From Ballet Slippers To Pointe Shoes: A Physician's Role
To dance ballet, specifically en pointe, requires significant demands of a dancer, both physically and mentally. When starting ballet, a dancer may have the end goal of dancing en pointe and/or becoming a professional dancer; however, it has been estimated that there are only about 500 spots within professional dance companies for the 6 million+ dancers in the U.S. (3). Once in a company, it is even more important to stay injury-free, which may not be easy, as body weight forces increase by twelve times while dancing on pointe (1,3,5). This is also likely why most ballet injuries occur in the lower extremities. (1,5).
So who decides if and/or when a dancer is ready to go en pointe? Historically, the decision was made by the instructor (2). More recently, though, healthcare professionals have been included in the process (3). It is important to get as many specialists involved as possible in order to minimize the risk of injury in the young dancer.
Based on prior reports, there are several potential components to the pre-pointe evaluation, including age, anatomy, alignment & flexibility, technique & skill, strength, proprioception, postural control and stability, as well as training duration and frequency. Yet, there still appears to be no standard format in which to evaluate the readiness of a dancer to go en pointe (1,2,3,4,5,6).
Outside the pre-pointe evaluation done by the dance company evaluator, a physician can also provide valuable information. Below is a list of assessments that can be done in the clinic.
1. HISTORY OF (OR CURRENT) INJURY
Though this may not be on the top of an evaluator’s list or a physician’s mind, it is significant to note. Clearly, if a dancer is currently suffering from a lower extremity injury, she should refrain from starting pointe work. Asking about previous injuries is also important, though. Injuries do not always heal 100% and, oftentimes, the is injured area is weaker afterwards, which increases the risk of re-injury and/or compensation (3).
Age appears to be the most frequently reported variable when it comes to evaluating for readiness for pointe work (3,4). However, deciding on a standard age for all dancers is not simple given that not every dancer matures both physically and mentally at the same rate.
Chronologically speaking, there is concern about starting pointe work too early because of the potential risk of growth plate injury. However, recent studies are stating that x-rays are no longer considered a necessary study to order prior to going en pointe, as physicians may be able to tell when growth plates are closed, x-rays do not show when the bones are fully matured (1,5,6). Complete ossification of some foot bones may not take place until 18-20 years of age, which means that if a dancer were to wait to go en pointe until this point, she would likely lose her chance at a professional ballet career (1,5). Still, one should not completely ignore this factor, as the risk of growth plate injuries, including fractures and growth plate arrest, is present.
Though foot type alone may not prevent one from dancing en pointe, there are advantages and disadvantages of having a certain foot type.
Giselle, or peasant, foot type – Optimal forefoot type, as even pressure is placed across the toes (1).
Flat foot – Difficult to achieve full plantarflexion at the ankle (1,5).
Cavus (“high-arched”) foot – Looks good in ballet shoes, but tends to be more stiff/rigid and is less shock-absorbing (1,5).
Evaluation of hypermobility and flexibility of the lower extremity are also important factors to consider before starting pointe work. Flexibility can be assessed a couple different ways. The first method is to use a goniometer to measure ankle plantarflexion. The dancer should be able to actively plantarflex the ankle a minimum of 90° (Figure 1) (1,5). Another, quicker way, may be doing The Pencil Test, showing at least 180° from along the top of the tibia (lower leg) to along the top of the foot (Figure 2) (2).
Figure 1: Goniometer measuring at least 90° of ankle plantar flexion
Figure 2: Pencil Test measuring at least 180° from along top of tibia to top of foot
As you can tell, determining the readiness of a ballerina to start pointe work is not an easy, straightforward task, which is likely why there appears to be no standardization of the pre-pointe evaluation. Therefore, it is important to be thorough with any evaluation conducted, refer to specialists, as needed, and keep open communication with everyone involved (including the dancer and parents) in order to minimize the risk of injury of the young dancer as she progresses to going en pointe.
Disclaimer: The above information is meant for educational purposes only and should not be construed as medical advice. Please consult your own healthcare professional with questions or concerns related to your health.
1. Lai, J. C., & Kruse, D. W. (2016). Assessing Readiness for En Pointe in Young Ballet Dancers. Pediatric annals, 45(1), e21-e25.
2.Lin, V. K. (2011). When to go En Pointe. Springfield: Rehabilitation Medicine Associates (RMA).
3. Meck, C., Hess, R. A., Helldobler, R., & Roh, J. (2004). Pre-pointe evaluation components used by dance schools. Journal of Dance Medicine & Science, 8(2), 37-42.
4. Richardson, Megan, Marijeanne Liederbach, and Emily Sandow. "Functional criteria for assessing pointe-readiness." Journal of Dance Medicine & Science 14.3 (2010): 82-88.
5. Shah, S. (2009). Determining a young dancer's readiness for dancing on pointe. Current sports medicine reports, 8(6), 295-299.
6.Weiss, D. S., Rist, R. A., & Grossman, G. (2009). When can I start pointe work? Guidelines for initiating pointe training. Journal of Dance Medicine & Science, 13(3), 90-92.