Pre Pointe Assessment: Difference between revisions

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<div class="editorbox"><div class="editorbox">'''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by https://members.physio-pedia.com/course_tutor/michelle-green-smerdon/
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by [https://members.physio-pedia.com/course_tutor/michelle-green-smerdon// Michelle Green-Smerdon]<br> '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
 
== Introduction ==
== Introduction ==
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Dance injuries associated with pointe work are highly prevalent within the dance community,<ref name=":0">Altmann C, Roberts J, Scharfbillig R, Jones S. [https://www.ingentaconnect.com/content/jmrp/jdms/2019/00000023/00000001/art00006 Readiness for en pointe work in young ballet dancers are there proven screening tools and training protocols for a population at increased risk of injury?]. Journal of Dance Medicine & Science. 2019 Mar 15;23(1):40-5.</ref> particularly in young dancers who are growing and, at the same time, having to learn motor patterns and technically demanding skills.<ref name=":1">Richardson M, Liederbach M, Sandow E. [https://www.ingentaconnect.com/content/jmrp/jdms/2010/00000014/00000003/art00002 Functional criteria for assessing pointe-readiness.] Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.</ref> Pre-pointe assessments are used to determine whether a ballet dancer is safe to progress to dancing en pointe. This transition often occurs at around 12 years of age.<ref name=":0" /><ref name=":1" /><ref name=":2">DeWolf A, McPherson A, Besong K, Hiller C, Docherty C. [https://www.ingentaconnect.com/content/jmrp/jdms/2018/00000022/00000004/art00005 Quantitative measures utilized in determining pointe readiness in young ballet dancers.] Journal of Dance Medicine & Science. 2018 Dec 1;22(4):209-17.</ref>
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* Although every dancer should have a pre pointe assessment done before embarking on the pointe journey, there are many who do not.
* For those that do have an assessment, not all are done by health care professionals (physicians, dance instructors, pilates teachers, exercise specialists etc)
* Do they know enough about dance to determine pointe readiness?
* Other factors to consider – who covers cost? Who sends for assessment? Adult classes who have persons who did pointe years ago? Who makes decision to let ballerina go onto pointe? Disagreement of findings?
* “The data suggests, therefore, that it is perhaps the presence or absence of a healthcare professional that has a greater influence on the pre-pointe evaluation”
** Pre-Pointe Evaluation Components Used by Dance Schools Casey Meek, M.S., A.T.C., Rebeeea A. Hess, Ph.D., Richard Helldobler, Ph.D., and Joni Roh, Ed.D., A.T.C.
* kinetic chain assessment
* medical training would be able to observe any muscle imbalance, compensation, or other postural issues by the use of components such as releve and plie.
* To date, no standard measure exists for determining when a dancer is ready to begin to dance en pointe. Age, years of training, and correct execution of relevé are the most widely used criteria to determine which students begin pointe, with age being seen as the most important factor.
* To date, no studies have shown that there is an increased risk of injury specifically associated with starting pointe work too early.  
* However, research does suggest that young ballet students may be more vulnerable to dance injuries than professional adults due to their developing musculoskeletal system.  
* During periods of rapid growth, young dancers can appear relatively uncontrolled in their movements and exhibit a temporary loss of coordination.
* It has been suggested that functional tests that examine core stability, strength and flexibility of the feet and ankles, lower extremity alignment and postural control may be a more adequate evaluation for determining when a dancer is ready to begin pointe work
 
No set standards or protocols but rather guidelines: General criteria used
 
* Age
** 11/12
** dancers at this age vary greatly in terms of musculoskeletal maturity and motor skill development
** Adolescence is a period marked by rapid growth spurts, which create a weakness in growth plates
** Introduction of a technically demanding skill can cause serious injuries
** ballet dancing in technique shoes increases force on the bones the foot and ankle by four times the dancer’s weight, whereas pointe work increases these forces up to 12 times the dancer’s weight
**
* Years of dance
** It is assumed that by that age the dancer will have participated in at least 3 or 4 years of classical ballet training, and therefore will possess adequate cognitive ability, strength, technique skill, alignment, coordination, bone development and motor control necessary to begin pointe work.
** Without adequacy in these areas, excessive stress may be placed on trunk, pelvic girdle, leg, ankle, and foot, increasing the potential for injury.
** an indicator of the technique level of the student. Involved with technique are the components of releve, plie, tendu, and upper body alignment.
** poor technique can lead to compensating actions
 
