + major, the larger) and
iliacus (iliac, ilium). Since these share a common
distal attachment and appear to act together during
functional movement, they are frequently referred to
together as one muscle, the iliopsoas. The iliopsoas,
shown in figure 4.5, is approximately 16 inches (41
centimeters) long (Rasch and Burke, 1978). It runs
deep under the abdominal wall from the front of the
lower spine and inner portion of the ilium downward
to attach onto the medial side of the upper femur
at the lesser trochanter. Due to its deep location,
it is often difficult for dancers to “feel” or visualize,
and careful examination of its attachments on the
skeleton is helpful to understand its location and
function. The iliopsoas is one of the most powerful
muscles in the entire body (Michele, 1960) and can
develop a tensile pull in excess of 1,000 pounds
(454 kilograms). The iliopsoas has been shown
to be the most important muscle for hip flexion FIGURE 4.5 The iliopsoas muscle (anterior view).
above 90°, as evidenced by the inability to lift the
thigh above 90° when iliopsoas paralysis is pres-
ent (Smith, Weiss, and Lehmkuhl, 1996). It can also assist with hip abduction, particularly at higher
ranges. These two latter properties give the iliopsoas key importance for dance movements such as
high développés to either the front or side. The potential contribution of the iliopsoas to hip rotation
is still under debate, and although it may function as an external rotator when the femur is internally
rotated, it appears unlikely to play an important rotation role in other conditions.
Regarding its postural role, the iliopsoas is the only muscle in the human body that has attachments
on the spine, pelvis, and femur. Due to these attachments, the iliopsoas is in a unique position not
only to produce movement but also to stabilize the hip and effect the positioning of the lumbar spine.
Posturally the iliopsoas plays an important role in preventing the torso from falling backward and may
help maintain the lumbar curve. The former role is key when one is performing floor work in modern
dance, and many dancers who are unaccustomed to floor work may find themselves getting fatigued
and sore in the hip flexors, particularly the iliopsoas. Some also hold that the iliopsoas may play an
important role in integrating and coordinating movements between the femur, pelvis, and spine.
Attachments and Primary Actions of Rectus Femoris

Rectus femoris Anterior inferior iliac spine Tibial tuberosity via patellar Hip flexion
(REK-tus FEM-o-ris) Posterior head: just above acetabulum tendon (Knee extension)
Rectus Femoris
The rectus femoris, shown in figure 4.6, is one of the four muscles
that make up the quadriceps femoris. It is the only member of
the group that crosses the hip joint. The other three muscles
attach distally relative to the hip joint and act only on the knee.
“Rectus” means straight, so as its name implies, the rectus
femoris runs straight down the front of the femur or thigh. In
addition to its action of flexing the hip, the rectus femoris muscle
also extends the knee. Its combined movement of hip flexion and
knee extension used with kicking has given rise to its being called
the “kicking muscle.”
Palpation: Sit in a chair with the left foot crossed over the right
ankle. Place your fingertips on the center of the upper portion of
your right thigh, and feel the rectus femoris tighten under your
fingertips as you attempt to extend your right knee while your left
leg prevents this motion.
Sartorius
The sartorius is the longest muscle in the body. This slender
muscle runs from the front of the pelvis down the thigh obliquely
and medially to attach on the inside of the tibia as seen in figure
4.6. In addition to assisting with hip flexion, the sartorius can
also abduct and externally rotate the hip. Since this combination
of joint motions is used to assume the crossed-legged sitting
position on the floor, used by tailors in the past, the sartorius (L.
sartor, a tailor) is commonly called the “tailor’s muscle.” These
combined motions are also commonly used in dance vocabulary FIGURE 4.6 The rectus femoris, sarto-
such as a passé. Due to its long, thin composition, the sartorius rius, and tensor fasciae latae muscles
is designed for speed rather than strength, which may contribute (right hip, anterior view).
Attachments and Primary Actions of Sartorius

Sartorius Anterior superior iliac spine Medial surface of upper tibia Hip flexion
(sar-TOR-ee-us) (ASIS) and area just below (pes anserinus) Hip abduction
Hip external rotation
(Knee flexion)
to its being a common site of strain in the dancer. The sartorius also can act to produce flexion or
internal rotation of the knee, which will be further discussed in chapter 5.
Palpation: While standing on one leg, perform a front attitude (hip flexion and external rotation) with
the other leg and then carry this gesture leg to the side. Because the sartorius is the most superficial
of the anterior thigh muscles, it can be both seen and easily palpated below and slightly medial to the
ASIS. Note that as shown in figure 4.6, an inverted “V” is formed with the sartorius forming the medial
ray, the tensor fasciae latae composing the lateral arm, and the rectus femoris lying in between.
Posterior Muscles of the Hip
The posterior muscles of the hip include the gluteus maximus, hamstrings, and deep outward rotators.
All three of these muscle groups cross posterior to the axis of the hip joint for flexion-extension, and the
gluteus maximus and hamstrings share the common action of hip extension, such as used in a back
parallel tendu or in jumping. The hip extensors are well suited for propulsive activity such as jumping
and running due to their large cross-sectional area and the power they can generate. However, their
ability to produce force is dramatically influenced by the degree of
hip flexion, with about twice as much extensor strength present with
90° of hip flexion versus a neutral position of extension (Hamill and
Knutzen, 1995). This principle is often utilized by leaning the trunk
forward when going up a hill or stairs or in the preparation for a
jump. Posturally, these muscles can also play the important role of
producing a posterior tilt of the pelvis and countering the tendency
for an anterior tilt of the pelvis or forward lean of the torso.
Although the deep outward rotators cross posterior to the flexion-
extension axis through the hip, they generally have a very horizontal
line of pull. This makes them better suited for effecting hip external
rotation and hip horizontal abduction than hip extension.
Gluteus Maximus
The gluteus maximus (G. gloutos, buttock + maximus, largest),
shown in figure 4.7, is the largest and most superficial of the but-
tocks muscles. It forms the roundness of the back of the buttocks.
Its large size in humans is thought to be due to the demands of
upright stance and locomotion. The gluteus maximus is the most
powerful hip extensor and is crucial for movements requiring large
forces such as going up stairs, walking up hills, running, and
jumping. In addition to hip extension, the gluteus maximus can
produce hip external rotation, and the upper fibers can produce
hip abduction against resistance. Due to its insertion into the ilio-
tibial band or tract, a strong fascia of the lateral thigh that spans
between the pelvis and lower leg, the gluteus maximus indirectly
also helps support the femur upon the tibia.
Palpation: You can easily palpate the gluteus maximus by placing
your fingertips over the back of the buttocks while standing and
simply contracting or “setting” the muscle without any joint move- FIGURE 4.7 The gluteus maximus
ment necessary. To elicit a stronger contraction of the muscle, extend muscle and iliotibial band (right hip, pos-
and externally rotate the hip by lifting the leg in a back attitude. terior view).
Attachments and Primary Actions of Gluteus Maximus

Gluteus maximus Crest and posterior surface Line on posterior femur Hip extension
(GLOO-tee-us MAK-si-mus) of ilium, posterior surface between greater trochanter and Hip external rotation
of sacrum and coccyx linea aspera and iliotibial tract
Hamstrings
The hamstring muscle group forms
the bulk of the back of the thigh as
seen in figure 4.8. This group is
composed of three muscles: the
biceps femoris, semitendinosus,
and the deeper semimembranosus.
Their action of extension comes
into play in everyday movements
such as standing, walking, and
controlling forward motion of the
torso. Their function is considered
more postural and fine-tuning in
contrast to the “power” function of
the gluteus maximus. The biceps
femoris (bi, dual + L. capus, head)
appears to be particularly active
with hip extension and is consid-
ered the “workhorse” for hip exten-
sion (Hamill and Knutzen, 1995).
Because each of the hamstrings
inserts distal to the knee, all the
hamstrings act as knee flexors as
well as hip extensors. The medial
hamstrings—semitendinosus (L.
semi, half + tendinosus, tendon)
and semimembranosus (L. semi,
half + membranosus, membrane)— FIGURE 4.8 The hamstring muscles (right hip, posterior view). (A) Superficial view,
insert onto the medial part of the (B) deeper view.
tibia and so can also assist with
knee internal rotation or hip internal rotation when the hip and knee are extended. The lateral ham-
strings (biceps femoris) insert onto the lateral tibia and fibula and so can also assist with knee external
rotation or hip external rotation when the knee and hip are extended.
Palpation: Stand on one leg with your other leg held in a low arabesque position. The hamstrings
can be palpated on the lifted leg at the back of your upper thigh, just below the ischial tuberosity. While
maintaining the leg in this low arabesque position, internally rotate the leg and lift it slightly higher to
the back. The hamstrings and part of the adductor magnus can be felt contracting. Now, place your
Attachments and Primary Actions of Hamstrings

Hamstrings
Biceps femoris Long head: ischial Head of fibula Hip extension
(BI-seps FEM-o-ris) tuberosity Lateral tibial condyle Hip external rotation
Short head: linea aspera (Knee flexion)
of femur (Knee external rotation)
Semitendinosus Ischial tuberosity Medial surface of upper Hip extension
(sem-ee-ten-di-NO-sus) tibia (pes anserinus) Hip internal rotation
(Knee flexion)
(Knee internal rotation)
Semimembranosus Ischial tuberosity Medial condyle of tibia Hip extension
(sem-ee-mem-brah-NO-sus) Hip internal rotation
(Knee flexion)
fingertips on your buttocks and alternately internally

and externally rotate the hip while maintaining the
arabesque. Note the decrease in contraction of the
gluteus maximus as the leg internally rotates and the
increase as the leg is externally rotated.
Deep Outward Rotators

The deep outward rotators (DOR), or deep external
rotator muscle group, is comprised of the piriformis,
obturator internus, obturator externus (externus, out-
side), gemellus inferior, gemellus superior, and quadra-
tus femoris, as seen in figure 4.9, A and B. This group
of six small muscles is located deep to the gluteus
maximus in the region of the buttocks. The fibers of
this muscle group run primarily horizontally, spanning
from the inside and outside of the pelvis to the greater
trochanter of the femur. The piriformis (L. pirum, pear),
the most superior of the group, is located slightly above
the hip joint, and the quadratus femoris (L. quadratus,
square), the most inferior, is located slightly below it.
The obturator internus and gemelli are located in the
gap between the piriformis and quadratus femoris. As
their names suggest, the obturator internus (internus,
inside) has extensive attachments to the internal sur-
face of the membrane covering the obturator foramen
and adjacent areas, while the obturator externus has
extensive attachments to the external surface of the
obturator membrane and adjacent bones. The obtura-
tor internus is accompanied above by the gemellus
superior (L. geminus, twin, double + superior, above) and
below by the gemellus inferior (L. geminus, twin, double
+ inferior, below) to attach via a common, approximately
horizontal, tendon to the greater trochanter; and hence
these three muscles are sometimes referred to as a
three-headed muscle—the triceps coxae (Moore and
Dalley, 1999). The deep outward rotators function
as a group to help hold the head of the femur in the
acetabulum and can help prevent upward jamming of FIGURE 4.9 The deep outward rotators (right hip,
the femur with hip abduction, making its function very posterolateral view). (A) With gluteus maximus removed;
parallel to the rotator cuff’s function at the shoulder (B) deeper view with quadratus femoris, gemellus
joint, discussed in chapter 7. However, as their name superior, and gemellus inferior removed.
implies, this group of muscles is particularly known
for its action of hip external rotation. The ability of the group to produce hip external rotation without
other major accessory motions makes them key in dance for the production and maintenance of turn-
out. When the hip is flexed to 90°, some of these muscles are in an effective position to produce hip
horizontal abduction, making them important in movements such as a passé and rond de jambe in the
air (en l’air) at 90°. Some texts also suggest that the piriformis can assist with hip abduction.
Palpation: Standing on one leg, raise the other leg to the front to a parallel passé (retiré) position.
The uppermost of the deep external rotators, the piriformis, can be felt contracting (under the gluteus
maximus) several inches above and posterior to the greater trochanter as the leg is brought to the side
to a turned-out passé. Then, change positions to standing in parallel first, rock back on the heels, and
externally rotate both legs at the hip to achieve a turned-out first position. The lowest of the DOR, the
quadratus femoris, can be palpated deeply at the base of the buttocks between the ischial tuberosity
and greater trochanter while rotating the legs. The remaining DOR are located between the piriformis and
quadratus femoris and can be palpated as a group by placing the fingertips below the piriformis and
repetitively externally rotating the hip.
Attachments and Primary Actions of Deep Outward Rotators

Deep outward rotators
Piriformis Anterior surface of Superior surface of greater Hip external rotation
(PIR-i-form-is) sacrum, posterior ilium trochanter of femur Stabilization of hip joint
Obturator internus Internal surface of Medial surface of greater Hip external rotation
(ob-tu-RA-tor in-TER-nus) obturator foramen and trochanter of femur Stabilization of hip joint
obturator membrane,
ischium
Obturator externus Rami of pubis and ischium Adjacent to greater Hip external rotation
(ob-tu-RA-tor ek-STER-nus) and external surface of trochanter on upper, Stabilization of hip joint
obturator membrane posterior femur
Gemellus superior Posterior, lower part of With obturator internus Hip external rotation
(je-ME-lis) ischium muscle to medial aspect of Stabilization of hip joint
greater trochanter of femur
Gemellus inferior Ischial tuberosity With obturator internus Hip external rotation
(je-ME-lis) muscle to medial aspect of Stabilization of hip joint
greater trochanter of femur
Quadratus femoris Lateral ischial tuberosity The crest between Hip external rotation
(kwod-RA-tus FEM-o-ris) the greater and lesser Stabilization of hip joint
trochanter on posterior
femur
Lateral Muscles of the Hip
The lateral muscles of the hip include the gluteus medius, gluteus minimus, and tensor fasciae latae.
They all cross lateral to the axis of the hip joint for abduction-adduction and so share the common
action of hip abduction, used in movements such as a parallel side tendu or dégagé. These muscles
also play a very important stabilizing role in standing and locomotion. When the weight is on one leg,
these muscles act to prevent the pelvis from dropping down on the opposite side or the support femur
from excessively adducting (“sitting in the hip”).
Attachments and Primary Actions of Gluteus Medius and Minimus Muscles

Gluteus medius Outer surface of ilium Lateral surface of greater Hip abduction
(GLOO-tee-us ME-dee-us) trochanter of femur Hip internal rotation
Stabilization of pelvis on femur
Gluteus minimus Lower outer surface of Anterolateral aspect of Hip abduction
(GLOO-tee-us MI-ni-mus) ilium greater trochanter of Hip internal rotation
femur Stabilization of pelvis on femur
Gluteus Medius and Minimus

The gluteus medius (G. gloutos, buttock + medius, middle) is located on the side of the ilium as shown
in figure 4.10A. It provides the rounded contour to the side of the pelvis, although its posterior fibers
are covered by the gluteus maximus and its anterior fibers by the tensor fasciae latae. The gluteus
medius is the largest of the lateral muscles and is the most fundamental hip abductor, while the gluteus
minimus, tensor fasciae latae, and some additional muscles

may assist with greater resistance or in specific positions
of the joint. The gluteus medius is also a prime mover for
hip internal rotation.
The gluteus minimus (G. gloutos, buttock + L. minimus,
smallest), as its name implies, is a smaller muscle; it is
located deeply, underneath the gluteus medius, in a slightly
anterior and inferior position as seen in figure 4.10B. In
addition to their role in hip abduction, the anterior fibers
of these muscles are key for hip internal rotation, and the
posterior fibers assist with extension, at least under some
conditions. Their potential contribution to hip flexion or
external rotation is still under debate.
Palpation: While standing on one leg, lift the other leg to
the side in a parallel position (hip abduction). The gluteus
medius can be palpated laterally, below the crest of the
ilium and about 2 to 3 inches (5-7.6 centimeters) above the
greater trochanter. Since the gluteus minimus lies beneath
the gluteus medius, it is difficult to palpate it distinctly from
the gluteus medius.
Tensor Fasciae Latae

The tensor fasciae latae (tensor, to make tense + fascia,
band + lata, wide) is a small muscle located at the front
and side of the hip as seen in figure 4.6 on page 166. This
muscle is distinct in having no bony distal attachment; rather
it inserts into the iliotibial band approximately one-fourth of
the way down the outside of the thigh. Its name is derived FIGURE 4.10 The gluteus medius and mini-
from the fact that its action is to tighten this fascia, thereby mus (right hip, posterior view). (A) With gluteus
providing important lateral support for the knee joint. At the maximus removed, (B) deeper view with gluteus
hip joint, in addition to its role in hip abduction, it assists medius removed.
with hip flexion and hip internal rotation (the latter at least
when the hip is flexed).
Palpation: Standing on one leg, raise the other leg to the side while maintaining 45° of hip flexion. The
tensor fasciae latae can be palpated about 2 inches (5 centimeters) anterior to the greater trochanter.
Attachments and Primary Actions of Tensor Fasciae Latae

Tensor fasciae latae Anterior outer crest of ilium, Tibia via iliotibial band Hip abduction
(TEN-sor FA-she-eh LAT-te) lateral aspect of anterior Hip flexion
superior iliac spine Hip internal rotation
Medial Muscles of the Hip (Inner Thigh Muscles)
The medial muscles of the hip include the adductor brevis, adductor longus, adductor magnus, pectineus,
and gracilis. These medial muscles are sometimes called the “inner thigh muscles” by dance teachers.
Since all of these muscles cross medial to the axis of the hip joint, they all share the common action
of hip adduction used in movements such as bringing the leg close to the center of gravity of the body
in walking or closing into fifth position in ballet. Posturally, when standing on one leg the hip adductors
commonly co-contract with the hip abductors to aid with pelvic stability. The muscle mass of these inner
thigh muscles is much larger than the hip abductors or than might be expected given their relation-
ship to gravity in upright stance. One commonly cited explanation for this apparent discrepancy is that
each medial muscle has secondary actions, which allow it to contribute widely in activities that do not
necessarily involve adduction of the hip. Due to the difficulty in distinguishing individual muscles and
the tendency for these muscles to work together in functional movements, palpation will be described
for the medial muscles as a group at the end of this section.
Attachments and Primary Actions of Adductor Longus, Brevis, and Magnus

Adductor longus Anterior surface of pubis Middle third of linea aspera of Hip adduction
(ah-DUK-tor LON-gus) at crest femur Hip flexion (lower ranges)
Adductor brevis Inferior ramus of pubis Superior portion of linea Hip adduction
(ah-DUK-tor BRE-vis) aspera and distal portion of Hip flexion (lower ranges)
line between lesser trochanter
and linea aspera of femur
Adductor magnus Inferior rami of pubis Linea aspera of femur Hip adduction
(ah-DUK-tor MAG-nus) and ischium, ischial Hip extension (lower fibers)
tuberosity
Adductor Longus, Brevis, and Magnus

The adductor longus (adduct, move toward midline
+ L. longus, long) is the most superficial of these
three muscles and runs downward from the pubis
to the linea aspera along the middle portion of the
shaft of the femur as seen in figure 4.11. The adduc-
tor brevis (adduct, move toward midline + L. brevis,
short) is a smaller, deeper muscle that is located
above and behind the longus. The adductor magnus
(adduct, move toward midline + L. magnus, large), as
its name implies, is one of the largest muscles in the
body, and both its proximal and distal attachments
are extensive. Its proximal attachment spans from
the front of the pubis to the ischial tuberosity, and
its distal attachment spans the length of the shaft
of the femur from just below the lesser trochanter
to just above the medial epicondyle. The adductor
magnus is the deepest of the adductor muscles.
In addition to their action in hip adduction, the
medial hip muscles can also play a role in hip flexion
and extension. In anatomical position, the adductor
longus, brevis, and upper fibers of the magnus lie
anterior to the axis for flexion-extension of the hip
and so can produce hip flexion. In contrast, the line
of pull of the lower fibers of the adductor magnus
lies posterior and so can produce hip extension.
However, during flexion of the hip, the line of action
of these muscles relative to this axis changes. Thus,
FIGURE 4.11 The adductor longus, adductor brevis,
as flexion proceeds, they become less effective as
and adductor magnus (right hip, anterior view).
hip flexors, and between approximately 50° and
70° they become hip extensors (Smith, Weiss, and
Lehmkuhl, 1996). There is still much controversy regarding the potential contribution of the hip adduc-
tors to rotation, and further research will be required to clarify this issue.
Attachments and Primary Actions of Pectineus

Pectineus Superior ramus of pubis Line between lesser trochanter and the linea Hip adduction
(pek-TIN-ee-us) aspera on the upper shaft of the femur Hip flexion
Pectineus
The pectineus (L. pectin, comb), as seen in figure 4.12, is a
short, flat muscle located just lateral to the adductor longus
and partially covered by the rectus femoris and sartorius.
Its proximal attachment is more anterior and superior than
the adductor longus or magnus, allowing it to act as a prime
mover for hip flexion and hip adduction through a larger range
of motion. Due to its combination function as a prime mover
for both flexion and adduction and its transitional location,
the pectineus is classified in some texts as part of the
anterior hip flexor group and in other texts as part of the
medial hip adductor group. Its design favors power, and it
is used when the hip is vigorously flexed or to lift the thigh
to cross it over the other thigh during sitting.
Gracilis
The gracilis (L. gracilis, slender), as seen in figure 4.12,
is a superficial, slender, and long muscle that descends
more vertically than the more oblique course of the other
medial thigh muscles. It is located the most medially of
the inner thigh muscles. In addition to its action of hip
adduction, it can contribute to the earlier arc of hip flexion
(probably primarily when the knee is extended) and hip
internal rotation. It is the only medial muscle of the hip
that crosses the knee joint. It attaches onto the medial
tibia and can also act in knee flexion and knee internal
rotation as discussed in chapter 5.
Palpation of the medial hip muscles: Sit on the floor FIGURE 4.12 The pectineus and gracilis (right
with the legs separated in a second-position stretch. The hip, anterior view).
adductors can be palpated as a group along the inside of
the thigh. Press one leg in isometrically against the hand
(hip horizontal adduction) of the same side while using the other hand to palpate the medial muscles.
The adductor longus and gracilis are the prominent tendons that you can feel at the top of the inner
thigh. The adductor magnus can be palpated along the inside of the middle to lower half of the thigh.
Due to its depth, the adductor brevis is difficult to palpate. You can palpate the pectineus just above
the adductor longus tendon when lifting that leg over the other as you sit in a chair.
Attachments and Primary Actions of Gracilis

Gracilis Just below symphysis on pubis, Medial surface of upper tibia (pes Hip adduction
(grah-SI-lis) inferior rami of ischium and pubis anserinus) Hip flexion
(Knee flexion)
Summary of Hip Muscle Attachments and Actions
A summary of the attachments of primary hip muscles and their primary actions is provided in table 4.1,
and selected muscles and attachments are shown in figures 4.13, A and B, and 4.14, A and B. From
these resources, estimate the line of pull of the muscle, deduce its actions, and then check for accuracy
by referring to figure 4.13C or 4.14C. Note that the proximal attachment of the iliopsoas is not shown in
figure 4.13 but can be approximated from a close examination of figure 4.5 on page 165.
TABLE 4.1 Summary of Attachments and Primary Actions of Hip Muscles

Anterior muscles
Psoas major Transverse processes, Lesser trochanter of Hip flexion
(SO-us) bodies, and intervertebral femur Hip abduction (higher
discs of T12-L5 ranges)
Posture
Iliacus Iliac fossa, crest of ilium, Lesser trochanter of Hip flexion
(il-ee-AK-us) inner lateral sacrum femur Hip abduction (higher
ranges)
Rectus femoris Anterior inferior iliac spine Tibial tuberosity via Hip flexion
(REK-tus FEM-o-ris) Posterior head: just above patellar tendon (Knee extension)
acetabulum
Sartorius Anterior superior iliac Medial surface of upper Hip flexion
(sar-TOR-ee-us) spine (ASIS) and area just tibia (pes anserinus) Hip abduction
below Hip external rotation
(Knee flexion)
Posterior muscles
Gluteus maximus Crest and posterior Line on posterior Hip extension
(GLOO-tee-us MAK-si-mus) surface of ilium, posterior femur between greater Hip external rotation
surface of sacrum and trochanter and linea
coccyx aspera and iliotibial tract
Hamstrings
Biceps femoris Long head: ischial Head of fibula Hip extension
(BI-seps FEM-o-ris) tuberosity Lateral tibial condyle Hip external rotation
Short head: linea aspera (Knee flexion)
of femur (Knee external rotation)
Semitendinosus Ischial tuberosity Medial surface of upper Hip extension
(sem-ee-ten-di-NO-sus) tibia (pes anserinus) Hip internal rotation
(Knee flexion)
Semimembranosus Ischial tuberosity Medial condyle of tibia Hip extension
(sem-ee-mem-brah-NO-sus) Hip internal rotation
(Knee flexion)
Posterior muscles (continued)
Piriformis Anterior surface of Superior surface of Hip external rotation
(PIR-i-form-is) sacrum, posterior ilium greater trochanter of Stabilization of hip joint
femur
Obturator internus Internal surface of Medial surface of greater Hip external rotation
(ob-tu-RA-tor in-TER-nus) obturator foramen and trochanter of femur Stabilization of hip joint
obturator membrane,
ischium
Obturator externus Rami of pubis and Adjacent to greater Hip external rotation
(ob-tu-RA-tor ek-STER-nus) ischium and external trochanter on upper, Stabilization of hip joint
surface of obturator posterior femur
membrane
Gemellus superior Posterior, lower part of With obturator internus Hip external rotation
(je-ME-lis) ischium muscle to medial aspect Stabilization of hip joint
of greater trochanter of
femur
Gemellus inferior Ischial tuberosity With obturator internus Hip external rotation
(je-ME-lis) muscle to medial aspect Stabilization of hip joint
of greater trochanter of
femur
Quadratus femoris Lateral ischial tuberosity The crest between Hip external rotation
(kwod-RA-tus FEM-o-ris) the greater and lesser Stabilization of hip joint
trochanter on posterior
femur
Lateral muscles
Gluteus medius Outer surface of ilium Lateral surface of greater Hip abduction
(GLOO-tee-us ME-dee-us) trochanter of femur Hip internal rotation
Stabilization of pelvis on
femur
Gluteus minimus Lower outer surface of Anterolateral aspect of Hip abduction
(GLOO-tee-us MI-ni-mus) ilium greater trochanter of Hip internal rotation
femur Stabilization of pelvis on
femur
Tensor fasciae latae Anterior outer crest of Tibia via iliotibial band Hip abduction
(TEN-sor FA-she-eh LAT-te) ilium, lateral aspect of Hip flexion
anterior superior iliac Hip internal rotation
spine
Medial muscles
Adductor longus Anterior surface of pubis Middle third of linea Hip adduction
(ah-DUK-tor LON-gus) at crest aspera of femur Hip flexion (lower ranges)
Adductor brevis Inferior ramus of pubis Superior portion of linea Hip adduction
(ah-DUK-tor BRE-vis) aspera and distal portion Hip flexion (lower ranges)
of line between lesser
trochanter and linea
aspera of femur
(continued)
175
TABLE 4.1 Summary of Attachments and Primary Actions of Hip Muscles (continued)

Medial muscles (continued)
Adductor magnus Inferior rami of pubis and Linea aspera of femur Hip adduction
(ah-DUK-tor MAG-nus) ischium, ischial tuberosity Hip flexion (lower fibers)
Pectineus Superior ramus of pubis Line between lesser Hip adduction
(pek-TIN-ee-us) trochanter and the linea Hip flexion
aspera on the upper shaft
of the femur
Gracilis Just below symphysis Medial surface of upper Hip adduction
(grah-SI-lis) on pubis, inferior rami of tibia (pes anserinus) Hip flexion
ischium and pubis (Knee flexion)
Psoas major
Iliacus
FIGURE 4.13 Anterior view of primary muscles acting on the hip joint (right hip). (A) Muscles, (B) attachments, (C)
lines of pull and actions.
176
Gluteus
minimus
FIGURE 4.14 Posterior view of primary muscles acting on the hip joint (right hip). (A) Muscles, (B) attachments,
(C) lines of pull and actions.
This is because bony landmarks are more reflective of planes, such that one ASIS would not be higher or
the underlying bony structure and generally will pro- lower or rotated forward or backward relative to the
vide a more accurate appraisal than body contours. other ASIS.
Neutral Position Anterior and Posterior Pelvic Tilt

During standing in an upright position, an oblique Anterior and posterior pelvic tilts are opposite
plane through the PSIS of the ilia and the symphysis movements of the whole pelvis in the sagittal
pubis forms an angle of about 60° relative to the hori- plane about a mediolateral axis. In an anterior tilt
zontal plane. This angle is termed the angle of pelvic (increased inclination), the top of the pelvis rotates
inclination (Smith, Weiss, and Lehmkuhl, 1996). This forward such that the ASIS are forward relative to
is the neutral position of the pelvis and roughly cor- the pubic symphysis as seen in figure 4.15B. From
responds to a position in which both of the ASIS and a side view, a vertical plane extending from the
the pubic symphysis are in the same frontal plane ASIS would fall in front of the pubic symphysis. In
as seen in figure 4.15A. Since the angle of inclina- dance this is sometimes referred to as a “released”
tion cannot be determined in a class setting, the position of the pelvis.
vertical alignment of the landmarks is used as an In a posterior tilt or backward tilt (decreased inclina-
easy method to evaluate pelvic position. A neutral tion), the top of the pelvis rotates backward such that
position of the pelvis also takes into account other the ASIS are back relative to the pubic symphysis as
FIGURE 4.15 Pelvic alignment and movement. (A) Neutral, (B) anterior and posterior tilt, (C) lateral tilt, (D) rotation.
seen in figure 4.15B. From a side view, a vertical plane Pelvic Rotation
through the ASIS would fall behind the pubic sym-
physis. In dance this is often referred to as a “tucked” Pelvic rotation is movement of the whole pelvis in
position of the pelvis. Notice that when one is describ- the transverse plane about a vertical axis. It involves
ing an anterior or posterior pelvic tilt the reference is a rotation of the pelvis such that one ASIS is anterior
to the top of the pelvis. This is important to remember or posterior to the other ASIS. When viewed from the
since the bottom of the pelvis will be moving in the front or side, one ASIS is in front of the other as seen
opposite direction. in figure 4.15D. Pelvic rotation is commonly observed
in dancers who have scoliosis that involves rotation in
Lateral Pelvic Tilt the lumbar region. The rotation is named in terms
of the direction toward which the front of the pelvis
A lateral tilt is movement of the whole pelvis in turns. So, if the left ASIS is behind the right ASIS,
the frontal plane about an anteroposterior axis. It this means that the front of the pelvis is rotating to
involves a side tilt of the top of the pelvis such that the left, and this is termed left pelvic rotation.
one iliac crest and ASIS drops below the opposite
iliac crest and ASIS. So, when viewed from the front,
the pelvis is not level, and one ASIS is lower than the Angle of Femoral Inclination
other as seen in figure 4.15C; and when viewed from
behind, one PSIS is lower than the other. Lateral The angle of femoral inclination is an angle formed
tilts are named in terms of which side of the pelvis between the neck of the femur and the shaft of the
is low, so with a right lateral tilt the iliac crest, ASIS, femur when viewed from the front, as seen in figure
and PSIS are lower on the right side. Lateral tilt, or 4.16B. It occurs close to, but not strictly in, the frontal
pelvic obliquity, is commonly seen in dancers who plane, since the greater trochanter lies somewhat
have one leg shorter than the other or in dancers posterior to the head of the femur. In the newborn
who have certain types of scoliosis. this angle is about 150°; it decreases to approximately
Pelvic Alignment: Anterior Pelvic Tilt,

Posterior Pelvic Tilt, and Neutral
Use figure 4.15 for reference and the procedure described next to learn to identify an anterior pelvic
tilt, posterior pelvic tilt, and a neutral pelvis.
1. Stand in parallel first position with your side to a mirror, and place your right index finger on
your right ASIS and your left index finger on your left ASIS.
a. Tilt the top of the pelvis forward to create an anterior pelvic tilt, and note in the mirror that the
ASIS are in front of the pubic symphysis.
b. Tilt the top of the pelvis backward to create a posterior pelvic tilt, and note in the mirror that
the ASIS are behind the pubic symphysis.
c. Tilt the top of the pelvis in the necessary direction to create a neutral pelvis by lining up the
ASIS directly above the pubic symphysis, in the same vertical plane.
2. Stand in a parallel first position, and note the alignment of your pelvis. Make any necessary
corrections to effect a neutral pelvic alignment.
3. Perform a demi-plié and relevé in parallel and turned-out first positions. Note the alignment of
your pelvis throughout the movement and make any necessary adjustments to maintain neutral
pelvic alignment. Are there any differences in your pelvic alignment between standing, demi-plié,
and relevé in parallel or turned-out positions?
4. Repeat steps 2 and 3 with a partner and, if necessary, help each other to make the neces-
sary adjustments to maintain a neutral pelvic alignment.
5. Now, note if asymmetries exist in relative positioning of your ASIS in the transverse and frontal
planes. Place your fingertips on each ASIS, and look at the pelvis from the front. With neutral
alignment, the ASIS should be in the same transverse plane; that is, they should appear at the
same level or height versus have one lower than the other. They should also be in the same frontal
plane versus have one rotated in front of the other.
125° to 130° in the adult and further decreases to but increase the effectiveness of the hip abductors
about 120° in old age (Levangie and Norkin, 2001; (greater lever arm). Regarding lower leg alignment,
Mercier, 1995). The angle of inclination has an with a decreased angle of inclination there is a
important influence on the mobility and stability of tendency for the shaft of the femur to slope more
the femur, as well as knee and lower leg alignment. inward than normal and to produce a knock-kneed
Normally, this inclination helps angle the femur alignment termed genu valgum (see chapter 5), in
inward so that the center of the knee joint is close to which the knees are medial to the feet during stand-
being vertically aligned with the head of the femur ing in anatomical position.
and center of motion of the hip joint.
Coxa Valga
Coxa Vara
When the angle of inclination is abnormally
When the angle of inclination is abnormally increased, the condition is called coxa valga (coxa,
decreased, the condition is called coxa vara (coxa, hip hip + L. valga, turned outward) as seen in figure
+ L. varus, bent inward) as seen in figure 4.16A. This 4.16C. This condition increases the load on the
condition decreases the load on the femoral head femoral head but decreases the load on the neck of
but increases the load on the neck and increases the the femur. Regarding mobility, an increased angle
risk of fracture of the neck of the femur (Hamill and can increase the range available in hip abduction
Knutzen, 1995). Regarding mobility, a decreased but reduce the effectiveness of the hip abductors
angle can decrease the range of hip abduction (decreased lever arm). Regarding lower leg alignment,
FIGURE 4.16 Angle of femoral inclination (top row: left hip, anterior view). (A) Coxa vara, (B) normal, (C) coxa valga.
with an increased angle of inclination there is a ten-

dency for the shaft of the femur to run more vertical
or even slightly outward and to produce a bow-legged
alignment termed genu varum (see chapter 5), in
which the knees are placed lateral to the feet during
standing in anatomical position.
Angle of Femoral Torsion

The angle of femoral torsion is the angle of the head
and neck of the femur relative to the shaft of the
femur and the femoral condyles when viewed from
above as seen in figure 4.17. Due to this angle, when
one is standing erect with the knees facing directly
forward, the center of the head of the femur is not
located in the same frontal plane as the tip of the
greater trochanter, but rather slightly anterior to the
trochanter. In other words, if you place your fingertips
on your greater trochanter, the neck of the femur will
be angling slightly forward, placing the center of the
FIGURE 4.17 Angle of femoral torsion (left hip,
head of the femur slightly in front of the trochanter. superior view).
This angle is marked in the newborn, averaging about
35° to 40°, but it decreases with age to an average
Femoral Anteversion
of approximately 8° to 15° (Bauman, Singson, and
Hamilton, 1994; Rasch, 1989). This angle can influ- An abnormal increase in the angle of femoral torsion
ence the extent of turnout allowed at the hip and so is termed femoral anteversion (turning forward).
is important for the dancer to understand. Excessive femoral anteversion results in greater
internal rotation of the femur, which can be respon- Pelvic and Hip Mechanics
sible for in-toeing, or the tendency to have the toes
face inward, as seen in figure 4.18B. When femoral Due to the very limited motion allowed at the pubic
anteversion is excessive, more of the anterior head symphysis and sacroiliac joints, the pelvic girdle
of the femur becomes uncovered, and internal rota- primarily acts as a unit, with movement of the pelvis
tion of the femur is required to better position the tending to produce movement in the lumbar spine
head of the femur in the acetabulum (Hamill and and at both hip joints. In some conditions, linked
Knutzen, 1995). Increased femoral anteversion is also movements of the pelvis, lumbar spine, and hip
associated with decreased external rotation, prob- joints are encouraged, while in other cases there is
ably due to earlier contact between the neck of the an attempt to limit the associated movements in favor
femur and the lateral edge of the acetabulum. Due of stabilization of one of the segments.
to the restricted external rotation and the tendency
for in-toeing, excessive femoral anteversion is con-
sidered undesirable for the dancer in professional Linked Movements
training, particularly in classical ballet. Femoral of the Pelvis, Femur, and Lumbar Spine
anteversion can also negatively impact alignment
above and below the hip and is commonly associ- Movement of the pelvis occurs relative to the spine,
ated with lumbar lordosis, an increased Q angle, primarily at the lumbosacral joint, and relative to
and patellar problems (discussed in chapter 5), as the femur at the hip joint. Movements can be initi-
well as excessive pronation of the foot (discussed ated from the spine, pelvis, or femur and will tend
in chapter 6). to produce predictable secondary movements in the
other two segments as well. The linked movements
Femoral Retroversion that tend to occur will be influenced by whether
both ends of the chain are closed, the head is free
A decrease in the angle of femoral torsion, versus an
to move, or the leg/foot is free to move.
increase, is termed femoral retroversion (turning
backward). Femoral retroversion results in greater Closed-Chain Pelvic Movements
hip external rotation, which can lead to out-toeing,
or the tendency for the feet to face markedly out- While the terms closed and open kinematic chain
ward as seen in figure 4.18C. Due to the associated are more commonly used for limbs, the concept can
increased hip external rotation or turnout, femoral also be applied to the pelvis. During erect standing
retroversion is considered desirable for dancers in the distal part of the chain becomes fixed (foot).
dance forms emphasizing turnout. While not structurally fixed, the proximal end of
FIGURE 4.18 Angle of femoral torsion and potential influence on lower leg alignment (left hip, superior view).
(A) Normal, (B) femoral anteversion and associated in-toeing, (C) femoral retroversion and associated out-toeing.
the chain (head) can become functionally fixed slight abduction of the right hip, slight adduction
in many movements by the need to keep the head of the left hip, and compensatory left lateral flexion
upright and over the base of support (Levangie and of the lumbosacral joint, resulting in a curve convex
Norkin, 2001). When these two conditions exist, to the right. When the pelvis rotates right (with the
movements of the pelvis can be termed closed-chain front of the pelvis rotating to the right without the
pelvic movements, and they produce predictable feet or head moving), this is accompanied by slight
movements at the hip joint and lumbar spine. For external rotation of the left hip, slight internal rota-
example, when one is standing erect, if the pelvis tilts tion of the right hip, and compensatory spinal rota-
anteriorly from its neutral position (figure 4.19A) as tion to the left. Left lateral tilt and left rotation of
seen in figure 4.19B it will produce hip flexion and the pelvis are associated with opposite movements
a compensatory increase in the arch of the lumbar to those described for the right.
curve (lumbar hyperextension) in order to bring the These linked movements are summarized in table
torso and head back over the pelvis. In contrast, when 4.2, and it is important to note that the same linkings
the pelvis tilts posteriorly as seen in figure 4.19C, it tend to occur if the movement is initiated from the
will tend to create hip hyperextension (unless the spine. For example, arching the low back as in jazz or
knees are simultaneously bent) and compensatory African dance (lumbar hyperextension) produces an
decrease in the lumbar curve (lumbar flexion) in automatic anterior tilt of the pelvis and hip flexion,
order to bring the upper torso and head back over while flattening the low back (flexion, or decreased
the pelvis. Note that during anterior and posterior lumbar lordosis) as with a contraction is linked to a
pelvic tilts, the movements of the pelvis actually posterior tilt of the pelvis and extension of the hip.
involve “opposite movements” at the lumbosacral However, in dance, cueing from the pelvis can often
and hip joints due to their opposite facings. When produce the desired motion with less stress for the
the pelvis laterally tilts to the right (with the right low back. For example, using the cue to reach the
side lower than the left), the tilt is accompanied by bottom of the pelvis down toward the floor and back
FIGURE 4.19 Closed-chain pelvic movements. (A) Neutral, (B) anterior pelvic tilt, (C) posterior pelvic tilt.
TABLE 4.2 Primary Movements of the Pelvis When Standing With Secondary Movements
of the Spine and Hip
Movement of the pelvic girdle Associated movement of the spine Associated movement of the hip
Anterior pelvic tilt Lumbar hyperextension Hip flexion
Posterior pelvic tilt Lumbar flexion Hip extension
Right lateral tilt (right side lower) Left lateral spinal flexion Right hip abduction
Left hip adduction
Right rotation (front of pelvis rotating Left spinal rotation Right hip internal rotation
right) Left hip external rotation
A B C D
FIGURE 4.20 Lumbar-pelvic rhythm. (A) Neutral pelvis and spine, (B) spinal flexion, (C) anterior pelvic tilt and hip flexion,
(D) forward hang.
can produce the desired arch in the low back from this process used with forward flexion, beginning
the anterior tilt produced by greater contraction with extension of the hip joint and posterior tilting
of the hip flexors versus contraction of the spinal of the pelvis, followed by extension of the spine.
extensors located in the lumbar region. This return from forward flexion should be a well-
coordinated movement; and disruption of this
Lumbar-Pelvic Rhythm lumbar-pelvic rhythm, such as extending the back
In contrast to the condition just described, when too soon or returning in an asymmetrical manner,
the distal end of the chain is fixed (feet) by standing can increase risk for low back injury.
but the proximal end of the chain (head) is free This movement is commonly used in modern and
to move, linking between the spine, pelvis, and hip jazz classes (“roll-downs”); and cues frequently used
is termed the lumbar-pelvic rhythm. One impor- by teachers to bend the knees slightly and bring the
tant example of the lumbar-pelvic rhythm occurs pelvis under, before stacking the spine on the pelvis,
during bending forward from a standing position can be helpful for encouraging this desired lumbar-
and then returning to an upright position (Cail- pelvic rhythm and reducing low back stress. With
let, 1996). Only about 50° to 70° of spinal flexion forward flexion from a standing position, the ischial
(Soderberg, 1986) is possible in most individuals tuberosities move backward relative to the hip axis as
(figure 4.20B), and then additional movement is seen in figure 4.20, A-D; so the hamstrings can pull the
due to anterior tilting of the pelvis and flexion at the ischial tuberosities downward and forward, while the
hip joint (figure 4.20, C and D). When this flexion gluteus maximus draws the pelvis back to help return
is complete, support of the body weight relies on the pelvis to a vertical/neutral position. Starting this
passive support (flexion relaxation phenomenon). return motion with the pelvis delays extension of the
Return from this fully flexed position should reverse spine until the trunk is closer, such that the moment
Hip Extensor Function in Posture
The hip extensors can also be palpated in their postural role. Placing one hand below the ischial
tuberosity and gluteus maximus and the other hand on one of the buttocks, incline the trunk forward
about 45°, and feel the hamstrings and gluteus maximus contract. Then slowly bring the torso to
vertical, lean slightly back, and feel the hamstrings and gluteus maximus relax as the center of mass
of the torso falls behind the common hip axis.
arm of the resistance (weight of the torso) is less and occurs when one performs a high battement to the
the stress on the lumbar spine is markedly reduced. front. When the constraints of hamstring flexibility
are met, further movement of the leg upward will
Pelvic-Femoral Rhythm create a posterior tilt of the pelvis and a decrease in
When extreme ranges of motion are required at the lordosis (or even flexion) of the lumbar spine.
the hip joint, movements of the pelvic girdle occur This additional motion of the pelvis and spine will
in a different direction and for a different reason, change the facing of the acetabulum more upward,
that is, to place the acetabulum in a favorable posi- which in turn will allow the leg to go markedly
tion to enhance the range through which the leg higher relative to the ground. Often, extreme use
and foot can be moved. This text will use the term of this linked motion is not desirable in dance as it
pelvic-femoral rhythm to refer to the characteristic will distort desired body alignment, but the specific
linking of these movements of the pelvis to the vocabulary and dance form will dictate the amount
fundamental movements of the femur at the hip of pelvic motion permitted. For example, an extreme
joint as shown in table 4.3. This term was selected posterior pelvic tilt causes flexion of the support knee
to reflect its parallelism to the predictable linking of and spine, distorting the classical desired illusion
movements of the scapula with fundamental move- of a “lifted” and vertically aligned body. However,
ments of the humerus at the shoulder joint termed in jazz or contemporary choreography, a high kick
the scapulohumeral rhythm. However, an important to the front is sometimes purposely performed on
difference between these linkings in the upper and élevé with a bent support leg as shown in figure 4.21.
lower extremity is that because the pelvis is directly This bent knee positioning will allow a marked pos-
attached to the spine, movements of the pelvis will terior pelvic tilt so that a much greater height can
necessitate movement in the lumbar spine as previ- be achieved with the gesture leg, while extension of
ously described and listed in table 4.2. In contrast, the upper spine can be used to limit “dropping back
movements of the scapulae can occur without pro- and down” of the torso to within acceptable limits of
ducing a change in position of the spine. the choreographer.
An example of the pelvic-femoral rhythm entail- While end ranges of hip flexion tend to be linked
ing linking of a posterior pelvic tilt with hip flexion with a posterior tilt of the pelvis, other movements
TABLE 4.3 Linked Movements of the Pelvis That Accompany Movements of the Femur at the Hip Joint
Movement of the hip joint Associated movement of the pelvic girdle

Hip flexion Posterior pelvic tilt
Hip hyperextension Anterior pelvic tilt
Left hip abduction Right lateral pelvic tilt (right side lower and left side higher)
Right hip adduction Right lateral pelvic tilt
Left hip external rotation Left pelvic rotation
Right hip internal rotation Left pelvic rotation
of motion in an effort to maximize the height the

leg can be lifted. In addition, in strengthening and
stretching exercises, there is often an emphasis
on limiting initial use of linked pelvic motions so
that greater overload can occur to the targeted hip
muscle group.
Pelvic Stabilization
While the previous description emphasized the

linked movements between the pelvis, spine, and
hip joint, there are also many instances in which the
emphasis is on keeping the pelvis stationary or on
limiting the movements of the pelvis during move-
ments (or certain phases of movements) of either
the femur or spine. This process of keeping the pelvis
relatively stationary during movement is termed pelvic
stabilization and can be considered one component
of core stabilization. Since the muscles that are used
to lift the leg attach onto the pelvis, they will tend to
produce movements of the pelvis, lumbar spine, and
leg unless the pelvis is stabilized. For example, when
the thigh is lifted to the front in an attitude, because
the proximal attachments of many of the hip flexors
are on the front of the pelvis they will tend to simul-
taneously create an anterior pelvic tilt and lumbar
lordosis, as well as the desired motion of hip flexion.
However, other muscles can be used to stabilize the
pelvis and prevent these undesired movements of the
pelvis and spine so that visible motion is primarily
confined to flexion of the thigh at the hip joint.
There are various strategies for achieving the
desired stabilization of the pelvis and spine. In the
previous chapter, co-activation of the abdominals
and back extensors for trunk stabilization was
described. Another vital strategy when standing
FIGURE 4.21 Performing a front battement with a bent
support knee allows for greater use of the pelvic-femo- (closed kinematic chain conditions) is co-activa-
ral rhythm to increase leg height. tion of the abdominals and hamstrings, termed the
abdominal–hamstring force couple. As seen in figure
4.22, when the limb is fixed such as when standing
at the hip joint are linked with pelvic movements erect, the proximal attachment of the hamstrings
as follows. When the thigh is raised backward (hip can become the moving end, pulling the ischial
hyperextension), the pelvis tends to tilt anteriorly; tuberosities downward while the lower attachment
when one thigh is widely abducted or adducted, of the abdominals pulls the pubes upward, both
the pelvis tilts laterally; and when one leg is placed acting to produce a posterior pelvic tilt or prevent
forward and the other backward as in taking a long an anterior pelvic tilt.
stride, the pelvis rotates. Associated movements of In dance, use of the abdominal–hamstring force
the lumbar spine can be determined from table couple and other strategies for stabilization of the
4.2. As previously stated, in dance vocabulary, the pelvis are often encouraged when standing on one
timing and extent of these linked movements are or both legs so that movement is primarily isolated
often dictated by the aesthetics of the specific school to the hip joint proper, or at least that movements
of dance. Frequently, there is an emphasis on mini- of the pelvis are limited to an extent allowed by the
mizing these linked movements in early ranges of given dance aesthetic. The refined ability to appro-
motion and reserving their use for the end ranges priately time and control movements of the pelvis
DANCE CUES 4.2
“Use the Back of Your Leg”
T he instruction to “use more of the back of your leg” is sometimes employed by teachers to encour-
age greater use of the hamstring muscles when the feet are weight bearing, particularly when the
teacher feels that the student is overusing the “front of the legs” (quadriceps femoris). From an ana-
tomical perspective, this directive could be interpreted as encouraging greater use of the abdominal–
hamstring force couple. If more stability is established from above, through use of this force couple to
help maintain a neutral pelvis and to position the weight of the body appropriately over the support
foot/feet (vs. too far back), a dancer could theoretically use less quadriceps contraction to maintain
“balance.” Another interpretation of this cue relates to emphasizing greater use of the hip extensors
versus knee extensors in movements such as pliés, and this emphasis will be discussed in chapter 5.
The problem with this cue is that some dancers do not know how to use “more of the back of the
leg”; so substituting more specific cues or performing an exercise to help dancers find these muscles
can make the cue more meaningful. For example, thinking of pulling the bottom of the pelvis (ischial
tuberosities) down toward the floor until the pelvis is vertically aligned (ASIS and pubic symphysis in
same frontal plane) can help some dancers recruit the hamstrings in their force-couple role with the
abdominal muscles. Similarly, on the up-phase of the plié, focusing on pressing into the floor with
the feet and pulling the sitz bones down and forward to extend the hip joint, before thinking about
straightening the knees, can sometimes help dancers feel greater use of the hip extensors. Once a
dancer knows how to achieve greater hip extensor activation, the initial cue to use the “back of the
leg” or “more hamstrings” can be an effective reminder.
and torso with movements of the limbs is one of

the distinguishing factors in dance skill acquisition
(Bronner et al., 2000).
Muscular Analysis
of Fundamental Hip
Movements
As previously described, the hip joint is capable of
flexion, extension, abduction, adduction, external
rotation, and internal rotation. A summary of the
key muscles capable of producing these fundamental
movements of the hip can be seen in table 4.4. For
purposes of simplicity, initially think of movements
in a parallel position. Much of the research related to
the actions of muscles has been done with the limbs
in parallel (neutral) or almost neutral positions.
However, in dance many movements are performed
in a turned-out position and so represent combined
FIGURE 4.22 The abdominal–hamstring force couple. movements in which the appropriate hip external
The abdominal muscles pull up on the front of the pelvis rotators work with the hip flexors in movements to
while the hamstrings pull down on the back of the pelvis the front, probably with a combination of hip flexors
to produce backward rotation of the pelvis (posterior and hip abductors in movements to the side, and
pelvic tilt). with the hip extensors in movements to the back.
Using a turned-out position would likely influence
TABLE 4.4 Fundamental Hip Movements and the Muscles That Can Produce Them
Hip joint movement Primary muscles Secondary muscles

Flexion Iliopsoas Tensor fasciae latae
Rectus femoris Adductor longus and brevis (early flexion)
Sartorius Gracilis
Pectineus
Extension Gluteus maximus Adductor magnus (lower fibers)
Hamstring muscles:
Biceps femoris
Semitendinosus
Semimembranosus
Abduction Gluteus medius Tensor fasciae latae
Gluteus minimus Sartorius
Iliopsoas (upper ranges of abduction)
Adduction Adductor longus Pectineus
Adductor brevis
Adductor magnus
Gracilis
External rotation Deep outward rotators: Sartorius
Obturator externus Biceps femoris
Obturator internus
Piriformis
Quadratus femoris
Gemellus superior
Gemellus inferior
Gluteus maximus
Internal rotation Gluteus medius (anterior fibers) Tensor fasciae latae
Gluteus minimus (anterior fibers) Semimembranosus
Semitendinosus
the relative activation of the relevant muscle group. to chest, front leg raise, and front développé (table
For example, performing a turned-out arabesque 4.5, A-C, pp. 213-214), or in swinging the leg forward
would theoretically recruit more of the biceps femo- in walking, running, kicking, and many sports. In
ris than the medial hamstrings, due to the secondary dance, this type of hip flexion is used whenever the
functions of the medial hamstrings of hip internal leg is moved to the front such as in a tendu, dégagé,
rotation. Additional electromyographic (EMG) front attitude, front battement, or the front leg of a
investigation of basic dance vocabulary in parallel jump (sissone) as seen in figure 4.23.
versus turned-out positions would provide valuable The hip flexors are used in their reversal of custom-
insights into relative muscle activation. ary action when they contract concentrically to bring
the pelvis or trunk, or both, forward in an anterior
Hip Flexion pelvic tilt, a sit-up (see figure 2.8 on p. 43), and floor
work such as a contraction series in modern or chest
Hip flexion decreases the angle between the anterior lifts in jazz dance. An example of the combined
surfaces of the articulating bones. The iliopsoas, use of movement of the legs and torso is shown in
rectus femoris, and sartorius are assisted by other figure 4.24, in which the dancer raises from a flat
hip flexors (table 4.4) to perform their customary position on the ground by flexing at the hip and
action when contracting concentrically against grav- bringing both one thigh and the torso simultaneously
ity or resistance to lift the femur to the front in knee together. In contrast to a classic curl-up, the spine is
FIGURE 4.24 Hip flexion involving movement of the anterior

surface of one femur and the pelvis toward each other.
ments), gravity will tend to create further hip flexion

once a small amount of hip flexion is produced. So
it is actually the hip extensors that are primarily used
eccentrically to control hip flexion and prevent col-
lapse of the body to the ground. Examples of this type
of hip flexion occur on the down-phase of a parallel
plié, in the landing phase of a parallel jump, or when
one brings the trunk forward in a roll-down or to a
flat back position.
Hip Extension
Hip extension is a movement in a posterior direction
such that the angle between the posterior surfaces
of the articulating bones decreases. The hip exten-
sors—the hamstrings and gluteus maximus—per-
FIGURE 4.23 Sample dance movement showing hip form their customary open kinematic chain action
flexion. when contracting concentrically against gravity or
Photo courtesy of Myra Armstrong. Dancer: Lorin Johnson with American Ballet
Theatre.
resistance to move the femur backward in the back
leg raise (table 4.5D, p. 214), in the kneeling ara-
kept in a relatively neutral (extended) position, and besque (table 4.5E, p. 215), or in running (recovery
the trunk moves as a unit about the hip axis versus the phase). In dance, one uses this type of hip extension
sequential flexion of the spine generally used in the when moving the leg to the back with a leap (back
curl-up. More dramatic examples of this simultane- leg), tendu, dégagé, back développé, back attitude,
ous movement of the trunk and thigh occur with “V”- or arabesque penché as seen in figure 4.25.
sit or teaser types of movements (previously shown When the foot remains fixed and in contact with
in figure 3.43 on p. 129) in modern, jazz, or Pilates. the ground (closed kinematic chain movements), hip
Such advanced exercises require high strength and extension occurs against gravity when straightening
skill levels so that abdominal co-contraction can be from a flexed position, such as on the up-phase of
used to help stabilize the low back and pelvis in order a squat, plié, or jump or when bringing the trunk
for the hip flexors to bring the thighs and trunk back to a vertical position from a flat back position.
together without undesired and potentially injurious Concentric hip extension is also used in locomotor
arching of the low back. movements to bring the weight of the body over the
However, when hip flexion occurs while the lower foot, and posturally to create a posterior pelvic tilt,
limb is weight bearing (closed kinematic chain move- while isometric hip extension is used to maintain
cally against gravity or resis-

tance to move the femur
sideways in the side leg
raise (table 4.5, G and H,
pp. 216-217), a side kick
in karate, jumping jacks,
or side lunges. Examples
from dance include parallel
movements to the side such
as a lateral tilt, extension,
tendu, dégagé, or attitude
as shown in figure 4.26.
When one foot remains
fixed and in contact with
the ground (closed kine-
matic chain movements),
concentric hip abduction
plays a key role in pull-
ing the side rim of the
pelvis closer to the greater
trochanter on the weight-
bearing side, countering
the undesired tendency
caused by gravity for the
pelvis to drop (laterally tilt)
to the opposite side. This
function of the hip abduc-
tors, called the abductor
mechanism (Soderberg,
FIGURE 4.25 Sample dance movement showing hip extension.
1986), is important in walk-
© Angela Sterling Photography. Pacific Northwest Ballet dancers Louise Nadeau and Christophe Maraval.
ing and dancing to allow
maintenance of balance
an extended hip on the support leg in many dance and appropriate positioning of the body over the
movements. Bridging (table 4.5F, p. 215) is a con- support foot while on one leg. Performing a standing
ditioning exercise that is aimed at simulating these side leg raise (table 4.5H, p. 217) while attempting to
latter functions of the hip extensors. These closed maintain a level pelvis with the body weight appropri-
kinematic chain uses of hip extension are very impor- ately positioned over the support foot can be used to
tant in activities of daily living and in dance. develop this important postural function of the hip
As with other joint movements, when hip exten- abductors.
sion occurs in the same direction as gravity, the oppo- When an individual has dysfunction of the hip
site muscle group is generally key in controlling the abductors, such as gluteus medius weakness, a
movement. For example, when the leg is lowered in a distinct drop of the pelvis will be seen to the oppo-
controlled manner from being lifted to the front, this site side that the person is unable to correct. This
type of hip extension involves eccentric contraction undesired drop of the pelvis is called a positive
of the hip flexors versus the hip extensors. Trendelenburg sign.
Hip Abduction Hip Adduction

Hip abduction is movement in a sideways direction, Hip adduction is a sideward movement in a medial
such that the angle between the lateral surfaces of direction toward the median plane such that the
the articulating bones decreases. The gluteus medius angle between the medial surfaces of the articulat-
and minimus are assisted by other hip abductors ing bones decreases. The adductor longus, adductor
listed in table 4.4 to perform their customary open brevis, adductor magnus, and gracilis are assisted by
kinematic chain action when contracting concentri- the pectineus (table 4.4) to perform their customary
legs are brought together from an abducted position,

for example on the up-phase of a turned-out plié.
Posturally, closed kinematic chain adduction can be
used to laterally tilt or side-shift the pelvis relative to
the support leg, which is an important mechanism
used in locomotion and dance for assisting balance,
increasing economy of gait, and helping stabilize
the pelvis. This is one of the mechanisms involved
in meeting the directive used in dance of “being
over your leg.”
During upright standing, adduction of the gesture
leg will be in the same direction as gravity and so will
generally involve use of the antagonist muscles. For
example, when the leg is lowered in a controlled
manner from being lifted high to the side, eccentric
contraction of the hip abductors is used to control
the lowering of the leg, at least in the beginning of
the lowering.
FIGURE 4.26 Sample dance movement showing hip abduction.

Photo courtesy of Patrick Van Osta. CSULB dancer Dwayne Worthington.
open kinematic chain action when contracting

concentrically against gravity or resistance to move
the femur toward the midline in exercises such as
the single leg pull and side leg pull (table 4.5, J and
K, p. 218), the frog kick in swimming, and keeping
the swinging limb closer to the midline in walking.
In functional movement, hip adduction is often
combined with slight hip flexion or hip extension
to allow the limb to cross the midline without hit-
ting the other limb. Examples of this use of the hip
adductors from dance include grapevine-type steps,
the final phase of a dégagé when the leg closes
into fifth with an “in” emphasis, and the motion of
pulling the inner thighs “together and up” at the
top of a jump (with or without beats) as shown in
figure 4.27.
When the foot remains fixed and in contact with FIGURE 4.27 Sample dance movement showing hip
the ground (closed kinematic chain movements), adduction.
customary hip adduction occurs against gravity as the Photo: Roy Blakey. Dancer: Douglas Nielsen in “Spirit of Gravity.”
The Trendelenburg Test
Use the Trendelenburg test to evaluate the

hip abductor mechanism on (1) another
dancer and (2) yourself as explained next.
1. Evaluation of another dancer. Have your
partner stand on the left leg, with the
right hip and knee slightly flexed so that
the right foot clears the floor. Kneel
behind the dancer, and place your right
thumb on the right PSIS and the remain-
ing fingers of the right hand along the
right lateral crest of the ilium. Place
your left thumb on the left PSIS and
the remaining fingers on the left lateral
portion of the crest of the ilium. If these
matched landmarks appear at the same
height, that is, in the same transverse
plane, this is a negative Trendelenburg
sign (A); if the PSIS or crest of the ilium
is markedly lower on the unsupported
side, this indicates a positive Trendelen-
burg sign (B).
2. Self-evaluation. Stand on one leg (with
the opposite hip and knee slightly flexed
so that the foot is off the ground) in
front of a mirror. Place your right index
finger on your right ASIS and your left
index finger on your left ASIS. If these
landmarks appear at the same height, this is a negative Trendelenburg sign, while if the ASIS is
markedly lower on the unsupported side, this indicates a positive Trendelenburg sign and sug-
gests that hip abductor weakness is present.
Hip External Rotation or prone frog (table 4.5, M and N, pp. 219-220).
However, more commonly hip external rotation is
Hip external rotation involves lateral rotation of combined with other movements of the hip rather
the anterior thigh relative to the pelvis about the than being used in isolation, such as during the
mechanical axis of the femur in a transverse plane. swing phase of walking, the frog kick in swimming,
Because of the angulation of the neck of the femur, or the side leg raise and side leg pull (table 4.5, G
the long axis of rotation is not in the shaft of the [p. 216] and K [p. 218]) variations performed in
femur, but rather medial to it—a line extending an externally rotated position. Examples of move-
between the centers of the hip and knee joints. ments from dance that combine hip extension and
The deep outward rotators and gluteus maximus external rotation include the back leg of a grand jeté,
are potentially assisted by other hip external rotators an arabesque, or a back attitude as shown in figure
(listed in table 4.4) when contracting concentri- 4.28. Hip external rotation would also be used in
cally to rotate the legs outward from a parallel first any dance movements performed in a turned-out
to a turned-out first position or in the prone passé versus parallel position, and the direction of the
FIGURE 4.28 Sample dance movement showing hip external rotation combined with hip extension.
Photograph by David Cooper. Pacific Northwest Ballet School students.
accompanying movement (e.g., front, side, back) hip internal rotation (table 4.5P, p. 220). However,
would influence the muscles recruited to produce as with hip external rotation, hip internal rota-
the desired hip external rotation. tion is more commonly combined with other hip
A reversal of the customary action of the hip movements such as on the support leg during the
external rotators can also be used to rotate the pelvis swing phase of walking or in a side kick in karate.
away from a stationary femur. For example, during Examples of movements from dance include the use
standing with both legs fixed, rotation of the pelvis to of an internally rotated position with side lunges or
the right will result in internal rotation of the right other stylized movements in jazz or contemporary
hip joint and external rotation of the left. This closed dance (figure 4.29). Additionally, a quick internal
kinematic chain rotation is commonly used in throw- rotation of the thigh (with the knee bent) immedi-
ing, in swinging a baseball bat or tennis racket, and ately preceding hip external rotation in a turned-out
in a golf swing. The mechanism is commonly used in side développé is sometimes used as a teaching tool
dance for turning, dodging, or change-of-direction for helping students to learn to isolate rotation of
movements in which the thrust of the pushing leg the femur in the hip joint without undesired rota-
turns the pelvis in the desired direction. tion of the pelvis.
A reversal of the customary action of the hip
Hip Internal Rotation internal rotators can be used to rotate the pelvis
toward a stationary femur. This closed kinematic
Hip internal rotation involves medial rotation of chain internal rotation is used in walking and run-
the anterior thigh relative to the pelvis about the ning, in which the pelvis rotates toward the support
mechanical axis of the femur in a transverse plane. leg as the other leg swings forward, functioning to
The anterior fibers of the gluteus medius and gluteus increase stride length. In throwing, striking, and
minimus are potentially assisted by other hip inter- some dance movements, the initial plant of the for-
nal rotators (listed in table 4.4) when contracting ward foot places the forward thigh in lateral rotation.
concentrically to rotate the legs inward in the prone However, as the athlete comes forward over the foot,
Key Considerations for the Hip

Many forms of dance utilize movements that demand
very large range of motion of the hip. Comprehen-
sion of principles relating to multijoint muscles is
important for understanding what limits such move-
ments and what conditioning exercises could be used
to enhance performance of such dance movements.
Furthermore, when weight bearing, the hip must
withstand very large loads, making this joint vulner-
able to degenerative changes.
Actions of Multijoint Muscles
Many of the muscles of the hip are multijoint

muscles, including the psoas major, rectus femoris,
gracilis, sartorius, tensor fasciae latae, biceps femoris,
semitendinosus, and semimembranosus. To under-
stand the resultant action that occurs when multijoint
muscles contract, it is helpful to keep the following
concepts in mind that were previously discussed in
chapter 2.
First, remember that a multijoint muscle has the
tendency to cause movement at all of the joints it
crosses, unless a joint is stabilized by other muscles
or outside forces. Since these muscles of the hip
are attached to the pelvis, contraction will result in
accompanying pelvic motions unless the pelvis is
FIGURE 4.29 Sample dance movement showing hip
internal rotation.
purposely stabilized.
Sacramento Ballet dancer Merett Miller. Second, remember that motion at one joint alters
muscle length, which in turn affects the muscle’s
the pelvis is rotated toward the support leg, resulting ability to produce force or to be stretched across
in hip internal rotation on the front leg. the other joint(s) it crosses. For example, the rectus
femoris is more effective as a hip flexor if the knee
Hip Horizontal Abduction and Adduction is bent versus straight, because having it stretched
across the knee allows the muscle to work at a favor-
In dance, some movements such as rond de jambe able length to avoid active insufficiency. In regard to
en l’air occur with the hip flexed to 90°. As discussed range of motion, greater hip flexion is also allowed
in chapter 1, such movements are termed horizontal if the knee is flexed versus straight, as knee flexion
abduction and adduction. When these movements slackens the hamstring muscle across the knee joint,
are performed, the hip flexors, hip abductors, or allowing more range in flexion to occur at the hip
hip extensors are used to maintain the height of joint before passive insufficiency occurs.
the femur (depending on whether the leg is front, Third, a multijoint muscle usually does not exert
side, or back), while various muscles located medially equal effect at all of its joints, but rather has better
and anteriorly (adductor longus, adductor brevis, leverage at one joint than the other(s) and so has its
adductor magnus, and pectineus) act to pull the primary action at that joint. For example, the rectus
leg toward the midline for horizontal adduction, femoris is more efficient as a knee extensor than as
and various muscles located posteriorly and laterally a hip flexor, and the sartorius is more effective as a
(gluteus medius, gluteus minimus, gluteus maximus, hip flexor than as a knee flexor. This difference in
and DOR) act to pull the leg away from the midline effectiveness is important for achieving the desired
for horizontal abduction (Hall, 1999; Kreighbaum movement outcome when many muscles simultane-
and Barthels, 1996). ously contract.
Compressive Loads on the Hip Joint lessen low back and knee stress, the dancer should
apply the lumbar-pelvic rhythm, first utilizing the
The hip joint is required to bear body weight during abdominal–hamstring force couple to maintain a
upright standing and the support phases of move- neutral pelvis while motion is isolated to spinal flex-
ments such as walking and running. During standing ion. During this motion the dancer should focus on
with the weight evenly distributed between the two sequentially flexing the spine from the top down and
feet, each hip joint must support one-half of the keeping the head as close to the torso and pelvis as
weight of the body segments above the hip, or about possible. When spinal flexion is complete, focusing
one-third of total body weight (Hall, 1999). However, on rotating the pelvis about the femur, with the head
during standing on one leg, that hip must now sup- of the femur staying in place as much as possible and
port the total weight of the head, arms, and trunk, as the ischial tuberosities rapidly going up toward the
well as the weight of the opposite leg, or about 85% ceiling, will help achieve the aesthetic and desired
of total body weight (Smith, Weiss, and Lehmkuhl, positioning of the pelvis closer to being over the
1996). In addition, the load actually borne by each ankle joint (figure 4.30B).
hip is significantly greater than just body weight
during movement due to the additional compression Flat Back Positions
produced by contraction of the strong muscles of the
hip and impact forces translated upward from the Jazz and some modern classes also frequently use
foot. So, during walking and jogging, compressive flat back positions (figure 4.31A). In contrast to
loads on the hip can range from three to five and a roll-downs, these positions actually primarily involve
half times body weight (Hall, 1999) and with activities hip flexion (not spinal flexion) while contraction
such as stair climbing may reach seven times body of the spinal extensors is used to prevent undesired
weight (Levangie and Norkin, 2001). Hip loading flexion of the spine. Strong contraction of the ham-
can also be markedly increased by the wearing of string muscles is required (eccentrically) to control
hard-soled shoes, hard heel strikes during locomo- the flexion of the hip, and when muscles are not
tion, and carrying a load (as in partnering). The adequately warmed or when forceful bouncing is
high loads borne by the hip make it vulnerable to added to these positions, hamstring strains can occur.
degenerative changes that can lead to having total Furthermore, in this flat back position, the moment
hip replacements in dancers at younger ages than arm is very large for the spine, and so large forces
one would expect or hope. are imposed on the spine. To reduce injury risk,
it is recommended that when these positions are
used, the hamstrings and spinal extensors be first
Special Considerations adequately warmed up, the use of large bounces
for the Hip in Dance and momentum be avoided, and students be cued
to use firm abdominal co-contraction to help reduce
Varied movements, often encompassing a large spinal stress and avoid lumbar hyperextension. For
range of motion at the hip joint, requiring complex dancers having difficulty effectively activating this
coordination between movements of the pelvis and latter abdominal co-contraction, it may be helpful
femur, and utilizing multiple planes, are essential for to practice from a kneeling position with the chest
meeting the aesthetics of dance. Examples of such supported on a ball (to reduce the moment of the
movements include the roll-down, flat back positions, resistance). First, carefully allow the abdominals to
and many movements employing turnout such as relax and the low back to arch (figure 4.31B). Then
extensions and the arabesque. contract the abdominals to achieve the desired flat
back position (figure 4.31C). As skill develops, this
Roll-Down position can then be tried standing without the
ball, requiring well-coordinated co-contraction of
When first learning a roll-down, some dancers make the abdominals, back extensors, and hip extensors.
the error of emphasizing flexion of the hip too early, If needed, the fingertips can be placed on a wall or
before adequate flexion of the spine has occurred. barre to reduce the resistance from the weight of
This increases the torque from the weight of the torso the torso.
and often is accompanied by shifting the pelvis back Some dance sequences combine flat back posi-
in an attempt to counterbalance this torque and pre- tions with roll-downs. These combinations can be
vent the dancer from falling forward (figure 4.30A). helpful for developing spinal articulation; coordi-
However, to achieve the desired dance aesthetic and nated movements between the spine, pelvis, and
A A
FIGURE 4.30 Lumbar-pelvic rhythm and the roll-

down. (A) Roll-down with body weight back, (B) roll-
down with more desirable placement.
FIGURE 4.31 Flat back position. (A) Standing with co-contraction of abdomi-
nals and back extensors, (B) kneeling with inadequate abdominal contrac-
tion, (C) kneeling with adequate abdominal contraction.
195
femur; and the awareness of neutral, flexed, and and the observation that measurement of passive
hyperextended positions of the spine. However, the hip external rotation appeared to increase markedly
principles previously discussed should be applied to following participation in class (Garrick and Requa,
enhance technique and reduce spinal stress. 1994) suggest that the greater external hip rotation
seen in the average dancer may be due more to soft
Turnout tissue constraints than bony changes.
Various screening tests can be utilized to estimate
The use of external rotation of the hip is an impor- the passive hip external rotation present in a dancer,
tant element of classical ballet and many other dance and the results will vary markedly in accordance with
forms, and many dancers are concerned about how the measurement techniques used. However, studies
much turnout their bodies possess. The extent of hip agree that ballet dancers exhibit significantly greater
external rotation, or turnout, possible for a dancer passive and active hip external rotation than non-
is primarily determined by bony, ligamental, and dancers; and some studies also showed lower levels
muscular factors. Bony factors include the depth of hip internal rotation, with even lower levels of
and shape of the hip socket (acetabulum). A more internal rotation in male versus female ballet danc-
shallow acetabulum that faces more laterally is gen- ers (DiTullio et al., 1989; Garrick and Requa, 1994;
erally considered to favor external rotation, while a Hamilton et al., 1992; Khan et al., 1997).
deeper socket that faces more anteriorly can lessen Some orthopedic surgeons hold that a minimum
the extent of external rotation permitted. The angle of 60° of hip external rotation should be present by
of the shaft of the femur relative to the neck of the 15 years of age in a dancer who wishes to pursue a
femur also affects the extent of turnout possible. As career in classical ballet (Brown and Micheli, 1998;
described earlier in this chapter, individuals with Thomasen, 1982). Measurements performed by the
less anteversion or more retroversion tend to have author showed the average hip external rotation of
greater external rotation. Curvature and length of elite advanced/professional ballet dancers to be 59.9°.
the femoral neck may also affect mobility. A neck The technique for measurement, used on dancers who
that is more concave and longer will tend to facilitate had just warmed up, involved a prone position with
abduction and lateral rotation, while a shorter, less moderate force applied while an assistant stabilized
concave neck will lessen the potential end ranges of the hip such that the endpoint was reached at which
these motions, due to contact with the edge of the any additional rotation was of the pelvis and not the
acetabulum. femur. Use of protocols with less manual assistance,
The joint capsule and its associated ligaments or with the knees touching (hip adduction) versus
can also affect potential hip external rotation. The hip-width apart (neutral), would reveal lower values.
capsule and certain ligaments, particularly the ilio- Another study of elite professional ballet dancers
femoral ligament, become taut with hip external showed average hip external rotation of 52° for both
rotation. Hence, if they are more extensible they will men and women (Hamilton et al., 1992).
allow greater turnout. Similarly, adequate extensibil- While using an exact measure as a screening factor
ity of key muscles, including the hip internal rotators is probably unwise due to diverse results, the com-
and adductors, will allow the range permitted by plex relationship between passive and active use of
the bony and ligamental constraints to be realized. turnout, and the controversy regarding the extent to
The relative contribution of, and the magnitude of which turnout can change with training, the concept
change possible in, each of these constraints is an is still germane that a ballet dancer with very limited
area of controversy. It has been theorized that early hip external rotation will likely have difficulty achiev-
training may be able to actually affect bony con- ing the required aesthetic without undue stress and
straints, allowing for a molding of femoral torsion injury (Garrick and Requa, 1994; Hamilton et al.,
up to about age 11 or 12 (Brown and Micheli, 1998; 1992) and will be more prone to dropout from pro-
Sammarco, 1983), but that after this age, improve- fessional training (Hamilton et al., 1997). In many
ments in passive turnout would be due to stretch- other dance forms including modern, jazz, and tap,
ing of soft tissue constraints (capsule, ligaments, the aesthetic does not dictate as extreme a lateral
and muscles). Although an earlier study suggested facing of the feet, and there is likely more tolerance
changes in femoral torsion in favor of retroversion for lower values of hip external rotation. One study
with elite ballet dancers who began training prior to showed that when asked to adopt a comfortable
10 years of age (Miller et al., 1975), the failure in a turned-out first position, modern dancers’ mean
recent study to find greater retroversion in elite ballet position was 29° less turned out than the mean for
dancers (Bauman, Singson, and Hamilton, 1994) ballet dancers (Trepman et al., 1994).
Screening Test for Hip Turnout
A test is shown for measuring passive hip

external rotation. While the dancer is in a
prone position with one knee in 90° flexion,
the examiner places one hand on the lower
leg of the bent knee and externally rotates the
hip while the pelvis remains in a neutral posi-
tion with both ASIS in contact with the table
as seen in the picture. For a more accurate
measurement, care must be taken to empha-
size movement from the hip and avoid motion
at the knee or pelvis. For example, allowing
the pelvis to anteriorly tilt will slacken the hip
joint capsule and iliofemoral ligament and give
a falsely high measure of external rotation.
Using an assistant to prevent one side of
the pelvis from lifting (pelvic rotation) and to
prevent an anterior pelvic tilt is helpful.
The axis of the goniometer is placed over
the patellar tendon, the stationary arm verti-
cal and the movable arm along the middle of
the lower leg. A reading of 0° refers to the
position in which the lower leg and foot are
facing straight up toward the ceiling, 45° to
the position in which the lower leg is halfway
toward the table; 90° would be the theoretical
position if the knee faced directly to the side
with the lower leg lying flat on the table. If a
goniometer is not available, one can estimate
the range by visually dividing the 0°-to-90° arc
in half, then further dividing each half in thirds,
and approximating the degrees of motion.
In addition to the results of these passive hip In the author’s experience, few dancers use their full
external rotation tests being useful for comparison potential hip external rotation; and specific flexibility
with dance norms, they can also be helpful for better exercises, strength exercises, and focus on technique
understanding a given dancer’s potential turnout. can allow most dancers to markedly increase their
For example, in some cases the test will confirm use of turnout. A sample stretch is shown in figure
a dancer’s or teacher’s impression that turnout is 4.32A. This modified prone frog stretch allows the
relatively low, while in other cases results suggest pelvis to remain neutral while the dancer focuses on
that there is potential turnout that is not being fully externally rotating the legs at the hip and reaching
realized in the technique class. This latter discrep- the knees to the side. The abdominals should be
ancy is seen because in actual movement, in contrast firmly contracted to maintain a neutral pelvis, and
to passive measurement of hip rotation, adequate the dancer should focus on pressing the bottom
strength and appropriate activation patterns in key of the pelvis (ischium) slightly down and forward
muscles including the DOR are also important to to achieve the desired stretch and avoid undesired
allow utilization of the dancer’s potential turnout. anterior tilting of the pelvis. When performing the
hands on the thighs can be used to

carefully apply a stretch.
A sample strength exercise for
improving turnout is shown in figure
4.33A and later described in table
4.5M (prone passé, variation 1, p.
219). However, as with stretches, spe-
cific exercise technique is essential.
Here, it is necessary to focus on using
and strengthening the lower DOR
rather than the gluteus maximus.
Due to the ability of the DOR to pro-
A duce hip external rotation in such a
variety of positions and with limited
other joint actions, these muscles
are essential for effecting turnout in
dance movement. In essence, they
are able to produce turnout while
leaving the dancer free to move in
whatever direction is dictated by the
choreo-graphy. Focusing on rotating
(1) “lower,” at the bottom of the but-
tocks, (2) deeper below the gluteus
B
maximus, and (3) more specifically
but less forcibly can often help acti-
vate the DOR more than the gluteus
maximus. In addition, thinking of
bringing the greater trochanter back
toward the ischium, and palpating
with the fingers to be sure that the
quadratus femoris is contracting
in this area, can help achieve the
desired specific muscle activation. If
the dancer has difficulty adequately
C activating the DOR or experiences
knee discomfort, hip external rota-
tion can also be performed side-lying
FIGURE 4.32 Sample stretches for improving turnout. (A) Modified prone frog with the band just above the knee
stretch, (B) classic prone frog stretch with incorrect body positioning, (C) supine
(figure 4.33B) or prone on a ball
frog stretch.
(figure 4.33C, described in table 4.5N
on p. 220).
classic prone frog stretch (figure 4.32B), many danc- This use and maintenance of turnout is important
ers make the error of anteriorly tilting the pelvis, not only for meeting the aesthetics of classical ballet
which slackens the structures that are the target of and various other dance forms but also for injury pre-
the stretch and can put undesired stress on the low vention. Failure to maintain turnout at the hip and
back and knees. The other common error of trying excessive twisting from the knee down are believed
to force the feet down to the floor in this position can to be a contributing factor to many injuries of the
also place potentially injurious stress on the knees and knee, shin, ankle, and foot.
is counter to the goal of enhancing external rotation
at the hip versus the knee. For dancers who are tighter Influence of Turnout on Muscle Activation
and who experience knee or hip discomfort even
when performing the modified prone frog stretch, the When dancers work in a position of marked hip
supine frog stretch (figure 4.32C) provides a gentler external rotation, the line of pull of many of the
alternative where gravity and gentle application of the muscles of the hip is dramatically changed. How
much and in what manner this influ-

ences muscle use is an area that needs
further investigation. For example,
looking at the line of pull on skeletal
models, one would theorize that this
position of external rotation would
place the hip adductors in a more key
role in movement execution during
standing (closed kinematic chain
movements). In a second-position
grand plié, for instance, the motion
occurs closer to a frontal plane rather
A1 than in a sagittal plane. This would
place the hip adductors in a position
to work concentrically on the rise to
help bring the legs back together (hip
adduction) and eccentrically on the
lowering phase to control the separa-
tion of the legs. The knee extensors
(quadriceps femoris) would still be
required to produce knee extension
on the up-phase and to control knee
flexion on the down-phase of the plié,
A2 but their use could be de-emphasized if
greater focus was placed on the motion
at the hip. This concept that using
turned-out positions enhances recruit-
ment of the hip adductor muscles was
given preliminary support by findings
that highly skilled ballet and modern
dancers without patellofemoral pain
showed recruitment of the hip adduc-
tors when performing second-position
grand pliés. Furthermore, standing
in first position showed sustained hip
B adductor activity in some dancers, and
use of images to enhance hip external
rotation was accompanied by increased
hip adductor activation in some danc-
ers (Clippinger-Robertson, 1984).
However, the variability of use of
adductors seen between dancers sug-
gests that use of the hip adductors is
likely a learned activation achieved by
some dancers in line with the cues and
aesthetics of some schools of dance.
This conjecture is also given support
by another study that found only 58%
of the dancers studied utilized the hip
C adductors in the rising phase of the
demi-plié (Trepman et al., 1994). Fur-
thermore, in the author’s experience,
FIGURE 4.33 Strength exercises for the turnout muscles. (A) Prone when using exercises like the wall plié
passé with tubing, (B) side-lying passé with band, (C) prone frog on ball. to help dancers direct their knees more
Selective Muscle Focus in the Wall Plié
Stand in second position turned out with the upper back (at the level
of the shoulder blades) and posterior side of the sacrum against
the wall, while the heels are a few inches away from the wall in line
with the greater trochanter.
• Emphasizing use of the DOR muscles. Place the fingertips
deep, just lateral to the ischial tuberosities at the sides of the base
of the buttocks. Perform a demi-plié, and at the bottom of the plié pur-
posely let the knees drop inside the feet (A). Then, while maintaining
the same depth of plié, use the low DOR muscles located under your
fingertips to externally rotate the femur at the hip joint and pull the
knees back over the feet (B). Repeat this motion of letting the knees
fall in and pulling them back out several times until easy conscious
control of the DOR is established. Next, perform a second-position
grand plié slowly, focusing on using the DOR to maintain hip external A
rotation and guide the knees as directly side as possible on both the
down- and up-phase of the plié. Study of an anatomical model of the
22 hip muscles showed a 1.5-centimeter or more decrease in length
of the estimated line of pull in the gluteus maximus, hamstrings,
and all 6 deep outward rotators when replicating this second-posi-
tion plié performed correctly with the “knees side” versus “dropped
forward” (Clippinger-Robertson, 1984). However, when normalizing
this change in the axial line of pull of these muscles relative to their
“length” when standing in second position, a 54% change was seen
in the quadratus femoris, 52% in the gemellus inferior, and 46% in the
gemellus superior compared to much smaller percentage changes
in other muscles, such as 12% for the gluteus maximus and 5% for
the hamstrings. This dramatic percentage change in length in these
rotator muscles provides indirect evidence for their vital role in
establishing and maintaining appropriate positioning of the greater
trochanter for optimal turnout. B
• Emphasizing use of the inner thigh muscles. Place the hands
on the insides of the thighs. On the up-phase of the plié, focus on rotating the thighs at the hip joint,
emphasizing the DOR and at the same time pulling the “inner thighs together and up” (concentric
contraction of the hip adductors). Gently squeeze your “inner thighs” together and against your hands
to feel the hip adductors contracting under your fingers, and try to gain better control of activation
of these muscles. On the down-phase of the plié, focus on externally rotating the thighs at the hip
joint and then “reaching the knees as far to the side as possible” with the pelvis going straight down
toward the floor (eccentric contraction of the hip adductors).
• Influencing muscle use by forward trunk inclination. Lean the trunk forward by flexing at the hip,
and notice any change in the muscles being used. Some dancers feel greater use of the quadriceps
in this position and have difficulty utilizing the hip adductors. Maintaining a vertical (neutral) position
of the pelvis can be helpful for utilizing the DOR and hip adductors, at least when one is first learning
to emphasize activation of these muscles.
• Applying this muscle focus to class. Step a few inches away from the wall, and repeat the plié,
trying to maintain a vertical pelvis, use of the lower DOR, and use of the hip adductors. To transfer
a new muscle activation emphasis to class, it is often helpful to key in to a kinesthetic sensation or
develop an image that will allow for quick access. For example, if a dancer tends to lean the torso
forward at the base of the plié and excessively use the quadriceps, it may be helpful to think of slid-
ing down the wall as the knees reach to the side. In contrast, if a dancer tends to lose rotation on
the up-phase of the plié, focusing on the back of the leg “wrapping to the inside and lifting up” as the
knees straighten may be helpful.
200
to the side, dancers will often describe a very intense Extensions to the Front
sensation related to the use of the hip adductors and
make a comment that now they understand what their Many dancers seek to improve the height they can
teachers wanted when cueing them to use more of lift their leg to the front in movements like exten-
their “inner thighs.” Additional research using EMG sions. This presents a challenge because many of the
is needed to clarify the specific use of muscles desired muscles that effectively contribute to hip flexion in
to achieve the aesthetic and biomechanical goals of lower ranges (e.g., adductor longus, adductor brevis,
specific dance forms and schools. However, care must upper fibers of adductor magnus, and gracilis) are
be taken to not consider “average values” obtained no longer able to aid with flexion past 50° to 70°, and
from dancers necessarily “optimal.” other muscles such as the rectus femoris lose their
A B
C D
FIGURE 4.34 Sample strength exercise for improving front développés and extensions. (A) Front développé on
elbows, (B) front développé with hands back, (C) front développé with hands back and torso more vertical, (D) front
développé with torso vertical against a wall and no hand support.
ability to produce force due to active insufficiency. lumbar flexion, and no hands for support (figure
However, the iliopsoas can still produce effective 4.34D) will provide greater challenge to the hip flexors
force in this range, but many dancers appear to not and better replicate the demands of dance.
have adequate strength or sufficient ability to activate Additionally, progressing to performing dévelop-
this muscle and mistakenly believe that they cannot pés and extensions in a standing position will better
achieve high extensions. But regular performance of replicate functional demands and enhance transfer
strengthening exercises with an emphasis on learning to the technique class. Additional leg height can be
to better activate the iliopsoas and a focus on overload- developed when standing by applying the principle
ing the muscles in a high range of hip flexion can that greater force can be generated by a muscle with
markedly improve the height of front extensions. an eccentric, then isometric, then concentric contrac-
A sample strength exercise is provided in figure tion (chapter 2). Practically, this means that the leg
4.34 and described in table 4.5C (variation 1, p. 214). can be maintained at or lowered from a greater height
The front développé performed on the elbows (figure than the height to which the leg can be lifted with a
4.34A) is often the easiest position from which to work concentric contraction. An example of an exercise
on greater recruitment of the iliopsoas. However, as applying this principle involves raising the leg to the
improvements are made in strength and activation, front as high as possible with the knee straight (con-
moving the torso to a more vertical position (figure centric contraction), using the hand to raise the leg
4.34, B and C) and eventually performing it with the about 10° to 20° higher (figure 4.35A), and then slowly
torso vertical, the back against the wall with limited letting go with the hands and holding the position for
A B
FIGURE 4.35 Functional exercise for improving front extensions. (A) Using the hands to raise the leg slightly higher
than can be achieved with a concentric contraction, and (B) slowly lowering the leg to the height that can be achieved
with a concentric contraction.
Iliopsoas Emphasis in the Front Développé
Perform the following exercises to try to develop a better awareness of and ability to activate the
iliopsoas. After performing the exercise on one side, repeat the same sequence with the other leg.
When good iliopsoas control has been achieved, greater strength benefits can be obtained by adding
resistance from a band (figure 4.34 and table 4.5A, p. 213), ankle cuff (table 4.5B, p. 213), or springs
(table 4.5C, p. 214).
• Emphasizing use of the iliopsoas with the knee bent. Sitting on the floor with the right leg
crossed over the left and the torso rounded forward, press the fingertips of the right hand in about
1 inch (2.5 centimeters) medial to the ASIS, and feel the iliopsoas contracting under the abdominal
wall as the right knee is lifted toward the chest. Repeat this motion of lifting and lowering the knee
until more awareness of the iliopsoas is established. Next, try to consciously contract the iliopsoas
isometrically and then concentrically to lift the leg.
• Emphasizing use of the iliopsoas with a développé. Return to the starting position, and after
the right knee has been lifted, extend the knee slowly without letting the knee drop down; then bring
the leg to the front, and lift it higher three times with the knee straight; finally return to the starting
position. Use of the rectus femoris can be decreased by using a position in which the knee is bent,
but the challenge is to continue contracting the iliopsoas to keep the thigh close to the chest (e.g.,
maintain the same angle of hip flexion) as the quadriceps femoris is used to straighten the knee.
This is an important skill to learn because the rectus femoris is already shortened across the hip and
will reach a position of active insufficiency as it is also shortened across the knee, tending to make
the leg drop in height unless adequate contraction of the iliopsoas is used to maintain hip flexion.
Initially using a slightly tucked position (increasing the mechanical advantage of the iliopsoas), pal-
pating the iliopsoas, and using this feedback to make sure that it is continuing to work as the knee
straightens, as well as concentrating on continuing to bring the thigh slightly closer to the chest as
the knee extends, can help with the desired iliopsoas focus.
• Emphasizing use of the iliopsoas with the knee straight. Sitting with one leg to the front, raise
the leg, keeping the knee straight. First perform this movement with an emphasis on the quadriceps
femoris by firmly “pulling the kneecap up toward the hip” and thinking of lifting the leg from the knee.
Then, when you reach a height where you feel discomfort and cannot raise the leg higher, think of
reaching the leg out, slightly tuck the pelvis, and focus on lifting the leg with the iliopsoas. Optimally,
greater height of the leg with less sense of effort will be achieved.
• Applying this muscle focus to class. Some dancers can key in to the sensation of the iliopsoas
contracting and easily use that for feedback to transfer iliopsoas emphasis to other movements in
class. However, other dancers have little sensation associated with the iliopsoas, but rather just feel
that it is easier to lift the leg and that there is less sensation of discomfort in the rectus femoris and
other hip flexors. Images such as (1) folding the thigh into the chest before extending the knee in
développé or (2) lifting the thigh with a string, pulling from just below the crease in the front of the
thigh to the front of the lower spine, can sometimes be helpful.
4 counts (isometric contraction) or taking 4 counts as straight as possible without dropping the height of
to slowly lower the leg about 10° to 20° (eccentric the knee or creating a sense of excessive muscle strain
contraction; figure 4.35B) to the level that can be at the hip (table 4.5B, p. 213), and hold this position
achieved concentrically. A variation on this approach for 4 counts (isometric contraction) or take 4 counts
is to raise the leg to the front as high as possible with to slowly lower the leg (eccentric contraction).
the knee straight (concentric contraction), bend the In addition to hip flexor strength and iliopsoas
knee to decrease the moment of the resistance, raise activation, the height to which the leg can be lifted
the leg about 10° to 20° higher, slowly extend the knee can be influenced by hamstring flexibility. When the
knee is straight, the hamstrings are stretched across

the back of both the hip and knee, and hip flexion
can proceed passively only as far as extensibility of the
hamstrings will allow. A screening test can be utilized
to evaluate hamstring flexibility (Tests and Measure-
ments 4.4). If hamstring flexibility is low, emphasis
should be placed on stretching the hamstrings (table
4.7, C and D, p. 225) as well as strengthening the hip
flexors. If hamstring flexibility is high, this suggests
that the limiting factor is more hip flexor strength and
perhaps more specific activation of the iliopsoas.
When lifting the leg to the front in a turned-out
versus parallel position, another consideration comes
into play. Many dancers have difficulty maintaining
external rotation as leg height is increased. This is
logical for two reasons. First, the DOR become less
effective in their ability to produce external rotation,
and the upper DOR (the piriformis) may actually
switch its function to become an internal rotator in
high ranges of hip flexion (Smith, Weiss, and Lehm-
kuhl, 1996). Second, the anterior fibers of the gluteus
medius, gluteus minimus, and tensor fasciae latae
increase their leverage for hip internal rotation as the
hip is flexed. So, while when the hip is in extension
the maximum torque for internal and external rota-
tion is about equal in the general population, when
the hip is flexed the maximum torque generated by
the hip internal rotators is increased about three
times. To counter this problem, it is important that
dancers develop greater strength in the hip external
rotators and specifically in the lower DOR that are
still in a position to produce hip external rotation.
Focusing on bringing the greater trochanter “down
and under” can often help achieve the desired activa-
tion of the quadratus femoris.
FIGURE 4.36 The side extension.
Photograph by Rex Tranter. Pacific Northwest Ballet School students.
Extensions to the Side
Extensions to the side are one of the measures of Hence, strengthening the hip flexors and developing
skill used for selection of dancers in the professional greater activation of the iliopsoas as just described
ballet arena (figure 4.36), and many dancers strive with extensions to the front can improve movements
to increase their height. The use of turnout in this such as extensions to the side.
position produces a unique situation in which the In addition, proper mechanics play a fundamen-
anterior surface of the thigh is moving in a frontal tal role in optimizing leg height. When the thigh is
versus sagittal plane, a hybrid between hip flexion kept parallel or in medial rotation, range of motion
and hip abduction. Although research will be nec- is limited to about 45° abduction in general popula-
essary for better understanding of the interplay of tions, probably due to impingement of the greater
muscles in this action, EMG studies and study of the trochanter on the superior rim of the acetabulum and
line of pull of the muscle suggest that the iliopsoas nearby ilium. However, if the leg is externally rotated
as well as the hip abductors are key in higher ranges such that the greater trochanter rotates inferiorly, it
of hip abduction. As hip abduction progresses, the will no longer impinge, and the range of hip abduc-
distal iliopsoas slides over to the lateral side of the tion is tremendously increased. So, greater external
center of rotation of the hip joint and is thus posi- rotation will allow a greater range of hip abduction
tioned to be capable of producing hip abduction. to be achieved (Kushner et al., 1990), and use of this
Screening Test for Hamstring Flexibility
A test is shown for measuring passive flexibility of the hamstrings.

While the dancer is in a supine position, one leg is gently brought
toward the chest with the knee straight (hip flexion) by the examiner
as the other leg remains straight down (B). For a more precise test
for hamstring length, the pelvis is maintained in a neutral position
while the leg is raised to a point of slight resistance but no pain; for a
more functional test of hip flexion, slight posterior tilting of the pelvis is
allowed only to the point where the back of the lower leg still maintains
contact with the table. This latter approach allows the pelvic-femoral
rhythm normally associated with marked hip flexion, such as used
A
in front développés or grand battements in dance class.
The axis of the goniometer is placed on the greater trochanter,
the stationary arm horizontally along the side
of the trunk and the movable arm along the
outer thigh. A reading of 0° refers to the posi-
tion when the leg is lying flat on the table,
90° when the leg is going straight up toward
the ceiling (A), and greater than 90° when
the leg comes closer to the chest as shown
in B. While 90° is considered normal range
in general populations, the average value for
functional hip flexion for elite advanced/pro-
fessional female ballet dancers was shown
to be 150° (Clippinger-Robertson, 1991). If a
goniometer is not available, one can estimate B
the range by visually dividing the upper arc
in thirds (A) and approximating the degrees
of motion.
external rotation can also allow the leg to be placed an ankle weight (figure 4.38A and table 4.5G, p. 216)
farther to the side and the hips to be more level as or band (figure 4.38B and table 4.5G, variation 2, p.
seen in figure 4.37B. Many schools of dance allow the 216) are exercises designed to help the dancer focus
normally linked lateral tilt of the pelvis to occur in on the technique of fully rotating the femur as the
the later stages of the movement to achieve greater leg is being lifted. As described with extensions to
height of the leg as shown in figure 4.36, while other the front, as strength and desired activation patterns
schools limit the amount of lateral pelvic tilt. improve, progression of strength exercises to include
Whatever the aesthetic of the end position, the a more vertical position of the torso, and eventually
initial stages of the movement should focus on standing, will help with transfer of desired improve-
keeping the hips more level rather than excessively ments in leg height and technique to class. When
laterally tilting the pelvis, as seen in figure 4.37A, progressing from side-lying (with an ankle weight)
and maximally rotating and “dropping” the greater to a sitting or standing position, lifting the leg above
trochanter so that optimal range and placement of 90° is now opposed (due to the differing relationship
the gesture leg can be achieved as seen in figure 4.37, to gravity) versus assisted by gravity, and most danc-
B and C. So, adequate strength and activation of spe- ers will not have the strength to raise the leg close
cific external rotator muscles as well as the iliopsoas to the height achieved side-lying. Initially, using the
are important for achieving the desired height and hand to help find the desired drop of the greater
aesthetics in side extensions. The side leg raise with trochanter and maintain the desired height of the
A B
FIGURE 4.37 Side développé. (A) With hip excessively lifted, (B) more desired hip placement with trochanter close to
sitz bones on dancer and (C) on skeleton.
thigh as the knee is extended (figure 4.38C) can be or without undue sense of muscle strain at the hip.
useful. To help build necessary strength to eventually Rotator disks can also be added to focus on use of the
be able to achieve this height without use of the hand, DOR to maintain turnout on the support leg while
similar procedures to those described for standing developing height of the gesture leg.
front développés can be used. For example, the hand In addition to the specific desired active contrac-
can be used to help lift the leg with the knee bent as tion of prime movers, passive constraints offered by
shown in figure 4.38C, and then the hand is slowly antagonist muscles also influence how high the leg can
released as the position is maintained for 4 counts. be brought to the side. Because the stretch across the
As strength improves, this exercise can be progressed hip is not as direct for the hamstrings when the leg is
to extending the knee after the hand is released. The to the side versus front, the hamstrings will generally
focus should be on using the DOR to maintain the not limit range as soon but still are critical in determin-
turnout at the hip and the iliopsoas to maintain the ing how high the leg can be raised. The hip adductors
height of the knee, and only extending the knee as also are critical in determining how far to the side and
far as possible without letting the knee drop in height high the leg can be brought. So, if adequate range is
A
C1 C2
FIGURE 4.38 Strength exercises for improving side extensions. (A) Wall side leg raise, (B) side leg raise with band,
(C) standing side développé assisted by the arm.
207
Dropping the Greater Trochanter

Toward the Sitz Bones in the Side Développé
Perform the following exercises on both sides to try to develop a better awareness of the desired
movement of the greater trochanter that can markedly increase the height of the gesture leg, as well
as to help bring the leg more to the side.
• Observing the excursion of the greater trochanter in a passé. With your partner lying on the
left side with the top leg in a parallel passé, place your fingertips on the right greater trochanter and
right ischial tuberosity (sitz bones), and note the movement of the greater trochanter as the leg is
brought into a turned-out passé (retiré).
• Increasing the drop of the greater trochanter. When performing this turned-out passé, many
dancers primarily use horizontal abduction to bring the leg to the side and do not utilize sufficient
external rotation of the femur. To help your partner find this rotation, support the weight of the leg
and rotate the thigh internally and externally, emphasizing the external rotation and the drop of the
greater trochanter toward the ischial tuberosity. Remember that rotation occurs about the mechanical
axis of the femur, and so the knee should just pivot in place as the thigh rotates. With this addition
of rotation, the greater trochanter should come down much closer to the ischial tuberosity (figure
4.37C) than with pure horizontal abduction. After your partner has experienced the desired position
passively, he or she should try to produce the same drop of the trochanter by actively contracting
the lower muscles of the DOR. Dance teachers sometimes aptly describe this important distinction
of rotation by instructing students to imagine turning a door knob (rotation of the femur) versus just
opening the door (horizontal abduction of the thigh).
• Utilizing the drop of the trochanter in a développé. As the knee is raised from retiré, help
your partner externally rotate the femur further so that the trochanter stays dropped and the knee
goes slightly backward (as if to bring it behind the shoulder) before the knee extends to complete
the développé. Then, have your partner lift the hip (laterally tilt the pelvis) and internally rotate the
leg, and note how the leg drops and comes forward. Now, have your partner bring the pelvis down to
almost a neutral position, externally rotate the femur, and with one hand on your partner’s hip and
the other hand just below their knee, help them rotate further by bringing the greater trochanter back
and down; note that this movement of the greater trochanter allows greater elevation of the leg and
a more open second position.
not present, stretching the hip adductors and ham- extension is limited to 10° to 15° due to constraints
strings as shown in table 4.7, C-F (pp. 225-226) can also from the anterior ligaments, joint capsule, and in
improve leg height and lessen the effort required to some cases the hip flexors. Although elite dancers
lift the leg by decreasing the internal resistance from may have two or three times this range, bringing the
the opposing muscles that must be overcome. gesture leg to a position where it is horizontal to the
ground will necessitate an anterior tilt of the pelvis and
Extensions to the Back compensatory hyperextension of the spine to bring
the upper torso back to the vertical position. Many
Proper execution of movements to the back such as schools of dance also allow some pelvic rotation to
an extension, attitude, or arabesque is also key for increase leg height, with rotation of the torso in the
progression in technical level in various forms of opposite direction to keep the torso facing forward.
dance, and it offers a complex kinesiological chal- However, the extent and timing of these movements
lenge. The amount of movement possible at the hip of the pelvis and spine have important implications
in a backward direction is much more limited than to for achieving the desired aesthetic and for the stresses
the front or side. In the average individual, hip hyper- borne by the lumbar spine (see figure 4.39).
DANCE CUES 4.3
“Lift From Under the Leg”
F or performance of extensions or grand battements to the side, teachers sometimes cue students to
“lift from under the leg” or “use the hamstrings to lift the leg, not the quads.” This cue is not con-
sistent with current anatomical knowledge, and substituting an alternative cue is recommended. The
action of the hamstrings is hip extension, not hip flexion, and so they would pull the leg down, not lift it
up, in battements. However, the underlying aim of this cue, to achieve greater height of the leg with less
“effort,” particularly with less contraction of the quadriceps, can be addressed anatomically from several
perspectives. First, the reference to the sensation of the hamstrings working may relate to its potential
action at the knee versus the hip. When the knee hyperextends, the line of pull of the hamstrings now
crosses anterior to the axis of the knee joint, and so the hamstrings can produce further hyperextension
or be used to maintain hyperextension of the knee rather than the normal action of knee flexion. So,
some dancers with hyperextended knees may use the distal attachment of the hamstrings to maintain
the knee in hyperextension in a battement. Theoretically, this could allow less use of the quadriceps
femoris to maintain a straight (actually hyperextended) position of the knee. However, these actions
would be relative to the knee joint, and the hip flexors would still be necessary to lift the thigh.
A second interpretation of the intent of this cue relates to feeling the greater trochanter dropping
“back and under” just prior to emphasizing the use of the iliopsoas to lift the leg to the side. This func-
tion can be thought of as parallel to the SIT (subscapularis, infraspinatus, teres minor) force couple
acting on the shoulder that will be discussed in chapter 7. When the hip is in an extended position,
because of its attachments, contraction of the gluteus medius will tend to pull the greater trochanter
upward (large stabilizing component as discussed in chapter 2). However, some of the inferior muscles
of the hip deep outward rotators are in a position to act to counter this upward pull and facilitate the
desired rotary motion of the shaft of the femur in abduction and prevent bony impingement of the
greater trochanter, allowing the leg to be lifted much higher. So, alternative cues aimed at achieving
the desired drop of the greater trochanter or “wrapping the side of the thigh under” just prior to the
lift of the leg would better represent the desired mechanics.
To optimize height of the leg with less stress to contribution of hip external rotation and hip hyper-
the lumbar spine, the following considerations can extension can be emphasized, with less low lumbar
be helpful. (1) Maximize external rotation of the spinal hyperextension and pelvic rotation required
femur with the lower DOR muscles rather than rotate to achieve a horizontal leg height.
the pelvis (“open the hip”) during the first part of In addition to focusing on technique, strengthening
the movement. (2) Think of “reaching the leg out,” the hip extensors and back extensors can enhance leg
stretching across the front of the hip and utilizing the height in movements of the leg to the back. Since it is
full possible range of hip hyperextension, rather than the hip extensors that lift the leg, strengthening the
immediately anteriorly tilting the pelvis as the leg lifts. hip extensors in a range similar to the range of these
(3) Focus on “lifting the leg from the knee” to encour- motions and with an emphasis on using the hamstrings
age more use of the hamstrings to try to increase hip should be a focus. However, as the leg is lifted, the
extension range and the height of the leg. (4) When pelvis and torso will rotate forward unless the back
full range of hip hyperextension is reached and the extensors are used to bring the torso back up toward
pelvis must tilt anteriorly, “pull the lower abdominal an upright position. Hence, strengthening the back
area up and in” and “lift the upper back” to lessen extensors is also key. Sample strength exercises for
the shear stress in the lower lumbar area and better improving the arabesque are provided in figure 4.40.
distribute the necessary hyperextension throughout The kneeling arabesque with a band (shown in figure
more of the spine as described in chapter 3. (5) Delay 4.40A and described in table 4.5E, variation 1, p. 215)
the pelvic rotation, and limit the extent in accordance provides an effective exercise to focus on developing
with the aesthetic of the school of dance so that the strength and awareness of using the hamstrings while
keeping the pelvis stable. The back leg

raise on the ball (figure 4.40B and table
4.5D, variation 2, p. 214) allows the dancer
to work on lifting the leg higher while
coordinating the associated slight anterior
pelvic tilt and lumbar hyperextension.
Tactile feedback from the ball can help
the dancer focus on keeping both ASIS
in contact with the ball initially while
emphasizing use of the hamstring to
maximize hip hyperextension. After full
hip hyperextension is achieved, feedback
from the ball can help the dancer focus on
co-contracting the abdominals and back
extensors as the pelvis slightly anteriorly
tilts and the ASIS on the side of the gesture
leg raises off the ball slightly to facilitate
pelvic rotation and greater height of the
gesture leg. The standing back leg raise
(figure 4.40C and table 4.5D, progression
2, p. 214) represents a more functional
exercise designed to transfer gains to
A dance performance. Similar procedures
to those described for standing front and
side développés can be used to develop
height of the gesture leg. For example,
the hand can be used to help lift the leg
slightly higher to the back with the knee
bent and then the hand slowly released as
the position is maintained for 4 counts.
Again, a rotator disk can be used to focus
on maintaining turnout on the support leg
while improving height and technique of
the gesture leg.
Other exercises for strengthening
the back extensors presented in chapter
3 would also be helpful for improving
movements like the arabesque. One
study showed that strengthening the
spinal extensors increased the height
of the arabesque by 3.6° (Welsh et al.,
1998). University dancers participating
in a class taught by the author for 14
weeks—incorporating exercises for back
extensor strength, hip extensor strength,
hip flexor flexibility, and technique
focus—increased the average height
of the gesture foot by approximately
8 inches (20 centimeters). However,
B
as previously discussed, exercises that
involve spinal hyperextension carry
FIGURE 4.39 The arabesque with (A) excessive pelvis rotation and inade- a high risk and should be performed
quate abdominal co-contraction and (B) more desired hip hyperextension and only by dancers without a history of low
coordinated use of the abdominal muscles and back extensors. back problems, in a pain-free range, with
FIGURE 4.40 Strength exercises for improving the ara-

besque. (A) Kneeling arabesque with band, (B) back leg
raise on ball with ankle weight, (C) standing back leg raise
C
with ankle weight.
initial supervision, and with meticulous technique flexor flexibility (hip hyperextension range) is high,
including co-contraction of the abdominal muscles this suggests that strength and technique should be
to lessen lumbosacral stress. a greater focus.
While technique and specific strength are key,
the height the leg can be lifted, the aesthetics of the
movement, and the stress to the back are also mark- Conditioning Exercises
edly influenced by hip flexor flexibility. A screening for the Hip
test can be utilized to evaluate hip flexor flexibility
(Tests and Measurements 4.5). If hip flexor flexibil- Adequate strength and flexibility of the muscles
ity is low, emphasis should be placed on stretching crossing the hip are important for performance of
the hip flexors (table 4.7, A-C, pp. 224-225) as well demanding movements such as jumps, battements,
as strengthening the hip and back extensors. If hip and split leaps. However, when performing hip
Screening Test for Hip Flexor Flexibility
A test is shown for measuring passive flexibility

of the hip flexors. For some dancers, the con-
straints will also be the hip ligaments and joint
capsule. With the dancer in a supine position
with one hip over the edge of the table, one
knee is bent and held at the chest to help main-
tain a neutral pelvis while the examiner uses
one hand on the other knee to help bring the leg
toward the floor and the hip into hyperextension
as shown in B. For a more precise test of the A
hip hyperextension range, the movement must
be isolated to the hip versus the lumbosacral
joint, and the pelvis should not be allowed to
anteriorly tilt.
The axis of the goniometer is placed on
the greater trochanter, the stationary arm
horizontally along the side of the trunk and the
movable arm along the outer thigh. A reading
of 0° refers to the position when the thigh is
horizontal; negative degrees would indicate that
the thigh is angled up from the horizontal; and
positive degrees would indicate that the thigh
is angled down toward the floor relative to the B
horizontal. While 15° is considered normal
range in general populations, the average value
for hip hyperextension for elite advanced/professional female ballet dancers was shown to be 27°
(Clippinger-Robertson, 1991). Again, this is an area of a lot of variability between dancers, and even
within this elite group a range from 6° to 47° was recorded. If a goniometer is not available, one can
estimate the range by visually locating the position where the femur would be one-third of the way
toward the floor (30°) and dividing that arc in thirds.
conditioning exercises, it is important to remember that are not utilized in activities of daily living. For
that due to the previously described attachments of example, walking only utilizes about 40° of hip flex-
the hip muscles, particular attention needs to be paid ion and 12° of hip abduction (Hamill and Knutzen,
to using the abdominals and other necessary muscles 1995), inadequate to develop the strength to raise
to maintain a stable pelvis and spine. To avoid redun- the leg above 90° desired in key dance vocabulary
dancy, this need for lumbopelvic stabilization has not such as front or side extensions. The dancer might
been listed under technique cues for all the exercises selectively choose to strengthen one or two areas in
in tables 4.5 and 4.7, but it is essential for exercise order to improve a specific movement. However, for
effectiveness and safety. the more advanced dancer, the ideal program should
be balanced and designed to include exercises for
Strength Exercises for the Hip each of the key muscle groups of the hip: the hip
flexors, extensors, abductors, adductors, external
Supplemental hip strengthening is particularly rotators, and probably the internal rotators.
important for the dancer because dance requires
strength to hold the limbs in high ranges of motion (Text continues on p. 221.)
TABLE 4.5 Selected Strength Exercises for the Hip

Muscle group: Hip flexors
Muscles emphasized: Iliopsoas
Joint movement: Hip flexion with knee flexion maintained
A. Knee to chest Lean back on the elbows with both 1. Perform sitting with a slight tuck
(Elastic band) knees bent and a band looped and resting back on the hands
above the knees. Bring one knee (figure 4.34B, p. 201).
toward the same shoulder, pause, 2. Perform sitting with vertical
and return to the starting position torso and pelvis more neutral
as the other knee stays in place. (figure 4.34D, p. 201).
(Maintain a slight posterior
pelvic tilt, and emphasize using
the iliopsoas versus the rectus
femoris.)
chair with the hips at the front
edge of the chair, the torso resting
back against the back of the chair,
and the pelvis in a slight posterior
tilt.
Variation 2: After bringing the knee
to the chest, extend it without
letting the knee move away from
Variation 2 your body.
Muscle groups: Hip flexors and knee extensors
Muscles emphasized: Iliopsoas and quadriceps femoris
Joint movement: Hip flexion with knee extension
B. Sitting 2-arc front leg raise Sit leaning back on your hands 1. Increase the height the leg is
(Body weight) with one knee bent with the foot raised.
on the ground while the other leg 2. Bring the torso to a more
is extended to the front. Raise the vertical position and the lumbar
extended leg as high as you can spine more neutral.
with good form, pause, bend the 3. Perform sitting with the torso
knee slightly, raise the leg slightly vertical and the back against a
higher with the knee bent, extend wall.
the knee at this higher arc, pause,
4. Add an ankle weight.
and slowly lower the leg to the
starting position. 5. Perform standing.
(Use the quadriceps femoris for
knee extension, but emphasize
using the iliopsoas for hip flexion.
Avoid letting the angle of hip
flexion change as the knee extends
at the top of the movement.)
Variation 1: Perform turned out,
but if using a weight cuff place it
close to the knee rather than at
the ankle.
(continued)
213
TABLE 4.5 Selected Strength Exercises for the Hip (continued)

Joint movement: Hip flexion with knee extension
C. Front développé Lean back on the elbows with one 1. Increase springs.
(Reformer) knee bent with the foot on the 2. Sit with weight back on hands.
carriage and the other knee bent 3. Bring the torso to a more
with the strap above the knee. vertical position with the pelvis
Bring the knee with the strap more neutral.
closer to the chest, extend the
knee, bend the knee while bringing
it closer to the shoulder, and then
lower it to the starting position.
(Focus on using the iliopsoas, and
avoid letting the knee lower as it is
extended.)
Variation 1: Perform in the same
body position only with a band
looped just above the knees.
Muscle group: Hip extensors

Muscles emphasized: Hamstrings
Joint movement: Hip extension with knee flexion maintained
D. Back leg raise Lean forward with your arms 1. Maintain the end position with
(Ankle weight) resting on a barre or the back of a the leg, and carefully raise
chair and a weight on each ankle. the torso up toward a vertical
Bring one leg back, slightly bend position, co-contracting the
the knee, and then raise the leg abdominals and back extensors.
higher up until it is approximately 2. Perform standing with the torso
parallel to the floor. more vertical and without arm
(Keep the knee slightly bent as the support (figure 4.40C, p. 211).
leg lifts, and focus on using the 3. Extend the knee at the top of
hamstrings. Use the abdominals to the movement.
keep the low back from excessively
arching.)
Variation 1: Perform turned out.
Variation 2: Perform prone with
the hips resting on a ball, box, or
bench (figure 4.40B, p. 211).
214
Joint movement: Hip extension with knee extension
E. Kneeling arabesque Kneel on the Reformer, facing 1. Increase springs.
(Reformer) the footbar, with one foot against 2. Increase the height the leg is
the shoulder rest and the other raised.
leg back with the strap on the
foot and the knee slightly bent.
Slowly raise the leg with the strap,
gradually extend the knee, pause,
and then lower the leg to the
starting position. Keep the hands
in contact with the front of the
carriage, and allow the torso to tilt
forward as the leg raises.
(Focus on using the hamstrings
to “lift the knee,” and use the
abdominals to avoid arching the
low back.)
body position with a band looped
around one foot or ankle and the
other foot (figure 4.40A, p. 211).

