Patient Presentation
During a discussion among several pediatricians about readiness for various sports training, one pediatrician asked what her colleagues did for young girls who wanted to start ballet dancing on pointe. There were a few general comments but nothing substantial except one person said that she thought there was a recent paper about the topic. Through a literature search, the pediatrician found a paper and then shared the information with her colleagues.
Discussion
Ballet dancing originated in Italy and was patronized by Queen Catherine de Médici of France who began the first ballet school in 1581. King Louis XIV of France was a major patron as he founded the Académie Royale de Danse in 1661. The Sun King was a performing dancer himself. The first documentation of a dancer performing en pointe (ie on pointe or on the tips of the toes) was in 1832 by Marie Talioni performing in La Sylphide.
Dancers are highly trained athletes and when dancing on pointe have the special appeal of appearing to effortlessly defy gravity. Ballet dancing shoes are slippers (made of soft leather, canvas, or satin, that has flexible, thin usually leather soles that that hug the foot), demi-pointe (similar to pointe shoes except for a smaller toe box and no shank in the arch, used more in Europe than United States) and pointe shoes. Pointe shoes have a toe box made of layers of paper, fabric and glue with a squared off end on the toe (i.e. the platform) that the dancer stands on and which provides the majority of the support. The shank is usually made of leather and supports the arch. Fabric (usually satin) surrounds these main pieces and the shoe is attached to the foot by elastic near the ankle and satin ribbons. A professional ballerina once described it to the author as “dancing in a Dixie® cup”. Pointe shoes are highly specialized equipment that needs a trained specialist to properly fit. The fit is extremely important for long-term injury prevention.
When dancing in ballet slippers, the relevé (elevated) foot position places the pressure on the metatarsals at 4x body weight. In demi-pointe or pointe shoes, the pressure is on the toes at 12 times body weight. The “ideal” foot is the “Giselle” foot where the first 3 toes are of relatively the same length allowing for distribution of the force across a greater area. Dancers with different anatomy still can be successful though. Dancing on pointe requires complete plantarflexion of the foot and ankle to 90° or more and is stabilized as the ankle “locks” into position with the subtalus locking between the tibia and calcaneus.
The change from dancing on the metatarsal heads to dancing on the toes seems like it should increase the likelihood of injuries but studies have not shown this. Specifically one study which looked at recreational (non-professional but serious) dancers before pointe shoes and after pointe shoe use did not find an increase in the likelihood of injuries during the past month or past 3 years. Longer term data was not evaluated. Also no studies have found that dancing on pointe before growth plate closure is linked to growth plate arrest, therefore radiographs are unnecessary to use as a factor for determining pointe readiness. Also the growth plates in these bones do not close until 18-20 years well after most dancers are already successfully dancing on pointe.
The quality of the preparatory training is paramount and experienced, ballet-specific instructors are important for preparation, decision making for placement into pointe shoes and training dancers using them. European ballets schools tend to be more rigorous with formalized systems of training and qualified instructors. This is not always true in the United States where dance studios may provide instruction in many different dance types and may not have instructors with specific training as ballet instructors. Studios can be placed under pressure to place dancers into pointe shoes because of the psychological aspirations of the dancer and family, and because of the financial pressures to do so.
As with any athletic activity, training and coaching under the direction of professional dancers with ballet-specific training is the most appropriate for dancers going on pointe.
Learning Point
There is no specific testing that can determine when a dancer can successfully transition to on pointe. One study found that 3 functional tests that help evaluate strength, flexability, alignment, postural control and balance correlated with teacher subjective rating for on pointe dancing readiness. These 3 are:
- Airplane test – The dancer stands on one leg. The trunk is bent forward while the non-weight bearing leg is elevated behind them. The arms are extended in front creating the look of an airplane flying, or the letter “T” from the side or a Warrior III yoga pose.
The arms are lowered toward the ground, and the weight bearing leg is bent or folded in a controlled manner (i.e. plié) (<a href="View images here) - Sauté test – The dancer stands in a neutral pelvis, upright stable trunk position with arms at the side. The knees are bent and the dancer does a short jump into the air landing with control and a appropriate bending on the knees to absorb the shock. (<a href="View video here)
- Topple test – a pirouette or turn is performed on one leg. The non-weight bearing leg’s hip is abducted and flexed with the foot aligned next to the weight being leg’s knee. The dancer should be able to do this in the relevé (elevated) foot position.(<a href="View video here“)
The great ballet choreographer George Balanchine once said that it took 4 or more years of serious training before a dancer was ready and with serious training starting around 7-8 years, this would be around 11-12 years or more.
A 2009 study ended with these considerations for pointe readiness. “A dancer should have adequate mental maturity and physical capability to begin dancing on pointe, rather than requiring a specific age or number of years. The dancer should have adequate flexibility in the foot and ankle complex to achieve full pointe, sufficient training to achieve proper placement, strength to achieve postural control and balance, proprioception, alignment, technique, mastery of movement, the ability to learn and perform choreography, and the ability to listen to apply corrections.” These ideas seem appropriate for any athlete including dancers.
Questions for Further Discussion
1. What resources do you have available locally to evaluate dancers for on pointe readiness?
2. What history questions should be gathered to evaluate dancers for on pointe readiness?
Related Cases
- Disease: Ballet Dancing | Exercise and Physical Fitness
- Symptom/Presentation:Health Maintenance and Disease Prevention
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Exercise and Physical Fitness.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Nunes NM, Haddad JJ, Bartlett DJ, Obright KD. Musculoskeletal injuries among young, recreational, female dancers before and after dancing in pointe shoes. Pediatr Phys Ther. 2002 Summer;14(2):100-6.
Shah S. Determining a young dancer’s readiness for dancing on pointe. Curr Sports Med Rep. 2009 Nov-Dec;8(6):295-9.
Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. J Dance Med Sci. 2010;14(3):82-8.
Pearson SJ, Whitaker AF. Footwear in classical ballet: a study of pressure distribution and related foot injury in the adolescent dancer. J Dance Med Sci. 2012;16(2):51-6.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 