*
 
* Present injuries
** The presence of newly acquired injuries, or injuries that have not fully healed, will cause the student to compensate for the injury.
** Compensating while learning a new technique will establish poor technique habits and predispose the dancer to more injuries.
** Additionally, past injuries often leave the injured structure in a weaker state than before the injury, which may also cause compensation or a lack of ability to withstand the stress of dancing en pointe.
**
* Past injuries
* Releve alignment and stability
* Plie alignment and stability
* Tendu
* Upper body alignment and stability
* Technique requirements and skill acquisition
** The correct execution of movements such as releve, plie, and tendu were the most commonly reported technique requirements.
** The ability to control proper alignment and balance during dynamic tasks, such as turning and jumping, plays a critical role in prevention of LE injury
** poor technique due to fatigue or overuse, with most injuries being sustained toward the end of rehearsals or performances.
** Twitchett and colleagues found that dancers perceive fatigue to be the primary cause of most of their injuries, and many believe that increased fitness may be the answer to this problem. That perspective is reinforced by studies that argue that a high level of fitness is vital for a long and injury-free career in dance.
** Ankle plantar flexion ROM
** Require above average ROM
** Professional women ballet dancers possess an average of 113° of ankle plantar flexion, compared to 48° among persons in the general population and adolescent dancers have been reported to possess 10° to 20° more plantar flexion than age matched non-dancers.
** Without this available range of plantar flexion dancers may compensate by coming out of neutral foot alignment into a “winged” (subtalar and mid-foot eversion) or “sickled” (subtalar and mid-foot inversion) position while en pointe, thus exposing the ligaments and tendons of the foot and ankle complex to increased stress loads
 
Intrinsic muscle strength
 
* The intrinsic muscles of the foot, which cross the metatarsal phalangeal (MP) joints, must work 2.5 to 3 times harder than the muscles crossing the ankle joint during the rise to full pointe.
* Chronic fatigue of the muscles crossing the MP-joints at the ball of  the foot is thought to be a causal factor for injuries in pointe work
 
Lower extremity strength and neuromuscular control


* The importance of pelvic and trunk stability for proper lower extremity (LE) kinetics and kinematics is becoming increasingly clear as research emerges. Stabilization of the trunk and pelvis through activation of the core musculature has been identified as necessary for proper initiation of LE movement.
Basic evaluation protocols have not yet been standardised <ref>Cantergi D, Moraes LR, Loss JF. Applications of Biomechanics Analysis in Dance. InScientific Perspectives and Emerging Developments in Dance and the Performing Arts 2021 (pp. 25-44). IGI Global.</ref>, but attempts have been made to identify musculoskeletal variables between pre-pointe and novice pointe students to ascertain readiness.<ref name=":2" /> Previously, chronological age, years of dance training, ankle plantar flexion range, and correct execution of relevé were the only indicators of readiness. However, research suggests that a combination of a biomechanical assessment, and an assessment of the entire kinetic chain, muscle imbalance, compensation, and other postural issues is more useful to gauge safe and successful performance.<ref name=":1" /> Similarly, there is a lack of research regarding pre-pointe training programmes. While a programme is often introduced and is very beneficial, there is no gold standardised programme.<ref name=":7" />
* There is evidence that hip abductor and external rotator muscles, in combination with trunk control, are responsible for maintaining a level pelvis and preventing femoral adduction and internal rotation during single leg stance.
* As the base of support narrows, for example during relevé en pointe, the dancer will rely increasingly on proximal control to maintain proper vertical alignment and balance. Weak or fatigued hip abductors have been associated with increased postural sway and subtalar joint inversion during single leg stance, which can leave the dancer vulnerable to inversion ankle sprain


Study one: Megan Richardson et al, 2010
There is much debate over who should complete the pre-pointe assessment for the dancer, but it is thought that a healthcare provider has the greatest influence over the pre-pointe assessment.<ref>Russell JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871955/ Preventing dance injuries: current perspectives.] Open access journal of sports medicine. 2013;4:199.</ref> It has also been suggested that functional tests which examine core stability, strength and flexibility of the feet and ankles, lower extremity alignment and postural control may be  adequate to determine when a dancer is ready to begin pointe work.<ref>Glumm SA. [https://etda.libraries.psu.edu/catalog/13992sbg5276 Functional Performance Criteria to Assess Pointe Readiness in Youth Ballet Dancers.]</ref>


* The nine tests selected were designed to objectively measure key areas of motor activity, including abdominal and thigh muscular control, leg muscle strength, ankle joint range of motion, balance and turn ability, and dynamic LE alignment. Tests included
Please see the glossary at the bottom of this page for definitions of any unfamiliar ballet terms.
** the “Pencil Test,”
** Double-Leg Lower Test
** Single-leg Bench Step-down Test
** “Airplane Test,”
** Single-leg Sauté Test,
** Passé-relevé Balance Test
** “Topple Test
** modified “Romberg Test,”
** Single-leg Heel Rise Test.  