Muscles emphasized: Hamstrings/abdominal–hamstring force couple
Joint movement: Hip extension with knee flexion
F. Bridging Lie on your back with both heels 1. Add a 4-count hold in the bent-
(Body weight on ball) on the top of a ball with your knees knee position.
extended. Posteriorly tilt the pelvis, 2. Lift one leg off during the hold.
and raise the pelvis to attempt to 3. Carefully perform with one heel
form a straight line along the side on the ball and the other leg
of the knee, pelvis, and shoulder. extended in the air, starting
Then bend the knees to about and ending with the knee
90° (bringing the ball toward the slightly flexed versus straight.
buttocks), pause, straighten the Begin with a very small range
knees (bringing the ball away), of motion and only if no knee
and slowly lower the trunk to the discomfort is experienced.
starting position.
(Emphasize pressing down with the
heels and lifting from the bottom of
the pelvis. Keep the pelvis in line
as the knees bend and straighten,
and avoid letting the low back arch
or the knees hyperextend.)
Progression 2
(continued)
215

Muscle groups: Hip abductors and hip external rotators
Muscles emphasized: Gluteus medius, iliopsoas, and DOR
Joint movement: Hip abduction with external rotation
G. Side leg raise Lie on your side with your back 1. Raise top leg higher while still
(Ankle weight) against a wall and both hips maintaining good form.
externally rotated, with the knees 2. Increase the turnout achieved
extended and an ankle weight and maintained.
on the top leg. Raise the top 3. Increase ankle weight.
leg, pause, and then lower to the
starting position.
(Focus on keeping the hips level in
the early range of the motion and
bringing the greater trochanter of
the femur back and down toward
the ischial tuberosity as the leg
is raised. In higher ranges, only
allow as much lateral tilt of the
pelvis as necessary and lift your
waist off the floor to help limit
the tilt. Maintain as much turnout
as possible as the leg lowers,
and keep the sacrum, midback,
and little toe of the gesture leg in
contact with the wall throughout
the exercise.)
Variation 1: Perform with both
legs parallel to emphasize the hip
abductors alone.
(Focus on keeping the pelvis level
initially by reaching the upper
iliac crest away toward your feet
while thinking of lifting the waist
off the floor by bringing the lower
iliac crest toward the lower ribs.
Emphasize movement of the femur
to achieve full hip abduction. Stop
at a range before marked lateral
tilt of the pelvis is necessary—
generally 45° to 60° abduction
when parallel.)
Variation 2: Perform with a band
looped above the knees in parallel
or turned out (figure 4.38B, p.
207).
216
Muscle group: Hip abductors
Muscles emphasized: Gluteus medius/stabilization
Joint movement: Hip abduction
H. Standing side leg raise Stand in parallel with an ankle cuff 1. Increase ankle weight.
(Ankle weight) on one leg. Raise the leg with the 2. Increase height to which the leg
weight, pause, and then return to is raised.
the starting position.
(Focus initially on keeping the
pelvis level and then minimizing
the lateral pelvic tilt as the leg
raises higher. Keep the weight
of the body over the support leg
without “sitting in the hip.”)
Muscle groups: Hip abductors, hip flexors, and hip external rotators
Muscles emphasized: Iliopsoas and DOR
Joint movements: Hip abduction and external rotation with knee extension
I. Side développé Lie on your side with your head 1. Increase springs.
(Reformer) toward the footbar, one leg 2. Shorten straps.
between the shoulder rests, and 3. Increase height to which the
the other leg with the knee bent knee is raised.
and the strap above the knee.
Bring the top knee up toward the
top shoulder, slowly extend the
knee, pause, bend the knee, and
(Focus on using maximum turnout
and bringing the trochanter back
and down, with the knee going as
directly to the side as possible
while the pelvis initially stays
almost level versus laterally tilted;
emphasize using the iliopsoas to
pull the thigh toward the shoulder,
and avoid letting the knee lower as
it straightens.)
(continued)
217

Muscle group: Hip adductors
Muscles emphasized: Hip adductors/stabilization
Joint movement: Hip adduction
J. Single leg pull Lie on one side with both legs 1. Increase weight.
(Ankle weight) extended, the top leg up on the 2. Use a taller chair or support for
seat of a chair and an ankle weight the top leg.
on the lower leg. Raise the lower
leg up toward the top leg, pause,
and return to the starting position.
(Keep directly on the side of the
hip, and avoid rocking forward or
backward.)
Variation 1: Perform standing in
first position with surgical tubing or
a wall pulley providing resistance
from the side, in opposition to hip
adduction.
Variation 2: Perform lying on the
side or standing with the legs
turned out.
Muscle groups: Hip adductors and hip external rotators
Muscles emphasized: Adductor magnus and DOR/ROM
Joint movement: Hip adduction with external rotation
K. Side leg pull Lie on your side with your head 1. Increase springs.
(Reformer) toward the straps, one arm 2. Shorten straps.
between the shoulder rests, the 3. Increase height to which the leg
lower knee bent, and the other leg is raised.
overhead with the knee extended
and the back strap on the foot. Pull
the top leg down in line with the
middle of the footbar, pause, and
then return to the starting position.
(Focus on turning out and pulling
down with the back of the inner
thigh; avoid letting the leg move
forward; emphasize dropping the
greater trochanter down as the
leg raises back to its overhead
position.)
218
Muscles emphasized: Hip adductors and lower DOR/ROM
Joint movement: Hip horizontal adduction with external rotation
L. Wall “V” Lie supine with your buttocks 1. Increase ankle weights.
(Ankle weights) against a wall, with the legs turned 2. Bring legs further to the side.
out and extended up toward the
ceiling and weight cuffs on the
ankles. Simultaneously bring both
legs away from each other and
toward the floor, pause, and then
bring the legs back together to the
starting position.
(Lower the legs in a very slow and
controlled manner, and attempt to
keep the little toes in contact with
the wall throughout the exercise.
Avoid hyperextending the knees.)
Variation 1: Perform with both legs
parallel.
Muscle group: Hip external rotators
Muscles emphasized: DOR
Joint movement: Hip external rotation with knee flexion maintained
M. Prone passé Lie prone crosswise to the long box 1. Increase range of external
(Reformer) on the Reformer with the hands rotation while still maintaining a
on the floor and the knee just past neutral pelvis.
the edge of the box. Bend the 2. Increase springs.
knee that is closest to the straps 3. Shorten straps.
to about 90°, and place the strap
around the foot. Start with the hip
slightly internally rotated, and then
slowly rotate from the hip to bring
the knee outward and the foot
toward the back of the extended
knee. Pause, and return to the
starting position.
(Emphasize rotating from the hip
with the leg moving as a unit, and
avoid letting the lower leg twist at
the knee. Maintain the knee at 90°
flexion, as well as a neutral pelvis
with both ASIS in contact with the
box.)
Variation 1: Perform prone on the
floor with a figure 8 loop of elastic
tubing around the ankle and foot
of the bent knee, with the other
end of the tubing secured directly
to the side that would oppose the
movement (figure 4.33A, p. 199).
(continued)
219

Joint movement: Hip external rotation with horizontal abduction
N. Prone frog Lie prone with the hips on a ball, 1. Raise the knees slightly higher.
(Body weight on ball) the forearms on the floor, and 2. After the knees are lifted,
the feet together with the knees extend both knees, keeping the
bent and out to the sides. Press heels together. Focus on lifting
the feet together, externally rotate the heels as the knees extend
both hips, lift the knees toward the and bend.
ceiling, pause, and then return to
(Focus on using the lower DOR to
rotate the hips and then reach the
knees out, around, and up; avoid
lifting the feet first or twisting the
knees.)
Variation 1: Perform on a Pilates
ladder barrel.
Muscle groups: Hip external rotators and hip abductors
Joint movement: Hip external rotation with abduction
O. Hip rotation on elbows Lean back on your elbows with 1. Bring legs further to the side.
(Elastic band) both knees extended and a 2. Make the band loop smaller.
band looped above the knees. 3. Use a heavier band.
Simultaneously bring both legs
to the side, externally rotate both
legs, bring both legs further to the
side, pause, and then return to the
starting position.
(Focus on using the lower DOR
at the base of the buttocks to
externally rotate femurs and
increase the turnout as the legs go
further to the side.)
Muscle group: Hip internal rotators
Muscles emphasized: Gluteus medius and gluteus minimus
Joint movement: Hip internal rotation with knee flexion maintained
P. Prone hip internal rotation The same as exercise M, only 1. Increase range of internal
(Reformer) with one strap on the foot farthest rotation while still maintaining a
from the strap and moving in the neutral pelvis.
opposite direction; that is, starting 2. Increase springs.
with the hip slightly externally 3. Shorten straps.
rotated and internally rotating
from the hip such that the knee
faces inward and the foot of the
bent knee moves away from the
extended knee. Pause, and return
Variation 1: Perform prone on the
floor with a figure 8 loop of elastic
tubing around the ankle and foot
of the bent knee, with the other
end of the tubing secured directly
to the side that would oppose the
movement.
220
Sample strength exercises for the hip are pro- movements such as jumping and closed-chain move-
vided in table 4.5, and a brief description of their ments such as pliés, or standing on one leg at the
importance follows. Because many of the muscles barre or center floor. Bridging (table 4.5F) is designed
of the hip also cross the knee, additional exercises to help with this latter postural goal by encouraging
that also strengthen the hip are described with the use of the abdominal–hamstring force couple. The
knee in chapter 5. abdominal muscles are used to stabilize the pelvis,
while the hamstrings are used to pull the ischial tuber-
Hip Flexor Strengthening osities downward and lift the pelvis via hip extension.
Other useful strengthening exercises that more closely
Adequate strength in the hip flexors, and particularly mimic the demands of jumping include squats and
in the iliopsoas, is important for high movements to lunges described in the chapter on the knee (chapter
the front and side such as développés and extensions. 5), as well as jumping drills described in the chapter
One study showed an improvement of extensions to on the ankle and foot (chapter 6).
the side (à la seconde) averaging about 6 inches (15
centimeters) following six weeks of hip flexor strength- Hip Abductor Strengthening
ening emphasizing use of the iliopsoas (Grossman
and Wilmerding, 2000). Similarly, the author found Strengthening the hip abductors is key for achieving
average increases of 6 inches for front extensions and adequate height in movements to the side such as
5 inches (13 centimeters) for side extensions follow- a développé or extension. Elite ballet dancers have
ing a 14-week class incorporating hip strengthening, been shown to have significantly greater hip abductor
stretching, and technique exercises. strength than normal (Hamilton et al., 1992), provid-
The knee to chest (table 4.5A) and front dével- ing support for the importance of this muscle group
oppé (table 4.5C) are hip flexor strengthening for ballet. The side leg raise (table 4.5G) and side
exercises designed to focus on use of the iliopsoas développé (table 4.5I) are designed to help improve
through the use of a range of hip flexion greater the height the leg can be lifted. Strengthening the
than 90°, initial use of a posterior pelvic tilt, and hip abductors is also important for side-to-side motion
the initial use of a flexed knee as discussed earlier and stability during standing on one leg. The standing
in this chapter. However, as strength and the abil- side leg raise (table 4.5H) is designed to emphasize
ity to recruit the iliopsoas are developed, exercises this latter stability on the support leg.
should progress to extending the knee after the hip is
flexed, performing hip flexion with the knee initially Hip Adductor Strengthening
extended (sitting 2 arc front leg raise, table 4.5B),
using a neutral pelvis, and bringing the torso to ver- Strength exercises for the hip adductors are impor-
tical or standing to better replicate the functional tant for muscle balance relative to the often stronger
demands required in dance class and performance. hip abductors, and a study of professional ice hockey
It may also help to review the procedure given for players found a 17-fold greater risk for hip adductor
palpating the iliopsoas and then focus on trying strains if hip adductor strength were less than 80%
to feel the iliopsoas contract under your fingertips of abductor strength (Tyler et al., 2001). Strength
during each of these exercises. exercises for the hip adductors are also important
for optimal placement of the pelvis when standing on
Hip Extensor Strengthening one leg and to help achieve the use of these “inner
thigh muscles” in turned-out positions encouraged
Developing sufficient strength in the hip extensors by many schools of dance. The single leg pull (table
is important to allow the leg to be lifted high to the 4.5J) is designed to encourage use of the adductors
back as in a back attitude or arabesque. To achieve in the final phase of closing into and standing in
maximum range and the desired dance aesthetic, first or fifth position. The side leg pull (figure 4.5K)
particular emphasis should be placed on using the utilizes a large range of motion so that both dynamic
hamstrings. The back leg raise (table 4.5D) and flexibility and strength are encouraged and pelvic
kneeling arabesque (table 4.5E) were designed with stabilization is challenged. The wall “V” (figure
this goal in mind. Use the hamstrings to bend the 4.5L) is an alternative for dancers who do not have
knee slightly, and then focus on using these same access to the equipment required by the side leg pull.
muscles to lift the leg “from the knee” up toward the The wall “V” actually involves horizontal adduction
ceiling and higher than the pelvis. versus pure hip adduction. However, it was included
Adequate strength and appropriate recruitment because it offers the advantage of working in a large
of the hip extensors are also important for propulsive range of motion.
Hip External Rotator Strengthening Stretches for the Hip

Developing specific strength and activation of the hip Extreme range of motion at the hip is essential to
external rotators can help dancers realize and main- achieve the desired dance aesthetic. Table 4.6 pro-
tain their full potential turnout. The prone passé vides the normal range of motion for non-dancers
(table 4.5M) is designed to emphasize strengthening in each of the primary movements of the hip, and
the DOR with larger range of motion of the femur. selected average values for elite dancers are also
Care must be taken that the knee is stabilized with provided to demonstrate the need for ranges tremen-
appropriate muscles and that the rotation is occur- dously higher than seen in non-dance populations.
ring from the hip and not at the knee. The prone Since the passive limits to many hip movements (as
frog (table 4.5N) incorporates a smaller motion of shown in table 4.6) are muscular in nature, consis-
the femur and is helpful for encouraging mainte- tent stretching can yield dramatic improvements in
nance of turnout, such as when holding one leg in range of motion. Stretching of the hamstrings, hip
passé during a pirouette. This exercise can also be flexors, and hip adductors is particularly important
helpful for dancers who feel that they are excessively for achieving dance aesthetics. Sample flexibility
using the front of the thigh (sartorius) for rotation, exercises for these and other hip muscle groups are
since the slight horizontal abduction against gravity provided in table 4.7, and a brief description of the
utilized in this exercise will encourage activation of importance of these exercises follows. Dancers who
the desired deep outward rotator muscles. utilize turned-out positions in their dance forms
Strengthening and specific use of the hip external should perform these stretches with the targeted leg
rotators can also be encouraged through addition turned out as well as parallel.
of external rotation to the other hip movements
of flexion, extension, abduction, and adduction. Hip Flexor Stretches
For example, hip rotation on elbows (table 4.5O)
combines hip abduction with hip external rotation. Adequate hip flexor flexibility is critical for allowing
Many of the other exercises as just described and proper technique when working the leg behind the
included in table 4.5 can also have hip external body (i.e., hip hyperextension), and inadequate
rotation added to them. This approach will allow flexibility will tend to limit the height the leg can
strengthening of the rotators in a specific manner be raised and necessitate the undesired technique
that will tend to enhance particular movements errors of excessive and premature lumbar hyperex-
mimicked by the exercises. Furthermore, many of tension, anterior pelvic tilting, or “opening the hip”
these exercises can incorporate hip external rota- (i.e., pelvic rotation) in an effort to achieve desired
tion with the knee extended, a valuable alternative height of the back leg. For example, a dancer with
for any dancer who experiences knee discomfort tight hip flexors that allow only 5° of hip hyperexten-
in exercises in which the knee is bent, such as the sion will not even be able to perform a tendu to the
prone passé. back or walk (requires 10° of hip hyperextension)
without tilting the pelvis forward or arching the low
Hip Internal Rotator Strengthening back. In contrast, a dancer with 30° of hip hyperex-
tension would be able to raise the leg a third of the
Inclusion of strengthening exercises for the hip way to horizontal without an anterior pelvic tilt or
internal rotators is an area of controversy. One compensatory hyperextension of the spine.
approach is to selectively work the external rotators, Given this association with hip hyperextension, it
to purposely create an imbalance that will favor is not surprising that in a study of non-dancers, low
the maintenance of turnout and help prevent the mobility in hip extension showed the highest corre-
common technique error of letting the knee fall lation with low back pain (Mellin, 1988). Hence, it
medial to the foot. Another approach is to include is important that hip flexor range be evaluated (see
at least some internal rotation out of concern that Tests and Measurements 4.5, p. 212) and that daily
selectively strengthening the external rotators with- stretching be made a priority in dancers who are
out the internal rotators may predispose dancers limited by this constraint. However, angles beyond
to certain types of injuries. Further research will about 20° of hyperextension are often limited by
be necessary to clarify this controversy. Prone hip extensibility of the joint capsule and ligaments as well
internal rotation (table 4.5P) is an exercise for the as the hip flexors. Hence, stretches should be done
internal rotators that can be easily performed after carefully, with the body adequately warmed up and
prone passé by just switching the strap or tubing to with a slow application of a low to moderate stretch
the other foot. in a pain-free range.
TABLE 4.6 Normal Range of Motion and Constraints for Fundamental Movements of the Hip
(Non-Dance Populations)
Hip joint movement Normal range of motion* Normal passive limiting factors
Flexion 0-120° (knee flexed) Soft tissue: apposition of thigh on abdomen
0-80° (knee extended)** Muscle: hamstring group
Extension 0-15°** Joint capsule: anterior portion
Ligaments: iliofemoral and pubofemoral
Muscle: iliopsoas
Abduction 0-45° Joint capsule: inferior portion
Ligaments: pubofemoral, ischiofemoral, and lower
iliofemoral
Muscles: hip adductors
Adduction 0-30° Soft tissue: apposition of thighs
With opposite hip in abduction or flexion:
Joint capsule: superior portion
Ligaments: upper iliofemoral and ischiofemoral, iliotibial
band
Muscles: hip abductors
External rotation 0-45° Joint capsule: anterior portion
Ligaments: iliofemoral and pubofemoral
Muscles: internal rotators and others depending on joint
position
Internal rotation 0-40°** Joint capsule: posterior portion
0-45° Ligament: ischiofemoral
Muscles: external rotators
**From Gerhardt and Rippstein (1990).
The low lunge stretch (table 4.7A) is a stretch for necessary for allowing the desired upright (neutral)
the hip flexors that can easily be performed after position of the pelvis in floor work or floor stretches
class. However, if the dancer has difficulty feeling the where the knees are straight. If less than this range
stretch or keeping the pelvis from tilting forward, try is present, the dancer will display a posterior pelvic
the chair lunge stretch (table 4.7B). Performing this tilt accompanied by flexion of the lumbar spine,
stretch on a chair makes it easier to keep the pelvis and use of the hip flexors will be required to keep
more upright without a balance challenge and with the torso from falling backward in such positions.
less flexion of the front knee. As flexibility improves, Adequate and balanced hamstring flexibility may
the low lunge stretch can be advanced by extending also help prevent hamstring strains and low back
the back knee (progression 1) or going into a split pain, particularly in male adolescents (Mellin, 1988;
from the low lunge stretch (progression 2). The split Mierau, Cassidy, and Yong-Hing, 1989).
stretch is actually a compound stretch, challenging Both the supine hamstring stretch and sitting
multiple muscle groups including the hamstrings on hamstring stretch use this combination of hip flexion
the front leg and the hip flexors in the back leg. and knee extension to apply an effective stretch to
the hamstrings. The supine hamstring stretch (table
Hip Extensor Stretches (Hamstrings) 4.7C) uses a position in which the back is supported
Extreme hamstring flexibility is a necessity for to more closely replicate the position needed for
achieving the aesthetic goals of the skilled dancer standing hip flexion with a vertical torso. The sit-
and for successful execution of movements such as ting hamstring stretch (table 4.7D) incorporates
a split (front leg), split leap, penché (support leg), stretching both the low back and hamstrings and
and high kick to the front. Furthermore, hamstring is more similar to the position needed in “roll-
flexibility allowing greater than 90° of hip flexion is downs” commonly used in modern and jazz classes.
TABLE 4.7 Selected Stretches for the Hip

(Method of stretch) (Technique cues) Progression
Joint position: Hip hyperextension
A. Low lunge stretch Assume a lunge position with 1. After reaching the stretch
(Static) weight on the front foot, with the position, bring the toes under
knee bent to 90° and weight on (metatarsophalangeal extension)
the lower back leg. Then slide the to help support the body weight,
back leg back until a stretch is felt and extend the back knee.
across the front of the back hip. 2. After reaching the stretch
(Keep the front knee directly over position, place the hands on
the front ankle, and keep both ASIS the front thigh, and arch the
facing directly front while focusing torso up and back while trying
on pressing the bottom of the to keep the pelvis as vertical as
pelvis forward.) possible.
Variation 1: Perform with the back
leg turned out.
Variation 2: After reaching the lunge
stretch position, use the hands to
support the body weight, and slide
the front leg forward as far as your
flexibility will allow or until in a split
position. This combines a hip flexor
stretch on the back leg with a hip
extensor (e.g., hamstrings) stretch
on the front leg.

Joint position: Hip hyperextension with knee flexion
B. Chair lunge stretch Place one knee on a chair seat 1. Move the foot on the ground
(Static) with the other leg in front of the further forward.
side of the chair. Bend the front 2. Carefully add an upper back
knee until a stretch is felt across arch.
the front of the back hip.
(Use one hand on the back of
the chair to help keep the torso
upright, not forward, while using the
abdominals to effect a posterior
pelvic tilt as the bottom of the
pelvis is pressed forward.)
Variation 1: Perform with the back
knee turned out.
Variation 2: Perform standing,
grasping the foot of the back
leg with the hand and using it to
pull the knee back and up until a
stretch is felt across the front of
the hip.
224
Joint position: Hip flexion with knee extension
C. Supine hamstring stretch Lie on the back with one knee bent 1. Bring the top leg closer to the
(Static) with the foot on the ground and chest.
the other knee extended. Use the 2. Perform with the lower leg
hands to bring the extended leg up resting on the floor with the
toward the chest until a stretch is knee extended.
felt at the back of the thigh.
(Focus on flexing at the hip rather
than the spine and keeping the
back of the lower sacrum in
contact with the floor.)
Variation 1: PNF—While in this
stretch position, contract the
hamstrings by attempting to lower
the top leg back toward the ground
(i.e., hip extension) as the arms
resist the motion.
Variation 2: Perform static or PNF
variation with the extended leg
turned out.
Variation 3: Perform the stretch,
carrying the extended leg to the
side to include a stretch of the
hip adductors as well as the
hamstrings.
Muscles emphasized: Hamstrings and low back extensors
Joint position: Hip flexion with knee extension and lumbar flexion
D. Sitting hamstring stretch Sit with one knee bent to the side 1. Grasp foot or lower leg with the
(Static) and the other leg forward with the hands, and use them to pull the
knee extended. Lean forward from torso forward and down over the
the hip until a stretch is felt on the extended leg.
back of the extended leg. 2. Perform with both legs extended
(Pull the pelvis back on the side of to the front.
the outstretched leg, and turn the 3. Perform with both legs extended
torso so that it leans directly over to the front with one ankle
the outstretched leg; emphasize crossed over the top of the
flexing the hip joint rather than just other ankle.
the spine.)
Variation 1: Perform with the
extended leg turned out.
(continued)
225
TABLE 4.7 Selected Stretches for the Hip (continued)

Muscle groups: Hip adductors and hip extensors
Muscles emphasized: Hip adductors, hamstrings, and hip internal rotators
Joint position: Hip abduction with external rotation
E. Side développé stretch Lie on one side with the bottom leg 1. Bring the upper leg closer to the
(Static) extended and the top leg flexed at top shoulder.
the hip and knee, with both hips 2. Perform the stretch standing
externally rotated. Grasp the foot instead of side-lying.
or lower calf of the upper leg with
the hand of the upper arm, and use
it to pull the knee close to the top
shoulder and then to help extend
the knee. Hold this final position
with both knees extended.
(Focus on bringing the greater
trochanter back and down as the
leg is extended.)
Variation 1: PNF—Add PNF by using
the top arm to resist knee flexion.
Variation 2: Perform the original
stretch lying on your back instead
of your side.
Muscles exmphasized: Hip adductors and hamstrings
Joint position: Hip horizontal abduction with hip flexion
F. Second-position stretch Spread the legs away from each 1. Open the legs further to the
(Static) other to the sides with the knees sides.
slightly bent (or straight, in 2. Perform with both knees straight
accordance with current flexibility), and feet against a wall to help
and then lean the torso forward at spread legs further to the side.
the hips until a stretch is felt along
the inner thighs.
(Bring the ischial tuberosities back,
and reach the torso forward while
the knees stay facing directly up
toward the ceiling.)
back with the legs going to the side
slightly above hip height in either a
parallel or turned-out position.
Variation 2: PNF—Add PNF to either
variation by placing the hands
against the inner thighs to resist
bringing the legs together.
back with the feet against a wall
and the back of the legs resting on
the ground as they are spread away
from each other.
226
Muscle group: Hip abductors
Muscles emphasized: Tensor fasciae latae and associated iliotibial band, gluteus medius, and gluteus minimus
Joint position: Hip adduction with slight hip flexion
G. Side-lying hip abductor stretch Lie on your side with the top hip 1. Bring the knee further down
(Static) extended, with the knee flexed toward the floor without allowing
to about 90° and the bottom hip the pelvis to laterally tilt.
flexed with the knee bent and ankle
just above the outside of the top
knee. Use the foot of the bottom
leg to press the top knee down
toward the floor until a stretch is
felt on the top hip or outer thigh.
(Focus on pulling the lateral iliac
crest of the upper leg up toward
the lateral rib cage and avoid
letting it tilt laterally downward
as the top knee is pressed
downward.)
Variation 1: Perform at the edge of
a table or bench with the top knee
straight and the top leg angled
off the table so that it can be
stretched below the tabletop.
Variation 2: Have a partner stabilize
the top hip with one hand and
gently adduct the top leg with
the other hand until a gentle to
moderate stretch is felt.
Joint position: Hip horizontal adduction
H. Knee across body stretch Lie on your back with one leg 1. Bring the knee further across
(Static) extended on the floor and the other the body.
leg flexed at the hip and knee.
Place the opposite hand on the
bent knee and use it to pull the
knee across the body and slightly
up toward the opposite shoulder
until a stretch is felt on the side of
the buttocks.
(Focus on keeping the trunk stable
and avoid letting the pelvis, back,
or shoulders rotate off the floor as
the knee is pulled across the body.)
Variation 1: Move the knee up
slightly and then down slightly
before bringing it across the body
to focus on stretching different
components of the hip deep
outward rotators and to find an
angle with which the pinching
sensation in the hip that some
dancers experience can be
avoided.
(continued)
227
TABLE 4.7 Selected Stretches for the Hip (continued)

Joint position: Hip internal rotation
I. Knees-in stretch Lie on your back with your 1. Spread the feet further apart,
(Static) feet spread about 2 1/2 feet and use the hands to gently
(76 centimeters) apart and knees press on the top of the thigh to
bent to approximately 90°. Bring increase internal rotation at the
your knees together and toward hip.
the floor by rotating the upper
legs inward at the hip joint until a
stretch is felt along the lower side
of the hips and in the buttocks
area.
(Emphasize moving the whole
upper and lower leg together from
the hip, allowing the feet to spread
away from each other without
twisting the knees.)
Muscle groups: Hip internal rotators* and hip adductors

Muscles emphasized: Hip adductors
Joint position: Hip external rotation with horizontal abduction
J. Frog stretch Sit with both knees bent and facing 1. Bring the knees closer to the
(Static) to the sides, with the soles of the floor.
feet together. Use the forearms to 2. When the knees are within
gently press the knees toward the 3 inches (7.6 centimeters)
floor until a stretch is felt along the of the floor, progress to the
inner thighs. modified prone frog stretch if no
(Focus on leaning forward at the knee discomfort is experienced
hips and externally rotating the (figure 4.32A, p. 198).
hips as the knees are pressed
toward the floor.)
back (figure 4.32C, p. 198).
Variation 2: PNF—Add PNF to either
variation by using the forearms or
hands to resist bringing the knees
up and toward each other.
Variation 3: Have a partner place
their hands just above the knees and
carefully apply a stretch to variation 1.
*Constraints to external rotation can include the joint capsule, ligaments, and muscles.
To isolate the stretch more to the hamstrings, per- string flexibility should slightly bend the knees and can
form it with a flat back position; and to emphasize place a mat or towel roll under the ischial tuberosities
stretching the low back, emphasize rounding the back to facilitate desired positioning of the body.
forward. Sitting hamstring stretches require range of
the hamstrings of greater than 90° to allow the weight Hip Adductor Stretches
of the torso to produce desired hip flexion when the Adequate adductor flexibility is essential for allowing
torso is brought forward. Dancers with inadequate ham- the leg to be raised to the side to a desired height and
to allow the dancer to work with the legs more the hip external rotators may serve a role in injury
directly to the side when using turned-out positions. prevention.
Adequate flexibility as well as strength in the hip The knee across body stretch (table 4.7H) is com-
adductors may help prevent the common occurrence monly recommended to stretch the piriformis and
in dance of adductor or “groin” strains. other deep outward rotator muscles. For this stretch
The side développé stretch (table 4.7E) is a to be effective, particular care must be taken to keep
compound stretch, stretching the adductors and the pelvis flat on the ground so that the medial
hamstrings in a turned-out position, with the goal of attachments of the DOR are held stationary as the
improving turned-out movements to the side such as lateral attachments onto the greater trochanter move
développés, extensions, and battements. In contrast, away to produce a stretch as the femur is brought
when the second-position stretch (table 4.7F) is done across the body. The knees-in stretch (table 4.7I) is
with the knees slightly bent, it isolates the stretch probably less effective but offers an alternative for
more to the hip adductors and slackens the stretch dancers who experience pinching of the hip flexors
on the hamstrings. This stretch is designed to try to in the knee across body stretch.
“open up the hips” to allow the legs to be worked
more directly to the side, particularly in movements Stretches for the Hip Internal Rotators
where the femur is approximately horizontal such as and Improving Turnout
a passé, rond de jambe in the air, or Russian split. If Many dancers desire to increase hip external rota-
this stretch is performed with the knees straight, the tion; but as previously discussed, the constraints are
gracilis and hamstring muscles also will potentially more complex than just the hip internal rotators
be stretched. and the extent of improvement less marked, and
long-term consequences of stretching on joint health
Hip Abductor Stretches
are controversial. So, until additional information is
Improved flexibility in the hip abductors does not available, it is advisable that such stretches be done
have as clear an association with dance movement particularly carefully, when the body is warm and
goals as seen with the hamstrings and hip adductors. with a slow, gentle application of force in a pain-
Instead, the rationale for stretching these muscles is free range.
to reduce the risk for injuries involving lateral hip The frog stretch (table 4.7J) is designed to try to
and knee pain that have been theorized to relate to enhance turnout when the hip is flexed such as in
hip abductor tightness. a front attitude. The supine version replicates the
The side-lying hip abductor stretch (table 4.7G) position needed more in movements to the side such
is designed to stretch the hip abductors, but meticu- as a passé (figure 4.32C, p. 198). In this position it
lous form is necessary for the stretch to be effective. is sometimes difficult to apply sufficient stretch with
The dancer must pull the iliac crest of the top hip your own hands, and using a partner to very slowly
up toward the waist to stabilize the proximal attach- and carefully apply a stretch can be helpful. More
ment of the hip abductors so that a stretch will be flexible dancers can perform the modified prone
produced when the thigh is pressed down, that is, frog stretch (figure 4.32A, p. 198) if adequate stabi-
adducted. If care is not taken, the pelvis will tend to lization of the trunk can be maintained and no knee
laterally tilt (downward on the top hip), lessening discomfort is experienced.
the stretch. As described under the variations, this
exercise can also be done with the knee straight over
the edge of a table. Hip Injuries in Dancers
The hip joint is designed for stability with a relatively
Hip External Rotator Stretches deep articular socket, relatively large contact areas
As with the hip abductors, increased flexibility in between the adjacent femur and acetabulum of the
the hip external rotators is not directly linked with a pelvis, and very strong ligaments and joint capsule.
specific enhancement of dance technique. However, Hence, hip dislocation or ligamental injury is rare.
with the extensive use of the externally rotated posi- However, due to the large stresses translated through
tion in ballet, some dancers exhibit increased range the hip region and poor nutritional status of many
in external rotation and decreased range in internal dancers, stress fractures do sometimes occur. More
rotation (Hamilton et al., 1992; Khan et al., 1997). frequently, though, it is the muscles and related
Some medical professionals conjecture that such structures that become injured.
a pattern may predispose dancers to hip injuries Studies have reported that in ballet dancers
such as the piriformis syndrome and that stretching 5.8%, 8.6%, and 11% and in modern dancers 4%
of total injuries were to the hip and pelvis (Quirk, the risk for sustaining stress fractures in the pelvis
1983; Schafle, Requa, and Garrick, 1990). A survey and femur include high-intensity training, changing
of modern dancers reported 11.3% of total injuries to a harder training surface, athletic amenorrhea,
were to the hip, with an additional 4.8% to the poor nutrition, osteoporosis, external rotation of the
hamstrings (Solomon and Micheli, 1986). The lower hip beyond 65°, coxa vara, and muscle fatigue with
incidence of dancer injuries reported for the hip, in resultant loss of shock absorption (Lacroix, 2000;
contrast to some other regions of the body, is likely Lieberman and Harwin, 1997; Ruane and Rossi,
due in part to the marked structural stability pres- 1998; Teitz, 2000).
ent at this joint. However, many dancers experience Symptoms will vary according to the site of the
minor musculotendinous problems at the hip for stress fracture, but they may include pain in the
which they often do not seek medical treatment. groin, thigh, or knee that is worsened with weight
bearing. Initially, pain may increase at the beginning
Prevention of Hip Injuries of class, decrease during class, and increase again
after class (Lieberman and Harwin, 1997; Sammarco,
Due to the common involvement of the muscles in 1987). Although this pain will often subside with rest
injury, regular strengthening and stretching of the or layoffs, it will return as soon as dancing is resumed.
hip muscles, as well as sport-specific training (Emery Pain is often produced with a passé position or with
and Meeuwisse, 2001), are important for preventing hopping on the affected side (Clement et al., 1993),
injuries. Strengthening exercises should ideally be and limitation of or pain with hip internal rotation
very dance specific, for example incorporating the is common.
high angles of movement utilized in dance move- Treatment will vary according to the severity of
ments as well as muscles needed to promote optimal the stress fracture but often involves reduction of
technique. Dancers should resist the temptation to weight bearing sufficiently to be pain free. Crutches
neglect proper technique in order to gain greater may be required and dancing is often temporarily
height of the leg. Poor habits can result in inappro- discontinued. When symptoms subside, exercise
priate development of muscles and undue stresses, in the water, followed by non-weight-bearing floor
which over time could precipitate injury. Performing barre and exercises on the Pilates Reformer, is often
an adequate warm-up prior to stretching, rehearsal, a helpful adjunct to other traditional strength and
or performance can theoretically help prevent inju- flexibility programs. Stress fractures are serious inju-
ries. Increasing the body’s internal temperature will ries, and Sammarco (1987) states that a minimum of
allow a muscle to stretch further and absorb greater two months and sometimes as much as six months
forces before it is injured (Safran et al., 1988; Taylor is required before the dancer is able to return to
et al., 1990; Warren, Lehmann, and Koblanski, 1971, class. Furthermore, if appropriate treatment is not
1976). obtained, pain will tend to dramatically increase
with very serious potential consequences, including
Common Types of Hip Injuries in Dancers complete bone fractures necessitating surgical treat-
ment and prolonged disability.
A description of selected hip injuries that involve
the bone, muscle, or tendon follows. Some types of Hip Fractures in the Elderly
injuries to the hip can have grave consequences if Although not a problem with young dancers, in
ignored and not properly treated. Furthermore, older individuals with osteoporosis, the large com-
there are many other serious injuries that can pressive forces borne by the hip during locomotion
cause symptoms similar to those described in this can result in fractures of the femoral neck. This is
section, including tumors, infections, referred pain a very problematic fracture due to instability of the
from the lumbosacral spine or pelvic viscera, and fracture site, the limited ability to form new bone,
injury to the growth plate or growth centers where and close approximation of important blood vessels
tendons attach. Hence, dancers are encouraged to that can be readily injured by the fracture (Moore
obtain medical treatment if hip pain is persistent and Dalley, 1999). Fracture of the hip occurs with a
or severe. startling frequency, particularly in females over the
age of 45 years. Osteoporosis has been estimated to
Stress Fractures be responsible for 200,000 hip fractures per year;
Stress fractures can occur at various sites in the pelvis approximately 40,000 of these hip fractures result
and femur, including the pubic ramus, femoral in death due to complications, making hip fractures
neck, and femoral shaft. Factors that may increase a leading cause of death in older individuals in the
United States (Rasch, 1989). Regular physical activity eccentrically, such as with split stretches, large kicks
and aggressive measures to prevent osteoporosis can to the front, split leaps, and flat back bounces. Strains
reduce risk for this serious problem. can also occur with repetitive movements in which
the muscle becomes fatigued such as with running,
Osteoarthritis or with sudden forceful muscle contractions such as
The large forces borne by the hip can also result in with the takeoff in sprinting or leaping.
damage to the joint cartilage instead of the bone. Factors that have been theorized to increase
Osteoarthritis involves a progressive thinning and the risk for muscle strains include inadequate
wearing away of the articular cartilage of the hip strength, imbalanced strength between right and
joint and associated inflammation. Osteoarthritis left sides (Burkett, 1970), imbalanced strength with
of the hip joint is frequently associated with dull, antagonists, muscle fatigue, electrolyte imbalance,
aching pain in the groin, outer thigh, or buttocks inadequate flexibility (Jonhagen, Nemeth, and Eriks-
that is worse in the morning and gets better with light son, 1994; Liemohn, 1978), inadequate warm-up
activity. However, this pain is classically aggravated (Dorman, 1971; Ekstrand and Gillquist, 1982; Safran
by vigorous activity and relieved with rest. When the et al., 1988; Warren, Lehmann, and Koblanski, 1971,
condition worsens, resting no longer relieves the hip 1976), and poor coordination and technique (Lac-
or groin pain, which may also occur at night. Loss of roix, 2000; Lieberman and Harwin, 1997). Further-
hip range of motion, particularly hip internal rota- more, it is believed that these factors can interact to
tion, is characteristic. Shortening of the hip flexors further increase injury risk (Worrell, 1994). So, for
(contractures) also often occurs, negatively affect- example, a dancer who is inadequately hydrated and
ing the ability to stand or walk with desired pelvic has inadequate flexibility is more likely to sustain a
mechanics and adding stress to the low back. strain than a dancer with just one of these factors.
Treatment often involves activity modification However, there are many studies with conflicting
and regular gentle exercise such as swimming, water results, and additional dance-specific research is
aerobics, or cycling for strengthening of the hip mus- needed to better develop preventive measures.
culature and maintaining range of motion without Muscle strains tend to exhibit tenderness over the
excessive joint loading (Browning, 2001). Various specific area of injury, and in some cases swelling
medications aimed at reducing pain, diminishing and muscle spasm may be evident. Pain can gener-
joint inflammation, promoting cartilage healing, ally be produced with stretch as well as with forceful
or restoring the normal joint protective function of contraction of the involved muscle. With skeletally
synovial fluid may be used by the attending physi- immature dancers, it is also important to realize that
cian (Marshall and Waddell, 2000). While current the attachment of the muscle onto the bone is often
methods of early treatment probably cannot reverse less strong than the muscle or tendon itself, and thus
osteoarthritis, they can reduce pain and slow the an avulsion fracture may occur where the muscle is
progression. When severe degeneration and pain actually pulled off from this attachment site (Lieber-
exist, the orthopedic surgeon may recommend total man and Harwin, 1997).
hip replacement surgery. Treatment will vary dramatically according to the
The young age at which some dancers, and par- degree of strain, but often it initially includes relative
ticularly male dancers, have had total hip replace- rest, anti-inflammatory medication, physical therapy
ments is very alarming. It is essential that further modalities, and modification of activity to be pain
research be conducted to clarify contributing factors free. In milder strains, extra warm-up of the area
and possible interventions that can be used to reduce prior to class, use of a pain-free range during class
the risk of osteoarthritis for dancers. (e.g., limiting the height of the leg to the front with
a hamstring strain), and use of ice following class to
Hip Muscle Strains decrease the inflammatory response may be recom-
Muscle strain is one of the most common athletic mended. With more severe strains, dance may have
injuries of the pelvis and hip. Various muscles can be to be temporarily restricted; and when tolerated,
involved, including the hamstrings, adductor longus, swimming, stationary cycling, or a pool barre may be
gracilis, sartorius, rectus femoris, and iliopsoas—with utilized to allow movement and slight conditioning
the hamstrings being most commonly involved. Mul- in a pain-free manner.
tijoint muscles appear to be particularly susceptible As acute symptoms decline, institution of a pro-
to being strained. The mechanism of injury most gressive flexibility and strengthening program for the
often relates to movements in which the involved involved muscle is usually recommended. The strength-
muscle is being either passively stretched or working ening exercises are often advanced from isometric to
concentric, to eccentric, to functional exercises as hip capsule (Jacobson and Allen, 1990). This theory
tolerated (Jonhagen, Nemeth, and Eriksson, 1994; is further supported by anatomical studies that show
Worrell, 1994). This latter functional strengthening that when the femur is externally rotated, the head
step is sometimes neglected by dancers and is essential of the femur is directed forward with the iliopsoas
to prevent the common tendency for strains to reoccur tendon crossing the head of the femur laterally
or become chronic (Best and Garrett, 1996; Garett, (Caillet, 1996). However, when the femur is rotated
Califf, and Bassett III, 1984; Safran et al., 1988). inward, the iliopsoas tendon moves medially over the
head of the femur and capsule and can produce a
Iliopsoas Tendinitis snap, click, or clunk. This snapping associated with
Because the iliopsoas is of primary importance the iliopsoas tendon is termed internal snapping hip
during lifting of the leg above 90° to both the front (Schaberg, Harper, and Allen, 1984).
and side, this muscle is used in a demanding and Treatment may include anti-inflammatory medica-
repetitive way in ballet and various other dance tion, stretching of the hip flexors, and correction of
forms. Considering these demands, it is not surpris- related dance technique. In the author’s experience,
ing that the iliopsoas is a common site of injury in this click often occurs when the dancer is failing
dancers. In addition to being strained, the tendon to maintain full hip external rotation as the leg is
of the iliopsoas can also become inflamed; this con- lowered. Strengthening the hip external rotators,
dition is termed iliopsoas tendinitis. The iliopsoas abductors, and iliopsoas while working on technique
tendon is believed to be particularly vulnerable to maintain turnout and minimize letting the femur
when the hip is flexed, abducted, and externally rotate inward as the leg is lowered can be useful in
rotated as when the dancer performs a développé alleviating the snapping.
or battement in second. This commonly used posi- There is also another version of the snapping hip
tion has been theorized to cause the tendon to turn syndrome that involves the iliotibial band’s move-
in a “U” as it passes beneath the inguinal ligament, ment over the greater trochanter as seen in figure
such that it can readily become irritated (Sammarco, 4.41. This lateral and more superficial version is
1987). called external snapping hip. In certain movements,
Iliopsoas tendinitis occurs more frequently in one can palpate a snap by placing the fingers over
females and is characterized by crepitus, pain, and the greater trochanter, and in some cases this snap
stiffness in the groin area. As with other forms of ten- can also be heard. This snap commonly accompanies
dinitis, pain is often present at the beginning, lessens ronds de jambe, standing on one leg and shifting
during, and then increases after class or rehearsal. the pelvis toward that leg, and landing from a leap.
Pain is often also exacerbated by lifting the leg to a During landing from a leap, as the tensor fasciae
high level to the front or side. latae muscle contracts to help stabilize the pelvis,
Treatment commonly includes anti-inflammatory its associated band of fascia may snap forward from
medicine, careful hip flexor stretching, and tech- behind the trochanter and jerk the pelvis into flex-
nique evaluation with correction if needed. In some ion (Sammarco, 1987). The dancer often reports a
cases, this condition is associated with “hiking” the sensation of the hip slipping out of place.
hip and inadequate use of external rotation during Factors that have been suggested to increase the
movements such as développés. Strengthening of the risk of external snapping hip include a wide pelvis,
iliopsoas and DOR while correcting technique can prominent trochanter, ligamental laxity, weakness of
often help decrease symptoms and aid recovery. the hip abductors, “sitting” in the hip, and tightness
of the iliotibial band (Khan et al., 1995; Lieberman
The Snapping Hip Syndrome and Harwin, 1997; Mercier, 1995; Reid et al., 1987;
Some dancers experience a snapping sound, or clunk, Teitz, 2000). In dancers, a prevalence of the last
classically occurring when returning the leg to first or factor, iliotibial band tightness and associated low
fifth position from a développé or extension to the values of hip adduction, has been found. However,
side, and in some cases from a développé or extension a study of runners found significant weakness of the
to the front. This snapping is prevalent in dancers, and hip abductors in the affected limb and reported 92%
in one study of ballet dancers it accounted for almost of the affected runners were pain free after a 6-week
half of the hip injuries seen (Quirk, 1983). rehabilitation program that emphasized strengthen-
Various theories have been suggested regarding ing and stretching of the hip abductors (Fredericson,
the mechanism of this snap, but one study provides Guillet, and DeBenedictis, 2000).
strong evidence that the mechanism is likely the Hence, treatment of external snapping hip should
iliopsoas tendon snapping over the femoral head and include stretching the hip abductors and iliotibial
FIGURE 4.41 Snapping hip (right hip, lateral view). The FIGURE 4.42 Trochanteric bursitis includes inflamma-
iliotibial band snaps (A) forward with hip flexion and (B) tion of the bursa located superficial to the greater
backward when the hip extends. trochanter and deep to the iliotibial band (right hip,
anterior view).
band and strengthening the hip abductors. Anti- increase injury risk (Desiderio, 1988; Lieberman and
inflammatory medication is sometimes prescribed. In Harwin, 1997).
the author’s experience, the snapping often occurs Pain is generally present along the side of the
when the dancer excessively shifts the pelvis later- hip, and palpation over the greater trochanter usu-
ally relative to the support leg and fails to maintain ally reveals localized tenderness and in some cases
turnout on the support leg. Hence, strengthening crepitus. Pain can often be reproduced if the dancer
the deep outward rotators, hip abductors, and hip lies on the affected side or if the leg is passively or
adductors and applying use of these muscles to actively adducted across the midline of the body
maintain full turnout with the pelvis appropriately (Teitz, 2000). As with the external snapping hip,
positioned over the support foot will often be helpful this pain is often exacerbated by rond de jambe or
for successful reduction of snapping and pain. in landing on one leg from a leap or jump.
Treatment may include anti-inflammatory medica-
Trochanteric Bursitis tion, heat application prior to class and ice after class,
Sometimes independently or in association with stretching of the iliotibial band, strengthening of
external snapping hip, the bursa that lies over the hip abductors, and working on dance technique
the greater trochanter and beneath the iliotibial to avoid excessive lateral tilt (Trendelenburg sign)
band—the trochanteric bursa—becomes inflamed. or lateral shift of the pelvis. In some cases, aspira-
When this bursa becomes inflamed and swollen it tion of the fluid from the bursa and corticosteroid
is readily further irritated by compression or move- injection may be medically prescribed (Sammarco,
ment of the overlying iliotibial band as seen in figure 1987). If such conservative measures fail, recent
4.42. Occasionally, calcium is deposited within the research suggests that the gluteus medius tendon
inflamed bursa. In dance, the mechanism of injury may be torn (Kagan II, 1999); this tear is similar to
is theorized to be overuse from factors such as unbal- rotator cuff tears seen at the shoulder and discussed
anced pressures from dancing on a raked stage or in chapter 7.
alignment problems such as scoliosis, pelvic rota-
Piriformis Syndrome
tions, leg length differences, or excessive foot pro-
nation on one side that cause weight to be unevenly Pain in the buttocks with or without pain radiating
borne by the legs. Tightness of the iliotibial band, a down the back of the ipsilateral thigh may be due
wide pelvis, inadequate hip abductor strength, and to the piriformis syndrome. Spasm of the piriformis
technique errors such as “sitting in the hip” may also muscle, one of the DOR of the hip, can compress
rotators, strengthening of the hip abductors, and

correction of any related technique or alignment
problems can be helpful. In an unresponsive case,
a physician may elect to use an injection of an anes-
thetic and corticosteroid (Honorio et al., 2003).
Sacroiliac Inflammation and Dysfunction

The sacroiliac joints undergo great stresses as forces
are translated to and from the torso and lower
extremities. Injury can include ligaments, muscles,
or neural structures related to the sacroiliac joints
(Chen, Fredericson, and Smuck, 2002). In other
cases, the problem is believed to be due to an actual
disruption of normal motion of these joints termed
sacroiliac dysfunction. Slight motion does exist in
the sacroiliac joints, with translatory (0.1-1.6 millime-
ters) and angular movement (0.8-3.9°) occurring in
predictable patterns along various axes (Sturesson,
Selvik, and Uden, 1989). In some instances the os
FIGURE 4.43 Piriformis syndrome. Spasm of the piri- coxae can get wedged and “lock,” most commonly
formis muscle can create compression of the sciatic
with an anterior displacement of the os coxae on the
nerve (right hip, posterolateral view).
sacrum (DonTigny, 1990). With exaggerated lumbar
lordosis or spinal hyperextension or hip hyperexten-
the adjacent sciatic nerve as seen in figure 4.43 and sion, the os coxae will tend to move anterior on the
can produce the radiating symptoms characteristic of sacrum. Since the sacrum is wider anteriorly, the os
more serious back injury (Papadopoulos and Khan, coxae may wedge and lock.
2004; Rich and McKeag, 1992). This condition occurs Due to differences in pelvic structure and hor-
quite frequently in dancers, and possible reasons mones associated with pregnancy and menstruation,
include the extensive use of external rotation with sacroiliac motion is markedly greater in females
associated increased risk of strain, tightness, or imbal- versus males, and sacroiliac problems are more
ance with internal rotator strength and flexibility. It prevalent in women than men (Colliton, 1999). In
may also relate to technique issues (excessive activa- fact, it has been reported that 30% of males have
tion of the upper DOR and insufficient use of the fused sacroiliac joints (Hamill and Knutzen, 1995).
lower DOR in turnout) and posture (frequently seen Furthermore, with men, sacroiliac motion tends to
with fatigue posture and dancers who “push” their decrease with aging, while with women the motion
pelvis forward to try to achieve greater turnout). A tends to increase (Smith, Weiss, and Lehmkuhl,
common association of piriformis spasm with sacro- 1996). Various mechanisms for sacroiliac injury have
iliac dysfunction has also been noted, and piriformis been described, including falling on the buttocks or
syndrome occurs much more frequently in females hip, weightlifting or partnering, a sudden twisting
than males. motion, leaning forward, repetitive standing on one
Localized tenderness and muscle spasm are often leg, and excessive lumbar lordosis.
present in the mid-buttocks region (area of the piri- Pain is often present posteriorly, over one or
formis muscle). A dull aching pain in this same area both sacroiliac joints. Sharp twinges of pain often
often occurs after dancing and with extended sitting. occur with certain movements, and this association
Weakness of the hip abductors and tightness of the has been used to develop various pain provocation
hamstrings (on the affected side) are commonly tests that can be helpful for distinguishing sacroiliac
associated with this condition. inflammation from other sources of pain (Young,
Treatment often initially emphasizes anti-inflam- Aprill, and Laslett, 2003). In some cases pain is
matory medicine and reducing muscle spasm. Ultra- also experienced in the buttocks, posterior thigh,
sound, passive stretching of the piriformis muscle, or groin. When sacroiliac dysfunction is involved,
or use of ice massage or FluoriMethane spray while limitation of range in specific motions of the hip is
the muscle is stretched can sometimes provide relief often present. For example, with anterior displace-
(Roy and Irvin, 1983). Later, a balanced strength and ment of an os coxa, dancers will often say that their
flexibility program for both the external and internal range in extensions to the front and side on the
affected side is markedly reduced and that the hip femur via closed kinematic chain pelvic movements,
feels “jammed.” With anterior displacement, pain is the lumbar-pelvic rhythm, and the pelvic-femoral
often aggravated by movements that tend to bring rhythm. When the lower limb is weight bearing, many
the os coxae forward such as an arabesque. Weakness of the muscles that classically move the limbs now
of the gluteus medius and tightness of the piriformis serve key functions for creating the desired move-
muscle are also frequently present, both of which ments or stabilization of the pelvis. For example,
tend to increase the stress on the sacroiliac joints the abdominal–hamstring force couple can help
and perpetuate the problem. maintain a neutral pelvis in the sagittal plane, and
Treatment will vary according to the structures the abductor mechanism prevents undesired lateral
involved and type of displacement, if present. For tilt of the pelvis in the frontal plane.
example, with anterior displacement stretches in The hip joint is a ball-and-socket joint formed
flexion, abdominal strengthening, and avoidance between the head of the femur and the acetabulum,
of hyperextension (such as accompanying a high and the angle of the neck of the femur relative to the
arabesque) may be initially indicated, whereas with shaft of the femur—femoral inclination and femoral
posterior displacement, back extensor strengthen- torsion—influences potential hip range of motion
ing and avoidance of flexion (such as accompany- and lower limb alignment. In general, the design
ing curl-ups) may be initially indicated. In general, of the hip favors stability through the depth of the
restoration of hip abductor strength and pelvic acetabulum, extensive contact of articulating bones,
stabilization are key (Barclay and Vega, 2004), and a strong joint capsule and ligaments, and many large
reduction of piriformis and other muscle spasms are and powerful muscles that cross the hip joint. The
often also a focus. Gentle joint mobilization tech- joint capsule and iliofemoral and pubofemoral liga-
niques, a sacroiliac belt to aid with stabilization, and ments limit hip external rotation, hip extension, and
correction of biomechanical factors such as true leg posterior tilting of the pelvis and play an important
length difference with a heel lift are also sometimes role in helping passively maintain upright posture
prescribed. In select cases, physicians may utilize with less muscular contraction needed. Many of the
a corticosteroid injection for patients who do not 22 muscles that cross the hip joint have multiple
respond to a comprehensive rehabilitation program actions at the hip joint, and some also have actions
(Chen, Fredericson, and Smuck, 2002). at the spine and knee. These muscles are important
for movements of the lower limbs in all directions.
Because the weight and length of these levers are so
Summary great, marked strength is required in key muscles to
The os coxae are joined anteriorly at the pubic sym- move these limbs through space in the extreme range
physis and posteriorly indirectly via the sacroiliac of motion and with a specific aesthetic demanded by
joints to form the pelvic girdle. The pelvic girdle the dance form. Adequate flexibility is also essential
serves as a link between the torso and the lower to achieve these large-range open kinematic chain
limbs, and movements of the pelvis termed anterior motions. Supplemental strength and flexibility exer-
pelvic tilt, posterior pelvic tilt, lateral tilt, and rota- cises can help dancers achieve their performance
tion help it move in coordination with the spine and goals, as well as help reduce injury risk.

1. Examine closely the location of the iliofemoral ligament in figure 4.4. Using the human
skeleton model or your own body, review its functions and describe whether the following
movements will make it taut or slack: (a) Anterior pelvic tilt, (b) posterior pelvic tilt, (c) hip
external rotation.
2. Draw the following muscles on a skeletal chart, and use an arrow to indicate the line of pull
of each muscle. Then, next to each muscle, list its actions. (a) Iliopsoas, (b) rectus femoris,
(c) sartorius, (d) gluteus maximus, (e) hamstrings, (f) deep outward rotators (as a group),
(g) tensor fasciae latae, (h) gluteus medius and minimus (as a group), (i) hip adductors (as
a group).
3. Locate the muscles or muscle groups listed in question 2 on your body, perform actions that
these muscles produce, and palpate their contraction.
4. Using figures 4.17 and 4.18 as a reference, identify the angle of femoral torsion on a femur
from a disarticulated skeleton and examine how changing that angle would influence turnout
and facing of the knees.
5. Working with a partner, demonstrate the fundamental movements of the pelvis (hip flexion,
extension, abduction, adduction, external rotation, and internal rotation) on the partner,
including both of the following: (a) where the pelvis is stationary and the thigh moves and
(b) where the thigh is stationary and the pelvis moves.
6. Working with a partner, have the partner lie supine with both legs extended, and then measure
the degree of hip flexion present on one side with the knee extended versus bent. Explain
the difference and what could be done to make the two values more similar.
7. Using a skeletal model, evaluate how standing in a turned-out position would change the line
of pull of the hip flexors, hip abductors, hip extensors, and hip adductors. Postulate how this
might change muscle use in a second-position plié and in a side extension.
8. Analyze “lifting the hip” when performing a passé in terms of motions at the spine, lumbo-
sacral joint, and hip joint proper. What muscle action could correct this undesired action?
What dance cues could be used to try to achieve this correction for the dancer?
9. How does the abductor mechanism relate to standing on one leg in dance and the common
errors of “sitting in the hip” or “hiking the hip”?
10. Demonstrate one exercise for strengthening and one exercise for stretching the following
muscle groups: (a) hip flexors, (b) hip extensors, (c) hip abductors, (d) hip adductors, (e)
hip external rotators.
11. When strengthening or stretching the hip extensors, how could one emphasize the hamstrings
versus the gluteus maximus? When strengthening the iliopsoas, how could one emphasize
the iliopsoas versus rectus femoris?
12. A dancer wishes to improve the height she can raise her leg to the side.
a. Analyze this movement focusing on the hip of the gesture leg, including the joint move-
ments, muscle groups, and sample muscles of the hip.
b. Describe factors that would influence the degree of pelvic and spinal lateral tilt accompa-
nying the motion of raising the leg.
c. Identify appropriate strength and flexibility exercises that could be used to increase the
height of the leg and how they could help. Provide three cues that could be utilized to try
to implement the desired hip mechanics and technique.
Joints
The Knee and
Patellofemoral
© Angela Sterling Photography. Pacific Northwest Ballet dancers Melanie Skinner and Casey Herd.
CHAPTER FIVE
237
T his chapter will consider the knee joint and the

closely related patellofemoral joint. The knee is
the largest articulation in the body, and it is exposed
the femur is expanded with two enlargements termed
the medial and lateral condyles as shown in figure
5.1. These condyles contain the smooth articular
to tremendous stresses due to its location between surfaces that rest on the upper tibia to form the knee
the very long upright bones of the lower extremity. joint proper. You can palpate a portion of the femoral
The knee must accept, transfer, and dissipate large condyles by bending your knee to 90° and then press-
forces from above, due to body weight and the effects ing your fingertips on the sides of the lower portion
of gravity, and below, from the impact associated with of the patella. To help locate these articular surfaces,
weight-bearing movements. Whenever the knee is repetitively slightly bend and straighten your knee
bent while standing, gravity will tend to make it bend from this 90° position and feel the condyles move
further, and the photo on page 237 exemplifies the under your fingertips. These condyles also bear
skilled contraction of antigravity muscles required prominent projections to the sides that are termed
to prevent the body from collapsing and achieve the the medial and lateral epicondyles. You can locate
desired positioning of the knee. Although the associ- the epicondyles by sliding your hand down your thigh
ated patellofemoral joint, located just above the front toward the knee and finding the widest point of the
of the knee joint proper, contributes additional sta- knee, at the distal portion of the femur. On the front
bility to the tibiofemoral joint, it also must withstand of the femur, between the condyles, sits a smooth,
very large forces. Both of these joints are vulnerable shallow, concave surface that cannot be palpated.
to twisting motions, making good alignment and It is termed the femoral groove, and it articulates
technique during dance particularly important. with the patella. Posteriorly, a deeper indentation
This chapter will present basic anatomy and separates the medial and lateral condyles and is
mechanics of the knee and patellofemoral joints that termed the intercondylar fossa (L. inter, between +
influence optimal performance and the vulnerability condylar, condyles + fossa, trench), or intercondylar
of this joint to injury. Topics covered will include notch (figure 5.1B).
the following: The proximal end of the tibia is also expanded
and contains two condyles, again termed the medial
• Bones and bony landmarks of the knee region
and lateral condyles. In contrast to what occurs
• Joint structure and movements of the knee with the femur, the superior surfaces of these con-
• Description and functions of individual knee dyles are relatively flat or slightly concave versus
muscles rounded, and hence this upper surface is called
• Knee alignment and common deviations the tibial plateau. On this superior surface of the
• Knee mechanics tibia in between the flattened tibial condyles is a
roughened area termed the anterior and posterior
• Structure and movements of the patellofemoral joint intercondylar areas that contains two small peaks or
• Patellofemoral alignment and the Q angle projections termed the intercondylar eminence (L.
• Patellofemoral mechanics prominence). The intercondylar eminence serves
• Muscular analysis of fundamental knee movements as an attachment site for ligaments and helps sta-
bilize the tibia and femur during weight bearing.
• Key considerations for the knee in whole body On the anterior tibia, approximately 1/2 inch (1.3
movement centimeters) from its proximal end are a roughened
• Special considerations for the knee in dance area and projection called the tibial tuberosity (L.
• Conditioning exercises for the knee tuberosus, lump), or tibial tubercle. You can easily
• Knee injuries in dancers palpate this tuberosity by running your finger down
the middle of the kneecap and along the patellar
tendon until you feel a bump on the tibia: This is
Bones and Bony Landmarks the tibial tuberosity.
of the Knee Region The patella is approximately triangular in shape
with its narrow apex projecting downward and
The femur, tibia, and patella are all bones that take termed the inferior pole of the patella. The upper,
part in the knee joints and patellofemoral joints. flatter edge of the patella is called the superior
Recall from chapter 1 that the upper leg, or thigh border, and the side edges are called the medial and
bone, is termed the femur; the primary weight- lateral borders. The undersurface of the patella bears
bearing bone of the lower leg is termed the tibia; and angled surfaces termed facets, which articulate with
the kneecap is termed the patella. The distal end of the underlying femur.
The Knee and Patellofemoral Joints 239
Intercondylar
eminence
FIGURE 5.1 Bones and bony landmarks of the knee region (right knee). (A) Anterior view, (B) posterior view.
Joint Structure Knee Joint Classification

and Associated Movements
and Movements of the Knee
The tibiofemoral joint is a modified hinge joint, and
The knee is very complex in its structure and func-
its primary joint motions are flexion (or bending)
tion and is thought to have evolved from three sepa-
of the knee and extension (or straightening) of the
rate joints. Although there is only one joint cavity,
knee (see figure 5.2). In addition, its motion also
the following three articulations are present.
incorporates slight internal and external rotation,
1. Between the medial condyle of the femur and and hence it is termed a “modified” hinge joint.
the slightly concave medial plateau of the tibia
2. Between the lateral condyle of the femur and Knee Joint Capsule and Ligaments
the slightly concave lateral plateau of the tibia
3. Between the backside of the kneecap and the The knee joint is surrounded by an extensive and
underlying surface on the anterior femur, the irregular joint capsule lined with the largest synovial
femoral groove membrane found in the body (Hamill and Knutzen,
1995). In 20% to 60% of people, this membrane
The first two articulations between the femoral contains a permanent fold, termed a plica (L. a fold),
condyles and tibia compose the tibiofemoral joint, that sometimes becomes inflamed. The stability
or what is commonly referred to as the knee joint. As offered by this joint capsule is reinforced by numer-
with other synovial joints, the articular surfaces are ous strong ligaments. More than at any other joint in
covered by articular cartilage that reduces friction and the body, the ligaments are essential to stabilize and
aids with the distribution and absorption of forces. guide the relative movements of the bones coming
The third articulation is named the patellofemoral together to form the joint (Magee, 1997). However,
joint and will be discussed in a later section of this these ligaments are arranged such that ligamentous
chapter. stability is not constant (Kreighbaum and Barthels,
(coronary ligaments). Although the medial collateral

ligament is stronger than its lateral counterpart
(the lateral collateral ligament), it is much more
frequently injured.
The medial collateral ligament becomes taut
with knee extension and external rotation. It is key
for medial stability of the knee and is the principal
restraint to forces that tend to open up the inside of
the knee, termed valgus stress (L. valgus, turned out-
ward). At 25° to 30° of knee flexion, almost 80% of the
valgus stress to the knee is supported by the medial
collateral ligament (Besier, Lloyd, Cochrane, and
Ackland, 2001). This valgus type of stress can occur in
dance when the knee is allowed to fall inward relative
to the foot, for example in a poorly performed plié.
The medial collateral ligament also is a key restraint
for external rotation of the tibia whether the knee
is flexed or extended (Levangie and Norkin, 2001).
This may contribute to the vulnerability of the medial
collateral ligament to injury in dancers.
Lateral Collateral Ligament

(Fibular Collateral Ligament)
The collateral ligament located on the outside of
the knee joint is called the lateral collateral liga-
FIGURE 5.2 Movements of the knee joint. (A) Open kine-

matic chain flexion-extension, (B) closed kinematic chain
flexion-extension, (C) external rotation-internal rotation.
1996). Instead, key ligaments are taut to favor stability

when the knee is extended, while key ligaments are
slack to favor mobility when the knee is flexed.
Four knee ligaments that are particularly impor-
tant are the paired collateral ligaments and the
paired cruciate ligaments. As seen in figure 5.3, the
collateral ligaments run longitudinally on each side
of the knee, while the paired cruciate ligaments are
located within the knee joint.
Medial Collateral Ligament

(Tibial Collateral Ligament)
The collateral (side by side) ligament located on
the inside of the knee joint is called the medial col-
lateral ligament (MCL) or tibial collateral ligament
(see figure 5.3). This ligament is composed of two
layers, a superficial and a deep layer (Magee, 1997).
The superficial layer is a broad, flat, membranous
band that joins the medial condyles of the femur and
tibia. The deep layer of this ligament runs inferiorly
from its proximal attachment on the medial condyle
of the femur and merges with the joint capsule and
with the capsular fibers that attach the margins of FIGURE 5.3 Key knee ligaments and the menisci (right
the medial meniscus to the edge of the tibial condyle knee, anterior view).
ment (LCL) or fibular collateral ligament. The lateral affects stability and alters the normal mechanics of
collateral ligament is cordlike in shape and joins the the knee.
lateral condyle of the femur with the head of the fibula.
It becomes taut with knee extension. This ligament Posterior Cruciate Ligament
helps provide lateral stability to the knee and is the
The posterior cruciate ligament (PCL) runs from
primary constraint to forces that tend to open up the
the posterior intercondylar area of the tibia upward,
lateral aspect of the knee, termed varus stress (L. varus,
forward, and inward to attach to the outer and front
bent inward). It has been estimated that the lateral
part of the medial femoral condyle. The posterior
collateral ligament supports close to 70% of the varus
cruciate is key in preventing posterior displacement
stress applied to the knee (Besier, Lloyd, Cochrane,
of the tibia relative to the femur or anterior displace-
and Ackland, 2001). An example of this varus stress
ment of the femur relative to the tibia. It is easiest
would occur if the dancer were to sit with the lower legs
to remember the functions of the cruciate ligaments
crossed with the feet resting on the inside of the knees,
relative to the tibia; that is, the anterior cruciate
such as is done in the yoga lotus position. Dynamically,
prevents anterior displacement of the tibia while
varus stress would occur in lateral movements and
the posterior cruciate prevents posterior displace-
crossover movements like a grapevine.
ment of the tibia. The posterior cruciate has been
The lateral collateral ligament may also assist the
estimated to provide 95% of the total restraining
medial collateral ligament and other structures in
force to posterior movement of the tibia, termed
limiting external rotation of the tibia, particularly
“posterior drawer” (Butler, Noyes, and Grood, 1980).
at about 35° of knee flexion (Levangie and Norkin,
Unlike what occurs with the knee ligaments previ-
2001). Both of the collateral ligaments slacken with
ously discussed, a majority of the posterior cruciate
knee flexion, and lessening of these constraints is
ligament appears to become taut with knee flexion
vital for allowing functional rotation of the tibia used
versus extension, and some authors hold that it is
in movements such as pivoting.
the key stabilizer of the knee when the knee is not
Anterior Cruciate Ligament extended. During early knee flexion, the posterior
cruciate ligament becomes taut when the tibia dis-
The cruciate ligaments (L. cruciatus, shaped like a places posteriorly and then becomes the fulcrum
cross) are strong, cordlike ligaments that internally about which further knee flexion occurs (Caillet,
join the tibia and femur. These ligaments derive 1996). Large forces have been shown to be borne by
their name from the fact that they cross within the this ligament when deep knee flexion is performed,
knee joint. The anterior cruciate ligament (ACL) such as in a parallel squat (Escamilla, 2001). How-
runs from the anterior intercondylar area of the ever, the posterior cruciate ligament is 20% to 50%
tibia upward and backward and outward to insert greater in cross-sectional area, up to 50% stronger
onto the inner and back part of the lateral femoral (Diduch, Scuderi, and Scott, 1997), and less com-
condyle. As could be postulated from its attach- monly injured than the anterior cruciate.
ments, this ligament is important for preventing
anterior displacement of the tibia relative to the Ligamental Stress Tests
femur, or posterior displacement of the femur
relative to the tibia; and it has been estimated Simple ligamental stress tests that are performed
that the ACL is responsible for 85% of the force by physicians are shown in Tests and Measurements
that restrains anterior displacement of the tibia 5.1 to illustrate the key function of the primary liga-
(Irrgang, 1993). The ACL also has secondary func- ments just discussed. The presence of abnormal or
tions of helping to control rotation of the knee pathologic motion suggests that the ligament serving
(Diduch, Scuderi, and Scott, 1997), varus and valgus as a primary constraint to that motion is injured. Many
stresses, and hyperextension when the knee is fully more complex tests are also classically performed that
extended (Caillet, 1996; Magee, 1997). The rotary utilize multiplane motions and incorporate rotation
restraints offered by the cruciates are important for to further evaluate functional stability of the knee.
normal functioning of the locking mechanism of the
knee, discussed later in this chapter. Functionally, Specialized Structures of the Knee
the anterior cruciate plays a particularly key role
when large forces or deceleration is involved as with Various specialized structures are associated with
jumping, lowering the body down to the floor, or the knee that provide additional joint stability and
quick changes of direction in dance. This ligament aid with knee function. These structures include the
is essential for joint integrity, and its loss critically menisci, bursae, and iliotibial band.
Selected Orthopedic Stress Tests for the Knee
Selected tests are shown that are commonly performed by physicians to test the stability of the knee
and evaluate ligamental injury. Consider each test in terms of the restraints offered by a normal,
intact ligament and the excessive motion that would be allowed if injury occurred. In A, the hands are
positioned to apply a valgus stress to a slightly bent knee to evaluate the integrity of the medial col-
lateral ligament. When the medial collateral ligament is torn, excessive “opening up” of the inside of
the knee is evident. In B, the hands are positioned to apply a varus stress to evaluate the integrity of
the lateral collateral ligament. When the lateral collateral ligament is severely torn, excessive “opening
up” of the outside of the knee may occur. In C, the hands are positioned to pull the tibia forward to
evaluate the integrity of the anterior cruciate ligament (ACL). When the ACL is torn, excessive anterior
displacement of the tibia relative to the femur is evident. In D, the hands are positioned to carefully
press the tibia backward to evaluate the integrity of the posterior cruciate ligament. When the poste-
rior cruciate ligament is torn, excessive posterior displacement of the tibia occurs; and even before
the posterior pressure is applied, the tibia will appear farther back than normal (“posterior sag”) as
evidenced by a concavity beneath the patella.
242
The Menisci The medial meniscus is larger in circumference

than the lateral and is “C” shaped, barely forming a
The menisci (G. meniskos, crescent)—the medial semicircle. The lateral meniscus is more “O” shaped,
meniscus and lateral meniscus—are two fibrocartilage almost forming a complete circle, except where it
discs that sit on the tibial plateau and form the articu- attaches to the intercondylar area. The medial and
lar surface for the respective medial and lateral con- lateral menisci are joined to each other anteriorly
dyles of the femur as seen in figure 5.4. These menisci via the transverse ligament. The menisci are joined
are thicker around their perimeter than centrally, and to the tibia anteriorly at the anterior intercondylar
so form a kind of collar that aids in joint integrity by area, posteriorly at the posterior intercondylar area,
increasing the depth and fit of the articulation. The and by vertical fibers of the coronary ligaments along
inferior surfaces of the menisci are flat to contour their periphery to the edges of the tibial condyles.
to the tibial plateaus, whereas the superior surfaces The inner borders, superior surface, and inferior
are concave to conform to the shape of the femoral surface of the menisci are free. The medial meniscus
condyles. By helping to overcome the difference in is also securely attached to the medial collateral liga-
contour between the articulating femoral condyles ment and one of the medial hamstring muscles (the
and tibial condyles, and providing more surface area semimembranosus), making the medial meniscus
of contact between these bones, the menisci also help less freely movable than the lateral. During knee
absorb shock, decrease frictional wear, and facilitate flexion, the menisci move posteriorly with the femur,
knee movements. Furthermore, due to the properties with the more movable lateral meniscus traveling
of cartilage (viscoelastic properties), when they are approximately twice as far (0.4 vs. 0.2 inches [11 vs. 5
loaded they further increase the contact area and millimeters]) as the medial (Dye and Vaupel, 2000).
decrease joint stresses—approximately doubling the During knee extension, the menisci move anteriorly
contact area in the joint and bearing as much as 45% with the femur. Perhaps partly due to its firmer
of the total load absorbed by the knee (Hall, 1999; attachments and more restricted movement, the
Hamill and Knutzen, 1995; Soderberg, 1986). More- medial meniscus is much more frequently injured
over, the further separation of the joint surfaces they than the lateral meniscus (Caillet, 1996).
provide allows for greater lubrication of the joint, and
a 20% increase in friction has been demonstrated to Bursae
occur with removal of the meniscus. The vital impor- More than 20 bursae are commonly present around
tance of the menisci is evidenced by the tendency for the knee joint (Hamill and Knutzen, 1995). For exam-
early degenerative changes in knees where a menis- ple, as illustrated in figure 5.5, one bursa lies beneath
cus has been surgically removed due to injury. the distal tendons of a group of muscles key for medial
FIGURE 5.4 The menisci and selected associated

structures (right knee, superior view).
FIGURE 5.5 Selected bursae of the knee (right knee,

anteromedial view).
rotation of the tibia (pes anserine bursa). Anteriorly, Muscles

bursae lie between the anterior surface of the patella
and the overlying skin (prepatellar bursa), as well as In addition to the vital ligaments of the knee, various
underneath (deep infrapatellar bursa) and in front of additional muscles that cross the knee provide addi-
(superficial infrapatellar bursa) the patellar tendon. tional stability to this joint. Some of these muscles,
With the use of floor work in dance, some of these particularly the quadriceps femoris, have also been
bursae can readily become inflamed (bursitis). shown to serve as important shock absorbers that
play a significant role in protecting the knee from
Iliotibial Band early degenerative changes.
Recall that the iliotibial band is a fascial band that
begins superiorly at the ilium and runs down the
side of the thigh to attach to the lateral condyle of Description and Functions
the femur, the posterior femur, the patella, and the of Individual Knee Muscles
lateral condyle of the tibia. The tensor fasciae latae,
described in the previous chapter on the hip, inserts Twelve muscles cross the knee joint and aid the liga-
into this band (figure 4.6, p. 166). When the tensor ments with providing stability, as well as give rise to
fasciae latae contracts, it tightens the iliotibial band, the movements of the knee. The most important
which makes this band’s function similar to that of a muscular support is provided by the quadriceps com-
dynamic ligament of the knee. Due to the anterior plex anteriorly and the hamstrings posteriorly. Slight
attachments of some of its fibers, some hold that the lateral support is also offered by the lateral hamstring
iliotibial band can act as a knee extensor when the muscle, the biceps femoris. Slight medial support is
knee is slightly flexed (0° to 30° knee flexion), but provided by one of the medial hamstring members,
then it acts as a flexor of the knee when the knee the semitendinosus, as well as by other members of
is flexed greater than 40° (Dye and Vaupel, 2000). the pes anserinus (sartorius and gracilis). A more
Although controversial, the tensor fasciae latae detailed description of these muscles can be found in
via the iliotibal band may also assist with external Individual Muscles of the Knee on pages 245-250 and
rotation of the tibia or knee (Smith, Weiss, and 251. Note that many of these muscles cross multiple
Lehmkuhl, 1996). The iliotibial band is unique to joints and also can produce movement at the hip or
humans and appears to be a unique adaptation to ankle as well as the knee.
the demands of erect posture, providing key lateral
support to the knee as well as the hip.
Individual Muscles of the Knee

Anterior Muscles of the Knee
The anterior muscles of the knee are the quadriceps femoris group. Because the knee flexes in the
opposite direction (with the distal segment moving posteriorly vs. anteriorly) to many of the other synovial
joints, anterior muscles of the knee produce extension of the knee. This is in contrast to the spine, hip,
shoulder, elbow, wrist, and fingers, where concentric contraction of anterior muscles from anatomical
position produces flexion at their respective joints.
Attachments and Primary Actions of the Quadriceps Femoris

Quadriceps femoris (KWOD-ri-seps FEM-o-ris)
Rectus femoris Anterior inferior iliac spine Tibial tuberosity via patellar Knee extension
(REK-tus FEM-o-ris) Posterior head: just above tendon (Hip flexion)
acetabulum
Vastus medialis Medial and posterior surfaces Quadriceps femoris tendon Knee extension
(VAS-tus me-dee-A-lis) of femur and medial border of patella
Vastus intermedius Anterior and lateral aspects Quadriceps femoris tendon Knee extension
(VAS-tus in-ter-ME-dee-us) of femur and superior border of patella
Vastus lateralis Upper lateral and posterior Quadriceps femoris tendon Knee extension
(VAS-tus lat-er-A-lis) surfaces of femur and lateral border of patella
Quadriceps Femoris
The quadriceps femoris group is located on the front of the thigh, and as its name indicates (L. quattuor,
four + capus, head), it is composed of four muscles: the rectus femoris (L. rectus, straight + femoris,
femur) vastus lateralis (L. lateral great muscle), vastus intermedius (L. intermediate great muscle),
and vastus medialis (L. medial great muscle). The rectus femoris, seen in figure 5.6A, is the only one
of this muscle group that crosses the hip joint, and its function as a flexor of the hip was discussed in
chapter 4. The remaining quadriceps, the three vasti muscles (L. vastus, great) seen in figure 5.6B,
originate from the femur and so can produce joint movement only at the knee, not the hip. As their
names suggest, the vastus medialis is the most medially located of the vasti, and the lateralis is
the most laterally located. The vastus intermedius lies between these two muscles and underneath
the rectus femoris. The tendons of all four of the quadriceps muscles converge to form the quadriceps
femoris tendon. The quadriceps femoris tendon attaches to the superior patella, and the patella is then
attached to the tuberosity of the tibia via the patellar tendon. Hence, although the quadriceps converge
onto the patella, the continuing attachment of the patella onto the tibia allows the quadriceps femoris
group to act as powerful extensors of the knee.
All of the quadriceps act as prime movers to produce knee extension such as in a frappé or main-
tain knee extension such as in the gesture leg during a rond de jambe. When the knee is in weight-
bearing positions, gravity tends to produce knee flexion, and the quadriceps play a key antigravity func-
tion in movements such as pliés, walking, running, and jumping. Given this antigravity function, it is not
surprising that the quadriceps are one of the strongest muscle groups in the body. They are capable
of generating greater than 1,000 pounds (454 kilograms) of force (Hamill and Knutzen, 1995; Smith,
Weiss, and Lehmkuhl, 1996).
FIGURE 5.6 The quadriceps femoris (right knee, anterior view). (A) Rectus femoris, (B) the three vasti muscles.
Palpation: You can palpate the rectus femoris running down the middle of the front of the thigh. You
can palpate the vastus intermedius under the rectus when you approach from the medial or lateral
side. The vastus lateralis can be palpated laterally to the rectus, from just below the greater trochanter
down to the patella. The distal portion of the vastus medialis can easily be palpated medial to the
rectus femoris along the lower third of the thigh. If you place the palm of your hand on the upper thigh
in a sitting position, you can feel the whole quadriceps femoris group contracting under your hand if
you raise the leg to the front with the knee bent (hip flexion) and then extend the knee as you would
with a parallel front développé.
Posterior Muscles of the Knee
The posterior muscles of the knee are the hamstrings, popliteus, and gastrocnemius. The hamstrings and
gastrocnemius are multijoint muscles, while the popliteus only crosses and acts on the knee joint.
Hamstrings
As described in the preceding chapter on the hip, the hamstrings—the biceps femoris, semitendino-
sus, and semimembranosus—originate from the ischial tuberosity of the pelvis (figure 5.7A) and the
posterior femur (figure 5.7B) and attach distally below the knee on the tibia and fibula. All three of the
hamstrings act to produce knee flexion and can help prevent knee hyperextension. In addition, they can
contribute to rotary movements of the knee. The semitendinosus (L. semi, half + tendinosus, tendon)
and semimembranosus (L. semi, half + membranosus, membrane) insert medially on the tibia and so
Attachments and Primary Actions of Hamstring Muscles

Hamstrings
Biceps femoris Long head: ischial Head of fibula Knee flexion
(BI-seps FEM-o-ris) tuberosity Lateral tibial condyle Knee external rotation
Short head: linea aspera (Hip extension)
of femur (Hip external rotation)
Semitendinosus Ischial tuberosity Medial surface of upper Knee flexion
(sem-ee-ten-di-NO-sus) tibia (pes anserinus) Knee internal rotation
(Hip extension)
(Hip internal rotation)
Semimembranosus Ischial tuberosity Medial condyle of tibia Knee flexion
(sem-ee-mem-brah-NO-sus) Knee internal rotation
(Hip extension)
FIGURE 5.7 The hamstrings and popliteus muscles (right knee, posterior view). (A) Superficial view of hamstrings, (B)
popliteus and long head cut to show short head of biceps femoris.
cause slight medial rotation of the tibia or knee. In contrast, the biceps femoris (bi, dual + L. capus,
head) inserts laterally on the fibula and tibia and so its action is slight external rotation of the tibia
or knee. In dance forms utilizing turnout, slight use of the biceps femoris is often encouraged to help
continue the turnout, primarily effected at the hip, through the lower leg.
Palpation: Stand on your left leg with the ball of your right foot about 10 inches (25 centimeters)
behind the left foot and the right knee bent. In this position the biceps femoris can be palpated on the
right leg along the lateral posterior thigh, with the tendon easily palpated immediately proximal to the
back of the knee. The semitendinosus tendon can also be palpated immediately proximal to the back
of the knee, only on the medial side of the posterior thigh. The semimembranosus can be palpated
on either side of the semitendinosus tendon. Flexing the knee by lifting the foot off the floor, with your
hand placed just above the knee joint (posteriorly), allows you to feel the hamstrings contracting and
makes the tendons more prominent.
Attachments and Primary Actions of the Popliteus

Popliteus Tripartite tendon: Medial posterior aspect External rotation of femur (when
(pop-LIT-ee-us) 1. Lateral femoral condyle of upper tibia foot fixed)
2. Head of fibula Internal rotation of tibia (when
3. Posterior aspect of lateral foot free)
meniscus “Unlocking” knee
Popliteus
The popliteus is a small muscle running behind the knee, as shown in figure 5.7B, that is key for knee
joint stability and proper mechanics. It is the most deeply located muscle in this region, lying close
to the knee joint capsule. It attaches proximally to the lateral femoral condyle, lateral meniscus, and
fibula, and distally to the posteromedial aspect of the tibia. When the tibia is fixed such as during
weight bearing, the popliteus (L. poples, ham/posterior knee) acts to externally rotate the femur and
also withdraws the lateral meniscus at the beginning of knee flexion. When the knee is straight, this
external rotation function is important to unlock the knee and allow flexion to proceed. In open versus
closed kinematic chain conditions when the tibia is free, such as when one performs a circling motion
of the foot in the air (rond de jambe en l’air), the femur acts as the fixed segment and the popliteus
acts on the tibia versus the femur, producing internal rotation of the tibia.
Palpation: Because of its deep location and because it is covered by the plantaris and lateral head
of the gastrocnemius, the popliteus cannot be readily palpated.
Gastrocnemius and Plantaris

The gastrocnemius and plantaris are more fully described in chapter 6 with the ankle and foot (figure
6.15, p. 313). The plantaris (L. relating to the sole of the foot) can act as a weak assistant to knee
flexion. The gastrocnemius (G. gaster, belly + kneme, leg) originates above the femoral condyles and
inserts into the calcaneus via the Achilles tendon. In non-weight-bearing positions, such as a back
attitude, the gastrocnemius may assist with knee flexion. However, when the foot is fixed and the knee
is in strong extension, such as when functioning as the support leg during movements at the barre or
center floor, the gastrocnemius may reverse its role and pull down and back on the femoral condyles
and help maintain knee extension versus producing knee flexion.
Additional Secondary Muscles of the Knee
The sartorius and gracilis are biarticular muscles whose primary function at the hip was discussed
in chapter 4, but they also cross and can act on the knee joint. They insert on the medial aspect of
the proximal tibia in combination with the semitendinosus. The tendinous expansions of these three
muscles where they attach onto the medial tibia are referred to as the pes anserinus (L. pes, foot +
anser, goose) as seen in figure 5.8. The sartorius and gracilis aid the medial hamstrings with knee flexion
and internal rotation of the tibia or knee. However,

depending on the specific insertion of the muscle,
when the knee is in full extension or hyperextension,
the line of pull may pass anterior to the knee axis
such that it reverses its function to being an exten-
sor of the knee (Basmajian and DeLuca, 1985). This
may be one mechanism that dancers use for helping
maintain extension of the knee with less quadriceps
activation when raising the leg to the front.
Summary of Knee Muscle

Attachments and Actions
A summary of the attachments of the muscles that
cross the knee is provided in table 5.1, and some of
the more primary of these muscles and their attach-
ments are shown in figures 5.9, A and B, and 5.10,
A and B. From these resources, deduce the line of
pull and resultant possible actions of the primary FIGURE 5.8 Pes anserinus (right knee, medial view).
muscles of the knee, and then check for accuracy
by referring to figures 5.9C and 5.10C.
TABLE 5.1 Summary of Attachments and Primary Actions* of Knee Muscles

Anterior muscles
Quadriceps femoris (KWOD-ri-seps FEM-o-ris)
Rectus femoris Anterior inferior iliac spine Tibial tuberosity via Knee extension
(REK-tus FEM-o-ris) Posterior head: just above patellar tendon (Hip flexion)
acetabulum
Vastus medialis Medial and posterior Quadriceps femoris Knee extension
(VAS-tus me-dee-A-lis) surfaces of femur tendon and medial border
of patella
Vastus intermedius Anterior and lateral aspects Quadriceps femoris Knee extension
(VAS-tus in-ter-ME-dee-us) of femur tendon and superior
border of patella
Vastus lateralis Upper lateral and posterior Quadriceps femoris Knee extension
(VAS-tus lat-er-A-lis) surfaces of femur tendon and lateral border
of patella
Posterior muscles
Hamstrings
Biceps femoris Long head: ischial tuberosity Head of fibula Knee flexion
(BI-seps FEM-o-ris) Short head: linea aspera of Lateral tibial condyle Knee external rotation
femur (Hip extension)
(Hip external rotation)
Semitendinosus Ischial tuberosity Medial surface of upper Knee flexion
(sem-ee-ten-di-NO-sus) tibia (pes anserinus) Knee internal rotation
(Hip extension)
(continued)
TABLE 5.1 Summary of Attachments and Primary Actions* of Knee Muscles (continued)

Posterior muscles (continued)
Hamstrings (continued)
Semimembranosus Ischial tuberosity Medial condyle of tibia Knee flexion
(sem-ee-mem-brah-NO-sus) Knee internal rotation
(Hip extension)
Popliteus Tripartite tendon: Medial posterior aspect of External rotation of
(pop-LIT-ee-us) 1. Lateral femoral condyle upper tibia femur (when foot fixed)
2. Head of fibula Internal rotation of tibia
3. Posterior aspect of lateral (when foot free)
meniscus “Unlocking” knee
Additional secondary muscles

Gracilis Just below symphysis Medial surface of upper Knee flexion
on pubis, inferior rami of tibia (pes anserinus) (Hip adduction)
ischium and pubis (Hip flexion)
Sartorius Anterior superior iliac spine Medial surface of upper Knee flexion
(ASIS) and area just below tibia (pes anserinus) (Hip flexion)
(Hip abduction)
(Hip external rotation)
Tensor fasciae latae Anterior outer crest of ilium, Tibia via iliotibial band Lateral support of knee
lateral aspect of anterior (Terminal knee extension)
superior iliac spine
(Knee external rotation)
(Hip abduction)
(Hip flexion)
Gastrocnemius Medial and lateral femoral Calcaneus (foot) via Knee flexion
condyles Achilles tendon (Ankle plantar flexion)
*Special circumstances for action or action at other joints given in parentheses
Knee Alignment the knees more medial than either the femoral head
or greater trochanter. Due to this femoral obliquity
and Common Deviations in the frontal plane, it is normal for the tibia to angle
Knee alignment can be evaluated relative to the outward slightly relative to the femur. This angula-
frontal, sagittal, or transverse plane. Appropriate tion functions to help establish an approximately
alignment of the bones involved in the knee joint can vertical positioning of the tibia, desirable for transfer
have important implications in terms of how stresses of body weight. The angle between the femur and
are borne and the resultant injury predispositions, tibia, which opens out laterally, is termed a valgus
as well as for one’s ability to meet the performance angle or valgus angulation. In adults, an angle of
and aesthetic demands of dance. Common align- about 170° to 174° is considered normal (Magee,
ment deviations include valgus angulation, genu 1997; Smith, Weiss, and Lehmkuhl, 1996), and such a
recurvatum, and tibial torsion. normal alignment of the tibia relative to the femur is
termed genu rectum (L. genu, knee + rectus, straight)
as seen in figure 5.11A.
Valgus Angulation
As discussed in chapter 4, when one views the legs
Genu Valgum
from the front or back, the shafts of the femur are not However, in some cases this relative lateral deviation
totally vertical but rather angle slightly inward, with of the tibia is exaggerated and the angle between the
FIGURE 5.9 Anterior view of primary muscles acting on the knee joint (right knee). (A) Muscles, (B) attachments, (C)
lines of pull and actions.
FIGURE 5.10 Posterior view of primary muscles acting on the knee joint (right knee). (A) Muscles, (B) attachments,
251
FIGURE 5.11 Knee alignment. (A) Anterior view, (B) lateral view.
tibia and femur is considerably less than 170°. This (1997). This alignment of the knee is of concern in
condition is termed genu valgum, or “knock-knees.” terms of aesthetics, the resultant increased load on
In such a case, when a dancer stands with the feet the lateral meniscus and increased tension on the
parallel and the knees touching, the feet cannot medial collateral ligament, negatively impacting
touch and remain separated. To help remember this alignment of the patella, and the commonly associ-
terminology, associate the “l” in valgum with the “l” ated “rolling in” (excessive pronation) of the foot.
in lateral. So, in genu valgum, the tibia angles later- Orthopedic evaluation of 40 elite ballet students
ally relative to the femur (figure 5.11A). You can showed no cases of genu valgum (Hamilton et al.,
also remember this terminology by thinking that 1997). One could postulate that this lack of occur-
with genu valgum, a piece of sticky gum is holding rence was due to dropout from injury or screening
the knees together while the tibia angles laterally. out due to aesthetic considerations, or that ballet
A distance of 3.5 inches (9-10 centimeters) or more training tends to alter this knee alignment. Further
between the ankles is considered excessive by Magee investigation of this issue would be valuable.
Genu Varum appears to be aesthetically acceptable, as evidenced

When the angle between the tibia and femur gets by its presence in elite dancers. Its potential implica-
larger and approaches 180°, or the angle of the tibia tions for injury risk will require additional study.
relative to the femur actually opens medially versus
laterally, the condition is termed genu varum, or Genu Recurvatum
“bowed legs.” In such a case, when a dancer stands
in a parallel position with the feet touching, there When one views the knees from the side, the knees
is space between the knees. If two or more fingers can appear slightly bent, straight (extended), or
fit between the knees when the ankles are touch- hyperextended as seen in figure 5.11B. When the
ing, this is considered evidence of genu varum. You knees are hyperextended, this is termed genu
can remember this terminology by imagining that recurvatum (L. genu, knee + re-curvus, bent back), or
a barrel of rum is being held between the knees, “back-knee,” as the knees curve backward predomi-
making the legs bow. In addition to involving the nantly in the sagittal plane. Genu recurvatum is more
angle of the femur relative to the tibia, this condi- common in females than males, and more common in
tion often involves an actual lateral bowing of the individuals of any gender with generalized joint laxity
femur or tibia itself (or of both) (figure 5.11A). This (“hypermobility”). In the dance arena, hyperextended
positioning is of concern in terms of aesthetics, the knees are sometimes wrongly attributed to excessive
resultant increased load on the medial meniscus and strength and use of the quadriceps femoris. However,
increased tension on the lateral collateral ligament, since this hyperextension actually is often associated
and the associated tendency to “roll out” (excessive with attempting to maintain stability by “hanging” on
supination). However, a high prevalence of genu ligamental constraints versus using muscular control,
varum has been noted in elite athletes, and it is knee hyperextension is actually associated with less
interesting that orthopedic evaluation of 40 elite activity of the quadriceps than in subjects who stand
ballet students revealed that 46% demonstrated genu with the knees slightly bent (Basmajian and DeLuca,
varum (Hamilton et al., 1997). So, although extreme 1985) and is often associated with weak quadriceps
genu varum may be detrimental, a small amount (Scioscia, Giffin, and Fu, 2001).
Knee Alignment: Valgus Angulation
Perform the following observations, and use figure 5.11 as a reference to identify your valgus angula-
tion.
1. Stand facing a mirror with your feet parallel and approximately hip-width apart. Observe the
relationship between the hip, knee, and ankle joints. Due to the slight inward angulation of the
femur, with normal valgus angulation the tibia should angle out just slightly relative to the femur
so that an angle is formed between these bones of about 170°. Note whether your angle seems
less than, greater than, or about equal to 170°.
2. Now, move your feet together so that the inner borders touch, and note the position of your knees.
With normal alignment, the knees also are approximately touching. However, if when standing in
this position you can see space between your knees, this is suggestive of the presence of genu
varum, or “bowed legs.”
3. In contrast, if you are unable to bring your feet together because your knees make contact well
before the inner borders of your feet can touch, this is suggestive of the presence of genu valgum,
or “knock-knees.”
4. After identifying the alignment of your knees, slowly move the pelvis between positions of anterior
tilt, neutral, and posterior tilt, and note if and how they influence your knee alignment.
A slight amount of knee hyperextension is con- cations for ankle and foot mechanics, as well as the
sidered desirable in some dance aesthetics such as knee, and will be readdressed in chapter 6.
classical ballet. However, excessive hyperextension
can be of concern from an injury perspective. One
approach to meet both biomechanical and aesthetic Knee Mechanics
conditions is to limit the amount of knee hyperex-
tension when the leg is weight bearing and reserve The mechanics of the knee joint are more complex
use of a mildly hyperextended knee for the non- than is the case for other true hinge joints, primarily
weight-bearing gesture leg when aesthetics dictate due to two factors. First, flexion and extension at the
the “hyperextended line.” tibiofemoral joint do not involve simple movement
For dancers, a knee that does not fully extend around one axis but rather incorporate rolling and
and appears bent is also of concern from an gliding with a shifting axis at different degrees of
aesthetic perspective. This condition is termed flexion. Second, small amounts of transverse rotation
genu antecurvatum (L. genu, knee + ante-curvus, for- also accompany flexion and extension.
ward curve) or “hyperflexed knees” (figure 5.11B).
Careful evaluation by a dance medicine physician Knee Flexion and Extension
is essential to determine how much of this limita-
tion is structural versus soft tissue or neuromuscular The knee joint motions of flexion and extension
in nature, as well as whether it is azppropriate to occur primarily in the sagittal plane between the
carefully stretch the knee to facilitate full extension. condyles of the femur and tibia. The movements of
In many cases, desired changes can be achieved the femoral condyles relative to a fixed tibia (closed
with a very careful but consistent stretching pro- kinematic chain) can be compared to that of a bicycle
gram, combined with dance technique modifica- wheel, with the femoral condyles rolling backward
tion. and forward upon the tibial condyles like a bicycle
wheel on the road as seen in figure 5.12A. In addi-
Tibial Torsion tion, the femoral condyles glide or slide over the
tibial condyles similarly to a bicycle wheel when it
When one views the knee from the front, malalign- skids. This latter sliding motion is necessary to keep
ment of the knee can also be seen predominantly in the femur positioned over the tibial condyles. For
the transverse plane, as evidenced by inward or out- example, when the femoral condyles roll backward
ward facing of the knee relative to the hip joint, ankle during flexion (such as during the descent of a first-
joint, or both. This transverse rotation can be due to position parallel plié), the femur would roll off the
malalignment of related joints (e.g., femoral torsion) back of the tibia (figure 5.12A) without an anterior
or rotation along the length of the bones themselves. sliding motion that occurs after about 25° of flexion
If the distal end of the tibia faces medially or exces- (figure 5.12B) to offset the backward motion associ-
sively laterally when the distal end of the femur faces ated with rolling (Levangie and Norkin, 2001). The
directly forward, the malalignment is termed tibial opposite occurs in extension (such as in rising from
torsion. One can picture outward or external tibial the plié), with the femoral condyles first rolling for-
torsion by imagining that the upper tibia and tibial ward and then sliding backward to offset the forward
tuberosity stay facing front while the lower tibia is motion associated with rolling (figure 5.12C). So,
rotated externally so that it is facing slightly toward this simultaneous use of rolling and sliding allows for
the side as seen in figure 5.34B (p. 290). In this situa- the desired surfaces of the femur to stay in contact
tion, the foot will be pointing outward relative to the during flexion and extension and prevents excessive
knee. Some dancers exhibit marked external tibial relative movement of the associated bones that could
torsion, and this bony alignment offers an advantage jeopardize joint integrity.
for achieving a more turned-out position with the
feet without creating undesired torsion at the knee. Knee Rotation
Conversely, with inward or internal tibial torsion,
the feet point straight ahead or toward each other Although the primary motions at the knee joint are
when the patellae face forward. When standing, flexion and extension, the fact that the two condyles
most people exhibit a slight external tibial torsion, at the distal end of the femur are different in size and
which increases from approximately 5° at birth to an shape and are not quite parallel necessitates slight
average of about 15° at skeletal maturity (Luke and transverse rotation. The degree of rotation permitted
Micheli, 2000). Tibial torsion has important impli- varies with the degree of knee flexion and is strongly
FIGURE 5.12 Motions of the femoral condyles on a fixed tibia (right knee, medial view). (A) Posterior rolling accompany-
ing knee flexion, (B) anterior sliding to offset backward motion of femur during flexion, (C) anterior rolling with posterior
sliding to offset forward motion of femur during knee extension.
influenced by ligaments. As previously described, jection of the medial condyle is necessary to compen-
when the knee is extended, key ligaments are relatively sate for the lateral-to-medial obliquity of the femoral
taut, and little or no rotation of the tibia relative to the shaft as it progresses distally, allowing the knee joint
femur is allowed. However, when the knee is bent, the to be more parallel to the floor than if the condyles
collateral ligaments are more slack, and 20° to 30° were the same size and shape. Due to this difference
of internal and 30° to 45° of external rotation of the in size, when the knee extends in a standing position
tibia are possible (Magee, 1997; Rasch, 1989). (closed kinematic chain), the excursion of the lateral
The increased rotation permitted as the knee condyle is completed (close packed) while that of
bends enhances movement possibilities. For exam- the medial remains uncompleted. In essence, all of
ple, this rotation is critical for permitting the body to the articulating surface has been used on the lateral
turn when the foot is in contact with the ground from side, while leaving about a half inch (1.3 centimeters)
a position of kneeling, squatting, sitting, or stand- on the medial side. To use the remaining articular
ing. It would be very difficult and cumbersome to surface on the medial side and reach full extension
change direction if this rotation at the knee were not (close-packed position), the medial femoral condyle
available, and the rotation is vital for quick changes continues to roll and slide, producing internal rota-
in direction such as a pivot when running or danc- tion of the femur relative to the tibia as shown in figure
ing. In non-weight-bearing conditions, this rotation 5.13B. The extent of this rotation is small, approxi-
allows the foot to turn, as when one climbs a pole, mately 5° to 7° (Soderberg, 1986), though significant.
performs inside ankle kicks in soccer, or “presents This final rotation that creates a congruous position
the heel” in ballet. of both condyles of the femur relative to the menisci
and underlying tibia is termed the locking mechanism
The Locking Mechanism of the Knee or “screw-home” movement of the knee.
This locking mechanism of the knee is an
The linking of rotation with the final 20° of knee energy-efficient mechanism that allows individuals
extension has particular importance for posture and to maintain the knee in extension over prolonged
knee stability and is termed the “locking mechanism” periods of standing without requiring muscular
of the knee (Hamill and Knutzen, 1995). This auto- contraction, as the knee cannot flex without the
matic mechanism is thought to relate to the restraints knee’s first being “unlocked.” To bend the knee,
offered by the cruciate ligament and the shape of the the reverse process occurs in which the popliteus
surfaces articulating at the knee joint. In terms of the muscle works to externally rotate the femur relative
latter, the medial femoral condyle projects extensively to the tibia, thereby unlocking the knee and allowing
both longitudinally and medially. This downward pro- flexion to occur.
the human body. Recall that the quadriceps muscle

complex inserts into the superior border of the
patella, and the inferior pole of the patella is joined
to the tibial tuberosity via the patellar ligament or
patellar tendon as seen in figure 5.14A. Some texts
refer to this band as the patellar ligament since it
attaches bone to bone, while others term it a tendon
because functionally it is a tendon, being composed
of fibers continuous with those of the quadriceps
tendon. The patella is located slightly above and
in front of the knee joint proper as seen in figure
5.14B, and the facets located on its posterior surface
articulate with the slightly concave femoral groove,
or patellar groove, as shown in figure 5.14, C and
D; this articulation is termed the patellofemoral
joint.
Functions of the Patella
As with other sesamoid bones, the patella increases

the ability of the muscle within which it is located to
produce effective force or torque. The patella serves
to increase the moment arm, that is, the perpen-
dicular distance of the line of action of the quadri-
ceps femoris from the axis of rotation of the knee
joint (figure 5.15B). Since torque is determined
FIGURE 5.13 Locking mechanism of the knee with (A) by the force generated by the muscle times the
closed kinematic chain and (B) open kinematic chain perpendicular distance from the line of pull of the
movements. muscle to the axis of rotation (chapter 2), the same
force of contraction of the quadriceps will result
When the knee is not weight bearing, such as in greater torque than if a patella were not present
when the knee is extended in the air in a kick or and the quadriceps ran closer to the middle of the
développé, the tibia is no longer fixed and is now knee joint (figure 5.15C). Decreases in quadriceps
the most easily moved segment. Hence, the rota- torque of up to 49% have been found when the
tion occurs primarily in the tibia relative to the patella has been surgically removed (Levangie and
femur rather than in the femur relative to the Norkin, 2001). The patella also serves to central-
tibia. In this condition the close-packed position ize the divergent pulls of the four muscles of the
of the condyles is achieved through external rota- quadriceps femoris complex, serves as a retainer
tion of the tibia relative to the femur as shown in to help prevent the femur from sliding off the tibia
figure 5.13A, rather than the internal rotation of anteriorly, and allows for a better distribution of
the femur seen in weight-bearing conditions. This compression stresses on the femur by increasing
external rotation of the tibia generally occurs during the surface area of contact. A reduction of compres-
the last 20° to 30° of knee extension. This natural sion stresses is further facilitated by the fact that
mechanics of the knee is sometimes emphasized the undersurface of the patella is lined with thick
when dancers straighten the knee to enhance the articular cartilage that deforms under load in such
look of turnout. a way as to distribute forces over an even greater
contact area. The smooth properties of this cartilage
also allow transmission of quadriceps force around
Structure and Movements an angle during knee flexion, minimizing the
of the Patellofemoral Joint losses due to friction. These latter functions are
critical for preventing injury to the quadriceps
As described in chapter 1, the patella is formed tendon, since tendons are not designed to with-
within the tendon of the quadriceps femoris muscle stand either large compressive forces or high fric-
group and is the largest sesamoid bone found in tion.
The Locking Mechanism of the Knee
Perform the following observations and refer

to figure 5.13 to clarify the locking mecha-
nism of the knee.
• Demonstrate the rotation of the tibia
accompanying knee extension in an open
kinematic chain movement. While sitting at
the edge of a table with the knees bent to
90°, use a pen to mark an “x” on the midpoint
of your patella and another “x” on your tibial
tuberosity on your left side. Slowly extend
your left knee. Note the movement of the
tibial tuberosity relative to the mark over your
patella. Redraw the tibial mark with the knee
in full extension, and note that it has moved
laterally, demonstrating the slight external
rotation of the tibia relative to the femur that
occurs in the final phases of knee extension
with the foot free as shown in the figures.
• Demonstrate the rotation of the femur
accompanying knee extension in a closed kinematic chain movement. Stand in first-position parallel
and bend the knees about 30°. From this position of slight flexion, slowly straighten your knees, and
again note the relative change of your tibial tubercle and mid-patella. The mid-patella mark should
now be located more medially, demonstrating the slight internal rotation of the femur relative to the
tibia that occurs in the terminal phases of knee extension when the foot is fixed.
Movements of the Patella Connective Tissue Constraints

During flexion and extension of the knee joint In addition to being anchored to the tibia by the
proper, the patella undergoes a complex gliding patellar tendon below, the patella is further stabilized
movement that includes movements up and down by various other connective tissue structures as seen
with very slight medial, lateral, and rotational com- in figure 5.14A. For example, lateral extensions from
ponents. This leads some authors to consider this a the quadriceps tendons (termed patellar ligaments)
synovial, modified plane joint (Magee, 1997), while and fibrous expansions of the vasti and iliotibial band
others do not consider it a true joint. The kneecap (medial and lateral patellar retinaculum) also pro-
remains at a relatively constant distance from the vide lateral and medial stability for the patella and
tibia because of the patellar tendon. Thus, the are key in preventing the patella from coming out of
change of position of the patella occurs in relation its groove (patellar subluxations or dislocations).
to the femur; the patella slides down during flexion
and up during extension within the femoral groove. Muscles of the Patellofemoral Joint
An excursion of the patella on the femoral condyles
of approximately 2 3/4 inches (7 centimeters) occurs Since the quadriceps femoris directly attaches to the
from extension to full flexion (Frankel and Nordin, patella, adequate and balanced strength of its com-
1980). As this excursion proceeds, there is also a ponents is essential for stability and proper move-
continuous transition in contact surface size and ment of the patella. Other muscles, including the
location that has important implications for potential pes anserinus group and hamstrings, can affect the
cartilage injury. patella less directly. The interplay of these muscles
FIGURE 5.14 The patellofemoral joint (right knee). (A) Anterior view of the patellofemoral joint and associated key
muscles and connective tissues, (B) anterior view of location of patella relative to the femur, (C) posterior view of the
patella showing facets, (D) inferior view of the location of the patella relative to the femur.
is particularly important in the initial stages of knee indication of the lateral force (vector) applied to the
flexion, before the patella becomes well seated and patella, which tends to make the patella track later-
more stable at about 20° of flexion. ally in order to establish a straight-line relationship
between the proximal and distal attachments of the
quadriceps femoris muscle group. Females gener-
Patellofemoral Alignment ally have larger Q angles than men, with a normal
and the Q Angle range considered to be 8° to 15° for males and 10°
to 19° for females (Diduch, Scuderi, and Scott,
The shape, height, mobility, and facing of the patella 1997; Hamill and Knutzen, 1995; Palmer and Epler,
in the femoral groove, as well as its angular relation- 1990) when the knee is in extension and the quad-
ship to the tibia, are important for determining riceps is relaxed. Although controversial, Q angles
stability and tracking of the patella. This angular greater than 15° (Insall, Bullough, and Burstein,
relationship is termed the Q angle. The Q angle 1979; Quirk, 1987), 17° (Hamill and Knutzen, 1995),
or quadriceps angle is a static measurement of the or 20° (Caillet, 1996; Smith, Weiss, and Lehmkuhl,
angle that the patellar tendon makes relative to the 1996) are considered abnormal and a risk factor for
shaft of the femur as seen in figure 5.16. Since the patellofemoral problems.
patella is relatively free to move upon the femur
when the knee is extended, when the quadriceps
femoris muscle contracts it will try to establish a Patellofemoral Mechanics
straight line between its proximal attachment onto
the femur and pelvis and its distal attachment onto Underlying positioning, movement, and the forces
the tibial tuberosity. Thus, the Q angle provides an associated with patellofemoral function are two
FIGURE 5.15 Function of patella to increase moment arm and torque of the quadriceps femoris (right knee). (A) Lat-
eral view of the patellofemoral joint, (B) increase in moment arm due to the presence of the patella, (C) decrease in
moment arm if the patella is absent.
important principles. These principles are the law of

valgus and patellofemoral compression forces.
Law of Valgus
Because the femur normally runs slightly obliquely
inward, the previously described Q angle is formed
with its concomitant tendency to pull the patella lat-
erally as seen in figure 5.17. This predisposition for
lateral motion of the patella is referred to as the law
of valgus. This underlying tendency in the normal
knee can be further exaggerated in the abnormal
knee by many structural and functional factors,
including femoral anteversion, genu valgum, tibial
torsion, a laterally placed tibial tuberosity, a patella
that sits high (patella alta), an excessively mobile
patella (hypermobile), tightness of the lateral sta-
bilizers of the patella, and generalized quadriceps
weakness. Lateral tracking causes the patella to abut
against the lateral portion of the femoral groove.
The resultant excessive shear forces can damage
the cartilage lining the underside of the patella and
cause patellofemoral dysfunction and pain.
It is important to realize that although many of the
factors that tend to increase lateral tracking are struc-
tural and not readily changed, quadriceps strength
can be easily improved and the vastus medialis is
in a perfect position to counter this tendency for
lateral tracking of the patella. Hence, adequate and
balanced strength of the quadriceps is an essential FIGURE 5.16 The Q angle (right knee, anterior view).
Patellofemoral Alignment: The Q Angle and Patellar Tracking
Perform the following procedures to measure your Q angle, and note the movements of the patella
and presence of lateral patellar tracking.
1. Sit with your legs extended to the front and your quadriceps relaxed. Grasp the sides of your patella
between your thumb and index finger, and move the patella from side to side. Note how mobile it
is with the quadriceps relaxed. Passive movement of the patella up to half of its width medially
and up to half of its width laterally is considered normal (Magee, 1997). Now, draw an “x” in ink
on your tibial tuberosity and another “x” on the midpoint of your patella as shown in A. Then, draw
one line connecting the tibial tuberosity and the midpoint of the patella and extending about 3
inches (7.6 centimeters) past the patella. Draw a second line from the midpoint of the patella
upward, in line with the anterior superior iliac spine of the pelvis. The angle that is described with
its apex at the midpoint of the patella is the Q angle. Use a protractor or goniometer to measure
it and note if it is above “normal” values for your gender.
2. Now slowly tighten your quadriceps, focusing on “pulling” the kneecap up toward your waist without
letting the knee move backward into hyperextension. While keeping the quadriceps contracted,
draw another “x” on the midpoint of the patella, and note any lateral excursion of the patella
(“lateral patellar tracking”) that has occurred as shown in B. Also, with the quadriceps firmly con-
tracted, grasp the sides of the patella between your thumb and index finger and carefully attempt
to move the patella from side to side. Note how limited passive movement of the patella is when
the quadriceps is contracted and how important the quadriceps is for stabilizing and directing
movement of the patella.
measure for promoting sound patellar mechanics femoral compression force is the force pressing the
and preventing patellofemoral injuries. kneecap back against the underlying femur. This
force can become quite large, and an understanding
Patellofemoral Compression Forces of its genesis is important for preventing and alleviat-
ing patellofemoral problems.
Another important consideration in patellar mechan- The two most important determinants of patel-
ics is patellofemoral compression forces. Patello- lofemoral compression forces are the magnitude
riceps tendon and patellar tendon changes; now the

force does not just act vertically, but rather there is a
larger component of the quadriceps force that acts
in a direction to create compression of the patella
against the underlying femur (C 2) as seen in figure
5.18B. Thus, with increasing knee flexion, an increas-
ing quadriceps force (Fm 3) and an increase in the
percentage of this force that is being directed toward
the patellofemoral joint act together to increase com-
pression forces (C 3) as seen in figure 5.18C.
Drawing from activities of daily living, as the
angle of knee flexion and magnitude of quadriceps
contraction increase from walking to stair climbing
to deep knee bends, associated compression forces
have been calculated to rise from approximately .5
to 1.2 times body weight to 3.3 times body weight to
7.6 times body weight (Reilly and Martens, 1972). For
a dancer weighing 120 pounds (54 kilograms) these
activities would be associated with approximately 60
to 144 pounds (27-65 kilograms), 396 pounds (180
kilograms), and 912 pounds (414 kilograms) of com-
pression force, respectively. Examples of movements
from dance that would have high patellofemoral
compression forces include the grand plié, fondu,
FIGURE 5.17 Law of valgus. Orientation of quadriceps lunge, movements used to get up from and down
in the frontal plane, Q angle, and consequent valgus to the floor, and the jump. Large jumps have been
vector (right knee, anterior view). estimated to be associated with forces of about 20
times body weight (Dowson and Wright, 1981), that
of quadriceps contraction and the angle of knee is, about 2,400 pounds (1,089 kilograms) of compres-
flexion. That is, the harder the quadriceps contracts sion force for a 120-pound dancer.
the greater the compression force, and the farther
the knee bends the greater the compression force.
However, often these two factors are linked together. Muscular Analysis
For example, when one bends the knee from a stand- of Fundamental
ing position such as in a grand plié, the center of
gravity of the body falls increasingly posterior to the Knee Movements
axis of rotation of the knee joint as the plié proceeds.
This increases the effect that gravity has to make the As previously described, the knee is primarily capable
knees bend further (increased moment arm of the of flexion and extension, with some transverse rota-
resistance), requiring greater quadriceps force to tion. The knee joint functions to help support the
counter this effect of gravity and a resultant higher weight of the body as well as to change the length
compression force. of the lower limb in accordance with movement
At the same time, as the knee bends, the effect of requirements. For example, in walking, through
the changing angle between the quadriceps tendon appropriate timing of flexion and extension of
and patellar tendon also contributes to the rising com- the knee, vertical movement of the whole body’s
pression force. When the knee is in full extension or center of gravity is minimized and energy economy
very slight flexion, the patella is being pulled upward maximized. A summary of the key muscles capable
almost parallel to the femur, and the quadriceps tendon of producing the fundamental movements of the
and patellar tendon are almost in line. Hence, this knee is provided in table 5.2.
force is acting primarily in a vertical direction, and
there is little or no patellofemoral compressive force Knee Flexion
(C 1) irrespective of the magnitude of quadriceps
tension (Fm 1) as seen in figure 5.18A. However, as Remember that knee flexion involves bringing the
knee flexion proceeds, the angle between the quad- posterior surfaces of the upper leg and lower leg
FIGURE 5.18 Increasing patellofemoral compression force. (A) Knee almost straight, (B) greater knee flexion, (C)
greater magnitude of quadriceps contraction.
closer together. The hamstrings and other flexors ent. Once the knee is “unlocked” and begins to
of the knee (table 5.2) are used concentrically when flex, gravity becomes the primary force and tends
flexion is occurring against gravity or resistance as to create further flexion of the knee. Under these
in prone knee curls (table 5.3E, p. 276) or standing circumstances the knee flexors are not working to
knee curls (table 5.3F, p. 277). The knee flexors are create knee flexion; rather the knee extensors are
also used concentrically to flex the knee as the lower working to either maintain that angle of knee flex-
limb swings backward during walking and running ion (isometrically) as seen in figure 5.20 or control
gait. In dance, the knee flexors can also be used to further flexion (eccentrically) as when the body is
shorten the length of the limb to facilitate turning, being lowered to the floor. So, the knee extensors
as in fouetté turns, and to effect a desired shape such (quadriceps femoris) act in this postural or “antigrav-
as in a passé, attitude, or the back leg of the stylized ity” role very frequently in dance on the support leg
stag leap seen in figure 5.19. or legs. In impact movements such as jumping, this
However, during standing with the weight of the eccentric knee flexion is vital for shock absorption
body supported by the foot, the situation is differ- and deceleration of the falling body.
TABLE 5.2 Knee Movements and the Muscles That Can Produce Them
Knee joint movement Primary muscles Secondary muscles

Flexion Hamstrings Popliteus*
Gracilis
Sartorius
Gastrocnemius
Extension Quadriceps femoris Tensor fasciae latae
External rotation Biceps femoris Tensor fasciae latae
Internal rotation Semitendinosus Gracilis
Semimembranosus Sartorius
Popliteus (when foot free)
*Unlocks the knee at beginning of knee flexion.
FIGURE 5.19 Sample dance movement showing knee flexion and FIGURE 5.20 Knee extensors working isometrically to pre-
associated prime movers. vent gravity from producing further knee flexion.
Photo: Roy Blakey. Dancer: Douglas Nielsen in Viola Farber’s “Last Call.” Photo: Roy Blakey. Dancer: Douglas Nielsen.
Knee Extension (brushes), battements (kicks), and the movement

shown in figure 5.21.
Remember that knee extension involves “straighten- When the foot is weight bearing (closed kinematic
ing” the knee or decreasing the angle of knee flex- chain), the quadriceps are used concentrically to
ion. The four quadriceps muscles are the extensors extend the knee. This movement is used in walking
of the knee and are used concentrically to extend up stairs or rising from sitting in a chair. Examples
the knee both when the foot is free and when it is of strengthening exercises that include this form
weight bearing. When the foot is free (open kine- of knee extension are the wall squat (table 5.3G,
matic chain), the quadriceps are used to produce p. 277) and plié/leg press (table 5.3H, p. 278) and
knee extension isometrically in exercises such as lunge (table 5.3I, p. 278). In dance, this form of
straight leg raises (table 5.3B, p. 275) and concentri- knee extension is used during rising from a plié
cally in exercises such as terminal knee extension or fondu. Concentric powerful use of the knee
(table 5.3C, p. 275) and sitting knee extension (table extensors is also operative in movements such as
5.3D, p. 276). In dance, the knee extensors can be the takeoff in jumping to help effect the desired
used concentrically to produce a straight position vertical rise of the center of gravity and propel the
of the knee in the gesture leg in the développé body through space as seen on the left leg in figure
or isometrically to maintain a straight position of 5.21. Knee extension is also used isometrically in
the knee of the gesture leg in the tendu, dégagés dance to maintain an extended knee on the support
en l’air that includes circling of the foot (en dehors

and en dedans). With this movement dancers are
classically instructed to keep the knee stationary as
the foot describes a semicircle, oval, or tear shape
(depending on the teacher’s approach).
Key Considerations
for the Knee
When analyzing more complex movement that
encompasses multiple joints, it is important to take
into account the actions of multijoint muscles and
specifically Lombard’s paradox.
Actions of Two-Joint Muscles

Of the 12 muscles that act on the knee joint, all
except the vasti muscles and popliteus cross the hip
joint or the ankle joint in addition to the knee joint.
When these muscles contract to produce movement
at the knee, they also tend to move other joints. In
some cases the multiple actions of a given muscle can
be used together. For example, in a développé to the
front, the actions of the rectus femoris (hip flexion
and knee extension) are both utilized to effect the
motion. However, this is actually a difficult situation
for the muscle in that it is shortening across both
joints and can easily reach such a shortened posi-
tion that it has difficulty generating force (active
FIGURE 5.21 Sample dance movement showing knee extension. insufficiency). And many dancers may experience
© Martha Swope. Dancer: Susan McLain in “Diversion of Angels” with the Martha Graham Dance discomfort or cramping in the rectus femoris when
Company. performing a développé to the front, especially when
working on increasing the height of the leg, until
adequate strength of other hip flexors, such as the
leg in many movements performed at the barre or iliopsoas, is developed.
center floor. However, more frequently, the multiple actions
are not desired simultaneously, and the muscle
Knee Rotation remains the same length or is actually lengthened
across one joint as it shortens across the other joint.
The internal rotators and external rotators of the An example of the former condition occurs with
knee listed in table 5.2 are key for controlling twisting relevés in which the gastrocnemius remains the
or pivoting movements of the body when the foot same length across the knee joint, as no change in
is on the ground, as in association with changes in joint angle occurs there, while it shortens across
direction. In dance the subtle rotations of the tibia the ankle joint to effect ankle plantar flexion. An
are also sometimes used when the foot is in the air to example of the second condition occurs when one
enhance the aesthetics of a movement. For example, extends the leg back from a passé position (such as
in a back attitude, slight external rotation of the tibia with an arabesque) in which the rectus femoris is
and “winging” of the foot are sometimes encouraged being lengthened across the hip joint (via hip hyper-
in classical ballet to help effect the desired turned- extension) as it is shortening across the knee joint
out line of the lower extremity. Less frequently, to produce knee extension. This latter condition
rotations of the tibia are actually incorporated into allows a more favorable length of the muscle to be
the movement, as in performing a rond de jambe maintained such that greater force can be generated
and active insufficiency delayed. Consciously using conservative approach hold that a fuller range of
this principle when performing this movement—that motion is needed to develop adequate strength and
is, concentrating on fully hyperextending the hip explosive power necessary for high-level athletic
and feeling the rectus femoris stretch across the performance. They also hold that such exercises,
hip and the hip extensors (hamstrings) lift the knee if performed with good technique and advanced
up, before extending the knee—can often help you appropriately, can actually have a protective effect
maintain a greater height of the leg as the knee is through strengthening the knee structures and
extended. involved musculature, such that greater forces can
be withstood during activity before injury occurs.
Lombard’s Paradox Looking at this issue as specifically related to
dance, there are several additional factors that
As discussed in chapter 2, in accordance with should be taken into account. First, potential risk to
Lombard’s paradox, when the hamstrings and rectus the knee is probably lessened by (1) the traditional
femoris simultaneously contract, extension of both use of music and counts to encourage a slow and
the knee and hip will tend to predominate (Lom- controlled descent and rise from a plié; (2) the com-
bard and Abbott, 1907). This co-contraction of the monly used directive to “lift out of your knees,” as
quadriceps and hamstrings to produce knee and well as to avoid hesitating, or “sitting,” at the bottom
hip extension is frequently used during everyday as of the plié and to instead keep movement continu-
well as dance movements, as in standing up from a ous; (3) the use in some dance forms of a barre,
chair, the up-phase of pliés, and the takeoff phase which can aid with balance, as well as in some cases
of jumps. provide some unweighting of the knees; (4) the lack
of external weights (such as barbells) so that only
body weight is of concern; and (5) the common
Special Considerations use of turned-out positions that may recruit other
muscles such as the hip adductors and lessen the
for the Knee in Dance required magnitude of quadriceps contraction and
When taking into account the mechanics of the tib- resultant patellofemoral compression forces. Fur-
iofemoral and patellofemoral joint, there are several thermore, performing pliés in different positions
issues in dance that warrant further discussion. These may represent slightly different benefits and risks.
issues include use of the grand plié, twisting of the For example, third- and fourth-position grand pliés
knee in turnout and other movements, knee hyper- performed center floor not only require marked
extension, and specific muscle use as they relate to strength in the quadriceps but also high skill levels to
achieving the desired aesthetic of common types of maintain balance, turnout, and alignment and have
dance while keeping knee injury risk low. been found to involve greater overall longitudinal
rotation at the knee relative to second-position grand
The Grand Plié pliés (Barnes et al., 2000).
Lastly, potential functional strength benefits
There is much controversy about the use of a full should be considered. Many female dancers have
squat or grand plié. Concerns cited are the large lower absolute quadriceps strength levels than some
stresses applied to the menisci and posterior cruciate other types of athletes or than might be desired
ligament (Escamilla, 2001) and the dislocating force (Kirkendall et al., 1984; Koutedakis, Agrawal, and
due to the approximation of the calf and back of the Sharp, 1998; Koutedakis et al., 1997; Mostardi et al.,
thigh and the parallel component of the hamstring 1983), and grand pliés (as well as jumps and hinges)
muscles (angle of muscle attachment—chapter 2), as are among only a few exercises that include sufficient
well as very high associated patellofemoral compres- overload to effectively enhance strength. Not to
sion forces. These concerns have led to the common provide adequate stimulus to improve quadriceps
recommendation of limiting active knee flexion strength and not to allow practice of motor patterns
(such as accompanies squats, pliés, and lunges) to including marked knee flexion in a slower, more
about 90° or a position in which the thigh is parallel controlled manner might actually be a disservice to
to the floor (parallel squat) for recreational athletes dancers and increase their risk when choreography
or deconditioned older individuals. demands the use of full knee flexion, often at a faster
However, the application of these recommenda- tempo and in a more complex movement pattern
tions to competitive athletes, including well-condi- later in the class or in rehearsal and performance
tioned dancers, is highly debatable. Critics of this (figure 5.22).
DANCE CUES 5.1
“Lift Out of Your Knees”
T he instruction to “lift out of your knees” is sometimes used by teachers in an effort to reduce knee
stress when dancers are performing demanding movements such as grand pliés or movements
involving going down to the floor.
This cue of “lifting out of your knees” is often further explained as “don’t let your weight drop into
your knees.” One could interpret these cues from an anatomical perspective in several ways. One inter-
pretation is that they encourage the use of muscles to control motion at the knee, rather than allowing
excessive momentum and reliance on passive constraints. For example, eccentric contraction of the
quadriceps muscles (in conjunction with co-contraction of many other muscles) can be used to control
the flexion of the knee as the body lowers toward the floor; and when full flexion is approached, this
muscle contraction is maintained rather than the dancer’s relaxing the quadriceps and “sitting in the
plié,” relying on passive tissues such as the ligaments of the knee to maintain the flexed position. Such
an approach is advantageous in terms of creating more joint stability and less ligamental stress.
Another interpretation of this cue relates to contraction of muscles above the knee, particularly of
the hip and torso. For example, using the hip extensors eccentrically and “pulling up” with the abdomi-
nal muscles and back extensors to help maintain desired positioning of the torso relative to the knee
during knee flexion may reduce knee stress. The potential influence of muscle use on forces borne
by the body was demonstrated in one study that included jump technique cueing, which resulted in
greater use of the hamstrings and 22% reduction in peak impact forces (Hewett et al., 1999).
Considering all these factors, although the recom-

mendations of limiting knee flexion to about 90°
for beginning recreational athletes seem prudent,
another approach is warranted in the dance arena.
One recommended approach would be to use grand
pliés judiciously in dancers with “healthy knees,” with
limited consecutive repetitions and close attention
to technique and appropriate conditioning and
skill level. Appropriate skill and strength should be
present so that the descent and rise are controlled,
the knees go as much to the side as hip turnout per-
mits, and the pelvis stays vertical as shown in figure
5.23A—versus the common error of tilting the torso
and pelvis anteriorly with resultant internal rotation
of the femur and in-facing of the knees as shown in
figure 5.23B. Keeping in mind the dislocating forces
when in full flexion, dancers should be advised to
maintain an active contraction of muscles with a
quick reversal in direction at the bottom of pliés to
enhance joint stability and avoid a position in which
support is provided solely by passive constraints such
as ligaments.
Due to the inherent greater strength and balance
challenges, a more conservative approach can be
FIGURE 5.22 Sample dance movement demanding high employed when a barre is not used for first-, third-,
levels of knee flexion, quadriceps strength, and neuromuscular fourth-, and fifth-position grand pliés, as is commonly
coordination. done in modern and jazz dance. Such center floor
Photo courtesy of Keith Ian Polakoff. CSULB dancer Dwayne Worthington.
movements should be used with more skilled dancers with two-hand support; (2) side to the barre with
who do not experience knee discomfort; and when decreasing one-hand support; (3) center floor with
one is teaching these movements to more beginning range increasing in accordance with ability to main-
dancers, a logical progression should be used. For tain balance and body placement; and (4) center
example, skill can be developed (1) facing the barre floor with choreographic-specific challenges such as
adding off-center torso and arm movements.
The Hinge
Hinge movements take on various forms but gener-
ally involve keeping the torso in line with the knees
as the knees flex and lower toward the floor on a
diagonal. They represent an important element of
dance vocabulary in jazz and some forms of modern
dance, including Horton and Graham techniques,
as seen in figure 5.24. The position of the torso
makes this movement even more challenging than
the grand plié in terms of quadriceps strength and
neuromuscular coordination. Hence, a well-designed
progression similar to that used with grand pliés is
recommended for less-skilled or -conditioned danc-
ers, or those new to this movement. An example of
a progression would be (1) a series of wall squats
(table 5.3G, p. 277) performed very slowly or with
holds; (2) side to the barre with one-hand support
while performing a hinge with gradually increasing
FIGURE 5.24 Example of a hinge (side tilt) as seen in the

FIGURE 5.23 First-position grand plié with (A) desired Graham technique.
body placement and (B) undesired body placement. Photo courtesy of Scott Peterson. Dancer: Susan McLain.
range while form is maintained; (3) center floor with significant portions of their turnout from the knee,
range gradually increasing while form is maintained; the ankle-foot, or both; and in a study of elite ballet
and (4) gradual addition of choreographic-specific dancers only approximately 58% of active turnout
challenges such as adding torso or arm movements came from the hip (Hamilton et al., 1992). While
or classic pre- and post-linking movements. When some individuals are critical of the use of full turnout
adequate strength and skill are developed, the risks of the feet, the issue is complex in that use of such
are dramatically lowered, and hinges offer both an positioning of the feet at an early age may facilitate
important artistic element and an effective means of the development of hip external rotation, and the
developing strength and skill for many demanding incidence of knee injuries has not been shown to
movements that require lowering the body weight be higher in schools that emphasize greater turnout
to(ward) the floor or raising the body away from than schools that allow less lateral positioning of
the floor. the feet. Furthermore, some rotation of the tibia is
normal. For example, 7 to 14° of external rotation
Twisting of the Knee in Dance was found to occur during stair climbing (Hamill
and Knutzen, 1995). In one study of dance, about
Although the relative rotary motion between the tibia 27° of knee external rotation was found to accom-
and femur expands functional movement capacities, pany a plié, and about 22° of knee external rota-
excessive rotation can produce potentially injurious tion occurred on the support leg during a penché
ligamental or patellofemoral stress. Thus, particular (Worthen, Patten, and Hamill, 1998). So, further
care must be taken to avoid excessive rotation with research is needed to clarify the relationship between
turnout or other dance movements. tibial rotation and injury risk.
However, whatever the aesthetic demands of the
Forcing Turnout school of dance, it is logical that the greater the pro-
portion of turnout that can be achieved from the
Some dancers use excessive rotation from the knee
downward to achieve turnout, and this practice is
termed “screwing the knee” or forcing turnout. To
avoid forcing turnout during dynamic movement,
it is important to recall that knee flexion allows
more rotation of the tibia due to slackening of
ligamental constraints, as well as external rotation
of the femur associated with unlocking the knee.
Thus, when the knee bends, such as at the base of
a plié or during a weight shift, it is easy to shift the
heel forward to obtain greater turnout of the feet.
However, this practice should be avoided because
when the knee straightens, the femur internally
rotates and the ligaments become taut, and unde-
sired torsional stress will occur at the knee if the
foot is positioned excessively outward (figure 5.25).
Conversely, when extending the knees it is easy to
exaggerate the associated internal rotation of the
femur if external rotation is not maintained at the
hip joint. Again, the distal tibia is being held more
externally rotated by the foot against the floor as
the femur internally rotates, resulting in torsional
stress at the knee. Both of these undesired practices
also create a more laterally positioned tibial tuberos-
ity relative to the midpoint of the patella, increas-
ing the Q angle and increasing patellofemoral
stress.
Unfortunately, how much rotation from the knee
downward is “normal” versus potentially injurious is
controversial. In reality, dancers training in dance FIGURE 5.25 Dancer demonstrating extreme forced
forms where “perfect” turnout is emphasized derive turnout while standing in first position.
DANCE CUES 5.2
“Bring the Heel Forward”
T he instruction to “bring the heel forward” or “present the heel” is sometimes used by teachers in
an effort to maximize turnout in open kinematic chain movements in which the foot is moving
on the floor or coming off the floor, such as with a tendu or dégagé.
A desired anatomical interpretation is to think of the upper leg and lower leg as one continuous unit
in which rotation that started at the proximal end (the hip joint) will result in rotation at the bottom
end—such that the back of the heel will rotate from its original position of facing backward (when
the leg is parallel) medially and forward. To reinforce this concept, the image is sometimes used of
reaching the leg out and spiraling it around the axis running lengthwise through the middle of the
limb. This movement can be thought of as like that of a screwdriver, where rotation of the proximal
end by the hand results in rotation at the distal end. In contrast to this desired initiation, some danc-
ers respond to this cue by bringing the heel forward from externally rotating the tibia relative to the
femur at the knee joint. Hence it can be helpful to incorporate the hip into this cue, such as by cueing
to start the rotation by bringing the trochanter back and continuing the rotation down the leg such
that the heel rotates “in and forward.”
hip, the less rotation will be required from the knee Valgus Stress in Dance
downward. The need to emphasize fully develop- Floor work in jazz and modern often includes posi-
ing external rotation from the hip is given further tions that incorporate internally rotating the back
support by findings that (1) ballet students exhibit leg, with the lower leg and foot facing back as seen
increased active range of hip external rotation but in figure 5.26. Although performance of such posi-
not increased external rotation below the hip when tions is often not recommended for sedentary or
compared to nondancing university students (Khan recreational athletes, it is an important element of
et al., 1997); (2) elite female ballet dancers with some dance forms; and many dancers have adequate
more total injuries had lower values of total turnout hip range of motion to allow performance of such
(Hamilton et al., 1992); and (3) in personal clinical positions without undue knee stress. However, if
experience, many dancers with patellofemoral pain inadequate hip or quadriceps flexibility is present
syndrome experienced relief of symptoms by improv- (particularly in men with limited hip internal rota-
ing turnout technique. tion), such positions might cause excessive valgus
To lessen knee stress, emphasize utilizing the knee stress and knee discomfort.
hip external rotators to help direct the knee over If dancers do experience knee discomfort, they
the foot during movements such as pliés, and avoid should perform supplemental stretching daily;
shifting the heel forward when the knee is flexed. and the position can be temporarily modified as
Furthermore, maintain as much external rotation as shown in figure 5.26 as adequate hip flexibility is
possible at the proximal end of the femur (hip joint), developed.
and avoid exaggerating the slight internal rotation Valgus, varus, and rotational stresses also occur at
of the femur relative to the tibia (associated with the knee in dynamic movement as when the dancer
the locking mechanism of the knee) when extend- changes direction, moves side to side, or moves
ing the knees in movements such as rising from on a diagonal. Studies looking at sidestepping and
a plié. When the foot is free, such as in brushes, crossover cutting maneuvers suggest that such move-
emphasis should be on rotating the hip and car- ments can place large stresses on the anterior cruci-
rying the external rotation down the leg such that ate and collateral ligaments of the knee that are of
the “heel comes forward,” rather than “bringing the sufficient magnitude to cause ligament injury if the
heel forward” from excessive tibial rotation. In the muscles of the knee do not provide adequate stability
author’s experience, most dancers do not fully utilize (Besier, Lloyd, Cochrane, and Ackland, 2001). These
or maintain the potential hip external rotation that stresses are markedly higher in situations in which
their bodies possess. changes are unanticipated and the muscles do not
than modern dancers (average of 13° vs.

5°). However, even dancers with extreme
hyperextension can learn to control the
extent of hyperextension allowed both in
standing and in dance movements.
Two tactics for controlling knee hyper-
extension in dance include (1) limiting the
degree of knee extension and (2) limiting
the degree of femoral internal rotation.
The first approach relies on the principle
of stopping the knee earlier as it extends,
when the center of mass of the whole body
is just over the axis of the knee joint rather
than anterior to the knee joint, so that
passive knee hyperextension is avoided.
Sometimes cueing to do just this, that is, to
simply not straighten the knees so far or to
“pull the knees straight up” versus “push-
ing the knees back,” may be sufficient to
prevent the problem. Similarly, thinking of
“pulling up” just below the back of the knee
at the same time that the front of the knee
is being “pulled up” can encourage co-con-
traction of the hamstrings and quadriceps
femoris. Since the hamstrings are flexors of
FIGURE 5.26 Potential valgus stress of can be reduced by allowing the
right ischial tuberosity to lift slightly off the floor. the knee, if recruited early enough when
the knee is still slightly bent, they can be
used to prevent excessive knee extension.
have adequate time to counter the increased loads Alternatively, keeping the knees farther forward, in
placed on the knee (Besier, Lloyd, Ackland, and front of the ankle, as they are straightened can also
Cochrane, 2001). It is likely that dancers who train prevent the center of mass of the body from moving
regularly will develop strategies for standard dance anterior to the axis of the knee where it will tend to
vocabulary that will help minimize the stress to the produce knee hyperextension.
knee ligaments. The second approach relies on the linking of femo-
ral internal rotation with hyperextension of the knee.
Hyperextended Knees in Dance Since the final ranges of knee extension naturally
incorporate internal rotation of the femur due to the
When the body is standing erect, the gravity line locking mechanism of the knee, focusing on using the
falls slightly in front of the knee joint axis, leading external rotators at the hip to limit this internal rota-
to a “locking” of the knee in extension by a small tion of the femur and keep the knees facing directly
gravitational torque. This locking is also due to the forward rather than twisting inward can prevent unde-
terminal rotation associated with full knee extension sired knee hyperextension. Excessive internal femoral
previously discussed (e.g., the locking mechanism rotation can also be avoided by focusing on “pulling
of the knee). Because this end position is passive up” with the abdominal muscles while bringing the
and does not involve contraction of lower extrem- bottom of the pelvis forward to create a neutral pelvis,
ity muscles, dancers with genu recurvatum will not so that the femoral internal rotation associated with
exhibit the same passive endpoints, and the knees an anterior tilt of the pelvis is avoided.
will not stop at extension but rather will continue However, with whichever method is used, since the
to a position of hyperextension (figure 5.27A). hyperextended position will “feel straight” to a dancer
Hyperextended knees are very prevalent in dancers, who is used to hyperextending the knees, this new
and one study (Trepman et al., 1994) showed that position will often feel as though the knees are bent.
all of the dancers studied exhibited knee hyperex- Often a mirror and visual correction must be used
tension when standing in turned-out first position, initially by the dancer until the internal sensation of
but with significantly greater magnitude in ballet “straight” is relearned.
overload and resultant increase

in size (hypertrophy), others
conjecture that other factors
such as the type of muscle con-
traction (higher emphasis on
concentric vs. eccentric), speed
of muscle contraction, or the
range of motion utilized by the
sport may also influence subtle
differences in muscle develop-
ment. In the dance arena, many
dancers’ bodies can change to
develop a “longer,” less “bulky”
look after training at schools
that emphasize this aesthetic.
Further scientific investigation
into this area is warranted, but
two possible mechanisms for
decreased thigh development
are movement economy and
altered muscle recruitment
patterns.
In terms of movement econ-
FIGURE 5.27 Knee hyperextension. (A) Standing with the heels separated and knees omy, dancers with marked thigh
hyperextended; (B) correction of knee hyperextension, allowing the heels to be brought development sometimes appear
closer together. to be using excessive effort
with movement, sometimes
Knee Hyperextension described by dance teachers as “gripping” or “work-
and Genu Varum ing tensely.” In contrast, dancers with the desired
“long” muscle sometimes appear to be working more
When genu varum is present, allowing the knees economically, without apparent wasted effort. Two
to hyperextend can increase the distance between examples of these extremes are shown in figure 5.28,
the knees, giving the leg a more “bowed” look. In where the execution of a second-position plié was
contrast, using the approaches just described to associated with 25% versus 125% of a maximum iso-
correct knee hyperextension—so that the knees are metric quadriceps contraction in a highly skilled ballet
farther forward relative to the ankles and the knees dancer noted for her “long lines” (figure 5.28A) versus
face forward rather than inward as the inner thighs a less skilled dancer noted for working with excessive
(hip adductors) are slightly contracted to pull the “gripping” (figure 5.29B). Considering the marked
legs “together and up”—can help minimize the dis- difference in muscle effort associated with perfor-
torted appearance of genu varum. And over time, mance of the same movement, one could theorize that
some dancers appear to be able to reduce apparent the second dancer would have greater hypertrophy
genu varum. of the quadriceps from dance training. This concept
of greater economy being associated with skill level
Overdevelopment of the Quadriceps was given further support by another study that
found significantly lower levels of activation of the
In some dance forms such as ballet, there is the rectus femoris and biceps femoris in key phases of a
desire to develop the body so that the legs appear turned-out demi-plié in more experienced dancers
“long”; and “short, thick, overdeveloped” thighs are (Ferland, Gardiner, and Lèbé-Neron, 1983).
avoided. Although genetics, body type, and limb In terms of altered muscle recruitment patterns,
length contribute to the appearance of the thighs, it may be that dancers with greater thigh develop-
and dancers are encouraged to embrace the body ment recruit the quadriceps femoris more in various
type they have, training can also influence this devel- dance movements. This might relate to alignment
opment. While some hold that thigh development is issues such as positioning of the torso or the amount
simply related to the amount of quadriceps stress or of turnout used at the hip. For example, leaning
Controlling Hyperextended Knees

When the Foot Is Weight Bearing
Stand with your side to a mirror in a parallel first position and fully straighten your knees. Note if
the knees appear slightly bent, straight (extended), or if they bow backward (hyperextension or genu
recurvatum). If your knees are hyperextended, try the following exercises to help control this hyper-
extension.
• Limiting the degree of knee extension. While looking in the mirror, slowly bend and then straighten
your knees. Identify the position visually and kinesthetically in which the knees are just straight and
not overextended. Then, try to find this position kinesthetically and just use a visual check in the mirror
to see if you were accurate. Focus on pressing down into the floor with the whole foot and keeping
the ischial tuberosities (“sitz bones”) facing down and forward over the ankles rather than facing back
and over the heels as the knees straighten (A).
• Limiting the degree of femoral internal rotation. Now, bend your knees slightly and let your
knees drop in. Then, use your hip external rotators (deep outward rotators) to bring the knees out
relative to the foot as shown in B. Repeat this procedure several times; and when you have clear
ability to activate the external rotators, concentrate on using these same deep outward rotators to
keep your knee facing straight ahead as you slowly straighten your knees just to an extended, not
a hyperextended, position. Also focus on using the abdominal–hamstring force couple to keep the
“bottom of the pelvis under” so that the pelvis maintains a neutral position as the knees straighten.
Notice when you relax the deep outward rotators and the abdominals whether the knees go “in and
back” and the pelvis tilts anteriorly.
A1 A2 B1 B2
For the dancer with extreme genu recurvatum, these technique cues can be used to allow the heels
to be brought closer together during standing in turned-out first position (figure 5.27B). Working with
the feet separated and knees hyperextended tends to stretch out the posterior capsule and other
restraints, increasing the degree of knee hyperextension over time and necessitating progressively
greater separation of the heels. For dancers who are used to working with their heels separated more
than an inch, it may be necessary to gradually bring the heels closer together over several months as
skill for controlling hyperextension is developed and new balance strategies are learned.
272
1 1
2 2
3 3
1
1
2 2
3 3
FIGURE 5.28 EMG recordings during a second-position plié

of (A) a highly skilled dancer with movement economy and (B)
a less-skilled dancer with excessive muscular effort. Key: 1 =
hip adductor (adductor longus), 2 = quadriceps femoris (vastus 1
medialis), 3 = hamstrings (biceps femoris).
the torso slightly forward in movements such as a

turned-out plié is often associated with more sense
of effort in the quadriceps than performing the same
movement with the torso more vertical. Alternatively, 2
degree of quadriceps activation may relate more to
habit and preferential muscle recruitment strategies.
The electromyography (EMG) tracings from the 3
dancers shown in figures 5.28 and 5.29 exhibit a wide
variety of recruitment patterns in terms of magnitude
of quadriceps contraction and of relative contribu-
tion of the hamstrings and hip adductors. Teaching
FIGURE 5.29 Example of muscle activation patterns for a
dancers to emphasize greater use of the hip exten- skilled dancer performing a second-position grand plié with
sors and hip adductors may allow less contribution (A) routine performance, (B) cueing to “let the knees drop
of the knee extensors, which would be potentially in,” and (C) cueing to “reach the knees side.” Key: 1 = hip
advantageous in terms of reducing patellofemoral adductor (adductor longus), 2 = quadriceps femoris (vastus
compression forces as well as meeting quadriceps medialis), 3 = hamstrings (biceps femoris).
development aesthetics. Such recruitment patterns of the pes anserinus group and tensor fasciae latae
could theoretically be encouraged by cues that direct were also described in this previous chapter on
students to use more of the inner thighs (hip adduc- the hip, while exercises for the gastrocnemius are
tors) and back of the leg (hamstrings). An example described in chapter 6.
in which cueing designed to emphasize greater use
of the hip muscles (e.g., reaching the knees as close Knee Extensor (Quadriceps Femoris)
to directly side as possible on the down-phase and Strengthening
then pulling the inner thighs up and together on
The knee extensors are very important antigravity
the up-phase of a plié) changed muscle recruitment
muscles that act to control the lowering of the body,
patterns such that greater activity in the adductor
propel the body through space, or maintain an
and hamstrings occurred, as shown in figure 5.29C.
extended position of the knee. Furthermore, ade-
In contrast, cueing to promote the undesired tech-
quate quadriceps strength plays an important role
nique of “letting the knees drop inward” resulted in
in knee joint stability, the prevention or progression
greater activation of the quadriceps in this skilled
of knee osteoarthritis (Suter and Herzog, 2000), and
dancer (figure 5.29B).
proper tracking of the patella. While some female
While excessive use of the quadriceps femoris
dancers are concerned about developing excessive
should be discouraged in order to meet aesthetics in
bulk in the quadriceps femoris muscles, adequate
some dance forms, this does not mean that the quad-
strength is essential for injury prevention; and the
riceps should not be used and that the quadriceps
exercises in table 5.3 can generally be used to develop
should not be strong. As previously discussed, the
strength without excessive bulk because the amount
quadriceps are essential for controlling positioning
of weight (resistance) and volume (number of sets
of the knee. The issue is one of relative contribution
and reps) are generally too low to stimulate a large
of the quadriceps and magnitude of contraction, not
increase in muscle size (hypertrophy).
of avoiding its use.
The knee extension can be strengthened iso-
metrically by pulling the kneecap upward (quad
Conditioning Exercises sets) or isotonically by resisting knee extension. For
dancers who have a history of kneecap problems or
for the Knee who experience knee discomfort with grand pliés, it
Adequate strength and flexibility of the muscles is advisable to begin with exercises such as the quad
crossing the knee are important for performance of set (table 5.3A) and straight leg raise (table 5.3B) in
demanding movements such as jumps, hinges, falls, which the knee is isometrically maintained in a posi-
floor work, and grand pliés. A balance of strength tion of extension so that patellofemoral compression
and flexibility is also important for preventing forces are low. Exercises incorporating only the final
injury. 20° to 30° of extension, such as the terminal knee
extension (table 5.3C) exercise, can also be useful
Selected Strength Exercises for the Knee for providing greater overload to the quadriceps
while patellofemoral compression forces still remain
The most key muscle groups acting on the knee and relatively low. However, for males without patellar
patellofemoral joints are the quadriceps femoris problems and females who have developed adequate
(knee extensors) and hamstrings (knee flexors). For patellar stability and are pain free, performing knee
joint stability and proper mechanics it is essential that extension exercises utilizing a larger range of motion
both of these muscle groups have both adequate (table 5.3D) is valuable to develop the strength
and balanced strength. With the common use of needed for demanding dance movements utilizing
the quadriceps as antigravity muscles, they can be greater degrees of knee flexion.
three times stronger than their antagonists, the When one performs any of these extension exercises,
hamstrings (Hamill and Knutzen, 1995), and it is proper technique is important. Due to the prevalence
important that dancers not neglect strengthening of knee hyperextension in dancers, it is important to
the hamstrings. Sample exercises for these muscles take care that the knee is brought only to a straight
are provided in table 5.3, and a brief description of position and not beyond straight to a position of
their importance follows. Since the hamstrings and hyperextension. The persistent use of hyperextension
one component of the quadriceps femoris (rectus in these exercises can actually decrease knee stability
femoris) act on the hip as well as the knee, some and irritate tissues rather than provide the desired
strengthening exercises for these muscles were increase in joint stability and muscle strength.
described in chapter 4. Exercises for other members (Text continues on p. 279.)
TABLE 5.3 Selected Strength Exercises for the Knee

Muscle group: Knee extensors
Muscles emphasized: Vastus medialis
Joint movement: Knee extension maintained
A. Quad set Sit on the floor with the legs 1. Increase reps from 8 to 12.
extended forward, and pull the 2. Increase sets from 1 to 2 and
kneecap up toward the hip by then 3.
firmly contracting the quadriceps
and holding the contraction for
5 seconds. Slowly release the
muscle.
(Focus on pulling the kneecap up
without pushing the knee back to
avoid hyperextension.)
Variation 1: Perform with one leg
extended and the other knee bent
with the foot on the floor.
Muscle groups: Knee extensors and hip flexors
Muscles emphasized: Quadriceps femoris, especially vastus medialis
Joint movement: Hip flexion with knee extension maintained
B. Straight leg raise Sit with one knee bent with the 1. Increase the weight from 2
(Ankle weight) foot on the floor while the other pounds to 10 pounds gradually,
leg is extended to the front with a in 1- to 2-pound increments.
weight cuff on the ankle. Perform
a quad set and then, while
maintaining a firm contraction of
the quadriceps, raise the extended
leg, hold for 4 counts, and lower it
(Use the quadriceps to maintain
a straight but not hyperextended
position of the knee, as the hip
flexors are used to lift and lower
the whole leg.)
Joint movement: Knee extension
C. Terminal knee extension Sit with one knee bent with the foot 1. Increase the weight from 5
(Ankle weight) on the floor while the other leg is pounds to 15 pounds gradually,
extended to the front with a foam in 1- to 3-pound increments.
support or a towel roll under the
distal thigh and a weight cuff on the
ankle. Slowly extend the knee to a
straight position, hold 4 counts with
the quads firmly contracted, and
(Avoid letting the knee hyperextend.)
chair with the outstretched knee
bent about 30°.
Variation 2: Perform on a knee
extension machine, only utilizing a
range of the last 30° of extension.
(continued)
275
TABLE 5.3 Selected Strength Exercises for the Knee (continued)

Joint movement: Knee extension with hip flexion maintained
D. Sitting knee extension Sit on a Reformer, using the arms 1. Increase the resistance from
(Reformer) to support one thigh and the one spring gradually in small
strap over the foot of that leg. increments.
Then slowly extend the knee to a 2. Bring torso more vertical with
straight position, pause, and return lumbar spine neutral.
(Keep the thigh stationary while
the foot pulls the strap as the
knee extends to a straight but not
hyperextended position.)
position, only sitting on the floor
with a looped band anchored under
the support foot and around the
instep or ankle of the gesture leg.
Variation 1
Muscle group: Knee flexors
Joint movement: Knee flexion
E. Prone knee curl Lie prone on the box with the 1. Gradually increase springs.
(Reformer) knees slightly bent and the straps 2. Increase range of knee flexion.
on the feet. Then slowly bring the 3. Lift knees half an inch off the
heels toward the buttocks, pause, box (slight hip hyperextension),
and slowly lower the leg to the and maintain this position
starting position. throughout the exercise without
(Firmly contract the abdominals to letting the pelvis tilt anteriorly.
maintain a neutral pelvis and avoid
an anterior pelvic tilt.)
Variation 1: Perform with one leg at
a time.
Variation 2: Perform on a knee-curl
weight apparatus.
Variation 3: Perform one leg
at a time with an elastic band
looped around the feet to provide
resistance.
276
Joint movement: Knee flexion
F. Standing knee curl Stand with body weight supported 1. Increase the weight from 5
(Ankle weight) on one leg, with the foot about pounds to 12 pounds gradually,
2 feet away from a wall and the in 1- to 2-pound increments.
forearms resting on the wall. Begin
with the top of the other foot about
1 foot behind the support leg, and
slowly bring the heel toward the
buttocks with a weight around the
ankle, pause, and slowly return to
(Keep the knee in place as it
flexes, and avoid letting it move
forward.)
Variation 1: After flexing the knee
about 30°, lift the whole leg back
and up toward the ceiling (hip
extension).
Variation 2: Perform with a band
tied in a loop under the arch of
the support foot and around the
gesture leg providing resistance.
Muscle groups: Knee extensors and hip extensors
Muscles emphasized: Quadriceps femoris
Joint movement: Knee extension with hip extension
G. Wall squat Stand with the back against a wall 1. Gradually increase the hold from
with the feet parallel, hip width 4 counts to 5 seconds.
apart, and about 1 1/2 to 2 feet 2. Add dumbbells in each hand.
from the wall. Slowly bend the
knees until the thighs are parallel
to the floor with the knees above
the ankles, hold for 4 counts, and
slowly straighten the knees to
(Maintain a firm contraction of the
abdominals so that the pelvis is in
a neutral position with the back of
the sacrum and midthoracic spine
staying in contact with the wall
throughout the exercise.)
(continued)
277
TABLE 5.3 Selected Strength Exercises for the Knee (continued)

Muscles emphasized: Hamstrings/abdominal–hamstring force couple
H. Plié/leg press Start supine on a Reformer, with 1. Gradually increase the
(Reformer) feet parallel in line with hip joints resistance from three springs.
on the foot plate, and knees bent. 2. Perform with one leg with lower
Slowly extend the knees until they resistance.
are just straight, pause, and slowly
bend the knees to return to the
starting position.
(Avoid hyperextending the knees;
guide knees over second toe;
maintain a stable torso and neutral
pelvis.)
Variation 1: Increase range by
allowing the feet to come off the
plate until the knees bend to about
90°, and add a relevé after the
knees straighten.
Variation 2: Perform in turned-out
positions.
(Turn out in accordance with hip
external rotation with the knees
straight.)
(Weight apparatus) Variation 3: Perform on a leg-
press machine in parallel position,
keeping the heels in contact
throughout the exercise.
Muscles emphasized: Hamstrings and quadriceps femoris
I. Lunge Stand with feet parallel and about 1. Gradually increase weight.
hip width apart and arms down
by each side holding a dumbbell.
Step far forward with one foot and
then slowly lower the body until the
front knee is bent to about 90°.
Then slowly straighten the knee,
and push off with the front foot to
(Guide knee over front foot and
keep torso vertical rather than lean
forward or backward.)
278

Muscles emphasized: Hamstrings and quadriceps femoris
J. Forward lunge Stand facing the combo chair. Bring 1. Gradually decrease springs.
(Pilates chair) the pedal down with one foot, and
place the other foot on the top
platform of the chair. Then slowly
raise the body up over the top foot,
pause, lower the body and pedal
down until the top knee is bent
about 90°, and raise up again.
(Guide front knee over foot; avoid
excessive forward lean of the
torso, and maintain an almost
vertical position; focus on pressing
the top foot firmly down and
engaging the hip extensors as the
body is lifted over the top foot;
work only in a range where good
form can be maintained and no
knee discomfort is experienced.)
Knee Flexor Strengthening Closed Kinematic Chain Strength Exercises

The flexors of the knees, including the hamstrings, As discussed in chapter 1, closed kinematic chain
are important for achieving and maintaining bent exercises for the lower extremity involve movement
positions of the gesture leg such as used with a passé at multiple joints (hip, knee, and ankle) while the
or attitude. With the tremendous demands for ham- foot remains fixed or encounters considerable resis-
string flexibility in dance, it is advisable to follow the tance. This is in contrast to an open kinematic chain
knee flexion exercises described next with hamstring exercise in which the distal segment of the extremity
stretching exercises so that the hamstrings do not (e.g., the foot) is free to move. Strength exercises
become tighter, or to utilize exercises emphasizing previously described for the knee such as terminal
hip extension to strengthen the hamstrings. knee extension and prone knee curl are examples of
Prone and standing knee curls emphasize resisted open kinematic chain exercises. Examples of closed
knee flexion. The prone knee curl (table 5.3E) can kinematic chain exercises described in table 5.3, G
be performed with springs or an elastic band resist- through J, include the wall squat, plié/leg press,
ing knee flexion. The standing knee curl (table 5.3F) lunge, and forward lunge.
can also be performed with elastic resistance, but The wall squat (table 5.3G) provides an effective
also afford a relationship to gravity that will allow an way of particularly strengthening the quadriceps
ankle weight to effectively resist knee flexion. The while working on maintaining trunk stabilization
back leg raise shown in chapter 4 (table 4.5D, p. 214) and avoiding the common error of leaning the torso
offers a variation that emphasizes the hip extension forward in pliés. The plié/leg press (table 5.3H)
function of the hamstrings. offers resistance to develop strength in the knee
Controlling Hyperextended Knees

When the Foot Is Not Weight Bearing
Sit with one leg outstretched in front of you and the other knee bent with the foot on the floor. Practice
maintaining a straight but not hyperextended knee in the following exercises.
• Quad set (table 5.3A, variation 1). Place two fingertips about 1 1/2 inches (3.8 centimeters)
above the patella and about 1/2 inch (1.3 centimeters) medial to the inner border of the patella. Focus
on pulling the kneecap up toward your hip without pushing the knee back into hyperextension. A firm
contraction should be felt in the muscle under your fingertips (vastus medialis). If you have difficulty
avoiding pushing your knee back, place the fingertips of your other hand behind your outstretched
knee to help prevent your knee from hyperextending. Co-contraction of the quadriceps and gastrocne-
mius (knee flexor) may be necessary to establish a straight but not hyperextended position. For most
dancers (depending on the size of the calf muscle), the heel of the outstretched leg should stay on
the floor, and lifting of the heel off the floor indicates that the knee is being hyperextended.
• Straight leg raise (table 5.3B). Perform a quad set and then raise the leg off the ground, hold
for four counts, and then lower the leg back to the starting position. Use your fingertips to check that
the vastus medialis is staying contracted, and make sure the knee stays straight and not hyperex-
tended throughout the movement. Avoid the common error of hamstring substitution. When the knee
hyperextends, the line of pull of the hamstrings can switch from behind to in front of the axis of the
knee joint, and thus the hamstrings can produce extension rather than its normal function of flexion
of the knee. When raising the leg off the floor, some dancers will hyperextend the knee and then use
the hamstrings (vs. the quadriceps) to maintain the hyperextension, while other hip flexors such as
the iliopsoas are used to lift the leg. With this substitution, the vastus medialis will not be felt firmly
contracting under the fingertips. This undesired substitution will not produce the desired strengthen-
ing of the quadriceps or develop a desired muscle activation pattern.
in a manner similar to that used with pliés and the Closed kinematic chain exercises have gained
preparation for turns and jumps. It can be performed great popularity in the fitness and rehabilitation
with traditional weight apparatus (leg press machine) arenas in recent years because they better replicate
or on a reformer with a large number of springs functional movements in terms of the loads placed
offering resistance. The lunge (table 5.3I) and par- upon the joints and the complex muscle contrac-
ticularly the forward lunge (table 5.3J) are used to tion involved in coordinating multiple joints. It has
develop lower body strength but can produce injury also been proposed that they place less stress on the
if performed improperly, with too much overload, anterior cruciate ligament and are associated with
or with underlying biomechanical problems. Thus, less patellofemoral compression force in the angles
such exercises should be reserved for adequately of 0° to 53° of knee flexion (Hungerford and Barry,
skilled and conditioned dancers without a history of 1979). However, some of their theoretical advantages
knee problems and performed only with qualified have been questioned by recent research findings
supervision. (Irrgang and Neri, 2000); for example, it appears
With any of these closed kinematic chain exer- that both open and closed kinematic chain exercises
cises, proper technique is particularly important. can be effective in improving joint proprioception
In addition to stabilization and focus on proper (Perrin and Shultz, 2000). Furthermore, open kine-
positioning of the torso, care must be taken to guide matic chain exercises may offer advantages in terms
the knee over the second toe, avoid letting the knee of producing effective overload with less resistance,
fall inward, and lower only to a point at which cor- helping to correct muscle imbalances, and replicat-
rect form can be maintained and no knee pain is ing dance demands of the gesture leg. So, one rec-
experienced. ommended approach is to include a combination
of open and closed kinematic chain strengthening ballet dancers tested exhibited quadriceps tightness
exercises in supplemental conditioning programs for (Clippinger-Robertson, 1991). Another study of pre-
dancers (Clippinger, 2002). In terms of rehabilita- professional ballet dancers showed that 95% of these
tion, medical professionals will select appropriate dancers had at least minimal tightness of the rectus
exercises in accordance with the specific injury and femoris (Molnar and Esterson, 1997). A quick screen-
relative advantages and disadvantages of these two ing test is shown in Tests and Measurements 5.4 that
types of exercises. can be easily used to check quadriceps flexibility.
Stretches for this muscle group are often neglected
Selected Stretches for the Knee in the dancer’s regular stretching routine. Tight
quadriceps muscles may increase the risk for patel-
Table 5.4 provides the normal range of motion for lofemoral problems, so it is important that adequate
general populations (non-dance) as well as the struc- flexibility be achieved and maintained.
tures that primarily limit further ranges of motion To effectively stretch the vasti components of the
for knee flexion and extension. And sample stretches quadriceps, the knee must be brought into full flex-
to improve range in these movements are described ion, and the position of the pelvis is irrelevant since
shortly and shown in table 5.5. these muscles do not cross the hip. In contrast, due
In addition, adequate flexibility of some of the to the proximal attachment of the rectus femoris on
multijoint muscles that cross the knee is important the anterior pelvis, care must be taken that the pelvis
for optimal knee mechanics. For example, tightness is in a neutral or tucked position, since an anterior
in the iliotibial band can exert lateral forces on the pelvic tilt will slacken the rectus femoris and decrease
patella and increase knee injury risk (Jenkinson and stretch effectiveness. Because the rectus femoris is
Bolin, 2001; Reid et al., 1987). Similarly, adequate a hip flexor, bringing the hip into hyperextension
flexibility in the hip adductors is important for cor- prior to bringing the knee toward the buttocks will
rect placement of the knees over the feet in posi- also increase the stretch to the rectus femoris.
tions such as turned-out second (Clippinger, 2005). The quadriceps are commonly stretched by using
Distally, tightness of the calf muscles limits the depth the hand to bring the heel toward the buttocks while
of the plié and can contribute to compensatory foot standing, sitting on a chair (chair quadriceps stretch,
pronation and resultant suboptimal knee mechan- table 5.5B), lying on one side, or lying prone (heel-to-
ics. Stretches for the hip abductors and adductors buttocks stretch, table 5.5A). For whichever variation
were described in chapter 4, and calf stretches are is being used, it is important to realize that due to
described in chapter 6. knee joint structure, when the knee fully flexes the
distal tibia should angle medially relative to the shaft
Knee Extensor (Quadriceps) Stretches of the femur. Hence, this normal motion should be
allowed and twisting of the tibia should be avoided.
Despite having markedly increased flexibility in many The chair quadriceps stretch (table 5.5B) allows the
other areas, dancers are frequently low in flexibility quadriceps to be stretched in a position in which the
in the knee extensors or quadriceps femoris muscle torso is vertical and maintaining a neutral pelvis can
group. This tendency for tightness appears to be more be more readily achieved. The low lunge quadriceps
prevalent (at least in ballet dancers) in dancers with stretch provides a challenging position for the more
many years of training and almost universal in male flexible dancer with adequate hip flexor flexibility
ballet dancers; 75% of female and 100% of male elite in that the weight is on the thigh and above the
TABLE 5.4 Normal Range of Motion and Constraints for Primary Movements of the Knee
Knee joint movement Normal range of motion* Normal passive limiting factors
Flexion 0-135° Soft tissue apposition: posterior aspects of thigh and calf or
heel and buttocks
Muscles: quadriceps femoris
Extension 0-10° Capsule: posterior portion
Ligaments: cruciates, medial collateral, lateral collateral, and
oblique posterior (a ligament located posteriorly)
Muscles: hamstrings (when hip in marked flexion)
TABLE 5.5 Selected Stretches for the Knee

Muscles emphasized: Quadriceps femoris
Joint position: Knee flexion with hip extension
A. Heel-to-buttocks stretch Stand on one leg with a slight 1. Bring the heel closer to the
(Static) posterior pelvic tilt. Bend the buttocks.
gesture leg and, with one hand 2. Bring the knee further back
grasping the foot, gently bring before bringing the heel to the
the knee back until the thigh is buttocks to increase the stretch
approximately vertical. Then bring applied to the rectus femoris.
the heel toward the buttocks
until a moderate stretch is felt
across the front of the thigh while
a neutral position of the pelvis is
maintained.
abdominals to prevent the pelvis
from tilting anteriorly and avoid
twisting the knee.)
floor on one side, using the upper
arm to pull the heel of the upper
leg toward the buttocks.
Variation 2: Perform lying prone on
the floor.
B. Chair quadriceps stretch Sit sideways to the back of a 1. Same as exercise A.

(Static) chair with one foot on the ground
and the other knee hanging
over the front edge of the chair,
approximately perpendicular to
the floor. Use the hand on the
same side to bring the heel of the
hanging knee toward the buttocks
until a moderate stretch is felt
along the front of the thigh.
abdominals to prevent an anterior
pelvic tilt; reach the hanging knee
directly down toward the floor, and
avoid twisting the knee.)
282

Joint position: Knee extension with hip flexion
C. Standing hamstring stretch Stand on one leg with the other leg 1. Gradually increase the height
(Static) lifted to the front while the ankle of the object that supports the
is supported on a barre, chair, or outstretched leg.
box. While maintaining a straight 2. Bring the torso closer to the
knee, lean the torso over the front leg.
outstretched leg until a moderate
stretch is felt along the back of the
knee or back of the thigh.
(Tighten quadriceps if necessary to
maintain the knee in a fully straight
but not hyperextended position; lean
the torso forward by flexing at the
hip while keeping the upper back
extended versus rounded forward.)
patella on the back leg (figure 5.30A). However, this stretching such structures is controversial. Hence,
stretch is often inappropriate for more beginning- it is important that such dancers see an orthopedist
level or tight dancers, in whom inadequate flexibility to determine their restraints and whether it is advis-
necessitates an uncomfortable position in which the able for them to stretch the knee. However, if not
weight is borne on the patella (figure 5.30B). In such contraindicated, very careful, gentle, and consistent
instances, alternatives such as performing the lunge stretching of the knee such as using the standing
stretch without bringing the heel to the buttocks hamstring stretch (table 5.5C) can often result in
(with the lower leg on or off the floor; figure 5.30C) gradual improvement (often taking months or a year
or substituting a prone, side-lying, or standing posi- to achieve a “straight” look). Because the structures
tion (figure 5.30D) are advised. being stretched are not primarily muscular, stretches
should be done with particular care when the body
Knee Flexor Stretches is adequately warmed, avoiding excessive force or
pain that can result in injury.
When the hip is flexed as in a front développé, lack
of adequate hamstring flexibility can limit the ability
to fully straighten the knee. Because the hamstrings Knee Injuries in Dancers
also cross the hip, stretches for these muscles were
described in connection with the hip in chapter 4. The fact that the knee joint is located between
However, there are other times when the hip is not the longest bones of the body and that, although
flexed that some dancers may not be able to fully broad, it is a very shallow articulation, leaves it very
straighten their knees. This may be due to structural vulnerable to valgus and varus stresses with resultant
factors such as the angle between the tibia and femur, potential injuries to the ligaments and menisci. This
as well as soft tissue restraints such as the ligaments potential vulnerability is further heightened by the
and capsule listed in table 5.4, and the prudence of rotation allowed at the knee when it is in a flexed
Screening Test for Quadriceps Femoris Flexibility
While the dancer is lying prone,

the examiner applies light
pressure on the ankle to bring
one heel toward the buttocks
as shown in the figure. Stop if
any pain is experienced. The
dancer should focus on using
the abdominal muscles to pre-
vent the pelvis from anteriorly
tilting throughout the test. The
goal is to be able to easily
bring the heel to the buttocks
with the foot relaxed, but if they
cannot be easily approximated,
the examiner uses a ruler to
measure the distance between
the heel and the buttocks while
maintaining light pressure. Hold-
ing the ankle at a right angle
makes the test more challeng-
ing, but some dancers will be
stopped by approximation of the
posterior thigh and calf muscles
versus quadriceps tightness
with this test variation.
position. Anteriorly, the quadriceps, patella, and Prevention of Knee Injuries

patellar tendon (collectively termed the extensor
mechanism) serve key antigravity, deceleration, Given that the absolute strength of the quadriceps in
acceleration, and stability functions and also can be some dancers may be lower than desirable and that
readily involved in both acute and chronic injuries. low thigh power production tends to be linked with
With this general injury vulnerability and the large greater severity of lower extremity injuries (Kouteda-
demands placed on the knee with jumping, floor kis et al., 1997), many dancers would benefit from
work, and repetitive flexion, it is not surprising that including supplemental quadriceps and hamstring
knee injuries are common in dancers. The percent- strengthening (the latter for balance) in their regular
age of total injuries involving the knee has been training regimes. In addition to isolation exercises,
reported as 16.1% to 17.3% for ballet dancers (Gar- this training would also ideally include exercises aimed
rick, 1999; Quirk, 1987) and 14.5% to 18% for dancers at developing functional strength, such as jumping
at performing arts schools (Rovere et al., 1983; Wiesler drills, in which proprioception and neuromuscular
et al., 1996). A survey of modern dancers revealed skills could be developed in movements commonly
the knee was the most commonly reported site of associated with injury. One study showed that a pro-
injury with 20.1% of dancers reporting injury to this gram utilizing bounding drills (plyometric training)
area (Solomon and Micheli, 1986), while a survey of reduced ACL injury to almost one-third of that seen
Broadway dancers found 15% of dancers reported in untrained athletes (Hewett et al., 1999).
sustaining an injury to the knee during their produc- Adequate flexibility of the quadriceps and paying
tion (Evans, Evans, and Carvajal, 1996). close attention to technique may also help reduce
A B
C D
FIGURE 5.30 Low lunge quadriceps stretch. (A) Flexible dancer with weight on the thigh above the kneecap, (B) tighter
dancer with weight on the kneecap, (C) alternate hip flexor stretch, (D) alternate quadriceps stretch.
285
injury risk. In terms of technique, excessive twisting Symptoms of this injury include pain on the inside
of the tibia relative to the femur, inadequate stabiliza- of the knee where the medial collateral ligament is
tion of turnout from the hip, letting the knees “fall located. When the ligament is palpated, tenderness
in” relative to the feet, overuse of the quadriceps, and swelling are commonly present. Tests performed
or excessive foot pronation can put undue stress on by the physician that are designed to stress this liga-
the knee and may increase the risk for certain types ment (see Tests and Measurements 5.1 on p. 242)
of knee injuries. will also generally be positive.
Treatment will vary greatly depending on the
Common Types severity of the ligamental sprain and the approach
of Knee Injuries in Dancers of the attending physician. More serious sprains may
involve initial bracing or immobilization and use of
Many different types of injuries can occur around the crutches or a cane for locomotion (Diduch, Scuderi,
knee. A discussion of a few of these injuries that more and Scott, 1997; Mercier, 1995), while less serious
commonly occur in dancers follows, and interested sprains may require only temporary limitation of spe-
dancers are referred to the publications written by cific dance movements such as fifth position. Quad-
James Garrick (1989, 1999), Ronald Quirk (1987), riceps strengthening, and later strengthening of the
and other authors cited in this section for a more other muscles that cross the knee, are instituted, with
detailed presentation of knee injuries. care taken to use positions and ranges of motion
that are pain free and that avoid undue valgus stress.
Knee Ligamental Injuries With its location outside of the joint (extra-articular),
this ligament has good healing capacity (Scioscia,
Serious ligamental injuries to the knee are very
Giffin, and Fu, 2001). Hence, recovery from tears
common in skiing and contact sports. Although they
of the medial collateral ligament with conservative
are less common in dance, when they do occur they
treatment tends to be excellent, with a very good
can severely affect the dancer’s ability to dance, and
prognosis for future full return to dance.
prompt medical treatment is essential. With youth,
particular care must be taken that adequate medical Anterior Cruciate Ligamental Injury One of the
treatment be obtained, since the ligaments of the most dreaded injuries for the dancer is rupture of
knee are generally stronger than the growth plates the ACL as seen in figure 5.32. Anterior cruciate
and injury to a ligament may also involve epiphyseal injury occurs most frequently in sports that involve
injury. deceleration, twisting, pivoting, and jumping—all
The ligaments are key to the stability of the knee, motions that occur in dance. Females appear to
so when a ligament is torn, knee stability is temporar-
ily jeopardized. The two most commonly involved
ligaments in dancers are the medial collateral liga-
ment and the ACL. Dancers with extreme general-
ized joint mobility (hypermobility) are probably
more vulnerable to such ligamental injury.
Medial Collateral Ligament Injury The most
commonly occurring ligamental injury in sport
involves the medial collateral ligament (Caillet,
1996). Such injuries often result from a medially
directed force against the lateral side of the knee
(valgus-deforming force) that tends to open up the
inside of the knee as seen in figure 5.31. In dance,
this type of force can occur when a dancer falls on
another, as may happen, for example, in contact
improvisation. Noncontact injuries of the medial
collateral ligament may also result from deceleration,
pivoting, or forcing turnout and pushing the knee
forward relative to the foot, such as in fifth-position
turned-out pliés (Quirk, 1988). It appears that the
medial collateral ligament is particularly vulnerable FIGURE 5.31 Injury to the medial collateral ligament
to twisting of the tibia externally (Hall, 1999). (right knee, anterior view).
have a markedly greater incidence of anterior cruci- good indicator of the degree of injury, and dancers
ate tears than males in competitive sport; different should seek medical evaluation if instability is pres-
sources estimate two to seven times greater risk in ent, even if pain is limited. Tests performed by the
females (Diduch, Scuderi, and Scott, 1997; Ireland, physician that are designed to test integrity of this
2000; Scioscia, Giffin, and Fu, 2001). This increased ligament, including the anterior drawer test (Tests
incidence in females has been attributed to the shape and Measurements 5.1C on p. 242), will generally
and size of the femoral notch, less muscular devel- be positive, and some orthopedists will utilize equip-
opment, greater ligamental laxity, less developed ment to measure the exact anterior displacement of
proprioception, greater hamstring flexibility that the tibia allowed on the injured side in comparison
may lessen the hamstrings’ potential protective effect to the uninjured side.
on the ligament, and anatomical alignment tending Recommended treatment for minor anterior cru-
to create a greater Q angle (Boden, Griffin, and Gar- ciate injuries may involve initial immobilization in a
rett, 2000; Scioscia, Giffin, and Fu, 2001). compression dressing with ice and elevation followed
A common mechanism for injury to this liga- by hamstrings and quadriceps strengthening (Mer-
ment in contact sports is a blow to the lateral knee cier, 1995). However, if the rupture is complete, this
that includes external rotation. In noncontact ACL is one injury for which early surgical repair is often
injury, a common position on landing involves the recommended for active individuals. Dancers with
body’s falling such that the hip is adducting and anterior cruciate deficient knees will often describe
internally rotating, with the knee collapsing into their knee as separating or “going out” (e.g., tibia
valgus while the tibia translates forward from an sliding forward and then coming back) with move-
externally rotated position. This position is termed ments such as walking down stairs. Repeated episodes
“the position of no return” and is shown in figure of instability may cause further instability, injury to
5.32B. The most prevalent mechanism of injury in the menisci, and joint surface degeneration (Evans,
modern, ballet, and jazz dance appears to be landing Chew, and Stanish, 2001; Suter and Herzog, 2000).
in hyperextension from a jump on one leg as shown Hence, surgery to improve stability and joint func-
in figure 5.32C (Liederbach and Dilgen, 1998). tion is often recommended, and Weiker (1988) holds
Classically the dancer feels a “pop” and is unable that surgical repair of an ACL tear offers an 85% to
to continue dancing at the time of ligamental injury. 95% chance of being able to continue a professional
The knee generally feels unsteady, with significant dance career in contrast to only a 25% to 30% chance
pain and ensuing rapid swelling. However, because without surgery.
ligaments themselves do not generally contain pain The ACL tends to heal poorly because it is located
receptors, the degree of pain is not necessarily a within the joint (intra-articular), where joint fluid
FIGURE 5.32 Injury to the anterior cruciate ligament (right knee, medial view). (A) Abnormal anterior movement of the
tibia, (B) position of no return, and (C) classic mechanism in dance.
interferes with fibrin clot formation essential for the One of the most common mechanisms of
healing process (Scioscia, Giffin, and Fu, 2001). So, injury of the meniscus is extension from a flexed,
reconstruction rather than repair of the torn liga- abducted position of the knee (valgus stress) while
ment is often the treatment of choice with dancers. the leg is externally rotated with the foot fixed. In
One commonly used method utilizes a graft taken contact sports, such as football, this mechanism is
from the central one-third of the patellar tendon of often sudden and traumatic. However, in dance, it
the injured dancer (including a bony block from is believed that this mechanism may be operative
the tibial tuberosity and another from the patella), chronically, that is, that repetitive forced turnout
which is then fixed to the tibia and femur. Another may result in long-term wearing and splitting of
method utilizes a graft taken from the injured the meniscus (Quirk, 1987; Scioscia, Giffin, and
dancer’s medial hamstrings. Fu, 2001; Silver and Campbell, 1985). Dancers have
Whether a surgical or conservative approach is also reported meniscal injury associated with losing
taken, the dancer should seek rehabilitative treat- balance or twisting when in a position of deep knee
ment from a qualified physical therapist who is flexion such as that associated with floor work in
working closely with the attending physician. Open modern or jazz, or center floor first or fifth grand
kinematic chain knee extension exercises such pliés. In full flexion the menisci are pinched between
as terminal extension can place large stresses on the articulating bones; and if there is a twist in this
the ACL that may cause damage to an injured or vulnerable position, injury can readily occur. To
reconstructed ligament. Hence, there are specific lessen injury risk, full weighted knee flexion should
recommendations regarding the appropriate range be used cautiously, with appropriate progressions for
of motion, appropriate use of open and closed beginners, and with an emphasis on good form.
kinematic chain exercises, and loading of the joint In some cases of acute meniscal injury, a “pop-
in different phases of rehabilitation that must be ping” or “tearing” sensation is experienced, followed
closely followed. Also, unlike what occurs with many by severe pain (Mercier, 1995). More frequently,
other injuries, hamstring strength is particularly symptoms include moderate pain that gradually
emphasized, as the hamstrings can pull the tibia subsides (Diduch, Scuderi, and Scott, 1997). It is
posteriorly, aiding the anterior cruciate in its func- common to have localized tenderness on the joint
tion. Long-term rehabilitation goals for anterior line over the meniscus. Swelling is generally slow,
cruciate as well as other knee injuries are to maxi- often not reaching a maximum until the day after the
mize dynamic stability of the knee and prepare it initial injury, and may recur on multiple occasions
to function with the diverse loading presented with (Scioscia, Giffin, and Fu, 2001). Grand pliés may be
dance training (Boden, Griffin, and Garrett, 2000; painful, and range of knee motion may be limited.
Brown and Clippinger, 1996; Irrgang, 1993; Loosli There is often an apprehension about assuming the
and Herold, 1992). position of a full squat. In the days or even weeks fol-
lowing the initial injury, painful locking, catching,
Meniscal Injury or giving way, especially with flexion and twisting
The meniscus is designed to move with the tibia on movements, often occurs. Quadriceps femoris atro-
the femur in a well-coordinated manner. However, if phy generally proceeds rapidly.
this coordinated movement becomes disrupted, the Initial recommended treatment for meniscal
meniscus can become trapped between the opposing injury often involves limiting activity, ice, compres-
articular surfaces of the tibia and femur with resultant sion, elevation, and anti-inflammatory medications,
injury from compression, torque, or traction. The followed by quadriceps strengthening (Diduch,
meniscus can be split, broken into pieces, or loosened Scuderi, and Scott, 1997; Mercier, 1995). Many small
by tearing of its ligamentous attachments. The medial meniscal tears, especially small ones located in the
meniscus has been reported to be torn 10 (Mercier, outer third of the meniscus where the blood supply
1995) to 20 times (Caillet, 1996) more frequently is adequate (figure 5.33B), can heal spontaneously.
than the lateral in general populations. One study However, if the knee does not respond adequately
of dancers also showed a predominance of medial to conservative therapy or there are repeating epi-
meniscus tears, with 13 of the 15 meniscal tears exam- sodes of catching, locking, or giving way, surgery
ined arthroscopically involving the medial meniscus is often recommended. These episodes can relate
(Silver and Campbell, 1985). This increased vulner- to encroachment of the torn portion of the menis-
ability of the medial meniscus is probably related cus into the joint, where it can be caught between
to its reduced mobility due to its attachment to the the condyles, as shown in figure 5.33, C and D. If
medial collateral ligament and joint capsule. allowed to continue, this mechanical impingement
Extensor Mechanism Injury

Any component of the extensor mechanism—includ-
ing the quadriceps muscle itself, the tendons of the
quadriceps, and the patella—can be injured, but
the latter two are particularly commonly involved. A
description of several injuries involving these latter
two structures follows.
Patellofemoral Pain Syndrome Patellofemoral pain

syndrome refers to anterior knee pain that relates
to the patella and associated retinacular support
as seen in figure 5.34A. In cases in which there is
documented damage to the thick cartilage that lines
the backside of the patella, patellofemoral pain can
be more specifically classified as chondromalacia
patella, which literally means soft (“malacia”) car-
tilage (“chondro”). Patellofemoral pain is the most
prevalent type of knee pain in adolescents and young
adults, and one of the most common complaints
FIGURE 5.33 Meniscal injury (right knee, superior bringing athletes to sports medicine clinics (Caillet,
view). (A) Normal meniscus, (B) small circumferential 1996; Garrick, 1989; Mercier, 1995; Weiker, 1988).
tear, (C) partial tear encroaching into the joint (“bucket Patellofemoral pain is commonly seen in activities
handle” tear), (D) tear of posterior area encroaching into involving high-impact or repetitive knee flexion.
the joint (“posterior horn” tear). Since dance contains both of these elements, it is
not surprising to find patellofemoral pain syndrome
prevalent in the dance population. In a survey of 362
is believed to cause damage and arthritic changes to
pre-professional and professional modern and ballet
the articular surface of the knee.
dancers, 38% reported having three or more classic
However, even if surgery is indicated, if the type
symptoms of patellofemoral pain syndrome associ-
of injury allows, surgery is often performed through
ated with dance at some time during their dance
a small scope (arthroscopic surgery) with an attempt
training (Clippinger-Robertson et al., 1986).
to preserve or repair whatever part of the meniscus is
In addition to the high and repetitive compression
viable or has sufficient blood supply to allow healing
forces associated with dance, there are other underly-
(Quirk, 1987; Scioscia, Giffin, and Fu, 2001). Such
ing anatomical and biomechanical factors that tend
an approach allows for a shorter recovery period and
to increase risk for patellofemoral pain. For example,
less risk of future degenerative arthritis than open
factors that tend to produce decreased stability of
surgery involving full removal of the meniscus. The
the patella such as genu recurvatum and weakness
stress to the loaded tibiofemoral joint has been esti-
of the vastus medialis—as well as factors that tend
mated to be three times higher when the meniscus
to produce patellar malalignment such as genu
is removed (Hall, 1999).
valgum, excessive femoral anteversion, an increased
Recovery from meniscal injury, even when surgery
Q angle, or a tight iliotibial band—can all increase
is required, is generally excellent. Over the long
risk for patellofemoral pain syndrome (Grabiner,
term, this type of injury holds a very good prognosis
Koh, and Draganich, 1994; Reider, Marshall, and
for full return to dance.
Warren, 1981; Sheehan and Drace, 1999; Winslow
and Yoder, 1995). Some of these latter malalign-
The Terrible Triad
ments are commonly seen grouped together, and
With some injuries, multiple structures can be the composite is termed the miserable malalignment
involved. When a rotational component is added to syndrome as seen in figure 5.34B. In general, patel-
the medially directed force on the knee, the ACL lofemoral pain syndrome occurs more frequently
and medial meniscus, as well as the medial collat- in females than in males. This is believed to be due
eral ligament, can be injured simultaneously. This to the greater Q angle and valgus vector associated
combination injury is termed the “terrible triad” with the wider pelvis, the tendency for greater genu
(G. trias, three). It is a serious injury that requires recurvatum, or greater quadriceps weakness found
prompt medical diagnosis and treatment. in females versus males. In essence, patellar instability
Femoral
anteversion
FIGURE 5.34 Patellofemoral pain syndrome. (A) Common site of pain, (B) commonly associated malalignments.
and malalignment factors are believed to allow ment or instability factors previously discussed are
abnormal lateral excursion of the patella against the commonly present.
lateral lip of the femoral groove, causing excessive Initial recommended treatment often involves ice
patellar shear stress. after activity, modified activity, and anti-inflammatory
Classic symptoms of patellofemoral pain syn- medication (Garrick, 1989; Roy and Irvin, 1983).
drome include (1) generalized (nonspecific) pain Dance movements associated with high compression
behind or around the patella, and particularly medial forces or pain, such as pliés, lunges, jumps, and floor
to the patella; (2) pain with knee flexion such as in work, should be temporarily avoided or modified to
grand pliés; (3) pain with extended sitting; (4) pain utilize a pain-free range (table 5.6).
going down stairs; and (5) weakness, swelling, and However, the most important aspect of success-
pain during or after activity. One of the symptoms ful long-term rehabilitation is the development of
that most clearly distinguishes patellofemoral pain quadriceps strength to counter the valgus tendency
syndrome from other knee injuries is pain with and restore optimal patellar tracking. Unfortu-
extended sitting, such as in a theater, a car, or a nately, quadriceps atrophy appears to occur rapidly,
plane. While other injuries often are pain free with and reflex inhibition can reduce the ability of the
rest, the quadriceps are slightly stretched by the quadriceps to produce desired force within hours
bent knee position accompanying sitting, produc- (Kennedy, Alexander, and Hayes, 1982; Urbach et al.,
ing a small amount of patellofemoral compression 1999). Many classic exercises used to strengthen the
and thus pain. A medical evaluation will classically quadriceps muscles will tend to aggravate the condi-
reveal pain when applying pressure to the backside tion. Hence, a closely supervised physical therapy
of the patella, and swelling and crepitus may be pres- program initially using isometric (e.g., quad set
ent (Mercier, 1995). Relative atrophy of the vastus and straight leg raise, table 5.3, A and B) and small
medialis is also usually apparent, and other malalign- arc exercises (terminal knee extension, table 5.3C)
TABLE 5.6 Dance Movements That Were Frequently within this terminology (Bergfeld, 1982;
Reported to Aggravate Knees of Ballet and Modern Dancers Blazina et al., 1973; Cook et al., 2000).
With Patellofemoral Complaints Jumper’s knee is believed to involve an
initial acute tear of the quadriceps tendon
Dance movement Ballet Modern Both during a movement involving an explosive
Plié 60% (27) 69% (41) 65% (68) contraction of the quadriceps muscle.
Then, before this site has time to heal,
Jumps 27% (12) 22% (13) 24% (25) additional trauma aggravates the injury
Flexion to extension 18% (8) 22% (13) 20% (21) and it becomes chronic, often with a small
area of granulation tissue at the site of the
Turnout 20% (9) 10% (6) 14% (15)
original tear (Quirk, 1987).
Kneeling/floor work 0% (0) 20% (12) 12% (12) As its name implies, this injury is par-
Number of respondents 45 59 104 ticularly common in athletes participat-
ing in sports involving jumping, such as
Dancers who reported three or more classic symptoms of chondromalacia patella
From Clippinger-Robertson et al. (1986). volleyball or basketball players. It can
also be found in sports that repetitively
stress the quadriceps such as running,
in which compression forces are low, and with care- kicking, or climbing. Considering that dance con-
ful attention to activating appropriate muscles and tains both jumping and many repetitive movements
avoiding knee hyperextension, is usually very effec- that stress the quadriceps, it is not surprising that
tive. When quadriceps atrophy or apparent inhibi- jumper’s knee occurs readily in dancers. Factors that
tion is marked, electrical stimulation of the quadri- have been theorized to further increase the risk for
ceps femoris muscle while the dancer superimposes this injury in dancers include participation in very
conscious contraction may also be prescribed. athletic roles involving a lot of jumping (Quirk,
Attention to and correction of any underly- 1987), excessive increase in dance workload, abrupt
ing abnormalities or technical errors that can be change in dance style, performing on hard floors,
improved, such as a tight iliotibial band, genu inadequate quadriceps strength, growth spurts, and
recurvatum, or forced turnout, can also be helpful. calf tightness leading to a limited plié that requires
In the author’s experience, working with dancers to large forces to be absorbed in a short period of time
maintain turnout at the hip and emphasize use of (Khan et al., 1995; Poggini, Losasso, and Iannone,
the hip adductors, while de-emphasizing use of the 1999; Quirk, 1987).
quadriceps during movements such as turned-out
pliés, can also often provide symptom relief (Clip-
pinger-Robertson et al., 1986). In some cases, taping
techniques (McConnell taping) or a brace (patellar
stabilization brace) may have a subtle positive influ-
ence on joint mechanics (Jenkinson and Bolin,
2001; Powers et al., 1999) while adequate quadriceps
strength is being developed.
Although in a vast majority of cases conservative
treatment emphasizing quadriceps strengthening
will be successful in relieving symptoms, in a small
number of nonresponsive cases, surgery may be
recommended (Weiker, 1988). One common surgi-
cal approach is to resurface the posterior side of
the patella and try to encourage cartilage healing.
Another surgical approach utilizes various proce-
dures to improve the alignment of the extensor
mechanism.
Jumper’s Knee Jumper’s knee refers to injury to
the patellar tendon right at its junction with the
inferior pole of the patella as seen in figure 5.35.
Some authors have also included injury to the quad- FIGURE 5.35 Jumper’s knee and associated site(s) of
riceps tendon at its junction with the superior patella pain (right knee, lateral view).
Pain is classically of insidious onset and is cen- than females, in adolescent dancers it is common in
tered in the tendon just superior or just inferior to both genders. Osgood-Schlatter disease is common
the patella (Blazina et al., 1973). This pain is gener- in athletics involving rigorous or repetitive quad-
ally “aching” in nature and usually goes away after riceps contraction such as with running, jumping,
a period of rest. In milder forms of tendinitis, the and grand pliés. Factors discussed in the context of
pain will often appear at the beginning of activity, patellofemoral pain syndrome that tend to produce
disappear or decrease significantly after “warming patellar malalignment will also increase the stress to
up,” and then reappear after completion of activity. the quadriceps tendon and may increase the risk for
In more advanced stages, the pain becomes more Osgood-Schlatter disease as well.
persistent and will tend to be present before, during, Osgood-Schlatter disease is characterized by pain
and after activity. In general, this pain is aggravated and swelling over the tibial tuberosity. The tibial
by performing jumps and can be reproduced by tuberosity is generally exquisitely tender to the touch
extending the knee against resistance. In some cases, or when pressure is applied, such as with kneeling,
the pain is accompanied by a sensation of “weakness” and it sometimes becomes enlarged.
or “giving way.” Recommended treatment often includes ice after
Commonly recommended treatment for milder activity and anti-inflammatory medications (Stanitski,
forms of jumper’s knee involves heat or extra warm- 1993). Dance should be modified to reduce move-
up prior to activity (or both), ice after activity, anti- ments that produce tendon stress and pain such as
inflammatory medication, and in some cases physical the grand plié, deep fondu, and jump. Knee pads
therapy modalities (Bergfeld, 1982). Jumping and with a felt or foam horseshoe fashioned to take the
other high-load flexed movements of the knee are direct pressure off the tibial tuberosity can be worn
temporarily avoided as quadriceps strengthening if dance choreography requires floor work, and
and stretching are initiated (Diduch, Scuderi, and braces are sometimes prescribed (Micheli, 1987).
Scott, 1997). Although quadriceps strengthening Quadriceps strengthening, quadriceps stretching,
is essential, full arc or plyometric types of exercises and correction of any related technique factors can
often aggravate the condition and should be avoided. also sometimes provide relief. Luckily, this condition
Instead, initial treatment often involves terminal knee is almost always self-limiting and goes away when
extension exercises (table 5.3C, p. 275) performed the tuberosity unites with the main part of the tibia
in a pain-free range of motion, as well as straight leg (Diduch, Scuderi, and Scott, 1997; Quirk, 1987).
raises (table 5.3B, p. 275) with the knee in a position However, if pain persists into adulthood, it is impor-
that is pain free (often requiring a very slightly flexed
vs. fully extended position). Later stages of therapy
may include eccentric quadriceps strengthening.
In addition, technique factors such as poor landing
mechanics with jumping should be corrected if indi-
cated. In most cases, conservative treatment will lead
to successful rehabilitation. However, if it should fail,
some physicians recommend that the small area of
granulation tissue within the quadriceps tendon be
surgically excised (Quirk, 1983, 1987).
Osgood-Schlatter Disease
Osgood-Schlatter disease also involves the quad-
riceps tendon; but in contrast to jumper’s knee,
it involves the inferior attachment of the patellar
tendon where it joins to the tibial tuberosity as seen
in figure 5.36. This condition is not really a disease
but rather involves an injury to the growth center
of the tibial tuberosity (apophysis) due to traction
produced by the quadriceps via the patellar tendon
(Micheli, 1987). This injury usually becomes evi-
dent between 8 and 15 years of age, and especially
during the peak of the adolescent growth spurt FIGURE 5.36 Osgood-Schlatter disease involves injury
(Mercier, 1995; Stanitski, 1993). Although in the to the growth center associated with the tibial tuberosity
general population it is more prevalent in males (left knee, sagittal section).
tant for the person to get rechecked by a physician, The cruciate ligaments are key stabilizers to limit
as in some cases a fragment of the tibial tuberosity anterior-posterior movement and rotation, as well as
may actually fully detach. guiding the sliding of the femur relative to the tibia
during knee flexion. The collateral ligaments are key
Rehabilitation of Knee Injuries stabilizers in the frontal plane to limit medial-lateral
movement and valgus-varus stress. The iliotibial
Although treatment approaches will vary in accor- band provides additional lateral support to the knee.
dance with the type of injury and other factors, one Overlying the ligaments and capsule are 12 muscles
common rehabilitation concern is effective resto- and their tendons, which provide additional support
ration of quadriceps strength and function. The as well as movement. The action of the quadriceps
quadriceps femoris muscles, and particularly the femoris is knee extension, while the hamstrings and
vastus medialis, appear to be quite prone to muscle remaining muscles produce knee flexion, slight rota-
inhibition following surgery, injury, or even relatively tion, or both. In a weight-bearing position, once the
minor trauma or swelling (Hopkins et al., 2001). knee begins to flex, gravity will tend to make it flex
Muscle inhibition is the inability to fully activate further. Hence, the knee extensors play a critical
the motor units in a given muscle with a voluntary role not only to produce concentric knee extension,
contraction. This inhibition tends to produce muscle but also to isometrically maintain a bent position of
weakness, atrophy, and decreased neuromuscular the knee or eccentrically control additional flexion
control. Researchers have found 20% deficits in of the knee.
quadriceps strength to be common, with more severe Tibiofemoral design favors both stability and
deficits ranging from 30% to 45% occurring in some mobility, partly achieved through static struc-
instances (Hurley, Jones, and Newham, 1994; Suter tural elements, such as the broadness of the joint
and Herzog, 2000). (favoring stability) and the shallowness (favoring
The inhibition and related strength deficits can mobility). These contrasting demands are also met
also be very persistent, evident months and even years through the tibiofemoral joint’s ability to change
after the original injury. For example, an average of its characteristics with position. When the knee is
20% knee extensor inhibition was found in patients straight, broad articular surfaces provide support,
22 months after ACL reconstructive surgery. Such major ligaments are taut, rotation is limited, and
decreases in quadriceps strength potentially interfere stability is favored. However, when the knee bends,
with restoration of normal knee function, increase the collateral ligaments become slack, forces that
the risk of reinjury, and may predispose the knee would tend to dislocate the joint increase, rotation
joint to degenerative diseases such as osteoarthritis. increases, and mobility is favored. This mobility is
This extensor inhibition has been shown to occur desirable to allow pivoting-type movements when
commonly with both acute and chronic injuries and the foot is weight bearing and positioning of the
may involve the uninjured as well as the injured limb, foot in space when the foot is free. However, this
making it inadvisable to use the noninjured side increased instability also can leave the joint at greater
as “normal” when one is performing strength tests risk for injury. Common alignment deviations such
(Urbach et al., 1999). Hence, effective rehabilitation as genu varum, genu valgum, and genu recurvatum
is recommended for even relatively minor knee inju- can also influence injury predisposition. To foster
ries so that more serious or recurrent knee injuries optimal knee mechanics and prevent injury it is
can be avoided. important that dancers develop adequate and bal-
anced strength and flexibility in the key musculature;
emphasize optimal mechanics; and avoid positions
Summary or movements that produce excessive valgus, varus,
The knee joint proper is formed between the or rotation of the knee.
respective medial and lateral condyles of the femur The patellofemoral joint is formed between the
and tibia and is called the tibiofemoral joint. The posterior surface of the patella and the underlying
tibiofemoral joint is a modified hinge joint that pri- femoral groove. In contrast to what occurs with
marily allows flexion and extension, but also some the tibiofemoral joint, the stability of the patella is
transverse rotation. Although the articular contact low when the knee is in a position of extension but
area is very broad, the shallowness of the joint makes increases as flexion of the knee proceeds. However,
it inherently unstable. Additional necessary stability because it is a sesamoid bone and there is not a true
is provided through a combination of ligaments, “joint” between the patella and the underlying femur,
the joint capsule, the menisci, and strong muscles. stability and excursion of the patella are markedly
influenced by anatomical and biomechanical fac- with forced turnout. To encourage optimal patello-
tors such as the law of valgus. The law of valgus and femoral mechanics and lessen the risk of injury, it is
related Q angle give rise to a tendency for lateral important that dancers develop adequate quadriceps
tracking of the patella that can be exaggerated by strength and balanced muscle activation patterns
alignment abnormalities, inadequate quadriceps and that they focus on correct alignment between
strength, or twisting of the tibia, such as occurs the hip, knee, and foot.

1. Locate the following bony landmarks on a human skeleton: (a) medial femoral condyle and
epicondyle, (b) lateral femoral condyle and epicondyle, (c) tibial plateau, (d) tibial tuberos-
ity, and (e) patella.
of each muscle. Then, next to each muscle, list its actions: (a) rectus femoris, (b) vastus late-
ralis, (c) vastus intermedius, (d) vastus medialis, (e) biceps femoris, (f) semitendinosus, (g)
semimembranosus, and (h) popliteus.
3. Locate the following muscles on your partner, and have your partner perform actions that
these muscles produce while you palpate their contraction: (a) quadriceps femoris, (b) biceps
femoris, (c) semitendinosus, and (d) semimembranosus.
4. Sitting in a chair, resist knee flexion by putting your left foot behind your right foot while
pulling back with the right leg (resisted isometric knee flexion). Place your right hand under
the right side of the back of the thigh and your left hand under the left side of the back of the
thigh. Palpate the hamstrings as you pull back with (1) the tibia and foot externally rotated,
(2) parallel, and (3) internally rotated relative to the femur. Explain the differences you feel
in muscle contraction during these conditions.
5. Demonstrate two exercises for strengthening and two exercises for stretching the following
muscles: (a) quadriceps femoris, (b) hamstrings.
6. Delineate differences in exercise design required in order to focus on the rectus femoris
versus the vasti muscles for both strengthening and stretching exercises.
7.Mark the midpoint of your patella and tibial tuberosity with a pen or adhesive dot. Then perform
a standing first-position demi-plié, and note the change in relationship between the dots on
the patella and tibial tuberosity when the knee extends on the up-phase of the movement.
Explain how this relates to the locking mechanism of the knee.
8. Use a marking pen to draw the Q angle on your knee (or your lab partner’s knee) accord-
ing to the directions provided earlier in this chapter. Then, sitting with both legs extended
forward, note any lateral motion of the patella as you perform a quad set. Compare your Q
angle with that of three other dancers. Describe how the law of valgus relates to this lateral
tracking of the patella, and list two other alignment deviations that will tend to enhance this
tendency for lateral tracking.
9. Place one hand on the front of the thigh about 6 inches (15 centimeters) above the patella
and the other behind and above the knee on the hamstring muscles. Palpate these muscles
while performing a demi-plié in first position (parallel), and note that contraction is present
in both muscle groups. Explain how this can be occurring even though they have antagonistic
functions at the hip and knee.
10. Perform an analysis of a back attitude, accounting for the joint movements, muscles groups,
and sample muscles of the hip and knee of the gesture leg. Then, describe how active and
passive insufficiency could be operative.
(continued)
Study Questions and Applications (continued)
11. A dancer’s teacher has noted that his knees are “hyperextending” at takeoff and “falling in”
when landing in plié.
a. Describe what joint motions could be occurring at the spine, hip, and knee that could
contribute to these technique errors.
b. Describe how the “locking mechanism” of the knee could contribute to these technique
errors and how its negative effect could be minimized.
c. Identify appropriate strength and flexibility exercises that could be utilized to maximize
jump height and help prevent the undesired motions of the knee.
d. Provide three cues that could be utilized to try to implement the desired technique adjust-
ments.
and Foot
The Ankle
Photograph by Rex Tranter. Pacific Northwest Ballet School students.