Each dancer’s test result for each test outcome was categorized as a “fail” (1.0) or “pass” (2.0)
=== General Criteria Used ===


Best predictors
# '''Age'''
#* Dancers are often encouraged to start pointe work between 11 and 12 years of age. There is a large variation in musculoskeletal and motor development at this age. There are regular, rapid growth spurts which can heighten the risk of growth plate injuries<ref name=":7">Green-Smerdon M. Pre-Pointe Assessment Course. Plus. 2022.</ref>
# '''Years of dance'''
#* It is assumed that by 12 years of age, a dancer will have participated in at least 3 or 4 years of classical ballet training, and therefore, will have the necessary cognitive ability, strength, technique skill, alignment, coordination, bone development and motor control to begin pointe work<ref>McCormack MC, Bird H, de Medici A, Haddad F, Simmonds J. [https://www.thieme-connect.com/products/ejournals/html/10.1055/a-0798-3570 The physical attributes most required in professional ballet: a Delphi study.] Sports medicine international open. 2019 Jan;3(01):E1-5.</ref>
# '''Injuries'''
#* Dance students will compensate for newly acquired injuries, or injuries that have not fully healed
# '''Relevé alignment and stability'''
# '''Plié alignment and stability'''
# '''Tendu'''
#'''Upper body alignment and stability'''
#'''Technique requirements and skill acquisition'''
#*When assessing a dancer, commonly technique in carrying out certain movements is assessed. According to Meck,<ref>Meck C, Hess RA, Helldobler R, Roh J. [https://www.ingentaconnect.com/content/jmrp/jdms/2004/00000008/00000002/art00001 Pre-pointe evaluation components used by dance schools]. Journal of Dance Medicine & Science. 2004 Jun 1;8(2):37-42.</ref> the most valuable input with regards to requirements of technique were to focus of assessing a relevé, plié, and tendu.
#*The requirement of sufficient ankle plantar flexion range of motion is essential for pointe work


* “Airplane” test
== Strength Testing ==
* Sauté test
* “Topple” test


Second study, Hewitt et all 2016
==== Intrinsic Muscle Strength ====
When a dancer moves to full pointe, the intrinsic muscles of the foot work 2.5 to 3 times harder than the other muscles in the foot.<ref>Barreau X, Gil C, Thoreux P. [https://link.springer.com/chapter/10.1007/978-3-662-60752-7_110 Ballet. Injury and Health Risk Management in Sports] 2020 (pp. 725-731). Springer, Berlin, Heidelberg.</ref> Because of the repetitive nature of ballet, chronic fatigue of the muscles which cross the joints of the foot are a major factor in injuries associated with pointe work.<ref name=":7" />


* The participants completed five tests, used to measure physical attributes important to pointe training.
==== Lower Extremity Strength and Neuromuscular Control ====
** Heel rise
When assessing lower extremity strength, it is important to look at the kinetic chain as a whole. This is because the kinetics of the lower limb are largely dependent on pelvis and trunk stability. To gain stability of the pelvis and trunk, a dancer needs to activate their core muscles. This helps provide them with the control needed to execute the necessary movements.<ref>Willson JD, Dougherty CP, Ireland ML, Davis IM. [https://journals.lww.com/jaaos/Abstract/2005/09000/Core_Stability_and_Its_Relationship_to_Lower.5.aspx Core stability and its relationship to lower extremity function and injury.] JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2005 Sep 1;13(5):316-25.</ref>
** Plank
** Sauté
** Topple
** airplane
* findings of this study indicate that three tests (airplane, topple, and sauté) have some value in discriminating between dancers of different skill levels and may be useful for determining pointe readiness
* The results revealed that the topple test differentiated between pre-pointe and beginner pointe as well as pre-pointe and intermediate pointe. Two of the tests, sauté and airplane, differentiated between pre-pointe and intermediate pointe, with those in the intermediate skill group demonstrating significantly better scores. Though mean values appeared different, no significant difference was observed between beginner and intermediate pointe groups on any of the tests
* support Richardson and colleagues, who found that the airplane, topple, and sauté tests discriminated between dancers of different skill levels. The sauté, airplane, and topple tests integrate both technique and physical ability, which could be one reason these tests stand out in both studies.