CHAPTER SIX
297
W ith this chapter we turn to the ankle and

the foot. The ankle serves as the connection
between the foot and leg, vital for translation of
of the toes or fingers) as seen in figure 6.1, which
help form arches that run across (transverse arch)
the foot and the length (longitudinal arches) of the
forces and motion of the foot relative to the leg and foot. In regard to specific bones, the tibia can be
of the leg relative to the foot. The foot is a complex easily palpated under the skin along the anterior
structure that has evolved from a flexible grasping lower leg and hence is often casually termed the
organ to a relatively rigid structure, which allows it “shinbone.” This bone is the larger, stronger, and
to meet the demands associated with weight bearing more medially located of the two lower leg bones.
and locomotion. The presence of various arches It ends distally with a concave surface and a medial
and the relative positioning of various joints allow projection that extends further inferiorly termed
the foot to play the dual role of a rigid lever for pro- the medial malleolus (L. malleus, hammer). The
pulsion and a flexible accommodating structure for projection of the medial malleolus can be easily
shock absorbency. One of the hallmarks of dancers is palpated on the medial side of the ankle (see figure
the marked development of fine strength, fine articu- 6.5, p. 303). The thinner, more laterally located
lation, and range of motion of the feet in plantar fibula also ends distally with a projection, termed
flexion as demonstrated in the photo on page 297 the lateral malleolus (figure 6.2B), that can readily
and as exemplified by pointe work. However, with be palpated on the lateral side of the ankle. These
the large forces being generated at and absorbed by inferior structures of the tibia and fibula come in
the ankle-foot complex, it is not surprising that this
is the most common site of injury in dance.
This chapter will present basic anatomy and
mechanics of the ankle and foot that influence opti-
mal performance and the vulnerability of these joints
to injury. Topics covered will include the following:
• Bones and bony landmarks of the ankle and

foot
• Joint structure and movements of the ankle and
foot
• Description and functions of individual muscles
of the ankle and foot
• Alignment and common deviations of the ankle
and foot
• Mechanics of the ankle and foot
• Muscular analysis of fundamental movements of
the ankle and foot
• Key considerations for the ankle and foot in whole
body movement
• Special considerations for the ankle and foot in
dance
• Conditioning exercises for the ankle and foot
• Ankle and foot injuries in dancers
Bones and Bony Landmarks

of the Ankle and Foot
The tibia, fibula, and 26 bones of the feet all take
part in the various joints of the ankle and foot. The
bones of the feet are composed of 7 tarsals (G. tarsos,
sole of the foot), 5 metatarsals (G. meta, after), and
14 phalanges (L. phalanx, bone between two joints FIGURE 6.1 Bones of the foot (right foot, superior view).
The Ankle and Foot 299
FIGURE 6.2 Bony landmarks of the foot (left foot). (A) Medial view, (B) lateral view.
contact with the upper surface of the large tarsal is important for locating the lateral ligaments of
bone called the talus (L. ankle, ankle bone, figure the ankle and is often a site of swelling with lateral
6.2A) to form the ankle joint. ankle sprains.
The talus is often termed the cornerstone of the Anteriorly, the calcaneus articulates with the
foot because forces coming down from the lower leg tarsal bone called the cuboid (G. kybos, cube + eidos,
are translated forward and back on the foot through resemblance) as seen in figure 6.2B, and the talus
the talus. The talus sits on the largest tarsal bone, articulates with the tarsal bone called the navicular
the calcaneus (L. calcaneum, heel). The calcaneus (L. boat shaped) as seen in figure 6.2A. The navicular
projects backward to form the “heel” and can be contains a small projection termed the tubercle of
easily palpated in the heel area. There is a small space the navicular (L. tuberculum, a swelling). This projec-
formed between a portion of the talus (its narrower tion can be palpated about 1 to 1 1/2 inches (2.5-3.8
neck) and the underlying calcaneus that is termed centimeters) anterior to and about a finger breadth
the tarsal tunnel or canal. This bony tunnel opens below the medial malleolus. This landmark can be
up laterally as a small bony depression filled with used for evaluation of the arches of the feet.
soft tissues called the sinus tarsi (L. sinus, cavity + G. The remaining three tarsal bones, termed the
tarsus, sole of the foot) (figure 6.2B). This landmark cuneiforms (L. cuneus, wedge), are located in a row
in front of the navicular and are called the first, Ankle Joint Classification and Movements
second, and third cuneiform going from medial to
lateral. These cuneiforms are each in line with the Because the “ankle joint” is formed between the
three medial metatarsals, while the two lateral meta- bones of the lower leg and the upper portion of the
tarsals are in line with the cuboid. Each metatarsal talus, its technical name is the talocrural (L. crus, leg)
consists of a base (proximally), a body, and a head joint. The ankle joint is classified as a hinge joint and
(distally). While the bases of the metatarsals articulate is more specifically formed by the articulation of the
with the cuboid and cuneiforms, the heads articulate superior dome of the talus with the distal tibia and
with their respective phalanges. The heads of the fibula (figure 6.3). The tibia is the primary weight-
metatarsals can be easily palpated on the underside bearing bone of the lower leg, and it translates most
of the foot (plantar surface) at the base of the toes of the weight between the femur and the talus, while
when the toes are repetitively flexed and extended. the medial malleolus extends to provide medial sup-
The metatarsals and toes are numbered 1 through port for the ankle. The fibula serves as a lateral strut,
5, from medial to lateral. There are three phalanges providing additional stability by helping to form a
in each of the toes except the great toe. These are slot or mortise into which the talus can fit. The fibula
termed the proximal, middle, and distal phalanges has also been estimated to transmit about 6% to 7%
for toes 2 through 5 (the lesser toes). The first toe of the load when the ankle is in a neutral position,
is termed the hallux (L. hallux, great toe), and it but up to one-sixth of the load of the leg when the
contains only two phalanges, the proximal and distal ankle-foot is in a position of dorsiflexion and ever-
phalanges. Located directly below the head of the sion (DiFiori, 1999; Sammarco, 1980).
first metatarsal are two small sesamoid bones called The distal tibia and fibula form a fibrous joint
the medial and lateral sesamoid (figure 6.2A). (distal tibiofibular joint), and the very strong interos-
Due to the large number of bones in the foot and seous membrane and adjacent ligaments (including
the complexity of the joints, it is customary to refer the anterior and posterior tibiofibular ligaments)
to segments of the foot rather than individual bones allow the tibia and fibula to function as a structural
for some descriptions of motion or mechanics. The unit like a mortise. This mortise fits over the convex
segments of the foot are the rearfoot, midfoot, and superior portion of the talus, gripping it tightly along
forefoot (figure 6.2A). The rearfoot, or hindfoot, is its flattened sides to provide much-needed stability
composed of the talus and calcaneus. The midfoot is for this joint, while still allowing for small move-
composed of the navicular, cuboid, and cuneiforms. ments of the fibula relative to the tibia—necessary to
The forefoot is composed of the metatarsals and accommodate the changes in contact area with the
phalanges. talus accompanying ankle joint movement. A cast of
this mortise would closely replicate the shape of the
talus, making it the most congruent joint found in
Joint Structure and Movements the human body.
of the Ankle and Foot Due to this mortise architecture, with the medial
and lateral malleolus extending downward, only
There are 34 joints in the ankle-foot complex (Smith, small side-to-side movements and rotation are
Weiss, and Lehmkuhl, 1996). The ankle, subtalar, permitted at this joint; and consistent with its clas-
and transverse tarsal joints are particularly key sification as a hinge joint, the fundamental motions
for desired functioning of this region, and their allowed are flexion and extension. The specialized
movements are intimately linked. Other more terms of ankle dorsiflexion and plantar flexion are
distal joints are important for subtle adjustments used because there is lack of agreement as to which
of the foot and movements of the toes. A sum- movement would be considered flexion and which
mary of the primary joints of the ankle and foot extension: Functional and anatomical perspec-
is provided in table 6.1. Most of these joints are tives would suggest opposite answers. So as seen
named according to the bones that compose the in figure 6.4, a neutral or anatomical position is
joints (e.g., tarsometatarsal), making learning the when the foot forms a 90° angle with the tibia, and
names easier and logical. Many joint capsules and dorsiflexion refers to bringing the top of the foot
approximately 100 ligaments provide stability for (dorsum) and the shin closer together such as in
these joints and provide constraints for movements “flexing the foot.” Conversely, plantar flexion refers
of the ankle-foot complex. For purposes of simplicity, to the opposite motion of bringing the bottom or
this text will cover only selected primary ligaments sole of the foot (plantar surface) and the shin away
of the rearfoot. from each other such as in “pointing the foot.” The
TABLE 6.1 Summary of Joints of the Ankle and Foot
Name Type of joint Movements

Ankle and foot
Ankle (talocrural) Hinge Plantar flexion
Dorsiflexion
Subtalar Gliding Inversion
Eversion
Abduction
Adduction
Slight plantar flexion
Slight dorsiflexion
Transverse tarsal
Talonavicular Modified ball and socket Primarily inversion and eversion
Calcaneocuboid Gliding Slight abduction
Slight adduction
Slight plantar flexion
Slight dorsiflexion
Other intertarsal Gliding Primarily slight dorsiflexion and some plantar flexion
Tarsometatarsal Gliding Primarily slight dorsiflexion and some plantar flexion
Toes
Metatarsophalangeal Condyloid Flexion of the toes on the metatarsals
Extension of the toes on the metatarsals
Abduction of the toes on the metatarsals
Adduction of the toes on the metatarsals
Interphalangeal Hinge Flexion of the digits (phalanges) of the toes
Extension of the digits (phalanges) of the toes
t
in )
l jo ent
a on
rs
e ta omp
s c
er lar
n sv vicu
a
Tr lona
(ta
FIGURE 6.3 Key joints of the foot (left foot, medial view).
301
(Metatarsophalangeal
joint)
joint)
joint)
FIGURE 6.4 Movements of the ankle and foot.
axis for this movement is close to a frontal plane, but (figure 6.3). The articular surfaces of these bones
it deviates slightly posteriorly and inferiorly from the fit well together, and additional stability is provided
medial to lateral side, and it also does not stay fixed by a flattened area on the medial calcaneus termed
but rather shifts slightly with dorsiflexion and plantar the sustentaculum tali (L. sustenataculum, a prop or
flexion. You can obtain a rough estimate of the axis support + tali, relating to talus) that acts like a shelf
by putting your thumb and forefinger on the medial to help support the medial talus. This joint is gener-
and lateral malleolus and imagining a line running ally classified as a gliding synovial joint (Moore and
through these points. However, there are very large Dalley, 1999), but it allows more movement than is
individual differences, and divergent averages are often associated with a gliding joint.
given by different sources for the location of this The specialized terminology of inversion-eversion,
axis. For example, Levangie and Norkin (2001) hold abduction-adduction, and plantar flexion-dorsiflexion can
that on average the axis is rotated laterally 20° to 30° be used to describe these movements (figure 6.4).
in the transverse plane and inclined 10° downward Inversion involves lifting the inner border of the
on the lateral side, while Kreighbaum and Barthels foot so that the distal portion of the calcaneus and
(1996) suggest much lower average values of 13° sole of the foot face medially or inward. Eversion is
rotation and 7° inclination. the opposite movement, involving lifting the outer
border of the foot so that the distal heel and sole of
Subtalar Joint the foot face laterally. Abduction can be thought of
Classification and Movements as moving the forefoot away from the median plane
or midline of the body, while adduction refers to
The subtalar joint (L. sub, under + talar, relating the opposite movement of the forefoot toward the
to talus) is formed between the inferior portion of midline of the body. Note, however, that this special-
the talus and the superior portion of the calcaneus ized form of abduction-adduction of the foot occurs
primarily in a transverse plane around a vertical axis, the last component runs from the medial malleolus
more akin to horizontal abduction-horizontal adduc- diagonally downward and backward to attach onto
tion of the shoulder or hip. The slight dorsiflexion the talus (posterior tibiotalar). Together these liga-
and plantar flexion that occurs is in the same direc- ments prevent forward or backward displacement of
tion as described with the ankle but involves the talus the tibia or of the talus and are vital for providing
upon the calcaneus rather than the talus relative to medial stability to the ankle joint. Because one band
the mortise joint. attaches onto the calcaneus, the deltoid ligament also
provides stability for the subtalar joint and helps limit
Ankle Joint Capsule eversion and abduction of the foot. These ligaments
also help link movements between the tibia, ankle
and Rearfoot Ligaments
joint, and subtalar joints, particularly inversion of the
The ankle joint is surrounded by a thin fibrous cap- foot and external rotation of the tibia (Hintermann,
sule that is relatively weak, but it is reinforced on each 1999). As with the knee, the integrity and function of
side by strong ligaments, called the medial and lateral the ligaments can be demonstrated by manual stress
collateral ligaments. Other closely approximated tests performed by a physician. If the medial side of
ligaments hold the tibia and fibula together at the the joint opens up and a gap is formed with eversion,
mortise joint (anterior and posterior tibiofibular injury to the deltoid ligament is suggested.
ligaments), and still others provide key stability to The deltoid ligament is very strong and extensive.
the subtalar joint. This strength is important because the medial mal-
leolus does not extend distally as far as the lateral,
Medial Collateral Ligament and so the lesser stability from bony architecture is in
part compensated for by the greater massiveness of
The medial collateral ligament (collateral, side by the medial ligaments. In fact the deltoid is so strong
side)—also called the deltoid ligament (G. deltoeides, that when forces are large enough to cause injury, the
triangular)—is composed of four parts that fan out medial malleolus may be avulsed and other bones
from their attachment on the medial malleolus to fractured rather than the deltoid ligament’s being
their respective attachments on the surrounding ruptured.
bones. As can be seen in figure 6.5, one division
runs downward (tibiocalcaneal ligament) from the Lateral Collateral Ligament
medial malleolus to attach onto the medial aspect
of the calcaneus; two components run from the The lateral collateral ligament is composed of three
medial malleolus diagonally downward and forward discrete bands, shown in figure 6.6, that connect the
to attach onto the talus and navicular (anterior tib- lateral malleolus with adjacent bones of the foot. The
iotalar ligament and tibionavicular ligament); and anterior talofibular ligament (ATFL) runs almost
FIGURE 6.5 Key ligaments of the medial aspect of the FIGURE 6.6 Key ligaments of the lateral aspect of the
ankle (right foot). ankle (right foot).
horizontally anteriorly from the lateral (fibular) mal- ment is believed to contribute to a lowered medial
leolus to the lateral talus and limits anterior move- longitudinal arch and a “flatfoot.”
ment of the talus relative to the fibula, or posterior The tarsal tunnel, formed by a concave groove
movement of the fibula relative to the talus. It also (sulcus) in the inferior talus and superior calca-
can limit adduction and inversion of the foot, espe- neus, runs from the medial to the lateral sides of
cially when the foot is plantar flexed. The posterior the ankle and is filled with short and strong bands
talofibular ligament (PTFL) is directed posteriorly called the interosseous talocalcaneal ligaments (L.
from the posterior portion of the lateral malleolus inter, between + os, bone). These ligaments function
to the talus and prevents excessive posterior slippage to bind these bones together and contain abundant
of the talus on the fibula or anterior slippage of the neural receptors that are believed to be important
fibula on the talus. The calcaneofibular ligament for the quick responses necessary for maintaining
runs downward and slightly backward from the distal balance and helping to prevent injuries such as ankle
end of the lateral malleolus to attach onto the lateral sprains (Smith, Weiss, and Lehmkuhl, 1996).
aspect of the calcaneus. It spans both the ankle joint
and subtalar joint and is very important for prevent- Transverse Tarsal Joint
ing inversion and adduction of the foot when the
foot is dorsiflexed (Hintermann, 1999).
Classification and Movements
As a whole, the lateral collateral ligaments are
The transverse tarsal joint lies just in front of the
important in coupling movements between the tibia
talus and calcaneus and forms a shallow “S” when
and foot, particularly eversion of the foot and inter-
viewed from above (figure 6.3). The transverse tarsal
nal rotation of the tibia. They are also very vital for
joint is actually a combination of the talonavicular
lateral ankle stability and, more specifically, for pre-
(between the talus and navicular) and calcaneocu-
venting excessive inversion of the foot. Their rela-
boid (between the calcaneus and cuboid) joints. The
tive contribution appears to shift with the position
talonavicular is generally classified as a modified
of the foot, such that the PTFL and calcaneofibular
ball-and-socket joint, while the calcaneocuboid is
ligament are taut and provide primary stability in
classified as a gliding joint (Hamilton and Luttgens,
ankle-foot dorsiflexion, while the ATFL becomes
2002; Moore and Dalley, 1999) or saddle joint (Hall-
taut and is particularly responsible for providing
Craggs, 1985; Magee, 1997). Although the shape of
stability in plantar flexion. With the frequent use
each joint by itself would tend to allow more free
of plantar flexion in dance and the fact that this is motion, the navicular and cuboid bones articulate
the weakest of the lateral collateral ligaments, it is with each other in a manner that allows very little
not surprising that the ATFL is commonly injured motion between them and hence restricts overall
in dancers. These lateral ligaments are so essential motion and makes both joints act functionally as a
for ankle stability that when they are seriously single segment. Together, these joints allow inver-
or repeatedly injured, the ankle often becomes sion-eversion and lesser degrees of plantar flexion-
chronically unstable (see Ankle Sprains on p. 360 dorsiflexion and abduction-adduction.
for more information), and abnormal movement These movements at the transverse tarsal joint
may be present when manual stress tests are per- can be used to provide additional range to the same
formed by a physician (see Tests and Measurements movements of the rearfoot or to move the forefoot
6.1) (Malone and Hardaker, 1990; Sammarco and in a direction opposite to that of the rearfoot. An
Tablante, 1997). example of the former occurs when plantar flexion
of the transverse tarsal joint is added to that of the
Spring Ligament
subtalar joint and ankle joint to allow the dancer to
The subtalar joint also has its own joint capsule and “point” the foot further. An example of the latter
additional ligaments, including the spring ligament occurs with walking, where transverse tarsal inver-
and interosseous talocalcaneal ligaments, that pro- sion can be used to keep the lateral forefoot from
vide additional stability. The spring ligament (plantar rising off the ground when eversion of the subtalar
calcaneonavicular ligament) shown in figure 6.5 is a joint and internal rotation of the tibia are occurring.
broad ligament that spans between the sustentacu- However, this ability to counterrotate the forefoot
lum tali of the calcaneus and the undersurface of the is greater when the rearfoot everts and dramatically
navicular. It forms a taut sling under the head of diminishes as the subtalar joint inverts. Hence, when
the talus, thereby helping to support the weight of the extreme inversion of the foot occurs such as when
body received by the talus and to maintain the medial one steps wrong off of a curb or lands wrong from
longitudinal arch. Permanent stretching of this liga- a jump, the forefoot has limited ability to counter-
Selected Orthopedic Stress Tests for the Ankle
Two tests are shown that are commonly performed by physicians to test the stability of the ankle
and evaluate lateral ligamental injury. Consider each test in terms of both the restraints offered by a
normal intact ligament and the excessive motion allowed when injury occurs.
Anterior Drawer Test
When one hand is used to push backward on the lower tibia while the other hand is used to pull the
calcaneus (and talus) forward, the ATFL resists this motion. When the ATFL is torn, the talus will slide
anteriorly from under the tibia. This is termed a positive anterior drawer sign as shown in A.
Talar Tilt Test
When the foot is inverted, the calcaneofibular ligament resists this varus stress. When the calcaneo-
fibular and anterior talofibular ligament are torn, excessive calcaneal varus is permitted, and the talus
will gap and rock in the ankle mortise. This is termed a positive talar tilt sign as seen in B.
rotate, and an ankle sprain can readily occur unless “cupping” or “flattening” of the foot when it is weight
muscles (the evertors of the foot) act quickly to bearing, similar to that which occurs in the hand to
counter this undesired extreme inversion. facilitate grasping objects.
The joints between the heads of the metatarsal
Classification and Movements bones and the adjacent proximal phalanges—the
of Other Joints of the Midfoot and Forefoot metatarsophalangeal joints (MTP)—are condyloid
joints. These joints allow a considerable amount of
The remaining joints between the tarsal bones motion in flexion (30-45°) and extension (90°), with
(intertarsal joints), as well as the joints between the greater motion allowed in extension (Smith, Weiss, and
tarsal bones and the proximal ends of metatarsals 2 Lehmkuhl, 1996). This extension motion (sometimes
through 5 (tarsometatarsal [TMT] joints), are glid- termed hyperextension) is important in weight-bear-
ing joints. These joints permit small motions that ing functions such as in walking or rising onto the toes
continue the function of the transverse tarsal joint, in demi-pointe, allowing the toes to maintain contact
acting to continue or counter the motions of the with the ground while the heel rises. The motion of
hindfoot in accordance with the goal of the move- abduction-adduction is more limited and is oriented
ment. The tarsometatarsal joints also contribute to relative to a line through the second toe. So, abduction
of the toes would involve movement of the toes away the opposite motions of plantar flexion, inversion,
from the second toe, while adduction would involve and adduction (Hall, 1999). As will be discussed later
bringing the toes back toward the second toe. in this chapter, these combination movements serve
Lastly, the joints between adjacent phalanges—the very important functions in weight-bearing activities
interphalangeal (IP) joints—are hinge joints. They such as walking, running, and dancing.
allow flexion and extension of the toes. Flexion refers
to bringing the plantar surfaces of the digits closer
Special Structures of the Ankle and Foot
together such as when curling the toes under, while
extension refers to decreasing the flexion of the
There are many specialized structures associated
digits, or straightening the toes.
with the ankle and foot that enhance their function.
A description of some of these structures that are
The Composite Movements particularly important follows.
of Pronation and Supination
Plantar Fascia
Due to the oblique orientation of the axes of the
ankle, subtalar joint, and transverse tarsal joints and A special very strong and inelastic band of connec-
the close structural interrelationship of many of these tive tissue called the plantar fascia (L. plantaris,
joints, an isolated movement of an individual joint in relating to the sole of the foot + sheet of fibrous
a single plane is rare or even not possible, depending tissue) is located in the sole of the foot as shown in
on the joint. In functional movement, many motions figure 6.7. It attaches from the heel (underside of
of the foot are composites, involving joints in the rear- the calcaneus) and runs forward, fanning out and
foot, midfoot, and forefoot in multiple planes. Two dividing into slips that attach to the sheaths of the
particularly important examples of such movements flexor tendons of the toes, underside of the proxi-
are pronation and supination. When bearing weight, mal phalanges, and ligamentous structures near the
pronation can be described as a composite movement heads of the metatarsals. The plantar fascia is covered
that involves dorsiflexion (primarily from the ankle), only by fat and the skin, and can be readily palpated
eversion (primarily of the rearfoot), and abduction on the underside of the medial arch of the foot when
(primarily of the forefoot), while supination involves the foot and toes are simultaneously dorsiflexed.
Foot Supination and Pronation
Stand in a parallel first position with your feet facing straight ahead and your knees slightly bent.
• Identifying foot inversion and eversion. Without changing the position of your knee or the facing
of your forefoot, slightly lift the inner border of the heel and arch of one foot, thinking of rotating about
the longitudinal axis of the foot running through the second toe. This motion is inversion of the foot.
Now, slightly lift the outer border of the heel and foot. This motion is eversion of the foot. Notice that
the amount of possible movement of the foot is small if the knee remains facing straight ahead and
is not allowed to move inward or outward relative to the foot.
• Identifying foot supination. While still standing in first position, rock your body weight back onto
your heels so that the front of your foot can move. Keeping your weight back, carefully and slowly lift
the inner borders of your feet and notice how the front of your feet tend to point very slightly inward.
The position you are in reflects all three elements of foot supination: plantar flexion (relative), inver-
sion, and forefoot adduction.
• Identifying foot pronation. Returning to your original first position, bend your knees (plié) and
allow your knees to fall inside your feet as you carefully lift the outer borders of your feet. Notice how
the front of your feet point very slightly outward. The position you are in reflects all three elements of
foot pronation: dorsiflexion, eversion, and forefoot abduction.
In addition to protecting and dividing the muscles

of the plantar area of the foot into compartments,
this fascial structure is very important for support of
the medial longitudinal arch of the foot. It creates a
trusslike structure (Frankel and Nordin, 1980), which
is a rigid structure composed of elements that are
fastened at their base to prevent movement between
the individual elements and to maintain their shape
(figure 6.8A). Thus, the rearfoot and forefoot are held
together by the plantar fascia, and the flattening of
the arch that would be expected during standing and
bearing weight on the foot is prevented. Furthermore,
due to its attachment onto the base of the phalanges,
when the toes extend, such as before toe-off in walk-
ing, the band is tightened by being stretched across
the metatarsophalangeal joints (windlass effect) as
shown in figure 6.8B. This tightening of the band
tends to raise the medial longitudinal arch and supi-
nate the foot, which in turn locks the midtarsal joints
and makes the foot more stable for toe-off in walk-
ing and running (Levangie and Norkin, 2001). This
support of the arch and stabilization of the foot via
the windlass mechanism are also operative whenever
FIGURE 6.7 The plantar fascia (right foot, inferior dancers go on demi-pointe (figure 6.8C).
view).
Deep Fascia and Intermuscular Septa
of the Lower Leg
Strong sheets of fascia divide muscles of the lower leg
and foot into three primary compartments—anterior,
posterior, and lateral. The posterior compartment
FIGURE 6.8 The function of the plantar fascia (right foot, medial view). (A) Tether of a truss in standing, (B) windlass
effect with metatarsophalangeal extension, (C) windlass effect with demi-pointe.
can be further subdivided into the superficial poste- Heel Pad

rior compartment and the deep posterior compart-
The heel pad is composed of fat cells located within
ment as seen in figure 6.9. These compartments
chambers formed by fibrous tissue walls (septa)
provide a functional division of muscles in that all
constructed in a manner to withstand strain and pres-
of the muscles in a given compartment share at
sure. This pad has been found to be very important
least one common action at the ankle-foot complex.
for shock absorption (Jorgensen, 1985), and loss
The bone and strong fascia forming boundaries for
of the shock absorbency of this fat pad has been
each compartment limit the compartment’s ability
shown to be associated with an increased shock
to expand, which in select individuals can lead to
wave amplitude at heel strike and increased soleus
undesired increases in compartment pressures.
activity and load on the Achilles tendon. The effec-
tiveness of the cushioning offered by the heel pad
Retinaculum
tends to decline with age, with noticeable decline in
Thickened bands of connective tissue called reti- most individuals past 40 years of age (Levangie and
naculum (L. band, halter) are located around the Norkin, 2001).
ankle and foot that help hold tendons in place and keep
them from bowing forward across the front of the ankle Sesamoids
or sliding in front of the medial or lateral malleolus.
For example, the superior peroneal (fibular) retinacu- Two small sesamoid bones lie beneath the head of
lum extends from the lateral malleolus to the fascia of the first metatarsal, located within the tendon of the
the back of the leg and lateral side of the calcaneus flexor hallucis brevis (figure 6.2A, p. 299). Their
(figure 6.10). It functions to help hold the peroneal function is similar to that of the patella located in
muscles in place behind the lateral malleolus. the quadriceps femoris at the knee. They increase
the moment arm of the muscle within which they are
Tendon Sheaths located, increasing the muscle’s ability to produce
torque. They also help distribute the load and pres-
Many of the tendons in the foot are encased by sure beneath the metatarsal head during walking and
synovial tissue, forming tendon sheaths that protect running. Furthermore, they help protect the tendons
the tendons from excessive friction. For example, of their associated muscle and the tendon of the
on the dorsum of the foot, tendon sheaths surround flexor hallucis longus that runs between them—all
the tendons of the tibialis anterior, extensor hallu- of which without the sesamoids would be subjected
cis longus, and extensor digitorum longus muscles to great compression forces with each step or when
(figure 6.10). one goes on demi-pointe.
FIGURE 6.9 Compartments of the lower leg (right leg, transverse section).
Description and Functions

of Individual Muscles
There are 24 muscles of the ankle and foot. Twelve
of these muscles are located entirely within the foot
and are called intrinsic muscles (L. intrinsecus, on the
inside). The remaining 12 muscles have distal tendon
attachments on the foot but otherwise lie outside the
foot. Hence, these muscles are called extrinsic muscles
(L. extrinsecus, from without). The extrinsic muscles
of the foot can be grouped by location into anterior,
posterior, posteromedial, and lateral crural muscles.
Each of these groups has at least one shared action
at the ankle-foot, and each is located in the same
osseofascial compartment of the leg (figure 6.9).
All of these extrinsic muscles cross at least two
joints and so have actions at more than one joint.
However, for purposes of simplicity, the actions at
the ankle, subtalar, and midtarsal joints and other
relevant joints are not differentiated here. Instead,
dorsiflexion and plantar flexion are listed relative to
the ankle-foot, while, since the ankle cannot contrib-
ute to other movements, inversion and eversion are
FIGURE 6.10 Examples of retinaculum and tendon
listed only relative to the foot. Also, for purposes of
sheaths (right foot, lateral view).
simplicity and in keeping with many anatomy texts, the
actions of foot abduction and adduction will not be
Bursae included on charts. However, in general, the muscles
with the action of foot inversion can also produce foot
There are many bursae in the region of the ankle adduction, while the muscles with the action of foot
and foot. Some of these bursae can become inflamed eversion can also produce foot abduction. Many of
and painful in dancers. For example, the bursa the names of the muscles of the ankle and foot reflect
located between the attachment of the Achilles the action that the given muscle performs, making it
tendon onto the heel and the overlying skin (super- easier to learn these muscles. (See Individual Muscles
ficial calcaneal bursa—figure 6.11) can easily become of the Ankle and Foot, pp. 310-323.)
irritated by ill-fitting ballet or street shoes, while the
deeper bursa is at greater risk for inflammation when
there is a prominent upper angle of the calcaneus
(Mercier, 1995). A heel lift, padding, use of a ballet
shoe that ends lower on the heel, or modification
of dance shoes to reduce pressure to the area can some-
times afford relief for the more superficial bursa.
Muscles
In addition to the many ligaments and joint cap-
sules of the ankle-foot complex, many muscles act
to provide stability as well as produce the complex
movements of the many joints in this region. Some
of these muscles play a vital role in shifting the body
weight to the desired position relative to the foot,
as well as absorbing the large forces associated with
impact during weight-bearing movements such as
walking, running, and jumping. FIGURE 6.11 Bursae of the heel (left foot, lateral view).
Individual Muscles of the Ankle and Foot

Anterior Crural Muscles
The anterior crural muscles are located on the front of the lower leg. They are contained within the
anterior compartment of the leg and include the tibialis anterior, extensor digitorum longus, extensor
hallucis longus, and peroneus tertius. Because these muscles all pass anteriorly to the axis of the
ankle joint, they have the common action of dorsiflexion. When the foot is free, this dorsiflexion can
be used to raise the toes and front of the foot and to prevent their striking the ground in movements
such as walking and running. Loss of the ankle dorsiflexors causes the foot to hang down, a condition
termed “drop-foot” (Smith, Weiss, and Lehmkuhl, 1996) when swinging the leg forward in walking. Loss
of the dorsiflexors also prohibits the desired smooth lowering of the foot to the ground during walking,
and a distinctive slap or clop occurs (Moore and Agur, 1995).
Attachments and Primary Actions of Tibialis Anterior

Tibialis anterior Upper two-thirds of lateral tibia Medial and inferior surfaces of A-F dorsiflexion
(tib-ee-A-lis) and adjacent interosseous medial cuneiform and base Foot inversion
membrane of first metatarsal
Tibialis Anterior
As its name implies, the tibialis anterior (tibial, tibia + anterior, toward
the front) originates from the front of the shin (figure 6.12). It runs down
the anterolateral portion of the shin and then crosses inward over the
top of the ankle to insert onto the medial undersurface of the foot (first
cuneiform and base of first metatarsal). The tibialis anterior is respon-
sible for the roundness of the lower leg in this region, and its paralysis
results in a flatness or even concavity in this area accompanied by an
excessively prominent anterior tibia (Smith, Weiss, and Lehmkuhl, 1996).
This muscle is a powerful dorsiflexor of the ankle-foot and is estimated
to provide 80% of the dorsiflexion power of the foot (Frey and Shereff,
1988; Scheller, Kasser, and Quigley, 1980). During weight bearing, this
dorsiflexion function can be used to bring the body weight forward over
the foot to prevent the body from falling backward or to ready the body
for an upcoming movement such as a quick rise onto the toes (Karpovich
and Manfredi, 1973). Due to its medial progression to the undersurface
of the foot, when the muscle contracts it is capable of producing slight
inversion of the foot as well as dorsiflexion. During movement when the
foot is weight bearing, this inversion function of the tibialis anterior helps
support the medial longitudinal arch and prevent excessive pronation.
Palpation: The tendon of the tibialis anterior can be easily seen and
palpated where it crosses the front of the ankle when the foot is actively
dorsiflexed. The upper belly of the tibialis anterior can be palpated on
the lateral side of the anterior margin of the tibia.
FIGURE 6.12 The tibialis anterior

(right foot, anterior view).
Attachments and Primary Actions of Extensor Hallucis and Digitorum Longus

Extensor hallucis longus Anterior fibula and Upper surface of base of Great toe extension
(ek-STEN-sor HAL-u-sis LON-gus) adjacent interosseus distal phalanx of great A-F dorsiflexion
membrane at the middle toe (hallux) Foot inversion
half of leg
Extensor digitorum longus Lateral condyle of tibia Upper surface of lesser Lesser toe extension
(ek-STEN-sor di-ji-TOR-um LON-gus) Upper anterior fibula toes and their extensor A-F dorsiflexion
expansions Foot eversion
Extensor Hallucis Longus

The great toe or hallux has an extensor of its own, called the extensor hallucis longus (EHL) (figure
6.13). This is fitting, in that the great toe is very important in locomotion. The superior muscular portion
of the extensor hallucis longus (extensor, extend + hallux, great toe + longus, long) is located deep to
the tibialis anterior and peroneus tertius, but it rises to the surface to lie between these muscles in the
distal third of the lower leg. Its tendon crosses the front of the ankle, just lateral to the tibialis anterior,
and runs slightly medially to attach to the dorsal surface of the great toe. As its name implies, it has
a primary action of extending the first MTP joint and the IP joint of the great toe. Due to its crossing
anterior to the ankle joint axis and its medial line of pull, this muscle can also assist with ankle-foot
dorsiflexion and foot inversion.
Palpation: The tendon of this muscle is located
just lateral to the tibialis anterior at the front of
the ankle. If you bring the big toe up toward the
shin (hallux extension) the tendon will become
more prominent and you can palpate the tendon
from the top of the big toe and along the dorsum
of the foot.
Extensor Digitorum Longus

The extensor digitorum longus (EDL; extensor,
extend + digit, finger or toe + longus, long) and
the associated peroneus tertius are the most
laterally located muscles of the anterior crural
muscles (figure 6.14). The extensor digitorum
longus has a long tendon that begins about
halfway down the lower leg; and when it crosses
the front of the ankle joint, this tendon divides
into four slips that attach distally to the dorsal
surface of each of the lesser toes. As the name
extensor digitorum longus implies, its primary
action is to extend the toes (extension of the
MTP and both proximal and distal IP joints of
the four lesser toes). Crossing the front of the
ankle with tendons running laterally, it also can
produce ankle-foot dorsiflexion and foot eversion.
The extensor digitorum longus can work together
with the tibialis anterior as a helping synergist,
neutralizing out the inversion of the tibialis ante- FIGURE 6.13 The extensor FIGURE 6.14 The extensor
rior to allow the often-desired neutral dorsiflexion hallucis longus (right foot, digitorum longus and peroneus
of the ankle-foot. anterior view). tertius (right foot, anterior view).
Palpation: The tendon of the extensor digitorum longus can be found just lateral to the tendon of
the extensor hallucis longus at the level of the ankle. Extending toes 2 through 4 against resistance
provided by your hand will make the tendons more prominent; and while the single tendon can be
palpated near the ankle, distally the tendon divides into four parts, all of which can be palpated from
below the ankle to their attachment on the top of the toes.
Attachments and Primary Actions of Peroneus Tertius

Peroneus tertius Anterior fibula and adjacent interosseus Upper surface of base of A-F dorsiflexion
(per-o-NEE-us TER-shus) membrane in lower third of leg fifth metatarsal Foot eversion
Peroneus Tertius
The peroneus tertius (perone, fibula + tertius, third) is considered misnamed by some because it is
not contained in the lateral peroneal compartment and produces ankle-foot dorsiflexion versus the
plantar flexion produced by the other peroneals. It is actually considered part of the extensor digitorum
longus, and it is considered its fifth tendon. The peroneus tertius originates from the lower fibula and
interosseus membrane and inserts onto the dorsal surface of the base of the fifth metatarsal (figure
6.14). Due to its lateral placement and the fact that it crosses in front of the ankle joint axis, its actions
are ankle-foot dorsiflexion and eversion of the foot. The peroneus tertius has been observed only in
humans and great apes, although it is not present in all humans.
Palpation: When it is present, you can palpate the tendon of the peroneus tertius just lateral to the
extensor digitorum longus tendon going to the fifth toe while performing the same movement as for
palpation of the extensor digitorum longus.
Posterior Crural Muscles
The posterior crural muscles are located on the back of the lower leg. These muscles are contained
within the superficial posterior compartment of the leg and include the gastrocnemius, soleus, and
plantaris muscles. The plantaris is considered a vestigial, rudimentary muscle that is absent in about
8% of humans (Rasch, 1989). In addition to being a weak assistant flexor of the knee, the plantaris
contributes to plantar flexion. However, because its contribution is so minimal in terms of force produc-
tion relative to the gastrocnemius and soleus (Levangie and Norkin, 2001), the plantaris will not be
discussed further in this text. The posterior crural muscles all produce ankle-foot plantar flexion and
are very important for propulsion.
Attachments and Primary Actions of Triceps Surae

Triceps surae
Gastrocnemius Posterior aspect of medial and Posterior calcaneus via A-F plantar flexion
(gas-truk-NEE-mee-us) lateral condyles of femur Achilles tendon (Knee flexion)
Soleus Posterior aspect of upper Posterior calcaneus via A-F plantar flexion
(SO-lee-us) tibia, fibula, and interosseus Achilles tendon Stabilizes lower leg on foot
membrane
Gastrocnemius
The gastrocnemius (gaster, belly + kneme, leg) is a double-bellied superficial muscle that attaches
above the knee on the medial and lateral femoral condyles and is responsible for most of the rounded
appearance or prominence of the “calf” of the leg (figure 6.15). It runs down the back of the lower leg
as two separate bellies (medial and lateral) until about halfway down the back of the calf, where the
heads join onto an aponeurosis that becomes the tendocalcaneus or Achilles tendon. This tendon
continues down the lower leg to attach to the heel (calcaneus) and is the largest and strongest tendon
in the body (Whiting and Zernicke, 1998). The gastrocnemius contains a preponderance of fast-twitch
fibers (Smith, Weiss, and Lehmkuhl, 1996) and is a very powerful plantar flexor of the ankle, making it
vital for the execution of forceful movements such as jumping.
Because the gastrocnemius crosses the knee, it can also assist with knee flexion. And, because it
crosses the knee, position of the knee will also influence the ability of the gastrocnemius to be stretched
or produce force. Creating a position of passive insufficiency by extending the knee and dorsiflexing
the ankle-foot will favor effective stretching, while creating a position of active insufficiency by flexing
the knee and plantar flexing the ankle-foot will reduce the ability of the gastrocnemius to produce force
and require that the soleus play a greater role in producing necessary plantar flexion. One can capital-
ize on this differential use of these muscles by performing calf (plantar flexor) strengthening exercises
with the knees bent and straight.
Palpation: The gastrocnemius can be seen contracting and can be easily palpated at the upper calf
when you rise onto your toes (relevé; e.g., plantar flexion).
Soleus
The soleus (soleus, fish or sole) derives its name from its flat appearance, resembling the sole (a
flat fish). This muscle lies deep to the gastrocnemius as seen in figure 6.16. It can be seen below
the prominent double-bellied gastrocnemius and more medially in the lower posterior leg. Unlike the
gastrocnemius, it does not cross the knee joint. Rather it originates from the posterior tibia and fibula
and runs down the back of the lower leg to insert together with the gastrocnemius into the posterior
calcaneus via the Achilles tendon. The soleus muscle is an important plantar flexor of the ankle and
plays an important postural role to steady the leg upon the foot in standing. The soleus contains a
high percentage of slow-twitch fibers, allowing it to perform sustained tonic activity (Smith, Weiss,
and Lehmkuhl, 1996); and electromyographic data support the idea that it is the soleus that is active
FIGURE 6.15 The gastrocnemius (right foot, posterior FIGURE 6.16 The soleus (right foot, posterior view).
view).
regularly during standing posture to keep the body from falling forward (Basmajian and DeLuca, 1985).
Although some controversy still exists, there is some support for the concept that the medial half of
the soleus may also act as an invertor of the calcaneus (Levangie and Norkin, 2001). The soleus and
gastrocnemius together contain three muscle bellies and hence are termed the triceps surae (L. tri,
three + caput, head + sura, calf of the leg).
Palpation: Although much of the soleus is covered by the more superficial gastrocnemius, the soleus
protrudes on both sides of the gastrocnemius in the lower calf. You can feel the soleus contracting in
the lower calf area when you go onto demi-pointe while sitting in a chair with the knee bent.
Posteromedial Crural Muscles
The posteromedial crural or deep posterior crural muscles are located in the deep posterior compart-
ment of the leg. They include the popliteus, flexor hallucis longus, flexor digitorum longus, and tibialis
posterior muscles. The primary function of the popliteus is at the knee, as was discussed in chapter 5.
Although the remaining three muscles are located posteriorly, as they approach the ankle they course
medially, running behind the medial malleolus to attach onto the foot. The resultant line of pull of these
three muscles allows them to all function as inverters of the foot as well as plantar flexors.
Attachments and Primary Actions of Tibialis Posterior

Tibialis posterior Posterior aspect of upper half Plantar surface of navicular, with Foot inversion
(tib-ee-A-lis) of interosseous membrane and offshoots to adjacent bones A-F plantar flexion
adjacent tibia and fibula Supports arch
Tibialis Posterior
The tibialis posterior (tibial, tibia + posterior, toward the back) lies
deep to the triceps surae in the medial portion of the deep posterior
compartment. It originates from the upper interosseous membrane
and adjacent portions of the tibia and fibula. It runs medially down
the back of the leg, passes under the medial malleolus, and then runs
forward to attach onto the inferior surface of the navicular bone and
(by means of fibrous expansions) into adjacent tarsal bones and into
the bases of the metatarsals as seen in figure 6.17. Its line of pull
makes it a powerful invertor of the foot whether the foot is plantar
flexed or dorsiflexed. The tibialis posterior also assists with weight-
bearing ankle-foot plantar flexion. The tibialis posterior is considered
an important muscle for preventing undesired pronation; and with its
fibrous expansions and sling-like support of the talus, it is in a desir-
able position to help maintain the medial longitudinal arch and lock
the tarsal joints during movements. Due to these latter roles, the tibi-
alis posterior is considered a key medial dynamic stabilizer of the foot
(Frey and Shereff, 1988; Levangie and Norkin, 2001). The importance
of the tibialis posterior in this function is evidenced by the eversion,
loss of height of the medial longitudinal arch, and forefoot abduction
that accompany rupture of the tibialis posterior tendon.
Palpation: The tendon of the tibialis posterior can be palpated just
below the medial malleolus as it travels forward toward the navicular.
Pointing the foot and bringing the big toe inward (ankle-foot plantar
flexion and inversion of foot) will make the tendon become more
prominent.
FIGURE 6.17 The tibialis posterior
(right foot, posterior view).
Attachments and Primary Actions of Flexor Digitorum and Hallucis Longus

Flexor hallucis longus Posterior aspect of lower Plantar surface of base of Great toe flexion
(FLEK-sor HAL-u-sis LON-gus) two-thirds of fibula distal phalanx of great toe A-F plantar flexion
Lower interosseous Foot inversion
membrane
Flexor digitorum longus Posterior surface of tibia Bases of distal phalanges Flexion of lesser toes
(FLEK-sor di-ji-TOR-um LON-gus) and tibialis posterior fascia of toes 2-4; each tendon A-F plantar flexion
passes through opening in Foot inversion
corresponding tendon of
flexor digitorum brevis
Flexor Hallucis Longus

The flexor hallucis longus (FHL; flexor, flex + hallux, great toe + longus,
long) originates from the posterior aspect of the fibula, runs medi-
ally across the back of the leg to cross behind the medial malleolus,
and then forward along the medial portion of the plantar aspect of
the foot to attach to the undersurface of the great toe (figure 6.18).
As its name implies, the primary action of this muscle is to flex the
great toe at the MTP and IP joints. However, in movement, this action
appears to be more important in establishing firm contact of the great
toe on the ground in closed kinematic chain movements and produc-
ing a powerful push-off such as during walking, running, and jumping
(Femino et al., 2000; Moore and Agur, 1995) rather than actually pro-
ducing flexion that bends the big toe under. The flexor hallucis longus
also assists with ankle-foot plantar flexion and inversion of the foot.
Similar to what occurs with the tibialis posterior, this inversion can
serve to raise the medial longitudinal arch, lock the transverse tarsal
joint, and thereby stabilize the foot. The course of the flexor hallucis
longus under the sustentaculum tali is particularly advantageous
for supporting the talus and preventing excessive pronation. During
standing on the toes, this muscle is also important for preventing
excessive “rolling in,” supporting the medial longitudinal arch, and
helping to stabilize the hallux.
Palpation: You can palpate the distal portion of the flexor hallucis
longus by placing two fingers under the proximal phalanx of the great
toe while actively flexing the great toe.
Flexor Digitorum Longus

FIGURE 6.18 The flexor hallucis
The flexor digitorum longus (FDL; flexor, flex + digit, finger or toe + longus, longus (right foot, posterior view).
long) originates from the posterior aspect of the upper tibia and from
the fascia covering the tibialis posterior, and runs down the posterior
medial tibia (figure 6.19). As its name implies, the primary function of the flexor digitorum longus is to
flex the digits of the toes. The distal tendon of the flexor digitorum longus divides into four separate
tendons, each inserting into the base of the distal phalanges of toes 2 through 5, producing flexion of
both the distal and proximal IP joints. This motion produces a pressing of the toes against the ground
that is key to application of force to the ground during push-off in closed kinematic chain movements
such as running or jumping, and can be used more subtly to help maintain stability. The flexor digitorum
longus also assists with ankle-foot plantar flexion, foot inversion, and maintaining the longitudinal arch
during dynamic weight bearing.
Palpation: You can palpate the distal portion of the flexor digitorum
longus tendons by placing a finger under the middle phalanx of any
of the lesser toes (toes 2 through 5) while actively flexing that toe.
Proximally, the tibialis posterior, flexor digitorum longus, and flexor hal-
lucis longus all cross behind the medial malleolus in close proximity.
The mnemonic “Tom, Dick, and Harry” can be used to help remember
the relative order of these muscles (figure 6.20). Their tendons are
positioned from anterior to posterior in the following order: tibialis pos-
terior (Tom), flexor digitorum longus (Dick), and flexor hallucis longus
(Harry). Hence, the tendon that can be seen and felt just posterior to
the medial malleolus is that of the tibialis posterior, with the other two
sequentially behind this tendon.
FIGURE 6.19 The flexor digitorum FIGURE 6.20 Relative position of tibialis posterior (Tom), flexor
longus (right foot, posterior view). digitorum longus (Dick), and flexor hallucis longus (Harry) (right
foot, medial view).
DANCE CUES 6.1
“Use the Floor”
T he directive to “use the floor” is commonly used by teachers in association with movements like
tendus and dégagés. As just discussed, one of the important roles of the tibialis posterior and long
flexors of the toes is to press the toes into the ground for “pushing off” in locomotor movements. So,
one desired anatomical interpretation of this cue is to emphasize pressing down into the floor as the
foot slides forward on the floor, rather than just shape the foot into plantar flexion with little or no
contact with the floor as it moves forward. The former approach of emphasizing pressing into the
floor is a useful way of strengthening these posteromedial crural muscles (and many of the intrinsic
muscles of the feet), as well as rehearsing the skill of pushing down into the ground to generate the
forces (ground reaction forces) that are responsible for propelling the body in the desired direction. If
performed with the desired but often unrealized emphasis, the relatively simple movements of tendus
and dégagés can provide significant benefits for dancers.
Lateral Crural Muscles
The lateral crural muscles are located on the lateral portion of the lower leg in the lateral compartment
of the leg. The lateral crural muscles are composed of the peroneus longus and peroneus brevis. These
muscles are closely associated in terms of origin and function and are sometimes jointly referred to as
Attachments and Primary Actions of Peroneal Muscles
Muscle Proximal attachment(s) Distal attachment(s) Primary actions(s)

Peroneus longus Lateral tibial condyle Lateral aspect of first Foot eversion
(per-o-NEE-us LON-gus) Lateral aspect of upper two- cuneiform A-F plantar flexion
thirds of fibula Proximal first metatarsal Depresses head of first
metatarsal
Peroneus brevis Lateral aspect of lower two- Tuberosity at proximal end Foot eversion
(per-o-NEE-us BRE-vis) thirds of fibula of fifth metatarsal A-F plantar flexion
the peroneal muscles. These lateral crural muscles cross the

lateral portion of the ankle behind the malleolus and both produce
eversion of the foot and ankle-foot plantar flexion.
Peroneus Longus
The peroneus longus (perone, fibula + longus, long) originates
from the lateral and upper portions of the tibia and fibula. It
courses superficially along the lateral lower leg and then contin-
ues under the foot to insert onto the undersurface of the first
cuneiform and first metatarsal (at the base of the great toe),
as shown in figure 6.21. Because the peroneus longus passes
behind the lateral malleolus to insert onto the plantar surface of
the foot, its line of pull is such that it can assist with ankle-foot
plantar flexion as well as perform its primary function of foot
eversion. In addition, because the peroneus longus courses
all the way under the foot to the inner aspect, it has the ability
to pull the medial aspect of the foot down into the supporting
surface and help control downward pressure of the first meta-
tarsal head in closed kinematic chain movements. Thus, the
peroneus longus is in a position to shift the body weight medi-
ally and help initiate pronation during walking, as well as help
position the great toe appropriately for push-off. The peroneus
longus is also in a position to offer support to various arches
of the feet. First, the peroneus longus passes under the apex
of the lateral longitudinal arch and thereby provides support for
this arch. Second, its medial attachment allows it to support FIGURE 6.21 Peroneus longus and brevis (right
the transverse arch, functioning like a bowstring by pulling the foot, lateral and inferior views).
medial border toward the lateral border and helping to limit the
depression of the cuboid (Levangie and Norkin, 2001; Soderberg, 1986).
Peroneus Brevis
The peroneus brevis (perone, fibula + brevis, short) originates lower on the fibula than the longus and
runs deep to the longus for much of its upper course. As its name suggests, the peroneus brevis is a
shorter muscle than the peroneus longus, attaching distally onto the lateral foot (proximal fifth meta-
tarsal) rather than coursing underneath the foot as seen in figure 6.21. It shares a similar proximal
line of pull to the peroneus longus, and so it also assists with ankle-foot plantar flexion and is a prime
mover for foot eversion. The peroneals’ line of pull also enables them to produce abduction of the
forefoot, a motion used by dancers to create a beveled foot, a commonly used position in many ballet
and some modern schools of dance.
When weight bearing, both the peroneus longus and brevis are considered important dynamic stabiliz-
ers of the foot and the lower leg relative to the foot. These muscles provide an important counterbalance
for the invertors of the foot such as the tibialis anterior, tibialis posterior, and flexor hallucis longus and
are essential for preventing ankle inversion sprains.
Palpation: The tendons of the peroneals can be made more prominent by pointing and beveling the
foot (plantar flexion and eversion). They can be palpated below and above the lateral malleolus. The
peroneus brevis passes closest to the lateral malleolus, while the longus lies just posterior to the
brevis. The peroneus brevis is more prominent with ankle-foot plantar flexion and eversion of the foot,
and its course can be followed along the lateral foot to the base of the fifth metatarsal.
Summary of Extrinsic Ankle-Foot Muscle Attachments and Actions
A summary of the attachments of the extrinsic muscles of the ankle and foot is provided in table 6.2,
and these muscles and some of their attachments are shown in figures 6.22, A and B, 6.23, A, B, and
C, and 6.24, A and B. From these resources, deduce the line of pull and resultant possible actions of
the primary extrinsic muscles of the ankle and foot, and then check for accuracy by referring to figures
6.22C, 6.23D, and 6.24C.
TABLE 6.2 Summary of Attachments and Primary Actions of Extrinsic Muscles of the Ankle-Foot

Anterior muscles
Tibialis anterior Upper two-thirds of Medial and inferior A-F dorsiflexion
(tib-ee-A-lis) lateral tibia and adjacent surfaces of medial Foot inversion
interosseous membrane cuneiform and base of
first metatarsal
Extensor hallucis longus Anterior fibula and Upper surface of base of Great toe extension
(ek-STEN-sor HAL-u-sis LON-gus) adjacent interosseus distal phalanx of great toe A-F dorsiflexion
membrane at the middle (hallux) Foot inversion
half of leg
Extensor digitorum longus Lateral condyle of tibia Upper surface of lesser Lesser toe extension
(ek-STEN-sor di-ji-TOR-um LON- Upper anterior fibula toes and their extensor A-F dorsiflexion
gus) expansions Foot eversion
Peroneus tertius Anterior fibula and Upper surface of base of A-F dorsiflexion
(per-o-NEE-us TER-shus) adjacent interosseus fifth metatarsal Foot eversion
membrane in lower third
of leg
Posterior muscles
Triceps surae
Gastrocnemius Posterior aspect of medial Posterior calcaneus via A-F plantar flexion
(gas-truk-NEE-mee-us) and lateral condyles of Achilles tendon (Knee flexion)
femur
Soleus Posterior aspect of Posterior calcaneus via A-F plantar flexion
(SO-lee-us) upper tibia, fibula, and Achilles tendon Stabilizes lower leg
interosseus membrane on foot
Posteromedial muscles
Tibialis posterior Posterior aspect of upper Plantar surface of Foot inversion
(tib-ee-A-lis) half of interosseous navicular, with offshoots to A-F plantar flexion
membrane and adjacent adjacent bones Supports arch
tibia and fibula
Flexor hallucis longus Posterior aspect of lower Plantar surface of base of Great toe flexion
(FLEK-sor HAL-u-sis LON-gus) two-thirds of fibula distal phalanx of great toe A-F plantar flexion
Lower interosseous Foot inversion
membrane
Posteromedial muscles (continued)
Flexor digitorum longus Posterior surface of tibia Bases of distal phalanges Flexion of lesser toes
(FLEK-sor di-ji-TOR-um LON-gus) and tibialis posterior of toes 2-4; each tendon A-F plantar flexion
fascia passes through opening in Foot inversion
corresponding tendon of
flexor digitorum brevis
Lateral muscles
Peroneus longus Lateral tibial condyle Lateral aspect of first Foot eversion
(per-o-NEE-us LON-gus) Lateral aspect of upper cuneiform A-F plantar flexion
two-thirds of fibula Proximal first metatarsal Depresses head of
first metatarsal
Peroneus brevis Lateral aspect of lower Tuberosity at proximal end Foot eversion
(per-o-NEE-us BRE-vis) two-thirds of fibula of fifth metatarsal A-F plantar flexion
• Foot eversion
• Foot eversion
FIGURE 6.22 Anterior view of primary muscles acting on the ankle and foot (right foot). (A) Muscles, (B) attachments,
319
Gastrocnemius
• A-F plantar flexion
• Knee flexion
• Foot inversion
• Foot inversion
FIGURE 6.23 Posterior view of primary muscles acting on the ankle and foot (right foot). (A) More superficial view of
muscles, (B) deeper view of muscles, (C) attachments, (D) lines of pull and actions.
Intrinsic Muscles of the Foot
Remember that by definition the intrinsic muscles have both their proximal and distal attachments within
the foot, but some of these intrinsic muscles have similar functions to the extrinsic muscles. To help
distinguish between extrinsic and intrinsic muscles with similar functions, the terms short (brevis) and
long (longus) are sometimes used. For example, the extrinsic extensor of the great toe is called exten-
sor hallucis longus while the intrinsic extensor is called extensor hallucis brevis. This short extensor
of the hallux (extensor hallucis brevis), as well as the short extensors of the digits (extensor digitorum
brevis), is located on the dorsum of the foot as seen in figure 6.25. The remaining 10 intrinsic muscles
are called the plantar muscles and can be grouped into four layers as seen in figure 6.26. While the
first three groups are located on the plantar aspect of the foot in progressively deeper layers, layer 4
is actually located between the metatarsals and phalanges.
The intrinsic muscles of the foot are responsible for abduction, adduction, flexion, and extension of
the toes. Some of these muscles are also important for dynamic maintenance of the arches, propulsion,
and fine adjustments of the feet. One of the important and often overlooked functions of the intrinsic
muscles is to maintain the IP joints in extension to aid the flexor hallucis longus and flexor digitorum
longus in producing a powerful push-off in locomotor movements. If the toes are not maintained in
FIGURE 6.24 Lateral view of primary muscles acting on the ankle and foot (right foot). (A) Muscles, (B) attachments,
extension they curl under, markedly

decreasing the effectiveness of
push-off. A detailed presentation of
the intrinsic muscles of the feet is
beyond the scope of this book. How-
ever, it is important for dancers to
realize the extensiveness of these
muscles and to remember that
these muscles are very important in
dancers due to the high-magnitude,
precise, and intricate demands Extensor Extensor
incurred by the feet. For interested hallucis digitorum
readers, table 6.3 presents the brevis brevis
names, locations, and functions of
these muscles. FIGURE 6.25 The dorsal intrinsic muscles of the foot (right foot,
superior view).
FIGURE 6.26 The layers of the plantar intrinsic muscles of the foot (right foot; inferior view except for superior view
used for layer 4, dorsal interossei).
322
TABLE 6.3 Summary of Attachments and Primary Actions of Intrinsic Muscles of the Foot

Dorsal aspect
Extensor hallucis Lateral portion of dorsal Dorsal surface of base of Extension of MTP joint of great
brevis surface of calcaneus distal phalanx of great toe toe
Extensor digitorum Lateral portion of dorsal Tendons of extensor Extension of MTP and IP joints
brevis surface of calcaneus digitorum longus (toes 2-4) of toes 2-4
Plantar aspect
First layer
Abductor hallucis Tuberosity of calcaneus Medial side of base of Abduction and flexion of MTP
Plantar aponeurosis proximal phalanx of great joint of great toe
toe
Flexor digitorum Tuberosity of calcaneus Both sides of middle Flexion of MTP and proximal IP
brevis Plantar aponeurosis phalanges of toes 2-5 joints of toes 2-5
Abductor digiti Tuberosity of calcaneus Lateral side of base of Abduction of MTP joint of toe 5
minimi brevis Plantar aponeurosis proximal phalanx of fifth Flexion of proximal IP joint of
toe toe 5
Second layer
Quadratus plantae Two heads: Tendons of flexor digitorum Assists flexor digitorum longus
Medial surface longus with flexion of distal IP joints of
Lateral margin of plantar toes 2-5
surface of calcaneus
Lumbricals Tendons of flexor digitorum Medial aspect of expansion Flexion of MTP joints of toes 2-5
longus over toes 2-5 Extension of proximal and
distal IP joints of toes 2-5
Third layer
Flexor hallucis Plantar surfaces of cuboid Both sides of base of prox- Flexion of MTP joint of great toe
brevis and lateral cuneiforms imal phalanx of great toe
Adductor hallucis Oblique head: bases of Tendons of both heads Adduction of MTP joint of great
metatarsals 2-4 attach to lateral side of toe
Transverse head: base of proximal phalanx of Flexion of MTP joint of great toe
plantar ligaments of great toe Assists in support of trans-
metatarsophalangeal joints verse metatarsal arch of foot
Flexor digiti minimi Base of fifth metatarsal Base of proximal phalanx of Flexion of MTP joint of toe 5
brevis fifth toe
Fourth layer
Plantar interossei Bases and medial sides of Medial sides of proximal Adduction of toes 3-5
(three muscles) metatarsals 3-5 phalanges of toes 3-5 Flexion of MTP joints of toes 3-5
and tendons of extensor Extension of distal IP joints of
digitorum longus toes 3-5
Dorsal interossei Adjacent sides of First: medial side of proximal Abduction of MTP joints of toes
(four muscles) metatarsals 1-5 phalanx of second toe 2-4
Second to fourth: lateral Flexion of MTP joints of toes
sides of toes 2-4 and 2-4
tendons of extensor Extension of distal IP joints of
digitorum longus toes 2-4
323
Alignment lateral margins of both feet stay in contact with

the ground, the inner soles of the feet form a shal-
and Common Deviations low dome; the central portion forms an arch that
of the Ankle and Foot is generally not in contact with the ground. This
central concavity is due to the medial longitudinal
There are numerous alignment problems that can arch—consisting of the three medial metatarsals,
involve the ankle and foot, including abnormal the cuneiforms, the navicular, and the calcaneus.
positioning of the tibia, arches, rearfoot, and toes. The medial longitudinal arch is the higher of the
Some of these problems are described in terms of longitudinal arches and is the arch that people are
the direction of the deviation of the bones; and generally referring to when talking about the foot.
similar to the situation with the knee, valgus refers It is designed to allow accommodation to uneven
to a lateral deviation of the distal segment while surfaces, change in direction, and easy shift of the
varus reflects a medial deviation of the distal seg- body weight from one side of the foot to the other.
ment. As with some other regions of the body, a In contrast, the lateral longitudinal arch—consist-
thorough medical evaluation is necessary to distin- ing of the two lateral metatarsals, the cuboid, and
guish between structural and functional alignment the calcaneus—is designed for stability and weight
problems. Furthermore, it is important to realize bearing and generally is in contact with the ground
that ankle and foot deviations are very common in during standing.
both dancers and the general population, and that While the longitudinal arches are responsible for
their significance for injury and the need for correc- the doming in a lengthwise direction, the transverse
tion are highly controversial. arch is key for the doming in a medial-lateral direc-
tion. The transverse arch consists of the tarsal bones
Tibial Torsion in the midfoot (navicular, cuneiforms, and cuboid)
and the metatarsals. This transverse arch can be
As discussed in the previous chapter, the tibia gen- further divided into the tarsal, posterior metatarsal,
erally exhibits external rotation along its length, and anterior metatarsal arches (Magee, 1997). The
termed external tibial torsion, such that in the aver- height of the tarsal transverse arch, particularly influ-
age adult the ankle mortise faces about 15° laterally enced by the cuneiforms, varies markedly between
with the tip of the medial malleoli slightly anterior individuals and is instrumental in creating the high
and superior relative to the lateral malleoli as seen instep valued in classical ballet. The anterior meta-
in figure 6.27. However, individual variation can be tarsal arch is also very important for dancers, and a
great, with measures ranging from 4° of internal loss of this arch is often evidenced by callus forma-
tibial torsion to 56° of external tibial torsion being tion under the head of the second metatarsal and
reported (Smith, Weiss, and Lehmkuhl, 1996). Inter- by metatarsal pain.
nal tibial torsion is associated with walking with the
feet turned inward relative to the knee (toeing-in),
while exaggerated external tibial torsion is associ-
ated with walking with the feet turned out relative
to the knees (toeing-out). Theoretically, an increase
in external tibial torsion might be advantageous
for maximizing turnout of the feet. However, one
study of professional ballet dancers did not show an
increase in average external tibial rotation above
that found in the general population (Hamilton et
al., 1992).
Arches of the Feet

The bones of the feet are not arranged in a flat
structure, but rather involve a series of longitudinal
and transverse arches to form a structure similar
to an elastic half-dome as seen in figure 6.28A. You
can better visualize these arches by standing with
your feet side by side and noting that while the FIGURE 6.27 Tibial torsion (left foot, superior view).
FIGURE 6.28 Arches of the foot. (A) Normal bony arches, (B) key ligaments and muscles that can help support the
medial longitudinal arch, (C) pes cavus, (D) pes planus.
In relaxed standing (static stability), these arches or pes planus (L. pes, foot + planus, flat). A footprint
are supported by the shapes of the bones, the plantar of this type will show much greater area of contact
fascia, and the ligaments that help hold these bones than a normal foot (figure 6.29B). A flatfoot can be
together, without assistance from the muscles of the further classified as a flexible flatfoot or a rigid flat-
feet (Basmajian and DeLuca, 1985; Smith, Weiss, foot or pes planus. With a rigid pes planus, there is
and Lehmkuhl, 1996). However, during movement a decreased arch both when bearing weight and not.
(dynamic stability), various extrinsic and intrinsic This type of flatfoot is often secondary to structural or
muscles add active support and serve as a second pathological factors and is relatively rare. In contrast,
line of stability for the arches of the feet, called into with a flexible or functional pes planus, an arch is
play as demands increase (figure 6.28B). present when not bearing weight or when on demi-
Presence of these arches allows the feet to with- pointe, but when the dancer stands, the medial lon-
stand greater forces while still maintaining their gitudinal arch flattens; the head of the talus moves
integrity, to better absorb shock, and to have greater inferomedially and causes the foot to pronate (figure
mobility and stability. When bearing weight, the 6.28D). This movement of the talus also brings the
foot tends to spread slightly, which helps to absorb adjacent navicular with it, a landmark readily used for
the impact of the force; but the strong arches with evaluation of the arches. It has been postulated that
their springlike quality from associated ligaments congenital ligamentous laxity or excessive pronation
and fascia resist excessive spreading and provide an over time may cause stretching of the soft tissues,
elastic recoil that assists in locomotion (Hamill and such as the spring ligament and tibialis posterior
Knutzen, 1995). tendon, with resultant loss of height in the medial
longitudinal arch of the foot during weight bearing
Pes Planus (Flatfoot) (Hamilton and Luttgens, 2002; Smith, Weiss, and
When the foot demonstrates a decrease or loss of Lehmkuhl, 1996; Soderberg, 1986). The flexible
the medial longitudinal arch, it is called a flatfoot, flatfoot has been reported to occur in about 15% of
the general population (Omey and Micheli, 1999) problems (Conti and Wong, 2001; Hamilton, 1982;
and is common in dancers. McCrory et al., 1999; Yakut et al., 1997).
Individuals with flatfeet have been shown to have
more firing of muscles during standing, probably to Rearfoot Valgus and Varus
try to prevent further flattening of the arches and
offer stability to the intertarsal joints. There is some Another important consideration for foot align-
evidence that pes planus and its associated exces- ment is the position of the calcaneus. Because the
sive pronation increase the risk for certain types of calcaneus is part of the medial longitudinal arch,
injuries such as shin splints, plantar fasciitis, and the subtalar joint, and one of the transverse tarsal
metatarsal stress fractures. However, the general joints, its position will influence the position of the
proposed association of flexible pes planus with rearfoot, midfoot, and forefoot.
increased injury risk is controversial and complex, Rearfoot position can be estimated by the inter-
perhaps because the additional undesired stress to section at the subtalar joint of a line running down
the structures working to support the medial arch the back of the lower third of the tibia and a line
may at least in part be counterbalanced by the ben- bisecting the back of the calcaneus as seen in figure
eficial shock absorbency offered by this foot type. 6.30 (Kreighbaum and Barthels, 1996). A line that
bisects the calcaneus would ideally be approximately
Pes Cavus (High-Arched Foot)
perpendicular to the floor during standing and when
The condition opposite to pes planus is pes cavus. the dancer is viewed from behind (Kreighbaum and
Pes cavus (L. pes, foot + cavus, hollow) involves an Barthels, 1996). This would be considered a neutral
abnormally high arch (figure 6.28C), and a footprint position of the rearfoot (figure 6.30A). If the line that
would show less area of contact than for a normal bisects the calcaneus deviates outward distally more
foot or flatfoot (figure 6.29, A and C). How much than 2° (Levangie and Norkin, 2001), creating an
of pes cavus is congenital and how much it can everted foot, this condition is termed rearfoot valgus
be developed is controversial, but in the author’s (L. turned outward) (figure 6.30B). This condition
experience, dancers can increase their arch to some is commonly associated with excessive pronation
degree with supplemental conditioning and dance during gait and requires midtarsal inversion to bring
training. Although the aesthetic of this cavus foot the lateral toes down to the ground in the same plane
type is valued in most forms of dance, this foot type with the hallux during standing. A dancer with rear-
is generally a more rigid foot type, allowing limited foot valgus will find it easy to “roll in,” or place too
pronation for shock absorbency. Hence, it may much of the body weight on the inside of the foot
increase the risk for certain types of injuries such and tend to lift the outside toes off the floor.
as stress fractures, tarsal sprains from going over If the line that bisects the calcaneus deviates
the foot on pointe, plantar fasciitis, and metatarsal inward versus outward distally, this malalignment
FIGURE 6.29 Footprint associated with (A) normal foot, (B) pes planus, (C) pes cavus.
Pes Planus
Perform the following observations to identify the presence of flexible or rigid pes planus.
1. While sitting down (non-weight bearing), mark the following landmarks on one foot:
a. Inferolateral aspect of the head of the first metatarsal
b. Tubercle of the navicular
c. Distal point of the medial malleolus
Note the relationship of these three points. If the tubercle of the navicular falls on the line between
the head of the first metatarsal and the medial malleolus, this is considered a normal arch. In
contrast, if the tubercle of the navicular drops markedly below this line, this is considered rigid
flatfoot, or rigid pes planus.
2. Now stand up, placing weight on the foot that has the markers, and note if the relationship of
the points changes. If the three points still stay in line, this would still be considered a normal
arch. However, if the navicular was in line when non-weight bearing but drops below the line when
weight bearing, this is considered a flexible flatfoot, or flexible pes planus. The degree to which
the navicular drops is reflective of the severity of the pes planus.
to bring the medial toes down to the ground in the

same plane with the lateral toes during standing. A
dancer with rearfoot varus will find it easy to “roll
out,” with too much of the body weight placed on
the outside of the foot and inadequate weight borne
by the hallux.
Position of the Toes

The arches and position of the rearfoot, as well as
genetic factors, can also influence the position of the
FIGURE 6.30 Rearfoot position (right foot, posterior toes. Prevalent problems involving the toes include
view). (A) Neutral, (B) rearfoot valgus, (C) rearfoot varus. claw toes, hammertoes, and hallux valgus.
is called rearfoot varus (L. bent inward) (figure Claw Toes and Hammertoes
6.30C). Rearfoot varus is commonly associated with Claw toes and hammertoes represent conditions in
excessive supination during gait and increased risk which the lesser toes, usually particularly the second
for ankle sprains, and it requires midtarsal eversion toe, remain excessively flexed. With claw toes the
MTP joint is generally in fixed hyperextension and will allow. Strength and use of these muscles can be
both IP joints are in fixed flexion as seen in figure 6.31. improved with doming exercises performed sitting
With hammertoes, the MTP joint is generally in fixed (table 6.6J, p. 349), followed by repetition of the
hyperextension, the proximal IP joint is in fixed flex- exercise standing, focusing on very slightly lifting the
ion, and the distal IP joint is in hyperextension such metatarsal heads up (vs. letting them drop) as the toes
that the tip of the toe becomes depressed downward reach forward (IP extension). Mild deformities can
(Levangie and Norkin, 2001; Mercier, 1995). These also sometimes be improved or relieved with over-and-
conditions are commonly associated with pes cavus under taping to adjacent toes, selection of dance and
in which the exaggerated arch involves a lowering of street shoes that are not too short, use of various pads
the heads of the metatarsals relative to the rearfoot. or toe caps to avoid pressure sores and corns from the
These conditions tend to place excessive stress on associated abnormal friction from shoes, and making
the metatarsal heads, can interfere with balance and sure that the dancer is standing with his or her body
placement on demi-pointe and pointe, and leave the weight appropriately positioned (vs. too far back) so
flexed joints vulnerable for blisters and corns. that the toe flexors are not having to be used exces-
It is important for dancers and teachers to realize sively to maintain stability. Although in the general
that these conditions are generally due to shortened population, surgery may be recommended for resis-
toe flexors or intrinsic muscle imbalance, and relax- tant forms of these deformities, this type of surgery
ing the toes will not produce the desired correction. is generally not recommended for the dancer.
However, aggressive daily stretching by using one
hand to bring the toes (appropriate IP joints) into Hallux Valgus and Bunions
extension while holding the MTP joint in a neutral Hallux valgus (L. great toe + turned outward) is a
position can sometimes offer gradual but notice- lateral deviation of the distal end of the great toe
able improvement. In addition, using the intrinsic (hallux) at the MTP joint, often also involving a
interossei and lumbrical muscles to stabilize the MTP deviation of the first metatarsal toward the midline of
joint in a neutral versus hyperextended position can the body (metatarsus primus varus) as seen in figure
also decrease clawing during standing flat versus on 6.32. This bony deviation changes the line of pull of
demi-pointe or pointe (Levangie and Norkin, 2001). the muscles that cross the MTP joint, such that many
These muscles can create the desired flexion of the of these muscles will tend to have a bowstring effect
MTP joint without producing undesired further that further increases the valgus deformity, and in
IP flexion of the toes. Furthermore, the extrinsic more advanced cases causes the sesamoids to displace
and intrinsic toe extensors can be used to actively to the lateral side of the head of the first metatarsal.
extend the toes as much as the flexion contractures This valgus deviation of the hallux also tends to
make the medial aspect of the first metatarsal head
become more prominent, and the resultant friction
and trauma from overlying footwear can readily lead
to a bony outgrowth (exostosis), an inflamed bursa
between the exostosis and skin, and a callus on the
overlying skin. This bony and soft tissue enlargement
on the inside of the head of the first metatarsal is
termed a bunion.
Hallux valgus has been reported to affect as many
as 22% to 36% of adolescents; a greater prevalence is
in active females, and particularly female ballet danc-
ers (Kravitz et al., 1986; Omey and Micheli, 1999).
The etiology is still controversial, but it likely involves
both familial factors and other factors that tend to
increase lateral deviation forces on the hallux such
as tight shoes, pointe work, metatarsus primus varus,
pes planus, excessive pronation, forcing turnout, and
joint hyperlaxity. In early stages, use of shoes with
a wider toe box, a felt pad, a toe separator, hallux
valgus taping, control of pronation, and strengthen-
FIGURE 6.31 Claw toes associated with pes cavus ing the arch muscles and the abductor of the hallux
(right foot, medial view). (A) Hallux, (B) second toe. may give some relief. However, in later stages, loss of
FIGURE 6.32 (A) Hallux valgus (anterior view) with (B) bunion formation (left foot, superior view).
range of motion, pain, and the degree of deviation not remain in contact with the floor, and contact
often prohibit optimal mechanics and make these of the lateral toes will depend on the angle of this
approaches ineffective. Although surgery is often rec- metatarsal break and the length of the toes. Hence,
ommended in this later stage for other populations, the directive sometimes given by dance teachers to
its use with performing dancers is controversial; and keep all the metatarsals and toes in contact with
some orthopedists recommended against it due to the floor when on demi-pointe is not appropriate
the tendency to lose hallux extension that is neces- for most dancers. Probably a better cue is to focus
sary for dance (Baxter, 1994; Dyal and Thompson, on keeping the body weight centered over the first
1997; Howse, 1983). and second metatarsal heads with the middle of the
back of the calcaneus in line with the middle of the
Foot Type back of the lower tibia (i.e., neutral rearfoot position
without undue inversion or eversion of the rearfoot
The foot as a whole can be classified into different or midfoot). However, this neutral positioning will
types based on its shape and the relative length of have to be modified slightly for schools of dance that
the toes. One classification divides feet into three desire the beveled line on demi-pointe or pointe. With
types: (1) the squared foot, in which the first and pointe, the foot type, pointe shoe design, and aesthetic
second toes are the same length; (2) the Egyptian concerns (neutral vs. beveled) will influence toe con-
foot, in which the first toe is longer than the second; tact and weight placement. One study that involved
and (3) the Morton’s or Greek foot, in which the performing relevés with pointe shoes showed that
second toe is longer than the first. It is generally held the greatest pressures were over the hallux, and the
that a relatively short, broad, square foot type is less pressures over the second toe varied with the length
prone to injury, and there is some support for this of the toe, such that greater pressures were present
conjecture in dancers (Ende and Wickstrom, 1982; with a long second toe or with capping of the second
Hamilton et al., 1997). toe (Teitz, Harrington, and Wiley, 1985).
The foot type and relative lengths of the metatar-
sals and toes will also influence what bones of the foot
remain in contact during rising onto the ball of the Mechanics
foot. The axis at which the foot bends (e.g., where of the Ankle and Foot
toes extend at the MTP joints), called the metatar-
sal break, is not perpendicular but rather makes an The design of the ankle-foot complex is such that
oblique angle from about 50° to 70° to the long axis certain positions offer greater stability and certain
of the foot (Sammarco, 1980). Thus, on demi-pointe, positions offer more mobility, important for meet-
the lateral two or three metatarsals will generally ing the many functions this structure must serve.
While weight is distributed in a manner to avoid distribution and tends to increase loads borne by the
excessive stress to any one structure with standing, metatarsal heads associated with the lesser toes while
in movement the use of dorsiflexion, plantar flexion, decreasing the load borne by the metatarsal head of
pronation, and supination alter foot characteristics the hallux (Rasch, 1989).
and stability.
Influence of Ankle Dorsiflexion
Weight Distribution and Plantar Flexion on Stability
on the Foot During Standing
The integrity offered by the mortise architecture of
During ideal standing, approximately 50% of the the ankle is not uniform in all positions. Although
body weight should be borne by the heel and the there are large individual variations in shape, the
remaining 50% transmitted across the metatarsal talus is generally slightly wedge-shaped with the
heads (Sammarco, 1980). When weight bearing, the anterior articulating surface being broader than the
anterior transverse metatarsal arch tends to flatten posterior (figure 6.34A). This structure produces a
so that all five metatarsal heads come in contact with snug and stable fit when the ankle is in dorsiflexion
the ground. However, the load is not generally borne or a neutral position with the foot at a 90° angle
evenly by these metatarsals. Instead, the load on the to the tibia, such as when standing (figures 6.34, B
metatarsal head of the great toe should be about and D). However, when the ankle goes into plantar
twice that of each of the metatarsal heads of the lesser flexion, such as when wearing shoes with high heels,
toes (figure 6.33). This is a helpful guideline to keep raising up on the toes, or jumping, the narrower por-
in mind, as many dancers stand with excessive weight
on their heels or on the medial or lateral metatarsal
heads. Wearing high heels can also alter this weight
FIGURE 6.34 Change in ankle stability with position.

(A) Talus with wider anterior articular surface, (B) talus
sitting in mortise formed by malleoli and reinforced by
ligaments, (C) decreased stability in plantar flexion with
FIGURE 6.33 Ideal weight distribution on the foot narrower portion of talus in mortise, (D) increased stabil-
during standing (right foot, inferior view). ity in dorsiflexion with wider portion of talus in mortise.
tion of the talus lies within the malleoli, allowing for Plantar Flexion
more joint play and less stability (figure 6.34C). This
position of plantar flexion relies more on ligaments Ankle-foot plantar flexion involves bringing the ante-
and muscles for stability and is commonly involved rior surface of the shin and the dorsum of the foot
in the mechanism of ankle sprains. away from each other. For example, the triceps surae
and other plantar flexors of the foot (table 6.4) are
Influence of Pronation used concentrically to point the foot as in tendus,
and Supination on Foot Mechanics dégagés, or the sitting point (table 6.6B, p. 344) when
the foot is not weight bearing. When the foot is weight
In movement, transfer of the body weight and rela- bearing, the same muscles are used to rise onto the
tive positioning of the bones of the feet can function toes, such as in pointe work (figure 6.35) and the calf
to make the foot more or less stable (Levangie and raise (table 6.6A, p. 343) or to propel the body into
Norkin, 2001). The position of supination places the space, as in jumps (table 6.6C, p. 345). Although many
weight of the body on the lateral longitudinal arch, muscles are capable of producing plantar flexion,
which is designed for stability; and due to ligament due to their size and location (effective leverage due
design and axes of the transverse tarsal joint the foot to large distance of Achilles tendon from the axis of
is “locked” and stable. This stable position of the foot the ankle joint), the gastrocnemius and soleus are
is desirable for transfer of weight to the foot and for the primary muscles, while other muscles can make
providing a stable segment about which the rest of only a small contribution. Their primary importance
the body may move, as well as for use of the foot as is demonstrated by the inability of an individual to
a rigid lever for propulsion in movements such as rise onto the toes when paralysis of the triceps surae
walking, running, or jumping. However, the foot also is present (Smith, Weiss, and Lehmkuhl, 1996).
has the need to be able to accommodate to uneven
surfaces and absorb shock. These qualities are met by
pronation, in which the foot “unlocks” and becomes
the flexible structure necessary to allow for small
movements between the tarsals and movement of
the forefoot relative to the rearfoot. This pronation
also shifts the weight of the body toward the medial
longitudinal arch of the foot, which is designed
for mobility. Thus, the arrangement of the various
arches and joints allows the foot to act as a rigid lever
for propulsion and an adaptive structure for force
absorption and accommodation, initiated by use of
the positions of supination and pronation.
Muscular Analysis
of Fundamental Movements
Movements are simplified in this discussion to ankle-
foot dorsiflexion, ankle-foot plantar flexion, foot
inversion, and foot eversion without differentiation
regarding the contribution of the various joints of the
rearfoot and midfoot. Also for purposes of simplifica-
tion, movements of the toes are not discussed in the
text but merely included in table 6.4. When thinking
about the movements of the toes, it is important to
keep in mind that one of the key functions of the
toes is to press down against the ground to propel
the body in space. A summary of the key muscles FIGURE 6.35 Sample dance movement showing ankle-
capable of producing the fundamental movements foot plantar flexion.
of the ankle and foot is provided in table 6.4. Photo by Richard Newman. Dancer: Lauren Newman with Inland Ballet Theatre.
TABLE 6.4 Ankle-Foot Movements and the Extrinsic menco or tap dance (figure 6.36). Although all of the
Muscles That Can Produce Them anterior crural muscles can produce dorsiflexion,
the tibialis is the most powerful dorsiflexor.
Joint move- Primary muscles Secondary muscles When the foot is on the ground and weight bear-
ment ing, the dorsiflexors can be used to very slightly
Ankle-foot pull the lower leg toward the foot, to help shift the
weight of the body forward such as before a relevé
Plantar flexion Triceps surae: Tibialis posterior
or in preparation for moving forward in space.
Gastrocnemius Flexor hallucis longus
Soleus However, in most cases when the foot is weight
Flexor digitorum bearing, gravity is the primary force and tends
longus
to create dorsiflexion of the foot. Hence, under
Peroneus longus these circumstances the dorsiflexors of the foot are
Peroneus brevis not working concentrically to create dorsiflexion;
Dorsiflexion Tibialis anterior Extensor hallucis rather the plantar flexors of the foot are used either
Extensor digitorum longus to maintain the angle of dorsiflexion (isometrically),
longus Peroneus tertius such as with standing in one place, or to control
further dorsiflexion (eccentrically), such as during
Foot
landing from a jump.
Inversion Tibialis posterior Flexor hallucis longus
Tibialis anterior Flexor digitorum Inversion
longus
Extensor hallucis Inversion of the foot involves lifting the inner border
longus of the foot. When the foot is unweighted, inversion
Eversion Peroneus longus Extensor digitorum
Peroneus brevis longus
Peroneus tertius
Toes
Flexion
Great toe Flexor hallucis *
longus
Toes 2-5 Flexor digitorum *
longus
Extension
Great toe Extensor hallucis *
longus
Toes 2-5 Extensor digitorum *
longus
*Although there are no other extrinsic muscles, there are many intrinsic muscles
listed in table 6.3 that can assist in producing these movements.
Dorsiflexion
Ankle-foot dorsiflexion involves bringing the
anterior surface of the shin and the dorsum of the
foot toward each other. The tibialis anterior and
other dorsiflexors of the ankle-foot (table 6.4) are
used concentrically to flex the unweighted foot, for
example in the swing phase of walking; when the
foot is actively flexed as a gesture in modern dance; FIGURE 6.36 Sample dance movement showing ankle-
in sitting dorsiflexion with weights (table 6.6D, foot dorsiflexion and associated prime movers.
p. 345); or before or after striking the floor in fla- Photo courtesy of Steve Zee and Jazz Tap Ensemble. Dancer: Steve Zee.
of the foot tends to be linked with forefoot adduction

such as in the strength exercises sitting big toe up
and away (table 6.6F, p. 347) and side-lying big toe
up (table 6.6G, p. 347). However, this position is not
commonly used in dance and is considered undesir-
able aesthetically in some dance forms such as ballet
(sickling the foot). The flexor hallucis longus has
been shown to be capable of producing inversion
and forefoot adduction (Femino et al., 2000).
The functional significance of inversion is more
operative when the foot is weight bearing. Here,
the tibialis anterior, tibialis posterior, flexor hallucis
longus, and other inverters of the foot (table 6.4)
can be used to shift the weight very slightly laterally
to create a locked and stable position of the foot,
or to limit pronation, or both. This former slight
lateral shift can be used in certain jumps (as seen in
figure 6.37) to allow a stable base desirable for the
generation of large forces that propel the body in
space, as well as to create the desired direction of
force (ground reaction force) so that the body will
travel in the desired direction and the limb will be
appropriately positioned relative to the rest of the
body. Often, after the push-off phase is completed,
the foot will be adjusted to a neutral or beveled posi-
tion, in line with the choreographic aesthetic. In
contrast, the latter function of limiting pronation is
very important for keeping the center of gravity in FIGURE 6.37 Sample dance movement showing foot
inversion.
the desired position over the foot so that balance can Photo courtesy of Steve Zee and Jazz Tap Ensemble. Dancer: Steve Zee.
be more easily maintained. Appropriate control of
pronation is also important for prevention of injuries
such as shin splints. line desired by many ballet schools when on demi-
pointe or pointe as seen in figure 6.38. To achieve this
latter aesthetic, the everters can be used to shift the
Eversion body weight and position the forefoot and midfoot
relative to the rearfoot while co-contraction of the
Eversion of the foot involves lifting the outer border
plantar flexors and inverters is used to help maintain
of the foot. When the foot is unweighted, eversion
balance. The everters perform the important func-
is usually combined with forefoot abduction. This
tion of limiting supination of the foot. This latter
combination of movements is considered a desired
function is very important for maintaining balance,
aesthetic in some dance forms such as ballet, and
preventing “falling out” of turns, and preventing
is often referred to as “winging” or “beveling the
ankle sprains.
foot” and often encouraged when the foot is pointed
in movements such as an arabesque (figure 4.25,
p. 189) or in strengthening exercises such as sitting Key Considerations
little toe up and away (table 6.6H, p. 348). The pero-
neus longus appears to be particularly important in for the Ankle and Foot
creating this combined movement of forefoot abduc- in Whole Body Movement
tion, slight eversion, and plantar flexion (Femino
et al., 2000). When considering more complex full movements of
This movement of eversion is also very important the body it is helpful to look again at the role of foot
when the foot is weight bearing. Here, the evert- pronation and supination, as these movements are
ers (table 6.4) can be used to shift the weight very not only important for the foot but also serve impor-
slightly medially to create an absorbent position of tant functions during weight bearing for the body as a
the foot such as in walking, or to create the beveled whole. The importance of pronation and supination
propulsive period. The foot initially contacts the

ground (heel strike, or contact, period) on the lateral
heel with the foot in a position of slight supination
(Taunton, Clement, and Webber, 1981). This puts
the foot in a stable position for transfer of weight
onto the foot. Then as the body weight begins to shift
over the foot, the tibia quickly begins to internally
rotate on this fixed foot, producing pronation and
a shift of the body weight medially. This foot prona-
tion allows the foot to adapt to the surface and aids
with shock absorption. Then, as the body moves
farther over the foot in midstance, the foot begins
to resupinate and body weight is shifted slightly
laterally toward the head of the second metatarsal
(Sammarco, 1980). This resupination stabilizes the
forefoot and allows the foot to serve as a rigid lever
upon which the plantar flexors can act to help push
the body forward (propulsive period).
Excessive Pronation
Although as just described, pronation is an essential
element of normal foot mechanics, excessive prona-
tion may increase the risk for some types of injuries
(Hall, 1999). When pronation is of high velocity
or is excessive in amount, it is believed to place
undue stress on the medial foot and the ligaments,
fascia, and muscles that help support the medial
longitudinal arch. Furthermore, when pronation is
prolonged and extends into the propulsive period of
gait when the foot should be resupinating, the foot
FIGURE 6.38 Sample dance movement showing foot
eversion.
is unstable rather than stable when propulsive forces
Photo courtesy of Marty Sohl. Alonzo King’s Lines Ballet dancer Maurya Kerr. are applied, placing undue stresses on the foot and
decreasing the effectiveness of the push. Over time,
repetitive abnormal pronation is also believed to
will be further addressed through an examination cause stretching of tissues that support the arch and
of their role in walking, the negative implications of to contribute to the production of pes planus.
excessive pronation, and the coupling of the lower Excessive pronation can come from many causes
leg and foot with these movements. including malalignment, muscle imbalances, and
technique. In regard to malalignment, rearfoot varus
Foot Pronation and Supination in Walking and tibial varum require more pronation before the
inner portion of the foot can contact the ground
The interplay of pronation and supination can be (Taunton, Clement, and Webber, 1981). In terms
easily illustrated with walking gait. Walking is clas- of muscle imbalance, if the triceps surae is tight,
sically divided into two phases—the stance phase, compensatory pronation will occur to unlock the
or support phase, and the swing phase. During the transverse tarsal joints in order to gain the neces-
stance phase the foot is in contact with the ground, sary apparent dorsiflexion. Inadequate strength in
while during the swing phase the foot is being swung the extrinsic inverters of the foot and the intrinsic
forward in space to reach an appropriate position muscles that help maintain the medial longitudinal
for the next step. The stance phase is the phase that arch may also be a factor in failing to adequately
places the weight-bearing demands on the ankle limit extent or duration of pronation. With regard
and foot and will be the focus of this discussion. The to technique, failing to maintain adequate turnout
stance phase can be further subdivided into three at the hip, such that the knees “fall inside the feet”
periods—the contact period, midstance period, and during movements like pliés, can cause relative
Foot Supination and Pronation in Walking
• Identify normal foot mechanics in walking. Walking very slowly, mark on your body the normal
foot mechanics during the stance phase of walking that were just described in the text and that are
shown in A.
• Observe three to five individuals walk-

ing. Position yourself so that a dancer walks
directly toward you and then directly away from
you. Observe the mechanics listed in the text
and notice if supination—pronation—supination
occur and to what extent and with what timing.
Notice differences between sides in the same
individual and any malalignments in the knees,
hip, and spine that might influence this gait.
• Observe yourself walking. Now observe
yourself walking by walking toward a mirror
or keying in to internal cues. Make the same
observations as just described. Also note your
shoe wear pattern. Look at the ideal pathway
of the center of pressure on the foot shown in
B, and consider what clues shoe wear can give
regarding foot mechanics in walking.
335
internal rotation of the lower legs and compensatory and end of stance, respectively (Hamill and Knutzen,
pronation of the feet. 1995). If this mechanism were not available, these
rotations of the lower leg would tend to spin the foot
Coupling of the Leg and Foot on the ground or disrupt the integrity of the ankle
joint by causing the talus to rotate within the mortise
Due to the oblique axis of the subtalar joint, the (Levangie and Norkin, 2001). This coupling is also
shapes of various bones, and soft tissue interaction, important for the dancer to keep in mind in regard to
there is a coupling of movements between the leg technique, as rotation of the leg can be used to place
and foot when the foot is fixed and weight bearing body weight appropriately over the axis of the foot,
as shown in figure 6.39 (Hintermann, 1999). Since such that excessive pronation or supination can be
the ankle joint is a hinge joint that does not allow avoided. On the other hand, the common tendency
much rotation, rotation of the lower leg is translated of allowing the foot to pronate during standing will
to the foot; and conversely, rotation (abduction and produce internal rotation of the tibia with resultant
adduction) of the foot is translated to rotation of loss of turnout if the whole limb is allowed to follow,
the lower leg. This coupling is such that supination or knee stress if turnout of the femur is maintained
is accompanied by external rotation of the leg, and at the hip while the tibia rotates internally.
external rotation of the leg is accompanied by man-
datory supination (Soderberg, 1986). Conversely,
pronation is accompanied by internal rotation of Special Considerations
the leg, and internal rotation of the leg produces for the Ankle and Foot
pronation of the foot.
During walking, this coupling is important for in Dance
absorbing the rotations of the lower leg as the tibia
When one is trying to apply the mechanics of the
internally and externally rotates at the beginning
ankle and foot to dance, there are several technique
areas that deserve more discussion. One of these
is the issue of achieving the desired aesthetics and
placement in demi-pointe and pointe positions.
Another issue is achieving desired foot placement
when the knee bends, such as in pliés. In ballet, still
another important concern is the introduction of
pointe work.
Demi-Pointe, Pointe,
and the Stirrup Muscles
The repetitive use of demi-pointe and pointe in
dance places great demands on the foot and requires
specialized strength, flexibility, and technique devel-
opment. In terms of flexibility, extreme ankle-foot
plantar flexion is required to achieve the desired
aesthetic of these positions and allow the dancer
to get high enough to allow the body weight to be
appropriately placed over the ball of the foot (demi-
pointe) or toes (pointe). For proper mechanics and
aesthetics on pointe, it is recommended the dancer
have 90° to 100° of ankle plantar flexion (Hamilton et
al., 1992). About 90° of extension of the hallux at the
MTP joint (figure 6.40) is also necessary for a desired
high demi-pointe position (Sammarco, 1980).
In terms of plantar flexion strength and range, the
FIGURE 6.39 Coupling of the leg and foot (left foot, ankle-foot plantar flexors have to contract forcefully
lateral view). (A) Internal rotation of leg and foot pronation, to achieve and maintain this position of the foot, and
(B) external rotation of leg and foot supination. ballet dancers have been reported to have very high
of the foot. Their co-contraction (in combination

with other muscles) can be used to allow the weight
to rise to the toes and lower from the toes without
undesired inversion or eversion, and to make subtle
adjustments of the body weight to enhance balance
and dance aesthetics. For example, contraction, or
pulling up, with the lateral stirrup muscles will shift
the body weight medially on the foot (eversion) and
prevent excessive rolling out (inversion) on the foot,
such as is commonly seen in “falling out” of multiple
pirouettes. Conversely, contraction, or pulling up,
with the medial stirrup muscles will shift the body
weight laterally on the foot (inversion) and prevent
excessive rolling in (eversion) on the foot. In terms
of these medial stirrup muscles, theoretically, the
tibialis posterior should be emphasized more than
the tibialis anterior when on demi-pointe or pointe
due to its additional desired action of ankle-foot
plantar flexion.
FIGURE 6.40 (A) Hallux range of motion and demi-
pointe. About 90° of extension of the metatarsopha- Pointing the Foot
langeal joint is necessary for (B) optimal positioning in in Open Kinematic Chain Movements
demi-pointe.
This same balanced use of the stirrup muscles can
levels of plantar flexor strength. Although the triceps be utilized during plantar flexion of the foot without
surae muscles produce a large percentage of the weight bearing, such as in a tendu. The peroneals
plantar flexor torque, other plantar flexors can help and tibialis posterior are used synergistically and in
slightly reduce the demands on the triceps surae and accordance with the aesthetic of the given dance
help achieve the desired aesthetic. Two such plantar form to create a neutral position or slightly “bev-
flexors are the flexor hallucis longus and flexor digito- eled” position of the foot and to get a more fully
rum longus. The flexor hallucis longus and flexor digi- pointed position, with the desired “stretch” across
torum longus have been shown to have a shortening the instep. Due to their more distal attachment,
effect on the foot in a front-to-back direction (Smith, these stirrup muscles can be used to add slight
Weiss, and Lehmkuhl, 1996), and so can help achieve plantar flexion at the intertarsal joints and tar-
the desired “high-arch” look in pointe. Three other sometatarsal joints, while the gastrocnemius and
plantar flexors—the tibialis posterior, tibialis anterior, soleus, which attach proximally onto the calcaneus,
and peroneus longus—function together to lift the would primarily effect plantar flexion at the ankle
arch and help maintain balance on demi-pointe and joint proper.
pointe. These three muscles can be termed the stir- The flexor hallucis longus and flexor digitorum
rup muscles because they run behind the medial longus can also be used to achieve this more fully
and lateral malleoli to converge to attach onto the pointed look, and tension on the flexor hallucis
undersurface of the medial longitudinal arch in a longus has been shown to increase the height of
stirrup-like arrangement. All three muscles have the medial longitudinal arch (Femino et al., 2000).
attachments onto the plantar surface of the cunei- These muscles can also increase the point of the foot
forms, with the tibialis anterior and peroneals also by bringing the MTP joint into flexion. However,
both attaching onto the base of the first metatarsal, to prevent the undesired curling under of the toes
while the tibialis posterior has additional attachments (IP flexion) accompanying use of these flexors, the
on the navicular and other metatarsal bases. Their intrinsic toe extensors (lumbricals and interossei)
attachments put them in a perfect position to lift the must be used synergistically to maintain the IP joints
midfoot higher up in plantar flexion, irrespective of in extension. Lastly, other intrinsic muscles can be
the position of the toes. used to “lift the arch” and increase the point. Think-
In terms of stability, the stirrup muscles can be ing of pulling the base of the toes and the underside
used to keep the body weight appropriately posi- of the arch back with strings running behind each
tioned in a medial-lateral direction over the axis side of the malleoli, while stretching across the
Stirrup Muscle Function in Relevé
• Use the stirrup muscles to adjust your body weight placement. Rise onto the ball of your foot
using your hand on a wall or barre to help balance. Purposely shift your body weight outward so that
your foot rolls out (inversion) and excess weight is borne by the fourth and fifth toes as seen in C.
Then pull up with the outer stirrup muscles by thinking of lifting the underside of the outer border
of the foot up toward the ceiling to bring your body weight back over the long axis of the foot. Now,
shift your body weight inward so that your foot rolls in (eversion) with excess weight on the big toe as
seen in D. Then pull up the inner stirrup muscles by thinking of lifting the underside of your medial
arch toward the ceiling to bring your body weight back so it is centered between your first and second
toe. Lastly, keeping your weight over the axis of the foot, contract both sides of the stirrup muscles
together to keep your body weight appropriately positioned and to raise your arch slightly higher to
help reach full height in a demi-pointe position as seen in A and B.
• Perform a normal relevé. Perform several relevés as you normally would and without thinking
about the stirrup muscles. Note the placement of your body weight. Then, make any necessary cor-
rection with the stirrup muscles, and repeat a relevé trying to maintain correct positioning. Which
muscle(s) do you need to focus on using more? What cue could you utilize to help make this correc-
tion quickly, such as when in class?
instep and reaching the toes out, can sometimes help in line with the second toe) in standing movements
achieve the desired muscle activation. involving bending one or both knees, such as pliés
or weight shifts, can help encourage proper foot
Knee-Foot Alignment mechanics in many dancers and help prevent the
common tendency of not maintaining adequate hip
Due to the coupling of the leg and foot discussed external rotation, letting the knees excessively fall
previously, positioning of the knee relative to the in and the feet pronate. However, it is important to
foot is important for correct foot mechanics. Using realize that the specific relationship of the knee to
the cue to keep the knee over the foot (a plumb the foot that will yield the desired neutral subtalar
line dropped from the center of the patella being and midtarsal foot position will vary greatly between
DANCE CUES 6.2
“Point From the Top of the Foot”
T he instruction to “point from the top of the foot,” often in conjunction with “and don’t use your
Achilles,” is sometimes used by teachers in an effort to achieve a greater point of the foot without
causing discomfort under the Achilles (posterior impingement). However, from an anatomical perspec-
tive, this cue can be confusing in that the muscles on top of the foot do not point the foot (they are
dorsiflexors), and the Achilles and associated gastrocnemius and soleus are prime movers for plantar
flexion. A more anatomically sound cue could focus on creating a stretch across the top of the foot by
reaching the foot “out and down,” focusing on articulating each of the joints that can contribute to
plantar flexion/flexion (talocrural, subtalar, intertarsal, tarsometatarsal, and MTP joints) rather than
just the ankle joint. In addition, focusing on using the stirrup muscles and the intrinsic muscles of the
feet to pull the bottom of the metatarsals back toward the heel can increase the point of the foot with
less tendency for impingement.
dancers, based on many factors including femoral and mental maturity (Hamilton, 1988; Sammarco,
torsion, tibial torsion, and forefoot abduction. 1982; Weiker, 1988).
Thus, although this cue is often helpful in a class However, these age guidelines were in part based
setting, the individual dancer may need to adjust it on the concern for injury of structures still in the
slightly for his or her body. Furthermore, in dance growth process. And the limited number of injuries
forms that require the feet to face almost directly to reported that appear to be related to premature
the side, dancers should realize that this will tend to pointe has led to some less conservative recommen-
produce pronation of the foot and internal rotation dations and a greater emphasis on functional readi-
of the tibia if hip external rotation is not sufficient. ness. In terms of age, two dance medicine groups
Focusing on using the external rotators of the hip suggest that if other criteria are met, with select
and knee to maximize turnout at the hip and pro- individuals a minimum of 10 years of age may be
hibit internal rotation of the tibia can help reduce appropriate (Solomon, Micheli, and Ireland, 1993),
the tendency toward or degree of foot pronation. at least to begin pointe work at the barre (Ryan and
Stephens, 1987). In terms of functional concerns,
Beginning Pointe there is an increasing awareness of the varied age at
which dancers reach adequate strength, flexibility, and
Beginning pointe is a major and often highly antici- technical proficiency. Hence, a greater emphasis on
pated step in the training of a female classical ballet individual readiness may be appropriate. Suggested
dancer. With rising technical demands in profes- functional tests include the ability to plantar flex the
sional dance, teachers and parents frequently have foot in a line parallel to the line of the tibia (Solomon,
questions regarding the appropriate timing to begin Micheli, and Ireland, 1993) when measured with a
pointe. The goal is to avoid injury in dancers who are goniometer or as evidenced in a tendu and relevé.
still maturing while still allowing them to develop the Another commonly used test is the ability to maintain
proficiency on pointe that is necessary to be competi- balance in retiré on demi-pointe with good alignment
tive in the ballet world. Unfortunately, the answer of the ankle, a straight knee, maintenance of turnout
to this question is not simple; it encompasses many at the hip, and good pelvic and spinal alignment
individual factors such as skeletal maturity, mental (Khan et al., 1995). The author also recommends use
maturity, technical proficiency, and years of training. of a pirouette, noting the alignment just described
Considering all of these factors, several orthopedists with the retiré, with particular attention paid to the
who are noted for their expertise with dancers have ability to prevent excessive rolling out on the foot.
recommended that dancers begin pointe at a mini- The ability to go on pointe without knuckling or
mum of 11 years of age if they have undergone three sickling is another commonly held criterion.
to four years of disciplined ballet training and exhibit While in general agreement with these sugges-
sufficient strength, technical proficiency, and skeletal tions, from a kinesiological perspective the author
Influence of Knee Position on Foot Mechanics
• Knee position in a parallel plié. Perform a demi-plié in parallel first position. As the knees bend,
purposely guide the midpoint of the kneecap well inside the feet and notice how the feet tend to pro-
nate. Now guide the knees over the feet, and find the path of the knee where the foot stays neutral
without rolling in or out and with desired weight distribution on the foot. Lastly, purposely guide the
midpoint of the kneecap well outside the feet, and notice how the foot inverts. Perform a parallel plié
the way you normally would and see if you need to make any correction in knee placement so that a
neutral position of the foot is maintained.
• Knee position in a turned-out plié. Repeat the procedures just described while performing a
second-position demi-plié in turnout. Do you notice any difference with the addition of turnout? Adjust
the facing of your feet slightly out and in from how you normally stand, and notice the effect on your
feet. How do changes in foot position influence foot mechanics? How does maintaining turnout at the
hip influence foot mechanics? How do these factors relate to coupling of the leg and foot?
would emphasize that there are unique challenges and can be prioritized, with additional exercises
related to pointe work that will not be developed with selected in accordance with the specific dancer’s
demi-pointe. These demands include (1) greater technique needs.
challenge to the flexor hallucis longus due to the In terms of introduction of pointe work into
necessity of producing force at a shorter length technique class, the approach used by some ballet
(because it is not lengthened across the MTP joint as schools of starting with simple exercises at the barre
with demi-pointe) and its key role in pushing down for the last 15 to 30 minutes of technique class,
into the ground to facilitate going from demi-pointe which gradually progress in difficulty and duration,
to pointe (MTP flexion); (2) greater strength and is very sound from a physiological perspective. Ini-
coordinated contraction required in other flexors tial presentation of pointe work that is too difficult
and extensors of toes (particularly the great toe) to or too long in duration for current strength and
stabilize the toes in extension and prevent toe flexion coordination levels can result in the development
(knuckling) when actually on pointe (figure 6.41); of undesired compensations or injury. In contrast,
and (3) greater forces borne by the first two toes a well-designed program that is initially performed
and balance challenges associated with decreasing two to three times per week and gradually progresses
the base of support from the ball of the foot to the in duration and difficulty should allow the necessary
small toe box of the pointe shoe. development of strength and skill for more advanced
Hence, in addition to the prior suggestions, the work with sound technique.
author would also encourage the use of supplemental
conditioning exercises and an initial progressive use
of pointe within the technique class to assist with the Conditioning Exercises
transition into pointe work. Some pointe-specific for the Ankle and Foot
exercises are shown in figure 6.42, and other relevant
exercises that will be described in the next section The ankle-foot is a common site of injury in dance,
are included in the sample pointe preparation rou- and adequate strength and flexibility are necessary
tine given in table 6.5. These exercises should be for lowering injury risk, as well as enhancing per-
added three to six months prior to beginning pointe formance.
and performed only if no pain is experienced and
there are no medical contraindications. The last two Strength Exercises for the Ankle-Foot
exercises are more advanced exercises and should
be added only after the other exercises have been Sample strength exercises for the ankle-foot are
performed for about six weeks. If time is limited, the provided in table 6.6, and a brief description of their
exercises with an asterisk are most specific to pointe importance follows. When strengthening exercises for
FIGURE 6.41 (A) Coordinated toe flexor and
extensor co-contraction necessary for correct
positioning when pointing the foot or going on
pointe to avoid (B) undesired curling under of
A B the toes (excessive IP flexion).
A B
FIGURE 6.42 Sample exercises for beginning or improving pointe work. (A) Big toe extension, (B) toe extension, (C) big toe
flexion, and (D) toe wall climbs.
341
TABLE 6.5 Sample Pointe Preparation Routine
Exercise Repetitions Purpose

*Demi to pointe (band) (table 6.6B, variation 2) 6 times (all toes) Strength to help rise from demi to pointe
Big toe flexion (figure 6.42C) 6 times (great toe only) Strength to help rise from demi to pointe
*Toe extensions (band) (figure 6.42A) 6 times (great toe only) Stability on pointe and to prevent
(figure 6.42B) 6 times (all toes) knuckling under
Sitting big toes up and away (band) (table 6.6F) 8-12 times Prevent rolling in
Sitting little toes up and away (band) (table 6.6H) 8-12 times Prevent rolling out
*Doming (table 6.6J) 8-12 times MTP joint stability and strength to keep
toes extended instead of curled (flexed)
Sitting dorsiflexion (band) (table 6.6E, variation 1) 8-12 times Muscle balance
*Sitting pointe stretch (table 6.8F) 3 times with 20-second ROM to allow ideal positioning of body
hold over toes
Toe wall climbs (figure 6.42D) 1-4 times up and down Strength to help rise from demi to pointe
Fondu forced arch (table 6.6A, variation 2) 6-12 times Stirrup muscles and positioning of
instep over toes
this region are performed, particular care must be jump (Devita and Skelly, 1992). Ballet dancers have
taken with respect to developing balanced strength been shown to have plantar flexor strength markedly
between antagonist muscles. For example, move- greater than that of many other athletes (Hamilton
ments performed in class such as relevés and jumps et al., 1992), reinforcing the importance of strength
tend to develop the ankle-foot plantar flexors, and in this area for dancers. Adequate strength in the
an emphasis on supplemental strengthening of the plantar flexors is also believed to be important for
dorsiflexors is recommended for many dancers to prevention of Achilles tendinitis; a study of runners
maintain a healthy ratio between these antagonists. showed lower strength levels of the plantar flexors
Similarly, many dancers exhibit weakness in the foot in runners with Achilles tendinitis when compared
everters relative to the foot invertors. When a known to runners without tendinitis (McCrory et al.,
imbalance is present, one approach is to repeat the 1999).
exercise in a second set of repetitions on the weaker Calf raises (table 6.6A) provide a functional way to
side (after 2-3 minutes of recovery) for a limited time work on building this strength and technique, while
until a better balance in strength is achieved. For sitting point (table 6.6B) is a convenient exercise
some key movements, exercises are included that that can easily be performed with a band. Dancers
use bands and weights. Bands offer a great advantage can also strengthen these muscles functionally by
in terms of convenience and can be easily carried performing repetitive jumps, starting with two feet
in a dance bag, and exercises can be performed and progressing to single-leg jumps (table 6.6C). The
during a break. However, for dancers who find that dancer must be thoroughly warmed up before per-
they have marked weakness in certain areas, weights forming jumps and should perform them on a resil-
may better allow them to develop greater strength ient floor. Performing jumps on a Pilates Reformer
throughout a wider range of motion and to easily also offers an opportunity to work on technique with
monitor progress. increasing springs, height of jumps, or quickness
and complexity of jumps for progression. Jumps
Plantar Flexor Strengthening are particularly useful for developing the explosive
Adequate strength in the plantar flexors is important power of the gastrocnemius needed for both high
for work on demi-pointe and pointe, and for a power- and quick jumps used in dance choreography. In
ful push-off such as used for turns and jumps. The contrast, performing ankle-foot plantar flexion with
ankle plantar flexors have also been found to play a the knees bent, as described in table 6.6A (variation
vital role in absorbing energy when landing from a 3), will emphasize greater use of the soleus.
TABLE 6.6 Selected Strength Exercises for the Ankle-Foot

Muscle group: A-F plantar flexors
Muscles emphasized: Triceps surae and stirrup muscles
Joint movement: A-F plantar flexion
A. Calf raise Stand on one foot with the other 1. Gradually increase the height of
(Dumbbells) foot against the ankle of the relevé.
support leg. Slowly rise onto the 2. Gradually increase from 5-pound
ball of the foot, pause, and slowly to 10-pound dumbbells.
lower to the starting position. 3. Add a brief hold at the top.
(Keep the body weight centered
between the first and second toes,
and avoid rolling in or rolling out;
rise up high onto the ball of the
foot, focusing on using the stirrup
muscles to give a slightly greater
lift to the arch of the foot.)
Variation 1: Perform calf raises
supine on Pilates Reformer.
Variation 2: Fondu forced arch—
Bend the support knee (fondu)
and rise as high as possible onto
the ball of the foot with a bent
knee. Then straighten the knee
(trying to keep the heel as high
as possible), pause, and lower to
starting position with a straight
knee while standing on the floor or
lying supine on the Reformer, with
the foot on the jump board.
Variation 3: Perform calf raises
while sitting in a chair with the
knees bent to 90°, leaning forward
and using your hands on your
thighs or a weight plate on top of
the lower thighs for resistance.
Variation 2
(continued)
343
TABLE 6.6 Selected Strength Exercises for the Ankle-Foot (continued)

Muscle group: A-F plantar flexors and MTP flexors
Muscles emphasized: Stirrup muscles and MTP flexors
Joint movement: A-F plantar flexion with MTP flexion
B. Sitting point Sit with one leg outstretched to the 1. Pull the band tauter for the
(Elastic band) front with the band under the ball starting position.
of the foot and the hands pulling 2. Use a heavier band.
the band taut. Slowly point the
foot, leading with the ball of the
foot and only adding the toes at
the end of the movement. Pause,
and slowly return to the starting
position.
(Focus on using the stirrup
muscles to keep the foot in a
neutral position throughout the
movement and avoid inverting or
everting the foot.)
Variation 1: Perform with the knee
slightly bent and the heel resting
on the ground.
Variation 2: Maintain the plantar-
flexed position throughout the
exercise, and start with the
toes back (metatarsophalangeal
extension) as if on demi-pointe.
Then reach the toes out to be
in line with the metatarsals
(metatarsophalangeal flexion),
pause, and slowly allow the toes
to come back to the starting demi-
pointe position.
Variation 2
344
Muscles emphasized: Gastrocnemius
C. Single-leg jumps After adequate warm-up including 1. Increase height while
(Body weight) jumps from two feet, perform maintaining good technique.
repetitive jumps taking off from 2. Increase speed and height while
and landing on the same leg. maintaining good technique.
Stand facing a barre with the
fingertips on the barre if needed.
(Focus on maintaining correct
mechanics of the foot, and avoid
excessive pronation or double heel
strikes when landing.)
Variation 1: Perform supine on
the Pilates Reformer with a jump
board.
Muscle group: A-F dorsiflexors

Muscles emphasized: Tibialis anterior and extensor digitorum longus
Joint movement: A-F dorsiflexion
D. Sitting dorsiflexion Sit with legs bent over the edge of 1. Gradually increase how high the
(Weight) a table, the Pilates Cadillac, or a toes are lifted.
counter with a weight hanging from 2. Gradually increase from 5
the top of one foot with the ankle- pounds to 15 pounds.
foot in slight plantar flexion. Slowly
raise the foot up toward the shin,
pause, and slowly return to the
starting position.
(Keep the foot in a neutral position,
guiding the space between the first
and second toe toward the middle
of the shin.)
Variation 1: Focus on leading with
the great toe and inverting the foot
instead of keeping it in neutral to
emphasize the tibialis anterior.
Variation 2: Focus on leading with
the fifth toe and everting the foot
instead of keeping it neutral to
emphasize the extensor digitorum
longus and peroneus tertius.
(continued)
345

Muscle groups: A-F dorsiflexors and foot inverters
Muscles emphasized: Tibialis anterior
Joint movement: A-F dorsiflexion with inversion
E. Sitting big toe up and in Sit with one leg outstretched and 1. Bring the heel of the bent leg
(Elastic band) the other leg bent and supported closer to the buttocks so that
by the arms. Loop the band under the band is tauter.
the arch of the outstretched leg 2. Use a heavier band.
and over the toes of the bent leg.
Bend the knee enough to make
the band taut. Then flex the foot
(leading with the great toe), pause,
and slowly return to the starting
position.
(Focus on bringing the great toe
both up and in so that inversion is
combined with dorsiflexion of the
foot.)
Variation 1: Sitting dorsiflexion—
Dorsiflex the foot in a neutral
position rather than leading with
the big toe to emphasize general
strengthening of the dorsiflexors.
Variation 2: Sitting little toe up
and in—Dorsiflex the foot, leading
with the little toe to emphasize
the extensor digitorum longus and
peroneus tertius.
Variation 3: Perform any of these
exercises facing the end of the
Pilates Cadillac with one foot in the
strap that has a spring attached at
the low end of the Cadillac.
Variation 2
346
Muscle group: Foot inverters
Muscles emphasized: Tibialis posterior
Joint movements: Foot inversion and forefoot adduction with A-F plantar flexion
F. Sitting big toe up and away Sit with the lower legs crossed 1. Pull band tauter by moving the
(Elastic band) to the front and a band looped feet further away at the start.
around the ends of the feet with 2. Use a heavier band.
the heels separated so that the
band is taut. With feet pointed,
move the front of the feet (leading
with the great toes) up and away
from each other, pause, and slowly
(Keep both feet pointed throughout
the exercise, and isolate the
movement to the feet, avoiding
movement of the knees.)
Variation 1: Secure the loop under
or around something sturdy. Place
only one foot in the loop, and move
the foot up and away (leading with
the great toe).
Variation 2: Perform the same
movement, sitting with the side
to the end of the Pilates Cadillac
and one foot in a strap that has a
spring attached low to the end of
the Cadillac.
Variation 2
G. Side-lying big toe up Lie on your side with a weight 1. Gradually lift the great toe
(Weight) hanging from the end of your higher.
bottom foot. With the foot pointed, 2. Gradually increase the weight
bring the forefoot up toward the from 5 pounds to 15 pounds.
ceiling, leading with the great toe.
Pause, and slowly control lowering
(Keep the foot pointed throughout
the movement.)
(continued)
347

Muscle group: Foot everters
Muscles emphasized: Peroneals
Joint movements: Foot eversion and forefoot abduction with A-F plantar flexion
H. Sitting little toe up and away Sit with legs outstretched to the 1. Move little toes further away.
(Elastic band) front and a band looped around 2. Spread the feet farther apart for
the ends of the feet with the feet the starting position.
separated so that the band is 3. Use a heavier band.
taut. With the feet pointed, bring
the front of the feet away and up,
leading with the little toes. Pause,
and slowly control the return to the
starting position.
(Keep the feet pointed throughout
the movement; isolate the
movement to the feet, and
concentrate on keeping the knees
facing straight up to avoid including
movement of the hip.)
Variation 1: Secure the loop under
or around something sturdy. Place
only one foot in the loop, and bring
the forefoot up and away (leading
with little toes).
Variation 2: Perform the same
movement, sitting with the side
facing the end of the Pilates
Cadillac and one foot in a strap
that has a spring attached low to
the end of the Cadillac.
Variation 2
I. Side-lying little toe up Lie on your side with a weight 1. Gradually lift the little toe higher.
(Weight) hanging from the end of your top 2. Gradually increase the weight
foot. With the foot pointed, bring from 5 pounds to 15 pounds.
the forefoot up toward the ceiling,
leading with the little toe. Pause,
and smoothly lower the foot to the
starting position.
(Keep the foot pointed throughout
the movement.)
348
Muscle group: MTP flexors
Muscles emphasized: Intrinsic foot muscles (lumbricals and interossei)
Joint movement: MTP flexion with IP extension
J. Doming While sitting, press the toes firmly 1. Add the use of one hand to
(Hand) down and back into the floor as resist the raising of the arch.
you raise the metatarsal arch of
the foot. Hold for 5 seconds.
(Keep the toes extended as you
press them down and avoid letting
them curl under.)
Muscle groups: MTP flexors and toe flexors

Muscles emphasized: Intrinsic foot muscles
Joint movements: MTP flexion and toe flexion
K. Towel curl Sit with one knee bent and the 1. Gradually increase weight from
(Weights) heel on the floor with a 2-pound 2 pounds to 10 pounds.
weight on a small towel in front of
the foot. Push the close end of the
towel slightly away so that wrinkles
form in the towel. Grab a wrinkle in
the towel with your toes, and then
pull the towel toward you.
(Focus on fully flexing the toes to
grab the towel and then raise the
metatarsal and medial longitudinal
arches as you pull the towel.)
(continued)
349

Muscle groups: Foot everters and inverters
Muscles emphasized: Peroneals and tibialis anterior/A-F proprioception
Joint movements: Foot eversion and inversion with A-F dorsiflexion
L. Side-to-side Stand with body weight on one foot 1. Use a slightly larger range of
(Half foam roller) placed on the flat side of a half motion but in a safe territory so
foam roller while the other leg is that an ankle sprain is avoided.
slightly bent with the foot touching 2. Perform with hands clasped
the ankle of the support leg. Slowly behind the head.
shift the body weight outward 3. Perform with eyes closed.
and then quickly evert the foot to
4. Perform on demi-pointe with very
return to center. Next, slowly shift
small movements, positioned
the body weight inward and then
so that the hand can be used to
quickly invert the foot to return to
aid with balance when needed.
center. Place the fingertips on a
wall or barre to aid with balance if
needed.
(Focus on making the adjustments
from the ankle and foot rather than
the hip.)
Variation 1: Perform repetitively in
the same direction (e.g., rolling
out to center eight times and then
rolling in to center eight times).
Variation 3: Perform on an ankle
disk or balance board.
Muscle groups: A-F plantar flexors and dorsiflexors, and foot everters and inverters
Muscles emphasized: Foot everters and inverters/A-F proprioception
Joint movements: A-F plantar flexion, foot eversion, A-F dorsiflexion, and foot inversion combined to produce a circular motion
M. Ankle disk circles Stand with your weight on one foot 1. Perform with minimal or no use
(Ankle disk) and the foot positioned toward of the hand for balance.
the center of the disk. Slowly 2. Use a disk with a larger half
shift your body weight, and use sphere attached to the bottom.
your feet so that you make a
counterclockwise circle with the
edge of the disk, contacting the
ground sequentially. Place the
fingertips on a wall or barre to aid
with balance if needed. After six
times, reverse the direction of the
circle (clockwise).
(Work to make the circle as
smooth and symmetrical as
possible, and emphasize using the
ankle-foot muscles.)
350
Muscles emphasized: Stirrup muscles/A-F proprioception
N. Ankle disk relevé Stand with both feet on the disk 1. Perform with minimal or no use
(Ankle disk) and the ball of the foot positioned of the hand for balance.
toward the middle of the disk so 2. Perform with eyes closed.
that on relevé the disk is balanced 3. Perform on one leg at a time.
with no edge touching the ground.
Start with the heels dropped and
the back edge of the disk touching
the ground. Slowly rise on the ball
of the foot, and hold this position
for 4 counts. Then smoothly lower
to the starting position. Use one
hand on a barre or wall to aid with
balance if needed.
(Keep the body weight centered
between the first and second toes,
and focus on using the stirrup
muscles to help raise to a full
demi-pointe position.)
351
DANCE CUES 6.3
“Lift From Under the Pelvis as You Rise to Relevé”
T he cue to “lift from under the pelvis as you rise to relevé” is sometimes used by teachers to encour-
age maintaining vertical alignment of the pelvis and torso as the body rises. As discussed in chapter
3, with ideal standing alignment the center of mass of the body falls just in front of the ankle joint.
So, to rise to demi-pointe or pointe, the center of mass of the body must move forward several inches
so that it is placed over the new base of support. There are many tactics for facilitating this shift. One
anatomical interpretation of this cue is to progressively shift the pelvis and torso forward as a unit
(maintaining desired vertical alignment), by focusing on using the hip extensors to position the bottom
of the pelvis over the moving base of support as the plantar flexors are used to raise the body and the
abdominal muscles and back extensors are used to help keep the torso positioned over the pelvis.
In turned-out positions, a focus on use of the lower deep outward rotators is added to the use of the
abdominal–hamstring force couple, and for some dancers this has the feeling of lifting “up and forward”
from under the pelvis. In contrast, one undesired approach to shifting the center of mass forward is
to make the shift primarily from leaning the torso forward (hip flexion), distorting the desired body
alignment and reinforcing undesired motor programs for maintaining balance.
Dorsiflexor Strengthening 6.6E) will strengthen the inverters in dorsiflexion

and is particularly helpful for preventing rolling in
Inadequate strength in the dorsiflexors may increase while on flat or in plié.
the risk for some injuries such as shin splints. There
have been conflicting results, but at least some Foot Everter Strengthening
dancers tend to be low in dorsiflexor strength both
When rising onto the toes, most beginning-level
in terms of balance with their plantar flexors and
dancers and many trained dancers tend to invert
in relation to other athletes (Hamilton et al., 1992;
the foot, and taken together the inverters of the
Liederbach and Hiebert, 1997). This tendency does
foot tend to be stronger than the everters of the
appear to be specific to dance form, with flamenco
foot (Levangie and Norkin, 2001). Hence, develop-
(Wilmerding et al., 1998) and tap dancers (Mayers,
ment of adequate strength and use of the everters is
Judelson, and Bronner, 2003) not necessarily exhib-
important for achieving the desired dance aesthetic
iting this ratio imbalance or weakness that is seen
of rising up right over the axis of the foot. In addi-
in ballet dancers. Table 6.6 provides an exercise for
tion, the peroneus longus can be seen as a direct
strengthening these muscles with a weight (table
continuation of the biceps femoris in terms of its
6.6D) or elastic band (table 6.6E, variation 1) for
location (Smith, Weiss, and Lehmkuhl, 1996), and
resistance. All of the muscles that produce ankle-
appropriate use of these two muscles can aid with
foot dorsiflexion also produce either inversion or
maintaining desired turnout throughout the seg-
eversion of the foot, and so can also be strengthened
ments of the lower extremity. Furthermore, adequate
with exercises that incorporate these motions with
everter strength is important for preventing ankle
dorsiflexion.
sprains or their recurrence, and persistent peroneal
Foot Inverter Strengthening weakness is common in dancers following injury
(Ende and Wickstrom, 1982). Sitting little toes up
Adequate strength in the inverters of the foot is and away (table 6.6H) and side-lying little toe up
important for preventing excessive rolling in and the (table 6.6I) will strengthen these everters. Both
injuries associated with excessive pronation. Sitting exercises are done in plantar flexion because this
big toe up and away (table 6.6F) and side-lying big is the position in which ankle sprains tend to occur
toe up (table 6.6G) will strengthen the inverters in and in which the foot is less stable. However, dancers
plantar flexion and are particularly helpful for pre- who have problems with rolling out when standing
venting rolling in while on or going through demi- flat may benefit from adding another set performed
pointe or pointe. Sitting big toe up and in (table with the foot neutral versus plantar flexed.
Intrinsic Muscle Strengthening allowing the ankle-foot dorsiflexion needed in move-

ments such as pliés and lunges. When the knee is
Many exercises can be performed for the intrinsic
bent, such as in a plié, the gastrocnemius is slackened
muscles of the foot. Two that are particularly help-
across the knee joint, and the soleus is generally
ful for dancers are doming (table 6.6J) and towel
the primary constraint. When the knee is straight,
curls (table 6.6K). Both of these exercises focus on
the gastrocnemius is stretched as well as the soleus.
strengthening muscles important for helping main-
Having adequate and symmetrical flexibility in the
tain the arches of the foot.
calf muscles is vital to give the dancer adequate time
Ankle-Foot Proprioceptive Exercises to absorb the large forces associated with landing
from movements such as jumps. Furthermore, when
Proprioceptive exercises are exercises designed to the triceps surae is tight, the foot is often allowed to
challenge reflexes related to balance and movement excessively pronate in order to unlock the midtarsal
coordination. They often incorporate tools such as joint and allow greater apparent dorsiflexion. This
balance boards, wobble boards, foam rollers, ankle excessive pronation can increase injury risk at the
disks, or the biomechanical ankle platform system knee and foot.
(BAPS) board. Use of such exercises has been shown Unfortunately, at least elite ballet dancers tend
to be important for developing better balance, quick to have lower ranges of motion in ankle-foot
corrections of movements such as falling out of a dorsiflexion than even sedentary controls (Clip-
turn, and prevention of injuries such as ankle sprains. pinger-Robertson, 1991; Hamilton et al., 1992;
Proprioceptive exercises are often advanced from Liederbach and Hiebert, 1997). One study of elite
single-plane to multiplane movement, from two feet ballet students showed that 67% lacked the 10° of
to one foot, from eyes open to eyes closed, and from dorsiflexion required for just normal walking gait
using a flat foot position to incorporating a relevé. (Molnar and Esterson, 1997). Another study showed
Three examples of exercises with a proprioceptive a 50% reduction in dorsiflexion when compared
emphasis are provided in table 6.6, L-N. to general norms (Hamilton et al., 1992). In this
latter study, female ballet dancers with higher total
Stretches for the Ankle-Foot injuries were also associated with lower bilateral
plié and decreased ankle-foot dorsiflexion. In a
Adequate flexibility in plantar flexion and dorsiflex- study that followed both ballet and modern dance
ion of the ankle-foot is particularly important for students for one year, those who reported previous
dancers. Table 6.7 provides average range of motion leg injuries correlated significantly with lower dorsi-
for these movements in the general population as flexion values and with more new injuries (Wiesler
well as the primary constraints to these movements. et al., 1996).
As previously described, adequate range of the great This research supports the strong need to incor-
toe (MTP joint extension) is also important to allow porate regular calf stretching into the dancer’s rou-
correct positioning on demi-pointe. tine to counter the effect of training and decrease
injury risk. Hamilton (1988) claims that just putting
Plantar Flexor (Calf) Stretches
stretching boxes (incline boards) in the studios and
Adequate flexibility in the plantar flexors and espe- encouraging regular stretching of the triceps surae
cially the gastrocnemius and soleus is essential for markedly reduced the incidence of Achilles tendinitis
TABLE 6.7 Normal Range of Motion and Constraints for Plantar Flexion and Dorsiflexion of the Ankle-Foot
Ankle-foot joint movement Normal range of motion* Normal passive limiting factors
Plantar flexion 0-50° Capsule: anterior portion
Ligaments: anterior talofibular, anterior portion of deltoid
Muscles: dorsiflexors of foot
Bony opposition: posterior talus and posterior tibia
Dorsiflexion 0-20° Capsule: posterior portion
Ligaments: posterior talofibular, calcaneofibular, and deltoid
Muscles: plantar flexors of foot
Bony opposition: anterior talus and anterior tibia
Influence of Foot Pronation

on Dorsiflexion Range of Motion
Bring the right leg back to perform a standing lunge calf stretch with your side to a mirror.
• Dorsiflexion range with a parallel foot. Check the back foot so that it is parallel, facing straight
ahead, and in line with the tibia. This position will tend to throw the body weight slightly outward on
the foot and create a locked position of the midtarsal joints (slight foot inversion). Now bend the
front knee, and lean the body forward until a stretch is felt in the back of the calf. Note the angle of
dorsiflexion that can be reached on the back ankle-foot.
• Dorsiflexion range with the foot toed out. Now shift your weight forward onto your front foot, and
adjust your back foot so that it is facing slightly outward relative to your tibia. Again, bend the front knee
further, and lean the body forward until a stretch is felt in the back of the calf. Note that the foot unlocks
and pronates, allowing a much greater angle of apparent dorsiflexion than could be reached before.
• Relationship to technique. Consider how this undesired use of pronation would influence the
structures being stretched and would relate to dancers with shallow pliés or asymmetrical pliés (with
less dorsiflexion on one side).
in professional ballet dancers. Table 6.8 provides ballet, at least 90° of plantar flexion is recommended
two stretches with a straight knee to emphasize the to meet biomechanical and aesthetic demands for
gastrocnemius (table 6.8, A and B, p. 356) and two pointe work. Although other dance forms such as
stretches with a bent knee to emphasize the soleus modern and jazz do not require as extreme measure-
(table 6.8, C and D, p. 357). In all of these exercises, ments, high ankle-foot plantar flexion range is still
particular care must be taken that the foot is paral- important for aesthetics during pointing and for
lel (in line with the tibia) and that the foot remains proper placement on demi-pointe. Hence, stretching
neutral or slightly inverted versus pronated. It is the feet to gain adequate plantar flexion is important
also important that the stretch be experienced in for meeting dance demands.
the calf. If pain and limitation is experienced in the This plantar flexion range is not just from the
front of the ankle, the dancer should stretch only in a ankle joint, but rather comes from a combination
pain-free range and seek an evaluation from a sports of the talocrural, subtalar, midtarsal, and metatarso-
medicine professional to rule out impingement or phalangeal joints. The contribution of these other
other medical conditions that could be worsened by joints is often underestimated; and even with the gen-
forcing this stretch. eral population, 10% to 40% of the range of plantar
flexion comes from joints distal to the talocrural joint
Stretches to Improve Pointing of the Foot (Levangie and Norkin, 2001). However, as seen from
Adequate flexibility of the ankle-foot dorsiflexors table 6.7, although increasing this range includes
is necessary to achieve the high ranges of plantar stretching the dorsiflexors of the foot (particularly
flexion used in movements such as pointing the foot the tibialis anterior, extensor hallucis longus, and
and relevés. In contrast to the range for dorsiflex- extensor digitorum longus), it also probably includes
ion, range of ankle-foot plantar flexion in dancers stretching joint ligaments and capsules. Hence such
tends to be much greater than found in the general stretches should be done when the feet are fully
population. One study of elite professional ballet warmed, and with very slow and careful application
dancers showed the mean for female dancers to be of stretch in a pain-free range.
113° (Hamilton et al., 1992), and in another study of Table 6.8 provides two stretches for improving
elite advanced and professional ballet dancers it was range in plantar flexion—one performed standing
97° (Clippinger-Robertson, 1991). These numbers and one sitting. The standing pointe stretch (table
reflect an extreme deviation from the American 6.8E, p. 358) offers a stretch that can easily be done
Academy of Orthopaedic Surgeons norm of 50°. In either in class prior to moving across the floor or
Screening Test for Range of Motion for Ankle-Foot Plantar Flexion
Two tests are shown for measuring passive range of motion of the ankle-foot in plantar flexion. For
many dancers this range will be influenced by the bony structure of the arches, joint capsules, and
ligaments, as well as the constraints offered by the ankle-foot dorsiflexors. While the dancer is sitting
with the legs extended to the front and one foot pointed, the examiner places one hand on the top of
the instep of the pointed foot and gently presses down to bring the foot into further plantar flexion.
For the first test (A) the axis of the goniometer is placed just below and slightly in front of the lateral
malleolus, the stationary arm along the fibula, and the moving arm parallel to the bottom of the foot.
It is considered “0” when the foot is at a right angle to the lower leg, and the amount the foot can
point (plantar flexion) from this position is measured as positive degrees. While 50° is considered
normal range in general populations, the average value for elite female ballet dancers in one study
was found to be 97° (Clippinger-Robertson, 1991), and achieving a value of at least 90° is considered
desirable for optimal body placement for demi-pointe and pointe.
If a goniometer is not available, one can place a ruler with its upper portion in line with the middle
of the lateral portion of the tibia and middle of the medial malleolus as shown in B. Note whether the
head of the first metatarsal is above, on, or below the line made by the top of the ruler. For pointe
work, the goal is to have this landmark approximately on or below the line of the ruler.
immediately following class. The sitting pointe about halfway down the foot and applying a smaller
stretch (table 6.8F, p. 358) offers the advantage of stretch as shown in table 6.8F. If pain is still present,
more easily being able to control the magnitude the dancer should seek a medical evaluation to rule
and location of the stretch. Quick application of out medical conditions that could be aggravated by
high forces, such as associated with sticking the feet stretching too far or hard.
under a couch and lying back, can create ligament
sprains and other injuries to the feet and should be Great Toe Flexor Stretches
avoided. Also, if pain and limitation is felt at the back As previously described, about 90° of MTP joint
of the ankle when the dancer is trying to perform extension of the great toe is needed to allow
these stretches, he or she should use one hand to the dancer to go high onto demi-pointe, and to
hold the heel in place (attempting to prevent pos- keep the weight over the axis of the foot rather
terior impingement) while placing the other hand than roll in or out in an attempt to get more range.
TABLE 6.8 Selected Stretches for the Ankle-Foot

Muscles emphasized: Gastrocnemius
Joint position: A-F dorsiflexion with knee extension
A. Standing lunge calf stretch Stand in a lunge position with the 1. Move the back foot farther back,
(Static) front leg bent and the back leg and shift the hips and torso
straight. Shift your hips and pelvis farther forward.
forward until a stretch is felt in the
calf of the back leg.
(Keep both feet parallel and
facing forward instead of letting
the forefoot toe-out and the foot
pronate; keep the heel of the back
foot in contact with the ground.)
Variation 1: PNF—From the above
position, contract the calf muscle
of the back leg by pressing the
ball of the foot into the ground as
if to plantar flex the foot. Relax,
and shift the bottom of the pelvis
slightly farther forward to increase
the stretch of the back calf.
B. Half foam roller calf stretch Stand facing a wall with the hands 1. Bring the heel further down.
(Static) on the wall and one foot about 12 2. Shift the hips and torso further
inches behind the other foot and forward.
the ball of the back foot resting 3. Use a larger-diameter roller.
on the flat surface of a half foam
roller. Allow the front knee to bend
as the back heel slowly presses
back and down toward the floor,
rocking the roller backward, until a
stretch is felt in the calf of the leg
that is back.
(Keep the back foot facing forward
and avoid toeing-out or pronation.
Maintain good body placement
such that a straight line could be
drawn between the sides of the
ankle, knee, pelvis, and shoulder.)
356
Muscles emphasized: Soleus
Joint position: A-F dorsiflexion with knee flexion
C. Standing lunge bent-knee calf stretch From the position used in exercise 1. Bend the back knee further and
(Static) A, bring the back foot in about shift body weight further forward
8 inches (20 centimeters). Bend over the back foot.
the back knee until a stretch is felt
low in the calf of the back leg.
(Keep both feet facing forward and
avoid toeing-out or pronation.)
Variation 1: PNF—From the above
position, contract the calf muscle
of the back leg by pressing the
ball of the foot into the ground as
if to plantar flex the foot. Relax,
and slightly deepen the bend of
the back knee to apply a greater
stretch.
D. Half foam roller bent-knee calf stretch Perform the stretch as described in
(Static) exercise B but with the back knee
bent throughout the exercise and
the trunk more vertical.
(continued)
357
TABLE 6.8 Selected Stretches for the Ankle-Foot (continued)

Muscle groups: A-F dorsiflexors and toe extensors
Muscles emphasized: Extensor digitorum longus
Joint position: A-F plantar flexion with MTP and IP flexion
E. Standing pointe stretch Stand on the left foot, with the 1. Shift the body weight slightly
(Static) other leg slightly bent and the top further toward the foot being
of the distal right foot in contact stretched.
with the floor. Gently press the
right heel forward until a stretch
is felt across the upper instep.
If necessary, slightly bend the
support knee and bend the right
knee further to emphasize the
stretch in the upper versus lower
foot. Repeat on the other side.
F. Sitting pointe stretch Sit with the right foot on the ground 1. Pull the forefoot slightly further
(Static) and the left knee bent, with the downward (i.e., greater A-F
ankle resting on the right thigh. plantar flexion).
With the left hand grasping the heel
and holding it in place, use the
right hand to gently pull the foot
into further plantar flexion until a
stretch is felt across the front of
the upper instep. Repeat on the
other side.
(Focus on using the right thumb to
press the arch upward as the other
fingers pull the forefoot slightly
“out and then down.”)
358

Muscle group: Flexors of great toe
Muscles emphasized: Flexor hallucis longus and brevis
Joint position: Extension of the great toe at the MTP joint
G. Big toe stretch While sitting, use the hand to pull 1. Pull the great toe slightly farther
(Static) the great toe slightly out and then back in a pain-free range but
gently back toward the top of the only to a maximum of 90°.
foot until a stretch is felt along the
plantar aspect of the great toe.
(Keep the great toe in line with the
first metatarsal and the subtalar
joint in a neutral position as you
apply the stretch.)
If the big toe cannot be brought back sufficiently to studies of ballet dancers, 38% (Garrick and Requa,
create a right angle, the big toe stretch (table 6.8G) 1988), 42.4% (Quirk, 1983), and 48.5% (Garrick,
should be carefully added to the dancer’s regular 1999) of all injuries involved the ankle-foot complex.
stretching routine. This exercise involves stretching Studies involving modern dancers showed that 26.6%
not only the flexors of the great toe but also often (Solomon and Micheli, 1986), 36% (Schafle, Requa,
the joint capsule and ligaments. Hence, it should be and Garrick, 1990), and 38% (Hardaker and Moor-
performed slowly and gently. If pain and limitation man, 1986) of injuries were in the ankle and foot.
is experienced, the dancer should stretch only in Studies of flamenco dancers indicated incidences
a pain-free range and seek a medical evaluation to of injury to the ankle-foot complex of 45% and
rule out arthritis or other conditions that could be 40% (Salter-Pedersen and Wilmerding, 1998),
worsened by overzealous stretching. and a study of tap dancers showed that 36% of all
injuries occurred in the ankle and foot (Mayers,
Judelson, and Bronner, 2003). So, despite differ-
Ankle and Foot Injuries ing demands of varied dance forms, all of the dance
in Dancers forms studied showed a high incidence of injury to
the ankle and foot, although at least in ballet, with
Very large forces are generated and absorbed in the a higher incidence in female versus male dancers
ankle-foot complex in dance. For example, ankle (Liederbach, 2000).
joint compression forces have been calculated to
reach 5 times body weight during walking and 9 to Prevention of Ankle and Foot Injuries
13 times body weight during running (Hamill and
Knutzen, 1995). Considering these high forces and Considering the high incidence of injury involving
the complex structure and demands of the foot, it is the ankle and foot, prevention of injuries to this
not surprising that the ankle-foot complex is the site region should be a priority for dancers. Preventive
most frequently injured in dance. In three extensive conditioning measures include trying to avoid abrupt
increases in dance training by maintaining condition son et al., 1993), and then gradually progressed to
during layoffs or breaks, performing supplemental normal weight bearing on land.
strengthening exercises for the ankle-foot two to Proprioceptive exercises are also key in the
three times per week, and performing daily stretch- rehabilitation process, as many injuries have been
ing to maintain adequate ankle-foot dorsiflexion to shown to impair reflex responses and subtle aspects
foster shock absorption and help avoid excessive of movement coordination that can interfere with
foot pronation. Preventive technique considerations full return to dance and increase the risk of injury
include utilizing appropriate placement of the body recurrence. Last, as symptoms allow, specific dance
weight over the axis of the foot to avoid excessive movements that originally aggravated the condition,
inversion or eversion, utilizing the stirrup muscles to such as jumps or turns, are gradually reintroduced
facilitate balance and a high demi-pointe or pointe in a progressive manner, with particular care taken
position with less Achilles stress, maintaining turnout to correct any technique problems that could con-
at the hip to prevent compensatory foot pronation, tribute to reinjury.
and “going through the foot” (emphasizing a toe- Because altered foot mechanics play an important
heel contact pattern) and using adequate plié depth role in many injuries of the ankle and foot, particu-
to help lessen impact when landing from jumps lar care should be paid to correcting any underly-
(Devita and Skelly, 1992; Dufek and Bates, 1990). ing technique problems. In some cases, assistive
In terms of equipment considerations, careful selec- devices such as tape, arch supports, heel cups, and
tion of well-fitting shoes and use of floors with good shock-absorbing inserts may be incorporated into
resiliency and friction characteristics (Fiolkowski the rehabilitation process. Potential mechanisms
and Bauer, 1997) whenever possible can also help by which these supports work are still controversial
prevent injuries to the ankle and foot. and may relate to very slight changes in skeletal
movement, shock absorption, or minimizing muscle
work (Marshall, 1988; Nigg, Nursae, and Stefanyshyn,
Rehabilitation of Ankle and Foot Injuries
1999; Scranton, Pedegana, and Whitesel, 1982; Yakut
As with injuries to other regions of the body, initial et al., 1997).
recommended treatment usually utilizes ice and anti-
inflammatory medications to control pain and swell- Common Ankle and Foot Injuries in Dancers
ing. For dancers, many physicians recommend using
nonsteroidal anti-inflammatory medications for Given the large number of joints and ligaments
many injuries such as tendinitis or plantar fasciitis, composing the ankle-foot complex, it is not surpris-
reserving corticosteroids for select conditions with ing that a vast number of different types of injuries
unresponsive pain, as the repetitive use of steroids can occur in this region. A discussion of selected key
has been implicated in tissue weakening and rupture injuries follows, and interested dancers are referred
(Hardaker, 1989; Weiker, 1988)—particularly if activ- to the writings of Hamilton (1988), Malone and
ity is not adequately controlled immediately follow- Hardaker (1990), Norris (1990), Spilken (1990), and
ing injection (Roberts, 1999). Various other physical other authors cited in this section for a more detailed
therapy modalities such as contrast baths, massage, presentation of injuries to the ankle and foot.
ultrasound, electrical stimulation, or phonophoresis
(ultrasound used to deliver hydrocortisone cream) Ankle Sprains
are often used to reduce pain, increase range of The ankle sprain is one of the most common acute
motion, and promote healing. (traumatic) injuries seen in dancers. Although
As soon as symptoms allow, stretching and range termed an ankle sprain, technically this injury
of motion exercises are added in a pain-free range involves injury to ligaments of both the ankle joint
to help restore normal range of motion. Again, as and the subtalar joint. About 85% of ankle sprains
symptoms allow, strengthening exercises are added, involve inversion (Whiting and Zernicke, 1998)
often progressing from isolation exercises to func- and tend to occur when the ankle is in a less stable
tional exercises and proprioceptive exercises as position of relative plantar flexion, during loading
permitted by healing. Due to the fact that weight or unloading of the foot such as in landing poorly
bearing can often aggravate more severe ankle and from a jump, falling out of a turn, or miscalculating
foot injuries, functional exercises are frequently a step.
initially performed where loading can be reduced, Ankle sprains are classically put into three grades
such as in a swimming pool or on a Pilates-based based on the degree of damage. Hamilton (1988)
Reformer (Brown and Clippinger, 1996; Hender- describes Grade I as a mild sprain involving partial
tear of the ATFL and occasionally the anterior tib- the foot and ankle-foot plantar flexion will tend to
iofibular ligament with little or no resultant instabil- produce discomfort.
ity. Grade II sprains are moderate sprains generally In terms of treatment, many dance medicine
involving complete tears of the ATFL with minimal physicians recommend surgical repair for Grade III
damage to the calcaneofibular ligament. A moder- sprains in professional dancers to achieve adequate
ately positive anterior drawer sign is present, but a ankle-foot stability and avoid early joint degeneration
normal or minimally abnormal talar tilt is seen on that can be associated with instability (Hamilton,
stress X-ray films (Tests and Measurements 6.1, p. 1988; Hardaker, 1989; Safran, Benedetti, et al., 1999).
305). Hamilton holds that this is the type of sprain However, for Grade I and Grade II ankle sprains, a
most commonly seen in dancers. In the demi-pointe conservative treatment approach is generally recom-
or pointe position, the ATFL is almost vertical and mended. Because this is a traumatic versus an overuse
so is easily torn when an adduction-inversion force injury, initial treatment is aimed at limiting damage;
is applied, while the calcaneofibular ligament is in and this is one injury for which RICE (Rest [relative],
a position almost parallel to the floor where it will Ice, Compression [elastic ankle wrap], Elevation) is
likely avoid large disruptive forces (figure 6.43A). particularly relevant. Early protection such as taping,
Grade III injuries are severe ankle sprains and are strapping, an air cast, functional walking orthosis, or
rare. Grade III injuries involve a complete rupture a walking plaster cast may also be utilized in accor-
of the lateral ligament complex and result in gross dance with the injury severity.
instability, with grossly positive drawer sign and stress As symptoms allow, a comprehensive rehabili-
films (figure 6.43B). tation program should be followed that includes
When the ankle is sprained, dancers will often stretches to help restore normal motion, strength-
hear a pop or experience a tearing sensation with ening exercises with a particular emphasis on the
immediate pain. However, it is important to realize peroneals, functional exercises such as relevés while
that the extent of pain is not necessarily a good indi- holding dumbbells, and proprioceptive exercises
cator of the seriousness of the injury. Swelling occurs such as side-to-side or fondu développés performed
quickly around the ligaments (lateral malleolus); and on balance boards and foam rollers. Proprioceptive
if the sprain is sufficiently serious, the dancer feels exercises are key for reestablishment of reflexes
that the ankle is unstable and is unable to continue necessary for regaining a sense of the joint’s feel-
dancing or to walk normally. Depending on the sever- ing stable and prevention of reinjury (Eils and
ity, after several hours, swelling progresses, range Rosenbaum, 2001). Impaired reflex response of the
of motion becomes limited, and discoloration may peroneals and increased postural sway have been
appear. On examination, both passive inversion of shown to persist for weeks or even months after the
FIGURE 6.43 In plantar flexion (right foot), (A) the anterior talofibular ligament (ATFL) is almost vertical and can be
readily sprained when (B) inversion-adduction force is applied.
initial injury (Nawoczenski et al., 1985), and in some to control pronation including orthotics, arch sup-
populations the likelihood of lateral ankle sprain ports, and taping, as well as technique modification
recurrence is as high as 70% to 80% (Hertel et al., and triceps surae stretching (when indicated), can
1999). However, one study of soccer players showed be helpful. Adding viscoelastic inserts or a heel cup
only a 5% recurrence of ankle sprains in athletes to reduce shock can also sometimes offer relief
performing regular proprioceptive exercises versus (Marshall, 1988; Warren, 1983).
25% seen in controls (Tropp, Askling, and Gillquist,
1985). Hence dancers with ankle sprains are encour- Ankle-Foot Tendinitis
aged to undergo comprehensive rehabilitation Tendinitis (tendon + G. itis, inflammation) is an
(Sammarco and Tablante, 1997), consider the use of inflammation of a tendon or its covering/sheath (or
dance-specific ankle taping or braces (Rovere et al., both) due to microscopic tearing of collagen fibers
1988) with the initial return to dance, and continue secondary to overload (Fernández-Palazzi, Rivas,
select peroneal and proprioceptive exercises well and Mujica, 1990). Although tendons have a tensile
after full return to dance. strength that is about twice that of muscle (Frey and
Shereff, 1988), their collagen fibers have poor elas-
Plantar Fasciitis
ticity and so can be injured when forces are applied
Plantar fasciitis is an inflammation of the plantar rapidly, obliquely, or during high-level eccentric
fascia, often involving microtears in the fascia that, contractions of their associated muscles.
if persistent, can lead to degeneration of collagen in When a tendon becomes injured, the surface
the fascia (Shea and Fields, 2002). Because of the key becomes roughened and it will no longer move
role the plantar fascia plays in supporting the longi- smoothly, but instead will tend to bind as it moves in
tudinal arch, jumping is commonly implicated with its sheath or covering, causing further pain, swelling,
this injury. Anatomical and biomechanical factors tenderness, and sometimes crepitus. Furthermore,
that can heighten injury risk include pes planus or the new collagen that the body tries to lay down for
pes cavus foot types, a tight triceps surae, and exces-
sive foot pronation (Hall, 1999; Hamill and Knutzen,
1995; Kreighbaum and Barthels, 1996). In some
cases a bone spur develops in conjunction with the
plantar fasciitis, and on occasion the plantar fascia
can rupture, often in association with impact load-
ing after it has already been weakened from chronic
inflammation, repeated cortisone injections, or both
(Howse and Hancock, 1988; Roberts, 1999).
Plantar fasciitis is characterized by pain and ten-
derness on the underside of the calcaneus at the
medial or central area (figure 6.44) where the plantar
fascia attaches onto the calcaneus. Surprisingly, only a
relatively small percentage of individuals complain of
pain extending distally along the plantar fascia itself,
and this may occur more in dancers with chronic cases.
Generally, pain can be accentuated through passively
extending the MTP joints, which in effect stretches
the plantar fascia. A hallmark of this condition is
morning stiffness. Some dancers complain that while
taking the first few steps in the morning, it feels as
though their feet are as stiff as boards.
In addition to ice, friction massage, and other
physical therapy modalities, recommended reha-
bilitation focuses on heel raises done on a step to
strengthen the triceps surae and eccentrically load
the Achilles tendon (Shea and Fields, 2002), as well
as strengthening the intrinsic muscles and extrinsic
muscles that help support the longitudinal arch. FIGURE 6.44 Common site of pain with plantar fasciitis
Because of associated risk from pronation, efforts (left foot, posterolateral view).
“healing” the tendon can be damaged by enzymes Achilles tendinitis is characterized by pain, tender-
associated with inflammation, and so the inflamma- ness, and swelling, most commonly about 0.8 to 2.4
tory response must be limited through such modes as inches (2-6 centimeters) above its attachment onto
ice, anti-inflammatory medication (Frey and Shereff, the heel (figure 6.45). This is an area where the
1988), and adequate relative rest. Additionally, it tendon is narrower and where blood supply is poor
appears that these new collagen fibers orient in (Frey and Shereff, 1988; McCrory et al., 1999). Danc-
accordance with the forces applied to the tendon, ers will also often complain of a feeling of tightness
suggesting that the high forces associated with eccen- and stiffness, particularly when awakening in the
tric contractions may help the fibers align in the morning, and decreased range of motion in pliés
desired longitudinal direction. However, one must and other movements involving ankle-foot dorsi-
take care when performing eccentric contractions flexion. Sometimes a feeling of weakness is present.
that the movement is very slow and controlled, or There may also be crepitus associated with active
injuries can sometimes be aggravated. motion. Pain is generally reproduced or increased
Tendinitis can occur in any of the tendons that with resisted ankle-foot plantar flexion such as in
cross the ankle. However, the Achilles tendon and relevés or jumps. Pain also tends to occur when the
tendon of the flexor hallucis longus are most com- triceps surae is working eccentrically or the tendon
monly involved in ballet dancers. is stretched, as in landing from jumps or the bottom
of a plié.
Achilles Tendinitis The Achilles tendon is not
Treatment is particularly challenging because
surrounded by the typical synovial tendon sheath,
healing and remodeling of the tendon are slow due
but rather by a sheath composed of fascia that is
to its relative avascularity, and it is often difficult for
termed a paratendon. Inflammation and injury can
the dancer to stop long enough for it to heal. How-
occur to the paratendon, the tendon itself, or both.
ever, if the dancer continues dancing with Achilles
It is not surprising that this tendon is commonly
tendinitis, it can lead to scar formation, areas of
injured when one considers that the triceps surae
tissue death (necrosis) within the tendon itself, and
is responsible for generating a majority of the force
sometimes rupture (Weiker, 1988). Hence, it is very
used in plantar flexion and that this tendon has been
important for the dancer to heed tendinitis in its
estimated to bear forces 4 to 10 times body weight
early acute stages while tendon damage is minimal
in running and jumping (Hamilton, 1988; Whiting
and to follow a well-supervised, comprehensive reha-
and Zernicke, 1998).
bilitation program that can appropriately progress
Factors that have been theorized to increase risk of
exercises so that further tendon damage is avoided.
injury include a tight triceps surae, congenitally small
Earlier stages of rehabilitation generally focus on
or thin Achilles tendons, excessive pronation, roll-
the use of medications and modalities to limit the
ing in or out when on demi-pointe or relevé, limited
inflammatory response and reduce symptoms. Wear-
range in ankle-foot plantar flexion or presence of an
ing 1/2-inch (1.3-centimeter) heel lifts or shoes with
os trigonum such that the triceps surae has to con-
slight heels, viscoelastic heel inserts, Achilles taping,
tract very hard in an effort to achieve adequate height
in relevé/pointe, inadequate triceps surae strength
and endurance, cavus foot type, and prominence
of the posterior superior portion of the calcaneus
(Ende and Wickstrom, 1982; Frey and Shereff, 1988;
Hall, 1999; Hamilton, 1988; Hardaker, 1989; Howse
and Hancock, 1988; Norris, 1990). Further research
will be necessary to show which of these factors actu-
ally are predictive of Achilles tendinitis and to what
degree. A study with runners showed that runners
with Achilles tendinitis had more of a cavus foot type,
greater maximum pronation magnitude and veloc-
ity, and lower plantar flexion strength and that they
performed less stretching (McCrory et al., 1999).
Floors also appear to be an important factor. In one
study, 45% of cases of Achilles tendinitis occurred
when dancing was on cement, while only 4% of
cases started when dancing was on wood surfaces FIGURE 6.45 Common site of pain and thickening with
(Fernández-Palazzi, Rivas, and Mujica, 1990). Achilles tendinitis (left foot, lateral view).
control of excessive pronation (where indicated), advanced cases, fusiform thickening of the tendon
and correction of related technique errors can also (nodules) can occur that can get stuck within the
sometimes help reduce symptoms. Later stages of tendon sheath or canal and cause pain, popping, and
rehabilitation generally focus on restoring adequate impaired ability to move the big toe (“triggering of
and symmetrical flexibility and strength of the triceps the big toe”) as seen in figure 6.46. Affected danc-
surae. The desired inclusion of eccentric contrac- ers may complain of having the big toe get stuck in
tions can be achieved by performing calf raises flexion or extension, and the release of the hallux
while holding weights on a step or platform, where is generally accompanied by a pop or snap on the
the lowering phase is emphasized by performing it posterior medial aspect of the ankle (Sammarco and
more slowly. Miller, 1979).
When Achilles tendinitis does not respond to Recommended treatment for flexor hallucis
conservative treatment or an actual rupture of the longus tendinitis includes anti-inflammatory medica-
Achilles tendon occurs, surgery may be recom- tions, deep friction massage, ice massage, and other
mended. Rupture usually occurs in male dancers modalities, as well as stretching and strengthening
over the age of 30 (Hamilton, 1988). The rupture the flexor hallucis longus and related muscles in
commonly occurs in rigorous movements such as pain-free ranges as inflammation subsides (Fond,
jumping or a quick change in direction, and the 1983; Norris, 1990). Temporary avoidance of relevé
dancer classically feels as if he has been “shot” or or pointe work is often recommended. Correction
“kicked in the back of the leg” (Teitz, 1986). Surgi- of any relevant technique errors such as excessive
cal repair of the tendon is often recommended for pronation or having the body weight too far medial
professional dancers because it has been shown to or back (such that the toes tend to “grab” the floor)
better restore plantar flexion strength (Scheller, can also often be beneficial.
Kasser, and Quigley, 1980). Nonsurgical treatment is usually successful in
alleviating symptoms. When conservative treatment
Flexor Hallucis Longus Tendinitis Flexor hallucis
fails, surgery may be recommended in accordance
longus tendinitis has a uniquely high prevalence in
with the particular case to remove dead areas of
ballet dancers (Hardaker, 1989). Its high occurrence
the tendon, reinforce the tendon, free the tendon
in dancers is thought to relate to its important func-
from adhesions, open the tendon sheath or flexor
tions of stabilizing the foot and preventing exces-
retinaculum, remove a bony block, or do a combina-
sive eversion in demi-pointe and pointe, as well as
tion of these (Hamilton, Geppert, and Thompson,
pressing the big toe down against the ground to
1996).
help go from demi-pointe to a full pointe position,
and helping to stabilize the big toe in full pointe Shin Splints and Tibial Stress Syndrome
when it is in a very shortened position. This muscle
may also be particularly prone to tendinitis for ana- This text will use the term shin splints, also termed
tomical reasons. The flexor hallucis longus tendon tibial stress syndrome, to refer to activity-related pain
passes through a fibro-osseous tunnel at the back of and generalized tenderness on the anterior or medial
the ankle just behind the medial malleolus (figure
6.46); and when strained or thickened, it will tend to
bind rather than move smoothly. Because it crosses
the ankle joint and toe joints, an excursion of 2 to 3
inches (5-7.6 centimeters) (Conti and Wong, 2001)
of the tendon may be required when going from a
plié to pointe, giving ample opportunity for irrita-
tion if it is not sliding smoothly in its fibro-osseous
tunnel.
Flexor hallucis longus tendinitis is characterized
by pain on the posterior medial aspect of the ankle,
deeper than experienced with Achilles tendinitis
(Fond, 1983). Tenderness, mild swelling, and in
some cases crepitus may be present that are generally
aggravated by flexion and extension of the great toe.
Weakness of flexion of the great toe may be present FIGURE 6.46 Chronic flexor hallucis longus tendinitis
with manual testing, and dancers may complain of a with a nodule near the entrance of the fibro-osseous
sense of weakness in the big toe on pointe. In more canal (right foot, medial view).
shin (figure 6.47), from traction of muscles on their ally, and then replaces the heel to push off for the
attachments onto the tibia that results in injury to next jump.
and inflammation of the membrane covering the Shin splints are evidenced by regular aching or
bone (periosteum), fascial inflammation, a stress long-lasting shin pain that is associated with repetitive
reaction of the bone, or a combination of these. exercise such as dance. At first, pain tends to lessen or
While the anterior shin pain was originally believed disappear after warm-up and return only with rigor-
to involve the tibialis anterior and tibialis posterior ous movements such as repetitive jumping, or with
muscles, there is evidence that the soleus (Hutchin- fatigue such as toward the end of class or rehearsal.
son, Cahoon, and Atkins, 1998; Michael and Holder, However, if not heeded, over time the pain often
1985) and flexor hallucis (Kortebein et al., 2000) increases in severity, does not disappear so readily with
may also be responsible in some cases. warm-up, and is brought on by less intense activity.
Shin splints often relate to too fast an increase or This shin pain is usually accompanied by generalized
change in overload such as beginning to dance after tenderness along the lateral border and crest of the
a long layoff, participating in intensive workshops, tibia (figure 6.47A) or the posteromedial border of
working with a choreographer with an unaccustomed the lower tibia (figure 6.47B).
style, or changing to less resilient or raked floors Recommended treatment for shin splints often
as can happen on tour. Shin splints also have been includes ice after activity and sufficient decrease
postulated to be related to abnormal pronation since in activity to allow a pain-free status. In dance, this
the muscles commonly involved in shin splints are often means removing movements like jumps and
all inverters that work eccentrically to control prona- sometimes also limiting the duration of dance. When
tion. Theoretically, abnormal pronation could put symptoms allow, strengthening of the involved mus-
excessive stress on these inverters and their proximal cles and developing a balance of strength between
attachments onto the tibia (Brukner, 2000). Various the dorsiflexors and plantar flexors of the foot are
studies, primarily involving runners, have shown an key, as low levels of dorsiflexor strength relative to
association of increased pronation with increased plantar flexor strength may increase risk for shin
risk for shin splints (Kortebein et al., 2000; Soder- splints (Gehlsen and Seger, 1980). Arch or shin
berg, 1986; Sommer and Vallentyne, 1995). In the taping, use of shock-absorbing insoles (Thacker et al.,
dance world, one study also found that dancers with 2002), and use of arch supports or orthotics in street
shin splints tended to demonstrate more double heel shoes to try to control excessive pronation (Michael
strikes during jumps (Gans, 1985). A double heel and Holder, 1985) can also sometimes provide relief.
strike occurs when a dancer places the heel on the For many dancers, technique modification involving
floor upon landing, lifts it off the floor unintention- maintaining turnout at the hips to limit pronation
versus using the foot inverters to “hold up the arches”
is essential for successful rehabilitation and preven-
tion of shin splint recurrence. However, if despite
conservative treatment pain persists or becomes
severe, it is important that the dancer see a physician
to rule out more serious conditions such as a stress
fracture or compartment syndrome.
Exertional Compartment Syndromes

of the Lower Leg
Compartment syndromes involve an activity-related
marked increase in pressure within one or more of
the compartments of the lower leg, producing pain
and potentially interfering with the blood flow to the
muscles so that they do not receive adequate oxygen
(Blackman, 2000; Martens et al., 1984). While in the
more common chronic or recurrent form (Geary
and Kelly, 1997) the pressures drop rapidly when
exercise stops, in rare instances and for reasons
FIGURE 6.47 Pain associated with shin splints thought poorly understood, the condition progresses to an
to reflect involvement of the (A) tibialis anterior and (B) acute form in which pressures continue to increase
tibialis posterior, flexor hallucis longus, or soleus. and then stay elevated. If the rise is severe enough
and stays elevated long enough, it can lead to death weakness of ankle-foot dorsiflexion and toe exten-
of the involved muscle tissue and injury to the sion; pain in the anterior compartment when the toes
nerves unless the compartment is decompressed via are extended; diminished sensation of the first dorsal
surgical opening of the fascia (Mercier, 1995; Whit- web space; and tenseness, swelling, and tenderness
ing and Zernicke, 1998). Although this condition in the anterior compartment (Geary and Kelly, 1997;
occurs infrequently in dancers (Lokiec, Siev-Ner, Korkola and Amendola, 2001; Leach and Corbett,
and Pritsch, 1991), dancers should be aware of it 1979) as shown in figure 6.48. When compartment
because it can be a medical emergency with perma- syndromes are suspected, techniques can be used to
nent dire consequences if medical treatment is not allow pressures in the desired compartments to be
pursued quickly. measured during exercise.
Recurrent compartment syndromes are classically Unfortunately at this time, there has been little
associated with leg pain described as ill-defined deep success with conservative treatment (Martens et al.,
cramping, aching, or burning that generally has a 1984); and common recommendations are to adjust
characteristic point of onset relative to exercise inten- training to a level below the level where pain and
sity or duration and that classically disappears shortly pressure become evident or to have surgery. Surgi-
after activity is stopped. Some individuals, however, cal approaches are directed at cutting the fascia in
primarily experience ankle weakness, the inability various ways so that pressures are prohibited from
to control the ankle when fatigued, and numbness rising to dangerous levels, and these approaches have
of the foot. Shortly after exercise, a tenderness and a reported high success rate.
tenseness over the muscle mass of the involved com-
partment may be present. For example, the anterior
Stress Fractures of the Lower Leg and Foot
compartment is the compartment most commonly The risk of lower leg and foot stress fractures can
involved, and the condition may be evidenced by also be increased by factors that tend to heighten
FIGURE 6.48 Exertional compartment syndrome of the lower leg involving the anterior compartment (right foot).
(A) Transverse section of the lower leg showing the anterior compartment, and (B) common complaints.
the stress borne by these bones during activity, such it becomes more severe and more persistent and is
as muscle fatigue or muscle weakness (Brukner, more easily initiated. Abnormal changes often do not
Bradshaw, and Bennell, 1998; Couture and Karlson, show up on an X ray for at least two weeks (Brukner,
2002; Hockenbury, 1999), a pes cavus foot type (Nigg, 2000), although other diagnostic techniques such
Nursae, and Stefanyshyn, 1999), and a pes planus as bone scans and magnetic resonance imaging can
foot type and other factors associated with excessive be helpful for establishing a definitive diagnosis at
pronation (Hughes, 1985; Matheson et al., 1987; a much earlier stage (Hutchinson, Cahoon, and
Taunton, Clement, and Webber, 1981). Studies of Atkins, 1998).
military recruits and runners suggest that factors A cornerstone to successful treatment for a stress
related to excessive pronation are particularly impor- fracture is to temporarily unload and in some cases
tant predisposing factors for stress fractures. immobilize the bone sufficiently to allow comple-
A stress fracture can occur in any of the bones tion of the remodeling process so that the bone is
of the lower leg or foot. In ballet dancers, the most stronger and better able to handle loads (Hershman
common site is the metatarsals (Brukner et al., and Mailly, 1990). The limitation of activity necessary
1996), and the metatarsal most commonly affected to achieve a pain-free situation will vary greatly by
is the second metatarsal, at its base (Harrington et the site, severity, and length of injury. For example,
al., 1993; O’Malley et al., 1996; Sammarco, 1982), as a small stress fracture that is treated very early may
seen in figure 6.49. According to one study of elite require discontinuing only high-impact movements
ballet students, 45% of stress fractures occurred in such as jumps and using viscoelastic inserts to reduce
the metatarsals, followed by 26% in the fibula, 13% shock. In contrast, a more serious or long-standing
in the tibia, and 3% in the cuboid (Lundon, Melcher, stress fracture or a stress fracture in a site such as the
and Bray, 1999). Another study of professional ballet tibia, noted for poor healing, may require not only
dancers showed 63% of stress fractures in the meta- total temporary stopping of dance but also immobi-
tarsals and 22% in the tibia. lization with a brace, a wooden-soled shoe, crutches,
A stress fracture is generally associated with or casting to even allow pain-free walking (Martire,
pain and tenderness, localized to the site of the 1994). Electrical stimulation may also have a positive
fracture, that is aggravated by weight bearing or effect on stimulating osteoblasts to lay down new
impact. The pain typically has a gradual onset and bone (Brukner, 2000).
initially is often a low-grade aching associated with When healing is sufficient, a very gradual and
certain movements (such as jumps) or the duration progressive resumption of impact activity is initi-
of dance (e.g., the dancer hurts toward the end ated. There are many different approaches, but
of class or rehearsal). However, if not heeded and one approach is to have the athlete pain free 10 to
dance is continued, the pain may progress such that 14 days before this gradual reintroduction begins
(Matheson et al., 1987). Reintroduction of activity on
an alternate-day basis may be beneficial, as rest days
have been shown to reduce stress fracture incidence.
Although the goal is to remain pain free, even well-
designed progressions often have points at which
bone pain recurs. If this should happen, an often
effective approach is to rest one to two days until no
pain occurs with walking and then resume activity
at the pace below the level at which pain occurred
(Brukner, 2000).
During rehabilitation, other stress fracture risk
factors should also be addressed, including pain-free
strengthening of associated muscles for better shock
absorbency, correction of any underlying technique
issues such as excessive pronation, stretching of
the triceps surae if inadequate dorsiflexion is pres-
ent, and addressing hormonal and dietary factors
as discussed in chapter 1, if indicated. Adequate
correction of risk factors is important not only to
FIGURE 6.49 Common site of stress fractures in danc- promote successful full return to dance but also to
ers (right foot, superior view). prevent recurrence. One study of stress fractures in
professional dancers reported eight refractures out improve the condition, this is often not the case with
of the original 51 dancers studied (O’Malley et al., impingement; and forced stretching of the calf to try
1996). To have another stress fracture occur after to improve the plié depth will generally only aggra-
prolonged rehabilitation not only is very discour- vate the condition. While reduction in inflammation
aging for the dancer but also may jeopardize the and technique modifications may sometimes offer
dancer’s career. some relief, if and when symptoms become severe
enough to limit dance to an unacceptable degree,
Impingement Syndromes of the Ankle surgery is usually recommended to excise the exos-
toses. Although this is the only definitive treatment,
With pointing and flexing of the foot, the talus in some cases exostoses recur, and repeat excision
changes its position in the mortise. With the extreme may be required, usually within three to four years
range of motion utilized in dance, the talus can come (Hardaker, 1989).
into contact with the tibia either anteriorly or pos-
teriorly; this contact is termed anterior or posterior Posterior Ankle Impingement and the Os Trigonum
impingement. Syndrome In contrast to anterior impingement
syndrome, posterior impingement has a unique high
Anterior Ankle Impingement When the ankle-foot occurrence in dance, probably due to the repetitive
is dorsiflexed as in walking, the front of the lower use of extreme ankle-foot plantar flexion. For the
tibia normally is accommodated by a depression, female ballet dancer, there is a particularly strong
called a sulcus, on the talar neck. However, with emphasis on maximizing plantar flexion to meet
the extreme dorsiflexion used in dance, such as in both aesthetic and biomechanical criteria in pointe
demi-plié, some dancers can reach a point where work; and not surprisingly, posterior impingement
the tibia actually comes directly in contact with the occurs more frequently in female versus male ballet
talus, and this contact between the bones is termed dancers. During extreme plantar flexion, the poste-
impingement. With repetitive impingement the bone rior portion of the talus is brought in approximation
itself can respond to the trauma by producing small with the posterior aspect of the tibia. The posterior
outgrowths (osteophytes or bone spurs). These osteo- border of the talus has a lateral tubercle (termed the
phytes then make impingement occur at an earlier posterior process) that normally fuses with the body
degree of dorsiflexion, causing larger osteophytes and of the talus between 9 and 12 years of age (Kadel,
a vicious cycle (Hamilton, 1988). Anterior impinge- Micheli, and Solomon, 2000). However, in some cases
ment tends to occur in sports involving jumping, and this process fails to fuse and remains a separate little
it is seen more commonly in male versus female danc- bone, termed an os trigonum.
ers, perhaps due to the greater jumping demands While some hold that the os trigonum actually
that tend to be imposed on men. represents a stress fracture of the posterior process
Dancers with anterior impingement syndrome will (Howse and Hancock, 1988) and that failure to unite
often complain of dull, chronic aching anterior ankle is due to repetitive trauma, this conjecture is still an
pain that tends to be exacerbated with ankle-foot area of controversy. If such an os trigonum is present,
dorsiflexion. They will also commonly note that there or if the posterior process is particularly long (Stieda’s
is a decrease in the depth of their plié, and that they process), adjacent capsular and synovial tissues can be
are stopping because of discomfort or the feeling of a readily compressed or impinged against the posterior
block on the front of the ankle, well before they feel tibia as shown in figure 6.50. With repeated pinching
a stretch in their calf. Tenderness and swelling may and inflammation, these soft tissues can become
also be present in this anterior aspect of the ankle thickened and fibrotic. In addition to posterior ankle
(Hardaker and Moorman, 1986). Suspected anterior impingement syndrome, this condition is called by
ankle impingement syndrome can be confirmed by other names including os trigonum syndrome.
the presence of exostoses where the front of the talus With posterior ankle impingement syndrome,
makes contact with the front of the tibia on X rays. pain, tenderness, and sometimes swelling are gener-
Recommended symptomatic treatment for this ally experienced at the back of the ankle, behind the
condition includes anti-inflammatory medications lateral malleolus and deep to the Achilles tendon.
and a decrease in ankle-foot dorsiflexion through This pain tends to be reproduced when the ankle-
consciously making the plié shallower and using foot is brought into full plantar flexion, such as in
heel lifts (bilaterally) in street shoes (Malone and tendu, demi-pointe, and particularly pointe work.
Hardaker, 1990), and if possible in dance shoes Passive plantar flexion may also reveal the feeling
(e.g., jazz shoes). Unlike many other injury situa- of a sudden hard stop or endpoint to the motion.
tions in which increasing strength and flexibility can A decreased passive range in plantar flexion and
FIGURE 6.50 (A) Posterior ankle impingement risk increased by the presence of (B) an os trigonum or (C) a Stieda’s
process (right foot, lateral view).
decreased ability to point the foot (active range of Because of their location under the base of the big
plantar flexion) are often present. Weakness and toe, these sesamoids bear large forces during move-
numbness may also be present. The diagnosis is often ments such as going on demi-pointe or pushing
confirmed by taking a lateral-view X ray with the off or landing in jumps. Hard floors, a cavus foot
ankle-foot in full plantar flexion, such as in standing type (Spilken, 1990), and bunions have also been
on pointe or demi-pointe, and the use of other imag- conjectured to increase the risk for sesamoiditis.
ing techniques to ascertain soft tissue involvement In the case of inflamed bunions, the tendency to
(Hamilton, 1988; Marotta and Micheli, 1992). shift the body weight more medially or laterally to
Recommended initial treatment often includes reduce pain puts undue stress on the sesamoid on
nonsteroidal anti-inflammatories; limitation of ankle- that side, while with more advanced bunions, the
foot plantar flexion in dance to pain-free limits; angulation of the first metatarsal can displace the
and physical therapy that includes an emphasis on sesamoids from their normal positioning and pro-
restoring plantar flexion range of motion, strength- duce excessive stress.
ening ankle-foot plantar flexors, and correction in Sesamoiditis is characterized by pain and tender-
any technique errors such as insufficient use of the ness over one or both sesamoids (figure 6.51). One
stirrup muscles on relevé, which could decrease can readily locate the sesamoids by passively hyper-
stress to this area. If there is dual involvement of the extending the great toe (MTP extension) with one
flexor hallucis longus, which runs in the groove just hand and palpating them over the head of the first
medial to the posterior process, this condition must metatarsal with the opposite hand. Pain is also often
also be addressed. However, the great plantar flexion reproduced or exaggerated with demi-pointe.
demands of dance training may preclude successful In addition to the normal ice, anti-inflamma-
conservative treatment; and if conservative treatment tory medications, and physical therapy modalities,
fails, surgical excision of the os trigonum is often treatment is aimed at reducing the load borne by
recommended for professional and other serious the sesamoids through various padding techniques.
dancers and tends to allow the ability to return to However, sesamoiditis often is difficult to treat in
full dance (Brodsky and Khalil, 1986; Marotta and dancers because the hallux extension accompanying
Micheli, 1992; Weiker, 1988). movements such as demi-pointe and the push-off in
locomotor movements tends to aggravate the condi-
Sesamoiditis tion. Restriction of demi-pointe in and out of dance
Sesamoiditis is an inflammation of the sesamoid class and use of a felt pad in relatively rigid athletic
bones that lie within the flexor hallucis brevis. shoes, or taping to limit hallux hyperextension (Dyal
and Thompson, 1997), can sometimes be temporar- Morton’s neuroma is associated with a sharp,
ily used to control symptoms. However if pain per- electrical or burning pain in the region of the third
sists, other potential causes of pain including stress (or second) interspace that may radiate down into
fractures or fractures of the sesamoids need to be the adjacent toes. Numbness or tingling may also be
evaluated. Detecting a fracture or stress fracture is evident in the adjacent toes. This pain can generally
not always as straightforward as one would expect, be reproduced or aggravated by gently squeezing the
as approximately 6% to 30% of feet have sesamoids forefoot together or pressing between the appropri-
that are in two or more parts from birth (bipartite or ate metatarsals. The pain is also often aggravated
multipartite sesamoids) and are asymptomatic (Van by the wearing of narrow shoes, particularly narrow
Hal et al., 1982). Sequential X rays or a bone scan, or high-heeled shoes, and relieved by removal of the
both, are often used to help make the specific diag- shoes.
nosis. In some persistent cases, surgical treatment is Treatment involves anti-inflammatories and
required (Conti and Wong, 2001). wearing wider dance and street shoes. Use of a felt
metatarsal pad behind the metatarsal heads (Ryan
Morton’s Neuroma and Stephens, 1987) and correction of any technique
Morton’s neuroma involves fibrous tissue growth that problems that could aggravate the condition, such
is fusiform in shape (small benign tumor) and forms as shifting the weight too far laterally, can sometimes
around a sensory nerve in the foot as shown in figure alleviate compression. Interestingly, this condition
6.52. This nerve runs between each pair of metatar- often tends to clear after several years even when
sals and divides near the end of the metatarsals to no treatment is performed (Weiker, 1988), but pain
go to the adjacent side of the two adjacent toes. Due can often be limiting and surgery is often curative
to their placement between the metatarsals and the (Brown, 2002, personal correspondence).
ligaments that run between the metatarsals, these
sensory nerves are vulnerable to being compressed,
and it is this repeated compression that is believed
Summary
to cause the outgrowth of the lining of the nerve and The ankle joint proper is a hinge joint that primarily
neuroma (Dyal and Thompson, 1997). This neuroma allows dorsiflexion and plantar flexion. This joint
occurs most commonly in the third interspace (space has a very strong bony structure that is enhanced by
between the third and fourth metatarsals), followed strong medial and lateral collateral ligaments. Below
in frequency by the second interspace (between the and in front of the ankle joint, the subtalar joint and
second and third metatarsals). transverse tarsal joints can contribute slightly more
FIGURE 6.51 Common site of pain and tenderness FIGURE 6.52 Morton’s neuroma (right foot, superior
with injury to the sesamoids (right foot, inferior view). view).
plantar flexion and dorsiflexion to that of the ankle, gitudinal arch, allowing effective initial contact of
and also provide inversion, eversion, abduction, the foot with the ground or propulsion of the body.
and adduction of the foot. Together, these joints In contrast, pronation unlocks the foot, making it
give rise to the combined motions of pronation and more flexible and allowing it to function to accom-
supination. The MTP joints are condyloid joints that modate uneven surfaces and absorb the large forces
allow for flexion, extension, slight abduction, and associated with movement. Individual differences in
slight adduction of the toes on the metatarsals. The arch formation will influence the ability of the foot
IP joints are hinge joints that allow for flexion and to meet these opposite demands, with the rigid pes
extension of the digits themselves. These additional cavus foot type being stable but less able to absorb
joints have capsules and ligaments that provide shock, and the flexible pes planus foot type being
additional stability to the ankle-foot complex. Twelve able to easily accommodate but less stable.
extrinsic and 12 intrinsic muscles function to move While pronation and supination are normal foot
the ankle and foot. The extrinsic muscles have a movements, excessive amounts of either can easily
logical arrangement in which the anterior muscles lead to foot problems. Learning to use optimal place-
cause dorsiflexion, the lateral muscles eversion, the ment of the foot when standing, desired knee-foot
posterior muscles plantar flexion, and the medial alignment, and coordinated use of the stirrup muscles
muscles inversion of the ankle or foot. Many of these can aid with the development of desired dance skill.
muscles also have additional actions, important for Similarly, strengthening of the stirrup and other key
movement, placement of body weight, and support muscles and stretching to achieve both adequate dor-
of the arches of the foot. siflexion and plantar flexion can help enhance ankle
The arrangement of the arches in the foot is and foot function and prevent injuries. If an injury
important for meeting the diverse challenges of does occur, effective treatment and aggressive reha-
stability and mobility. When the foot is supinated, bilitation are vital to prevent recurrence or instability
the foot becomes stable with a formed medial lon- and to allow successful return to dance.

1. Locate the following bones and bony landmarks on a skeleton or drawing of a skeleton and
then on your own body: (a) tibia and medial malleolus, (b) fibula and lateral malleolus, (c)
talus, (d) calcaneus, (e) cuboid, (f) navicular and tubercle of the navicular, (g) cuneiforms,
(h) metatarsals and their base and head, (i) phalanges (proximal, middle, and distal), (j)
sesamoids.
of each muscle. Then, next to each muscle, list its actions: (a) gastrocnemius, (b) soleus, (c)
tibialis anterior, (d) tibialis posterior, (e) peroneus longus, (f) peroneus brevis.
3. Locate the following muscles on your partner or your own body, perform or have your part-
ner perform actions that these muscles produce, and palpate their contraction during these
movements: (a) gastrocnemius, (b) soleus, (c) tibialis anterior, (d) extensor hallucis longus,
(e) extensor digitorum longus, (f) tibialis posterior, (g) flexor hallucis longus, (h) flexor
digitorum longus, (i) peroneus longus, (j) peroneus brevis.
4. Observe a partner while standing from behind, and note the position of his or her rearfoot.
How would the presence of rearfoot valgus or varus tend to influence foot pronation?
5. Explore the concept of coupling of the leg and the foot. Note what happens to the lower
leg when the foot inverts and when it everts. Now, note what happens to the foot when the
lower leg internally rotates and when it externally rotates. How could this coupling relate to
turnout and pronation in dance?
(continued)
Study Questions and Applications (continued)
6. Working with a partner, demonstrate the fundamental movements of the ankle and foot
(plantar flexion, dorsiflexion, inversion, and eversion) including both of the following:
a. When the foot remains in contact with the ground (closed kinematic chain)
b. When the foot is free to move (open kinematic chain)
Then, provide a movement from dance that exemplifies each of these variations on the fun-
damental ankle-foot movements, and describe the primary muscle group and sample muscles
used to effect these motions.
7. Demonstrate two exercises for stretching the gastrocnemius and soleus. How does the posi-
tion of the knee influence which muscle is being emphasized?
8. Describe how one could attempt to correct a dancer who excessively pronates during a plié
through making changes at the foot, the lower leg, and the hip. What approach do you think
would be best over the long term and why?
9. Provide a strengthening exercise that would be the most important for preventing the follow-
ing injuries, and identify the muscle group targeted by the exercise: (a) lateral ankle sprain,
(b) shin splints.
10. A dancer has been having a difficult time performing multiple outside turns and keeps fall-
ing back out of her turns. Her teacher has noted that she is rolling out on her foot as the
turn progresses. Describe how the stirrup muscles of the foot could relate to this technique
error and how these muscles could be used to help correct the problem. Identify appropri-
ate strength exercises that could be utilized to prevent the undesired motion of the foot and
three cues that could be utilized to try to implement the desired technique adjustments.
Extremity
The Upper
© Angela Sterling Photography. Pacific Northwest Ballet dancers Melanie Skinner and Casey Herd.
CHAPTER SEVEN
373
T he upper extremities, which include the shoul-

der girdle, arms, and hands, are the focus of
this chapter. The arms are intimately connected with
• Conditioning exercises for the upper extremity
• Upper extremity injuries in dancers
movements of the shoulder girdle, and hence the

shoulder girdle and shoulder joint should be viewed
together as a functional unit. The shoulder girdle Bones and Bony Landmarks
and shoulder joint are characterized by a design of the Shoulder Complex
that maximizes mobility necessary for reaching,
grasping, lifting, and throwing. Such mobility makes The shoulder complex involves the clavicle (col-
specific muscle strength development and activation larbone), scapula (shoulder blade), and humerus
important for correct technique and injury preven- (upper arm bone) on each side of the body.
tion. In dance, very specific and subtle use of the When seen from above, the clavicle is shaped like
arms is often required to meet the aesthetics of the a stretched-out “S” that is convex anteriorly in its
school of dance or a given choreographer. In some medial portion and concave anteriorly in its lateral
cases, stylized use of the arms is vital to portray the portion (figure 7.1). The medial end (sternal end) of
desired emotional quality of the dance movement. the clavicle is slightly expanded, while the lateral end
Furthermore, with partnering, the arms often come (acromial end) is markedly expanded and flattened;
into play to help support a partner, as well as help these shapes aid in articulation with the respective
express a relationship between the dancers as shown adjacent bones.
in the photo on the previous page. The scapula is a large, triangular-shaped flat bone
The upper extremity will be covered all together that normally glides on the posterior rib cage. This
in this chapter. While some sports such as throwing bone has many muscles attached to it, and many dif-
sports, swimming, weightlifting, and gymnastics place ferent bony landmarks are used to clarify the sites
great stress on the upper extremity, dance tends to of attachment of these muscles. As can be seen in
place greater stress on the lower extremity. Hence, figure 7.2, the scapula has three borders, the medial
the upper extremity is not covered in as much detail (vertebral), lateral (axillary), and superior borders,
in this text as the lower extremity, and the emphasis as well as three angles (the superior, inferior, and
is on the shoulder joint. Topics covered will include lateral angles). It also has two surfaces; the anterior
the following: surface, which lies close to the ribs, is termed the
costal surface, while the posterior surface is termed
• Bones and bony landmarks of the shoulder com- the dorsal surface. The costal surface is slightly
plex hollowed to form the subscapular fossa. The dorsal
• Joint structure and movements of the shoulder surface is divided by a large spine, into a smaller
girdle but deeper hollowed area above the spine called
the supraspinous fossa and a larger but shallower
• Joint structure and movements of the shoulder
infraspinous fossa below the spine. The spine of
• Description and functions of individual muscles the scapula ends laterally in a large flattened process
of the shoulder complex called the acromion process (G. akron, tip + omos,
• Alignment and common deviations of the shoul- shoulder). This process articulates with the clavicle
der complex to form the acromioclavicular joint. The lateral
• Shoulder mechanics
• Muscular analysis of fundamental shoulder move-
ments
• Special considerations for the shoulder complex
in dance
• Other joints of the upper extremity
• Description and functions of selected individual
muscles of the elbow
• Structure and movements of the radioulnar
joints
• Key considerations for the upper extremity in
whole body movement FIGURE 7.1 The clavicle (right clavicle, superior view).
The Upper Extremity 375
FIGURE 7.2 Bony landmarks of the scapula (right scapula). (A) Costal surface, (B) dorsal surface.
angle of the scapulae ends before it creates a true of the humerus and the greater and lesser tubercles
angle in an indented area termed the glenoid fossa is termed the anatomical neck of the humerus, while
(G. glenoeides, socket of joint) or glenoid cavity. Just the region where the head and tubercles join to the
medial to this glenoid cavity, a large, beaklike pro- body of the humerus is termed the surgical neck. The
cess projects forward from the scapulae termed the lesser and greater tubercles are separated from each
coracoid process (G. korakodes, like a crow’s beak). other by a groove called the intertubercular sulcus or
This process is a site for attachments of key muscles groove. The tendon of the long head of the biceps
and ligaments for the shoulder and shoulder girdle. brachii muscle lies within this groove. You can gener-
With their positioning above the glenoid cavity, the ally palpate this groove with two fingers below the
acromion process and coracoid process also help acromion process when your arm is fully externally
protect the shoulder joint. rotated with the elbow by your side. If you follow the
The humerus is a long bone with a cylindrical intertubercular groove down the arm, its lateral por-
body that changes in form at both ends and is quite tion leads to a roughened prominence about half-
parallel in structure to the femur (figure 7.3). At way down the humerus called the deltoid tuberosity
the proximal end, the humerus expands to form (the site of attachment for the distal deltoid muscle).
the rounded head, the medial portion of which The landmarks of the distal end of the humerus will
articulates with the glenoid cavity to form the shoul- be described later with the elbow joint.
der joint. Slightly distal to this articular surface and
on the anterior aspect of the humerus lie the more
medially placed lesser tubercle and the more later- Joint Structure and Movements
ally placed greater tubercle. The greater tubercle of the Shoulder Girdle
can be palpated just below the acromion process
when the arm is hanging by the side in an inter- The shoulder girdle can be pictured as an incom-
nally rotated position. The slight narrowing of the plete ring formed by the two clavicles and two
humerus between the articular surface of the head scapulae (figure 7.4). Anteriorly, the paired clavicles
FIGURE 7.3 Bony landmarks of the right humerus. (A) Anterior view, (B) posterior view.
join onto the sternum and cartilage of the first rib trapezoid and conoid coracoclavicular ligaments)
(first costal cartilage) to form the sternoclavicular further connect the clavicle to the scapula via the
joint (figure 7.4B). The sternoclavicular joint can coracoid process and provide indirect support to
be classified as a saddle joint (Moore and Agur, help prevent such a dislocation.
1995), and it contains a fibrocartilage articular disc Functionally, movements of the sternoclavicular
that divides the joint cavity into two and serves as a joint, and to a lesser degree the acromioclavicular
shock absorber. This small joint serves as the only joint, contribute to movements of the shoulder girdle.
bony attachment of the entire upper extremity to the It is less complex to describe the combined movements
axial skeleton. However, the sternoclavicular joint is of these joints in terms of the resultant movements of
surrounded by a fibrous capsule that is reinforced by the scapulae that they create. These movements of the
various strong ligaments, and it is a stable joint that scapulae on the thorax are sometimes referred to as
is rarely dislocated. occurring at the scapulothoracic “joints,” although
Laterally, the paired clavicles join with the acro- these are not true joints. Possible movement pairs
mion processes of their respective scapulae at the of the scapulae include scapular elevation-depres-
acromioclavicular joints (figure 7.4A). This gliding sion, abduction-adduction, and upward rotation-
joint (Moore and Agur, 1995) is surrounded by a downward rotation (figure 7.5) (Smith, Weiss, and
capsule and reinforced by various strong ligaments. Lehmkuhl, 1996).
These ligaments limit the range of motion possible With elevation, the scapula as a whole moves
at this joint and prevent the clavicle and acromion upward toward the ear. This movement occurs
process from being pulled apart (Kreighbaum and when the shoulders are shrugged, such as in jazz
Barthels, 1996). However, they are not very effective isolations. Depression is the opposite movement
at preventing the clavicle from riding over the top to elevation and involves movement of the scapula
of the acromion when a lateral blow is applied to as a whole downward. During standing, gravity will
the shoulder, and two nearby strong ligaments (the tend to depress the scapulae when the elevators of
FIGURE 7.4 Bones and joints of the shoulder complex (anterior view). (A) Glenohumeral joint, acromioclavicular joint,
and sternoclavicular joint, (B) more detailed view of sternoclavicular joint.
FIGURE 7.5 Movements of the scapulae.
377
the scapulae stop contracting. However, when the ball-and-socket joint. Both the head of the humerus
body weight is supported on the hands with the and glenoid cavity are covered with articular cartilage.
arms down by the sides, the scapular depressors This glenoid cavity is quite shallow, and only about
must be contracted to hold the scapulae down to one-fourth to one-third of the almost hemispherical
prevent undesired elevation and to stabilize the head of the humerus makes contact with the glenoid
scapulae so the trunk can be elevated. Abduction or cavity (Frankel and Nordin, 1980). Furthermore,
protraction of the scapulae involves movement of the shape of the glenoid cavity is less curved and
the scapulae away from the spinal column and each more elongated (pear shaped) while the head of the
other, sometimes referred to in dance as “widening humerus is more spherical (Caillet, 1996), so that
the shoulder blades.” Adduction or retraction of rather than simple rotation occurring about a fixed
the scapulae is the opposite motion to abduction, axis, the axis of rotation shifts as the shoulder joint
and it involves bringing the scapulae toward each moves and the humeral head moves linearly (trans-
other and toward the spinal column; in dance this lates) as well as rotates (Hall, 1999). So, the shoulder
is sometimes referred to as “pinching the shoulder joint represents a very complex and much less stable
blades.” Upward rotation of the scapula involves ball-and-socket joint that is more prone to dislocation
turning the scapula about an axis through the spine and recurrent subluxation than the hip joint.
of the scapula such that the glenoid cavity moves As with other ball-and-socket joints, the shoulder
upward while the inferior angle moves laterally and joint has three degrees of motion: flexion-extension
anteriorly on the thorax. This motion is hard to approximately in the sagittal plane (figure 7.6A),
produce in isolation but is an essential movement abduction-adduction approximately in the frontal
that accompanies overhead movements of the arm. plane, and external-internal rotation approximately
The opposite motion, downward rotation, involves in the transverse plane (figure 7.6B). The special-
a downward rotation of the glenoid cavity. It can be ized terms of horizontal abduction and horizontal
exaggerated through bringing the hand behind the adduction (figure 7.6C) are given to movements of
low back. Some authors also include tilts, not further the arm occurring in a horizontal plane with the arm
described in this text. at shoulder height. Also, as with the hip joint, many
Note that these movements do not have an exact movements that occur during dance do not occur in
counterpart in the lower extremity because the bones exact anatomical planes. Some texts give a specialized
of the pelvis cannot move independently. However, term, scaption, to one of these types of movement.
the movements of the pelvic girdle as a whole relative Because the glenoid cavity faces slightly anterior to
to the spine at the lumbosacral joint serve a similar the frontal plane, some authors hold that a more
function of adjusting the relationship of the pelvis natural movement is abduction in the plane of the
so that movements of the femur are fostered. How- scapula, or scaption, rather than pure abduction in
ever, one important difference is that due to the the frontal plane. Another unique term used at the
relatively rigid linking of the pelvis posteriorly with shoulder joint is elevation. The term elevation is
the sacrum (at the sacroiliac joints), movement of generally used to describe movement of the humerus
one side of the pelvis will have a direct effect on away from the side in any plane. Note that this is a
the opposite side. In contrast, due to the fact that movement of the arm, in contrast to the “elevation”
the scapulae are only linked muscularly posteriorly, used to describe movement of the scapula. Many
movement of one scapula and arm can occur inde- of the movements at the glenohumeral joint can
pendently with minimal effect on the position or occur through a very large range of motion, and the
function of the opposite arm. shoulder joint is the most freely movable joint in the
human body (Hall, 1999).
Joint Structure and Movements Shoulder Joint Capsule and Key Ligaments
of the Shoulder
The shoulder joint is surrounded by a sleevelike
While the movements of the scapula just described fibrous capsule lined with synovial membrane that is
position the scapula to help facilitate movements of attached proximally to the perimeter of the glenoid
the arm, the movement of the arm actually occurs at cavity. Distally it is attached to the anatomical neck
the joint formed between the glenoid cavity of the of the humerus, except medially, where it is attached
scapula and the head of the humerus. This joint is slightly lower on the humerus. The capsule is loose;
called the shoulder joint or glenohumeral joint (see for example, when the arm is down by the side,
figure 7.4A). The glenohumeral joint is a triaxial, there are hanging folds in the inferior portion of
FIGURE 7.6 Movements of the shoulder joint. (A) Flexion-extension, (B) abduction-adduction and external rotation–
internal rotation, (C) horizontal abduction–horizontal adduction.
process of the scapula to help form an arch above

the medial capsule that allow the arm to be raised to the head of the humerus. This arch, composed of
the side and overhead. This looseness of the capsule the coracoid process, coracoacromial ligament, and
potentially allows 1 to 2 inches (2.5-5 centimeters) acromion process, is termed the coracoacromial arch
of separation between the humerus and scapula (Lyons and Orwin, 1998). The coracohumeral and
(Hamilton and Luttgens, 2002). However, despite its coracoacromial ligaments help prevent superior
limitations, the capsule is still vital for joint stability dislocation of the humerus, and the latter can be
(Warner et al., 1990). implicated in shoulder impingement. Classically,
The joint capsule is reinforced by various liga- shoulder impingement syndrome refers to a pinching
ments as seen in figure 7.7. Anteriorly, the capsule of soft tissues, such as the supraspinatus tendon or
is strengthened by the superior, middle, and infe- subacromial bursa, between the head of the humerus
rior glenohumeral ligaments. These ligaments help and the overlying coracoacromial arch.
prevent excessive displacement or translation of the
humerus, particularly in a forward direction. The Specialized Structures of the Shoulder Joint
inferior glenohumeral ligament has been shown to
be a particularly key restraint for preventing anterior Various specialized structures are associated with the
translation of the head of the humerus in higher shoulder that provide additional joint stability and
ranges of shoulder abduction (Warner et al., 1990), aid with shoulder function. These structures include
while the middle and superior glenohumeral liga- the glenoid labrum and various bursae.
ments resist anterior translation in lesser degrees of
abduction. The superior glenohumeral ligament is Glenoid Labrum
also vital for preventing inferior translation of the The glenoid labrum is a rim of fibrocartilage located
head of the humerus (Cavallo and Speer, 1998). at the perimeter of the glenoid cavity (figure 7.7B),
Superiorly, the capsule is reinforced by the functionally similar to the one found in the hip joint
coracohumeral ligament (not shown). This ligament (acetabular labrum). The glenoid labrum is thicker
runs from the base of the coracoid process into the around the circumference than centrally. It serves
capsule to attach to the greater tubercle and lesser to increase the size and depth of the glenoid cavity,
tubercles of the humerus, helping to form a tunnel increasing the superior inferior diameter by 75%
between these tubercles within which the tendon of and anterior-posterior diameter by 50% (Richards,
the long head of the biceps brachii lies. A related 1999). In addition, the labrum provides a site for
ligament, the coracoacromial ligament, spans attachments of the joint capsule, the glenohumeral
between the coracoid process and the acromion ligaments, and various tendons including the long
FIGURE 7.7 The shoulder joint (right shoulder). (A) Anterior view, (B) lateral view with head of the humerus removed.
head of the biceps brachii. The glenoid labrum has (particularly in midrange shoulder motion), as well
been found to be vital for joint stability, as well as as movement (Park, Blaine, and Levine, 2002). This
increasing the surface area of contact of the head of stabilization role can be demonstrated by the fact
the humerus (Levine and Flatlow, 2000) and serving that when these shoulder muscles are paralyzed, the
to add a cushioning effect against the impact associ- shoulder joint will tend to sublux, with the weight of
ated with forceful movements of the arms. the hanging arm separating the head of the humerus
from the glenoid cavity. This observation has led to the
Bursae expression that the shoulder is a “muscle-dependent
There are various bursae located about the shoulder joint.” Hence adequate strength, balanced strength,
joint. Two bursae that lie deep to the deltoid muscle and coordinated activation of the muscles of this
and separate and cushion the muscles of the rotator region are essential for optimal function and injury
cuff from the overlying coracoacromial arch and prevention.
sometimes become inflamed are the subdeltoid and
subcoracoid bursae. These bursae are located close
to each other, are sometimes connected, and hence
Description and Functions
are often jointly referred to as the subacromial bursa of Individual Muscles
(see figure 7.7B)(Mercier, 1995).
of the Shoulder Complex
Muscles There are many ways in which the muscles of the
shoulder complex can be organized and described.
Limited stability is provided by the glenoid labrum This text will use a functional approach, dividing the
and bony articulation, and the glenohumeral liga- muscles into three groups—the scapular muscles, the
ments and capsule primarily provide restraints at the rotator cuff, and other major glenohumeral muscles.
extremes of motion; hence, the muscles surround- (See Individual Muscles of the Shoulder Complex,
ing the joint are essential for providing stabilization pp. 381-394.)
Individual Muscles of the Shoulder Complex

Scapular Muscles
The scapular muscles are comprised of six muscles that connect the scapula with the axial skeleton
(skull, spine, and rib cage). These muscles work both to hold the scapula in place (stabilization) and to
generate the movements of the scapula previously described. The importance of these muscles is often
underestimated, but they play a vital role in functional movements involving the arms. For example, the
scapular elevators are essential for effective lifting movements, the scapular depressors for effectively
pushing downward, the scapular abductors for forward pushing movements, the scapular adductors
for pulling movements, the scapular upward rotators for elevating the arm overhead, and the scapular
downward rotators for forceful adduction of the arm.
The scapular muscles can be subdivided into those located anteriorly and posteriorly. The anterior
muscles are the subclavius, pectoralis minor, and serratus anterior. Due to its small size and negligible
contribution to scapular motions, the subclavius will not be further discussed. However, the latter two
muscles connect the scapula to the front of the rib cage and share the ability to pull the scapula ante-
riorly (scapular abduction). The posterior scapular muscles are the trapezius, rhomboids, and levator
scapulae. These muscles serve to connect the scapula to the spine and are all capable of pulling the
scapula posteriorly (scapular adduction). The individual scapular muscles also have other actions that
are described next and summarized in table 7.1 on page 384.
Attachments and Primary Actions of Trapezius

Trapezius Base of skull Outer third of clavicle Upper: Scapular elevation
(trah-PEE-zee-us) Ligament of neck Upper acromion Scapular upward rotation
C7-T12 spinous Upper spine of scapula Scapular adduction
processes Middle: Scapular adduction
Lower: Scapular depression
Scapular upward rotation
Scapular adduction
Trapezius
The trapezius (trapezion, irregular four-sided figure) is a
superficial paired muscle located on the back of the neck
and upper back on each side of the midline (figure 7.8). The
paired relatively flat muscles derive their name from the fact
that together they form a diamond shape, or trapezium. Due to
its shape the trapezius is also sometimes called the “shawl”
muscle (Smith, Weiss, and Lehmkuhl, 1996). Because of the
different line of pull and innervation of different portions of
the trapezius, it can be divided into three parts—the upper,
middle, and lower trapezius. To visualize the actions, it is
helpful to mentally construct the line of pull of these three
portions. The upper portion courses downward and laterally;
the middle portion is more horizontal; and the lower portion
courses upward and outward. As a whole the trapezius tends
to produce upward rotation and adduction of the scapula.
To understand how the trapezius could produce upward
rotation, it is important to note that it attaches onto the upper
FIGURE 7.8 Superficial posterior scapular mus-
cles: trapezius (left scapula).
scapula, forming a force couple (chapter 2) whereby the lower portion of the trapezius pulls down on
the medial border of the scapula as the upper portion of the trapezius pulls up on the acromion. The
combined action is to produce rotation in the same direction, that is, upward rotation of the scapula.
Upward rotation of the scapula accompanies elevation of the arm, and so the trapezius works when-
ever the arm is raised to the side (shoulder abduction) and in higher ranges of raising the arm to the
front (shoulder flexion). The lower portion of the trapezius also tends to depress the scapula, and this
function is often emphasized in dance training. In contrast, the upper portion of the trapezius tends
to elevate the scapula (as when you shrug your shoulders) and provides support for the distal end of
the clavicle and acromion process of the scapula. This latter function comes into play when a heavy
weight, such as a suitcase, is held in the hand (Hamilton and Luttgens, 2002). In such cases, tension
and often fatigue or soreness are experienced in the upper trapezius. This latter lateral support function
may also affect shoulder posture, in that weakness of the trapezius can result in a lower and forward
position of the point of the affected shoulder consequent to the downward rotation of the scapula from
the weight of the hanging arm and abduction of the scapula (Smith, Weiss, and Lehmkuhl, 1996). When
the head is free to move, the upper trapezius can assist with extension, lateral flexion, and rotation (to
the opposite side) of the cervical spine.
Palpation: Place the fingertips of your left hand just behind the outer third of the right clavicle with
your right arm held overhead. You can feel the upper trapezius contracting when you bring your right
shoulder up toward your ear (scapular elevation) in this position. On a partner, you can palpate the
lower portion of the trapezius contracting medial to the inferior angle of the scapula when your partner
actively pulls his or her shoulder blades together and down (scapular depression and adduction). You
can see and feel the entire muscle contracting when your partner pulls the shoulder blades together
with the elbows just above shoulder height (scapular adduction).
Attachments and Primary Actions of Levator Scapulae

Levator scapulae C1 to C4 or C5 transverse Medial border of scapulae Scapular elevation
(le-VA-tor SKAP-u-le) processes (from spine to Scapular downward rotation
superior border) Assists with scapular adduction
Levator Scapulae
The levator scapulae (L. levator, a lifter) is a small muscle
that lies beneath the upper trapezius and extends from the
upper cervical vertebrae to the upper medial border of the
scapula (figure 7.9). Hence, its line of pull is almost verti-
cal, with a slight lateral progression as it runs inferiorly.
Thus, its primary action is elevation of the scapula with the
ability to contribute slightly to scapular adduction. During
standing, due to the weight of the arm pulling downward
on the glenoid cavity, contraction of the levator scapulae
also tends to produce downward rotation of the scapula
(Rasch and Burke, 1978; Smith, Weiss, and Lehmkuhl,
1996). Loss of the levator scapulae is associated with the
shoulder’s being depressed, especially when the trapezius
is also not functioning adequately. Loss of both of these
muscles is associated with a marked slope of the shoul-
ders and a thin neck. When the head is free to move, the
levator scapulae can produce lateral flexion and rotation
(to the same side) of the cervical spine.
Palpation: Because the levator scapulae lies beneath FIGURE 7.9 Deep posterior scapular muscles: levator
the trapezius and commonly works in conjunction with the scapulae and rhomboids (left scapula).
trapezius, it is difficult to palpate in isolation.
Attachments and Primary Actions of Rhomboids

Rhomboids C6 or C7 to T4 or T5 Medial border of scapula from Scapular elevation
(ROM-boidz) spinous processes spine to inferior angle Scapular adduction
Scapular downward rotation
Rhomboids
The rhomboid (rhomboid, diamond shaped) muscles are paired muscles that lie beneath the trapezius
muscle (figure 7.9). They derive their name from the fact that they are shaped like a rhombus (G. rhom-
bos). They are often divided into the thinner and weaker upper portion called the rhomboid minor and
the thicker and stronger lower portion called the rhomboid major. The rhomboids run down and outward
from the spine to the medial border of the scapulae. Their line of pull is similar to that of the trapezius
except that their attachment is onto the medial border of the scapula. Hence, when the rhomboids
contract they produce downward rather than upward rotation of the scapula. They can also elevate and
adduct the scapula. Since downward rotation of the scapula accompanies shoulder adduction or exten-
sion, the rhomboids are used when these motions are performed forcefully or against resistance.
Palpation: Have a partner stand with the back of his or her right hand against the low back, and place
your fingers under the lower portion of the medial border of the right scapula. Then have your partner
lift his or her right hand backward (away from the back), and you will feel the rhomboids contract to
produce the necessary downward rotation of the scapula.
Attachments and Primary Actions of Serratus Anterior

Serratus anterior Lateral, outer aspect of Inferior angle and medial Scapular abduction
(ser-A-tus an-TEER-ee-or) lower 8 to 9 ribs border of scapula Scapular upward rotation
Scapular depression (lower fibers)
Serratus Anterior
The serratus anterior (serratus, saw) is named for
its serrated, or saw-toothed, anterior margin and
can be seen on the anterolateral rib cage below the
armpit. It actually runs from the lower eight or nine
ribs under the scapula to attach onto the inferior
angle and the entire length of the medial margin of
the scapula (figure 7.10). Part of the anterior portion
of this muscle is covered by the pectoralis major,
and posteriorly it is covered by the scapula. The
lowest four or five slips interdigitate with fibers of the
external oblique abdominal muscles. The serratus
anterior effectively attaches the medial scapula to
the front of the thorax. The line of pull makes it an
effective abductor of the scapula. The lower fibers
of the serratus anterior and the trapezius also form
a force couple for upward rotation of the scapula
(figure 7.11), used when one lifts the arms to the
side (shoulder abduction) and to the front (shoulder
flexion). In addition, the lower fibers of the serratus
FIGURE 7.10 Anterior scapular muscles: serratus
anterior can assist with scapular depression. anterior and pectoralis minor (left shoulder, deep view).
Functionally, the serratus anterior has been
shown to be active in pushing movements,
“forward-reaching” movements, throwing, and bench

pressing. In pushing movements, the serratus ante-
rior is vital for stabilizing the scapula so that the
pressure on the outstretched hand does not cause
the scapula to move posteriorly. It has also been
shown to be very active during swimming (Nuber et
al., 1986). The importance of the serratus anterior
for upward rotation is demonstrated by the difficulty
of raising the arms above shoulder height (or even
the inability to do so) when this muscle is paralyzed.
Loss of this muscle is also associated with back-
ward projection of the medial border of the scapula
(termed “winging” of the scapula) and inadequate
forward movement of the scapula on the thorax
(scapular abduction), when the arm is reached for-
ward (Smith, Weiss, and Lehmkuhl, 1996).
Palpation: Stand with the fingertips of the left
hand placed on the anterolateral aspect of the ribs,
just in front of the lower portion of the lateral border
of the scapula. The serratus anterior can be felt FIGURE 7.11 Force couple formed by the trapezius
contracting under the fingertips when the right arm and serratus anterior for upward rotation of the scap-
is raised forward to an overhead position. ula (right scapula, posterior view).
Attachments and Primary Actions of Pectoralis Minor

Pectoralis minor Outer surface of 2nd or 3rd to Coracoid process of Scapular abduction
(pek-to-RA-lis MY-nor) 5th ribs scapulae Scapular downward rotation
Scapular depression
Pectoralis Minor
As its name implies, the pectoralis minor (pectus, chest, breast + minor, lesser) is a small muscle located
in the upper area of the chest (deep to the pectoralis major) as seen in figure 7.10. The pectoralis minor
runs from three upper ribs upward and outward to attach to the coracoid process of the scapula. Due
to this line of pull it tends to produce abduction, depression, and downward rotation of the scapula.
However, it probably acts more for fine motor control and to assist the previously described scapular
TABLE 7.1 Summary of Actions of the Scapular Muscles
Scapular Scapular
upward downward Scapular Scapular Scapular Scapular
rotation rotation elevation depression abduction adduction
Upper trapezius x x x
Middle trapezius x
Lower trapezius x x x
Levator scapulae x x x
Rhomboids x x x
Serratus anterior x x x
(lower fibers)
Pectoralis minor x x x
muscles rather than as a prime mover (Moseley et al., 1992). Posturally, it can pull the medial border
and particularly the inferior angle of the scapula away from the rib cage (winged scapula). However, if
the scapula is adequately stabilized, contraction of the pectoralis minor will instead act to elevate the
upper ribs and contribute to a desired lifted posture of the chest (Hamilton and Luttgens, 2002), often
used in dance as part of presentation.
Rotator Cuff
The rotator cuff is composed of the four muscles that span between the scapula and the proximal
humerus—the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles form a
hood or cuff about the head of the humerus, and their tendons actually merge into the capsule of the
shoulder joint and provide a net compression force that helps stabilize the head of the humerus in the
glenoid cavity. In addition to helping keep the humerus in contact with the glenoid cavity, these muscles
produce rotation that is often used to position the head of the humerus or the arm to facilitate optimal
mechanics. Some of these muscles also have other actions at the shoulder joint.
Attachments and Primary Actions of Supraspinatus

Supraspinatus Inner portion of Top of greater tubercle of Shoulder abduction
(soo-prah-spi-NAH-tus) supraspinous fossa of humerus Stabilization of shoulder
scapula
Supraspinatus
The supraspinatus is a small but important muscle
located under the upper portion of the trapezius.
As its name implies, the supraspinatus (supra,
above + spin, spine) originates above the spine of
the scapula, in the supraspinous fossa, and runs
laterally to attach to the top of the humerus (figure
7.12). Near the tip of the shoulder, the muscle
fibers of the supraspinatus converge to form a short
tendon that courses underneath the acromion and
adheres to the capsule. This tendon is a common
site of injury. The superior line of pull of this muscle
allows the supraspinatus to be an effective abduc-
tor of the shoulder, and it appears to be particularly
important for initiation of abduction when the arms
are down by the sides (Hall-Craggs, 1985). Despite
its relatively small size, the supraspinatus has been
shown to be able to effect full abduction of the arm
when the deltoid is not operative and is estimated FIGURE 7.12 Posterior view of rotator cuff muscles:
to normally contribute about 50% of the torque for supraspinatus, infraspinatus, and teres minor (left
abduction when the deltoid is operative (Smith, shoulder, deep view).
Weiss, and Lehmkuhl, 1996). Its line of pull also
allows this muscle to help pull the humerus into
the glenoid cavity and help prevent downward dislocation of the shoulder.
Palpation: Place the fingertips of your left hand just above the spine of the right scapula. The supra-
spinatus can be felt contracting under the trapezius when you quickly and repetitively raise your arm
just about 8 inches (20 centimeters) to the side (shoulder abduction).
Attachments and Primary Actions of Infraspinatus and Teres Minor

Infraspinatus Medial portion of Middle of greater tubercle Shoulder external rotation
(in-frah-spi-NAH-tus) infraspinous fossa of of humerus Stabilization of shoulder
scapula Shoulder horizontal abduction
Component of SIT force couple
Teres minor Dorsal aspect of lateral Lower greater tubercle and Same as infraspinatus
(TE-reez MY-nor) border of scapula adjacent shaft of humerus
Infraspinatus and Teres Minor

The infraspinatus and teres minor are functionally aligned muscles located on the back of the scapula
(figure 7.12). As its name implies, the infraspinatus (infra, below) runs from below the spine of the
scapula (medial infraspinatus fossa) laterally and upward to attach onto the posterior aspect of the
greater tubercle on the back of the humerus. The teres minor (teres, round + minor, lesser) runs from
the inferolateral border of the scapula to attach just below the infraspinatus on the greater tubercle and on
the adjacent shaft of the humerus. As with the supraspinatus, the tendons of these muscles are adherent
with the shoulder capsule and are important for preventing dislocation of the shoulder. These muscles
produce external rotation and horizontal abduction of the shoulder. They also participate in the SIT force
couple, a force couple vital for proper shoulder mechanics that is discussed later in this chapter.
Palpation: While sitting in a chair, lean your torso forward about 30° and place the fingers of your
left hand just to the outside of the lateral margin of the right scapula while your right arm is hanging
straight down toward the floor. The infraspinatus and teres minor can be palpated when the arm is slowly
externally rotated in this position. The infraspinatus can be felt contracting just below the lateral portion
of the spine of the scapula. The teres minor can be felt contracting just below the infraspinatus.
Attachments and Primary Actions of Subscapularis

Subscapularis Costal surface of scapula Lesser tubercle of humerus Shoulder internal rotation
(sub-scap-u-LAR-is) (subscapular fossa) Stabilization of shoulder
Subscapularis
As its name suggests, the subscapularis (sub, under
+ scapular, scapula) is located deep to the scapula
(figure 7.13). The subscapularis courses from its
attachment on the costal surface of the scapula later-
ally, upward, and slightly forward to attach onto the
lesser tubercle of the humerus. This more anterior
attachment on the humerus allows the subscapularis
to function as an internal rotator of the humerus and
to help prevent anterior subluxation or dislocation
of the humerus. This muscle can also help prevent
inferior dislocation of the shoulder. Due to the slope
of the glenoid cavity, downward dislocation of the
humerus requires lateral movement of the head of
the humerus, which can be prevented by muscles
with a horizontal line of pull including the subscapu-
laris, infraspinatus, and teres minor (Hamilton and
Luttgens, 2002). In addition, the subscapularis plays
FIGURE 7.13 Anterior view of rotator cuff muscles:
a part in the SIT force couple.
subscapularis and supraspinatus (right shoulder, deep
view of costal surface of scapula).
Palpation: While sitting in a chair, lean your torso forward until it is about horizontal and gently place
the fingers of your left hand in your right lower armpit against the costal surface of the scapula while
your right arm is hanging straight down toward the floor. The subscapularis can be palpated contracting
when the arm is slowly internally rotated in this position.
Other Major Glenohumeral Muscles

The remaining group of muscles generally spans greater distances and connects the humerus to the
trunk (including the ribs, clavicle, sternum, scapula, spine, and pelvis). These muscles are important
for generating the large movements of the arm. In addition to the muscles described in this section,
the biceps brachii and the long head of the triceps brachii also cross the shoulder joint, but they will
be discussed later in this chapter in connection with the elbow.
Attachments and Primary Actions of Pectoralis Major

Pectoralis major Inner two-thirds of Intertubercular groove Clavicular:
(pek-to-RA-lis MAY-jer) anterior aspect of of humerus extending Shoulder flexion
clavicle down from tubercles Shoulder abduction above 90°
Sternum about 3 inches (7.6 Assists with shoulder adduction (lower ranges)
Costal cartilage of ribs centimeters) Sternal:
1 or 2 to 6 or 7 near Shoulder extension
sternum Shoulder adduction
Both:
Shoulder horizontal adduction
Shoulder internal rotation
Pectoralis Major
As its name suggests, the pectoralis major (pect, breast,
chest + major, larger) is a large superficial muscle
located on the chest, and its development can be readily
observed in the area of the upper chest (figure 7.14).
The lower border of the lateral pectoralis major forms
a muscular fold (anterior axillary fold) and most of the
front wall of the armpit. The pectoralis major runs from
the inner clavicle, sternum, and costal cartilages of the
upper six ribs laterally to attach via a flat tendon to the
intertubercular groove of the humerus. Near the distal
attachment, the muscle twists clockwise 180°, leaving
it twisted when in anatomical position but untwisted
when the arms are raised overhead. The muscle is fan
shaped and is often divided into a clavicular or upper and
a sternal or lower portion. The line of pull of the clavicular
portion is such that it can produce shoulder flexion and
aid with shoulder adduction. However, when the arm is
above shoulder height, the line of pull moves above the
axis of the shoulder joint and it can then produce the oppo-
site action of shoulder abduction (chapter 2, figure 2.9,
p. 44). In contrast, the proximal attachment of the sternal
portion is low enough that it tends to consistently produce
shoulder adduction (and shoulder extension if the arm is
in a starting position where it is raised to the front). All
portions of the pectoralis major tend to produce horizontal
adduction and assist with shoulder internal rotation. The
pectoralis major as a whole is particularly important in FIGURE 7.14 Anterior view of superficial shoulder mus-
cles: pectoralis major and deltoid (right shoulder).
pushing, throwing, and punching movements (Hamilton and Luttgens, 2002). When the pectoralis major
is missing, the arm can still be raised and lowered, but the power in shoulder flexion and extension is
markedly diminished (Rasch and Burke, 1978).
Palpation: Use your left hand to pinch the fold of muscle that forms the front of the right armpit (axilla)
while your right hand is placed on a stationary object such as a desk. You can feel the sternal head
of the pectoralis major contracting under your fingers when you firmly press your right hand down onto
the desk as if to extend the shoulder (isometric shoulder extension). To palpate the clavicular portion,
move the fingers of your left hand just below the middle of the clavicle and your right hand under the
desk. You can palpate the clavicular portion of the pectoralis major contracting when you firmly press
your right hand upward against the desktop (isometric shoulder flexion).
Different Actions of Pectoralis Major
The differing functions of the clavicular and sternal portions of the pectoralis major can be demon-
strated with the following exercise.
• Shoulder flexion and extension. Sit with your hands clasped at shoulder height with both elbows
extended. Pull down with the right arm (shoulder extension) and up (shoulder flexion) with the left arm
simultaneously, such that no net movement of the shoulders occurs. Note the lower sternal portion
of the pectoralis major contracting on the right side of your chest and the upper clavicular portion of
the pectoralis major contracting on the left side of your chest.
• Shoulder horizontal adduction. Press both hands and arms toward each other so that no net
movement of the shoulder occurs (isometric horizontal adduction). Note the clavicular and sternal
portions of the pectoralis major contracting on both the right and left sides of your chest.
Attachments and Primary Actions of Deltoid