Third study - DeWolf et al 2018
In single-leg stance, a dancer relies heavily on their hip abductor and external rotator muscles to maintain a level pelvis. This becomes increasingly challenging when the base of support is further decreased (i.e. when rising up onto pointe). Compensations can be seen further up the kinetic chain in the form of increased postural sway. This can also increase a dancer's risk of inversion sprains.<ref name=":7" />


* Six dependent variables were evaluated
== Evidence-Based Tests ==
** : non-weightbearing (NWB) plantar flexion (PF) and dorsiflexion (DF) range of motion (ROM);
While there is no gold standard, certain evidence-based tests may give an idea of pointe readiness and are recommended in a pre-pointe assessment.<ref name=":7" />
** weightbearing lunge test (WBL);
** relevé endurance (heel raise test);
** PF isometric strength;
** Airplane test;
** and Star Excursion Balance Test (SEBT) in three directions.


These tests werebroken into three categories for statistical analysis:
The '''single leg heel rise test''' can provide an objective measure of plantar flexion strength and it can be used to help determine a dancer’s readiness for pointe training. Performing 25 single leg heel rises is considered normal for human gait.<ref>Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. [https://www.sciencedirect.com/science/article/abs/pii/S0031940617300226 Updated reliability and normative values for the standing heel-rise test in healthy adults.] Physiotherapy. 2017 Dec 1;103(4):446-52.</ref> <ref>Thomas KS. [https://www.ingentaconnect.com/content/jmrp/jdms/2003/00000007/00000004/art00002 Functional eleve performance as it applies to heel-rises in performance-level collegiate dancers.] Journal of Dance Medicine & Science. 2003 Dec 15;7(4):115-20.</ref>


ROM (NWB PF and DF, WBL),
DeWolf et al.<ref name=":2" /> also advise that 15 continuous '''single-leg relevés''' and 2 cycles of the '''airplane test''' should be considered "cut-off levels" when performing pre-pointe assessments.


muscular capacity (relevé endurance, PF isometric strength),
Evaluating dynamic motor control, such as controlling alignment during ballet specific tasks, can also be useful in the pre-pointe assessment.<ref name=":3" /> The '''airplane test''', '''topple test''' and '''sauté test''' were able to distinguish between dancers of varying levels (i.e. pre-pointe, beginner pointe and intermediate pointe) and may be useful for determining pointe readiness.<ref name=":2" /><ref name=":3" /><ref name=":4" />


and balance (Airplane, SEBT).  
The '''relevé endurance test''' and the '''airplane tes'''t can both be used to distinguish between pre-pointe and pointe dancers.<ref name=":2" /> These tests also discriminated between dancers of different skill levels, integrating both technique and physical ability.<ref name=":2" /><ref name=":3" /><ref name=":4" />


* The analysis demonstrated that the pointe group performed significantly better than the pre-pointe group on the muscular capacity and balance testing (p < 0.01).  
==== 1. “Airplane” Test <ref name=":2" /><ref name=":3">Richardson M, Liederbach M, Sandow E. [https://www.ingentaconnect.com/content/jmrp/jdms/2010/00000014/00000003/art00002 Functional criteria for assessing pointe-readiness.] Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.</ref><ref name=":4">Hewitt S, Mangum M, Tyo B, Nicks C. [https://www.ingentaconnect.com/content/jmrp/jdms/2016/00000020/00000004/art00003 Fitness testing to determine pointe readiness in ballet dancers.] Journal of Dance Medicine & Science. 2016 Dec 15;20(4):162-7.</ref><ref name=":6">Batalden L. [https://www.proquest.com/openview/d70eb2979a20a874508323e2a67e1fed/1?pq-origsite=gscholar&cbl=5425112 Pointe-Readiness Screening and Exercise for the Young Studio Dancer.] Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.</ref> ====
* Calculations for both tests indicated that 15 continuous single-leg relevés and two repetitions of the Airplane test may be the best cut-off levels when using these tests as part of a pre-pointe screening protocol.  
'''<u>Aim</u>:''' To measure control of the lower extremities, core and balance. Hewitt et al.<ref name=":4" /> have found that this test is a useful way of determining a dancer's ability to hold their pelvis in a neutral position.
* In conclusion, the relevé endurance test and the Airplane test are appropriate for use in differentiating between pre-pointe and pointe dancers  


.
'''<u>Instruction</u>:''' The dancer stands with feet parallel on one leg. They bend over at the waist and extend the non-support leg backwards, until the leg and the trunk are parallel to the floor. In this position, the dancer is facing down towards the floor. Here, they lift their arms beside their torso in the shape of a “T.” Once the torso and leg are parallel with the floor, the dancer bends their supporting leg. At the same time, while keeping the trunk and non-support leg parallel to the floor, they bring their arms down towards the floor (elbows extended) until the fingertips make contact with the floor in front of their face. The dancer then extends their knee and arms to return to the starting position. The test is stopped if the dancer moves their supporting foot, falls out of the position, or chooses to stop. The number of completed repetitions on both sides are added together for a total score.<ref name=":4" />


Tests used as deciding criteria
'''<u>Remember</u>:''' Test both right and left sides.