Deltoid Outer anterior aspect of Deltoid tuberosity of Anterior:
(DEL-toid) clavicle humerus Shoulder flexion
Acromion of scapula Shoulder horizontal adduction
Lower border of spine of Assists with shoulder internal rotation
scapula Middle:
Shoulder abduction
Posterior:
Shoulder extension
Assists with shoulder external rotation
Deltoid Muscle
The deltoid (delta, triangular) muscle is the superficial muscle that forms the round contour of the
shoulder. As its name implies, it is triangular in shape (figure 7.15). The deltoid courses from the outer
clavicle and acromion process and spine of the scapula downward and outward to attach onto the deltoid
tuberosity located about halfway down on the lateral humerus. With its extensive proximal attachments,
it crosses the joint in many ways and is best thought of functionally as three muscles—the anterior
deltoid, middle deltoid, and posterior deltoid. The

anterior deltoid traverses the front of the shoulder,
and its lateral and downward course produces a line
of pull allowing its primary actions of shoulder flexion
and horizontal adduction (figure 7.14). It can also
assist with abduction of the shoulder and probably
internal rotation. The middle deltoid courses later-
ally over the top of the shoulder and then downward
to attach onto the humerus, making it an important
and powerful abductor of the shoulder (figure 7.15).
Its activity increases progressively as the arm is
raised and is greatest between 90° and 180° of
shoulder abduction (Basmajian and DeLuca, 1985;
Hamill and Knutzen, 1995), and the arm cannot be
raised above shoulder height when this muscle is
missing. The posterior deltoid crosses the back of
the shoulder joint and can be thought of as having
opposite actions to the anterior deltoid (figure
7.16). The posterior deltoid is an important shoulder
extensor, and a loss of the ability to raise the arm FIGURE 7.15 Lateral view of deltoid (right shoulder).
backward above waist height tends to accompany
loss of this muscle. The posterior deltoid also can
produce horizontal abduction, probably contributes slightly to shoulder external rotation, and helps
prevent downward dislocation of the humerus.
Surprisingly, there is one movement in which the anterior and posterior deltoid can actually work
together, and that is shoulder adduction. With shoulder adduction, their simultaneous synergistic
contraction allows shoulder adduction while neutralizing out undesired other actions of shoulder flex-
ion-extension, horizontal abduction-adduction, and external-internal rotation. In addition, the deltoid
appears to function to help stabilize the shoulder joint, and often two or three parts of the deltoid tend
to be active when the arm is moved, with greater activity in the portion of the muscle generating the
desired movement (Rasch, 1989).
Palpation: The deltoid can easily be seen and palpated at the front, top, and back of the shoulder.
Sit with the fingers of the left hand on the front of the right shoulder. You can feel the anterior deltoid
contracting when you raise your right arm to the front slowly from low fifth (shoulder flexion). You can
palpate the middle deltoid on the top of the shoulder just inferior to the tip of the acromion process
when raising the right arm from low fifth to second position (involves shoulder abduction). The poste-
rior deltoid can be felt contracting on the back of the shoulder when the right arm is raised backward
(shoulder hyperextension).
Attachments and Primary Actions of Coracobrachialis

Coracobrachialis Coracoid process of Anteromedial aspect of Shoulder flexion
(kor-ah-ko-bra-kee-AL-is) scapula middle of humerus Shoulder adduction
Coracobrachialis
The coracobrachialis (coraco, coracoid + brachi, arm) is a small muscle located beneath the pectoralis
major and anterior deltoid on the anteromedial aspect of the shoulder and arm. Its name describes its
attachments, and it runs from the coracoid process of the scapula downward to attach to the antero-
medial aspect of the humerus. It is pictured later in this chapter with the brachialis (see figure 7.42 on
p. 417). The actions of the coracobrachialis include shoulder flexion and horizontal adduction, but due
to its small size, its contribution is less significant than that of the pectoralis major or anterior deltoid.
It can also work with other muscles to produce shoulder adduction.
Attachments and Primary Actions of Latissimus Dorsi

Latissimus dorsi T6-L5 spinous processes Lower intertubercular Shoulder extension
(lah-TIS-i-mus DOR-see) Sacrum groove of humerus parallel Shoulder adduction
Crest of ilium to attachment of pectoralis Shoulder horizontal abduction
major
Posterior aspect of lower Shoulder internal rotation
3 ribs Depression of humerus
Latissimus Dorsi
The name of this muscle describes both its shape
and location (latissimus, widest + dorsi, back), and
it is the broadest muscle of the back and lateral
thorax. The latissimus dorsi is located superficially,
except where its upper portion is overlapped by the
lower fibers of the trapezius, and laterally it helps
form the back wall of the armpit (axilla). This very
extensive muscle’s proximal attachments include
the lower spine, pelvis, and associated fascia
(lumbodorsal fascia) as seen in figure 7.16. It runs
upward and outward and then forward. Similarly to
the pectoralis major, it twists 180° before attaching
with a flat tendon to the anterior humerus, parallel
to the attachment of the pectoralis major. Due to
this anterior attachment it tends to produce shoulder
internal rotation, as well as being a powerful exten-
sor of the shoulder used in resisted “downward
and backward pulling” motions of the arms, as in
swimming, rowing, rope climbing, and pull-ups. When
used in conjunction with the pectoralis major, the
latissimus dorsi is also a powerful adductor of the
arm (Hall-Craggs, 1985).
Due to its extensive bony and fascial attach-
ments, the latissimus dorsi also serves an important
function in stabilizing the trunk; and when the arms
are fixed (closed kinematic chain movement), the
distal attachment of the latissimus dorsi can aid with
lifting the pelvis as in crutch walking, sitting push- FIGURE 7.16 Posterior view of superficial shoulder
ups, or dance floor work. Posturally, the latissimus muscles: latissimus dorsi, teres major, and deltoid (left
dorsi can aid with depression of the humerus, and shoulder).
this function is sometimes emphasized in dance.
Loss of the latissimus dorsi is associated with forward displacement of the shoulder and loss of strength
in downward movements of the arm against resistance.
Palpation: Place your left hand on a stationary object such as a desk, with the elbows slightly bent
and the fingertips of your right hand about 8 inches (20 centimeters) below the back portion of your
left armpit on your posterolateral rib cage. You can feel the latissimus dorsi contracting under your right
hand when you press down firmly with your left hand (isometric shoulder extension).
Teres Major
The teres major (teres, round + major, larger) is similar in shape to the teres minor, only larger, hence
its name teres “major.” It runs from the lateral border of the lower scapula outward and upward to
attach onto the anterior humerus (figure 7.16). When resistance must be overcome, the teres major
comes into play and has the same actions as the latissimus major. Hence, it is sometimes called “the
latissimus dorsi’s little helper” (Rasch and Burke, 1978). When the arm is behind the back, the teres
Attachments and Primary Actions of Teres Major

Teres major Inferior angle of scapula Medial lip of intertubercular Shoulder extension
(TE-reez MAY-jer) groove Shoulder adduction
(Depression of humerus)
major appears to assist with extension (hyperextension) and adduction, even when resistance is not
present (Hamilton and Luttgens, 2002).
Palpation: Use the same movement as with the latissimus dorsi, only with the fingertips of your right
hand placed just lateral to the inferior angle of the scapula. You can feel the teres major contracting
under your right hand when you press down firmly with your left hand (shoulder extension).
Summary of Attachments and Actions

of the Muscles of the Shoulder Complex
A summary of the proximal and distal attachments of the muscles of the shoulder complex—the
scapular muscles, rotator cuff, and other glenohumeral muscles—is provided in table 7.2. Many of
these muscles and their attachments are shown in figures 7.17, A and B, and 7.18, A and B. From
these resources, deduce the line of pull and resultant possible actions of these muscles, and then
check for accuracy by referring to figures 7.17C and 7.18C for the larger muscles responsible for the
fundamental movements of the shoulder joint (e.g., “other glenohumeral muscles” category) and the
primary action(s) column in table 7.2 for the scapular muscles and rotator cuff muscles. Note that
figures 7.17 and 7.18 include the biceps brachii muscles and triceps brachii muscles to show their
relationship to the glenohumeral joint. However, they are discussed later in this chapter with the elbow,
and their attachments and actions are provided in table 7.6 (p. 420).
TABLE 7.2 Summary of Attachments and Primary Actions of the Muscles of the Shoulder Complex

Scapular muscles
Trapezius Base of skull Outer third of clavicle Upper: Scapular elevation
(trah-PEE-zee-us) Ligament of neck Upper acromion Scapular upward rotation
C7-T12 spinous processes Upper spine of scapula Scapular adduction
Middle: Scapular adduction
Lower: Scapular depression
Scapular upward rotation
Scapular adduction
Levator scapulae C1 to C4 or C5 transverse Medial border of scapulae Scapular elevation
(le-VA-tor SKAP-u-le) processes (from spine to Scapular downward rotation
superior border) Assists with scapular adduction
Rhomboids C6 or C7 to T4 or T5 Medial border of scapula Scapular elevation
(ROM-boidz) spinous processes from spine to inferior Scapular adduction
angle Scapular downward rotation
Serratus anterior Lateral, outer aspect of Inferior angle and medial Scapular abduction
(ser-A-tus an-TEER-ee-or) lower 8 to 9 ribs border of scapula Scapular upward rotation
Scapular depression (lower fibers)
Pectoralis minor Outer surface of 2nd or Coracoid process of Scapular abduction
(pek-to-RA-lis MY-nor) 3rd to 5th ribs scapulae Scapular downward rotation
Scapular depression
(continued)
TABLE 7.2 Summary of Attachments and Primary Actions of the Muscles of the Shoulder Complex (continued)

Rotator cuff muscles
Supraspinatus Inner portion of supra- Top of greater tubercle of Shoulder abduction
(soo-prah-spi-NAH-tus) spinous fossa of scapula humerus Stabilization of shoulder
Infraspinatus Medial portion of Middle of greater tubercle Shoulder external rotation
(in-frah-spi-NAH-tus) infraspinous fossa of of humerus Stabilization of shoulder
scapula Shoulder horizontal abduction
Teres minor Dorsal aspect of lateral Lower greater tubercle and Same as infraspinatus
(TE-reez MY-nor) border of scapula adjacent shaft of humerus
Subscapularis Costal surface of scapula Lesser tubercle of Shoulder internal rotation

(sub-scap-u-LAR-is) (subscapular fossa) humerus Stabilization of shoulder
Other glenohumeral muscles
Pectoralis major Inner two-thirds of anterior Intertubercular groove of Clavicular:
(pek-to-RA-lis MAY-jer) aspect of clavicle humerus extending down Shoulder flexion
Sternum from tubercles about 3 Shoulder abduction above 90°
Costal cartilage of ribs inches (7.6 centimeters) Assists with shoulder adduction
1 or 2 to 6 or 7 near (lower ranges)
sternum Sternal:
Shoulder extension
Shoulder adduction
Both:
Deltoid Outer anterior aspect of Deltoid tuberosity of Anterior:
(DEL-toid) clavicle humerus Shoulder flexion
Acromion of scapula Shoulder horizontal adduction
Lower border of spine of Assists with shoulder internal rotation
scapula Middle:
Shoulder abduction
Posterior:
Shoulder extension
Assists with shoulder external rotation
Coracobrachialis Coracoid process of Anteromedial aspect of Shoulder flexion
(kor-ah-ko-bra-kee-AL-is) scapula middle of humerus Shoulder adduction
Latissimus dorsi T6-L5 spinous processes Lower intertubercular Shoulder extension
(lah-TIS-i-mus DOR-see) Sacrum groove of humerus Shoulder adduction
Crest of ilium parallel to attachment of Shoulder horizontal abduction
pectoralis major
Posterior aspect of lower Shoulder internal rotation
3 ribs Depression of humerus
Teres major Inferior angle of scapula Medial lip of Shoulder extension
(TE-reez MAY-jer) intertubercular groove Shoulder adduction
(Depression of humerus)
392
Pectoralis
major
Serratus anterior
FIGURE 7.17 Anterior view of primary muscles acting on the shoulder complex. (A) Muscles, (B) attachments, (C)
lines of pull and primary actions of selected glenohumeral muscles.
393
FIGURE 7.18 Posterior view of primary muscles acting on the shoulder complex. (A) Muscles, (B) attachments, (C)
lines of pull and primary actions of selected glenohumeral muscles.
394
Alignment and Common ing of the external rotators and stretching of the
internal rotators (especially the pectoralis major
Deviations of the and latissimus dorsi) can also be helpful. When
Shoulder Complex rolled shoulders is a chronic posture, kyphosis is also
frequently present, and strengthening of the upper
With normal alignment of the shoulder complex, the back extensors (see chapter 3) is necessary. Several
clavicles should be approximately horizontal, while exercises for helping prevent and correct rolled
the scapulae lie flat against the rib cage posteriorly shoulders are shown in figure 7.20 and described
and extend from approximately the second through in tables 7.10 and 7.12. Double-shoulder external
the seventh rib (Rasch and Burke, 1978). Various rotation (figure 7.20B and table 7.10I, progression 3,
deviations from this ideal alignment occur, includ- p. 439) offers a time-efficient exercise that combines
ing rolled shoulders and winged scapulae. Because shoulder external rotation, scapular adduction, and
these deviations are often associated with muscular thoracic extension in a single exercise. The single-
imbalances, their occurrence is widespread, but they arm scarecrow (figure 7.20C and table 7.10H, varia-
are generally more readily corrected than some of tion 2, p. 439) provides an exercise for developing
the deviations seen at other joints that involve more shoulder external rotation while maintaining torso
permanent structural elements. stability when the arm is at shoulder height, a posi-
tion commonly required in dance. Stretches to help
Rolled Shoulders improve rolled shoulders include the sitting arms
overhead shoulder stretch (figure 7.20A and table
Rolled shoulders involves a forward rounding of 7.12C, variation 1, p. 450) and kneeling arms overhead
the shoulders that usually encompasses a position shoulder stretch (described later in table 7.12B, p.
of excessive scapular abduction and often internal 449), which emphasize stretching of the latissimus
rotation of the humerus (figure 7.19). Correction dorsi and lower fibers of the pectoralis major, as well
requires strengthening of the scapular adductors as the wall shoulder stretch (described later in table
(especially the trapezius and rhomboids) and in 7.12D, p. 450), which emphasizes stretching of the
some cases stretching of the scapular abductors anterior deltoid and the pectoralis major. In addition
(particularly the pectoralis minor). When internal to exercises, cueing to bring the scapulae slightly
rotation of the humerus is also present, strengthen- down and together while one reaches the shoulders
FIGURE 7.19 Shoulder alignment. (A) Rolled shoulders; (B) desired shoulder placement.
to the side can help correct rolled shoulders during backward rather than lying flat against the rib cage
static posture (figure 7.20D). in the desired manner (figures 7.21, A and B). This
postural deviation, termed “winged scapula,” can
Winged Scapula be caused by various muscular imbalances includ-
ing a tight pectoralis minor or inadequate strength
Since there is no bony attachment between the or activation of the serratus anterior or trapezius
scapula and the back of the rib cage, the positioning muscles. If the serratus anterior is not functioning
of the scapula is greatly influenced by the relative synergistically with the trapezius, when the trapezius
strength, flexibility, and activation of the surround- contracts to help upwardly rotate the scapulae during
ing muscles, and particularly the muscles of scapular elevation of the arm, its unopposed action will tend
stabilization. In some cases, the medial border or the to elevate the scapula, adduct the scapula, and pro-
inferior angle of the scapula, or both, will project duce a backward projection of the medial border
C
D
FIGURE 7.20 Sample exercises for improving rolled shoulders. (A) Sitting arms overhead shoulder stretch, (B) double-
shoulder external rotation, (C) single-arm scarecrow, (D) technique cue to bring shoulder blades slightly down and together
as the shoulders reach to the side.
DANCE CUES 7.1
“Pull Your Shoulders Back”
T he directive to “pull your shoulders back” or “pull your shoulders back and lift your chest” is
sometimes used by teachers in response to a student with rolled shoulders and functional kypho-
sis. One desired anatomical interpretation of this cue is to emphasize using the scapular adductors
to help bring the shoulders to a desirable position and the thoracic spinal extensors to help correct
the rounded upper back. However, some students respond to this directive by pinching the shoulder
blades together (excessive scapular adduction) and “rib-leading” (excessive lumbar extension versus
the desired upper thoracic extension). In such cases, cueing to “reach the shoulders to the side” as the
upper back “lifts up toward the ceiling” or to bring the shoulder blades slightly down and together as
the shoulders reach to the side may help achieve the desired placement.
of the scapula (figure 7.21C). The location of the utilized to foster this coordinated functioning of the
serratus anterior (figure 7.21D) allows it to be a key shoulder complex.
abductor of the scapula, and hence this muscle can
be recruited and strengthened by focusing on keep-
Scapulohumeral Rhythm
ing the scapula “wide” (scapular abduction) versus
allowing them to “pinch together” (scapular adduc-
Because the shallow glenoid cavity has contact with
tion) while performing a push-up (figure 7.21E)
only about one-third of the surface area of the head
and by adding a little extra push at the top of the
of the humerus, the glenohumeral joint is rather
push-up, further abducting the scapulae (termed a
susceptible to subluxation or dislocation. Hence,
“push-up plus,” table 7.10A, variation 1, p. 434). In
coordinated movements of the scapula are vital to
contrast, if the trapezius is not functioning prop-
position the glenoid cavity so that adequate contact
erly, the unopposed action of the serratus anterior
with the head of the humerus can be maintained and
during elevation of the arm will tend to depress the
the desired large range of movement of the humerus
scapula, abduct the scapula, and produce a back-
can be facilitated while the costal surface of the
ward projection of the inferior angle of the scapula
scapula is still kept in close contact with the thorax.
(figure 7.21F). Since the trapezius’ location allows
This movement of the scapula also often works to
it to function as a powerful adductor of the scapula
help keep the prime movers at the shoulder joint at
(figure 7.21G), performing sitting rowing exer-
a favorable length to generate force and avoid active
cises with a band (figure 7.21H and table 7.10D,
or passive insufficiency. This precisely coordinated,
variation 2, p. 435) or prone rowing exercises with
synchronous movement between the scapula and the
a weight while focusing on keeping the elbows at
humerus is termed the scapulohumeral rhythm.
shoulder height as they are brought slightly behind
This scapulohumeral rhythm involves character-
the torso as the shoulder blades are pulled together
istic scapular movements that supplement specific
(scapular adduction) can be used to recruit and
humeral movements. The most commonly discussed
strengthen this muscle. However, a winged scapula
linking is the upward rotation of the scapula that
may also relate to other medical conditions including
accompanies shoulder abduction as shown in figure
scoliosis or nerve injury, and if the winging is marked,
7.22. After the initial movement of the arm that pre-
evaluation by a physician is recommended.
dominantly occurs at the glenohumeral joint, there
is a linked relationship between upward rotation of
Shoulder Mechanics the scapula and elevation of the arm such that after
about 30° of abduction or 45° to 60° of flexion there
Coordinated movements between the shoulder is about 3° of glenohumeral motion for every 2° of
girdle and arms are essential for optimal move- scapular motion. So, with the total range of 180°
ment and preventing injuries. The scapulohumeral flexion or abduction, the glenohumeral-to-scapula
rhythm, combined external rotation with shoulder ratio is 2:1, that is, about 120° of glenohumeral
abduction, the SIT force couple, and synergies are motion and 60° of scapular motion as shown in figure
FIGURE 7.21 Winged scapula. (A) Posterior view, (B) lateral view; due to (C)-(E) inadequate serratus anterior function
or (F)-(H) inadequate trapezius function.
7.23 (Kreighbaum and Barthels, 1996; Levangie and listed in table 7.3. Note that there is a logical link-
Norkin, 2001). This upward rotation of the scapula ing where opposite movements of a movement pair
not only allows the arm to reach a greater height but of the glenohumeral joint are linked with opposite
also moves the acromion process out of the way as the movements of the scapula. For example, glenohu-
greater tubercle of the humerus approaches it with meral abduction is linked with scapular upward
abduction (Kreighbaum and Barthels, 1996). This rotation, while glenohumeral adduction is linked
latter function is vital for preventing impingement. with scapular downward rotation; glenohumeral
Other commonly linked movements between flexion is linked with scapular abduction and upward
the humerus and scapula in an upright position are rotation, while glenohumeral extension is linked
FIGURE 7.22 Upward rotation of the scapula accompa- FIGURE 7.23 The scapulohumeral rhythm with shoul-
nying elevation of the arm. der abduction.
with scapular adduction and downward rotation; other movements are less predictably linked and
and glenohumeral external rotation is linked with can be shaped by individual posture and movement
scapular adduction, while glenohumeral internal patterns. In dance, these movements are some-
rotation is linked with scapular abduction. Depend- times consciously biased to meet a given aesthetic.
ing on the relationship to gravity and what types of For example, some schools of dance may prefer a
external forces are present, these movements may more open position of the arms with slight scapular
be performed concentrically by the muscle(s) with adduction, while others may prefer a “wider back”
the associated action (see table 7.4) or controlled with a neutral position or even slight abduction of
eccentrically by the muscles that tend to produce the the scapula.
opposite motion. For example, when one is raising a
weight to the side (shoulder abduction), the upward Influence of Shoulder Rotation on Abduction
rotation occurs from synergistic concentric contrac-
tion of the upward rotators of the scapula. However, In raising the arm to the side (shoulder abduction),
when the weight is lowered (shoulder adduction), range is also facilitated by using external rotation
the downward rotation of the scapula tends to be to position the humerus (Concept Demonstration
produced by gravity, and eccentric contraction of 7.3). During the final 90° of abduction, this external
the upward rotators of the scapula works to control
the downward rotation. TABLE 7.3 Linked Movements of the Scapula
When the position changes from upright, things That Accompany Movements of the Humerus
get more complex; and it is important to consider at the Shoulder Joint
what effect gravity will have and which scapular
muscles will have to work to stabilize the scapulae. Movement of humerus Movement of scapula
For example, during a push-up, gravity tends to make Flexion Abduction and upward rotation
the scapulae come together (scapular adduction),
and the scapular abductors have to work to keep the Extension Adduction and downward rotation
scapulae in the desired position. In other cases, dif- Abduction Upward rotation
ferent types of external resistance such as the floor,
Adduction Downward rotation
a partner, or strength training apparatus influence
necessary scapular muscle recruitment. Medial rotation Abduction
While some of these linked motions, such as Lateral rotation Adduction
upward rotation of the scapula, are necessary to
allow high degrees of shoulder flexion or abduction, Hyperextension Elevation
Influence of External Forces on Scapular Stabilization
Use the following exercise with a partner to demonstrate the influence of pushing and pulling on the
muscles used to stabilize the scapula.
• Pushing. Face a partner with right palms in contact and arms at shoulder height with the elbows
extended. Push against your partner, and note that if you relax the scapular muscles, the right scapula
will tend to be pushed backward (scapular adduction). Now focus on keeping the scapula stationary
as you push, and notice the serratus anterior, located near your armpit on the front of your chest,
contracting to help stabilize the scapula with its function of scapular abduction.
• Pulling. Now face your partner with right hands grasped as if to shake hands. The next step is
for both of you to slowly pull on each other’s hand. Notice that if you relax the scapular muscles the
right scapula will tend to be pulled forward (scapular abduction). Now focus on keeping the scapula
stationary as you pull, and notice the contraction of the trapezius and other muscles between the
shoulder blades to produce scapular adduction and prevent forward movement of the scapula.
Influence of External Rotation

on Overhead Arm Movements
Working with a partner, raise his or her left arm in abduction, as if to bring it overhead through second
position to a high fifth position as directed in the following.
• Internal rotation. First, perform this motion slowly and gently while holding the arm in internal
rotation. Note how the scapula elevates excessively, the shoulder “hikes,” and it is difficult to bring
the arm fully overhead.
• External rotation. Now, from this elevated position, slowly externally rotate the arm, and note
how the scapula and shoulder “drop” and the arm can be easily brought overhead. Now slowly raise
your partner’s arm to the side from a low to high position, adding a gradual external rotation as the
arm is raised, and note how this allows the desired dance aesthetic of keeping the shoulders down
while bringing the arm overhead.
rotation of the humerus allows the greater tubercle priate activation of the external rotators (particularly
of the humerus to pass behind the coracoacromial the infraspinatus and teres minor of the rotator cuff)
arch (Caillet, 1996; Magee, 1997), which permits an are key for correct mechanics.
additional 30° of abduction of the humerus (Hamill
and Knutzen, 1995). It is interesting to note the par- SIT Force Couple
allel situation at the hip, where external rotation of
the femur and bringing the greater trochanter closer When the arm is relaxed and hanging by the side,
to the ischial tuberosities (sitz bones) allows much the head of the humerus tends to sit in the upper
greater hip abduction range than when the femur is part of the glenoid cavity (Magee, 1997), and with
maintained in a parallel or internally rotated posi- contraction of the middle deltoid a large compo-
tion. As with the hip, adequate strength and appro- nent of the muscle force will tend to pull the head
fd
FIGURE 7.24 The SIT force couple. When the arm is down by the side and the middle deltoid contracts (FD) to pro-
duce shoulder abduction, a large component of this force (fsd, stabilizing component) tends to pull the head of the
humerus upward while only a small component of this force (frd, rotary component) is capable of producing the desired
joint movement. However, the SIT muscles provide a force (Fd, dislocating component) that acts to pull the humerus
downward and a larger rotary component (fr) such that the resultant force of the SIT muscles (Fsit) acts as a force
couple to counter the upward pull of the deltoid and facilitate the desired shoulder abduction.
of the humerus upward (stabilizing component) flexors used to raise the arm (anterior deltoid and
rather than produce the angular rotation needed for pectoralis major) also tend to produce internal
shoulder abduction. However, this natural position- rotation of the shoulder. This undesired internal
ing and upward pull of the deltoid are countered rotation can be neutralized by the synergistic action
by members of the rotator cuff—the subscapularis, of external rotators such as the teres minor and infra-
infraspinatus, and teres minor (figure 7.24). These spinatus. Meanwhile, another synergy is occurring to
muscles are collectively referred to as the SIT force produce the desired upward rotation of the scapula
couple (S for subscapularis, I for infraspinatus, and (figure 7.25). In this case, the lower trapezius and
T for teres minor). The SIT force couple, perhaps lower fibers of the serratus anterior neutralize out
aided by some additional muscles (Hamill and the undesired action of scapular elevation produced
Knutzen, 1995), functions to depress the head of by the upper portion of the trapezius. Similarly, the
the humerus and counter the upward movement of serratus anterior neutralizes out the undesired action
the head of the humerus toward the acromion that of scapular adduction that would be produced by the
could pinch the interposed soft tissues (shoulder trapezius if it were unopposed. These are examples
impingement). The lower positioning of the humeral of helping synergists (chapter 2), as they assist with
head into the wider portion of the glenoid cavity the desired action of upward rotation of the scapula
produced by the SIT force couple also facilitates the while neutralizing out potential undesired elevation
desired rotation of the shaft of the humerus (e.g., or adduction of the scapula.
shoulder abduction).
Synergies Muscular Analysis

Many of the muscles of the shoulder complex have of Fundamental
multiple actions, and sophisticated use of synergies Shoulder Movements
is necessary to achieve the desired positions and
movements of the arms, scapulae, and torso. For As suggested by the previous discussion, analysis
example, when the arms are raised forward from low of shoulder movements is complicated by the use
fifth to high fifth, several synergies are operative. At of muscles to stabilize the joint, prevent impinge-
the glenohumeral joint, the two primary shoulder ment, effect the linked movements of the scapula,
Shoulder Flexion
In open kinematic chain movement, shoulder flex-
ion involves bringing the arm forward and upward
relative to anatomical position in an approximate
sagittal plane, such as when raising both arms for-
ward from low fifth to high fifth positions or raising
one arm forward from a low to an overhead position
(right arm in figure 7.26). This same motion (con-
centric shoulder flexion) is used in strengthening
exercises such as the front arm raise (table 7.10B,
p. 434) and the kneeling biceps lift (table 7.10M, p.
442). The shoulder flexors are used concentrically in
walking and running when the arms swing forward,
in underhand throwing, in some underhand swings
in racket sports, and in bowling. Concentric shoulder
Upward rotation
FIGURE 7.25 Example of scapular synergy ideally

utilized during shoulder abduction.
and neutralize undesired secondary actions of the

prime movers. In addition, due to the large range
of motion possible at the shoulder, some muscles
may change their relationship to the axis of motion
at the shoulder joint, and hence their function, in
different ranges of motion. For simplicity, this section
will emphasize providing examples of the primary
muscles capable of producing the desired shoulder
movement and accompanying scapular movement(s).
However, readers are encouraged to remember that
this presentation represents a great simplification, that
many other stabilizers and synergists would actually
be operative, and that specific movement conditions FIGURE 7.26 Sample dance movement showing shoul-
such as speed and resistance would influence which der flexion.
muscles actually were recruited. Photo courtesy of Myra Armstrong. Dancer: Lorin Johnson with American Ballet Theatre.
Shoulder Complex Movement and Muscles

Used in a Push-Up
Observe a dancer performing a push-up (with the elbows staying in), focusing on the joint motion and
muscles working at the shoulder complex.
• Up-phase. Note that in the up-phase of the push-up the motion at the shoulder is against grav-
ity. Hence, the joint motion, shoulder flexion, would be produced via concentric contraction of the
shoulder flexors. Examples of primary shoulder flexors are the anterior deltoid and pectoralis major
(clavicular) muscles.
• Down-phase. Note that in contrast, during the down-phase, gravity would tend to produce the
movement at the shoulder joint. Hence, although the joint motion is shoulder extension, the shoulder
flexors would be working eccentrically to control the lowering of the body and prevent it from falling to
the ground. So, the same shoulder flexors would be working on both the up- and down-phases of the
movement—concentrically on the up-phase and eccentrically on the down-phase.
• Scapular stabilization and movement. Now examine the influence of gravity on the scapulae and
note that the weight of the body will tend to make the scapulae come together or adduct, particularly
on the down-phase of the movement. Use of the serratus anterior and other scapular abductors to
keep the scapula “wide” throughout the push-up will help counter this tendency for adduction. Fur-
thermore, the later stages of shoulder flexion (greater than 60°) tend to be linked with slight scapular
abduction and upward rotation. Again, the serratus anterior, and to a lesser degree the trapezius, can
be used to achieve the desired scapulohumeral rhythm.
flexion also occurs in pushing motions when the to be accompanied by slight scapular abduction
hand is fixed (closed kinematic chain) and the elbow (serratus anterior) and upward rotation (trapezius
is by the side, such as in the up-phase of a push-up and serratus anterior, table 7.4) of the scapula
(table 7.10A, p. 432) or press-up (table 7.10C, p. (table 7.3, p. 399). Because of the scapular abduction
433). The shoulder flexors—primarily the anterior that naturally accompanies scapular upward rotation,
deltoid and the pectoralis major (clavicular portion, the serratus anterior has been shown to play a more
table 7.5)—would be used to effect these movements prominent role relative to the trapezius in shoulder
(table 7.4). Higher ranges of shoulder flexion tend flexion (Rasch, 1989).
TABLE 7.4 Scapular Movements and the Muscles That Can Produce Them
Scapular movement Primary and secondary muscles

Elevation Upper trapezius
Levator scapulae
Rhomboids
Depression Lower trapezius
Pectoralis minor
Serratus anterior (lower fibers)
Abduction (protraction) Serratus anterior
Pectoralis minor
Adduction (retraction) Trapezius
Rhomboids
Levator scapulae
Upward rotation Serratus anterior
Trapezius
Downward rotation Rhomboids
Pectoralis minor
Levator scapulae
TABLE 7.5 Shoulder Movements and the Muscles That Can Produce Them
Shoulder movement Primary muscles Secondary muscles

Flexion Anterior deltoid Coracobrachialis
Pectoralis major (clavicular) Biceps brachii
Extension Pectoralis major (sternal) Posterior deltoid
Latissimus dorsi Triceps brachii
Teres major
Abduction Middle deltoid Anterior deltoid (>15°)
Supraspinatus Pectoralis major (clavicular, >90°)
Biceps brachii (when shoulder
externally rotated)
Adduction Pectoralis major (especially sternal Posterior deltoid
portion) with latissimus dorsi Anterior deltoid
Teres major
Coracobrachialis
Biceps brachii
Triceps brachii
External rotation Infraspinatus Posterior deltoid
Teres minor Coracobrachialis (from internal
rotation to neutral)
Internal rotation Subscapularis Anterior deltoid
Teres major Pectoralis major
Latissimus dorsi
Coracobrachialis (>90°)
404
Shoulder movement Primary muscles Secondary muscles

Horizontal abduction Middle deltoid Latissimus dorsi
Posterior deltoid Teres major
Infraspinatus
Teres minor
Horizontal adduction Anterior deltoid Biceps brachii (short head)
Pectoralis major Coracobrachialis
Shoulder Extension
In open kinematic chain movements, shoulder exten-
sion often involves moving the arm backward and
downward from a position of flexion (such as from
high fifth to low fifth) in approximately the sagittal
plane. However, when the torso is upright, gravity
will tend to produce this movement, and shoulder
extension is primarily controlled with eccentric con-
traction of the shoulder flexors and scapular upward
rotators. However, if the arm is brought beyond
anatomical position (hyperextension), where the
motion is now against gravity (as seen with the right
arm in figure 7.27), or if the motion is opposed by
another external resistance such as a wall pulley,
elastic tubing, or springs (e.g., sitting row [table
7.10D, p. 435] or triceps kick back [table 7.10, E
and O, pp. 436 and 444]), the shoulder extensors—
including the posterior deltoid, latissimus dorsi,
and teres major—would be used concentrically to
produce the desired extension, accompanied by
relative scapular adduction, and downward rotation
(rhomboids, levator scapulae, and lower trapezius
to neutralize undesired elevation). Similarly, with
a pull-up (closed kinematic chain), extension
would occur against gravity (e.g., lifting the body
up against gravity), and the shoulder extensors
(including the pectoralis major [sternal], latissimus
dorsi, and teres major) would work concentrically
FIGURE 7.27 Sample dance movement showing
on the up-phase to produce this shoulder extension. shoulder extension.
Here, this hanging position would tend to produce
extreme elevation of the scapulae, and forceful and
deliberate scapular depression (lower trapezius, p. 437) performed with a weight. In dance, one or
serratus anterior) would ideally accompany shoulder both arms are often held in a position of about 90°
extension. abduction to facilitate balance or achieve aesthetic
goals (as seen with the left arm in figure 7.28). The
Shoulder Abduction shoulder abductors—particularly the supraspinatus
and deltoid—would be used to effect these motions.
When the hand is free to move (open kinematic When the shoulder is externally rotated, the biceps
chain), shoulder abduction refers to moving the brachii can also aid with shoulder abduction (Smith,
arm sideways away from the midline of the body Weiss, and Lehmkuhl, 1996). When the arms are
in approximately the frontal plane, as in raising raised above shoulder height, the clavicular por-
the arms to the side from low fifth to high fifth, tion of the pectoralis major can also assist with
jumping jacks, or the side arm raise (table 7.10F, abduction (table 7.4). Shoulder abduction (greater
the motion is now against gravity as shown in figure

7.29 (left shoulder “hyper”adduction combined with
slight shoulder flexion), or if the motion is opposed
by another external resistance such as a weight appa-
ratus (e.g., lat pull-downs), elastic tubing, water (e.g.,
swimming the breaststroke), or another dancer, the
shoulder adductors and scapular downward rotators
(rhomboids, levator scapulae with lower trapezius or
serratus anterior to neutralize elevation) come into
play. Similarly, in closed kinematic chain movements
such as the iron cross in gymnastics, the shoulder
adductors would be used concentrically against
gravity to raise the body. Unlike what occurs at the
hip, where there is a specific muscle group that pro-
duces hip adduction, at the shoulder there are not
specific muscles whose primary function is shoulder
adduction. Instead, muscles located on the front and
back of the shoulder are simultaneously contracted
to produce shoulder adduction. For example, com-
bined contraction of the pectoralis major and latis-
FIGURE 7.28 Sample dance movement showing shoulder abduction. simus dorsi results in shoulder adduction, as would
Photograph by Brooks Dierdorff. Dancer: Nicole Robinson.
combined contraction of the anterior and posterior
deltoid muscles.
than 30°) is accompanied by upward rotation of the
scapula (serratus anterior and trapezius); and full
abduction to an overhead position is not possible
without this coordinated upward rotation of the
scapula. The rotator cuff also contributes by helping
depress the head of the humerus (SIT force couple:
subscapularis, infraspinatus and teres minor) to
prevent impingement in middle ranges of abduction
and help counter potentially superiorly dislocating
components of the force produced by the middle
deltoid in higher ranges of abduction (Hall, 1999).
In higher ranges of abduction, the rotator cuff also
can produce slight external rotation (infraspinatus
and teres minor) to help clear the greater tubercle
relative to the acromion process and allow greater
range of the arm.
Shoulder Adduction
In open kinematic chain movements, shoulder
adduction involves moving the arm downward
and inward toward the midline of the body from
an abducted position in approximately the frontal
plane, such as in bringing the arms from second to
low fifth. However, when the torso is upright, gravity
will tend to produce this movement, and shoulder
adduction and its associated downward rotation are
generally controlled by eccentric contraction of the
FIGURE 7.29 Sample dance movement showing shoul-
shoulder abductors and scapular upward rotators.
der adduction.
However, if the arms are brought beyond anatomi- Photo by Edward Casati. Alonzo King’s Lines Ballet dancer Maurya Kerr in “Baker
cal position in front of or behind the body where Fix,” dress by Colleen Quen Couture.
Shoulder External Rotation

When the hand is free to move, shoulder external
rotation refers to rotating the humerus outward
along its long axis in an approximately horizontal
plane as when one rotates the arm outward from
anatomical position so that the point of the elbow
(olecranon process) faces into the side of the body. In
strengthening exercises, this movement is often per-
formed against external resistance with the elbows
in a flexed position, as in the kneeling scarecrow
(table 7.10H, p. 439) and double-shoulder external
rotation (table 7.10I, p. 439). In dance, external
rotation is often added to other movements of the
arm such as shoulder flexion or abduction to create
a desired aesthetic (right arm in figure 7.30). In
sport, shoulder external rotation is incorporated
into the backhand drive in racket sports and used
in the underhand pitch. Mechanically, as previously
described, the addition of external rotation to full
shoulder abduction decreases shoulder stress and
increases possible range without undesired scapular
elevation. The shoulder external rotators—particu-
larly the infraspinatus and teres minor of the rotator
cuff (Warner et al., 1990)—would be used concentri-
cally to effect this rotation. Shoulder external rota-
tion tends to be linked with adduction of the scapula
(trapezius, rhomboids).
FIGURE 7.30 Sample dance movement showing shoulder
Shoulder Internal Rotation external rotation.
Photo courtesy of Patrick Van Osta. CSULB dancer Dwayne Worthington.
In open kinematic chain movements, shoulder inter-

nal rotation refers to rotating the humerus inward
along its long axis in an approximately horizontal cuff) is a particularly strong internal rotator that is
plane, as when one rotates the arm inward from capable of producing this motion in isolation. Many
anatomical position so that the point of the elbow of the other muscles are called into play when more
(olecranon process) faces outward or forward. As force is needed, in different joint ranges, or when a
with external rotation, strengthening exercises specific combination of movements is present. For
against external resistance often incorporate a posi- example, the latissimus dorsi would tend to create
tion of elbow flexion, as in single-shoulder internal shoulder extension with internal rotation, whereas
rotation (table 7.10J, p. 440). In dance, similarly to the pectoralis major (clavicular portion) would tend
external rotation, internal rotation is often added to produce shoulder flexion and internal rotation.
to other movements of the arm such as shoulder Shoulder internal rotation tends to be linked with
flexion, extension, or abduction to create a desired abduction of the scapula (serratus anterior and
aesthetic (left arm in figure 7.31). In sport, shoulder pectoralis minor).
internal rotation is incorporated in overarm throw-
ing; certain overhead and forehand strokes in racket Shoulder Horizontal
sports; and the crawl, butterfly, and breaststroke in Adduction and Abduction
swimming. Internal rotation of the shoulder can be
important for placement and force application of Although not among the fundamental movement
the hand. The shoulder internal rotators—including pairs in the classic three planes associated with ball-
the subscapularis, teres major, latissimus dorsi, and and-socket joints, the specialized movements of
pectoralis major—could be used concentrically to horizontal adduction and horizontal abduction are
effect this rotation. The subscapularis (of the rotator included because of their common use in dance.
Horizontal adduction refers to bringing the arms for-

ward toward the midline from a horizontal position
(90° abduction) and keeping the arms at shoulder
height throughout this motion. An example from
ballet is bringing the arms forward from second
position to the front. When the torso is upright,
the horizontal adductors—including the anterior
deltoid, pectoralis major, and coracobrachialis—can
produce this movement, while the shoulder abduc-
tors (supraspinatus and middle deltoid) are used to
maintain the arms at shoulder height. If you wanted
to strengthen these muscles with weights, lying
supine would provide a more effective position for
gravity to resist horizontal adduction (e.g., supine
fly or bench press). Shoulder horizontal adduction
tends to be linked with abduction of the scapula
(serratus anterior and pectoralis minor).
Horizontal abduction refers to the opposite
movement of bringing the horizontally placed arms
back away from the front of the body while keeping
them at shoulder height, similar to the movement
of bringing the arms from middle fifth to second
position or accompanying some spinal hyperexten-
sion movements commonly used in African dance or
jazz dance. When the torso is upright, the horizontal
abductors—including the infraspinatus, teres minor,
middle deltoid, and posterior deltoid—can produce
this movement, while the shoulder abductors are
again used to maintain the arms at shoulder height. If
you wanted to strengthen these muscles with weights,
FIGURE 7.31 Sample dance movement showing shoulder inter- lying prone on a bench would allow a more effective
nal rotation. position for gravity to resist horizontal abduction
Photo courtesy of Keith Ian Polakoff. CSULB dancer Holly Clark. (e.g., prone fly or row with elbows out). Shoulder
DANCE CUES 7.2
“Hold Your Shoulder Blades Down”
T he directive to “hold your shoulder blades down” is sometimes used by teachers in response to a
student who excessively lifts the shoulders as the arms are raised overhead. As just discussed, one
desired anatomical interpretation of this cue is to emphasize using the scapular depressors (particularly
the lower trapezius and serratus anterior) to neutralize the undesired elevation (particularly of the
upper trapezius). However, this cue is sometimes misinterpreted to mean that the scapulae should be
fixed in place and not allowed to move. To fix the scapulae is counter to the normal scapulohumeral
rhythm and the desired upward rotation of the scapulae that accompanies overhead movements of
the arms to the front or side. Focusing on the bottom of the shoulder blade (inferior angle) initially
pulling slightly down and then out (scapular abduction)—well below the armpit—as the arms are
raised can sometimes facilitate desired recruitment of the serratus anterior. Alternatively, thinking of
the arms initially reaching slightly down and then out as they approach second position can sometimes
help counter the habit of excessive scapular elevation.
horizontal abduction tends to be linked with adduc- of the shoulders, or in kinesiological terminology,
tion of the scapula (trapezius, rhomboids). excessive scapular elevation (figure 7.32A). In many
forms of dance the goal is to emphasize upward
rotation of the scapulae without visible scapular
Special Considerations elevation when the arms are raised from the sides
for the Shoulder Complex (figure 7.32B). Theoretically, this aesthetic can be
achieved by appropriate use of the serratus anterior
in Dance and lower trapezius—synergists that can assist with
upward rotation but also produce scapular depres-
In activities of daily living, many of the movements of sion to counter the elevation of the upper trapezius
the shoulder primarily function to position the hand. (see figure 7.25, p. 402). However, many dancers
However, in dance, shoulder movements have aes- have difficulty achieving this, and the tendency for
thetic and gestural importance as well as functional excessive elevation can be countered by strengthen-
importance. Different dance forms often utilize ing the lower trapezius and serratus anterior (see
prescribed placement or carriage of the arms that table 7.10C, p. 435) and by focusing on using more
can vary markedly between and within dance forms scapular depression. Cues such as (1) focusing on
such as ballet, modern, jazz, and ethnic dance. This reaching the arms down and then out before raising
use of the arms is often subtle and may take years them overhead, or (2) imagining that the scapulae
of concentrated training to master. Although the have weights such that the medial border pulls down
detailed use of the arms is beyond the scope of this as the acromion process rotates up can sometimes
book, a few general principles that apply to many help recruit the appropriate scapular depressors
dance forms are helpful to look at from a kinesio- while still allowing the necessary upward rotation
logical perspective. These include avoiding excessive of the scapulae.
lifting of the shoulders, keeping the scapula wide, In certain movements, such as some floor work,
and connecting the arms to the torso. In addition, dancers can avoid excessive elevation of the shoul-
special demands are placed on the shoulder complex ders by contracting muscles that tend to depress
with partnering and use of positions in which the the humerus in addition to using the muscles just
body weight is supported by the arms. discussed that depress the scapula. The latissimus
dorsi and lower portion of the pectoralis major can
Lifting the Shoulders function to help depress the humerus when the
arms are down by the sides. You can feel this action
One of the most common technique errors related to of humeral and scapular depression when pressing
use of the arms in dance is excessive lifting or hiking down on the arms of a chair to come to standing if
DANCE CUES 7.3
“Connect Your Arms to Your Back”
L ooking at the possible actions of the anterior deltoid, middle deltoid, and posterior deltoid (refer
to figures 7.14-7.16 [pp. 387, 389, and 390] and table 7.2 [pp. 391-392]), one can see that all of
the fundamental shoulder movements can be accomplished with these muscles alone. However, in
dance there is the desire to use some of the larger muscles of the shoulder that connect the arms to
the trunk rather than just the shoulder girdle. For example, the latissimus dorsi has extensive attach-
ments, including onto the spine, pelvis, and lower ribs. When holding the arms in second position,
dancers are sometimes directed to think of lightly pressing the arms down, even though the arms are
remaining stationary in space. When following this directive, the latissimus dorsi and pectoralis major
can often be seen or felt contracting—acting isometrically as shoulder adductors—while the shoulder
abductors contract to maintain the arms at shoulder height. Such co-contraction can provide a differ-
ent look and kinesthetic sensation of a greater “connection of the arms to the trunk” through use of
muscles with more extensive attachments onto the trunk than that of the deltoid muscle.
A B
FIGURE 7.32 Elevation of the shoulders with overhead arm movements. (A) Excessive scapular elevation and
(B) desired scapular upward rotation without elevation.
you focus on first pulling the scapula and humerus

downward toward the chair (figure 7.33).
Wide Scapulae
Another common technique error in dance relates
to positioning of the arms relative to the body. This
problem is easiest to picture when the arms are being
held out at shoulder height to the side (second posi-
tion). If the arms are held too far back (excessive
shoulder horizontal abduction), the scapulae are
generally excessively “pinched together” (excessive
scapular adduction) as seen in figure 7.34B. Con-
versely, if the arms are held too far forward (excessive
shoulder horizontal adduction), the scapulae are
generally excessively separated (excessive scapular
abduction) as seen in figure 7.34C. Although differ-
ent dance forms vary on the exact desired aesthetic,
many utilize a position in which the scapulae are
“wide” versus pinched but still lying flat along the
back of the rib cage versus coming to the front of
the body, as seen in figure 7.34A. This is basically a
“neutral” position of the scapulae.
Thinking of keeping the elbows and scapulae
FIGURE 7.33 Use of depressors of the scapula and humerus when pulling slightly to the side can sometimes help you
supporting the body weight with the arms. find this position of the scapulae. This positioning
Photo courtesy of Betsey Toombs. Dancer: Wade Madsen. is often accompanied by a sensation of slight co-
contraction of the lower trapezius and serratus ante-

rior. When the scapulae are in this position, the arms
will be slightly in front of the coronal plane—that is,
in the plane of the scapula (scaption). For dancers
having difficulty finding this position, strengthen-
ing as well as utilizing cues to encourage use of the
muscles that would correct the deviation can help
(figure 7.34). For example, if the scapulae are exces-
sively adducted, strengthening and developing better
awareness of the scapular abductors (table 7.10K,
p. 440) are recommended.
Connection of the Arms to the Torso

This positioning of the arms can also influence the
A positioning of the torso and vice versa. For exam-
ple, when the arms are habitually held too far back,
this is frequently accompanied by excessive arching
of the low back (lumbar lordosis) and rib-leading,
as well as excessive scapular adduction (figure
7.34B). Conversely, when the arms are habitually
held too far forward, this is often accompanied by
a rounding of the upper back (kyphosis) and “clos-
ing in” of the chest, as well as excessive scapular
abduction (figure 7.34C). Instead, the goal is to
be able to utilize a neutral positioning of the arms
in which the torso is neutral and stabilized rather
than distorted by arm placement. Then, the arms
can be utilized to enhance the movement (allow-
ing for more revolutions in turns, for example)
rather than throwing the body off center. From
B
this neutral position, the arms can also then be
consciously utilized in “non-neutral” ways to meet
a given choreographic goal; but it is important
for dancers to know where their neutral position
is, as well as how to make other choices without
throwing off their balance.
Learning to use the arms in a manner that does
not distort torso or shoulder alignment is a complex
matter that incorporates many factors, including
learning adequate torso stabilization, utilizing bal-
anced synergies, and using muscles appropriately
that connect the arms to the torso. In terms of this
latter factor, focusing on using some of the larger
muscles that connect the arms to the torso, such as
the pectoralis major and latissimus dorsi, can some-
times help achieve more of a sense of connection
C of the arms to the torso and “center.” As previously
described, the pectoralis major and latissimus dorsi
can be used to depress the humerus. Hence, focusing
FIGURE 7.34 Arm placement will vary with the aesthetics on reaching the arm down toward the floor before
of a given dance form but is generally close to (A) a neutral raising it forward or back can sometimes help you
position of the scapulae and torso without (B) excessive find these muscles. Since these muscles are located
scapular adduction and spinal hyperextension or (C) exces-
lower than some of the other prime movers such as
sive scapular abduction and kyphosis.
the deltoids, you can sometimes feel these muscles
working more if you think about using the muscles upper extremity muscles to effectively support the
lower, by your armpit, rather than just on the upper weight of the body.
shoulder.
Partnering and Arm Support Other Joints

of the Upper Extremity
A lot of strength and proper mechanics are required
to lift another dancer, to execute the partnering cor- Distal to the shoulder joint are the elbow joint, joints
rectly and prevent injuries. In classical ballet schools, between the radius and ulna, wrist joint, and joints
young men who are in the middle of growth spurts between the various bones of the hand. As these
and not fully mature are often required to partner joints are discussed, consider the similarities and
young female dancers who may be almost as tall or differences in relation to the comparable joints of
taller than they are. In many dance forms such as the lower extremity.
modern and jazz, contemporary choreographers may
have women partner other women or men who may Elbow Joint Structure and Movements
weigh more than they do. Many contemporary chore-
ographers are also utilizing positions and movements The elbow joint is composed of two different
requiring that the body weight be supported by the articulations (figure 7.36). More specifically, the
arms as in handstands, cartwheels, or back flips. distal end of the humerus widens and forms bony
The type of strength needed for such movements prominences—the medial epicondyle and lateral
far exceeds that needed in a traditional dance class, epicondyle. Between these epicondyles are a medial
and it is highly recommended that dancers perform articular surface called the trochlea and a lateral
supplemental upper extremity strengthening exer- articular surface called the capitulum (little head).
cises, particularly for the shoulder flexors, extensors, The spool-shaped trochlea of the humerus articulates
and abductors (see table 7.10, p. 434). From an with a concave area on the proximal ulna called
injury prevention perspective, it is also important the trochlear notch (semilunar notch) to form the
to include exercises for the rotator cuff and muscles humeroulnar joint, while the spherical capitulum
of scapular stabilization. The importance of these of the humerus articulates with the flattened proxi-
smaller muscles can be seen in figure 7.35; here mal end of the radius, called the head, to form the
the scapular muscles must be used to establish the humeroradial joint.
scapulae as a stable platform in order for the other Due to ligamental binding of the radius to the
ulna, the humeroulnar and humeroradial joints
function together, and the elbow joint as a whole is
considered a hinge joint. Its axis runs through the
middle of the trochlea and capitulum, allowing only
the movements of flexion and extension (figure
7.37A). The trochlear notch of the ulna terminates
inferiorly and anteriorly with a small prominence
called the coronoid process, and superiorly and
posteriorly with a prominent process called
the olecranon process. When the elbow is fully
flexed, the head of the radius and the coronoid
process fit into small indentations on the ante-
rior humerus (radial fossa and coronoid fossa),
while the olecranon process can be palpated as
the “point” of the elbow. The olecranon process
comes in contact with the table or floor when you
lean on your elbows with the elbows bent and the
forearms approximately vertical. Sometimes when
you bump your elbow you get an odd tingling
sensation running down to your little finger; this
FIGURE 7.35 Sample dance movement with body weight sup- sensation is due to pressure on the ulnar nerve,
ported by arms, requiring high levels of upper extremity strength which runs in the groove between the olecranon
and scapular stabilization. process and the medial epicondyle. When the elbow
FIGURE 7.36 Bones and bony landmarks of the right elbow joint. (A) Anterior view, (B) posterior view.
goes into full extension, the olecranon process moves these deviations can help with achievement of the
into a large indentation on the back of the lower desired dance aesthetic.
humerus (olecranon fossa).
The bony configuration of the elbow joint makes Carrying Angle
it more stable than the shoulder. In addition, the
The trochlea extends more distally than the capitu-
paired articulations of the elbow joint are encased
lum. Hence in anatomical position with the elbow
in a joint capsule that is thickened by various liga-
extended and forearm supinated, the forearm deviates
ments, including medial (or ulnar) and lateral (or
slightly laterally relative to the humerus. This angula-
radial) collateral ligaments, to add greater joint
tion is termed the carrying angle, or cubital angle, of
stability (figure 7.38). The ulnar collateral ligament
the elbow (figure 7.39). Some have hypothesized that
is particularly key for stabilizing the elbow joint, and
this angle functions to keep the hands from hitting
its medial location allows it to resist valgus stress
the hips when a person is carrying something with
associated with lifting heavy objects or the support
the elbows by the sides, hence its name. The carrying
of body weight. Many muscles of the elbow and the
angle varies markedly between individuals and tends
extrinsic muscles of the hand that cross the elbow
to be greater in females versus males, and greater
joint have lines of pull that also provide consider-
in adults versus children (Goldman and McCann,
able joint stability, in addition to joint movement
1997). Normal values are considered to be 10° to 25°
(Kreighbaum and Barthels, 1996).
for females and 5° to 15° for males when the elbow is
extended in anatomical position (Frankel and Nordin,
Alignment of the Elbow 1980; Magee, 1997). An increase in this angle above
normal due to greater lateral deviation of the forearm
As with the knee, the elbow can be hyperextended is termed cubitus valgus, while a decrease in this angle
and can vary in its angulation. An understanding of below norms is called cubitus varus.
FIGURE 7.38 Medial view of the elbow showing cap-

sule and medial ligaments (right elbow).
FIGURE 7.37 Movements of the (A) elbow joint (flexion-

extension) and (B) radioulnar joints (pronation-supination).
Due to the asymmetrical shape of the trochlea

and the fact that the axis of the elbow joint angles
slightly downward as it runs medially, the carrying
angle decreases or even reverses when the elbow is
flexed from anatomical position. One study showed
a change from an average of 10° of valgus (lateral
angulation of forearm relative to longitudinal axis
of humerus) with the elbow fully extended to 8°
of varus (medial angulation of forearm relative to
longitudinal axis of humerus) with the elbow in full
flexion. This is important to keep in mind when
doing elbow flexion or extension strengthening
exercises, and for most dancers, one should allow
the forearm to deviate laterally versus trying to force
the forearm to stay in line with the humerus when
the elbow extends.
Elbow Hyperextension
While elbow flexion is often limited by contact of
the soft tissues of the arm and forearm, extension
can be limited by tightness of opposing ligaments
or muscles, or by contact of the olecranon process FIGURE 7.39 Carrying angle (right arm, anterior view).
of the ulna with the humerus. However, the point at
which the elbow stops when it extends is quite variable
between individuals; and many dancers, particularly from each other in a longitudinal direction as seen
female dancers, have the ability to extend the arm in figure 7.45, A and B.
well beyond straight, that is, to hyperextend the elbow The distal radioulnar joint is a pivot joint formed
(figure 7.40). Whether due to ligamental laxity or a between the head of the ulna and a concave surface
short olecranon process, dancers with marked elbow of the radius (ulnar notch). Note that while the
hyperextension often have to utilize muscular contrac- radius is the smaller bone proximally and terminates
tion of the elbow flexors in isolation or in coordina- in a “head,” the ulna is the smaller bone distally and
tion with the elbow extensors to avoid this undesired terminates in a “head.” This distal radioulnar joint
aesthetic, particularly in movements requiring arm allows that radius (with wrist and hand) to pivot
support. As with knee hyperextension, it often takes a around the head of the ulna (figure 7.45B). A trian-
retraining of the kinesthetic sense with use of outside gular articular disc connects the radius and ulna and
feedback, such as looking in the mirror, to relearn provides stability to the distal radioulnar joint.
the position of straight versus hyperextended. Together, the radioulnar joints allow the radius
to rotate relative to the ulna so that the palm is
facing downward with the thumb positioned medi-
Description and Functions ally, termed pronation, or the palm is facing upward
of Selected Individual with the thumb positioned laterally, termed supina-
tion (figure 7.45C). The axis of this motion can be
Muscles of the Elbow pictured as running between the head of the radius
proximally and the head of the ulna distally (figure
The muscles of the elbow are arranged so that those
7.45A). This motion is more complex than pure rota-
that cross anteriorly are in a position to cause elbow
tion about one bone, in that in a position of supination
flexion and those that cross posteriorly are in a posi-
(e.g., anatomical position) the radius and ulna lie
tion to cause elbow extension. This arrangement is
parallel to one another with the radius located lateral
similar to that at the shoulder or hip, but opposite
to the ulna. However, with pronation, although the
to that at the knee. (See Individual Muscles of the
proximal radius remains on the same side of the ulna
Elbow, pp. 416-422.)
as with supination, the distal radius crosses over to
the medial side of the ulna. (See Individual Muscles
Structure and Movements of the Radioulnar Joints, pp. 423-424.)
of the Radioulnar Joints
The radius and ulna are connected via two synovial
joints—the proximal radioulnar joint and the distal
radioulnar joint (figure 7.45). They are also connected
via a ligamentous sheet (middle radioulnar joint).
The proximal radioulnar joint is a uniaxial, pivot
joint lying within the capsule of the elbow joint. It is
formed by the articulation between the side of the
head of the radius and a notch on the ulna (radial
notch) as seen in figure 7.45A. A strong ligament, the
annular ligament, forms a three-quarters ring around
the head of the radius, keeping it close to the ulna
so that the desired rotation can occur without other
undesired motions. You can feel the head of the radius
moving under the skin by placing a finger about an
inch below the lateral epicondyle of the right humerus
and then slowly and repetitively bringing the palm
of the right hand to face downward (forearm prona-
tion) and then upward (supination).
The middle radioulnar joint is not a synovial
joint, but rather a fibrous joint involving connec-
tion via a ligamentous sheet called the interosseous
membrane. This joint functions to keep the radius
and ulna from excessively separating or sliding apart FIGURE 7.40 Elbow hyperextension.
Individual Muscles of the Elbow

Anterior Elbow Muscles
Three important anterior muscles that flex the elbow are the biceps brachii, brachialis, and brachio-
radialis. Some of the muscles of the forearm, wrist, and hand can also aid with elbow flexion but for
purposes of simplicity will not be discussed here. Elbow flexion is important for lifting motions, move-
ment involving bringing the hands toward the upper body, and gestural movements.
Attachments and Primary Actions of Biceps Brachii

Biceps brachii Long head: just above Tuberosity of radius via Elbow flexion
(BY-seps BRA-kee-eye) glenoid cavity of scapula a common tendon Radioulnar supination
Short head: coracoid (Shoulder flexion—long head)
process of scapula (Shoulder abduction when shoulder
in external rotation—long head)
(Shoulder adduction—long head)
Biceps Brachii
As its name implies, the biceps brachii (biceps, two
heads + brachium, arm) has two heads. It is located
superficially in the front portion of the upper arm (figure
7.41). The long head originates above the glenoid cavity
on the scapula, and its tendon passes over the top of the
humerus and then runs within the intertubercular groove
of the humerus. Due to this location, the long head of
the biceps brachii can depress the head of the humerus
to help prevent impingement when forceful contraction of
the biceps brachii is required such as in resisted elbow
flexion (Schmitz and Ciullo, 1999; Smith, Weiss, and
Lehmkuhl, 1996). The short head arises from the coracoid
process of the scapula. In the proximal part of the upper
arm these muscles exist as separate bellies, but about
midway down the humerus they join to become one belly
and attach to a tuberosity on the medial side of the radius
(radial tuberosity) via a common tendon.
The biceps brachii is an important flexor of the elbow.
With its attachment onto the tuberosity of the radius,
when the forearm is pronated the biceps tendon will be
twisted about halfway around the radius, and contraction
of the biceps will produce supination of the forearm as
well as elbow flexion. However, perhaps due to this wrap-
ping around the radius, the biceps brachii makes only a
minimal contribution to elbow flexion when the forearm is
pronated (Hamill and Knutzen, 1995). Hence, performing a
pull-up with the palms facing away from the body (forearm
pronation) is more difficult than performing a pull-up with FIGURE 7.41 Biceps brachii and supinator (right arm,
anterior view).
the palms facing the body, and the force generated by
the elbow flexors in a maximal voluntary contraction has
been shown to be least with the forearm pronated and most with the forearm supinated (Hamilton and
Luttgens, 2002). At the shoulder, the biceps brachii can assist with shoulder flexion (and abduction
when the shoulder is externally rotated with the elbow straight). Hence, performing elbow flexion with
the shoulder in a position of flexion, such as in partnering or the kneeling biceps lift (table 7.10M,
p. 442), will increase the difficulty for the biceps brachii, without influencing the difficulty for elbow
flexors that do not cross the shoulder such as the brachialis. In addition, the biceps brachii can assist
other muscles with adduction of the shoulder.
Palpation: The biceps brachii can be easily seen and palpated on the front of the upper arm. Sit with
the fingers of the left hand on the front of your right upper arm, with the right elbow bent and the right
palm under the top of a desk. You can feel the biceps brachii contracting when you press your right
palm up against the desk as if to bend the elbow (isometric elbow flexion). Move your fingers distally
on the biceps, and you will find its tendon standing out prominently at the fold of the elbow. Note that
the biceps brachii attaches proximally on the scapula and attaches distally below the elbow, and has no
actual attachment onto the humerus. Thus, when you relax this muscle, it can more readily be moved
from side to side than the underlying brachialis, which has extensive attachments onto the humerus.
Attachments and Primary Actions of Brachialis

Brachialis Anterior aspect of lower half of humerus Upper ulna Elbow flexion
(BRA-kee-al-is)
Brachialis
The brachialis (brachium, arm) is located on the
front of the arm beneath the biceps brachii (figure
7.42). It arises proximally from the anterior por-
tion of the lower half of the humerus and attaches
distally to the upper ulna. Due to its attachment on
the ulna, the brachialis does not produce supination
or pronation of the forearm and is not influenced
by the position of the forearm. The brachialis is
sometimes termed the “workhorse of the elbow”
because it appears to work in almost all conditions
of elbow flexion, regardless of speed, resistance, or
forearm position.
Palpation: Sit with the fingers of the left hand on
the front of your right arm (about 1 inch [2.5 centi-
meters] above the crease of the elbow and to the
sides of the biceps brachii) while the right elbow is
bent and the forearm pronated such that the right
dorsum of the hand is under the top of a desk. You
can feel the brachialis contracting just medial and
lateral to the biceps when you press your right hand
up against the desk as if to further bend the elbow
(isometric elbow flexion).
FIGURE 7.42 Brachialis and coracobrachialis (right

arm, deep anterior view).
Attachments and Primary Actions of Brachioradialis

Brachioradialis Above lateral epicondyle of Lateral aspect of styloid Elbow flexion
(bra-kee-o-ra-dee-A-lis) humerus process of radius Radioulnar supination from
pronation or vice versa to
achieve midposition
Brachioradialis
As its name implies, the brachioradialis (brachium, arm +
radi, radius) runs between the upper arm and the radius.
This muscle arises above the lateral epicondyle of the
humerus and runs down to attach distally to the lower
radius just above the styloid process (figures 7.43 and
7.47, p. 425). It is the muscle that gives the rounded
contour to the lateral forearm. When this muscle con-
tracts it flexes the elbow. Due to its location, this muscle
has been theorized to bring the forearm to a midposition
(neutral position) from a position of either pronation or
supination.
Palpation: Sit with the fingers of the left hand on the
anterolateral aspect of the right forearm just distal to the
crease of the elbow, with the right elbow bent and the right
hand in a fist; have the thumb side of the fist under the
top of a desk (forearm in a midposition between pronation
and supination). You can see and feel the brachioradialis
contracting when you press your right fist up against the
desk. Move your fingers distally on the brachioradialis to
the distal radius to follow its course.
Posterior Elbow Muscles
The posterior elbow muscles include the triceps brachii

and the anconeus. Because these muscles attach distally
to the ulna rather than the radius, their contribution is not FIGURE 7.43 Brachioradialis, pronator teres, and pro-
influenced by the position of the forearm. Other extensors nator quadratus (right arm, anterior view).
of the wrist and fingers that cross the elbow joint posteri-
orly can also contribute to elbow extension but have been
omitted for purposes of simplicity.
Attachments and Primary Actions of Triceps Brachii

Triceps brachii Long head: just below Olecranon process of Elbow extension
(TRY-seps BRA-kee-eye) glenoid cavity of scapula ulna via a common (Shoulder extension—long head)
Lateral head: upper half of tendon (Shoulder adduction—long head)
posterolateral humerus
Medial head: lower two-
thirds of posterior humerus
Triceps Brachii
The triceps brachii (triceps, three heads + brachi, arm) is located superficially and makes up the muscle
mass of the back of the arm (figure 7.44A). As its name suggests, this muscle contains three heads—the
long, medial, and lateral heads. The long head arises proximally from just below the glenoid cavity of
the scapula. The lateral head arises proximally from the posterolateral upper half of the humerus. The
medial head originates from approximately the lower two-thirds of the posterior humerus. All three heads
join and then attach distally via a strong flat tendon to the olecranon process of the ulna. The triceps
is a powerful extensor of the elbow that is not influenced by pronation or supination of the forearm.
However, the long head of the triceps brachii crosses the shoulder and so is influenced by the position
of the shoulder. Its actions at the shoulder are extension and adduction. So, for example, performing
elbow extension with the arm behind the body, as in triceps kick back (table 7.10E, p. 436), will put
the long head at a disadvantage (length–tension principle) and provide greater overload.
FIGURE 7.44 Triceps brachii, supinator, and anconeus (right arm, posterior view). (A) Superficial view, (B) deeper view.
Palpation: Sit in a chair with the fingers of the left hand placed midway on the posterior aspect of
the right arm and the right palm resting on the right edge of the seat of the chair. The triceps brachii
can be felt contracting under your fingers when the right hand presses down on the seat of the chair
to lift the body (elbow extension).
Attachments and Primary Actions of Anconeus

Anconeus Posterior aspect of lateral Lateral aspect of olecranon Assists with elbow extension
(an-KO-nee-us) epicondyle of humerus process of ulna
Upper posterior ulna
Anconeus
The anconeus (ancon, elbow) is a small muscle located just distal to the triceps brachii (figure 7.44B).
It runs downward and medially from its proximal attachment on the lateral epicondyle of the humerus
to its distal attachment on the posterior upper ulna. Its actions are to stabilize the elbow (Basmajian
and DeLuca, 1985) and assist with elbow extension.
Palpation: Using the same movement as just described for palpation of the triceps brachii, you can
feel the anconeus contracting when placing the fingertips of your left hand just lateral to the olecranon
process of the ulna when the right hand presses down on the seat of the chair.
Summary of Elbow Muscle

Attachments, Actions, and Roles in Movement
The muscles that cross the elbow joint serve to stabilize the joint as well as produce flexion and exten-
sion. A summary of attachments and actions of key muscles of the elbow are included in table 7.6,
while the movements of the elbow and the muscles that can produce them are included in table 7.7.
These tables also include key muscles and movements of the radioulnar joints, which will shortly be
described in more detail in the text.
TABLE 7.6 Summary of Attachments and Primary Actions of the Muscles of the Elbow and Radioulnar Joints

Biceps brachii Long head: just above Tuberosity of radius Elbow flexion
(BY-seps BRA-kee-eye) glenoid cavity of scapula via a common tendon Radioulnar supination
Short head: coracoid process (Shoulder flexion—long head)
of scapula (Shoulder abduction when shoulder in
external rotation—long head)
(Shoulder adduction—long head)
Brachialis Anterior aspect of lower half Upper ulna Elbow flexion
(BRA-kee-al-is) of humerus
Brachioradialis Above lateral epicondyle Lateral aspect Elbow flexion

(bra-kee-o-ra-dee-A-lis) of humerus of styloid process Radioulnar supination from pronation
of radius or vice versa to achieve midposition
Triceps brachii Long head: just below Olecranon process Elbow extension
(TRY-seps BRA-kee-eye) glenoid cavity of scapula of ulna via a common (Shoulder extension—long head)
Lateral head: upper half tendon (Shoulder adduction—long head)
of posterolateral humerus
Medial head: lower two-thirds
of posterior humerus
Anconeus Posterior aspect of lateral Lateral aspect Assists with elbow extension
(an-KO-nee-us) epicondyle of humerus of olecranon process
of ulna
Upper posterior ulna
Pronator teres Medial epicondyle Lateral aspect of Radioulnar pronation
(PRO-na-tor TE-reez) of humerus middle third of radius (Assists with elbow flexion)
Coronoid process of ulna
Pronator quadratus Anterior aspect of lower Anterior aspect Radioulnar pronation
(PRO-na-tor kwod-RA-tus) quarter of ulna of lower quarter
of radius
Supinator Lateral epicondyle Anterolateral aspect Radioulnar supination
(soo-pi-NA-tor) of humerus of upper radius
Lateral aspect of upper ulna
TABLE 7.7 Movements of the Elbow and Radioulnar Joints and Key Muscles
That Can Produce Them
Joint movement Primary muscle(s) Secondary muscle(s)

Elbow flexion Biceps brachii Pronator teres
Brachialis
Brachioradialis
Elbow extension Triceps brachii Anconeus
Radioulnar pronation Pronator quadratus Pronator teres
Brachioradialis (to midposition)
Radioulnar supination Supinator Brachioradialis (to midposition)
Biceps brachii
Looking at the role of these muscles in movement on the simplest level, if the movement is performed
slowly and without a stylized quality, the following generalizations are germane. The elbow flexors—includ-
ing the brachialis and biceps brachii—are most commonly used concentrically (in an open kinematic
chain) to bring the forearm toward the upper arm against gravity such as when lifting something from
the ground (e.g., a partner) or against other external resistance such as a dumbbell (concentration
curl, table 7.10L, p. 441) or springs (kneeling biceps lift, table 7.10M, p. 442). The same elbow flexors
would then be used eccentrically to control the lowering of the forearm (elbow extension). However, when
the arm is fixed (closed kinematic chain), the elbow flexors can be used with the shoulder muscles to
help bring the torso closer to the arms in pulling motions, such as in a pull-up or in rope climbing. In
contrast, the elbow extensors—primarily the triceps brachii—can be used to straighten the elbow in
open kinematic chain movements such as in the tennis serve or in an overarm throw. Strengthening
exercises often incorporate elbow extension against external resistance, such as dumbbells (overhead
triceps extension, table 7.10N, p. 443) or a spring (kneeling triceps kick back, table 7.10O, p. 444).
When the hand is fixed, the elbow extensors are commonly used concentrically in closed kinematic
chain pushing movements such as a push-up (table 7.10A, p. 434) or raising the torso from a chair
(press-up, table 7.10C, p. 435) or the floor in dance. In dance, the elbow flexors and extensors are
also commonly used gesturally to shape the arms in accordance with choreographic intent.
Change in Relative Positioning

of the Distal Radius and Ulna With Pronation
Use the following exercise to demonstrate the influence of pronation and supination on the relative
positioning of the radius and ulna.
Palpate the ulna with the fingertips of your left hand by following the border of this bone on your
right arm from the olecranon down to the small projection at the wrist (styloid process). Keep the
elbow bent to 90° and by your side. Then, pronate the forearm while keeping the fingertips on the
styloid process, and note how the radius is now medial to the ulna, distally.
A B C
FIGURE 7.45 The radioulnar joints (right forearm). (A) Position of supination, (B) position of pronation, (C) change in
hand position with supination and pronation.
Combining Shoulder Rotation With Forearm Movements

to Facilitate Positioning of the Hand
Use the following exercise to demonstrate how combining shoulder rotation with forearm pronation
and supination can allow more range of motion for the hand.
Hold one arm out in second position with the palm facing up. Then, leading with the thumb, pronate
the forearm and internally rotate the shoulder, and note where the thumb is facing in the end posi-
tion. Next, just pronate the forearm without letting the shoulder internally rotate. Lastly, just internally
rotate the shoulder without allowing any movement in the forearm. Compare the range of motion as
evidenced by the facing of the thumb at the end position for each of these three conditions.
422
Individual Muscles of the Radioulnar Joints

Selected Muscles of the Radioulnar Joints
The two muscles that are the most important pronators of the forearm are the pronator teres and pro-
nator quadratus. Two muscles that are particularly important supinators of the forearm are the biceps
brachii and the supinator. The biceps brachii has already been described within the context of elbow
flexion, and a description of the other muscles follows.
Attachments and Primary Actions of Pronator Teres and Pronator Quadratus

Pronator teres Medial epicondyle of Lateral aspect of middle Radioulnar pronation
(PRO-na-tor TE-reez) humerus third of radius (Assists with elbow flexion)
Coronoid process of ulna
Pronator quadratus Anterior aspect of lower Anterior aspect of lower Radioulnar pronation
(PRO-na-tor kwod-RA-tus) quarter of ulna quarter of radius
Pronator Teres
The pronator teres (pronation, turning palm posteriorly, or down + teres, round) is a small muscle
located anteriorly in the area of the elbow, partly covered by the brachioradialis (figure 7.43, p. 418).
It runs laterally and obliquely from its proximal attachments on the medial epicondyle of the humerus
and upper anterior ulna to its distal attachment on the lateral middle portion of the radius. As its name
suggests, the primary action of this muscle is pronation of the forearm, which it accomplishes by pulling
the radius over in front of the ulna. It can also assist with elbow flexion against resistance (Hamilton
and Luttgens, 2002).
Palpation: Sit with the fingers of the left hand placed on the anterior portion of the forearm, just
lateral to the distal biceps brachii tendon and just below the crease of the right elbow while the elbow
is flexed and the forearm is resting on your right thigh. You can feel the pronator teres contracting under
your fingers when the forearm is pronated.
Pronator Quadratus
The pronator quadratus (pronation, turning palm posteriorly, or down + quad, square, four-sided) is
located distally on the front of the forearm slightly proximal to the wrist (figure 7.43, p. 418). It is a thin,
square-shaped muscle that runs transversely between the ulna and radius, deeply right next to these
bones. As its name indicates, its action is to pronate the forearm, which it accomplishes by pulling the
lower end of the radius over and across the ulna. Electromyographic studies suggest that the pronator
quadratus is the major muscle responsible for pronation, with the pronator teres assisting, particularly
when the pronation is resisted or rapid (Hall, 1999; Hamilton and Luttgens, 2002).
Palpation: Due to its deep location, the pronator quadratus is difficult to palpate.
Attachments and Primary Actions of Supinator

Supinator Lateral epicondyle of humerus Anterolateral aspect of upper Radioulnar supination
(soo-pi-NA-tor) Lateral aspect of upper ulna radius
Supinator
The supinator (supination, turning palm anteriorly or upward) is a small, triangular-shaped muscle located
deeply and posteriorly (figure 7.44, p. 419). It runs inferiorly and laterally from its proximal attachment
posterolaterally on the lower humerus and upper ulna to wrap around the radius and attach to the
anterolateral aspect of the upper radius (figure 7.41, p. 416). A way of picturing this action more clearly
is to consider a position of pronation in which the radius would be moving forward and in front of the
ulna. The supinator is in an appropriate position to pull the radius back (supination) toward anatomi-
cal position, in which the radius and ulna are approximately parallel. The supinator appears to actively
produce supination of the forearm under all conditions (Hamilton and Luttgens, 2002).
Palpation: Sit with the fingertips of the left hand about 1 inch (2.5 centimeters) distal to the lateral
epicondyle of the humerus while the right elbow is bent and resting against your waist. You can feel the
supinator contracting under your fingertips when the forearm is slowly supinated.
Summary of Attachments, Actions,

and Movement Roles of the Muscles of the Radioulnar Joints
A summary of the attachments and actions of the primary muscles that act to produce forearm prona-
tion and supination was included in table 7.6. As with elbow flexion and extension, some of the other
muscles whose primary action is at the wrist or hand can also assist with pronation and supination,
but for purposes of simplicity they are not included in table 7.7.
In functional movement, the movements of pronation and supination are often used to appropri-
ately position or assist with the action of the hand. For example, concentric contraction of the prona-
tors—including the pronator quadratus and teres—is used in movements such as turning a screw
counterclockwise (to loosen it) and dribbling a basketball. In dance, the pronators would be used in arm
movements that involve facing the palm backward as in jazz. In contrast, concentric contraction of the
supinators is used in tightening a screw, an underhand pitch, and a tennis backhand drive. In dance,
the supinators—including the supinator and biceps brachii—would work when the dancer raises the
arms from the sides with the palms facing upward.
In functional movement, the movements of the forearm are also often linked with motions at the
shoulder joint. So, when the elbow is straight, forearm supination is often accompanied by external
rotation of the shoulder, while forearm pronation is often linked with internal rotation of the shoulder.
This combination allows a greater range of motion for the hand and more forceful movements such as
used in turning a doorknob. In dance movements, these movements can also be combined to enhance
range or provide a desired aesthetic, as in modern or jazz dance when the front arm is externally rotated
with the palm facing up and the back arm is internally rotated with the palm facing back.
Note that this is a different arrangement than occurs in the lower leg, where the tibia and fibula are
firmly connected and almost no motion is allowed between them. In the lower extremity, changing the
facing of the foot occurs more distally within the bones of the feet rather than at the more proximal
site of the forearm in the upper extremity.
Structure and Movements numbers and sequence of these bones, the tarsals
of the Wrist and Hand and metatarsals of the foot are much larger than the
corresponding carpals and metacarpals in the hand
The hand is a highly specialized structure that con- (to better serve their weight-bearing function), while
tains 27 bones and over 20 joints, and the wrist-hand in the hand the phalanges are larger than the pha-
complex involves the use of 25 key muscles. There langes in the foot (to better meet their manipulation
are many parallels between the foot and hand, but function). The distal row of carpals articulates with
one key distinction is that while the foot is designed the proximal end, or base, of the metacarpals. The
primarily for strength to support the body weight, shaft of the metacarpal is termed the body; and the
the hand is designed for manipulation. distal rounded head of the metacarpal articulates
The bones of the hand include eight carpals anteriorly with its respective phalanges. The heads of
(which are arranged in two rows of four), five meta- the metacarpals can easily be palpated at the knuck-
carpals (numbered from 1 through 5 starting from les of the hand while the phalanges make up the
the thumb), and 14 phalanges as seen in figure 7.46. digits of the fingers. The fingers are numbered like
However, while there is a parallel with respect to the the corresponding metacarpals, with 1 correspond-
ing to the thumb. They are also often designated as

thumb, index finger, middle finger, ring finger, and
little finger. The phalanges are termed the proximal,
middle, and distal phalanges for fingers 2 through
5. The thumb is also termed the pollex, and like the
hallux, it contains only two phalanges, the proximal
and distal phalanges.
The hand is joined to the forearm at the wrist
or radiocarpal joint. More specifically, the inferior
concave surface of the radius and the adjacent tri-
angular fibrocartilaginous disc articulate with the
convex articular surface formed by the proximal row
of carpals (scaphoid, lunate, and triquetrum bones)
as shown in figure 7.47. Note that due to the presence
of the fibrocartilage disc, the ulna does not directly
participate in the wrist joint. However, this disc adds
important stability to the wrist by binding the radius
and ulna together distally (Magee, 1997). It also
helps distribute the load between the radius and
ulna. It has been estimated that the radius bears 60%
of the load and the ulna 40% with the disc in place,
in contrast to 95% for the radius and 5% for the ulna
with the disc removed. The shape of the articular
surfaces makes the wrist a biaxial condyloid joint.
Hence, movements include flexion-extension and a
specially designated form of abduction-adduction.
Flexion refers to the motion of bringing the palm
of the hand toward the front of the forearm, while
FIGURE 7.46 Bones of the hand (right hand, anterior the reverse movement of bringing the palm away is
or palmar view). termed extension of the wrist as seen in figure 7.48.
Abduction of the wrist refers to bringing the hand
away from the midline such that the lateral surface
of the hand (thumb) comes closer to the lateral
Triangular
fibrocartilage disc
FIGURE 7.47 Radiocarpal and midcarpal joints (left hand, anterior or palmar view).
surface of the forearm. This motion is usually to a lateral movement of the thumb away from the
referred to with the specialized term radial deviation. index finger, while flexion is a return movement
The opposite motion of bringing the medial side of from extension; hyperflexion entails movement of
the hand (little finger) closer to the medial forearm the thumb across and parallel to the palm (i.e., in an
is termed adduction or ulnar deviation. almost frontal vs. sagittal plane). Abduction refers to
However, these movements at the radiocarpal movement of the thumb forward and away from the
joint or wrist joint do not occur in isolation but rather second finger in a plane perpendicular to the palm,
also incorporate the midcarpal joint. The term mid- while adduction would be the return movement to
carpal joint refers to the joint between the proximal anatomical position (i.e., in an approximate sagittal
and distal row of carpals. As with the foot, this “joint” vs. frontal plane). Given these movement descrip-
actually incorporates several joints, and in the hand tions, opposition can be seen as a combination of
these joints are gliding in nature. However, the slight abduction and hyperflexion.
gliding movements of the midcarpal joint contribute Moving further distally, the joint between the
additional range of motion and are automatically distal end of the first metacarpal bone and adjacent
linked to movements of the radiocarpal joint. proximal phalange, termed the metacarpopha-
Moving distally from the midcarpal joint, there are langeal joint, is a hinge joint allowing flexion and
many additional joints that are important for allowing extension. However, the metacarpophalangeal joints
the complex movements of the hand. As with the feet, for metacarpals 2 through 5 are biaxial condyloid
these joints are often named according to the bones joints—allowing flexion, extension, and slight abduc-
that compose the joints, making learning the names tion and adduction of the fingers. Flexion refers to
easier and logical. The joints between the carpals and bringing the anterior surface of the finger toward the
metacarpals 2 through 5 termed carpometacarpal palmar surface of the hand, while extension is the
joints are classified differently in different texts, reverse movement of bringing the anterior surface
but commonly as gliding joints (Hall, 1999; Magee, of the finger away to return to anatomical position
1997). These joints are linked by strong ligaments or slightly beyond (hyperextension) as seen in figure
such that almost no movement is allowed for joints 7.48. Abduction and adduction occur relative to the
2 and 3, slight flexion is allowed with 4, and more middle finger, and abduction refers to movement of
flexion with 5. This arrangement facilitates the abil- the second (index), fourth (ring), and fifth (little)
ity to cup the palm, which when combined with the fingers away from the third (middle) finger. The
motions of the first metacarpal facilitates the essen- reverse motion of bringing the fingers back toward
tial ability to grasp objects. the middle finger is termed adduction. The side-
In contrast to the other carpometacarpal joints, to-side movements of the third finger are termed
the first carpometacarpal joint is a biaxial saddle joint, radial and ulnar flexion rather than abduction
which allows for the specialized movement of opposi- and adduction. Comparable to the situation with
tion of the thumb to the fingers used to “grip” objects. the wrist, radial flexion refers to lateral movement
Opposition refers to the ability to bring the palmar tip of the third finger toward the radial side of the
of the thumb toward the palmar surface of the other forearm while ulnar flexion refers to medial move-
digits, and reposition is the reverse movement. This ment of the third finger toward the ulnar side of
specialized movement of opposition is facilitated not the forearm. Lastly, the joints between all adjacent
only by the presence of this saddle joint and the cup- phalanges, the interphalangeal joints, are uniaxial
ping of the palm but also by the orientation of the joint hinge joints—allowing flexion and extension of
relative to the other fingers. Unlike what occurs with the digits of the fingers and thumb. These move-
the large toe in the foot, the thumb is separated from ments of the fingers are comparable to those of the
the second finger more widely than the other fingers metacarpophalangeal joints, with flexion referring to
are separated from one another and is turned on its approximating anterior surfaces of the digits of the
axis so that it faces a plane perpendicular to that of fingers or bringing the anterior surface of the digits
the other fingers (Hamilton and Luttgens, 2002). In toward the palmar surface of the hand (or both).
addition to the specialized movement of opposition- Extension would involve the reverse movement. In
reposition, fundamental movements of the thumb general, movements toward the palm of the hand
include flexion-extension and abduction-adduction, (flexion) are of a larger range than movements
shown in figure 7.48. Note that due to the rotated toward the dorsum of the hand (extension).
orientation of the thumb, these movements of the Numerous strong ligaments interconnect the
thumb occur in a plane perpendicular to the plane bones and reinforce the capsules of the many joints
in which they classically occur. So, extension refers in the wrist-hand complex. Many muscles also act to
FIGURE 7.48 Movements of the (A) wrist, (B) fingers 2 through 5, and (C) thumb.
stabilize the joints and generate movements. As with at the wrist and hand. Many of these muscles pro-
the foot, there is a strong fascia that helps stabilize duce multiple actions, and an intricate coordination
the joints (palmar aponeurosis) and maintain the of muscles acting as prime movers, stabilizers, and
cupped shape of the palm of the hand. The shape synergists is often required to achieve the desired
and arrangement of the carpals and difference in movements of the wrist and hand. A brief overview of
mobility of the carpometacarpal joints make the palm these muscles follows. A summary of the attachments
slightly concave anteriorly, vital for protection of the and actions of the extrinsic muscles of the wrist and
nerves, tendons, and blood vessels that cross the hand hand is provided in table 7.8, while a summary of
anteriorly. There are also retinacula that help keep the fundamental movements of the wrist and hand, and
tendons in position. For example, the flexor retinacu- the extrinsic and intrinsic muscles that can produce
lum (composed of the palmar carpal and transverse them, is provided in table 7.9. Readers interested in
carpal ligaments) helps hold the flexor tendons close a more thorough presentation are referred to the
to the wrist and prevents them from coming away from anatomy texts listed in the References and Resources
the bones when the wrist is flexed. Synovial sheaths at the back of the book.
surround many of the tendons in this area to help
facilitate movement and diminish friction. Two small Primary Muscles of the Wrist
sesamoid bones are located on the palmar side of the There are six primary muscles that act on the wrist
metacarpophalangeal joint of the thumb, between joint—flexor carpi radialis, palmaris longus, flexor
which the long flexor of the thumb runs. carpi ulnaris, extensor carpi radialis longus, extensor
carpi radialis brevis, and extensor carpi ulnaris (fig-
Muscles of the Wrist and Hand ures 7.49 and 7.50). There are also extrinsic muscles
of the hands that cross the wrist joint and can assist
There are approximately 25 primary muscles (some with movements of the wrist as shown in table 7.8.
with multiple components) that perform functions As with the feet, many of the names of these muscles
FIGURE 7.49 Primary flexors of the wrist (right forearm, FIGURE 7.50 Primary extensors of the wrist (right fore-
anterior view). arm, posterior view).
TABLE 7.8 Summary of Attachments and Primary Actions of Extrinsic Muscles of the Wrist and Hand

Muscles of the wrist
Flexor carpi radialis Medial epicondyle of Base of 2nd and 3rd Wrist flexion
(FLEK-sor KAR-pee ra-dee-A-lis) humerus metacarpal Wrist radial deviation
Flexor carpi ulnaris Humeral head: medial Pisiform, hamate, and Wrist flexion
(FLEK-sor KAR-pee ul-NA-ris) epicondyle of humerus 5th metacarpal Wrist ulnar deviation
Ulnar head: olecranon
and posterior border of
ulna
Palmaris longus Medial epicondyle of Distal flexor retinaculum Wrist flexion
(pahl-MA-ris LON-gus) humerus and palmar aponeurosis
Extensor carpi radialis longus Lateral supracondylar Base of 2nd metacarpal Wrist extension
(ek-STEN-sor KAR-pee ra-dee-A-lis LON-gus) ridge of humerus Wrist radial deviation
Extensor carpi radialis brevis Lateral epicondyle of Base of 3rd metacarpal Wrist extension
(ek-STEN-sor KAR-pee ra-dee-A-lis BRE-vis) humerus Wrist radial deviation
Extensor carpi ulnaris Lateral epicondyle of Base of 5th metacarpal Wrist extension
(ek-STEN-sor KAR-pee ul-NA-ris) humerus and posterior Wrist ulnar deviation
ulna
428

Extrinsic muscles of fingers
Flexor digitorum profundus Proximal three-quarters Base of distal phalanges Flexion of fingers and hand
(FLEK-sor di-ji-TOR-um pro-FUN-dus) of anterior and medial of fingers 2 through 5 (MP and distal IP joints of
ulna fingers 2-5)
Assists with wrist flexion
Flexor digitorum superficialis Medial epicondyle of Middle phalanges of Flexion of fingers and hand
(FLEK-sor di-ji-TOR-um soo-per-fish-ee-A-lis) humerus and proximal fingers 2 through 5 (MP and proximal IP joints
anterior radius of fingers 2-5)
Assists with wrist flexion
Extensor digitorum Lateral epicondyle of Base of distal and middle Extension of fingers (MP,
(ek-STEN-sor di-ji-TOR-um) humerus phalanges of fingers 2 proximal IP, and distal IP
through 5 joints of fingers 2-5)
Assists with wrist extension
Extensor indicis Distal posterior ulna Extensor expansion of Extension of 2nd finger (MP,
(ek-STEN-sor IN-di-kis) 2nd finger proximal IP, and distal IP
joints of 2nd finger)
Extensor digiti minimi Lateral epicondyle of Extensor expansion of Extension of 5th finger (MP,
(ek-STEN-sor DI-ji-tie MI-ni-my) humerus 5th finger proximal IP, and distal IP
joints of 5th finger)
Extrinsic muscles of thumb (pollex)
Flexor pollicis longus Middle anterior radius Base of distal phalanx of Flexion of thumb (CMC, MP,
(FLEK-sor PAH-li-kis LON-gus) thumb and IP joints of thumb)
Assists with opposition of
thumb and wrist flexion
Extensor pollicis longus Middle posterior ulna Base of distal phalanx of Extension of thumb (CMC,
(ek-STEN-sor PAH-li-kis LON-gus) thumb MP, and IP joints of thumb)
and radial deviation
Extensor pollicis brevis Middle posterior radius Base of proximal phalanx Extension of thumb (CMC
(ek-STEN-sor PAH-li-kis BRE-vis) of thumb and IP joints of thumb)
Assists with abduction of
thumb (CMC joint of thumb)
Assists with wrist radial
deviation
Abductor pollicis longus Middle posterior ulna Radial side of base of Abduction of thumb (CMC
(ab-DUK-tor PAH-li-kis LON-gus) and radius 1st metacarpal joint of thumb)
Assists with extension
of thumb (CMC joint of
thumb), wrist flexion, and
wrist radial deviation
indicate their action, location, or both. To aid with arrangement of the muscles such that the flexors are
picturing the action of the muscles of the wrist and located on the front while the extensors are located
hand, remember to think about the line of pull of on the back of the forearm, wrist, and hand.
the respective muscles in reference to anatomical Another helpful organizational clue for the wrist is
position with the forearm supinated and the palm that the primary flexors of the wrist arise proximally
facing forward. In this position, there is a logical from around the medial epicondyle of the humerus,
430
TABLE 7.9 Fundamental Movements of the Wrist and Hand and the Muscles That Can Produce Them
Wrist MP PIP DIP CMC of thumb

Exten- Radial Ulnar Exten- Abduc- Adduc- Exten- Exten- Exten- Abduc- Adduc- Oppos-
Flexion sion deviation deviation Flexion sion tion tion Flexion sion Flexion sion Flexion sion tion tion ition
Muscles of the wrist
Flexor carpi radialis P P
Flexor carpi ulnaris P P
Palmaris longus P
Extensor carpi radialis longus P P
Extensor carpi radialis brevis P P
Extensor carpi ulnaris P P
Extrinsic muscles of the fingers and wrist
Flexor digitorum profundus S P P
Flexor digitorum superficialis S P P
Extensor digitorum S P P P
Extensor indicis S P P P
Extensor digiti minimi S P S P P
Intrinsic muscles of the fingers
Lumbricals P P P
Dorsal interossei S P S S
Palmar interossei S P S S
Abductor digiti minimi S P
Flexor digiti minimi brevis P
Opponens digiti minimi P P
Extrinsic muscles of the thumb (pollex)
Flexor pollicis longus S S P S
Extensor pollicis longus S S P P P
Extensor pollicis brevis S P P S
Abductor pollicis longus S S S P
Intrinsic muscles of the thumb (pollex)
Flexor pollicis brevis P S
Opponens pollicis P
Adductor pollicis P
Abductor pollicis brevis P S
P = primary action(s) of muscle; S = secondary action(s) of muscle; MP = metacarpophalangeal joint; PIP = proximal interphalangeal joint (for thumb PIP equivalent to interphalangeal joint); DIP = distal interphalangeal joint; CMC = carpo-
metacarpal joint of thumb.
while the extensors arise proximally from around Key Considerations

the lateral epicondyle of the humerus. Depending
on their distal attachment and resultant line of pull, for the Upper Extremity
they also can contribute to ulnar or radial deviation in Whole Body Movement
of the wrist. For example, the flexor carpi radialis and
the extensor carpi radialis longus and brevis attach In the upper extremities as a whole, a complex inter-
distally to the second and third metacarpals and so play of muscles is often utilized to allow for isolated
can produce radial deviation as well as their respec- movement and stabilization of the relevant joints.
tive flexion or extension of the wrist. In contrast, the It is often necessary to utilize synergies to achieve
flexor carpi ulnaris and extensor carpi ulnaris have the desired movements and to avoid positions of
distal attachments that include the fifth metacarpal active insufficiency or passive insufficiency when
and so can produce ulnar deviation as well as their multijoint muscles are involved. Furthermore, in
respective flexion or extension of the wrist. functional movement, movements of the various
upper extremity joints are often linked, and a mean-
Primary Muscles of the Fingers ingful movement analysis should take into account
There are five muscles that have proximal attach- the contributions of relevant joints.
ments in the forearm (extrinsic muscles) that can
be used to flex and extend the fingers. Three of Actions of Multijoint
these act on all four fingers at once, two to produce Upper Extremity Muscles
flexion of the fingers (flexor digitorum superficialis,
flexor digitorum profundus) and one to produce Many of the muscles of the upper extremity, and
extension (extensor digitorum) of the fingers. The particularly the hand, cross two or more joints and
remaining two muscles act selectively on the fingers, have actions or potential actions over each of these
one to extend the index finger (extensor indicis) and joints. Because the tendency of a multijoint muscle is to
the other to extend the little finger (extensor digiti produce movement at all of the joints it crosses, other
minimi). In addition, there are 14 smaller muscles muscles are often required to act as stabilizers and syn-
located within the hand (intrinsic muscles). Eleven ergists so that the movement occurs at just the desired
of these muscles work to flex, extend, abduct, and joints and in the desired direction for a given task. For
adduct the four fingers. They are arranged in three example, when the desired action of the biceps brachii
groups called the lumbricals (four muscles), dorsal is only supination, the elbow extensors (triceps brachii
interossei (four muscles), and palmar interossei and anconeus) can contract simultaneously (acting
(three muscles). Three additional intrinsic muscles as synergists) to prevent the undesired action of the
act selectively on the little finger (abductor digiti biceps (elbow flexion). Thus, when turning a door-
minimi, flexor digiti minimi brevis, and opponens knob (supination), the elbow can be appropriately
digiti minimi) to flex, abduct, or aid in bringing the positioned in extension to complete the task, rather
little finger across the palm for important movement than having the elbow flex and the hand pull away
of opposition with the thumb. Both the flexors and from the doorknob as supination is attempted.
extensors of the digits have complex splitting and In dance, synergies are often used to neutralize
attachments of tendon slips onto various positions or control the magnitude of secondary muscle
on the phalanges to allow for isolated or combined actions so that the desired aesthetics can be achieved.
movements of the various digits of the fingers. For example, when the dancer raises the arms from
second to high fifth, the triceps brachii can again work
Primary Muscles of the Thumb to limit elbow flexion while the biceps brachii is work-
In addition, there are four muscles that originate ing to produce the desired supination of the forearm.
in the forearm (extrinsic muscles) that can be used At the wrist, simultaneous contraction of the flexor
to flex, extend, abduct, or assist with opposition of carpi radialis and flexor carpi ulnaris allows desired
the thumb (flexor pollicis longus, extensor pollicis slight flexion of the wrist while the respective radial
longus, extensor pollicis brevis, abductor pollicis deviation and ulnar deviation are neutralized.
longus). Four other intrinsic muscles can also pro- Also, remember that with multijoint muscles,
duce movements of the thumb (flexor pollicis brevis, motion at one joint alters muscle length, which in
opponens pollicis, abductor pollicis brevis, adductor turn affects the muscle’s ability to produce force
pollicis). These muscles form the rounded contour or be stretched across the other joint(s) it crosses.
that can be felt below and medial to the thumb For example, components of the biceps brachii
(thenar eminence). and triceps brachii cross both the shoulder joint
and the elbow joint. Functionally, movements often issue in the upper extremity than strength. Because
utilize joint motion combinations that simultane- the shoulder is designed for mobility, adequate
ously lengthen the muscle at one joint and shorten strength in the surrounding muscles is key for stabil-
the muscle at the other joint such that active insuf- ity and injury prevention. Furthermore, many dance
ficiency is avoided and effective force production classes do not provide movements that progressively
can proceed. For example, during pulling motions, develop strength for the upper extremity as is done
the extension at the shoulder lengthens the biceps for the lower extremity. Hence, strengthening
brachii (across the shoulder joint) so that sufficient performed outside of class is often necessary to
tension can be generated as the elbow flexes (which successfully achieve dance movements requiring
shortens the biceps). However, in other cases such as high levels of strength such as partnering or inverted
when lifting a dancer to the front with an underhand positions.
grip, the biceps brachii will be shortened across both
the elbow and shoulder joints and active insufficiency Strength Exercises
can become operative. Both active and passive insuf-
for the Upper Extremity
ficiency also come into play with the extrinsic muscles
of the hands, and appropriate positioning of the wrist Selected strength exercises for the shoulder, scapula,
is often used to avoid these potential limitations. and elbow are provided in table 7.10, and a brief
description of their importance follows. Interested
Coordinated Movements readers are referred to texts by Kraemer and Fleck
of Multiple Upper Extremity Joints (2005); Peterson, Bryant, and Peterson (1995); and
other resources available through the National
In functional movement, there is often an intricate Strength and Conditioning Association for a
coordination between the hand, wrist, radioulnar, more comprehensive coverage of upper extrem-
elbow, and shoulder joints to facilitate successful ity strengthening exercises. When performing
execution of the desired movement. In open kine- strength exercises for the shoulder, it is important
matic chain movements, many joints often contribute to note that the resistance arm is very long when
to effective positioning of the hand for manipulation lifting a weight with the elbow straight. Due to this
of objects. For example, the later phase of overhead relationship, the muscle force required to support
throwing often involves wrist flexion and ulnar the limb at 90° of shoulder abduction has been
deviation, complemented by forearm pronation, calculated to be about 8.2 times the weight of the
internal shoulder rotation, and scapular abduction limb (Soderberg, 1986). This means that holding a
(Kreighbaum and Barthels, 1996). In dance, aesthetic 10-pound (4.5-kilogram) weight in the hand would
criteria are often more operative, and characteristic require about 82 pounds (37 kilograms) of muscle
placement and use of the arms are often associated force to support that weight. Hence, to achieve the
with different forms and schools of dance. For example, desired benefits and avoid injury, particular care
classical ballet often uses a slight internal rotation at the should be taken to perform such exercises slowly,
shoulder joint, flexion of the elbow, supination of the in a controlled manner, with correct technique,
forearm, and flexion of the wrist to achieve the desired in a range in which no joint discomfort is experi-
line of the arm when held out to the side such as seen enced, and with gradual increases of resistance in
in the opening photo for chapter 1 (p. 1). An example small increments as strength gains allow. It is also
of stylized use of the upper extremity for flamenco important to realize that there are great individual
dance can be seen in figure 7.31 (p. 408), the Graham differences in upper extremity strength in accor-
modern dance technique in figure 7.51A, and African dance with many factors, including gender and
dance in figure 7.51B. Development of the intricate body type. So, for example, a male dancer with
coordination required to achieve the given dance proportionally shorter arms might be able to safely
aesthetic may take years of training to perfect. lift a much heavier weight than a female dancer
with proportionally longer arms. In light of these
factors, many of the sample exercises given in table
Conditioning Exercises 7.10 utilize body weight, bands, or relatively light
for the Upper Extremity dumbbells for resistance. However, dancers inter-
ested in developing greater strength are en-cour-
Unlike some of the other joints previously discussed, aged to work with a qualified exercise specialist so
for many dancers, adequate flexibility is less of an that appropriate progressions can be made.
Passive Insufficiency With Finger Flexion
Fully flex the fingers with the wrist held in a neutral position of extension. Now, slowly flex the wrist
and notice how the fingers start extending slightly, and notice that it is not possible to maintain full
flexion of the fingers. This is due to passive insufficiency of the extensor digitorum. The extensor
digitorum is not long enough to stretch over all of the joints it crosses, including the wrist, midcarpal,
metacarpophalangeal, and interphalangeal joints. Under normal conditions when one makes a fist,
the wrist extensors (extensor carpi ulnaris and extensor carpi radialis longus and brevis) hold the
wrist in extension, acting as synergists to neutralize flexion of the wrist produced by the extrinsic
flexors of the fingers so that full lexion of the fingers can occur. The optimal position for grip func-
tion appears to be about 20° to 30° of wrist extension (Soderberg, 1986), and forcefully flexing
the wrist of someone holding a weapon can be used in combat to force the person to loosen the
grip on the weapon.
A B
FIGURE 7.51 An example of stylized use of the upper extremity in (A) the Graham-based movement and (B) African
dance.
Figure 7.51A: Photo courtesy of Scott Peterson. Dancer: Susan McLain.
Figure 7.51B: Photo courtesy of Keith Ian Polakoff. CSULB dancers Delyer Anderson and Dwayne Worthington.
433
TABLE 7.10 Selected Strength Exercises for the Upper Extremity

Muscle groups: Shoulder flexors and elbow extensors
Muscles emphasized: Pectoralis major
Joint movement: Shoulder flexion with elbow extension
A. Push-up with elbows in Support body weight on knees or 1. Lower chest closer to floor.
(Body weight) feet and hands in accordance with 2. Progress to feet if performing on
current strength level, with hands knees.
about shoulder-width apart. Slowly 3. Perform with knees or feet on a
bend the elbows and return to the ball or step.
starting position.
(Maintain a neutral position of the
pelvis and avoid arching the low back;
aim to create a straight line along the
side of the shoulder, hip, and knee;
keep the elbows close to the sides
as they bend and straighten.)
Variation 1: Push-up plus—After
returning to the starting position
with the elbows straight, continue
pressing against the floor so that
the shoulder blades come toward
the sides of the rib cage and
the upper back rounds. As skill
improves, isolate the movement
to just scapular abduction while
Variation 1 the upper spine stays in its neutral
extended position.
Muscle group: Shoulder flexors
Muscles emphasized: Anterior deltoid and pectoralis major (sternal)
Joint movement: Shoulder flexion with elbow extension maintained
B. Front arm raise Stand with feet hip-width apart 1. Gradually increase dumbbell
(Dumbbell) and a dumbbell in one hand with from about 3 pounds to 10
the palm facing down. Slowly raise pounds.
the arm to the front in a pain-free
range to a maximum of about
shoulder height, pause, and slowly
(Keep abdominals firmly contracted
to maintain a neutral pelvis and
avoid leaning the torso back as
the arm raises. Bend the knees
slightly if necessary to avoid knee
hyperextension.)
Variation 1: Perform with both
arms raising and lowering
simultaneously.
434
Muscle groups: Shoulder flexors, scapular depressors, and elbow extensors
Muscles emphasized: Lower trapezius and serratus anterior
Joint movement: Shoulder flexion with elbow extension and scapular depression
C. Press-up Sit at the very edge of a chair (with 1. Perform with more body weight
(Body weight) the chair securely positioned by supported on one arm.
placing its back against a wall) with 2. Perform with one arm.
the hands at the edge of the seat
and the fingers facing forward.
Then press down into the seat
of the chair so that the elbows
straighten, and shift the pelvis
forward so that it is just in front of
the chair seat. Then slowly bend
the elbows and lower the trunk,
pause, and straighten the elbows
to return to the starting position.
(Focus on firmly pulling the
shoulder blades down in the
starting position, and only work in
a range in which slight scapular
depression and adduction can
be maintained and no shoulder
discomfort is experienced; keep
the elbows close to your sides as
they bend and straighten.)
Variation 1: Perform with the
hands at the edge of the seat but
with the fingers facing to the side
and the elbows bending to the
side to focus on strengthening the
shoulder adductors.
Muscle groups: Shoulder extensors and scapular adductors

Muscles emphasized: Latissimus dorsi and lower trapezius
Joint movements: Shoulder extension and scapular adduction with elbow flexion maintained
D. Sitting row (elbows in) Sit with the legs outstretched to 1. Pull the elbows farther backward
(Elastic band) the front with the middle of the while still maintaining good
band passing under the balls of form.
the feet, one end of each band 2. Hold farther forward on the
in each hand, and the elbows band.
extended. Then pull the elbows 3. Use a heavier band.
backward, pause, and slowly return
(Focus on pulling the shoulder
blades slightly downward and
together as the elbows pull back.)
Variation 1: Perform sitting on a
box on the Reformer facing the
straps with one strap in each hand.
Variation 2: Sitting row (elbows
out)—Perform with the elbows
at shoulder height (shoulder
horizontal abduction) and the
palms facing down.
(continued)
435
TABLE 7.10 Selected Strength Exercises for the Upper Extremity (continued)

Muscle groups: Shoulder extensors and elbow extensors
Muscles emphasized: Latissimus dorsi and triceps brachii
Joint movement: Shoulder extension with elbow extension
E. Lunge triceps kick back Stand in a lunge with the left 1. Gradually increase dumbbell
(Dumbbell) foot forward, the torso partially from 5 pounds to 10 pounds.
supported by the right hand on the
left thigh and the left arm hanging
toward the floor with the elbow
extended and a dumbbell in the
left hand. Then slowly bend and
raise the left elbow up toward the
ceiling, extend the elbow, pause,
slowly bend the elbow, and return
to the starting position. Repeat on
the other side.
(Focus on keeping the elbow high
as it extends to a straight but not
hyperextended position; maintain
firm trunk stabilization.)
436
Muscle group: Shoulder abductors
Muscles emphasized: Middle deltoid and supraspinatus
Joint movement: Shoulder abduction with elbow extension
F. Side arm raise Stand with feet hip-width apart 1. Gradually increase dumbbell
(Dumbbell) and a dumbbell in one hand. from 3 pounds to 8 or 10
Slowly raise the arm to the side pounds.
to a maximum of shoulder height,
pause, and slowly return to the
starting position. Externally rotate
the shoulder as the arm raises
so that the thumb ends facing up
toward the ceiling, and maintain
the arm slightly forward of the
frontal plane in scaption. Repeat
on the other side.
(Focus on allowing the scapula to
upwardly rotate as the arm raises
without excessive elevation; use
a low enough weight and range of
motion that no shoulder discomfort
is experienced.)
Variation 1: Perform the exercise
without external rotation so that
the palm stays facing downward
and in the frontal plane, but limit
the range to about 60° abduction
(pain free).
Variation 2: Perform either version
of the exercise with a dumbbell in
each hand and both arms raising
simultaneously.
(continued)
437

Muscle group: Shoulder abductors and elbow extensors
Muscles emphasized: Middle deltoid
Joint movement: Shoulder abduction with elbow extension
G. Sitting overhead press Sit with the knees bent and feet 1. Shorten the band by gripping it
(Elastic band) on the floor while each hand holds with the hands closer together.
the end of a band that passes 2. Use a heavier band.
under the knees. Start with the
palms facing forward in front of
each shoulder and the elbows bent
close to the sides. Then slowly
extend the elbows as the hands
reach toward the ceiling, pause,
and slowly bend the elbows to
(Focus on the elbows reaching to
the side and the scapulae rotating
without excessive elevation as
the arms go overhead; extend
the elbows with control to a
straight but not hyperextended
position; use co-contraction of the
abdominals to avoid an anterior
pelvic tilt or rib-leading as the arms
go overhead.)
Variation 1: Perform sitting with
light dumbbells in the hands.
Variation 2: Kneeling overhead
press—Perform kneeling on
the Reformer, starting with the
sternum above the footbar and the
elbows facing outward. Then press
against the footbar as the elbows
extend so that the carriage moves
backward.
Variation 3: Perform any of these
versions with the elbows facing
forward instead of sideward to
emphasize the shoulder flexors
instead of the shoulder abductors.
Variation 2
438
Muscle groups: Shoulder external rotators and scapular adductors
Muscles emphasized: Infraspinatus, teres minor, and lower trapezius
Joint movement: Shoulder external rotation with scapular adduction
H. Kneeling scarecrow Kneel on the floor or a mat with 1. After full external rotation of the
(Dumbbells) the torso supported on an exercise shoulders, extend the elbows
ball and the elbows bent to about and reach the hands overhead
90°, with a dumbbell held in each in line with the shoulders and
hand such that the fists face the above the height of the ears.
floor. Tighten the abdominals firmly 2. After full external rotation of the
to stabilize the lumbar spine, raise shoulders, arch the upper back.
the elbows up toward the ceiling, 3. After full external rotation of the
externally rotate the upper arms shoulders, arch the upper back
at the shoulder joint so that the and then extend the elbows as
hands raise forward and up, hold the hands reach overhead.
4 counts, and then slowly derotate
the arms to bring them back to the
starting position.
(Focus on pulling the shoulder
blades slightly together as you
raise the elbows higher than your
back. Then focus on keeping the
shoulder blades slightly down and
together as the arms externally
rotate.)
Variation 1: Perform sitting, facing
toward the back of a chair with the
upper chest resting against the
back of the chair (shown previously
in figure 3.26A on p. 99).
Variation 2: Perform sitting with an
elastic band, one arm at a time,
as the other arm anchors the band
in front of the body (figure 7.20C,
p. 396).
Muscle group: Shoulder external rotators
Muscles emphasized: Infraspinatus and teres minor
Joint movement: Shoulder external rotation with scapular adduction
I. Double-shoulder external rotation Sit with the knees bent and the 1. Rotate further so that the hands
(Elastic band) legs crossed or the feet on the come back further.
floor while each hand holds the 2. Place the hands closer together
end of a band, with the palms on the band.
facing upward and the elbows 3. After external rotation of the
bent to about 90° and close to the arms, arch the upper back while
sides. Then externally rotate the firmly pulling up from the lower
arms at the shoulder joint, bringing attachment of the abdominals to
the thumbs backward. limit anterior tilting of the pelvis.
(Keep the elbows close to the 4. After external rotation of the
sides; focus on pulling the arms, arch the upper back and
shoulder blades slightly together extend the elbows, reaching the
and down as the arms externally hands out to the sides and slightly
rotate.) behind the back.
Variation 1: Perform sitting on the
box or kneeling, facing the straps
of a Reformer, with one strap in
each hand and the palms facing
upward while the elbows are bent
to about 90° by the sides.
(continued)
439

Muscle group: Shoulder internal rotators
Muscles emphasized: Subscapularis
Joint movement: Shoulder internal rotation with elbow flexion maintained
J. Single-shoulder internal rotation Kneel on a Reformer with the 1. Use heavier springs.
(Reformer) knees about shoulder-width apart 2. Use slightly shorter straps.
and the left knee against the
shoulder rest, with the left side
facing the straps. Hold one strap in
the left hand with the palm facing
up, the elbow bent to about 90°,
and the shoulder externally rotated
while the right hand supports the
left elbow. Then slowly internally
rotate the left arm at the shoulder
joint, bringing the little finger
toward the right elbow, pause, and
slowly externally rotate the arm
to return to the starting position.
Repeat on the other side.
(Keep the elbow close to the side
as the arm rotates, and focus
on keeping the shoulder blade
slightly down and back so that the
shoulder does not roll forward.)
Variation 1: Perform using an
elastic band or tubing that is
secured to a barre.
Muscle group: Scapular abductors
Muscles emphasized: Serratus anterior
Joint movement: Scapular abduction with shoulder flexion and horizontal adduction combined
K. Arm across Stand with the feet about shoulder- 1. Grip further up on the band.
(Elastic band) width apart and one end of a band 2. Use a heavier band.
secured under the left foot and
the other end held in the left hand,
which is positioned just in front of
the left thigh with the left elbow
extended. Then slowly raise the
arm on a diagonal such that the
movement ends with the hand in
front of the right shoulder, pause,
and slowly lower the arm to the
starting position. Repeat on the
other side.
(Focus on reaching the arm forward
and across the body such that
scapular abduction is emphasized.
Maintain the elbow close to fully
extended but not hyperextended
throughout the movement.)
440
Muscle group: Elbow flexors
Muscles emphasized: Biceps brachii and brachialis
Joint movement: Elbow flexion
L. Concentration curl Sit on an exercise ball or chair with 1. Gradually increase dumbbells
(Dumbbell) the right elbow resting against the from 5 pounds to 10 pounds.
right inner thigh and the right hand
holding a dumbbell, while the left
forearm rests on the left thigh to
help support the torso and the
left hand helps to stabilize the
right arm. Then slowly bend the
right elbow, bringing the right hand
toward the right shoulder, pause,
and slowly lower the hand to the
starting position. Repeat on the
other side.
(Focus on keeping the tip of the
elbow stationary as the elbow
flexes and extends; slowly return
to a straight but not hyperextended
position of the elbow.)
(continued)
441

Muscle groups: Elbow flexors and shoulder flexors
Muscles emphasized: Biceps brachii and pectoralis major (clavicular)
Joint movements: Elbow flexion and shoulder flexion
M. Kneeling biceps lift Kneel on a Reformer, facing the 1. Increase springs.
(Reformer) springs, with the soles of the feet 2. Slightly shorten straps.
against the shoulder rests. Hold
one strap in each hand with the
palms facing front and the elbows
slightly bent and positioned behind
the torso. Then slowly flex the
elbows and bring the arms forward
and up to about the height of the
forehead, pause, and gradually
return the arms to the starting
position. Time the elbow movement
so that the elbows reach about
90° flexion when they are by the
sides, and then extend in the
upper ranges of shoulder flexion so
that tension is maintained in the
straps.
(Focus on keeping the trunk
stationary and allowing the
scapulae to rotate and slightly
abduct without excessive elevation
as the arms raise.)
Variation 1: Perform standing
with your back to a barre with the
middle of an elastic band looped
around the barre and one end of
the band held in each hand.
442
Muscle group: Elbow extensors
Muscles emphasized: Triceps brachii
Joint movement: Elbow extension with shoulder abduction maintained
N. Overhead triceps extension Sit on an exercise ball or chair with 1. Gradually increase the dumbbell
(Dumbbell) the right elbow pointing up toward from 5 pounds to 10 pounds.
the ceiling and the right hand
holding a dumbbell while the left
hand helps stabilize the right arm.
Then slowly extend the right elbow,
bringing the right hand directly
up toward the ceiling, pause, and
slowly bend the elbow to return to
the starting position. Repeat on
the other side.
(Focus on keeping the torso and
upper arm stationary as the elbow
slowly extends to a straight but not
hyperextended position; carefully
control the flexion of the elbow
during the return movement.)
(continued)
443

Muscle groups: Elbow extensors and shoulder extensors
Muscles emphasized: Triceps brachii and latissimus dorsi
Joint movement: Elbow extension with shoulder extension
O. Kneeling triceps kick back Kneel on the Reformer, facing the 1. Increase springs.
(Reformer) straps, with the thighs against 2. Slightly shorten straps.
the shoulder rests. Begin holding
one strap in each hand with the
arms positioned to the front at
about 45° of shoulder flexion and
the elbows extended. Then pull
the elbows back behind the torso,
slowly extend the elbows, pause,
and slowly bend the elbows to
(Focus on keeping the elbows
high as they extend to a straight
but not hyperextended position;
keep palms facing forward as
elbows extend; maintain firm trunk
stabilization.)
Shoulder Flexors to limited upper extremity conditioning provided

Developing strength in the shoulder flexors is par- in many dance classes, the prevalence of the long-
ticularly important for choreography requiring body limbed body type (at least in the ballet world), and
support by the arms. The push-up (table 7.10A) is a the common occurrence of rapid weight loss (from
helpful exercise for developing this strength and the dieting) with associated upper extremity muscle
skill to stabilize the torso while using the arms. Push- loss. The press-up (table 7.10C) is another useful
up tests are commonly used to assess shoulder flexor exercise for developing the strength to support the
strength and primarily endurance. Many female body weight with the arms in floor work. Adequate
dancers test below average on this test, perhaps due shoulder flexor strength is also essential for lifting
or holding a partner, and the front arm raise (table 7.10, E and O) provide alternatives for strengthen-
7.10B) and sitting overhead press (table 7.10G, varia- ing the extensors.
tion 3) can help develop this strength.
However, such overhead positions, like that used Shoulder Abductors
in the overhead press, can create shoulder injury Adequate strength in the shoulder abductors is
such as impingement and should only be used if important for being able to hold the arms up in
no shoulder pain is experienced and after building second position, as well as some types of partner-
strength with exercises using lower ranges of should ing or lifting. The side arm raise (table 7.10F) is
flexion, such as push-ups and the front arm raise particularly helpful for holding the arms, while the
(limited to 60° or 90° flexion). sitting overhead press is more useful for overhead
partnering (table 7.10G). A push-up can also be
Shoulder Extensors
carefully advanced in stronger dancers by progres-
Strengthening the shoulder extensors is important sively lifting the hips more over the hands until
for pulling movements and for muscle balance. the dancer can perform the exercise in a hand-
Many athletes overemphasize strengthening the stand position with the legs resting against the
shoulder flexors relative to the shoulder extensors, wall and the elbows bending to the side on the
and the resultant muscle imbalance can lead to a down-phase. However, overhead positions involving
rolled shoulder posture. The shoulder extensors shoulder abduction hold a high risk for impinge-
are classically strengthened with the calisthenic of ment, and these types of exercises should be
pull-ups. However, many dancers have insufficient performed only if they are pain free and after a
strength to perform pull-ups or lack access to appro- base of strength and good mechanics have been
priate apparatus on which to perform them. The sit- developed through performance of exercises like
ting row (table 7.10D) and triceps kick back (table the side arm raise.
Push-Up Test
Perform the following test with another dancer to assess the

strength and endurance of key upper extremity muscles (shoul-
der flexors and elbow extensors).
Start in a push-up position with either your knees or feet (with
the toes tucked under/metatarsophalangeal hyperextension) as
the pivotal point in accordance with strength level. The hands
are placed approximately shoulder-width apart and directly
under the shoulders with the fingers facing straight forward or
slightly inward. A partner places a fist on the ground under your
chest and counts the number of times you can consecutively
lower your body while maintaining the back straight until you
touch the fist and then return to the starting position.
Goals: Goals vary by gender, age group, and study performed.
For ages 20 to 29, the norms given by the Canadian Physical Activity, Fitness and Lifestyle Appraisal
(as cited in Nieman, 1999) are as follows:
Male (from toes) Female (from knees)

Excellent ⱖ36 ⱖ30
Average 22-28 15-20
Shoulder Adductors less use of the posterior deltoid and greater use of
Since the shoulder adductors are not a separate the rotator cuff for external rotation.
muscle group, but rather reflect a pairing of flexors Shoulder Internal Rotators
and extensors working together, specific exercises
are not included for shoulder adduction in this text. Strengthening the shoulder internal rotators is
Due to the large muscles capable of producing this advisable for balance if a lot of exercises are being
movement, the greatest force can be generated with performed for the shoulder external rotators or if
shoulder adduction—often about twice the force that there is a history of shoulder injury. The shoulder
can be generated with shoulder abduction (Hamill internal rotators (particularly the subscapularis) are
and Knutzen, 1995). However, in the gym, exercises considered key for shoulder stability. Single-shoul-
for the shoulder adductors include lat pull-downs der internal rotation (table 7.10J, p. 440) provides
and pull-downs performed with high wall pulleys. an exercise that can easily be performed on the
The press-up (table 7.10C, p. 435) can also be modi- Reformer or using an elastic band or tubing. How-
fied by facing the fingers and bending the elbows to ever, with the prevalence of rolled shoulder, often it is
the sides to encourage use of shoulder adductors. advisable to at least initially emphasize strengthening
Similarly, strengthening of the shoulder adductors the shoulder external rotators exclusively.
can easily be included with the curl-up performed
Scapular Adductors and Scapular Depressors
on the Reformer (previously described in table 3.4D
on p. 135) by pulling the arms down from shoulder Adequate strength in the scapular adductors is
height to the sides in the frontal plane—that is, important for preventing rolled shoulders and for
shoulder adduction versus shoulder flexion. promoting correct arm placement during dance.
Due to the natural linking of scapular adduction with
Shoulder External Rotators external rotation, focusing on pulling the shoulder
Strengthening the shoulder external rotators should blades together when performing the exercises for
also be a priority due to their importance in promot- the shoulder external rotators (kneeling scarecrow
ing correct shoulder mechanics and in preventing [table 7.10H, p. 439] or double-shoulder external
rolled shoulders, impingement syndrome, and other rotation [table 7.10I, p. 439]) is a good way to
shoulder injuries. Everyday activity does not neces- strengthen both of these muscle groups with one
sarily provide the desired strength for the external exercise. The use of scapular adduction with shoulder
rotators, and they are generally able to produce less horizontal abduction while the torso is inclined (such
torque than the internal rotators or any other muscle as is commonly used with rows in a gym setting) has
group of the shoulder. Furthermore, one study also been shown to be a very effective way of overload-
showed that the ratio of internal rotation to external ing the trapezius muscle (Brunnstrom, 1972). When
rotation was about 30% higher in the dominant versus performing any of these exercises, adding an upper
the nondominant shoulders of 15 normal subjects, back arch provides a way to counter all of the ele-
due to higher internal rotation in the dominant versus ments that tend to be associated with rolled shoulder
the nondominant arm and approximately the same posture (shoulder internal rotation, scapular abduc-
external rotation in the dominant and nondominant tion, and kyphosis) with one exercise. Furthermore,
arm (Warner et al., 1990). The kneeling scarecrow when executing these exercises, focusing on pulling
(table 7.10H, p. 439) offers an effective exercise for the shoulder blades down is a good way to emphasize
the shoulder external rotators that can be performed strengthening the lower trapezius (scapular depres-
with weights, while double-shoulder external rota- sor), which is important in dance for preventing
tion (table 7.10I, p. 439) can be performed with an excessive elevation of the shoulders during arm
elastic band. movements and shoulder impingement injury. In
Performing the latter exercise with the elbow addition, the press-up (table 7.10C, p. 435), previously
slightly in front of the torso (with the shoulder in the described for strengthening the shoulder flexors,
plane of the scapula) will allow greater conformity offers an effective exercise for both learning to acti-
between the head of the humerus and glenoid fossa, vate and strengthening the scapular depressors.
greater force production due to a more optimal
length of the shoulder external rotators, and more Scapular Abductors
range of motion due to slackening of the joint cap- Adequate strength in the scapular abductors that is
sule (Greenfield et al., 1990). Gently pressing your balanced with strength of the scapular adductors is
elbow inward against your opposite hand (shoulder important for preventing winging of the scapulae and
adduction in the plane of the scapula) may also allow for promoting proper arm placement during dance.
Adequate strength in the serratus anterior is also torque (Hall, 1999). Furthermore, the elbow flexors
important for preventing shoulder impingement. One are more readily used in everyday activities such as
can strengthen the scapular abductors by focusing on lifting and carrying objects. Thus, in general the
keeping the scapulae wide (abducted) during push-ups, elbow flexors are almost twice as strong as the elbow
rather than letting the scapulae come together on the extensors (Hamill and Knutzen, 1995), making it
down-phase of the push-up, and including slight addi- important to place emphasis on strengthening the
tional scapular abduction at the end of the up-phase elbow extensors. In dance, adequate strength in the
of the push-up, termed a push-up plus (table 7.10A, elbow extensors is important for overhead partnering
variation 1, p. 434). Similarly, in the gym, one can and for floor work that involves pressing the body
strengthen the scapular abductors by reaching the arms up or supporting the body weight with the arms.
forward at the end of a bench press so that the scapulae Strength in the elbow extensors can also improve
abduct (“lock out”). Arm across (table 7.10K, p. 440) is the tone and contour of the back of the arm and
another exercise that can be performed for the scapular help prevent the undesired “sag” that some dancers
abductors that uses an elastic band for resistance. Focus- experience in this area.
ing on keeping the shoulder blade down as the scapula The elbow extensors can be strengthened with
moves forward will also help strengthen the depression many exercises, including the push-up (table 7.10A,
function of the serratus anterior. p. 434), press-up (table 7.10C, p. 435), lunge triceps
kick back (table 7.10E, p. 436), sitting overhead
Other Scapular Muscles press (table 7.10G, p. 438), overhead triceps exten-
Because of the multiple functions of the scapular sion (table 7.10N, p. 443), and kneeling triceps
muscles and their linked action with movements of kick back (table 7.10O, p. 444). While the position
the shoulder, various scapular muscles are recruited of the forearm does not influence the ability of the
in any strengthening exercises for the shoulder elbow extensors to produce force, position of the
complex. However, a study using electromyography shoulder will influence the contribution of the long
concluded that the combination of scaption with head of the triceps brachii. For example, putting the
external rotation, rowing, push-up plus, and press- shoulder in extension, such as with the triceps kick
up would challenge all of the scapular muscles and back, shortens the long head across the shoulder
provide a core program for rehabilitation and pre- and makes the exercise more demanding than if the
vention of shoulder injuries (Johnson, Gauvin, and shoulder was not extended.
Fredericson, 2003; Moseley et al., 1992).
Compound Strengthening Exercises
Elbow Flexors Other exercises including multiple joints and incor-
Strengthening the elbow flexors is important for porating movement patterns similar to those used in
types of partnering that involve holding or support- activity are useful for developing functional strength
ing another dancer with one elbow or both elbows in the upper extremity, such as bench presses and
flexed. Strengthening these muscles will also provide cleans. Male dancers or female dancers who have to
more tone and definition along the front of the perform highly demanding partnering or body sup-
arm. The concentration curl (table 7.10L, p. 441) is port may want to consider progressing from some
an effective exercise that is performed with dumb- of the basic exercises described in this text to more
bells, while the kneeling biceps lift (table 7.10M, advanced exercises using Pilates apparatus, weight
p. 442) can be performed on the Reformer or with an apparatus, or free weights as their strength develops.
elastic band for resistance. Remember that forearm Working with a qualified Pilates instructor, personal
position will influence the relative contribution of the trainer, kinesiologist, or strength coach to supervise
elbow flexors. So, performing elbow flexion with the and design a safe and effective program for your
forearm supinated should encourage use of the biceps needs is recommended.
brachii, the forearm in midposition should emphasize
use of the brachioradialis, and the forearm pronated Flexibility Exercises for the Upper Extremity
should deemphasize biceps brachii contribution.
Table 7.11 provides average range of motion for the
Elbow Extensors fundamental movements of the shoulder in the gen-
The attachment of the triceps brachii is closer to the eral population, as well as the primary constraints to
axis of the elbow joint for flexion-extension than that these movements. Many dancers exhibit adequate
of the biceps brachii, giving it a smaller moment arm shoulder flexibility or even excessive mobility, and
and a relative disadvantage in terms of production of supplemental stretching is not necessary or probably
TABLE 7.11 Normal Range of Motion and Constraints for Fundamental Movements of the Shoulder
(Non-Dance Populations)
Shoulder joint Normal range

movement of motion* Normal passive limiting factors
Flexion 0-180° Joint capsule: posterior portion
Ligaments: coracohumeral (posterior band)
Muscles: shoulder extensors and external rotators
Extension 0-60° Joint capsule: anterior portion
Ligaments: coracohumeral (anterior band)
Muscles: pectoralis major (clavicular portion)
Abduction 0-180° Joint capsule: inferior portion
Ligaments: glenohumeral (middle and inferior bands)
Muscles: shoulder adductor muscles
Adduction 0-45°** Apposition with trunk
External rotation Joint capsule: anterior portion
Arm 90° abduction 0-90° Ligaments: glenohumeral and coracohumeral
Arm by side 0-60° Muscles: shoulder internal rotator muscles (subscapularis,
pectoralis major, teres major, and latissimus dorsi)
Internal rotation Joint capsule: posterior portion
Arm 90° abduction 0-70° Muscles: shoulder external rotator muscles (infraspinatus and
Arm by side 0-80° teres minor)
**From Gerhardt and Rippstein (1990). This measure allows the arm to pass in front of the body.
advisable until there is a better understanding of the Shoulder Extensors

potential relationship between shoulder range of
Adequate flexibility in the shoulder extensors is
motion and shoulder instability (Rodeo et al., 1998;
important for allowing the arms to be brought fully
Sauers et al., 2001). Some other dancers may have
overhead or even slightly past overhead, necessary
tightness in specific areas that require supplemental
for movements such as partnering or ballet port
stretching to achieve the desired ranges for dance. A
de bras. If inadequate shoulder flexibility is pres-
few areas that are more frequently tight and that are
ent, the back is often arched (hyperextended) to
particularly important for dance are described in the
allow the arms to be moved farther back. This can
remainder of this section and in table 7.12.
put undue stress on the low back as well as disrupt
When one performs these and other stretches for
the desired aesthetic or “line.” One can quickly
the shoulder area, it is very important to stabilize the
evaluate the flexibility of the shoulder extensors
torso. When the arm approaches the end of its range
by bringing the arm forward in flexion and check-
in a given direction, it is easy to adjust the torso to get
ing that it can reach an overhead position without
more range of the distal end of the arm, reducing the
distorting torso alignment, as seen in Tests and
effectiveness for the targeted shoulder muscle.
Measurements 7.2. Two stretches for the shoulder
Shoulder Flexors extensors are provided in table 7.12. The kneel-
ing arms overhead shoulder stretch (table 7.12B)
Adequate flexibility in the shoulder flexors is is a stretch that can be performed with a chair
important for allowing the arm to be brought back- or ballet barre, while the sitting arms overhead
ward behind the body (shoulder hyperextension). shoulder stretch (table 7.12C) can be performed
If inadequate flexibility is present, the shoulder is sitting upright to work on maintaining correct torso
often rounded forward with the scapula elevated, positioning or sitting with the back supported by an
an undesired aesthetic in dance, in an effort to get exercise ball to provide a position in which gravity
more range. The arms back shoulder stretch (table will assist with providing a stretch to the shoulders
7.12A) is a stretch for the shoulder flexors that can be (table 7.12C, variation 1).
performed with a bar, dowel, ballet barre, or towel.
TABLE 7.12 Selected Stretches for the Shoulder

Muscle group: Shoulder flexors
Muscles emphasized: Pectoralis major (clavicular) and anterior deltoid
Joint position: Shoulder extension with elbow extension
A. Arms back shoulder stretch Grasp a bar, dowel, or towel behind 1. Lift bar higher while maintaining
(Static) the back with the hands slightly good form.
wider than shoulder-width apart 2. Move hands closer toward each
and the palms facing forward. other on the bar, dowel, or towel.
Slowly raise the arms backward
and upward until a stretch is felt
across the front of the shoulders.
(Emphasize keeping the scapulae
slightly down and together, and
only raise the arms as high as it
is possible while maintaining this
positioning of the scapulae.)
Muscle group: Shoulder extensors

Muscles emphasized: Pectoralis major (sternal) and latissimus dorsi
Joint position: Shoulder flexion
B. Kneeling arms overhead shoulder stretch Kneel about 4 feet (1.2 meters) 1. Allow more of the weight of the
(Static) away from the back of a chair or a torso to hang on the arms.
ballet barre with the hands slightly 2. Start kneeling slightly farther
wider than shoulder-width apart. away from the chair or barre.
Slowly flex at the hips and allow
the torso to fall through the arms
until a stretch is felt across the
front of the shoulders.
(Firmly contract the abdominals,
focusing on pulling the lower ribs
down and back and the pubic bone
up such that hyperextension of the
back and rib-leading are avoided,
and the stretch occurs at the
desired site of the shoulders.)
(continued)
449
TABLE 7.12 Selected Stretches for the Shoulder (continued)

Muscle group: Shoulder extensors
Muscles emphasized: Pectoralis major (sternal) and latissimus dorsi
Joint position: Shoulder flexion
C. Sitting arms overhead shoulder stretch Sit with the legs to the front with 1. Bring the arms further back.
(Static) the knees bent and the feet flat
on the floor while the arms are
clasped overhead. Slowly bring the
arms backward until a stretch is
felt in the lower or posterior area of
the shoulder.
(Initially contract the abdominals
firmly to maintain slight flexion
of the lumbar and lower thoracic
spine as the arms are brought
backward. As stabilization skill
improves, utilize a neutral position
of the spine but avoid any spinal
hyperextension or rib-leading as the
arms move backward.)
Variation 1: Perform sitting with the
arms overhead, the elbows bent
or straight, and the upper back
supported by an exercise ball so
that gravity assists with providing a
greater shoulder stretch.
Variation 1
Muscle group: Shoulder horizontal adductors
Muscles emphasized: Pectoralis major and anterior deltoid
Joint position: Shoulder horizontal abduction
D. Wall shoulder stretch Stand with your right side facing 1. Move the arm slightly farther
(Static) the wall and your right palm on back on the wall.
the wall, with the fingers facing up 2. Rotate the torso further, slightly
toward the ceiling. Slowly rotate away from the arm.
your torso to the left away from the
wall until a stretch is felt across
the front of the shoulder. Repeat
on the other side.
(Keep the right shoulder externally
rotated and the scapula pulled
downward as the torso is rotated.)
450
Muscle group: Shoulder horizontal abductors
Muscles emphasized: Posterior deltoid
Joint position: Shoulder horizontal adduction with elbow flexion
E. Supine elbow across shoulder stretch Lie supine on the floor with the 1. Move the arm slightly farther
(Static) right elbow bent facing outward at across the chest.
shoulder height and the left hand
on the elbow. Use the left hand
to pull the right elbow across the
chest until a stretch is felt across
the back of the shoulder. Repeat
on the other side.
(Keep the scapulae slightly
together, and avoid letting the
scapula come forward as the arm
is brought across the body.)
Screening Test for Shoulder Extensor Flexibility
A test is shown for measuring passive shoulder flexion, a motion that will generally reflect the flex-
ibility of the shoulder extensors in healthy dancers. While the dancer is sitting with both knees bent
and the feet on the floor, the examiner stabilizes the torso with one hand while the dancer brings one
arm as far overhead as possible without distorting torso alignment.
The axis of the goniometer is placed at the approximate axis of the shoulder joint, while the station-
ary arm is vertical and in line with the side of the torso and the moving arm is along the midline of the
upper humerus. A position with the arm straight overhead is considered “0,” and the number of degrees
the arm can be brought back beyond this point are considered a positive number. The ability to easily
achieve “0” degrees is important to allow for overhead positions, as used with partnering, without
undesired compensations of the trunk. However, many dancers exhibit much greater range of motion
in this direction, and the author considers a minimum of 10° desirable to help achieve the aesthet-
ics of various port de bras and gestural movements used in dance. If a goniometer is not available,
one can use a rough guide of being able to bring the elbow approximately 3 inches (7.6 centimeters)
behind the middle of the ear while vertical alignment of the head and torso are maintained.
451
Shoulder Horizontal Adductors wrist, and about 9% in the shoulder (Washington,

1987). After reviewing 20 years of ballet injuries
Adequate flexibility in the shoulder horizontal adduc-
at the Lewisham Hospital, Millar (1987) noted a
tors is necessary to allow the arms to be adequately
slow but steady increase in injuries to the neck and
“open” when held in second position and to help
upper extremities that he attributed to the greater
prevent rolled shoulders. The wall shoulder stretch
and more varied choreographic demands placed
(table 7.12D) is a stretch for this muscle group.
on ballet dancers who have to perform modern
ballets.
Shoulder Horizontal Abductors
and Posterior Capsule
Prevention of Upper Extremity Injuries
Recent studies suggest that tightness in the posterior
capsule and posterior rotator cuff may be an associ- A common mechanism of injury to the upper extrem-
ated factor with some shoulder injuries (such as the ity involves falling on an outstretched arm; but in
impingement syndrome). The supine elbow across dance, injuries more commonly relate to performing
shoulder stretch (table 7.12E) is designed to provide repetitive overhead movements or demanding move-
a stretch to this area. However, to be effective, the ments in which the upper extremity is supporting
scapula must be stabilized through conscious use of the weight of the dancer or another dancer. When
the scapular adductors to maintain the scapula close forces exceed the passive mobility, stability, and
to the spine so that a stretch is applied to the poste- dynamic control of the shoulder joint, injury can
rior shoulder versus the scapular adductors. occur (Warner et al., 1990).
Dancers can lower the risk of injury by develop-
ing adequate and balanced strength, developing
Upper Extremity Injuries and maintaining adequate flexibility, properly
in Dancers warming up, avoiding fatigue, and focusing on
good technique. In regard to strength, performing
Because dance is primarily weight bearing with the supplemental strength training two to three times
lower extremity, the reported incidence of injury in per week can develop a base of upper extremity
the upper extremity has been historically much lower strength. Then, when unaccustomed choreography
than in the lower extremity. In fact, many reports places high demands on the upper body, injury is
of female ballet dance injuries do not even include less likely to occur. Including exercises for the rota-
upper extremity injuries, and there are a very lim- tor cuff and scapular muscles, as well as the large
ited number of studies addressing upper extremity shoulder muscles, will provide greater joint stability
injuries in dancers. However, some forms of dance and foster proper shoulder and scapular mechan-
such as break dancing (Washington, 1987) show a ics necessary for avoiding impingement syndromes.
higher incidence of upper extremity injuries, and Lastly, focusing on correct arm placement with an
the incidence of upper extremity injuries in some appropriate scapulohumeral rhythm can reduce
modern, ballet, and jazz dancers appears to be on shoulder stress.
the rise.
In terms of increasing incidence, demands for Rehabilitation of Shoulder Injuries
the upper extremity have markedly increased in
some choreography with more use of nonclassical Although different injuries often require specific
partnering by men, women partnering other women treatments, some general principles follow for treat-
or men, floor work, and demanding movements ment of the shoulder. For more specific treatment pro-
requiring support of the body by the arms. In the tocols, interested readers are referred to the related
modern arena, contact improvisation can produce references provided at the back of this book.
additional stresses to the upper extremity when As with injuries to other joints, initial recom-
unanticipated movements require rapid use of the mended treatment usually involves the use of ice,
arms to support the body weight of the dancer or anti-inflammatories, and relative rest/protected
another dancer. In jazz, the trend to incorporate movement to control pain, swelling, and inflam-
acrobatic types of movements and hip-hop/break mation (Goldman and McCann, 1997). When
dancing choreography has markedly increased the symptoms are adequately controlled, various other
stresses to the upper extremity. One older study of physical therapy modalities such as ultrasound,
50 male break dancers showed that about 23% of electrical stimulation, or phonophoresis are often
the total injuries occurred in the hand, 7.5% in the prescribed to help restore normal range of motion
and to promote healing. However, unlike the situ- from a fall on the point of the shoulder or on an
ation with other joints, there is a greater priority outstretched hand (Hall-Craggs, 1985).
on maintaining range of motion in the early stages An acromioclavicular sprain is characterized
of a shoulder injury because the shoulder is particu- by severe pain that is aggravated by movements of
larly prone to contractures, capsulitis, and severe the arm and by localized tenderness and swelling
loss of movement if it is immobilized. Hence, early directly over the acromioclavicular joint (Roy and
treatment often involves exercises that are aimed at Irvin, 1983). Less severe sprains are associated with
maintaining range of motion without aggravating a subluxation, while more severe sprains are associ-
the condition, performed several to many times ated with a complete dislocation of the acromiocla-
per day. vicular joint as seen in figure 7.52. With more severe
When symptoms allow, progressive resistance sprains, the ligaments that connect the clavicle to the
exercises are gradually added. These strengthening coracoid process of the scapula (coracoclavicular
exercises should include exercises for (1) the rota- ligaments: coronoid and trapezoid ligaments) are
tor cuff, vital for shoulder stability and the SIT force torn; the distal end of the clavicle is raised relative
couple; (2) the scapular muscles, key for restoring to the acromion and may even ride above the acro-
an appropriate scapulohumeral rhythm; and (3) the mion process (figure 7.52B). The shoulder tends
other major glenohumeral muscles, important for to fall away from the clavicle, due to the weight of
shoulder joint stability and movements. the arm, and appears to droop relative to the other
Evaluation and, if necessary, correction of shoul- shoulder. The acromion of the scapula also appears
der mechanics are also essential for successful reha- more prominent on the injured side (Moore and
bilitation and the prevention of injury recurrence Agur, 1995).
of the shoulder. With many shoulder injuries, the Recommended treatment often involves use of a
scapulohumeral rhythm tends to become disrupted snug arm sling designed to support the weight of the
(scapular dyskinesis), and excessive elevation accom- arm (Yamaguchi, Wolfe, and Bigliani, 1997). Since
panied by inadequate or delayed upward rotation the stability of this joint is dependent on the liga-
of the scapula occurs. Use of technique cues and re- ments and the surrounding muscles do little for sta-
education, in conjunction with selective strengthen- bility, the focus of initial treatment is generally more
ing of necessary muscles such as the serratus anterior oriented toward trying to prevent excessive motion of
and lower trapezius, is often necessary to restore the acromioclavicular joint so that ligamental healing
proper mechanics. As with other joints previously can occur. With severe dislocations it is often difficult
discussed, progression to exercises involving support to maintain the desired alignment of the acromion
of the body weight (closed kinematic chain exercises) and scapula without the clavicle’s overriding the
and proprioceptive challenges (such as performing acromion; and for elite athletes, some physicians
exercises with single- or double-arm support on a recommend surgery to stabilize the joint.
foam roller, ball, or balance board) is also desired.
Shoulder Dislocation
Common Injuries of the Upper Extremity Due to the design of the shoulder for mobility and
its inherent instability, the shoulder (glenohumeral
A brief discussion of some of the more common joint) is vulnerable to dislocation. Although there
injuries that involve the upper extremity follows. are four types of dislocation that can occur, inferior
Although there is limited research related to upper and particularly anterior dislocations occur most
extremity injuries in dancers, interested readers are frequently in forming athletes (Moore and Agur,
referred to the vast number of studies of sports in 1995). In anterior or subcoracoid dislocations (figure
which upper extremity injuries are common such 7.53B), as the head of the humerus moves forward,
as swimming, throwing sports, racket sports, and the joint capsule, inferior glenohumeral ligament,
gymnastics. and sometimes the glenoid labrum can be torn from
their anterior attachment onto the glenoid cavity.
Acromioclavicular Sprain
Common mechanisms for this injury include an
(Acromioclavicular Separation)
abducted and externally rotated arm position, or less
An acromioclavicular sprain, acromioclavicular sepa- frequently an arm position involving extreme shoul-
ration, or “shoulder separation” refers to a sprain der extension with external rotation. In contrast, the
and often dislocation of the acromioclavicular joint. mechanism of injury for inferior or subglenoid dis-
It involves a tearing of the ligaments and frequently location (figure 7.53C) is a blow or large downward
the capsule of the joint. This injury often occurs force applied to the arm when it is fully abducted in
FIGURE 7.52 (A) Moderate and (B) severe sprain of the acromioclavicular joint (right shoulder, anterior view).
FIGURE 7.53 Two common types of shoulder dislocations (right shoulder, anterior view). (A) Normal positioning of the
head of the humerus, (B) anterior (subcoracoid) dislocation, (C) inferior (subglenoid) dislocation.
an overhead position. In dance, shoulder dislocations specific reduction maneuver has to be performed by
occur infrequently. When they do occur, potential a qualified physician as nerves and blood vessels can
mechanisms include falls, mistakes with partnering be injured if the procedure is performed incorrectly.
or contact improvisation, or demanding positions of Furthermore, additional injury such as fractures and
body support by an arm. rotator cuff tears can be associated with a dislocation
Anterior dislocation of the shoulder is visually and must be ruled out by a qualified medical profes-
apparent, as the rounded appearance of the shoul- sional before reduction is performed.
der due to the greater tubercle of the humerus The arm is often initially placed in a sling (Park,
disappears and a cavity can be felt below the acro- Blaine, and Levine, 2002) as initial symptoms are
mion while the acromion appears more prominent controlled. When rehabilitation occurs, a particularly
(Roy and Irvin, 1983). The initial dislocation of the strong emphasis is placed on building the strength of
shoulder is associated with intense pain. Pain with the rotator cuff muscles. Emphasis on strengthening
movement is severe, and the dancer may attempt the deltoid and scapular muscles, as well as progress-
to support the injured arm with the opposite arm. ing to proprioceptive exercises and functional open
Tingling and numbness may be present down the and closed kinematic chain movement patterns, is
arm to the hand. important for restoring correct mechanics and stabil-
This is a medical emergency, and a qualified ity (Shea, 2001). Unfortunately, traumatic shoulder
medical professional should be summoned or the dislocations often involve disruption of the glenoid
medical emergency system activated (call 911). In labrum and inferior glenohumeral ligament, as well
some cases, the humerus will go back into its socket as deformation of the joint capsule. This damage
by itself (spontaneous reduction), but in other cases a can readily lead to shoulder instability, and reports
of shoulder dislocation recurrence rates in athletes factors have the effect of allowing the head of the
vary from 50% to 90% (Yamaguchi, Wolfe, and humerus to migrate upward or not stay centered
Bigliani, 1997). Hence, corrective surgery may be in the glenoid cavity during shoulder flexion and
necessary, often involving the repair of any avulsion abduction, producing impingement. Secondary
of the glenoid labrum, ligaments, or capsule from impingement occurs more frequently in individu-
the rim of the glenoid fossa and “tightening” of the als under 35 years of age (Cavallo and Speer, 1998),
joint capsule (Levine et al., 2000; Nelson and Arciero, while primary impingement occurs more commonly
2000; Steinbeck and Jerosch, 1998). in older individuals.
Given that the supraspinatus tendon runs right
External Shoulder Impingement Syndrome over the top of the humerus to attach onto the upper
External shoulder impingement syndrome (subacro- portion of the greater tubercle (figure 7.54), it is not
mial impingement) is classically used to describe a surprising that the most common inflamed structure
pinching or impingement of inflamed or tender “pinched” with external shoulder impingement syn-
soft tissues between the head of the humerus and drome is the external surface of the supraspinatus
the overlying coracoacromial ligament, acromion tendon. However, other structures located in this
process, or both. The space inferior to the cora- area that can be involved include the tendon of the
coacromial arch and superior to the head of the biceps brachii and the subacromial bursa.
humerus, termed the subacromial space, is only The impingement syndrome is particularly preva-
about 0.4 inches (1 centimeter) when the arm is lent in sports that utilize repetitive shoulder flexion
down by the side (Kreighbaum and Barthels, 1996). and abduction, particularly overhead motions such
External impingement syndrome can be further sub- as in baseball, swimming, gymnastics, and weight-
divided into primary and secondary impingement. lifting (Briner and Benjamin, 1999; Cavallo and
Primary impingement occurs when this subacromial Speer, 1998; Kammer, Young, and Niedfeldt, 1999;
space is mechanically narrowed by factors such Warner et al., 1990). As many as 50% of competitive
as a hooked acromion, bone spurs, a thickened swimmers report impingement-type shoulder pain
rotator cuff, or fibrotic subacromial bursa (Myers, (Nuber et al., 1986). In dance, similar stresses can
1999). In contrast, secondary impingement occurs occur with overhead partnering, choreography that
when the subacromial space is functionally nar- requires very rapid and percussive use of the arms,
rowed by factors such as scapular or rotator cuff and movements that require support of the body
muscle weakness and fatigue, posterior capsule weight by the arms such as handstands, cartwheels,
tightness, or glenohumeral instability. These latter and handsprings.
Subacromial
bursa
Subacromial
bursa
FIGURE 7.54 Impingement syndrome (right shoulder). (A) Lateral view of coracoacromial arch. (B) With arm down by
side, adequate space is present between the humerus and coracoacromial arch, but (C) with shoulder abduction the
space is reduced and impingement can occur.
tion (Greipp, 1985), shoulder external rotation,

shoulder internal rotation, and shoulder horizontal
adduction (Warner et al., 1990) may increase the
risk for impingement. The latter decrease in range
is often due to tightness in the posterior capsule and
is theorized to produce undesired anterior glide
and elevation of the head of the humerus during
shoulder flexion.
When symptoms allow, strengthening exercises are
initiated. Particular emphasis is placed on strength-
ening the rotator cuff due to its important role in
helping prevent excessive upward movement of the
head of the humerus (SIT force couple). Further-
more, the impingement syndrome has been shown
to be associated with low strength in the external
rotators relative to the internal rotators (Warner et
al., 1990), suggesting that greater emphasis should be
placed on strengthening shoulder external rotation.
However, positions for strengthening the rotator cuff
FIGURE 7.55 Classic arc of pain during shoulder often have to be modified to avoid 60° to 120° of
abduction with external impingement syndrome. abduction, and a position in which the arm is slightly
raised (30° of abduction in the scapular plane) so
that blood flow is not decreased and impingement
External impingement syndrome is characterized
risk is low is often recommended. Strengthening of
by pain in the anterior, superior, or lateral shoulder
the scapular depressors and upward rotators (lower
(Wolin and Tarbet, 1997) that is aggravated by over-
trapezius and serratus anterior) is also essential for
head movements, particularly between 60° and 120°
restoring a normal scapulohumeral rhythm when
of shoulder abduction as seen in figure 7.55. Due to
the arm is raised overhead. With normal mechanics,
the mechanics of the shoulder, the initial range of
upward rotation of the scapula moves the acromion
abduction does not approximate the involved struc-
process out of the way as the humerus approaches
tures sufficiently to produce impingement. However,
it during abduction (Kreighbaum and Barthels,
usually at about 60° (although sometimes as early
1996). However, individuals with impingement
as 45°) the inflamed tendons or bursa is impinged
appear to exhibit inhibition and disrupted recruit-
against the overlying coracoacromial arch, produc-
ment patterns of the serratus anterior and lower tra-
ing pain. Blood supply to the supraspinatus tendon
pezius (Cools et al., 2003), with increased activity of
may also be compromised in this range of motion
the rhomboids (Johnson, Gauvin, and Fredericson,
(Kreighbaum and Barthels, 1996). In some cases, a
2003) or upper trapezius (Kibler, McMullen, and
snapping sensation or crepitus may also accompany
Uhl, 2001). This disruption of scapular synergies
the pain occurring in this arc. Sometimes the pain
can lead to excessive scapular elevation, or hiking
is severe enough to prohibit further raising of the
of the shoulder when raising the arm, perhaps to
arm, but if not, the pain usually diminishes after
compensate for decreased glenohumeral motion
about 120° when external rotation of the humerus
but tending to drive the humeral head upward and
places the greater tubercle behind the acromion so
increase impingement risk. Thus, restoration of
that impingement no longer occurs. Due to pain, the
adequate strength and shoulder mechanics is neces-
use of the shoulder joint is often limited, and muscle
sary for avoidance of impingement and resolution of
inhibition, weakness, and atrophy often follow.
symptoms. Correction of rolled shoulder and kypho-
During initial phases of treatment, shoulder
sis, when indicated, may also be prudent due to the
abduction and overhead movements are often lim-
decrease in subacromial space associated with these
ited or avoided. Dancers can temporarily modify use
postural problems (DePalma and Johnson, 2003).
of the arms to below shoulder height (or whatever
range is pain free) or perform some combinations
Rotator Cuff Tear
with and some without arms so that fatigue and
associated pain are avoided. Stretching to maintain In some cases, injury to the rotator cuff may not
normal range of motion is often recommended, as involve only inflammation (tendinitis) but rather an
low range of motion in shoulder horizontal abduc- incomplete or complete tear of the rotator cuff. Such
an injury most commonly involves the supraspinatus

(figure 7.56) at its musculotendinous junction where
blood supply is poor but may also include the infra-
spinatus tendon. In the younger athlete, this tear is
often associated with a traumatic event such as a fall
on an outstretched hand or forceful deceleration
of internal rotation as in throwing (Duda, 1985;
Yamaguchi, Wolfe, and Bigliani, 1997). During the
acceleration phase of throwing, shoulder internal
rotation can reach velocities of 9,000° per second in
male intercollegiate baseball players (Brindle et al.,
1999). Following the release of the ball, the rotator
cuff works eccentrically to quickly decelerate this
high-velocity internal rotation, leaving it vulnerable
for injury. A rotator cuff tear can also follow weaken-
ing of the tendon from tendinitis and impingement. FIGURE 7.56 Rotator cuff tear (left shoulder, posterior
Millar (1987) states that rotator cuff strains are the view).
most common shoulder injury in dancers and espe-
cially in male dancers.
ening of the rotator cuff, proprioceptive exercises,
The signs and symptoms of a rotator cuff tear
and restoration of proper shoulder mechanics. How-
are often very similar to those of the impingement
ever, in cases of a complete tear or when conservative
syndrome, with tenderness near the insertion of the
treatment is unsuccessful, surgical repair may be
supraspinatus and aching pain that is magnified by
recommended (Mercier, 1995; Yamaguchi, Wolfe,
shoulder abduction, especially between 60° and
and Bigliani, 1997).
120°. Pain is often persistent at rest and even at night
(Wolin and Tarbet, 1997) and is often referred to
Bursitis
the distal attachment of the deltoid. Furthermore,
wasting of the supraspinatus may be present; and Bursitis is an inflammation of a bursa, and the
with more serious tears there may be the inability subacromial bursa is most commonly involved at
to abduct the arm against resistance or hold the the shoulder (figure 7.54). As described with the
arm in abduction (Caillet, 1996), probably due to shoulder impingement syndrome, the subacromial
pain. One test used, the drop arm test (Tests and bursa’s location inferior to the coracoacromial arch
Measurements 7.3) involves trying to hold the arm in and superior to the supraspinatus tendon allows it to
abduction after it has been passively raised to about become readily inflamed due to impingement. Bursitis
90° (Magee, 1997; Mercier, 1995). can also result from irritation by calcium deposits in
Recommended initial treatment may involve use the rotator cuff tendons (Wolf III, 1999) that occur
of a sling and limitation of abduction, with additional in response to degenerative changes in these ten-
treatment similar to that used with the shoulder dons or secondary to other injuries of the shoulder
impingement syndrome, including careful strength- or acromioclavicular joint. As with impingement,
Drop Arm Test for a Rotator Cuff Tear
This test is performed by a physician or physical therapist when a tear of the rotator cuff is suspected.
The examiner lifts the patient’s arm to 90° abduction and then lets go. The patient attempts to hold
the arm in this position and then slowly lower it back down to the side. The inability to hold this
position alone or against slight resistance, or the inability to lower the arm in a smooth, controlled
manner without extreme pain, is considered a drop sign and suggests that a tear of the rotator cuff
is present.
bursitis is particularly common in individuals utiliz- conservative approaches fail, corticosteroids or more
ing repetitive overhead movements. aggressive measures such as breaking of the adhe-
Bursitis is often associated with a generalized ache sions under local anesthesia or surgical release of the
around the shoulder that is aggravated by full abduc- capsule by an orthopedic surgeon may be required,
tion, as well as external or internal rotation in abduc- followed by aggressive rehabilitation to avoid adhe-
tion (Magee, 1997; McCarthy, 1989; Millar, 1987). It sion (Caillet, 1996; Pearsall and Speer, 1998).
is also generally aggravated by sleeping with the arm
overhead. Tenderness may also be present over the Biceps Tendinitis and Rupture
front and lateral aspect of the shoulder joint. The biceps brachii tendon can become inflamed,
Recommended treatment often involves modi- resulting in tendinitis (figure 7.57). This most com-
fication of activity to avoid lifting or overhead arm monly involves the tendon of the long head of the
movements that aggravate the condition, modalities biceps brachii and its sheath (tenosynovitis). This
including ice or heat, anti-inflammatory medica- tenosynovitis most often occurs in adults over 40 or
tions, and, when symptoms allow, rehabilitation in younger athletes whose sports demand repetitive
emphasizing strengthening the rotator cuff and arm movements (Mercier, 1995). Factors including a
correcting any technique/training errors (McCar- narrow intertubercular groove, repetitive subluxing
thy, 1989). Careful injection of corticosteroids into of the tendon, or impingement under the coracoac-
the bursa (avoiding the closely aligned tendons) is romial arch may precipitate this injury.
also recommended by some physicians in cases that Biceps tendinitis is characterized by pain that
do not respond to these former treatments (Mercier, extends down the anterior aspect of the upper arm,
1995; Millar, 1987). lower than usually experienced with involvement of
the supraspinatus tendon. Tenderness is also gener-
Frozen Shoulder (Adhesive Capsulitis) ally present over the bicipital groove when palpated.
A frozen shoulder, or adhesive capsulitis, involves The intertubercular groove and associated biceps
chronic inflammation and fibrosis of the glenohu- tendon can be easily palpated on the anterior shoul-
meral capsule. In later stages it often involves adhe- der when the arm is abducted 90° and the elbow is
sions between the capsule and articulating surfaces, flexed 90°. The pain can often be replicated through
as well as inflammation of the subacromial bursa and utilization of maneuvers that place the biceps tendon
coracohumeral ligament. These changes result in a on a stretch such as shoulder hyperextension with
situation in which shoulder motion is dramatically the elbow extended.
reduced (e.g., inability to raise the arm overhead), Recommended treatment often involves the
hence the term “frozen shoulder.” The etiology is usual limitation of motion to pain-free ranges, anti-
not well understood, but frozen shoulder generally
occurs after inactivity of the shoulder consequent to
an injury or inflammation of the shoulder complex.
Although it is rare in young active individuals, it can
occur in older dancers, and particularly in women
versus men (Mercier, 1995).
Adhesive capsulitis is generally associated with
progressive loss of shoulder motion and an insidious
onset of pain, localized to the area of the rotator cuff.
This pain often interferes with sleep, prevents lying
on the affected shoulder, and is progressive in nature.
Tenderness is often present around the rotator cuff
and biceps tendon. In terms of range of motion, there
tends to be a generalized loss of both passive and active
range of motion, and universally a loss of external rota-
tion (Yamaguchi, Wolfe, and Bigliani, 1997). Although
the person is often comfortable when moving within
the restricted range, severe pain is often experienced
with accidental movement beyond this range.
Treatment often involves anti-inflammatory
medications and physical therapy that focuses on FIGURE 7.57 Biceps tendinitis (right shoulder, anterior
stretching and restoring range of motion. However, if view).
inflammatory medications, and physical therapy. sion (Magee, 1997) and tends to be aggravated by
However, successful treatment also needs to address movements involving active wrist extension, rotation
potential underlying causes such as technique or of the forearm (such as turning a doorknob or lid of
shoulder impingement syndrome. If inadequately a jar), or grasping of objects. If activity is continued,
treated, chronic tendinitis, similar to that described the pain often radiates down into the forearm and
at the ankle-foot, can result in an area of degenera- progresses such that it occurs during rather than
tion within the tendon that may precipitate complete only after activity.
rupture of the tendon (Mercier, 1995). Rupture usu- Initial recommended treatment generally involves
ally follows a forceful contraction of the biceps and cessation or modification of aggravating movements,
may be accompanied by the sensation of a “snap” oral anti-inflammatory medications, and physical
and ensuing pain and weakness of the arm. Increased therapy modalities such as heat, cold, electric stimu-
size and a distorted shape of the retracted biceps are lation, and ultrasound (Kulund et al., 1979; Nirschl
often visible. and Kraushaar, 1996a). Some physicians advocate
the injection of corticosteroids in individuals who
Lateral Epicondylitis or Tennis Elbow do not respond to other measures (Ciccotti and
Lateral epicondylitis involves injury in the area of the Charlton, 2001; Roberts, 2000). When symptoms
lateral epicondyle that is thought to entail inflamma- allow, balanced strength and flexibility of the elbow
tion and small tears of the proximal tendinous attach- and forearm muscles are developed with emphasis
ments of the extensors of the wrist (Moore and Agur, on strength and flexibility of the wrist extensors.
1995; Soderberg, 1986). Lateral epicondylitis is an Technique should also be evaluated and correction
overuse injury that is common in athletes utilizing the made, if indicated. Some dancers may benefit from
wrist extensors repetitively, such as pitchers and tennis wearing a band (counter brace) 1 inch (2.5 centi-
players. In fact, this injury is so common in tennis that meters) or more below the elbow (Barclay, 2004;
it is often termed “tennis elbow.” Approximately 45% Goldman and McCann, 1997) during rehearsals or
of tennis players who play daily develop tennis elbow classes that involve movements placing repetitive
(Weldon, 1988). In dancers, lateral epicondylitis is or large stresses on this area. Elbow counterforce
likely related to partnering and support of the body braces have been shown to decrease elbow angular
weight by the arms and has been reported to be the acceleration and reduce activity of the wrist exten-
most common injury to the elbow (Millar, 1987). sors (Groppel and Nirschl, 1986), valuable for the
Lateral epicondylitis is characterized by pain over treatment of lateral epicondylitis.
the lateral aspect of the elbow, usually 0.4 to 0.8
inches (1-2 centimeters) distal to the lateral epicon-
Carpal Tunnel Syndrome
dyle (Goldman and McCann, 1997) as seen in figure The carpal tunnel is a narrow tunnel found in the
7.58. The pain is initially associated with activity and hand. Its floor is formed by selected carpals that
relieved by rest. Pain can generally be reproduced create a concave surface, and its roof is formed by
with passive wrist flexion or by resisting wrist exten- a fibrous band formed by the flexor retinaculum
or transverse carpal ligament (figure 7.59). Hence,
this tunnel is termed a fibro-osseous tunnel (“osse-
ous” meaning bone). The carpal tunnel extends
about 1.2 inches (3 centimeters) and is traversed by
the nine tendons of the flexors of the fingers and
the median nerve (Caillet, 1996; Kreighbaum and
Barthels, 1996). Due to the limited space available
in this canal, the carpal tunnel becomes a common
site for nerve compression, termed carpal tunnel
syndrome (CTS).
Although the cause of this condition is poorly
understood, a higher risk is associated with occu-
pations involving repetitive finger or wrist flexion
(such as with computer keyboards), repetitive grip-
ping, or prolonged exposure to vibration. Similarly,
athletes engaged in activities with repetitive flexion
FIGURE 7.58 Lateral epicondylitis (right elbow, lateral or gripping such as racquetball players, golfers, and
view). rock climbers tend to sustain CTS (Rosenwasser and
FIGURE 7.59 Carpal tunnel with flexor retinaculum and carpals and containing the median nerve and flexors of the
fingers. (A) Anterior view of the tunnel, (B) cross section of tunnel.
Wilson, 1997). In dance, choreography demanding that aggravate the condition. Anti-inflammatory
repetitive support of the body by the arms, especially medications and physical therapy modalities such
in dancers not accustomed to such activity, may as ultrasound may reduce the symptoms (O’Connor,
increase the risk for CTS. During pregnancy, the Marshall, and Massy-Westropp, 2004). When symp-
associated fluid retention tends to cause compression toms allow, flexibility and strength exercises for
of the median nerve; and as many as 20% of pregnant the wrist-hand complex are often recommended.
women may experience carpal tunnel symptoms, However, initially, flexion-extension exercises of the
which tend to go away after delivery (Magee, 1997; wrist or fingers can increase pressures in the canal
Mercier, 1995). and aggravate the condition, and the effectiveness of
Carpal tunnel syndrome is characterized by numb- exercise for this condition is controversial. In cases
ness and tingling in the middle and index fingers, that do not respond to conservative treatment and
or these plus the thumb and the lateral half of the in which symptoms are severe or motor weakness is
ring finger (Moore and Agur, 1995). The tingling of developing, surgical release of the transverse carpal
the fingers can often be reproduced or worsened if ligament is sometimes recommended and has been
the wrist is held in a position of maximum flexion shown to generally have good outcomes (Barclay,
for a period of at least 1 minute (Phalen’s test). 2002; Kao, 2003).
Carpal tunnel syndrome is also often accompanied
by night pain, which has been conjectured to be due
to wrist flexion or the slight swelling associated with
Summary
decreased activity during sleeping (Mercier, 1995). The upper extremity has many structural parallels
In severe cases, the pain associated with CTS may to the lower extremity and also some important dif-
radiate into the forearm, arm, and even shoulder. ferences. Many of these differences are necessary to
If compression persists, motor function may also be meet the primary demand of the upper extremity for
affected, leading to weakness of wrist flexion; finger mobility and manipulation of objects, in contrast to
flexion; and flexion, abduction, and opposition of the demand for stability, support, and locomotion
the thumb. With more advanced cases this weakness of the lower extremity. A summary of the bones and
may be evidenced by the lack of fine coordination, joints of the upper extremity can be seen in figure
loss of grip strength, tendency to drop things, and 7.60, while figure 7.61 shows the superficial muscles
difficulty turning the lids on jars. of the arm. Refer back to figures 7.17 and 7.18
Treatment often involves the use of a splint that (pp. 393-394) for a summary of additional muscles of
prevents extreme wrist flexion or extension, and the shoulder complex. The ringlike shoulder girdle
modification or elimination of the movements hangs on the axial skeleton, connected to the axial
Glenohumeral joint/
shoulder (ball-and socket)
Elbow joint
(hinge)
FIGURE 7.60 (A) Bones and (B) joints of the upper extremity (right side, anterior view).
skeleton only at the sternoclavicular joint. This very muscles assist with these movements and can be
mobile structure can perform elevation, depression, functionally divided into three groups: the scapular
abduction, adduction, upward rotation, and down- muscles, rotator cuff, and other major glenohumeral
ward rotation in order to optimize the relationship of muscles. In addition to producing the movements
the glenoid cavity to the head of the humerus during of the shoulder, these muscles function to give this
the desired movement of the humerus. The shoulder structurally weak joint stability, maintain correct
joint is the most mobile ball-and-socket joint in the alignment, and foster correct mechanics for the SIT
human body, naturally allowing for a large range force couple and the scapulohumeral rhythm.
of motion in flexion, extension, abduction, adduc- Moving distally from the shoulder joint, the elbow
tion, external rotation, and internal rotation. Many joint functions as a hinge joint allowing flexion and
FIGURE 7.61 Superficial muscles of the right arm. (A) Anterior view, (B) posterior view.
extension. The proximal and distal radioulnar joints the amount of torque the muscle can generate in a
are pivot joints that allow the crossing over of the given movement.
distal end of the radius relative to the distal ulna in With the relatively weak structural design of the
the specialized movements of pronation and supina- upper extremity, muscular strength is essential not
tion of the forearm. The wrist joint is a condyloid only for providing stability but also for helping
joint allowing flexion, extension, radial deviation, prevent injuries in this region. Although the preva-
and ulnar deviation. One of the primary functions lence of upper extremity injuries in many dancers
of these joints as a group is to position the hand. is markedly less than that for the lower extremity,
The hand is designed for rapid mobility and preci- injury incidence is on the rise, at least in some dance
sion with its complex array of joints and muscles. forms. With increased choreographic demands on the
One of the unique properties of the hand is the upper extremity, it is important that dancers perform
ability to perform opposition, a function essential supplemental strengthening to both enhance their
for grasping and manipulation of objects. Many technique and lower the risk of injury. In some cases,
muscles cross these joints to produce movement; and performing stretches for the shoulder is also desirable.
due to the many multijoint muscles in this region, When injuries do occur, a good medical diagnosis and
relative positioning of the joints crossed by these treatment are important to prevent frozen shoulder,
muscles will influence which muscles are used and chronic conditions, and injury recurrence.

1. Locate the following bones and bony landmarks on a skeleton and then on your own body:
(a) Scapula and sternoclavicular joint; (b) spine, acromion process, supraspinous fossa, infra-
spinous fossa, coracoid process, and glenoid cavity of the scapula; (c) clavicle and acromio-
clavicular joint; (d) lesser tubercle, greater tubercle, medial epicondyle, lateral epicondyle,
trochlea, and capitulum of the humerus; (e) ulna and olecranon process of ulna; (f) radius
and head of radius; (g) metacarpals; (h) phalanges (proximal, middle, and distal).
2. Draw the following muscles on a skeletal chart and use an arrow to indicate the line of pull
of each muscle. Then, next to each muscle, list its actions: (a) Pectoralis major, (b) latissimus
dorsi, (c) teres major, (d) supraspinatus, (e) trapezius, (f) rhomboids, (g) serratus anterior,
(h) biceps brachii, (i) brachialis, (j) triceps brachii.
3. Locate the following muscles on your partner or your own body, perform or have your partner
perform actions that these muscles produce, and palpate their contraction during these move-
ments: (a) Pectoralis major, (b) deltoid, (c) latissimus dorsi, (d) biceps brachii, (e) triceps
brachii.
4. Observe a partner and note his or her carrying angle. How would this angle change when
performing a concentration curl (table 7.10L, p. 441)?
5. Working with a partner, demonstrate the fundamental movements of the scapula, and observe
and describe how these scapular motions are linked with the following movements at the
shoulder joint: (a) Shoulder flexion, (b) shoulder abduction, (c) shoulder horizontal adduc-
tion, (d) shoulder external rotation.
6. Analyze the following movements, accounting for the joint movement, muscle group, and
muscles used on the up-phase and down-phase at the scapula, glenohumeral joint, and elbow
joint. Be sure to consider the effect of gravity: (a) Pull-up, (b) push-up, (c) pulling a dancer
toward you, (d) bringing arms sideways from low fifth to second position.
7. Diagram the SIT force couple and describe its function and relationship to the impingement
syndrome. Describe two strengthening exercises that could be performed to promote use of
this force couple.
8. Demonstrate an exercise for strengthening the following muscles: (a) Pectoralis major, (b) middle
deltoid, (c) latissimus dorsi, (d) biceps brachii, (e) triceps brachii.
9. Describe how one could attempt to correct a dancer who has rolled shoulders and holds his
or her arms too far forward when in second position, including (a) strength exercises, (b) flex-
ibility exercise(s), and (c) technique cues.
10. A dancer excessively elevates the scapulae when bringing the arms sideways from low to high
fifth position. What corrections could be given in terms of (a) strengthening exercises and
(b) technique cues?
Analysis
of Human
Movement
© Angela Sterling Photography. Pacific Northwest Ballet dancers Louise Nadeau and Christophe Maraval.
CHAPTER EIGHT
465
P rior chapters of this text have addressed the

anatomy and mechanics of specific joints of the
human body. This chapter will focus on looking at
Divide Movement Into Phases
Divide a movement into phases based on change in
movement direction or different functional goals. For
movement of the body as a whole. When we examine
example, in simple movements previously examined
movements used in dance, they generally involve
such as isolation strength exercises or pliés, using
many joints moving in multiple planes as exempli-
the terminology up-phase and down-phase reflects
fied by the photo on page 465 involving partnering.
a change in movement direction that will facilitate
This pose involves an intricate coordination of prime
movers, stabilizers, and synergists at numerous joints movement analysis. However, in movements like
to achieve balance with such limited support, as walking, the phases have a more functional origin,
well as aesthetic challenges such as the desired lines with stance phase referring to the phase when the
and emotive qualities. Being able to analyze such foot is in contact with the ground and must support
movements will allow for a better understanding of the weight of the body, versus swing phase, referring
the primary muscles responsible for the generation to when the foot loses contact with the ground and
and control of the movement, potential flexibility moves forward in space to position the foot appro-
constraints, strength demands, and cues that can be priately for the next step. In movements that have
used to encourage optimal technique and reduce been rigorously researched such as walking, running,
joint stress. Topics covered in this chapter include and jumping, there are various standardized terms
the following: that have been adopted for these phases, while for
many other, less-studied movements, analysts are
• Anatomical movement analysis of whole body free to develop their own phases in a logical manner,
movements generally in accordance with movement direction
• Other methods for movement analysis or function.
• Research-supported movement analysis For some movements that have an apparent begin-
ning and end, termed discrete movements, dividing
• Optimal performance models
the movement functionally into a preparation phase,
• Movement cues execution phase, and recovery or follow-through
phase can be helpful (Kreighbaum and Barthels,
Anatomical Movement 1996). Examples of dance movements that can be
effectively divided into these phases include jumps,
Analysis of Whole Body leaps, pirouettes, and falls. In contrast, some move-
Movements ments, termed continuous movements, involve
repeated cycles, and these cycles become a functional
A schema for simplified anatomical movement analy- unit that is divided into logical phases. Examples of
sis was provided in chapter 2 (table 2.5, p. 64) and continuous dance movements that can be effectively
applied in the Study Questions and Applications at divided into phases within cycles are walks, runs,
the ends of chapters 3 through 7 for analysis of simple triplets, and prances.
movements involving a limited number of joints. In analysis of more complex movements, further
Now this schema will be expanded to incorporate subdivisions may be necessary. For example, with
additional elements for use in analyzing movements walking, the direction of joint movement and the
that are less isolated and that involve simultaneous type of muscle contraction of the prime movers
use of more joints of the whole body. change more than once during the stance phase,
leading to one classic approach of further subdivid-
Key Concepts ing the stance phase into contact, midstance, and
for Anatomical Movement Analysis propulsion periods as presented in chapter 6. These
further divisions can be termed phases, subphases, or
While the principles used in a simplified analysis periods or just given numbers. Furthermore, in many
of focusing on joint movements and prime movers movements, the two limbs may not be performing the
are still operative, the movement analysis process is same movements simultaneously but rather doing dif-
often complicated—when we look at more complex ferent things within a given phase. In such cases, the
movements—by the involvement of more joints, movements of both limbs must be accounted for. For
more phases, changes in the relationship to gravity, example, in a fondu développé front (devant), the
and intricate technique issues. A brief discussion of support leg and gesture leg must be listed separately
key concepts follows. for accurate description of the movement.
Analysis of Human Movement 467
Select Key Joints As done in previous movement analyses, when

delineating the prime movers, first list them in terms
Select the joints where visible movement occurs. With
of the functional group (e.g., hip flexors) and then
more complex movements, add more focus on the
provide specific examples (e.g., iliopsoas, rectus
joints that are particularly key for correct generation
femoris) obtained from figures 8.1 and 8.2 and table
of the movement, versus joint movements that may
8.1. Including the functional muscle group is recom-
be more gestural or supplementary in nature.
mended because it provides a simple way of trying to
Identify Key Joint Movements accurately reflect the muscles that would have to work
without having to refer to studies that investigate the
Identify the joint movements that occur in each relative contribution of specific muscles with factors
of the key joints in each phase of the movement. such as the speed of motion, changes in line of pull
Remember that movement terms refer to the direc- relative to the relevant axis of rotation in different
tion of movement and not a joint position or angle. ranges of motion, secondary actions of agonists, and
For example, when you begin to rise from a parallel the amount of resistance to the given motion. Then,
first-position plié, the hip would be described as when providing specific sample muscles, choosing
undergoing extension because that is the direction primary muscles versus secondary muscles for the
of the movement, even though if you stopped the given joint movement (table 8.1) will generally help
movement before its completion, the hip would provide muscles that are responsible for generating a
be in a position of flexion (relative to anatomical large percentage of the necessary force and that are
position). operative under many conditions. However, if more
accuracy is necessary, referring to EMG and other
Identify Type of Muscle Contraction research studies can be helpful.
Identification of the type of muscle contraction
requires an appraisal of external forces relative to Identify Key Stabilizers (Optional)
internal forces and the resultant direction of move- Remember that when a muscle contracts as discussed
ment (chapter 2). In dance, concentric contractions in chapter 2, the muscle unpreferentially tends to
are generally used to move the body or its segments bring both of its attachments toward one another
in a direction against gravity and to accelerate limbs. (law of approximation). In many movements, isomet-
Conversely, eccentric contractions are generally used ric co-contraction of many muscles is occurring to
to move the body or its segments in the same direc- stabilize segments of the body and prevent unwanted
tion as gravity and to decelerate limbs. Additionally, movement due to this law of approximation or due to
isometric contractions are used to maintain the posi- movement of body segments away from the center of
tion of the body or its segments with no apparent mass of the body. For example, when movements such
joint movement occurring. as brushes (dégagés) are performed, co-contraction of
many muscles of the hip and spine works to prevent
Identify Prime Movers undesired compensations of the pelvis or torso.
Once the type of muscle contraction has been iden- To simplify movement analysis, emphasis is usu-
tified, the prime movers can be easily determined. ally placed on the body segments that are moving.
Remember that with a concentric contraction the However, it is important to realize that appropriate
prime movers will be the muscle group whose action functioning of these muscles of stabilization is key
is in the same direction as the observed joint move- for technique and injury prevention. In recognition
ment, while with an eccentric contraction, the active of their role, one approach is to include one or two
muscles are those whose action is opposite to the stabilizers that are essential to prevent common tech-
observed joint movement. If you are having trouble nique/alignment errors and allow proper execution
delineating the prime movers, imagine what joint of the movement. Another approach is to address
movements would occur if all the muscles around the stabilizers with technique considerations only if a
joints under observation relaxed. The prime movers technique error is occurring that relates to inappro-
would then be the muscle groups that would have priate use of a stabilizer. For example, if one were
to function to create or control movement in the analyzing a movement, the function of the abdomi-
desired direction at each joint. If the goal is to have nal muscles as stabilizers to prevent hyperlordosis
no movement occur at a given joint but relaxation (figure 8.3, p. 471) could be listed in a section titled
results in movement, the muscle group with an action “stabilizers” or in a section addressing “alignment
opposing this movement would be working isometri- and technique considerations” if excessive arching
cally to maintain the desired joint position. of the low back was noted.
FIGURE 8.1 Anterior view of primary muscles.
468
FIGURE 8.2 Posterior view of primary muscles.
469
TABLE 8.1 Summary of Fundamental Movements of Major Joints and the Primary Muscles That Can Produce Them
Major joint Movement Prime mover Major joint Movement Prime mover
Spine Flexion Rectus abdominis Ankle-foot Plantar flexion Gastrocnemius
External oblique Soleus
Internal oblique Dorsiflexion Tibialis anterior
Extension Erector spinae Extensor digitorum
longus
Rotation External oblique
Internal oblique Inversion Tibialis anterior
Erector spinae Tibialis posterior
Lateral flexion Quadratus lumborum Eversion Peroneus longus

External oblique Peroneus brevis
Internal oblique Shoulder Flexion Pectoralis major
Erector spinae (clavicular)
Hip Flexion Iliopsoas Anterior deltoid
Rectus femoris Extension Pectoralis major (sternal)
Sartorius Latissimus dorsi
Extension Hamstrings Teres major
Gluteus maximus Posterior deltoid
Abduction Gluteus medius Abduction Middle deltoid

Gluteus minimus Supraspinatus
Adduction Adductor longus Adduction Pectoralis major and

latissimus dorsi*
Adductor brevis
Anterior deltoid and
Adductor magnus
posterior deltoid*
Gracilis
External rotation Infraspinatus
External rotation Gluteus maximus
Teres minor
Internal rotation Subscapularis
Internal rotation Gluteus medius
Teres major
Gluteus minimus
Elbow Flexion Biceps brachii
Knee Flexion Hamstrings
Brachialis
Extension Quadriceps femoris
Extension Triceps brachii
*Adduction is produced by simultaneous action of these paired muscles.
Identify Key Synergists (Optional) scapular depressors can act as synergists to prevent
undesired excessive elevation of the shoulders
As just discussed, when a muscle contracts, it tends
(figure 8.4) and could be listed in a section titled
to produce all of its possible joint movements. If
“stabilizers” or in a section addressing “alignment
some of these actions are not being used in the
and technique considerations” if undesired scapular
analyzed movement, it is likely that one or more
elevation was noted.
synergists are being used to neutralize the unde-
sired action(s). To simplify movement analysis, the Identify Any Requirements
action of these synergists is often ignored. However,
for Extreme Range of Motion
as with stabilizers, more sophisticated analysis may
(Movement Specific)
include one or more synergists that are key for cor-
rect execution of the movement, or this area can Some movements performed in dance require
be selectively addressed with technique consider- extreme ranges of motion in one or more direc-
ations if a related error is observed. For example, tions and joints. In such cases, it is important that
in movements where the arms are overhead, the a movement analysis note this, as it may be relevant
A B
FIGURE 8.3 Use of the abdominal muscles as stabilizers to prevent arching of the low back. (A) Excessive spinal
hyperextension, (B) desired spinal stabilization.
A B
FIGURE 8.4 Use of the scapular depressors to prevent undesired elevation of the scapulae. (A) Excessive scapular
elevation, (B) desired positioning of the scapulae.
471
for optimal performance of the movement. These movements that particularly rely on lower extrem-
extremes of motion may represent points in the ity strength are movements that involve projecting
movement where either inadequate strength or inad- the body through space such as jumps and leaps
equate flexibility can prohibit achieving the desired and movements involving lowering the body weight
position. For example, performing the jump shown toward the floor such as hinges and falls (figure
in figure 8.5 (sissone ouverte) requires high levels 8.6). Examples that rely more on upper extremity
of hip flexor strength and hip extensor (hamstring) strength are partnering and movements requir-
flexibility for the front leg, and high levels of hip ing arm support such as handstands or cartwheels
extensor strength and hip flexor flexibility for the (figure 8.7).
back leg. This concept is particularly relevant with
multijoint muscles in which active insufficiency or Body Alignment
passive insufficiency can readily limit potential range and Technique Considerations
of motion or when movements require ranges far After determining the joint movements and key
exceeding those used in activities of daily living, such
muscles involved in the movement under analysis,
as in the pictured jump (figure 8.5) or the extreme one should look more closely at the performance of
ankle-foot plantar flexion desired for pointe work. the movement in terms of alignment, joint mechan-
ics, and special dance considerations discussed in
Identify Any Requirements for Marked
previous chapters on specific joints. For example,
Strength or Power (Movement Specific)
in performance of some more stationary movements
Some movements performed in dance require at the barre or center floor, the goal is frequently to
marked strength or power (ability to generate a maintain an approximately neutral positioning of
large amount of force in a small amount of time) many joints, avoiding excessive pronation of the foot,
that may limit performance capacity not related to hyperextension of the knee, tilting of the pelvis, or
using extreme range of motion. Examples of dance elevation of the shoulders.
However, in more dynamic
movement, some of these
movements naturally occur,
and the concern becomes one
of magnitude. For example,
pronation is a normal part of
walking and running move-
ments that is important for
shock absorption, but exces-
sive pronation can increase
risk for certain types of injuries.
Similarly, some anterior tilting
of the pelvis and increased
spinal hyperextension must
occur with an arabesque in
order to achieve the desired
height of the leg, but excessive
amounts without coordinated
co-contraction of abdominal
muscles can increase injury
risk to the low back and are
considered undesired from
an aesthetic perspective. In
some cases, it may be neces-
sary to obtain an understand-
ing of what “normal” values
are from reading research
studies, observing “correct”
FIGURE 8.5 Sample dance movement requiring extreme range of motion of the ham- performances of movement,
strings and hip flexors. or practical knowledge gained
Photo courtesy of Myra Armstrong. Dancer: Lorin Johnson with American Ballet Theatre.
only is a knowledge of “normal” required

but also a skillful analysis is necessary so
that appropriate corrections can be gen-
erated that will enhance performance
and not just create new problems. One
important aspect of this skill is the abil-
ity to distinguish a causal relationship
between errors and decide if something
is a problem in itself or is an effect result-
ing from another more fundamental
problem. Another important consider-
ation is the ability to prioritize problems
and decide which areas to address first.
One key factor that influences this pri-
oritization is how much improvement
would be expected from the correction
of a problem.
Although there are many approaches
that can be taken, one approach com-
monly used by the author is to begin with
more central or proximal corrections,
as these corrections often positively
impact performance, as well as influ-
FIGURE 8.6 Sample dance movement demanding high levels of strength of ence more distal problems. For example,
the knee extensors. when addressing a dancer performing a
Photo courtesy of Patrick Van Osta. CSULB dancers Shana Menaker and Dwayne Worthington.
from personal experience of incorrect and correct

execution of a given movement before one can make
an appraisal of “excessive.” In other cases, “normal”
is more intuitively obvious or is set by the aesthetic
of a given school of dance.
Some examples of common problems to look for
are provided in table 8.2. These errors can come
from many sources including inadequate stabiliza-
tion of prime movers, inadequate use of synergists to
neutralize undesired secondary actions of muscles,
unbalanced co-contraction of antagonist muscles,
inadequate muscle contraction to counter external
forces, and inappropriate weight placement (or com-
binations of these). In some cases the problems may
be linked to inadequate or imbalanced strength or
flexibility in select muscles, while in other cases the
problems may relate more to neural control factors
and suboptimum coordination of muscles to pro-
duce desired movements. When movement analysis
is being performed, key alignment and technique
errors should be noted; and if the analyst has suf-
ficient knowledge, brief suggestions for improving
these problems can be given. Sample strength exer-
cises, stretches, mechanics, and cues that may help
improve these problems are provided in table 8.2. FIGURE 8.7 Sample dance movement demanding high
However, if recommendations are to be given in levels of upper extremity strength.
an effort to correct these technique problems, not Photo courtesy of Patrick Van Osta. CSULB dancer Delyer Anderson.
TABLE 8.2 Key Alignment/Technique Problems and Potential Corrective Measures
Corrective measures
Joint alignment/
technique problem
(Common terminology) Strengthen Stretch Mechanics Sample cues
Spine
Excessive cervical lordosis Neck flexors Neck extensors Use the flexors of the head Bring the bottom of the
(Forward head, leading with (example: figure (example: figure and neck to decrease chin back, and imagine
chin) 3.29B, 3.29C, p. 103) cervical extension. being suspended from
p. 103) behind the ears or just
behind the midpoint of the
top of the head.
Excessive thoracolumbar Abdominals Spinal extensors Contract the abdominals Pull the bottom of the
extension (upper emphasis) (lower and middle) with emphasis on the upper front of the rib cage down
(Rib-leading) (examples: (examples: table attachment bringing the and back toward the spine
table 3.4, B-D, 3.7, A and B, ribcage down and back. as the upper back lifts up
pp. 134-135) p. 144) and slightly forward.
Excessive lumbar lordosis Abdominals Spinal extensors Contract the abdominals to Pull the pubic bone and
(Arched low back) (lower emphasis) (lower) posteriorly tilt the pelvis and bottom of the front of
(examples: table Hip flexors reduce lumbar extension the rib cage toward each
3.4, E and F, (examples: figure until a neutral position of the other.
pp. 135-136 3.25, B and C, pelvis and normal lumbar
and figure 3.25A, p. 97) curve are obtained.
p. 97)
Kyphosis Upper back Anterior shoulder Contract the thoracic spinal Lift the upper back up and
(Collapsed, rounded, extensors muscles extensors to decrease slightly forward toward the
slumped, upper back) (example: figure (examples: thoracic flexion. ceiling.
3.26A, p. 99) table 7.12, B-D,
pp. 449-450)
Abdominals
(examples: figure
3.26B, p. 99, and
table 3.7D,
p. 145)
Pelvis
Anterior pelvic tilt Abdominals Hip flexors Use the abdominals (with Pull up the pubic
(Released pelvis) (lower emphasis) (examples: table inferior attachment onto symphysis to create a
(examples: table 4.7, A and B, pelvis moving) or abdominal– neutral position of the
3.4, A-C and E, p. 224) hamstring force couple to pelvis.
pp. 134 and Spinal extensors posteriorly tilt the pelvis until
135) (lower) the pubic symphysis and ASIS
are in vertical alignment.
Posterior pelvic tilt Spinal extensors Abdominals Use the hip flexors or spinal Bring the top of the pelvis
(Tucked pelvis) Hip flexors (examples: table extensors to anteriorly tilt forward, and lift the lower
(examples: 3.7, C and D, the pelvis until the ASIS and spine up.
table 4.5, A-C, pp. 144-145) pubic symphysis are vertically
pp. 213-214) aligned, and use the spinal
extensors to reduce flexion
of the lumbar spine.
474
Corrective measures
Joint alignment/
technique problem
Hip
Not achieving or Deep outward Hip internal Emphasize use of the lower Bring the greater
maintaining hip external rotators rotators, hip joint DOR to keep the femur trochanter toward the sitz
rotation (examples: table capsule, and externally rotated in the bones, and wrap the back
(Losing turnout) 4.5, M-O, pp. anterior ligaments acetabulum, particularly of the thigh inward.
219-220) (example: figure when extending the knees.
3.42, p. 126)
Hip flexors
(example: table
4.7A, p. 224)
Hip adductors
(example: table
4.7J, p. 228)
Knee
Valgus position of knee Deep outward Hip internal Prevent internal rotation of Maintain rotation at the
(Knees facing inward, rotators rotators (if the femur or tibia relative hip, and guide the knee
knees falling inside feet) (examples: table indicated) to the foot via contraction over the foot during knee
4.5, M-O, (example: figure of the hip external rotators, flexion.
pp. 219-220) 4.32, p. 198) knee external rotators, or
positioning of the foot.
Knee hyperextension Quadriceps Use the DOR to limit internal Keep the knees facing
(Pressing knees back, (examples: table rotation of the femur forward and just in front
locking knees) 5.3, C and D, associated with the final of the ankle bones (lateral
pp. 275-276) stages of knee extension, malleoli) as the knees
Hamstrings or stop knee extension extend.
(example: table before hyperextension
5.3F, p. 277) via co-contraction of the
Deep outward hamstrings and quadriceps
rotators or relative positioning of body
(examples: table segments.
4.5, N and O,
p. 220)
Ankle-foot
Excessive pronation Foot inverters Triceps surae Maintain adequate rotation Lift up the inner border
(Rolling in) (examples: (examples: at the hip, and contract the of the foot to achieve
table 6.6, E-G, table 6.8, A-D, biceps femoris as needed to a neutral position of
pp. 346-347) pp. 356-357) prevent undesired internal the foot and maintain
rotation of the tibia and appropriate rotation at the
associated pronation. Use hip for proper knee-foot
the foot inverters to limit alignment.
pronation, and keep adequate
weight on the lateral
metatarsal heads (toes).
Excessive supination Foot everters Avoid excessive rotation of Lift up the outer border
(Rolling out) (examples: table the tibia or varus position of the foot to achieve a
6.6, H and I, of the knee and associated neutral position of the foot
p. 348) supination. Maintain and maintain appropriate
adequate weight on the knee-foot alignment.
hallux.
(continued)
475
TABLE 8.2 Key Alignment/Technique Problems and Potential Corrective Measures (continued)
Joint alignment/
technique problem
Ankle-foot (continued)
Inadequate plantar flexion Ankle-foot Ankle-foot Maximize plantar flexion Pull up and forward with
(Stiff foot, inadequate plantar flexors dorsiflexors and of the intertarsal and the stirrup muscles.
point) (examples: table other passive tarsometatarsal joints, not
6.6, A and B, constraints to just talocrural joints. Shift
pp. 343-344) plantar flexion the body weight forward
Stirrup muscles (examples: adequately to facilitate
(examples: table table 6.8, E and F, optimal plantar flexion.
6.6, F, H, and N, p. 358)
pp. 347, 348,
and 351)
Intrinsic
muscles that
support medial
longitudinal arch
(examples: table
6.6, J and K,
p. 349)
Shoulder
Rolled shoulders Scapular Shoulder Prevent undesired “rolled Bring the shoulder blades
(Rounded shoulders, adductors internal rotators position” of the shoulders slightly together and down
closed chest) Shoulder and horizontal by contracting the shoulder as the shoulders reach
Often accompanied by external rotators adductors external rotators and sideward.
kyphosis Thoracic spinal (example: table scapular adductors.
extensors 7.12D, p. 450)
(examples: table
7.10, H and I,
p. 439)
Excessive scapular Scapular Upper trapezius Use the scapular depressors Reach the arm down, out,
elevation depressors (example: figure to prevent undesired and around as the scapula
(Lifted shoulders) (example: table 3.29C, p. 103) elevation during the desired rotates, without excessive
7.10C, p. 435) upward rotation of the lifting, when raising the
scapula that accompanies arm overhead.
shoulder abduction or flexion.
Excessive scapular Scapular Scapular Use the scapular abductors Reach the elbows away
adduction abductors adductors to prevent undesired and slightly forward so
(Pinched shoulders) (example: table Thoracic spinal scapular adduction, and use that the hands are visible
Often accompanied by 7.10K, p. 440) extensors the abdominals to prevent in the peripheral vision
thoracolumbar extension (example: table undesired thoracolumbar when the arms are at the
3.7B, p. 144) spinal extension. sides or overhead.
second-position plié, correction of excessive lumbar positive effects on distal joints. Similarly, providing cues
lordosis and an anterior pelvic tilt will often correct the and exercises to aid the dancer in achieving and main-
associated functional valgus position of the knees and taining appropriate external rotation at the hip will
excessive foot pronation. So, using various cues (and often positively influence distal joints as discussed in
supplemental exercises if indicated) to aid the dancer previous chapters. Adding sufficient external rotation
in establishing a neutral position of the spine and at the hip can correct relative functional tibial internal
pelvis should be prioritized, as this will also have rotation and the associated pronation of the foot.
Influence of Spinal-Pelvic Alignment

on Distal Joint Mechanics
Stand in a turned-out second position in front of a mirror.
• Valgus and varus position of the knee. Perform a demi-plié in a second position, focusing on
guiding the middle of your kneecap over your second toe as your knees bend. Then, purposely slowly
anteriorly tilt the pelvis, letting the top of the pelvis rotate forward. Notice the associated tendency
for your knees to move inward, creating a valgus position of the knee. Now, purposely slowly posteri-
orly tilt the pelvis, bringing the bottom of the pelvis forward while the top of the pelvis rotates back.
Notice the associated tendency for your knees to move outward, perhaps even to a position where
they are behind the axis of the foot (varus position of the knee). Lastly, establish a neutral position
of the pelvis where the top of the anterior pelvis (anterior superior iliac spines) is vertically aligned
above the bottom of the anterior pelvis (pubic symphysis) and see if you can more readily position
the midpoint of your patellas over your second toes.
• Foot pronation and supination. Again, perform a demi-plié in second position, focusing on guiding
the middle of your kneecap over your second toe, with the foot in neutral alignment. Then, purposely
slowly anteriorly tilt the pelvis, and notice that as the knees fall inward, the feet also tend to roll in,
creating a pronated position of the feet. Next, posteriorly tilt (tuck) the pelvis, and notice that as your
knees tend to move outward, the feet also tend to roll out, creating a supinated position of the foot.
Lastly, establish a neutral position of the pelvis, and see if you can position the mid-patella approxi-
mately over the second toe such that the foot is in a neutral position with slightly more weight placed
over the base of the big toe versus the little toe, and a formed longitudinal arch.
• Changes in muscle use. Again, while maintaining a second-position plié, anteriorly tilt your pelvis,
and this time also let your torso slightly lean forward. Notice if you feel any difference in muscle use
with this misaligned position than when in a neutral position. Go back and forth between these posi-
tions several times to check your observation. Some dancers experience a greater sense of work in
the quadriceps femoris and tensor fasciae latae in the misaligned position and more ability to feel
the hamstrings working in the correctly aligned position.
In contrast, correcting the distal foot pronation Special Considerations

by contracting the foot inverters, without addressing
the underlying more fundamental alignment of the In faster movements, movement analysis can become
spine and pelvis, will often not provide the desired more complex. Rather than the more sustained use
corrections proximally and may result in muscle of a prime mover with a certain type of contraction
fatigue and potentially shin splints if positioning throughout most or all of a phase, bursts of muscle
of proximal segments are producing large internal activity, the use of momentum, and quick changes
rotation forces of the tibia that are countered by only in contraction type play a more prominent role. For
relatively small muscles of the foot. It is also gener- example, as the thigh swings forward during low leg
ally not possible to maintain this distal correction in swings, the hip flexors are briefly used concentrically
dynamic movement, which requires complex adjust- to initiate the motion; next, momentum becomes
ment of the joints of the feet including relative prona- primary; and then toward the end of the forward
tion and supination to meet the demands of shock motion, the hip extensors are used eccentrically to
absorption and propulsion in locomotor movements. decelerate the thigh and then concentrically to initi-
However, it is important to note that in athletes that ate the swing of the leg in a backward direction in the
wear shoes (such as runners), distal correction with next phase of the movement. This eccentric use of
well-designed arch supports or orthotics, rather than muscles to aid with changing the direction of move-
superimposed contraction of the inverters, can often ment of a limb does not invalidate classic movement
be helpful for improving technique. analysis, which would suggest that the hip flexors
Influence of Movement Quality on Muscle Use
While standing or sitting in a chair, perform shoulder flexion and extension with your right arm accord-
ing to the following directions.
• Slow raise and lower. Slowly raise your arm to the front to shoulder height, pause, and then
slowly lower it. Note the predominance of muscle activity in the anterior shoulder muscles (including
the anterior deltoid), working concentrically when raising and eccentrically when lowering the arm.
• Resisted raise and lower. Slowly raise and then lower your arm as if moving through tar or
molasses. Note the muscle work on both sides of the shoulder (including the anterior and posterior
deltoid) as the antagonist creates internal resistance (eccentric contraction) while the agonist acts
concentrically as the prime mover.
• Slow raise and released lower. Slowly raise your arm to shoulder height, pause, and then relax
the muscles and just let the arm drop as gravity effects the movement. Now, just add a very small
amount of muscle contraction to decelerate and control the movement toward the end of the drop.
DANCE CUES 8.1
“Use Your Bones, Not Your Muscles”
I n contemporary dance techniques emphasizing a “released quality of movement,” teachers will some-
times cue students to “use your bones, not your muscles.” This cue is not consistent with anatomical
principles since bones cannot produce movement, and if the muscles were not used during movement
the dancer would collapse to the floor. One possible interpretation of the intent of this cue is to relax
muscles during portions of a movement, allowing gravity and momentum to play a more prominent
role in generation of movement of the limb or body part utilized. However, some muscle contraction
would be necessary toward the end of a given movement to decelerate the body segment to prevent
collapsing or to change the direction of movement. Rewording the movement cue to incorporate
muscle contribution with phrases such as “release and recover” or “fall and recover” would be more
consistent with anatomical and biomechanical principles.
work as prime movers to swing the thigh forward and movement when performing a high kick to the front
that the hip extensors work as prime movers to swing (grand battement). If the emphasis is “in,” the hip
the thigh backward. Rather, it just demonstrates extensors (hamstrings) can be felt working concen-
additional contribution of muscles revealed from trically sooner to close the leg back in to the starting
EMG studies of rapidly reversing reciprocal motions position on the down-phase of the movement; when
that would not necessarily be predicted from a pure the accent is “out,” the hip flexors can be felt work-
anatomical analysis of the movement. ing eccentrically longer in the down-phase of the
In addition to speed, dance often utilizes very movement. Similarly, other differences in qualities
subtle and specific execution directives that can or efforts of movement can influence muscle use.
influence muscle use. For example, many movements Laban (Hodgson, 2001) uses words such as “light”
can be purposely varied to provide an “accent,” or and “strong” or “free” and “bound” to describe the
emphasis, at different times during the movement, “efforts” associated with movement. With bound
as in emphasizing the “out” or “in” phase of the movements, internal resistance is often created
which muscles you feel working,

or do both. Use this to check your
analysis. If your body check is not
consistent with your theoretical
analysis, rethink your analysis and
make sure the effect of gravity is
being appropriately accounted
for. Also, make sure that the
sensation you are keying in to
in your body is one of muscle
contraction, and not one from
stretching the antagonist. In
addition, remember that you may
feel muscles working that are not
prime movers, but rather stabiliz-
ers and synergists.
Schema for Anatomical

Movement Analysis
A schema for analyzing move-
ments that incorporates the con-
cepts just discussed is provided
FIGURE 8.8 Performance of a jump with an appearance of effortlessness. in table 8.3. This schema will be
© Angela Sterling Photography. Pacific Northwest Ballet dancer Lisa Apple. used to analyze sample move-
ments in this section. Readers are
with co-contraction of antagonists and agonists. In also encouraged to develop analysis skills by applying
contrast, with some types of free movements (e.g., this schema to many other movements. Research
“release”), momentum is allowed to make a greater indicates that both practice of movement analysis
contribution, with muscular contraction often occur- in general and practice in distinguishing the criti-
ring more briefly to accelerate and decelerate body cal features of a given skill can markedly improve
segments, rather than working in a more continuous analysis ability (Hall, 1999). For readers new to this
manner to control movement. process, having the subject wear body-conforming
A related and subtle special consideration has attire such as a leotard and the use of a background
to do with the external appearance of effort and that facilitates observation (such as one with a grid,
movement economy. In many dance forms, part of vertical lines, or colors contrasting with those on the
the dance aesthetic is to perform demanding move- subject) can aid in the observation process. In some
ments without an undue appearance of effort and cases, adding sticky markers (such as dots) to key
without disrupting the expressive quality desired landmarks, or having the subject wear an elastic belt
by the choreographer (figure 8.8). One aspect of that contrasts in color to the leotard and background,
achieving this appearance likely relates to movement will make alignment considerations easier to evalu-
economy. The desire is often to achieve the objec- ate. For more complex or faster movements, using a
tive of the movement without any unnecessary work, video recording that can be repetitively observed or
effort, or apparent movements of body segments not watched at a slower speed can help with observation
designed to be part of the movement. This requires and train observation skills.
very skilled activation of muscles with appropriate
magnitude and timing and may involve less activation Sample Anatomical
of muscles in general, and specifically less reliance Movement Analyses
on co-contraction for movement accuracy.
An anatomical analysis of two sample dance move-
Analysis Check ments follows. These movements were selected to pro-
If possible, perform the movement under analysis vide an example of lower limb movement occurring
with your own body and palpate the muscles you primarily in the sagittal plane and lower limb move-
think should be working, or internally key in to ment occurring primarily in the frontal plane.
TABLE 8.3 Movement Analysis Schema
Basic analysis Supplemental analysis

1. Divide the movement into phases based on movement direction or functional 6. Identify key muscles acting as
goals. stabilizers that are important for correct
technique (optional).
2. Select the key joint(s) where visible movement occurs and that are particularly 7. Identify key muscles acting as
important for correct execution of the movement. synergists that are important for correct
technique (optional).
3. Identify the key joint movements that occur in each phase. 8. Identify any requirements for extreme
range of motion (movement specific).
4. Identify the type of muscle contraction in each of the phases or phase 9. Identify any requirements for marked
subdivisions. In more simple movement analysis, the entire phase generally strength or power (movement specific).
involves the same type of muscle contraction. With more complex movements,
multiple types of muscle contractions may exist within a given phase.
A. Identify concentric muscle contractions/phases. Concentric muscle
contractions act in the opposite direction to gravity or other external forces
where the action of the given muscle group is in the same direction as the
direction of the observed movement.
B. Identify eccentric muscle contractions/phases (if present). Eccentric muscle
contractions act in the same direction as gravity or other external forces
to decelerate or control movement, such as on the down-phase of a given
movement. The action of the active muscle group is in the opposite direction
to the direction of the observed movement.
C. Identify key isometric muscle contractions/phase(s) (if present). Isometric
muscle contractions exactly balance opposing forces so that there is no
change in joint angle and no visible movement is observed.
5. Identify the primary muscle group(s) (and sample prime movers) that 10. Identify any body alignment and
produce/control the joint movement(s) in each phase. Where appropriate: technique problems (dancer specific).
A. Begin with the primary muscle group that produces the joint movement on the
concentric phase(s) (muscles whose primary action is the joint movement
observed during the concentric phase).
B. Then identify the primary muscle group that produces the joint movement on
the eccentric phase(s) (muscles whose primary action is opposite to the joint
movement observed—often the same muscle group as used in the concentric
phase is used in the eccentric phase to control the opposite joint action).
11. Identify special considerations that
influence muscle use (movement specific).
12. Check your analysis by performing the
movement and rethinking the logic used.
Front Kick (Grand Battement Devant) in normal standing and in anatomical position.
From a Lunge The ankle-foot plantar flexors also work concentri-
With the front kick (table 8.4), the hip flexors work cally to decrease dorsiflexion by pulling the tibia
concentrically on the gesture leg (right leg) in the backward (ankle-foot plantar flexion with proximal
beginning of the up-phase (subphase A to B) to bring segment—the tibia—moving). These actions result
the leg forward, while the knee extensors keep the in appropriate positioning of the hip, knee, and
knee extended and the ankle-foot plantar flexors ankle to provide a stable support leg for the next two
point the foot. At the same time, the hip extensors subphases of the movement. In the next subphase
and knee extensors of the support leg (left leg) work (subphase B to C), the hip extensors, knee extensors,
concentrically to bring their respective joints from a and ankle plantar flexors of the support leg work iso-
position of flexion to the “extended position” used metrically to maintain their position, while the hip
flexors of the gesture leg concentrically contract in maintained over the support leg. One particularly
a forceful manner to raise the leg high to the front. key muscle group acting as stabilizers are the hip
Simultaneously, the knee extensors work to keep external rotators on the support leg. If these are
the knee extended, and generally the plantar flexors not appropriately used, the pelvis will tend to rotate
contract concentrically to produce a slightly greater toward the support leg (left pelvic rotation result-
pointed position of the gesture ankle and foot. ing in relative hip internal rotation of the support
Now, to reverse the movement, the hip flexors leg) as the gesture leg is lifted. Cueing dancers to
of the gesture leg work eccentrically to control the focus on maintaining turnout on the hip of the sup-
lowering of the leg during the initial part of the down- port leg is key for helping to limit pelvic rotation
phase (subphase C to D), while the knee extensors to a degree that is accepted by the aesthetic of the
and ankle-foot plantar flexors work isometrically to particular school of dance. In terms of synergists,
maintain their positions. In the final portion of the the hip adductors would theoretically act as help-
down-phase (subphase D to E), the hip extensors of ing synergists on the gesture leg to neutralize the
the gesture leg work concentrically to bring the leg undesired abduction action of lateral hip flexors,
behind the body, while the knee extensors work iso- such as the tensor fasciae latae and sartorius, so as
metrically to keep the knee straight. At the end of this to keep the leg appropriately positioned in front of
subphase, ankle-foot dorsiflexion of this leg can be the body. Focusing on the end of the up-phase of
produced by a combination of concentric contraction the movement, it can be ascertained that inadequate
of the ankle-foot dorsiflexors and the passive effect of hamstring flexibility (passive insufficiency) or inad-
shifting the body weight back so that the gesture leg equate hip flexor strength (active insufficiency), or
now helps support the body weight. During this sub- both, could limit the dancer’s ability to achieve the
phase, the support leg is also undergoing joint move- desired height of the leg.
ments to return to the starting position. In this case, the In terms of technique, one common error is
hip extensors, knee extensors, and ankle-foot plantar bending the knee of the support leg as the gesture
flexors all work eccentrically to control hip flexion, leg is lifted to the front. As described in chapter 4,
knee flexion, and ankle dorsiflexion, respectively. posteriorly tilting the pelvis will change the facing of
Because this movement is performed in a turned- the acetabulum and allow for less relative shorten-
out versus parallel position, the hip external rotators ing of the iliopsoas, both of which would facilitate
are working in an approximately isometric manner greater height of the gesture leg. One study showed
throughout the movement on both the support that an average of 30° of posterior tilting of the pelvis
and gesture legs. In different phases of the move- (beginning at about 45° thigh displacement) and
ment, changes in joint angle and other factors will an average of 82° of hip flexion were combined to
influence the relative contribution of specific hip effect the end position of a grand battement devant
external rotators and the degree to which they are (Ryman and Ranney, 1979). However, an excessive
activated. degree of posterior tilting of the pelvis or tight hip
Looking at the upper extremity and simplifying flexors will bring the femur forward and cause unde-
the analysis to the shoulders, the right and left shoul- sired flexion of the knee on the support leg.
der flexors work concentrically to raise the arms to Preventing this undesired knee flexion can be
the front to different heights on the up-phase of the accomplished in many ways, including emphasizing
movement. On the down-phase, gravity would tend using the quadriceps femoris to maintain the knee
to make the arms rapidly fall back down to the sides, in an extended position (often encouraged through
and so the shoulder flexors work eccentrically to con- cueing to “pull up the thigh of the support leg”),
trol the lowering of the arms (shoulder extension). A using an appropriately balanced co-contraction of
more detailed analysis of this movement would take the hip flexors and extensors on the support leg to
into account the subtle rotation that occurs at the limit hip hyperextension and associated posterior
shoulder to help position the elbow and forearm in tilting of the pelvis (often encouraged through
accordance with this classical aesthetic. cueing to “reach the sitz bones down toward the
Looking at the movement more specifically, floor on the support leg”), or limiting the backward
because of the challenge of balancing on one leg lean of the torso and associated hip hyperextension
and the large weight of the leg being displaced, many and posterior pelvic tilt (often encouraged through
muscles throughout the body would have to work cueing to “keep the torso directly above the pelvis”).
in an approximately isometric manner as stabilizers Although there is a natural slight backward shift
to maintain the desired “aligned” upright position of the torso as the leg kicks (Ryman and Ranney,
of the body with the body weight appropriately 1979) to offset the forward leg displacement and
put the hip flexors in a better position in terms of extensors eccentrically to help decelerate the leg
their length for force generation, excessive backward toward the end of the up-phase. There is also likely
lean is undesired from an aesthetic perspective. In use of the hip extensors concentrically at the end of
terms of special considerations, if the movement the down-phase to help close the leg back into the
is performed rapidly, there is likely use of the hip starting position.
TABLE 8.4 Anatomical Analysis of a Front Kick (Grand Battement Devant) From a Lunge
(hip, knee, ankle-foot, shoulder)
A B C D E
Contraction
Movement phases Joint movements type Prime movers: muscle group (sample muscles)
Up-phase
Subphase: A to B
Right hip Hip flexion Concentric Hip flexors (iliopsoas, rectus femoris)
(Hip external rotation maintained) Isometric Hip external rotators (deep outward rotators)
Right knee (Knee extension maintained) Isometric Knee extensors (quadriceps femoris)
Right ankle-foot A-F plantar flexion Concentric A-F plantar flexors (gastrocnemius, soleus)
Left hip Hip extension Concentric Hip extensors (hamstrings, gluteus maximus)
Left knee Knee extension Concentric Knee extensors (quadriceps femoris)
Left ankle-foot A-F plantar flexion Concentric A-F plantar flexors (gastrocnemius, soleus)
Right shoulder Shoulder flexion Concentric Shoulder flexors (anterior deltoid, pectoralis major)
Left shoulder Shoulder flexion Concentric Shoulder flexors (anterior deltoid, pectoralis major)
Subphase: B to C
Right hip Hip flexion Concentric Hip flexors (iliopsoas, rectus femoris)
Left shoulder Shoulder flexion Concentric Shoulder flexors (anterior deltoid, pectoralis major)
Contraction
Movement phases Joint movements type Prime movers: muscle group (sample muscles)
Down-phase
Subphase: C to D
Right hip Hip extension Eccentric Hip flexors (iliopsoas, rectus femoris)
Right ankle-foot (A-F plantar flexion maintained) Isometric A-F plantar flexors (gastrocnemius, soleus)
Right shoulder Shoulder extension Eccentric Shoulder flexors (anterior deltoid, pectoralis major)
Left shoulder Shoulder extension Eccentric Shoulder flexors (anterior deltoid, pectoralis major)
Subphase: D to E
Right hip Hip extension Concentric Hip extensors (hamstrings, gluteus maximus)
Right ankle-foot A-F dorsiflexion Concentric A-F dorsiflexors (extensor digitorum longus, tibialis
anterior)
Left hip Hip flexion Eccentric Hip extensors (hamstrings, gluteus maximus)
Left knee Knee flexion Eccentric Knee extensors (quadriceps femoris)
Left ankle-foot A-F dorsiflexion Eccentric A-F plantar flexors (gastrocnemius, soleus)
Right shoulder Shoulder extension Eccentric Shoulder flexors (anterior deltoid, pectoralis major)
Left shoulder Shoulder extension Eccentric Shoulder flexors (anterior deltoid, pectoralis major)
Lateral Tilt adduction with proximal segment—pelvis—moving)

With the lateral tilt (table 8.5), the hip abductors to help return the trunk to vertical in the initial part
work concentrically on the gesture leg (right leg) to of the return phase (subphase C to D). The right hip
raise the leg (hip abduction with distal segment— abductors, knee extensors, and ankle-foot plantar
femur—moving) in the beginning of the tilt phase flexors continue to act isometrically to maintain the
(subphase A to B), while the knee extensors work desired positioning of the gesture leg. Then, in the
isometrically to keep the knee extended and the later portion of the return phase (subphase D to E),
ankle-foot plantar flexors work concentrically to generally the hip abductors of the gesture leg briefly
point the foot. Then, as the torso tilts “up and over” work eccentrically to control the lowering of the leg
the support leg (subphase B to C), the hip adductors until the toe contacts the floor, at which point the
work eccentrically on the support leg (left leg) to help hip adductors work concentrically to draw the leg
control the lateral tilt of the trunk via the pelvis (hip back to the starting position while the knee exten-
abduction with proximal segment—pelvis—moving). sors continue to work isometrically to maintain the
Once the torso is no longer vertically aligned relative knee in extension. After the toe contacts the ground,
to the support leg, gravity would tend to make the concentric contraction of the ankle-foot dorsiflexors
trunk rapidly fall to the left, and it is the eccentric and the passive effect of shifting the body weight back
contraction of the hip adductors of the support leg over the right leg also act to produce the desired
(and the isometric contraction of the right lateral dorsiflexion of the right ankle.
flexors of the spine) that are vital for controlling Looking at the upper extremity and simplifying
this off-center movement and achieving the desired the analysis to the shoulders, the shoulder abduc-
dance aesthetic. tors work concentrically to simultaneously abduct
Now, to reverse the movement, the hip adductors the right and left shoulder on the tilt phase of the
of the support leg now work concentrically (hip movement. On the return phase, gravity would tend
TABLE 8.5 Anatomical Analysis of a Lateral Tilt (hip, knee, ankle-foot, shoulder)
A B C D E
Movement Contraction
phases Joint movements type Prime movers: muscle group (sample muscles)
Tilt phase
Subphase: A to B
Right hip Hip abduction Concentric Hip abductors (gluteus medius, gluteus minimus)
Subphase: B to C
Left hip Hip abduction Eccentric Hip adductors (adductor longus, adductor magnus)
Right hip (Hip abduction maintained) Isometric Hip abductors (gluteus medius, gluteus minimus)
Right and left Shoulder abduction Concentric Shoulder abductors (middle deltoid, supraspinatus)
shoulders
Return phase
Subphase: C to D
Left hip Hip adduction Concentric Hip adductors (adductor longus, adductor magnus)
Right hip (Hip abduction maintained) Isometric Hip abductors (gluteus medius, gluteus minimus)
Right and left Shoulder adduction Eccentric Shoulder abductors (middle deltoid, supraspinatus)
shoulders
Subphase: D to E
Right hip Hip adduction Concentric Hip adductors (adductor longus, adductor magnus)
Right ankle-foot A-F dorsiflexion Concentric A-F dorsiflexors (tibialis anterior, extensor digitorum
longus)
484
to make the arms rapidly fall back down to the sides, as skilled activation of many muscles of the support
and so the shoulder abductors work eccentrically to leg are vital for successful execution of this move-
control the lowering of the arms. A more detailed ment.
analysis of this movement would take into account In terms of technique, one common error is fail-
the more specific effects of gravity. For example, ure to keep the trunk movement primarily in the
as the right arm passes a vertical position, such as frontal plane. The trunk is commonly flexed at the
seen in table 8.5C, gravity would actually tend to hip joint, with the bottom of the pelvis going back
produce shoulder abduction rather than adduction, while the ribs project forward (excessive thoraco-
and the right shoulder adductors would actually be lumbar extension). In such a case, cueing to “keep
used eccentrically in the brief portion of the range the sitz bones down and forward over the support
of motion to bring the arms to the full overhead leg” (neutral position of hip extension via use of the
position, isometrically if position C was maintained, abdominal–hamstring force couple) while “the front
and concentrically for the brief portion of the return of the lower ribs are pulled down and slightly back”
phase until the arm passes a vertical position. (neutral position of the spine) can help achieve the
Looking at the movement more specifically, desired positioning.
because of the challenge of balancing on one leg In terms of special considerations, this movement
as the trunk moves laterally and the large weight of can be performed with many variations, including
the gesture leg, many muscles work as stabilizers in a off-center positions of the trunk and allowing marked
highly coordinated manner to achieve desired posi- lateral tilt of the pelvis to maximize leg height. In the
tioning of the segments of the body. One important latter case, marked right lateral flexion of the spine
example of stabilization occurs with the spine. In the is required in the tilt position to bring the shoulders
starting position, co-contraction of the spinal flexors and eyes to an approximately horizontal position.
and extensors can be used to achieve the desired This demands marked spinal flexibility and strength
approximately neutral alignment of the trunk with of the lateral flexors of the spine.
the desired lift or presentation of the torso. However,
as the trunk moves laterally, gravity now plays a key Potential Benefits
role, tending to produce lateral flexion of the trunk. of Anatomical Movement Analysis
Now, as previously stated, the right lateral flexors
have to work approximately isometrically to keep Anatomical movement analysis can be used to help
the desired neutral extended position of the spine. improve performance of a given movement in
Cueing students to “reach the spine out long and in various ways. First, such an analysis results in the
line with the middle of the sacrum” (vs. letting it fall determination of which muscles are acting as prime
sideways—laterally tilt) as the trunk tilts primarily movers. An understanding of the muscles acting as
from the hip joint can sometimes help achieve the prime movers can help with appropriate generation
desired positioning. of movement cues and strengthening exercises.
In terms of synergists, the oblique abdominal For example, in the front kick from a lunge, many
muscles have been shown to be key lateral flexors of dancers aim to improve the height to which they
the spine. However, contraction of the right internal can lift the leg. Anatomical analysis and reference
oblique would also tend to produce undesired right to EMG studies reveal that the hip flexors, and espe-
rotation and flexion of the spine. The right external cially the iliopsoas, are key for performance of this
oblique could be used as a synergist to neutralize movement in high ranges of motion. Hence, cues
undesired rotation, and the spinal extensors could aimed at emphasizing use of the iliopsoas, as well as
be used as synergists to neutralize undesired flexion supplemental exercises that focus on strengthening
of the spine. and activation of this muscle in a range of motion
Considering strength and flexibility and focus- similar to that required by the movement, should
ing on the end of the up-and-over phase of the result in improvement in leg height.
movement, it can be ascertained that inadequate Anatomical analysis also yields potential flex-
hip adductor flexibility, as well as inadequate hip ibility constraints for a given movement; and when
abductor strength, could limit the dancer’s ability to inadequate flexibility is operative, improving the
achieve the desired height of the leg. If performed flexibility of these muscles can improve perfor-
turned out, inadequate hamstring flexibility and mance of the given movement. So, in the front kick,
inadequate hip flexor and hip external rotator anatomical analysis reveals that adequate flexibility
strength could also limit the height of the gesture of the hamstrings is key for maximizing the height
leg. Lastly, adequate strength and flexibility as well to which the leg can be lifted to the front, and
Comparison of Passive and Active Range of Motion

for a Grand Battement
Perform the screening test for hamstring flex-
ibility described in chapter 4 (Tests and Mea-
surements 4.4, p. 205) on yourself by using
one hand to lightly bring one leg toward your
shoulder while the back of the other leg stays
in contact with the floor, as shown in the figure
(A). Compare the angle of hip flexion derived
passively with this hamstring test to the range
of hip flexion exhibited when actively raising A
the leg to the front at a relatively slow speed
(B). An easy way to practically compare these
measurements is to note the height of your foot
relative to your head and trunk. If the passive
hamstring test results (hip angle) are low rela-
tive to desired values for dancers and the foot
height is close to the level achieved actively, the
hamstrings are likely serving as constraints, and
hamstring stretching would be recommended to
help improve battement height. However, many
dancers achieve a much greater range passively
than they can achieve actively, especially in
movements such as slow front extensions in
which momentum cannot be of much help. In
such cases, the hamstrings are likely not the
primary limiting constraint, and focus should
move to strengthening the hip flexors (iliopsoas B
emphasis) and optimizing technique.
improving hamstring flexibility with supplemental Multijoint muscles such as the hamstrings that are
stretching exercises could improve performance if required to undergo extreme elongation appear
hamstring tightness is a limiting factor. One way to to be at greater risk for being strained. Although
quickly ascertain if strength or flexibility is a limiting this is a complex and controversial area, perform-
factor is to compare passive range of motion to the ing supplemental exercises for these muscles to
range used by the dancer during execution of the develop adequate flexibility, adequate strength,
movement (Tests and Measurements 8.1). If passive balanced strength between right and left sides for
range of motion is close to that achieved actively, the same muscle, and balanced strength between
this suggests that improving flexibility would likely the muscle of concern and its antagonist will likely
help improve the range utilized in the movement. reduce injury risk.
However, if the range achieved passively is mark- Lastly, evaluation of alignment and technique
edly higher than achieved in the movement, this factors can reveal factors that, when corrected,
suggests that flexibility is not limiting and that can enhance performance, help develop general
strength or activation patterns, or both, are more dance skills, and in some cases reduce injury risk.
likely implicated. For example, analysis might reveal that a dancer is
Analysis of potential muscle constraints can also excessively arching his or her back during the front
be useful for predicting and lowering injury risk. kick. This movement pattern, considered undesired
aesthetically in many dance forms, can interfere with movement, termed kinetic data. Many tools can be
allowing the normal slight posterior tilting of the utilized to measure kinematic quantities, includ-
pelvis that accompanies higher ranges of hip flexing timing devices, computer-linked film analysis
ion and hence limit the height of the leg, interfere (computerized cinematography), computer-linked
with establishing relationships of the center of mass video analysis (computerized videography), devices
of body segments desired for complex balancing, that are attached to joints to provide joint angle
produce increased shear forces in the low lumbar recordings during movement (electrogoniometry),
spine, create an undesired increase in spinal exten- and use of very small electric lights (light-emitting
sor activity, and negatively affect the biomechanics diodes, or LEDs) or electromagnetic markers inter-
of distal weight-bearing joints. Hence, correction of faced with cameras and computers (optoelectronic
this error can have significant impact on both dance systems).
performance and injury risk. However, as previously Examples of information obtained from kine-
stated, this aspect of anatomical analysis requires matic quantitative analysis include the displacement
a keen understanding of the desired movement of the center of gravity or landmarks of concern,
characteristics, as well as a skillful analysis of the joint angles at different phases of movement, and
causes of technique problems when they are present. the rate or duration of motion of body segments.
For example, is the lumbar lordosis just described Figure 8.9 shows the use of body landmark markers
related to hip flexor tightness, low back tightness, and the application of a special type of goniometer
abdominal weakness, or suboptimal muscle activa- (electrogoniometer, or elgon) that is hooked up to
tion patterns? a recorder so that it can monitor changes in joint
angle during the movement being studied.
Tools for obtaining kinetic data include devices
Other Methods used to measure applied forces for strength analysis
for Movement Analysis (dynamometers and tensiometers), pressure plat-
forms in shoes, or devices that can be attached to
Despite the potential value, it is also important to a foot to provide graphical or digital information
realize that a basic anatomical movement analysis
represents a gross simplification of what is actually
going on, used for practical purposes. Anatomical
analysis relies on determination of joint movement
(direction) through observation combined with
theoretical actions of key muscles to predict the
muscles that are primarily responsible for a given
movement. Hence, one can enhance its accuracy,
precision, and depth by referring to studies that
utilize quantitative analysis to substantiate or reject
theoretical predictions and by applying some basic
principles of mechanics.
Quantitative Versus Qualitative Analysis

The anatomical movement analysis presented in
this chapter utilizes a qualitative method of analysis.
Qualitative analysis involves a direct, subjective, non-
numerical evaluation by the senses, most commonly
a visual analysis. In contrast, quantitative analysis
involves objective numerical measurements of the
whole human body or its parts. These measure-
ments are generally not direct but rather are taken
from recordings of the movement performance.
Quantitative analysis can involve measurements
that relate to describing motion without reference
to the forces that produce the motion, termed kine- FIGURE 8.9 Use of body landmark markers and an elgon to
matic data, or relate to the forces associated with study the plié.
regarding the pressures on the plantar surface EMG records when performing a second-position
of the foot. Force platforms are used to provide plié were given in chapter 5 (figure 5.28 and 5.29,
information about the ground reaction forces in p. 273). Because factors such as electrode placement
vertical, mediolateral, and anteroposterior directions dramatically influence the records, these records are
(dynamography). When the foot presses against the often presented as a percentage of that seen with a
ground during movement, the ground applies equal maximum voluntary contraction of a given muscle
and opposite forces on the foot and body (Newton’s so that more meaningful comparisons can be made
third law) termed ground reaction forces. The between muscles and between subjects. EMG data
recordings of ground reaction forces from force are often used in conjunction with other data such
platforms can be used to determine many important as joint angles and positions of key body landmarks.
aspects of movement, such as weight placement, In figure 8.11, a camera, mirrors, and a control frame
pronation, the forces associated with takeoff, and were used to allow a three-dimensional analysis (3-D
the forces associated with landing (impact). Figure cinematography) of the knee with special consider-
8.10 provides an example of the vertical ground reac- ation to muscle activation and patellar positioning
tion force associated with landing from a forward in different angles of a plié. EMG studies can also be
leap (grand jeté devant) by an elite ballet dancer used to support or refute muscle activity predicted
(Clippinger and Novak, 1981). One way to get a from qualitative movement analyses.
more practical idea of the meaning of this informa-
tion is to compare the forces to body weight. In this Mechanical Analysis
example, the dancer’s maximum vertical ground
reaction force in landing from this jeté was almost 5 While beyond the scope of this book, integration of
times (485%) her body weight. concepts related to the laws of motion and kinetic
Although electromyography (EMG) is not a direct data provides very valuable information that can
measure of muscle force, some texts also consider be utilized in biomechanical analysis of movement.
EMG a source of kinetic data. Electromyography Interested readers are referred to the books by
can provide information about the onset, duration, Kreighbaum and Barthels (1996), Hall (1999), Laws
and peak of muscle activity, as well as the relative (2002), and Hamilton and Luttgens (2002). The
activity of the same muscle in different phases latter authors use a recommended approach in which
of a movement or with different trials of a given an anatomical analysis is followed by a brief mechani-
movement. Examples of EMG records when stand- cal analysis and brief discussion of mechanical prin-
ing in first position were given in chapter 2 (Tests ciples as they relate to optimizing performance of
and Measurements 2.1, p. 64), and examples of the movement being analyzed.
5
Vertical force (body weight)
Time
FIGURE 8.10 Example of use of recordings from a force platform to investigate forces associated with landing from a
grand jeté.
FIGURE 8.11 Use of EMG, body markers, and 3-D cinematography to investigate the plié.
Research-Supported are valuable for gait modification in rehabilitation

settings, as well as for the design of lower extremity
Movement Analysis prosthetics.
Whether one is performing an anatomical move- Similarly, extensive research has been done on
ment analysis or an analysis that integrates more running. Factors that contribute to optimal perfor-
mechanical principles, reading related research will mance, running economy, and injury risk with run-
allow the analyst to develop a much more in-depth ners ranging from endurance runners to sprinters
and accurate model of what is normal or desired for have been rigorously investigated. A simple analysis
a particular movement, as well as an appreciation of of running that integrates selected research findings
the magnitude and type of variability seen between follows. This was selected because of the common
individuals. This will allow the observer to better use of running, albeit often shaped by choreographic
focus on critical criteria and have a clearer idea of criteria, in dance.
how performance can be improved. For example, Unfortunately, scientific investigation of dance-
extensive research on walking gait has revealed specific vocabulary is much more limited. The leap
factors that are particularly key to allow walking to was selected as a sample dance movement for analysis
proceed with a limited displacement of the center because there have been some scientific investiga-
of mass of the body, such that movement economy is tions of this movement and because much of the
fostered, while still serving the primary goal of effec- research on jumps from other arenas is relevant for
tively moving the body through space (determinants developing a better understanding of optimal perfor-
of gait). In keeping with these determinants of gait, mance and injury risk. In keeping with the focus of
very specific magnitudes and timings of joint motions this text, this analysis will emphasize an anatomical
such as ankle dorsiflexion, knee flexion, pelvic rota- basis but bring in selected particularly key mechani-
tion, and trunk rotation have been discerned that cal principles and data.
Running The support phase begins when the foot strikes

the ground. The primary function of the muscles in
Running gait, like walking, can be classified as a con- the support phase is to control and arrest the down-
tinuous movement involving a sequential pattern of ward motion of the body caused by gravity, absorbing
movement that is repeated. To aid with description, the downward force of the runner and creating stabi-
the analysis involves only one leg as it goes through lization (Elliott and Blanksby, 1979), similar to what
a complete cycle of motion from the time that foot occurs in landing from a jump. This phase contains
strikes the ground until the same foot again strikes eccentric contraction of the hip extensors, knee exten-
the ground, termed a stride. Running is different sors, and ankle plantar flexors to control the respec-
from walking in that there is a brief period when tive hip flexion, knee flexion, and ankle dorsiflexion
the body is totally suspended and both feet lose produced by gravity and, at the ankle, also passively
contact with the ground (flight phase), and there due to forward movement (momentum) of the body
is no point during the cycle when both feet are in over the foot. This phase also allows the runner to
contact with the ground. Although researchers often move into position for the next phase.
use a more complex subdivision of phases into peri- As the center of gravity of the body moves in
ods, running is divided here into a support phase, a front of the foot, the propulsion phase (table 8.6)
driving or propulsion phase, and a recovery phase begins. The primary function of the muscles during
as seen in table 8.6 (Hay, 1993; Jensen, Schultz, and this phase is to generate the forces that will propel
Bangerter, 1983). the body. This phase is accompanied by hip exten-
TABLE 8.6 Anatomical Analysis of Running (hip, knee, ankle-foot)
Movement phases Joint movements Contraction type Prime movers: muscle group (sample muscles)
Support phase: Right leg A to B
Right hip Hip flexion Eccentric Hip extensors (hamstrings, gluteus maximus)
Right knee Knee flexion Eccentric Knee extensors (quadriceps femoris)
Right ankle-foot A-F dorsiflexion Eccentric and passive A-F plantar flexors (gastrocnemius, soleus)
Propulsion phase: Right leg C to D
Right knee Knee extension Concentric Knee extensors (quadriceps femoris)
Recovery phase: Right leg E to F and left leg A to E
Right and left hip Hip flexion Concentric Hip flexors (iliopsoas, rectus femoris)
Right knee Knee flexion Largely passive and 490
(early in phase) seconpdarily concentric
Right ankle-foot A-F dorsiflexion Concentric Ankle dorsiflexors (tibialis anterior, extensor
digitorum longus)
sion, knee extension, and ankle plantar flexion to following D for the left leg), the opposite leg enters
help produce the backward push of the foot against its recovery phase and the body is again airborne
the ground, which combined with rapid forward (Slocum and James, 1968).
swing of the opposite leg will help propel the body Although useful information can be gathered
upward and forward (Hay, 1993; Mann, Moran, and from this simplified analysis, research has demon-
Dougherty, 1986). strated additional elements that complement these
The next phase, the recovery phase, begins as basic elements. For example, at the end of the recov-
the foot leaves the ground (table 8.6E, right leg). ery phase and very beginning of the support phase,
The primary function of the muscles in this phase the hip actually undergoes a very brief period of
is to bring the leg forward in preparation for the concentric hip extension and the knee a very brief
beginning of the next cycle in which the foot again period of concentric flexion. This helps decrease
comes in contact with the ground. This phase can the undesired braking force that would tend to push
be pictured by looking at the right leg in table 8.6, E the body backward if the hip was still undergoing
and F, and then realizing that it would continue to flexion and the knee still undergoing extension as
swing forward until just before it contacts the ground, the foot contacted the ground. At the beginning of
as pictured with the left leg in table 8.6, A through E. the support phase this concentric contraction of the
So, the recovery phase is accompanied by hip flexion hip extensors, especially the hamstrings, then serves
produced by concentric contraction of the hip flex- to pull the body over the point of contact of the foot
ors. At the beginning of this phase, the knee flexes with the ground; and in sprinting, the strength of
(largely passively due to the transfer of inertial force) these muscles to effect this motion is considered
and the ankle dorsiflexes via concentric contraction essential for success (Kyrolainen, Belli, and Komi,
of the ankle-foot dorsiflexors. This knee flexion 2001; Mann et al., 1984). Brief ankle plantar flexion
and ankle-foot dorsiflexion shorten the distance controlled by eccentric contraction of the dorsiflex-
from the hip to the toes (functionally reducing limb ors has also been noted just as the foot strikes the
length), allowing the leg to clear the ground and ground to help position the foot at the same time the
swing forward more rapidly (decreased moment of ankle plantar flexors are co-contracting for stability
inertia). Later in the recovery phase, when the hip (Elliot and Blanskby, 1979).
has almost reached full flexion, the knee rapidly Similarly, at the very beginning of the recovery
undergoes extension (left leg—table 8.6, D to just phase, concentric contraction of the hip extensors
before foot contact in F), allowing a longer distance continues briefly and the hip flexors actually work
to be covered (increased stride length). The initial eccentrically first, to decelerate hip extension, prior
extension is passive (transfer of momentum) as the to working concentrically to bring the leg forward.
thigh decelerates, followed by concentric contraction At the ankle, the concentric contraction of the ankle
of the knee extensors. plantar flexors at the end of the support phase is fol-
To understand the relationship between the right lowed by a brief eccentric contraction of the ankle
and left legs during running, one must know that for dorsiflexors to decelerate this plantar flexion of the
the sake of simplicity table 8.6 only shows one half of foot prior to the previously described concentric
a stride. So, to picture a full stride, one must realize contraction of the dorsiflexors in the support phase
that following what is pictured in table 8.6F, the left (McGinnis, 2005). And at the end of the recovery
leg (shown in gray) would now go through what is phase the hip extensors (hamstrings) work eccentri-
shown for the right leg (shown in white) in A through cally to decelerate hip flexion and knee extension,
F. Similarly, after what is pictured in table 8.6F, the prior to working concentrically briefly at foot strike
right leg would now go through what is shown for the as previously described. So, an eccentric contrac-
left leg in A through F. Some key points that clarify tion is commonly used to decelerate a limb, just
the relationship between the right and left leg during prior to reversal of the direction of movement. This
running follow. When one leg is in the early part of common use of an eccentric contraction imme-
the recovery phase, the body is airborne (table 8.6E diately preceding a concentric contraction (i.e.,
for the right leg) with both feet out of contact with the stretch–shortening cycle discussed in chapter
the ground (flight phase). When knee flexion brings 2) makes running much more efficient, requiring
the recovery knee almost to the center of mass of the markedly less energy than if it were composed of only
body (table 8.6A for the left leg), the opposite leg sequential concentric muscle contractions (Biewener
contacts the ground and enters its support phase; and Roberts, 2000; Ito et al., 1983; Kram, 2000).
and when the recovery hip reaches about maximum For simplicity this analysis has been limited to
hip flexion in the late recovery phase (table 8.6, just sagittal plane movements at the hip, knee, and ankle.
These joints and selected movements are particularly that will propel the runner forward without excessive
key in running. The action of the arms appears to vertical movement of the body. Positioning of the
function primarily to counterbalance the off-center foot when it contacts the ground at the beginning of
thrust of the legs (Adrian and Cooper, 1989). However, stance phase is also key for determining the ground
a more complete analysis would include the smaller reaction forces generated. Since the ground reaction
movements of abduction-adduction and external rota- force is equal in magnitude but opposite in direction
tion-internal rotation of the hip and knee, as well as to the force produced by the foot when it contacts the
movements of the pelvis (tilts and rotations), spine, ground, having the lower leg still moving forward or
upper extremity, and key joints of the foot. Although having the foot land well in front of the line of grav-
these movements may be smaller or less fundamental ity (extending vertically from the center of mass of
for moving the body through space, they are essential the whole body) will produce a forward force on the
for running mechanics, and deviations in these move- floor resulting in a ground reaction force that pushes
ments are often implicated with common technique the body backward, termed a braking force. Avoid-
errors and overuse injuries. ing swinging the leg too far forward (“overstriding”)
In terms of stabilizers, one key muscle group is and cueing runners to think of “pulling the ground
the hip abductors. During the stance phase, these toward them” when the foot strikes can help reduce
muscles play a key role in preventing excessive braking forces and enhance running economy.
undesired lateral tilt of the pelvis (Trendelenburg In terms of special considerations, the goal of
sign) or lateral excursion of the pelvis relative to the running in athletics (such as long-distance running
support foot. In terms of flexibility, although a visual vs. sprinting) will also influence optimal mechan-
evaluation of running does not display requirements ics, supplemental conditioning, and appropriate
for extreme ranges of motion commonly seen in cues. For example, research has demonstrated that
dance movements, many runners exhibit suboptimal a successful endurance runner is characterized by
levels of flexibility at various joints, and inadequate less vertical oscillation, slightly longer strides, less
range of ankle dorsiflexion can result in compensa- change in velocity during the ground contact, and
tory excessive pronation during the support phase. a lower first peak in the vertical component of the
Similarly, tight hip flexors can produce an undesired ground reaction force, associated with a tendency to
excessive anterior tilt of the pelvis and limit the have smaller braking forces (Kyrolainen, Belli, and
desired positioning of the pelvis as the leg swings Komi, 2001). These characteristics are associated
forward such that stride length is negatively affected. with greater running economy or efficiency, and the
Although still controversial, adequate hamstring lower peak vertical forces (impact forces) that are less
flexibility may also have a positive effect on running rapid in development may also reduce injury risk in
performance and reduced injury risk (Hreljac, Mar- runners (Ferber et al., 2002; Hreljac, 2004; Hreljac,
shall, and Hume, 2000; Koceja, Burke, and Kamen, Marshall, and Hume, 2000).
1991). In terms of strength, research has shown that In dance, the goal often has more to do with
adequate “knee lift” (requiring hip flexor strength) meeting the aesthetics of the choreography versus
and high levels of hip extensor strength are key for optimizing economy or speed. For example, a cho-
high-level sprinting performance. The latter element reographer may desire that running be performed
of strength is key for increasing the power of the leg low to the ground, maintaining the knees in flexion
drive for greater acceleration of the runner. and emphasizing horizontal movement of the body.
In terms of technique, one common error is In another case, the choreographer may desire more
to swing the gesture leg around (circumduction) of a “prance,” emphasizing vertical movement of the
during the recovery phase. Cueing the runner to body at the expense of horizontal movement. So,
“swing the knee forward on a slight diagonal line” although many of the principles just discussed with
(slightly toward the midline) versus “swinging the running are still relevant, the movement will often be
knee around in a small semicircle” can help achieve shaped by aesthetic versus biomechanical criteria.
desired positioning. Unnecessary lateral motions
decrease the efficiency of running and decrease Leap (Grand Jeté en Avant)
forward propulsion (Hamilton and Luttgens, 2002).
Similarly, cueing to drive the back leg downward and In kinesiology, a leap is defined as a locomotor
backward at push-off with correct timing and posi- movement that involves taking off from one leg and
tioning of the trunk can help achieve optimal for- landing on the opposite leg, while a jump involves
ward propulsion. The desire is to produce a ground takeoff and landing on both feet. The leap analyzed
reaction force with a large horizontal component in table 8.7 follows these criteria. However, in many
forms of dance, the term “jump” is used more loosely increase the “point” of the foot. For many dancers,
and includes single and double takeoffs or landings the initial flight phase is also accompanied by a very
or both. brief continuation of the forward motion of the lead
This grand jeté movement can be divided into the leg (left leg) produced by concentric contraction
following phases: preparation, takeoff, flight, and of the hip flexors while the knee extensors contract
landing. For purposes of simplicity, this discussion isometrically to maintain knee extension and the
will focus on the hip, knee, and ankle. The prepara- ankle-foot plantar flexors contract isometrically to
tion phase involves hip flexion, knee flexion, and help keep the foot pointed. Then, further forward
ankle dorsiflexion of the takeoff leg (right leg in table motion of the leg is arrested, and this hip angle is
8.7A). Since this movement is primarily produced by maintained isometrically by the hip flexors while
gravity, eccentric contraction of the opposite muscles, transfer of momentum from the leg to the torso
the hip extensors, knee extensors, and ankle plantar facilitates desired forward motion of the center of
flexors, is necessary to control these movements. gravity of the body.
This movement is important to bring the center of During the flight phase, the center of mass of
gravity of the body over the foot of the support leg the body follows a parabolic path (as shown in table
(Adrian and Cooper, 1989), and a moderate amount 8.7). The shape of this trajectory is determined by
of hip and knee flexion is necessary to allow time to the angle (angle of projection), speed, and height
generate sufficient force (impulse) during takeoff of the body at takeoff. Hence, one of the key deter-
for an effective jump (Ryman, 1978). minants of achieving the desired height or distance
During the takeoff phase, as with running, the in a given jump is maximizing the velocity of the
takeoff leg (right leg) undergoes rapid hip exten- body at takeoff.
sion, knee extension, and ankle plantar flexion, In accordance with the laws of physics, once in the
against gravity, via concentric contraction of the hip air the center of mass of the body must follow this
extensors, knee extensors, and ankle plantar flexors, given parabolic path. However, to achieve the illusion
respectively. Proper timing and adequate force gen- of “suspension,” skilled dancers often manipulate the
eration associated with these joint movements are relative position of the center of mass within the body
essential for producing the forces that will propel by lifting or lowering the limbs. For example, during
the body. As the right leg extends, the left leg swings a grand jeté, a well-timed extra lift of the legs or lift
forward, utilizing concentric contraction of the hip of the arms near the peak of the jump will cause the
flexors to bring the thigh forward, isometric contrac- center of mass to move up within the body and allow
tion of the knee extensors to maintain the knee in a very brief moment in which the head and torso
extension, and concentric contraction of the ankle- move approximately horizontally, giving the illusion
foot plantar flexors to help point the foot. The right of floating (Laws, 2002; Ryman, 1978).
arm also swings forward (concentric contraction of During the landing phase (similar to the sup-
the shoulder flexors) as the left arm raises to the port phase in running), the primary function of
side (concentric contraction of the shoulder abduc- the muscles is to control and arrest the downward
tors). These movements of the right leg (takeoff leg motion of the body caused by gravity, with eccentric
via the resultant ground reaction force), combined contraction of the hip extensors, knee extensors,
with the forward movements of the left leg (lead and ankle plantar flexors to control the respective
leg) and right arm, propel the center of gravity of hip flexion, knee flexion, and ankle dorsiflexion pro-
the body up and forward for the flight phase. The duced by gravity on the landing leg (left leg in table
takeoff phase ends just before the foot of the takeoff 8.7E). This phase is also important for appropriately
leg loses contact with the ground (just before B in positioning the body for the next movement in the
table 8.7, where the toes would still be in contact given choreography. If the body changes direction
with the ground). or stays in place, this landing phase also functions to
When the takeoff leg no longer is in contact with halt the forward motion of the body; and on landing,
the ground, the flight phase (table 8.7, just prior to B the center of gravity needs to be behind the body so
through D) begins. This takeoff leg is rapidly brought that the push of the landing foot on the floor slows
backward and upward, ideally to the height of the the forward motion of the body. This is different
lead leg, via rapid concentric contraction of the hip from what occurs in sprinting or dance choreography
extensors. The knee of this back leg (right leg) is such as repetitive forward leaps in which the goal is
maintained in extension by utilizing a contraction of to have the center of gravity almost over the foot so
the knee extensors, while concentric contraction of that forward motion is maximized. As with sprinting,
the right ankle-foot plantar flexors serves to slightly it appears that some dancers may use the hamstrings
TABLE 8.7 Anatomical Analysis of a Forward Leap (Grand Jeté en Avant)
Movement phases
and selected joints Joint movements Contraction type Prime movers: muscle group (sample muscles)
Preparation phase: A
Right hip Hip flexion Eccentric Hip extensors (hamstrings, gluteus maximus)
Right knee Knee flexion Eccentric Knee extensors (quadriceps femoris)
Right ankle-foot A-F dorsiflexion Eccentric and passive A-F plantar flexors (gastrocnemius, soleus)
as body moves
forward over foot
Takeoff phase: A to just before B
Right knee Knee extension Concentric Knee extensors (quadriceps femoris)
Left hip Hip flexion Concentric Hip flexors (iliopsoas, rectus femoris)
Left knee Knee extension Isometric Knee extensors (quadriceps femoris)
Left ankle-foot A-F plantar flexion Concentric A-F plantar flexors (gastrocnemius, soleus)
Left shoulder Shoulder abduction Concentric Shoulder abductors (middle deltoid, supraspinatus)
Flight phase: just before B to D
Right knee (Knee extension Isometric Knee extensors (quadriceps femoris)
maintained)
Left hip Hip flexion Concentric Hip flexors (iliopsoas, rectus femoris)
Left knee (Knee extension Isometric Knee extensors (quadriceps femoris)
maintained)
Left ankle-foot (A-F plantar flexion Isometric A-F plantar flexors (gastrocnemius, soleus)
maintained)
494
Movement phases
and selected joints Joint movements Contraction type Prime movers: muscle group (sample muscles)
Landing phase: E
Left hip Hip flexion Eccentric Hip extensors (hamstrings, gluteus maximus)
Left knee Knee flexion Eccentric Knee extensors (quadriceps femoris)
Left ankle-foot A-F dorsiflexion Eccentric and passive A-F plantar flexors (gastrocnemius, soleus)
as body moves
forward over foot
Right knee (Knee extension Isometric Knee extensors (quadriceps femoris)
maintained)
Right ankle-foot (A-F plantar flexion Isometric A-F plantar flexors (gastrocnemius, soleus)
maintained)
in the early portion of this phase to initiate knee If a split position cannot easily be accomplished,
flexion so that braking forces are minimized and the this suggests that muscular constraints would offer
tendency for the femur to translate anteriorly on the internal resistance to the desired split position in the
tibia (knee shear forces) is lessened (Simpson and grand jeté, making it more difficult or not possible
Kanter, 1997; Simpson and Pettit, 1997). to achieve (depending on the extent of limitation).
While the landing leg plays the vital role of To more specifically determine the soft tissue con-
controlling the downward motion of the body and straints, tests presented in chapter 4 can be used.
preparing for the ensuing direction of motion of the Hamstring flexibility (Tests and Measurements 4.4
body’s center of gravity, the right leg may stay behind on p. 205) can be tested to see if these muscles are
in an arabesque as shown in table 8.7E. With this limiting the desired height of the front leg, while
variation of a grand jeté en avant, the hip extensors of hip flexor flexibility (Tests and Measurements 4.5 on
the back leg must contract rigorously with an isomet- p. 212) can be tested to see if these muscles are limit-
ric or slight concentric contraction to prevent the leg ing the desired height of the back leg.
from dropping and to achieve the desired aesthetic Analysis of the grand jeté also reveals that there are
of the arabesque position. The knee extensors work high strength demands for the hip extensors, knee
isometrically to maintain the knee in extension while extensors, and ankle plantar flexors of the takeoff leg
the ankle-foot plantar flexors work isometrically to (right leg) to overcome the weight of the body and
help maintain the point of the foot. project the body in space during the takeoff phase.
In terms of stabilization, the complex co-contrac- As with running, the greater the force generated by
tion of the spinal extensors and flexors is again key to the body against the floor at takeoff, the greater the
achieve the desired aesthetic of the movement. The ground reaction force that will propel the body, and
desire is to keep the upper torso relatively vertical the greater the acceleration of the body. During the
during the flight phase of the movement. Some danc- flight phase, moderate levels of hip flexor strength
ers get an undesired visible flexion and extension are needed to lift the lead leg, and moderate levels
of the trunk during the movement. One reason the of hip extensor strength are needed to lift the back
torso often flexes forward is that the pelvis must be leg to the desired split position. During the landing
tilted anteriorly to allow the back leg to reach the phase, there are high strength demands on the sup-
desired height. However, as discussed in connection port leg (left leg) of the hip extensors, knee exten-
with an arabesque in chapter 4, the back extensors sors, and ankle plantar flexors in order to decelerate
can contract to bring the upper torso back to verti- the body and absorb the large forces associated with
cal and to prevent the undesired forward motion of landing. A preliminary investigation of three elite
the whole torso. ballet dancers found vertical maximum forces of
Anatomical analysis also reveals that extreme approximately 3 to 6 times body weight associated
range of motion is required at the hips to achieve with landing from a grand jeté devant (Clippinger
the split position in the air. A quick test that can be and Novak, 1981).
used to help determine if hip flexibility is a limiting In terms of technique considerations, one
factor is a passive split (Tests and Measurements 8.2). common error in beginning dancers is to not achieve
Quick Check for Limitations Due to Passive Hip Constraints

in a Grand Jeté en Avant
Perform a passive split with
the torso vertical and com-
pare this position of the legs
to the position seen when
executing a grand jeté. If
a dancer cannot achieve
or has difficulty achieving
the passive split position,
this suggests that the ham-
strings or hip flexors are
likely limiting the desired
positioning of the legs in the
grand jeté.
the desired position of the back leg (almost paral- Flanagan, 1984; McNitt-Gray, Koff, and Hall, 1992)
lel to the floor) in the flight phase. This can relate that may relate to stretch-shortening optimization
to hip flexor tightness of the back leg, hamstring and movement economy. Experienced dancers have
tightness of the front leg, limited range in spinal also been shown to utilize a faster reaction time in
hyperextension, inadequate hip extensor strength of the preparatory plié prior to a sauté than in other
the back leg, inadequate spinal extensor strength, or movements requiring less power (relevé or pointe)
inappropriate timing and activation of key muscles. or than non-dance controls (Clarkson, Kennedy, and
Another important technique consideration is skilled Flanagan, 1984). Hence, encouraging dancers to
use of flexion of the support leg (hip flexion, knee use a moderate depth of preparatory plié (Ryman,
flexion, and ankle dorsiflexion) during the prepara- 1978) and to make a rapid reversal from flexion to
tion phase to provide a prestretch of the extensors extension can help some dancers reap potential
(hip extensors, knee extensors, and ankle plantar stretch-shortening cycle benefits and enhance jump
flexors) that will markedly enhance the ability of the height or distance.
muscle to generate force (stretch-shortening cycle) Similarly, the timing and magnitude of flexion of
in the takeoff phase. While some dancers appear to the support leg during the landing phase are also
display a natural use of this potential enhancement, important. In this case, the issue is primarily one
other dancers do not fully utilize this mechanism of absorption of forces versus generation of forces,
due to errors such as making the preparatory move- essential for injury prevention as well as achieving
ment too large or too small and excessively delaying dance aesthetic criteria. Increasing the time used to
the reversal from flexion to extension. One study decelerate the body when landing from a jump will
showed that 36% of young ballet dancers were not decrease the magnitude of the peak forces borne
able to use this elastic potential of muscle correctly by the body. An eccentric contraction of the exten-
and were able to jump higher from a semi-squatting sors of the hip, extensors of the knee, and plantar
position without a countermovement than when a flexors of the ankle to allow greater flexion at their
countermovement (preparatory plié) was used (Pog- respective joints can be used to provide more time for
gini et al., 1997). However, another study of skilled absorption of forces. So, soft landings are associated
dancers showed a consistent submaximal depth of with lower peak vertical ground reaction forces that
demi-plié prior to various movements, suggesting remain elevated for a longer period of time, while
a preset motor program (Clarkson, Kennedy, and hard landings are associated with higher peak vertical
DANCE CUES 8.2
“Don’t Stop Your Plié”
W hen dancers are performing a preparatory plié prior to a demanding movement such as a jump
or turn, the cue to “not stop your plié” is sometimes given. Often a further explanation of this
cue is to “avoid hesitating or stopping” at the bottom of the plié. From a mechanical perspective,
hesitating or delaying at the bottom of the plié will lessen the benefits of the stretch-shortening cycle.
The potential enhancement from the prestretch of key muscles such as the calf muscles, quadriceps
femoris, hamstrings, and gluteus maximus rapidly declines if there is much delay between the eccen-
tric and the following concentric contraction. So dancers should be encouraged to make a very rapid
reversal from the down- to the up-phase of the movement. The commonly used counting technique
of “and one,” with the “and” rapid and the “one” emphasized, versus an even count of “one” for the
down-phase of the plié and “two” for the up movement, can also be helpful in encouraging the desired
quick reversal of direction without a hesitation.
DANCE CUES 8.3
“Land Softly”
T he instruction to “land softly” is often used by teachers in an effort to reduce the forces associ-
ated with landing. From a biomechanical perspective, soft versus stiff landings are associated with
lower vertical ground reaction forces; greater absorption of forces by the hip and knee muscles; slightly
less absorption of forces by the ankle plantar flexors; and greater hip flexion, greater knee flexion,
and slightly less plantar flexion at the beginning of floor contact (Devita and Skelly, 1992; Kovacs et
al., 1999; Self and Paine, 2001). In soft versus stiff landings from a vertical fall of 23 inches (59 centi-
meters), Devita and Skelly found that overall the muscular system absorbed 19% more of the body’s
kinetic energy, thereby reducing impact stress to other tissues. While just using the cue of landing
“softly” may be sufficient to elicit the desired response from a dancer, some dancers are unclear as to
how to achieve this type of landing. For example, one study found that providing video feedback with
specific verbal analysis of how to land more softly was more effective in reducing peak vertical forces
both directly following instructions and one week later than simply instructing subjects to key into the
sensation of landing and try to land more softly (Onate, Guskiewicz, and Sullivan, 2001). Similarly,
using more abstract images has been found to be less effective than providing more concrete direc-
tives related to changes in joint angles or the sound of landing (McNair, Prapavessis, and Callender,
2000). One approach is to emphasize some of the biomechanical criteria associated with soft versus
stiff landings. Practically, these can be encouraged by directing dancers to think of slightly flexing the
knees and hips just before landing and then using a slightly deeper but slower plié to decelerate the
body. This directive can also be valuable for preventing knee hyperextension when landing, the classic
mechanism for anterior cruciate ligament tears in dancers.
ground reaction forces that stay elevated for a shorter forces increased (Simpson and Kanter, 1997). Two
period of time (Dufek and Bates, 1990). additional studies showed that trained dancers had
Also in line with these principles, a study of travel- significantly greater degrees of knee flexion and hip
ing dance jumps showed that the quadriceps femoris flexion (deeper pliés) when landing from vertical
was particularly important in attenuating impact jumps than non-dancers (Clarkson, Kennedy, and
forces as jump distance and vertical ground reaction Flanagan, 1984; McNitt-Gray, Koff, and Hall, 1992),
DANCE CUES 8.4
“Go Through Your Foot”
T he instruction to “go through your foot” is often used by teachers when landing from a jump to
achieve a certain aesthetic and prevent injuries. Toe-heel versus flat-foot landing has been shown
to be advantageous in terms of force absorption. For example, one study found peak vertical ground
reaction forces of about four times body weight with toe-heel landing in contrast to six times body
weight with flat-foot landing (Dufek and Bates, 1990). Another study found that toe-heel landings were
associated with a greater time to reach peak forces (Kovacs et al., 1999). Both of these factors are con-
sidered important for reducing the risk of lower extremity injuries. Hence, cueing to go through the
foot in a toe-heel manner can be useful for reducing impact. This mechanism appears to be developed
in dancers, as trained dancers exhibit a significantly longer time to reach minimum ankle position and
use a markedly larger ankle range of motion than nondancers when landing from jumps (McNitt-Gray,
Koff, and Hall, 1992). However, given the preponderance of ankle-foot injuries in dancers, this cue is
best combined with encouraging a soft landing with adequate flexion of the knees and hips because
the contribution of the plantar flexors has been shown to drop from 50% in stiff landings to 37% in
soft landings, with knee and hip extensors now providing greater absorption (Devita and Skelly, 1992;
Self and Paine, 2001).
while another study demonstrated that experienced absorption of large forces without injury. Thus,
dancers utilized a longer time to reach the maximum directives to promote good alignment and avoid
positions of flexion of the ankle (dorsiflexion) and excessive rotation or medial-lateral movements,
knee and hip (Ryman, 1978). Practically, these such as cueing to think of the knees as hinges and
concepts are often encouraged by such directives as guide the knee over the ball of the foot (Roniger,
“land softly,” feel your body “yield” as you land, or 2002) or second toe can be helpful. Furthermore,
“use your plié” when you land. These directives are when stability is a problem, providing supplemental
often used to discourage “stiff” landings with inad- coordination training such as balancing on one leg
equate flexion of lower extremity joints. with a balance board or foam roller, utilizing quick
Another mechanism that can be used to soften movements of the gesture leg while standing on
landings is well-timed use of the ankle-foot plantar one leg, and jumps can be helpful. A conditioning
flexors. The calf complex plays a critical role in program developed by Dr. Mandelbaum including
absorbing the impact associated with landing from strengthening exercises, agility drills, and plyomet-
jumps, and the ankle plantar flexors have been rics reinforcing soft landings with bent knees and
estimated to be responsible for 44% (on average), hips was found to reduce anterior cruciate tears by
34% (the knee), and 22% (the hip) of the total 88% in female soccer players when compared to
muscular work done when landing from a vertical controls in a 12-week playing season, while another
fall of 23 inches (59 centimeters) (Devita and Skelly, program with similar emphasis was shown to reduce
1992). Directives encouraging a toe-heel versus a maximum vertical ground reaction forces by 22%
flat-foot landing such as “go through your foot” are and abduction and adduction moments by 50%
often used to encourage use of this mechanism. (Hewett et al., 1996).
However, although optimal use of the plantar flex- In terms of special considerations, there are many
ors is important, it appears that with soft landings variations in the way a leap is executed with respect to
involving greater jump height the contribution of positioning of the legs, torso, and arms that will affect
the hip extensors and knee extensors becomes more muscle use and movement analysis. For example,
substantial (Zhang, Bates, and Dufek, 2000). the lead leg can swing forward straight or with a
Another important technique consideration is developing movement; there can be an extra “split”
placement of the knee relative to the foot when motion of the legs at the peak of the movement; or
landing from jumps. In leaps, stability must be the back leg can bend. In addition, aesthetic criteria
present on one leg to allow for development and play a key role and may dictate a leap that emphasizes
height (vertical component), distance (horizontal our understanding of a given movement. However,
component), or other criteria. whether this information can be used to develop an
When providing cues or considering the addition optimal performance model is controversial and
of supplemental conditioning exercises, it is very complex. Such models will need to take into account
important to keep the specificity of these goals in individual differences and the observation that with
mind. For example, several studies practicing jumps complex movement, different movement strategies
in various environments showed no gains in jump can be developed to achieve the same movement
height or gains lower than reported for other athletes outcome. The strategy that works for one elite ath-
in jump height (McLain, Carter, and Abel, 1997; lete may not necessarily be optimal for another due
Poggini et al., 1997). Instead, it appears that dancers to many variables such as body type, lever length,
may naturally tend to favor emphasizing improve- muscle fiber type, strength and power in key muscles,
ment in technique, efficiency of movement (Harley flexibility in key joint ranges of motion, and other
et al., 2002), or constraining peak impact forces. neuromuscular factors. Still, when studies of multiple
One would theorize that if increased jump height elite strategies are combined with theoretical ana-
was the goal, a program should be utilized that inte- tomical and biomechanical analyses, a pattern usually
grates key lower extremity strengthening exercises emerges that is consistent with scientific principles
to allow greater absorption of forces as jump height of movement. From such models, recommendations
increased, as well as cues and functional movement can be generated for instructing and improving skill
patterns emphasizing jump height. The specificity in a given movement task, taking into consideration
of motor control strategies is demonstrated by stud- the differences between individuals.
ies showing a greater contribution of the hip with In dance, this issue of generating models of
greater jump height (Vanrenterghem et al., 2004), optimal performance is made more complex by the
adjustment of lower extremity tension (stiffness) tremendous variety of movements used. In contrast
upon landing in accordance with jump height and to walking, running, hurdling, or high jumping,
floor force absorption characteristics (Devita and where there is one movement pattern or sequence
Skelly, 1992; Hamilton and Luttgens, 2002), and to be studied, dance contains many basic movement
significant improvement in dancers’ vertical jump categories including walks, runs, leaps, slides, skips,
height off two feet and off the right foot (but not jumps, lunges, swings, pliés, rises, reaches, brushes,
the left) after a plyometric training program (Griner, kicks, drops, isolations, contractions, turns, and falls,
Boatwright, and Howell, 2003). This latter finding is as well as countless variations and combinations of
particularly interesting given the tendency for many these and other movement vocabulary.
right-handed ballet dancers to prefer jumping off Generating models of optimal performance in
their left legs (Golomer and Fery, 2001). dance is also made more difficult by the need to meet
The process of improving jumps is also com- aesthetic criteria. In many forms of athletics, the
plicated by aesthetic requirements. For example, primary goal is to accomplish a movement outcome
greater hip flexion obtained by more forward lean that can be measured quantitatively. For example, in
of the torso will allow markedly greater force pro- the high jump, the goal is to jump as high as possible
duction in the takeoff phase of jumping, probably over a bar, and the success of the outcome is basi-
largely related to the ability of the gluteus maximus cally determined by how high a bar can be cleared.
to produce more force in this position. Similarly, In contrast, dance is heavily guided by meeting
greater hip flexion obtained by more forward lean aesthetic criteria not only in the outcome but also
of the torso will also allow for lower impact forces throughout the process of achieving the outcome.
upon landing (Devita and Skelly, 1992), probably With regard to turns, for example, in many schools
in part due to bringing the center of mass of the of dance there may be a quantitative component in
torso closer to the knees (decreased moment arm of that it is desirable, and considered a sign of greater
resistance). However, dance generally encourages a skill, to be able to perform multiple repetitions of
more vertical positioning of the torso, and aesthetics a given turn. However, the preparation for the turn
will limit the amount of forward lean of the torso and the manner in which the turn is performed are
that is permitted. considered vitally important, not just the number
of revolutions accomplished. This emphasis has
Optimal Performance Models led to the statement by some that when compared
to many forms of athletics, dance is process as well
So, anatomical and biomechanical analysis of move- as product oriented. Furthermore, while some of
ment can provide vital information that can deepen these aesthetic criteria involved in the “process” of
moving may be shared by many dance forms, others to rising to relevé can increase the upward vertical
differ between and within given dance forms. Some force (vertical component of the ground reaction
examples of aesthetic issues that may be important force), making it easier to rise.
are movement quality, movement economy, lack of Some cues, however, have been passed down
visible undesired compensations associated with through generations of teaching but do not stand
limb movements, placement or alignment of various up to scientific scrutiny. They may suggest that
body segments, desired “shaping” of various joints dancers do things that are not possible or that do
or body parts in standard vocabulary (e.g., plantar not actually occur with a given movement. Some-
flexed and everted foot, neutral foot, dorsiflexed times such cues persist because parts of them fit
and inverted foot), emotional expressiveness, and with sensation or a dancer’s sense of truth while
the desired relationship of the movement in time some other part of the description is inaccurate.
(rhythmicity). For example, as described in chapter 4, for a kick
However, despite these difficulties, it is essential to the side (battement à la seconde), the cue to
that more research be performed on dance move- lift the leg from underneath is inaccurate in that
ments and that information gained from research the hamstrings cannot lift the leg. However, when
on similar movements be applied to dance. While the movement is performed correctly, there is a
the qualitative anatomical analysis and knowledge sensation of the proximal femur (greater trochan-
of joint mechanics presented in this text can pro- ter) coming down and under just before the distal
vide a very beneficial basic understanding of dance femur and leg rises up. A cue that describes this
movements, specific research will test our assump- drop of the trochanter without implying that the
tions and deepen and clarify our knowledge. This hamstrings lift the leg would be more accurate and
knowledge can then be used to help the dancer less confusing to students. So, teachers and students
accomplish technical proficiency within the context are encouraged to closely evaluate the anatomical
of the desired aesthetic. While the variety of aesthet- and mechanical basis and accuracy of cues used in
ics present in the dance world will likely preclude dance, and teachers should be sure that they do not
a single model for optimal performance of a given perpetuate misconceptions or ask students to do
movement, research should help reveal fundamental something that is not physically possible. Examples
principles that can be adjusted in accordance with of cues have been given throughout this text. Often a
the specific aesthetic, as well as clarify key aspects subtle change in wording will allow the cue to evoke
that distinguish aesthetics. the desired sensation or action and at the same time
be supported by, versus countered by, anatomical and
biomechanical principles.
Movement Cues
There is a need to take the knowledge of movement Summary
obtained from anatomical and biomechanical analy-
sis and apply it in the classroom in a manner that Despite the wide array and complexity of dance
can be readily used by dancers to achieve desired movements, current technology makes analysis of
movement outcomes. One common approach is for movement tremendously easier than it was just a
teachers to use movement cues when describing or decade or two ago. There is a dire need to supple-
correcting movements. Some of these cues have a ment qualitative anatomical analysis with information
biomechanical basis that is logical. For example, cues gained from well-designed research studies address-
described in chapter 3 oriented toward utilizing suf- ing a wide variety of dance movements so that we
ficient abdominal stabilization could reduce undue can better understand the relevant muscles, forces,
stress on the low back and improve spinal-pelvic and neural factors involved in a given movement. In
alignment. Other cues are more oriented toward the turn, this information can be used for evaluation of
laws of motion. Such cues may foster skill improve- current teaching cues and strategies and the design
ment through taking fuller advantage of physics and of new approaches, where relevant. Such information
Newton’s laws of motion. For example, the cue to will also be useful for better understanding of injury
emphasize pressing down into the floor just prior mechanisms and prevention.

1. Perform a basic anatomical analysis (table 8.3, steps 1-5, p. 480) of the following:
a. A roll-down
b. A tendu side
c. A penché
2. Perform an anatomical analysis of a développé to the front (développé a la quatrième devant)
(table 8.3, steps 1-12). Contrast and compare this with a grand battement to the front as
analyzed in table 8.4 (p. 482).
3. Perform an anatomical analysis of a développé to the side (développé à la seconde) (table
8.3, steps 1-12). Contrast and compare this with a développé to the front.
4. Perform a basic anatomical analysis (table 8.3, steps 1-5) of a rise onto the ball of the foot
preceded by a plié (relevé). How does this differ from a rise performed with a straight knee
(elevé) and from a jump in parallel first position?
5. Observe a dancer performing the movements analyzed in question 3. Note any technique
problems. Theorize what could be done to correct any noted problems, and see if applying
these theorized corrections on the dancer results in the desired improvement.
6. Perform a basic anatomical analysis (table 8.3, steps 1-5) of a short movement sequence that
is regularly used at the barre or in the warm-up section of your dance technique class.
7. Select a movement from dance class that you are having difficulty performing with optimal
technique. Perform an anatomical analysis of this movement and provide four strength exer-
cises, two flexibility exercises, and three technique cues that could be used to help improve
your performance of this movement.
8. Design a movement sequence that involves all the fundamental movements of the shoulder,
spine, hip, knee, and ankle. Orally identify the movements as they occur.
9. Select three cues commonly used in dance classes to aid with performing given movements.
Evaluate their anatomical or biomechanical base in terms of accuracy. Is there a way each
cue could be stated that would be more consistent with scientific principles?
10. A dancer wants to improve her Russian splits.
a. Using the schema presented in table 8.3, analyze the movement in terms of the ankle,
knee, and hip joints.
b. What muscles serve as prime movers? What are the extreme range of motion requirements
in the split position, and what muscles should be stretched to improve this range? What
are the key strength demands of this movement, and what muscles should be strengthened
to meet these demands?
c. What cues could be used to enhance benefits from use of the stretch-shortening cycle just
prior to takeoff?
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Index
Note: Page numbers followed by an italicized f or t refer to the figure or table on that page, respectively.
A actin 37 dorsiflexion 23t

A band 38 active insufficiency 57–58, 59f plantar flexion 23t, 331–332
abdominal–hamstring force couple 185, of hip flexors and adductors during pronation 306
186f, 194 front développés 201 supination 306
abdominal muscles of rectus femoris 264 ankle strengthening 350t, 351t
actions 92f and strengthening exercises 66 beginning pointe work 341f
anterior view 92f adduction 23t, 24 annular ligament 415
co-contraction and flat back position adductor brevis 172, 175, 176f, 177f annulus fibrosus 74, 75
194 adductor hallucis 322f antagonist 54–55
co-contraction during back extensor adductor longus 60f, 468f anterior 17, 18t
strengthening 132–133 actions and attachments 172, 175 anterior cruciate ligament (ACL) 240f,
contraction type 125f attachment to bone 176f, 177f 241, 243f
external obliques 83 adductor magnus 60f, 61f, 468f, 469f injuries 286–288
and fatigue posture 101 actions and attachments 172, 176 and landing softly 497
internal obliques 83–84 posterior view 177f stress test 242
and lumbar hyperlordosis 95, 97f adenosine triphosphate (ATP) 38 anterior crural muscles 310–312
neural inhibition with back injury 153 agonists (movers) 54 anterior deltoid 60f
and pelvic stabilization 185 alignment anterior inferior iliac spine 158f
protection of spine 106–108 common problems 474–476t anterior intercondylar areas 238
“pull up with your abs” 98 of foot 324–331 anterior longitudinal ligament 75
rectus abdominis 82 of knee-foot 338–339 anterior pelvic tilt 177–178
“six pack” appearance 82 and movement analysis 472–473 anterior superior iliac spine (ASIS) 158f,
as stabilizers 55, 471f of pelvis 164, 177 159, 177, 178
strength and endurance tests 121–122 postural 93–95, 101 anterior talofibular ligament (ATFL)
transverse abdominis 84–85 of spine 81, 113–115 303–304, 360f
abdominal strengthening amenorrhea 9, 104 anteroposterior axis 21, 25f
and back injury 152 anatomical axes 19 aponeurosis 41
and back rehabilitation 153 anatomical planes 18–19 apophyseal joints 75
exercises 140–141 anatomical position 17, 18t appendicular skeleton 9–10
exercise technique 122f anconeus 419–420 appositional growth 5
sample progression 142 angular motion 44 arabesque 161, 209, 210f, 211f, 264
abdominal strengthening guidelines ankle. See also pointe work arches of foot 298, 304, 307, 324–326
adequate overload 124 alignment 324–331, 475–476t arm muscles. See elbow muscles
contraction type 124 anterior view 319f articular capsule 13
frequency vs. back extensor strengthen- bony landmarks and bones 298–300 articular cartilage 4, 13, 161, 256
ing 133 bursa 309 articular disc 14
kinesthetic awareness 127 extrinsic muscles 309 articulation 11
limiting injury risk 127–129 joint capsule 303 ASIS 158f, 159, 177, 178
neutral lumbar spine 127 joint structure 300–301 assistant mover(s) 54
pelvic tilt 123–124 lateral view 321f atlantoaxial joint 77
range of motion 124 mechanics 329–331 atlanto-occipital joint 45, 77
recovery 124–125 muscle attachments and actions 318– atlas 76
recruiting obliques and transverse 319 axes, anatomical 19, 21t, 22, 28
abdominis 122–123 muscular analysis of movements 331– axial skeleton 9–10
spinal rotation 124 333
stabilization exercises 125–126 orthopedic stress tests 305 B
summary 128t plantar fascia 306 back extensions 208–211
abduction 23t, 24 posterior view 320f back extensor strengthening
abductor digiti minimi brevis 322f proprioception 353 and abdominal co-contraction 132–133
abductor hallucis 322f range of motion tests 355 and back injury 152
acetabularfemoral joint. See hip stability 304, 330–331 enhancing effectiveness 130–132
acetabulum 158f, 159 stretching 353–354 and hyperlordosis 129
Achilles tendon ankle injuries McKenzie extension exercises 152
actions and attachments 313 Achilles tendinitis 363–364 strength test 131
and pointe work 339 impingement syndromes 368–369 back injury
tendinitis 363–364 sprain 360–362 and abdominal exercises 127–129
acromioclavicular joint 376, 377f, 453 tendinitis 362–364 and back extensor strength 129–130
acromion process 374 ankle movements 300–301, 302f disc herniation 151–152
523
524 Index
back injury (continued) movements 79 isometric 134t

facet syndrome 151 circumduction 23t, 24, 25 muscles activated 108
incidence in dancers 147 clavicles 9, 374–375, 393f with rotation 140t
lumbosacral sprain/strain 149 closed kinematic chain movements 29–30 strength and endurance tests 121–122
rehabilitation 152–154 examples 31 curvature of spine 81
and Scheuermann’s disease 154 and knee strengthening 279–280 cervical lordosis 103
sciatica 151 and lever action of skeletal system 45 flat back 103–104
spondylolisthesis 149–150 of pelvis 181–182 and ideal postural alignment 94f
ball-and-socket joints 15, 16–17t, 28 close-packed joint position 29 and iliopsoas 85–86
Bartelink, D. 107 coccyx 72, 73f, 158f kyphosis 98–100
biarticulate muscle 57 co-contraction 55 lumbar, and abdominal exercises 127
biaxial joints 16–17t, 28 of abdominals during flat back position lumbar lordosis 95–98
biceps brachii 416–417, 468f 194 lumbar while standing and sitting 115f
anterior view 393f Lombard’s paradox 58, 59f scoliosis 104–106
customary action of muscle 43 and spinal alignment 115
location 60f collagen 2, 14 D
biceps femoris 61f, 168, 174, 177f, 251f, collar bones 9 deep 18
469f collateral ligaments deep outward rotators 169–170, 191
binucleate cells 34 of ankle 303 and front développé 204
blood 2, 4 as extracapsular ligament 14 line of pull and action 177f
body orientation terminology 15–19 of knee 240, 243f strengthening exercises 219–220
bone density 6, 7 compact bone 4 stretches 227t, 228t
bone marrow 4 compartment syndromes 365–366 and turnout 196, 198
bones 2 compressive forces during a wall plié 199
development and growth 5–9 and ankle/foot injuries 359 dégagé
electrical stimulation and osteoblasts on hip 194 and body orientation 21
367 and patellofemoral pain syndrome 189 and hip adductors 170
as levers 45 compressive strength of bone 2 as open kinematic chain movement 30
structure 4–5 concentric contraction 51 “use the floor” 315
types and functions 3–4 and torque 50t degrees of freedom 28
Wolff’s law 6 condyles 11t, 238, 239f, 255f in hip joint 161, 164
bony markings 10, 11t condyloid joints 15, 16–17t and kinematic chains 30
brachialis 60f, 468f biaxial classification 28 deltoid ligament (ankle) 303
brachioradialis 418 congruency 29 deltoid muscle 61f, 388–389, 468f, 469f
breathing 77, 84–85, 122–123 connective tissue anterior view 393f
bunions 329 in bursa 14 posterior view 394f
bursa 14 in fibrous joints 11 deltoid tuberosity 375
functions 2 demi-plié
C in ligaments 14 movement analysis 64t
calcaneocuboid joint 301t, 304–305 mesenchyme 5 and muscle contraction type 65f
calcaneofibular ligament 304 and muscle attachment to bone 41 and stretch-shortening cycle 54
calcaneus 299, 299f continuous movements 466 demi-pointe 336–337
calcium 2, 6, 7, 8t, 38, 39, 104 contractility 34 dens 77
cancellous bone 4 contraction. See muscle contraction développé
capitulum 412 coracobrachialis 389, 393f, 417 and deep outward rotators 204
cardiac muscle 34, 35t coracohumeral ligaments 379 and hamstring stretches 283
cardinal planes 18, 19f coracoid process 375 and muscle contraction type 53
carpals 9, 424 core stability 112–113, 125–126 diagonal planes 22
carpal tunnel syndrome 459–460 coronal plane 18 diaphysis 4, 5
carpometacarpal joint 426 coronoid process 412 diastasis recti 82
cartilage 2, 4, 5. See also fibrocartilage costotransverse joint 77 directional terminology 17, 18t
cartilaginous joints 11, 12t, 13 costovertebral joint 77 disc injury 128, 152, 153
caudal 18t coupling 81 discrete movements 466
“C” curve 104 coxa valga/vara 179–180 distal 18t
in abdominal exercises 120, 123 cranial 18t distensibility of muscle 36
centered movement 113 cranial bones 9 dorsal 17f, 18, 18t
center of gravity (CG) 15 craniovertebral joints 76–77 dorsal interossei 322f
center of mass 15, 19, 53 crest 11t dorsiflexion 23t, 27
cervical region cross-bridges 38, 51 and ankle stability 330–331
rotation 76f cruciate ligaments. See anterior cruciate muscular analysis 332
strain 153–154 ligament (ACL); posterior cruci- normal range of motion 353t
cervical vertebrae 72 ate ligament range of motion and pronation 354
in abdominal exercises 120 crural muscles strengthening exercises 345t, 346t, 352
during adulthood 73f anterior 310–312 dynamic muscle contraction 51
atlantoaxial joint 77 lateral 316–318
atlanto-occipital joint 77 posterior 312–314 E
atlas 77 posteromedial 314–316 eccentric contraction 51–52
at birth 73f cubital angle 413 during abdominal exercises 124
curvature 81 cubitus valgus/varus 413 and back extensor strengthening 132
facet joints 76f cuboid bone 298 and torque 50t
intervertebral disc size 75 cuneiforms 298, 299f effort (E) 45, 46
lordosis 103 curl-up elastic components of muscle 36
Index 525
and stretch-shortening cycle 54 female athlete triad 7 stress fractures 366–368

elbow femoral anteversion 180–181 foot movements 27, 302f
alignment 413 femoral groove 238 coupling with lower leg movement 336
bony landmarks 413f femoral retroversion 181 dorsiflexion 23t
carrying angle 413–414 femur 9 inversion 23t
hyperextension 414–415 angle of inclination 178–179 knee influence on mechanics 340
joint structure 412–413 anteversion 180–181 plantar flexion 23t
lateral epicondylitis 459 bony landmarks 159, 160f, 238 pronation 306
movements 412–413, 414f and coxa vara 179 range of motion tests 355
elbow muscles external rotation during turnout 20 supination 306
anconeus 419–420 pelvic-femoral rhythm 184–185 foot muscles
attachments and actions 420–421 retroversion 181 extensor digitorum longus 311
biceps brachii 416–417 stress fractures 230 extensor hallucis longus 311
brachialis 417 fibrocartilage 13, 14f, 74, 243 flexor digitorum longus 315
brachioradialis 418 fibrocartilage disc 14 flexor hallucis longus 315
pronator teres 418 fibrous joints 11, 12t intrinsic 309, 320–323
supinator 419 fibula 9, 239f, 299f, 300 foot strengthening exercises 347t, 348t,
triceps brachii 418–419 fingers 29 349t, 351t, 352–353
elbow strengthening 436t, 441–444t first-class lever 45 beginning pointe work 341f
electromyography 62, 64 flat back 81, 103–104 foramen 11t
and movement analysis 488 and back extensor strength 140 force
of second-position plié 273 and hip 194, 196 and angle of muscle attachment 50
of spinal rotation 112 and iliopsoas 85–86 centrifugal on annulus fibrosus 74
ellipsoid joints 15 practicing with ball 195f compressive on hip 194
endochondral ossification 5, 6f flat bones 3f, 4, 5 compressive on patellofemoral joint
endomysium 41 flexibility 3, 29 260–261, 262f
endosteum 5 flexion 17, 22, 23t and extensibility of muscle 37
epicondyle 11t flexor digitorum longus 315, 316f, 322f on facet joints during spinal movement
of knee 238 and pointe work 337 76
epimysium 41 flexor hallucis brevis 322f and linear motion 44
epiphyseal plate 5, 13 flexor hallucis longus 315, 316f on lumbosacral disc when leaning for-
epiphyseal ring 74 and pointe work 337 ward 106
epiphyses 4 stretching 359t and mechanical advantage 47
epithelial tissue 2 tendinitis 364 and movement analysis 472
erector spinae 61f, 86–87, 91t, 93f, 469f floating ribs 77 and muscle cross-sectional area 40
and lateral flexion 111 fondu developpé front (devant) 466 parallel component 51f
and lumbar hyperlordosis 95 foot. See also pointe work and patellar function 256
and spinal extension 110 alignment 324–331, 338–339, 475–476t and rotation 44, 51f
strengthening exercises 132 anterior view 319f on spine during partnering 118–119
eversion arches 298, 304, 307, 324–325 and suction at hip joint 163
description 302 bones 10 torque 45–46
muscular analysis 333 bony landmarks 298–300 force couples 56
and pointe work 337 bursa 309 force, shear. See shear force
strengthening exercises 348t, 350t, 352 dorsal aspect 17f force vectors 15
extensibility of muscle 36 great toe stretches 355 forearm. See radioulnar joint
extension 17, 23, 23t heel pad 308 forefoot 299f, 300
extensor digitorum longus 60f, 311, 321f, joints 301t fossa 11t
468f lateral view 321f fovea 161
stretching exercises 358t mechanics 329–331 frontal plane 18, 25f, 27
extensor hallucis longus 311, 321f muscle attachments and actions 318– front développé 201f, 203
external oblique muscles 60f, 83, 90t, 92f, 319 fulcrum 45
468f plantar aspect 17f fusiform muscle 40
external rotation 23t, 25f posterior view 320f
extracapsular ligaments 14 proprioception 353 G
extracellular matrix 2, 13 rearfoot ligaments 303–304 gastrocnemius 251f, 469f
extrinsic muscles 309, 332t sesamoid bones 308 action at knee 248
stretching exercises 356–359t actions and attachments 312–313
F structures 15f location 61f
facet 11t types 329 muscle fiber type 39, 40
facet joints 75, 76 weight distribution while standing 330 during relevé 264
facet syndrome 151 foot injuries/problems strengthening exercises 345t
during hyperextension 115 bunions 329 stretching 356t
and lumbar hyperlordosis 95 claw toes 327–328 gemelli 169–170, 175, 177f
facial bones 9 flexor hallucis longus tendinitis 364 genu anterecurvatum 254
false ribs 77 hallux valgus 328–329 genu recurvatum 95, 253, 270
fascicles 41 hammertoes 327–328 genu valgum 179, 250, 252
fast-twitch fibers 39 Morton’s neuroma 370 genu varum 180, 253, 271
fatigue pes planus 325–326, 327 gesture leg 2
and lumbar hyperlordosis 95 plantar fasciitis 362 glenohumeral joint 377f, 378–380. See also
and muscle fiber type 39 prevention and rehabilitation 359–360 shoulder complex muscles
fatigue posture 95, 100–103, 102f, 140 rearfoot valgus and varus 326–327 glenoid cavity 375
fat pads 14 sesamoiditis 369–370 glenoid fossa 375
526 Index
glenoid labrum 14f bony landmarks 158–161 iliopsoas 165–166

gliding joints 15, 16–17t, 28 bursae 163 lateral 170–171
gluteus maximus 61f, 469f compressive forces 194 medial 171–174
actions and attachments 167, 174 coxa vara 179 and movements 187t
attachment to bone 177f effect of suction 163 multijoint 193
gluteus medius 61f, 469f femoral anteversion/retroversion 180– pectineus 173
actions and attachments 170–171, 175 181 posterior 167–169
line of pull and action 177f joint structure 161–162 posterior view 177f
gluteus minimus 170–171, 175, 176f, 177f labrum 163 rectus femoris 166
gracilis 60f, 173, 176, 177f, 251f, 468f ligaments 161–163, 163f tensor fasciae latae 171
Graham technique 267, 433f mechanics 181–186 hip rotators 169–170. See also deep out-
grand battement movements 161f ward rotators
emphasis of movement 478 muscles 163–164 strengthening exercises 222
“lift from under the leg” 209 muscles and movements 187t stretching 229
movement analysis 480–483 pelvic-femoral rhythm 184–185 hip strengthening exercises 213–220t
range of motion 486 range of motion 223t horizontal abduction 23t, 27, 193
stabilizer (fixator) muscles 55 hip abductors horizontal adduction 23t, 27, 45, 193
grand jeté en avant 492–499 and side extensions 204 horizontal plane 19, 26f, 27
grand plié strengthening exercises 216–217, 221 Horton technique 267
forces on knee 265–268 stretches 229 humeroulnar joint 412
muscle activation and turnout 199 hip adductors humerus 9, 375, 376f, 399t
and patellofemoral compressive forces 261 strengthening exercises 218–219, 221 hyaline cartilage 13
gravity. See also line of gravity stretches 228t hyperextension 23t, 24
and abdominal exercises 124 stretching 226t, 227t, 228–229 of elbow 414–415
and body orientation 15 hip extensor training 66f of hip 161
counteracting with muscle contraction 52 back leg raise 214t of knee 52, 270, 272, 280
influence on type of contraction 63 strengthening exercises 214–215, 221 of spine 75, 75f, 115–116, 117f, 148f
loss of and spine length 74 stretches 223, 225t hypertrophy 37
and “release and recover” movement 53 “use back of the leg” 186 and force of muscle contraction 40
in standing movements of spine 110 hip flexors of quadriceps 271
and upright stance 108 and abdominal exercises 124 H zone 37, 38
use in stretching exercises 67 and fatigue posture 100
greater trochanter 159, 204, 208 flexibility test 212 I
Greek root of names 59 and lumbar hyperlordosis 96, 97f I band 37
ground reaction forces 488, 497 minimizing in abdominal exercises 120 iliac crest 158f, 159, 178
growth plate 5 strengthening exercises 213–214, 221 iliac fossa 158f, 159
stretches 222–223, 224t iliacus 85–86, 90t, 174, 176f
H hip injuries iliocostalis muscles 86t, 87, 91t, 93f, 132,
hallux 300 fractures 7, 230–231 469f
hamstrings 246–247, 469f iliopsoas tendinitis 232 iliofemoral ligament 161
actions and attachments 168 muscle strain 231–232 iliolumbar ligament 78
and flat back position 194 osteoarthritis 231 iliopsoas 85–86, 90t, 468f
flexibility and neutral pelvis 115 piriformis syndrome 233–234 actions and attachments 165–166
flexibility and spine hyperextension prevention 230 attachment to bone 176f, 177f
117–118 snapping hip syndrome 232–233 customary action of muscle 43f
flexibility test 205 trochanteric bursitis 233 and fatigue posture 100
location 61f hip movements in front développé 203
moment arm 59f abduction 189 location 60f
passive insufficiency 59f adduction 189–190 reversal of customary action of muscle
and patellofemoral joint 257–258 back extensions 208–211 43f
and pelvic stabilization 185 extension 188–189 and side extensions 204
strengthening exercises 66, 276t, 277t external rotation 191–192 strengthening exercises 213t
stretching 67f, 223, 225t, 226t, 283, 283t flexion 187–188 stretching 224t
hand front développé 201–204 iliotibial band 167f, 189, 244
bones 9, 425f front extensions 201–204 iliotibial tract 177f
dorsal aspect 17f horizontal abduction 193 ilium 3f, 9, 158, 158f
joints 425–427 horizontal adduction 193 inferior 17, 18t
movements 421, 427f internal rotation 192–193 inferior articular process 73f, 74
muscles 427–431 side extensions 204–208 inferior pole of patella 238
muscles and movements 430t hip muscles inferior ramus of pubis 158f, 159
palmar aspect 17f activation during turnout 199 inferior vertebral notch 73
passive insufficiency with finger flexion adductor longus, magnus, brevis 172 infraspinatus 61f, 394f, 400–401, 469f
433 angle of femoral inclination 180f inguinal ligament 83f, 84f, 92f
structure 424 anterior 165–166, 176f insertion of muscle 42–43
head (bony marking) 11t attachments and actions 174–176 intercalated discs 34
hinge joints 15, 16–17t, 28 deep outward rotators 169 intercondylar eminence 239f
hinge movements 267 external rotators and turnout 269 intercondylar fossa 238
hip gluteus maximus 167 intercondylar notch 239f
alignment problems 475t gluteus medius 170–171 internal obliques 60f, 83–84, 90t, 92f, 468f
angle of femoral inclination 178–179 gluteus minimus 170–171 internal rotation 23t, 26
angle of femoral torsion 180 gracilis 173 interosseus membrane 300, 415
bones 158–161 hamstrings 168 interosseus talocalcaneal ligaments 304
Index 527
interphalangeal joint flexion 261–262 lateral condyle of knee 238

of foot 301t, 306 forcing turnout 268 lateral epicondyle 238
of hand 427 functions 238 lateral flexion 23t, 79
interspinales 88–89, 93f genu recurvatum 95 muscles involved 110–111
interspinous ligaments 76 genu valgum 179 muscle strengthening exercises 141
intertarsal joints 301t genu varum 180 spinal alignment 116f
intertransversales 88–89, 93f during grand plié 265–268 of spine 80f
intertransverse ligaments 76 during hinge movements 267 spine range of motion 143t
intertrochanteric line 159 hyperextension 270, 272 stretches 147
intervertebral discs 12t, 74 influence on foot mechanics 340 lateral malleolus 298
and abdominal exercises 128 joint capsule 239–240 lateral pelvic tilt 178
as cartilaginous joint 13 joint structure 12t lateral tilt 483–485
force when forward leaning and lifting “lift out of your knees” 266 Latin root of names 59
106 ligaments 14, 239–241 latissimus dorsi 61f, 469f
herniation 151–152 locking mechanism 255–256, 257 actions and attachments 390
and partnering 118 Lombard’s paradox 265 strengthening exercises 436t
pressure on 115 mechanics 254–256 law of approximation 50, 467
repair 152 menisci 14f, 243 law of valgus 259–260, 261f
sagittal and transverse sections 74f movements 239–244, 240f left lateral flexion 23t, 26, 110–111
size and region in spine 75 movements and muscles 262t left rotation 23t, 26
intervertebral foramina 73 Q angle 258, 260 leg. See lower extremity; lower leg
intra-abdominal pressure (IAP) 106, 113 range of motion 281t leg length difference 104
intracapsular ligaments 14 rotation 264, 268 lesser trochanter 159
intramembranous ossification 5 stretching 281–284 levator scapulae 61f, 382, 394f, 469f
intrinsic muscles of foot 309, 320–323, tibial torsion 254 lever arm 128–129, 161
349t, 353 and turnout 20 levers 45, 46f, 47f
inversion 23t valgus stress 240, 269–270 “lift from under the leg” 209
and ankle sprain 360 varus stress 241 “lift out of your knees” 266
description 302 kneecap. See patella ligaments
muscular analysis 332 knee injuries sprain 29
and pointe work 337 anterior cruciate ligament 286–288 in synovial joints 14
strengthening exercises 346t, 347t, bursitis 243–244 ligamentum flavum 76
350t, 352 extensor mechanism 289 ligamentum nuchae 76
involuntary muscle 34 jumper’s knee 291–292 linea alba 82, 92f
irregular bone 3f, 4, 5, 159 medial collateral ligament 286 linear motion 44
irritability 34 menisci 288–289 line (bony marking) 11t
ischial tuberosity 158f, 159 orthopedic stress tests 242 line of gravity 15, 93–95, 98
ischiofemoral ligament 161–162 Osgood-Schlatter disease 292–293 line of pull of muscle 43–44, 62
ischium 3f, 9, 158, 158f patellofemoral pain syndrome 289– Lombard’s paradox 58, 59f, 265
isometric contraction 52 291 long bones 3, 4
of stabilizer muscles 55 plica inflammation 239 longissimus muscles 86t, 87, 91t, 93f
and torque 50t prevention 284–285 longitudinal arch of foot 298
isotonic 51 rehabilitation 293 loose-packed joint position 29
stress tests 242 lordosis. See also lumbar lordosis
J terrible triad 289 cervical 81, 103
joint capsule 13 knee muscles low back pain
joint cavity 13 anterior view 251f and back extensor strength 129–130
joints gastrocnemius 248 mechanical 149
axes 28 hamstrings 246–247 rehabilitation 152–154
classification 11–15 plantaris 248 lower extremity
in movement analysis 467 popliteus 248 and angle of femoral torsion 181f
movements in horizontal plane 26f posterior view 251f bones 9
movement terminology 22–28 quadriceps femoris 244 closed kinematic chain movements
stability and mobility 29 summary of attachments and actions 31
jumper’s knee 291 249–250 movements 27
jumping knee strengthening open kinematic chain movements 31
and compressive forces on knee 261 closed kinematic chain movements skeletal structure 9, 10f
grand jeté en avant 492–499 279–280 lower leg
and plantar fasciitis 362 exercises 275–279 calf raises 342–343
and plantar flexion strengthening 342– kypholordosis 100 compartments 307–308, 308f
343, 345t kyphosis 81, 98–100, 99f, 115 compartment syndromes 365–366
and stretch-shortening cycle 54 coupling with foot movement 336
L extensor hallucis longus 311
K Laban terminology 478 flexor digitorum longus 315
kinematic chain 30 labrum 14 flexor hallucis longus 315
knee. See also patellofemoral joint laminae 72, 73f, 76 gastrocnemius 312–313
actions of two-joint muscles 264–265 lateral 18t gastrocnemius stretches 356t
alignment 250–254, 338–339, 475t lateral border of patella 238 interosseus membrane 300
bony landmarks 238 lateral collateral ligament peroneus brevis 317–318
bursae 243–244 of ankle 303–304 peroneus longus 317
compressive forces 261 of knee 240–241, 240f peroneus tertius 312
extension 263–264 stress test 242 plantar fascia 306
528 Index
lower leg (continued) and patellar function 256 characteristics 2, 39t

plantar flexor stretches 357t moment of force 45–46 contractility 34
retinaculum 308, 309f Morton’s neuroma 370 cross-sectional area 40
shin splints 364–365 motion segment 79 customary action 43
soleus 313–314 movement analysis fiber arrangement 40–41
stirrup muscles 337 alignment and technique 472–473 fiber type and function 39
stress fractures 366–368 benefits 485–487 functions 34
stretching exercises 356–359t correcting errors 473 growth 37
tendon sheaths 308, 309f and emphasis of movement 478 hypertrophy 37
tibialis anterior 310 extreme range of motion 470, 472 insertion 42–43
tibialis posterior 314–315 grand battement devant 480–483 learning names and actions 58–68
tibial stress syndrome 364–365 grand jeté en avant 492–499 line of pull 43–44
lumbar lordosis 95–98 lateral tilt 483–485 mechanical model 36–37
and back extensor strength 129 mechanical 488 microstructure 37, 38f
controlling 96f movement cues 500 multijoint 56–57
correcting 97f optimal performance models 499–500 names and word roots 62t
and iliopsoas 85–86 phases 466 origin 42–43
and long-lying position 128 prime mover(s) 470t posterior view 61f, 468f
lumbar 81 qualitative and quantitative 487–488 postural and nonpostural 40
during partnering 119 related research 489 prime mover(s) 467, 470t
and psoas paradox 108 roles of muscles 467 stabilizer (fixator) muscle 467
while sitting 115 running 490–492 strain 29
lumbar-pelvic rhythm 183f schema 479, 480t striated appearance 37
lumbar rotation 76f self-analysis 479 structure 42f
lumbar vertebrae 72 simplified schema 64t tissue properties 34–36
during adulthood 73f and speed of movement 477–478 types 34, 35t
at birth 73f strength requirements 472 myofibrils 37
curvature 81 synergists 470 myofilaments 37
facet joints 76f multiarticulate muscle 57 myosin 37
lordosis 81 multifidus 88–89, 93f
neutral spine during abdominal exer- and core stability 113 N
cises 127 strengthening exercises 132 navicular bone 298, 299f
size of intervertebral discs 75 multijoint muscles 56–57 neck of femur 159
structure 73f at hip joint 193 nervous tissue 2
lumbosacral joint 78–79 Lombard’s paradox 58 neural arch 72
lumbosacral sprain/strain 149 in upper extremity 432 neuroglia 2
lumbricales 322f muscle belly 41 neurons 2
muscle contraction neutral base alignment 114
M active insufficiency 57–58 nonaxial joints 28
malleolus 11t agonists (movers) 54 nonpostural muscles 40
McKenzie extension exercises 152 and alignment 30 nonstructural scoliosis 104
mechanical advantage 46–48, 47f antagonists 54–55 nucleus pulposus 74
medial 18t concentric 51
medial border of patella 238 dynamic 51 O
medial collateral ligament effort (E) 46 oblique muscles
of ankle 303 electromyography 62, 64 and lateral flexion 111
of knee 240, 240f, 243f and force couples 56 and protection of spine 107
stress test 242 influence of gravity 63 recruiting during abdominal exercises
medial condyle of knee 238 isometric (static) 52–53 122–123, 124
medial epicondyle 238, 239f Lombard’s paradox 58 and spinal flexion 108
median plane 17f, 18 in movement analysis 467 oblique planes 22
mediolateral axes 19, 20f, 24f passive insufficiency 57–58 obturator externus 175, 176f
medullary cavity 4 and “release and recover” movement obturator foramen 158f, 159
menisci 14f, 240f, 243, 243f 53 obturator internus 169–170, 175
injuries 288–289 sliding filament theory 37–39 odontoid process 77
mesenchyme 5 stabilizer (fixator) 55 olecranon process 412
metacarpals 9, 424 stretch-shortening cycle 54 open kinematic chain movements 29–30
metacarpophalangeal joint 426 synergist (neutralizer) 55 examples 31
metatarsals 10, 298, 299f type and abdominal exercises 124 lumbar-pelvic rhythm 183–184
and foot type 329 type and torque 50t and pointe work 337–338
sections 300 types 50–53 opposition of thumb 426
metatarsophalangeal (MTP) joint 301t, muscle fiber type 39–40 organs 2, 34
305 muscle fusion theory 107 origin of muscle 42–43
windlass effect 307 muscle(s) os coxae 9, 158, 160
midcarpal joints 425f actions deduced from attachments 63 Osgood-Schlatter disease 292–293
middle deltoid 61f angle of attachment 48, 50 os innominatum 9, 158
midfoot 299f, 300 anterior view 60f, 468f ossification 5
midsagittal plane 18 architecture 40–41 osteoblasts 5, 367
moment arm 46 attachment and action 63 osteoclasts 8
and abdominal exercises 129 attachment to bone 4, 5, 41–44, 42f osteopenia 6
of hamstrings 59f and bone density 6 osteoporosis 6, 7, 100, 230–231
influence on torque 49 cell structure 34 os trigonum syndrome 367–368
Index 529
P bones 158–161 stretches 354–355, 358t

pacemaker cells 34 bony landmarks 158–161 popliteus 247f, 248, 251f
palmar 18, 18t closed kinematic chain movements posterior 17, 18t
palmar aspect of hand 17f 181–182 posterior cruciate ligament 240f, 241, 242
parallel component 50 common alignment problems 474–475t posterior crural muscles 312–314
parallel elastic components 36 and ideal postural alignment 94–95 posterior deltoid 61f
pars interarticularis 95 and lumbar curvature 81 posterior intercondylar areas 238
partnering mechanics 181–186 posterior longitudinal ligament 75
and arm support 412 sacroiliac inflammation and dysfunc- posterior pelvic tilt 82, 177–178
and spine protection 118–120 tion 234–235 posterior superior iliac spine (PSIS) 158f,
passé 166, 169 stabilization 185–186 159, 160–161
passive components 36 stress fractures 230 posterior talofibular ligament (PTFL) 304
passive insufficiency 57–58, 59f penniform muscle 41 post meniscofemoral ligament (of Wris-
with finger flexion 433 perimysium 41 berg) 243f
patella 3f, 10f periosteum 4f, 5 postural alignment 93–95, 101. See also
bony landmarks 238–239, 239f permanent deformation 36 alignment
functions 256–257, 259f peroneus 61f pregnancy
law of valgus 259–260 peroneus brevis 317–318 and diastasis recti 82
movements 257 peroneus longus 317, 469f and os coxae 160
“pull up your knees” 52 peroneus tertius 312 preparatory movements 54
Q angle and tracking 260 pes anserinus 257–258 prestretch 54
tracking 68 pes cavus 325–326 primary curvature of spine 73f, 81
patellar tendon 251f pes planus 325–326, 327 primary ossification site 5
patellofemoral joint phalanges 299f prime mover(s) 54
alignment 258 of foot 10, 298, 300 principal planes 18
anterior and posterior view 258f of hand 9, 425 processes of vertebrae 73
compressive forces 260–261, 262f phases of movement 466 pronation 23t, 27, 422f
law of valgus 259–260 grand jeté en avant 492–499 excessive 334–335
mechanics 258–261 running 490–492 and foot mechanics 331
muscles 257–258 phasic muscles 40 influence on dorsiflexion range of
Q angle 258 piezoelectric effect 6 motion 354
structure 256 piriformis 169–170, 175, 233–234 muscles 423
patellofemoral pain syndrome 289–291 pirouette 56 during walking 334–335
and forcing turnout 269 pivot joints 15, 16–17t pronator quadratus 418
pectineus 60f, 468f uniaxial classification 28 pronator teres 418
actions and attachments 173, 176 plane joints 15 prone 17
anterior view 176f planes, anatomical 18–19, 19t proprioception of foot 353
attachment to bone 176f, 177f in complex movement 22 proprioceptive neuromuscular facilitation
pectoralis major dance movements within 21f (PNF) 67
actions 45 and motions of spine 79 proximal 18t
anterior view 393f planes, median 17f proximal attachment of muscle 43
attachments and actions 387–388 plantar 18, 18t PSIS 159
location 60f plantar aspect of foot 17f psoas major 85–86, 90t
pedicles 72, 73f plantar fascia 307f actions and attachments 174
pelvic-femoral rhythm 184–185 plantar fasciitis 362 anterior view 176f
pelvic girdle 9 plantar flexion 23t, 27 attachment to bone 176f
basin image 164 and ankle sprain 360f psoas minor 176f
joint structure 159–161 and ankle stability 330–331 psoas paradox 108
lumbar-pelvic rhythm 183f muscular analysis 331–332 pubic crest 158f
movements 159–161 normal range of motion 353t pubic symphysis 13, 160
neutral position 177 and pointe work 336–337 and neutral pelvic position 177
pelvic-femoral rhythm 184–185 range of motion for dancers 354 pubis 9, 158, 158f
role 158 range of motion tests 355 pubofemoral ligament 161
pelvic tilt 161 strengthening exercises 342–343 “pull up your knees” 52
during abdominal exercises 123–124 stretching 353–354, 357t push-up
and alignment 164 plantar interossei 322f shoulder complex muscles 403
anterior and posterior 177–178 plantaris 248 strengthening exercises 434t
and back extensions 208 plica 239 test 445
and closed kinematic chain movements plié. See also grand plié
181–182 alignment problems 476–477 Q
exercise 134t electromyography 273 Q angle 189, 258, 259f, 260
and fatigue posture 100 wall plié and muscle activation 199 quadratus femoris 169–170
during grand plié 267f plumb line and alignment 94 actions and attachments 175
lateral 178 plyometrics 54 quadratus lumborum 89, 91t, 93f
neutral position 177 pointe work anterior view 176f
posterior, and rectus abdominis 82 beginning 339–340 and lateral flexion 111
rotation 178 and hallux valgus 329 quadratus plantae 322f
and side développé 206f plantar flexion strength 336–337 quadriceps femoris 60f, 244, 246f, 468f
Trendelenburg sign 189, 191 plantar flexion strengthening 342–343 flexibility test 284
pelvis “point from the top of the foot” 339 overdevelopment 271, 273–274
alignment and distal joint mechanics range of motion tests 355 and patella function 68
477 strengthening exercises 343–351t and patellofemoral joint 257–258
530 Index
quadriceps femoris (continued) joint movements in 24f normal range of motion 448t
strengthening exercises 213t, 274 movement about mediolateral axis 20f “pull shoulders back” 397
stretching 281, 282t, 285f movements in 27 rotation and abduction 399–400
tendon 176f and turnout 20 rotation vs. circumduction 25f
sarcolemma 36 scapulohumeral rhythm 397–399
R sarcomere 37, 38, 51, 52 shoulder blades. See scapulae
radial deviation 425–426 sarcoplasm 37 shoulder complex muscles 380
radiocarpal joint 425, 425f sartorius 60f, 251f, 468f actions of pectoralis major 45
radioulnar joint 12t, 415, 422f actions and attachments 166, 174 anterior view 393f
radioulnar joint muscles 423–424 attachment to bone 176f attachments and actions 391–392
radius 9 fiber arrangement 40 coracobrachialis 389
ramus of ischium 158f, 159 line of pull and action 176f deltoid 388–389
rearfoot 299f, 300 scaption 378 infraspinatus 386
recoverable deformation 36 scapulae 9, 377f latissimus dorsi 390
rectus abdominis 60f, 82, 90t, 92f, 468f alignment 396–397 levator scapulae 382
rectus femoris 244, 251f, 468f bony landmarks 374–375 line of pull 393f, 394f
actions and attachments 166, 174 depression 376–377 movements 404t
active insufficiency 59f depression and excessive elevation 471f pectoralis major 387–388
attachment to bone 176f elevation 376–377 pectoralis minor 384–385
line of pull and action 176f elevation with overhead arm move- posterior view 394f
red blood cells ments 409–410 during push-up 403
manufacture in bone marrow 4 “hold shoulder blades down” 408 push-up test 445
reference axes 19 movements 376–378 rhomboids 383
relevé movements and humerus movements rotator cuff 385–386
and lever system 45 399t scapular muscles 381
“lift from under pelvis” 352 muscles acting on 384t serratus anterior 383
role of gastrocnemius 264 muscles and movements 404t SIT force couple 400–401
strengthening exercise using disk 351t neutral position during dance 410–411 subscapularis 386
use of stirrup muscles 338 rotation 384f supraspinatus 385
reposition of thumb 426 stabilization 400 synergies 401
resistance 45 strengthening of muscles 446–447 teres major 390
retinaculum 14, 15f synergy during shoulder abduction teres minor 386
retrocalcaneal bursa 15f 402f trapezius 381–382
rhomboids 61f, 383, 469f winged 396–397, 398f shoulder flexibility
posterior view 394f scapulohumeral rhythm 397–399 extensors and flexors 448
rib leading 96 scapulothoracic joint 376 horizontal adductors/abductors 452
ribs 9, 77–78 Scheuermann’s disease 99, 154 screening test 451
right lateral flexion 23t, 26 sciatica 151 stretches 448–451
muscles involved 110–111 sciatic notch 158f shoulder girdle 9
right rotation 23t, 26 scoliosis 81, 104–106 bones and joints 377f
roll-down 183f, 195f “S” curve 104 bony landmarks 374–375
role of hip 194 secondary curvature of spine 81 joint structure 375–378
rond de jambe 169 secondary mover(s) 54 movements 375–378
rotary motion 44 secondary ossification site 5 shoulder injuries
rotation secondary planes 19 acromioclavicular sprain 453
during abdominal exercises 124 second-class lever 45 adhesive capsulitis 458
and anatomical planes 22 semimembranosus 61f, 251f, 469f bursitis 457–458
of cervical spine 76f actions and attachments 168, 174, 177f dislocation 453–454
external 23t, 25 semispinalis muscles 87–88, 91t, 93f frozen shoulder 458
internal 23t, 26 semitendinosus 61f, 251f, 469f impingement syndromes 379, 455–456
of knee 254, 264 actions and attachments 168, 174, 177f prevention 452
of lumbar spine 76f series elastic components 36 rehabilitation 452–453
of pelvis 178 serratus anterior 60f, 383, 468f rotator cuff tear 456–457
during pirouette 56 sesamoid bones 3f, 4 shoulder movements
as a result of force 44 of foot 299f, 300, 308 abduction 405–406
of shoulder 399–400 inflammation 369–370 adduction 406
of spine 23t, 76f, 79, 80f, 112, 141–142, Sharpey’s fibers 5 extension 405
143t shear force external rotation 407
rotator cuff 385–386, 456–457 and abdominal muscles’ protection of flexion 402–403
rotatores 88–89, 93f, 132 spine 107 horizontal abduction 407–408
running 9, 490–492 during hyperextension of spine 119 horizontal adduction 407–408
and lumbar hyperlordosis 95 internal rotation 407
S shin splints 5, 364–365 muscle actions 404t
sacrococcygeal curvature 81 short bones 3, 5 shoulder strengthening
sacroiliac joints 79, 158f, 160–161 shoulder abductors 445
and fatigue posture 100 alignment 395–397 adductors 446
inflammation and dysfunction 234–235 alignment problems 476t exercises 434–440
sacrum 72, 73f, 158f, 161 excessive elevation in dance 409–410 extensors 445
tilt in normal stance 95 glenohumeral joint 378–380 external rotators 446
saddle joints 15, 16–17t glenoid labrum 14f flexors 444–445
biaxial classification 28 line of pull of muscles 44f improving rolled shoulders 396f
sagittal plane 18 mechanics 397–401 internal rotators 446
Index 531
side développé movements and muscles 109t and elasticity of muscle 37

drop of greater trochanter 208 movements of 26 exercise design 67
and pelvic tilt 206f and partnering 118–120 muscle sensitivity to 52
side extensions 204–208 as part of axial skeleton 9 and turnout 196, 198f
“lift from under the leg” 209 protection by abdominals 106–108 stretch-shortening cycle 54
strengthening exercises 207f range of motion 143t striated muscle 34
single-joint muscle 57 range of motion variability 146 structural scoliosis 104
sinus 11t rotation 112 styloid process 422
sissone ouverte 472 of scapula 374 subacromial bursa 380
sitting stretching 142 subcoracoid bursa 380
and intervertebral disc pressure 151 upper back lifted 118 subdeltoid bursa 380
and spinal alignment 115 spine (bony marking) 11t subscapularis 400–401
sitz bones 159 of ischium 158f subtalar joint 301t, 302–303
skeletal muscle. See muscle(s) spine strengthening exercises 134–140t superficial 18, 18t
skeletal system balance with abdominal strengthening superior 17, 18t
appendicular skeleton 9–10 133, 140 superior articular process 73f, 74
axial skeleton 9–10 extensor muscles 141 superior border of patella 238
definition 2 lateral flexion muscles 141 superior peroneal (fibular) retinaculum
skull 9 rotator muscles 141–142 308
sliding filament theory 37–39, 50 spine stretches 144–147 superior ramus of pubis 158f, 159
slow-twitch fibers 39 range of hyperextension 148f superior vertebral notch 73
smooth muscle 34, 35t spinous process 11t, 73, 73f supination 23t, 27, 422f
soleus 469f spondylolisthesis 149–150 and foot mechanics 331
actions and attachments 313–314 rehabilitation from 152 muscle 423–424
location 61f spondylolysis 95, 116, 149–150 during walking 334–335
muscle fiber type 39 spongy bone 4 supinator 419
stretching 357t sprain 29 supine 17
in upright standing 53 spring ligament 304 supraspinatus 385, 469f
speed of movement 48 stability. See core stability posterior view 394f
spinal canal 72 stabilizer (fixator) muscle 55 supraspinous ligaments 76
spinal column 72 standing posture sutures 11, 12t
spinalis cervicis 86t, 91t and closed-chain pelvic movements synergist (neutralizer) muscle 55, 470
spinalis muscles 87 181–183 synovial fluid 13
spinalis thoracis 86t, 91t, 93f and hyperextension of spine 116 synovial joints 13–14
spinal muscles weight distribution on feet 330 movements 22, 28
anterior view 92f static muscle contraction 52–53 structure 12t, 13f
deep posterior group 88–89 static stretching 67 subclassification 14–15, 16–17t
erector spinae 86–87 sternoclavicular joint 376, 377f synovial membrane 13
external obliques 83 sternocleidomastoid 60f, 468f systems, definition 2
and flexion of spine 108–109 sternum 9
iliopsoas 85–86 stirrup muscles 337 T
internal obliques 83–84 strengthening exercises 343t, 344t “tailor’s muscle” 166
posterior view 93f strain 29 talocrural joint 300–301, 301t
rectus abdominis 82 strength. See also tensile strength talometatarsal joints 305
semispinalis 87–88 compressive of bone 2 talonavicular joint 301t, 304–305
summary of attachments and actions tensile, of collagen 3 talus 298, 299f
90–91t tensile, of tendons 41, 362 tarsals 10, 298
transverse abdominis 84–85 strengthening exercises tarsal tunnel 299f
spine for arabesque 211f tarsometatarsal joint 301t
abdominal muscles as stabilizers 471f for front développés and extensions tendinous inscriptions 82, 92f
alignment 81 201f tendon 41
alignment and distal joint mechanics for front extensions 202f tendon sheath 14, 15f
477 Reformer front développé 214t tendu
alignment during lateral flexion 116f for side extensions 207f use of stirrup muscles 337–338
alignment in dance 113–115 for turnout 199f “use the floor” 315
alignment problems 474t strength test tensile strength
bones 72–74 for abdominal muscles 121–122 of collagen 2
bony landmarks 72–74 for back extensors 131 of tendons 41, 362
and centered movement 113 strength training tensor fasciae latae 60f, 167f, 244, 251f,
and core stability 112–113 design and muscle action 65–66 468f
craniovertebral joints 76–77 for hip extensors 66f actions and attachments 171, 175
extension 109–110 and muscle cross-sectional area 40 anterior view 176f
flexion 116–118 resistance types 66 teres major 61f, 390, 394f, 469f
flexion (lateral view) 75f stress fractures teres minor 386, 394f, 400–401
flexion relaxation phenomenon 117 causes of 8–9 third-class lever 45
hyperextension 115–116 femur 230 thoracic cage 77, 78f
hyperextension in dancers 142 lower leg 366–368 thoracic region 76f
hyperextension (lateral view) 75f pelvis 230 thoracic vertebrae 72
lateral 89 and spinal hyperextension 115 during adulthood 73f
lateral flexion 23t, 110–111 susceptibility of dancers 7 at birth 73f
lifting and lengthening 114 stretching facet joints 76f
mechanics 106–108 bounce stretching contraindicated 117 joints with ribs 77–78
532 Index
thoracic vertebrae (continued) troponin 38 V

kyphosis 81, 98–100 true ribs 77 valgus angulation 250
upper back lifted 118 true synergist 55 valgus of rearfoot 326–327
thoracolumbar fascia 107, 113 tubercle 11t, 42 valgus stress 240
thorax 9 tuberosity 11t in dance 269–270
thumb movements 426, 429t, 431 of fifth metatarsal 299f in demi-plié 477
tibia 9, 239f turnout varus of rearfoot 327
bony landmarks 238 active and passive 196 varus stress 241
palpation 298 and angle of femoral torsion 180 vasti muscle fiber arrangement 40
rotation and injury 268 “bring heel forward” 269 vastus intermedius 244, 468f
stress fractures 367 and deep outward rotators 169 vastus lateralis 244, 251f, 468f
torsion 254, 324 determining factors 196 and patella tracking 259
and turnout 20 and femoral retroversion 181 vastus medialis 244, 251f, 468f
weight-bearing function 300 forcing 268 and patellofemoral pain syndrome
tibialis anterior 60f, 310, 468f and gender 196 190
and pointe work 337 and ischial tuberosity 159 vector 50
tibialis posterior 314–315, 316f and lumbar hyperlordosis 95 ventral 18t
and pointe work 337 and muscle activation 198–199 vertebrae 9
tibial plateau 238, 239f and planes of body 20 structure 72
tibial stress syndrome 364–365 in side extensions 204 vertebral arch 72, 73f
tibial tuberosity 238 strengthening exercises 199f joints between 75–76
tibiofemoral joint 239 stretches 198f vertebral body 72, 73f
tissue types 2 test for 197 joints between 74–75
titin 36 two-joint muscle 57 vertebral canal 72
tonic muscles 40 actions at knee 264–265 vertebral column 9. See also spine
torque 45–46 resistance training 66 during adulthood 73f
and concentric contraction 51 stretching 67 at birth 73f
influence of moment arm 49 Type I and Type II fibers 39 joint between vertebral bodies 74–75
and lever action 47f movements 79–81, 80f
and type of muscle contraction 50t U regions 72
trabeculae 4 ulna 9 segmental movement 80f
trabecular bone 4 ulnar deviation 426 spondylolisthesis 149–150
transverse abdominis 468f uniarticulate muscle 57 spondylolysis 149–150
and protection of spine 107 uniaxial joint 28 vertebral endplate 74
recruiting during abdominal exercises upper extremity. See radioulnar joint vertebral foramen 72, 73f
122–123 bones 461f vertebra prominens 74
and spinal flexion 108 closed kinematic chain movements 31 vertical axis 21
transverse arch of foot 298 coordination of multiple joint move- joint movements about 26f
transverse ligament 240f, 243f ment 432 viscoelastic 36
transverse plane 18 flexibility exercises 447–452 properties of menisci 243
transverse process 73f, 74 joints 461f viscosity of muscle 36
transverse tarsal joint 304–305 multijoint muscles 431–432
transversus abdominis 60f, 84–85, 90t, 92f open kinematic chain movements 31 W
trapezius 60f, 61f, 381–382, 468f, 469f pronation 23t, 27 walking phases 334–335, 466
anterior view 393f skeletal structure 9, 10f wall plié 200
Trendelenburg sign 189, 191, 233 strength and partnering 119 Wolff’s law 6
triaxial joints 16–17t, 28 strengthening exercises. See elbow wrist. See also radioulnar joint
triceps brachii 61f, 469f strengthening; shoulder strength- movements 425–426, 427f
actions and attachments 418–419 ening muscles 427-429, 431
posterior view 394f superficial muscles 462f muscles and movements 430t
strengthening exercises 436t, 443t, 444t supination 23t, 27 structure 424
triceps coxae 169 upper extremity injuries. See also shoulder
triceps surae 312, 314 injuries
and Achilles tendinitis 363 acromioclavicular sprain 453 Y
strengthening exercises 343t biceps tendinitis and rupture 458–459 “Y” ligament 161
trochanter 11t carpal tunnel syndrome 459–460
bursitis 233 prevention 452 Z
trochlea 412 tennis elbow (lateral epicondylitis) 459 Z line 37, 38
tropomyosin 38 upper trapezius 468f zygoapophyseal joints 75
About the Author
Karen Clippinger received her master’s degree in

exercise science from the University of Washington
in 1984. Her lifelong work has focused on the appli-
cation of scientific principles to enhance alignment
and movement performance while reducing injury
risk. She is currently a professor at California State
University at Long Beach, where she teaches func-
tional anatomy for dance, Pilates, placement for
the dancer, prevention and care of dance injuries,
and dance science related to teaching technique.
Ms. Clippinger has also taught dance anatomy and
kinesiology courses at UCLA, Scripps College, the
University of Washington, and the University of Cal-
gary. She serves as a faculty member for Body Arts
and Science International.
Prior to her appointment at CSULB, Ms. Clip-
pinger worked as a clinical kinesiologist for 22 years.
She has also served as a consulting kinesiologist
for the Pacific Northwest Ballet since 1981 and has
consulted for the U.S. race walking team, the U.S.
Weightlifting Federation, and the California Gover-
nor’s Council on Physical Fitness and Sports.
Ms. Clippinger has given more than 350 presenta-
tions in the United States and abroad. She has taught
workshops at many universities and has authored
numerous articles and chapters. She wrote an exer-
cise column for Shape Magazine for four years and
served as one of the founding coeditors in chief of
the Journal of Dance Medicine and Science from 1996
to 2005.
533
You’ll find other
outstanding dance,
anatomy, and
kinesiology resources at
www.HumanKinetics.com
In the U.S. call
1-800-747- 4457
Australia....................................................08 8372 0999
Canada .................................................. 1-800-465-7301
Europe.......................................... +44 (0) 113 255 5665
New Zealand........................................0064 9 448 1207
HUMAN KINETICS
The Information Leader in Physical Activity
P.O. Box 5076 • Champaign, IL 61825-5076 USA

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Dance

CHAPTER 1 The Skeletal System and Its Movements . . . . . . . . . . . . . . . . . . . . . . . 1

CHAPTER 2 The Muscular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

CHAPTER 3 The Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

CHAPTER 4 The Pelvic Girdle and Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . 157

CHAPTER 5 The Knee and Patellofemoral Joints . . . . . . . . . . . . . . . . . . . . . . . . 237

CHAPTER 6 The Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

CHAPTER 7 The Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

CHAPTER 8 Analysis of Human Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

References and Resources 503

Preface sidered the science of human motion and tradition-

© Angela Sterling Photography. Pacific Northwest Ballet dancer Patricia Barker.

W e start our discussion of dance anatomy and

• Support: Bones provide an internal framework for

Bones come in a large variety of shapes and sizes.

• Long bones are tubular in shape and much

Bone does not have uniform composition. For exam-

Structure of a Typical Long Bone

During fetal development, specialized connective Bone Remodeling

sion becomes electropositive, creating an electrical

TESTS AND MEASUREMENTS 1.1

Measurement of Bone Density

Stress Fractures Processed tofu with calcium sulfate 4 oz 145 70

TABLE 1.2 Bony Markings

Name Definition Example

Joint Architecture Fibrous Joints

synovial membrane and synovial fluid that gives rise

Body Orientation Terminology

The Center of Mass and Line of Gravity

The center of mass of the body is the single point

Pivot In pivot joints, an arch- or ring-shaped surface rotates about

Saddle In saddle joints, a saddle-shaped bone fits into a socket that

TABLE 1.5 Anatomical Position and Directional Terminology

plane and divides the body into anterior and poste-

Anatomical Axes and Associated Movements

TABLE 1.6 Basic Anatomical Planes

“Bend the Knees to the Side”

TABLE 1.7 Basic Anatomical Axes

Plane Movement example

Planes and Axes in Complex Movement

Joint Movement Terminology FIGURE 1.12 Dance vocabulary showing movement of

TABLE 1.8 Joint Movement Terminology

of the cone) while the other end stays stationary

CONCEPT DEMONSTRATION 1.1

Fundamental Joint Movements

While standing in anatomical position, perform the following movements.

CONCEPT DEMONSTRATION 1.2

Types of Synovial Joints and Their Movements

CONCEPT DEMONSTRATION 1.3

Close- and Loose-Packed Joint Positions

Joint Stability and Mobility Close-Packed and

DANCE CUES 1.2

“Stand So That Your Bones Support Your Weight”

CONCEPT DEMONSTRATION 1.4

Closed and Open Kinematic Chain Movements

Study Questions and Applications

I n this chapter we examine the muscular system. It

A. Smooth muscle B. Cardiac muscle C. Skeletal muscle

Thin (actin) filament

Thick (myosin) filament