* Performance on three functional tests (the Airplane test, Sauté test, and Topple test) was closely associated with teacher subjective rating for pointe-readiness. It is concluded that these tests may be more useful for gauging acquisition of the skills required for safe and successful performance than the traditionally accepted indicators of chronological age, years of dance training, and ankle joint range of motion.
'''<u>Note</u>:''' An attempt is considered unsuccessful when there is pelvic drop, hip adduction, hip internal rotation, knee valgus, or foot pronation during the movement.<ref name=":4" />
* Among persons in the general population, Lunsford and Perry established that the ability to perform 25 single leg heel rises is considered normal for human locomotion.
{{#ev:youtube|huzr00t9aAU}}
* Thomas and Parcell later found that the average number of single leg heel rises an adult dancer can perform is similar to the Lunsford and Perry sample.
* Thus, we propose that performance on the single leg heel rise test provides an objective measure of plantar flexion strength that may be telling in regard to a dancer’s readiness for pointe training.
* Balance-specific training has been shown to improve balance scores and decrease incidence of injury in athletes.  
* Testing adolescent dancers’ ability to control their alignment and balance during such tasks as jumping, turning, plié, and passé relevé thus seems reasonable for pointe-readiness assessment


* It has been suggested that dynamic tests of motor control can better indicate pointe-readiness than chronological age alone or in combination with static musculoskeletal measurements.
==== 2. Sauté Test <ref name=":3" /><ref name=":4" /><ref name=":6" /> ====
* The correct execution of movements such as releve, plié and tendu were the most commonly reported technique requirements for pointe readiness and analyzing mechanics of these motions may provide insight into differences between pre-pointe and pointe dancers.
'''<u>Aim</u>:''' To evaluate dynamic trunk control and the alignment of the lower limb.<ref name=":4" />
* It has also been suggested that students with poor core stability or hypermobility of the feet and ankles may require additional strengthening to allow them to safely begin pointe training.


Pencil test – PF ROM
'''<u>Instruction</u>:''' The dancer begins in coupé derriere. Their gesturing leg and standing leg are turned out and they place their hands on their hips or across their chest. The dancer jumps into the air and must achieve the following:<ref name=":4" />


* The Pencil test is a method for determining overall plantar flexion of the ankle-foot complex
* Neutral pelvis
* The test is performed by having the dancer long-sit, while a straight-edge level or pencil is placed along the top of the dorsal talar neck.
* Upright / stable trunk
* The dancer passed this test if adequate plantar flexion (≥ 90°) was detected as evidenced by the straight edge clearing the distal most part of the tibia just proximal to the malleoli
* Straight standing leg in the air
* Pointed standing foot in the air
* The leg holding the coupé must not move
* Their landing into plié must be controlled (i.e. they roll through the foot from toe to ball to heel)


Airplane test
Participants in the study by Hewitt et al.<ref name=":4" /> attempted as many as 16 sautés on each leg. They added scores from the right and left sides together to find the total score. A pass was a minimum of 8/16 correctly performed jumps.<ref name=":4" />


* The airplane test measures control of the lower extremities , core and balance.
'''<u>Remember</u>:''' The single leg sauté test should not follow the single leg heel raise test as both tests primarily evaluate calf muscle strength.<ref name=":7" />
* It has been found to be a good test of the dancer’s ability to maintain the pelvis in a neutral position and has been utilized previously in a pilot pointe readiness study.
* The dancer stands in parallel, on one leg while bending over at the waist and extending the other leg backward such that it and the trunk are parallel to the floor. In this position, then, the dancer is facing downward at the floor and the arms lifted beside the torso in the shape of a “T.” Once the torso and leg were parallel with the floor, the dancer bends her supporting leg, (simultaneously keeping the trunk and nonsupport leg parallel to the floor), bringing the arms down toward the floor (elbows extended) until the fingertips made contact to touch the floor in front of the face. The dancer then extends the knee and upper extremities to return to the starting position.
* Both right and left sides were tested. The test was stopped when the dancer moved the supporting foot, fell out of the position, or chose to stop. The number of completed repetitions on both sides were added together for the total score. Four out of five consecutive trials performed are required to pass the test in Richardson’s study and 2 high quality repetitions in DeWolf’s study.. DeWolf details a point scoring system for various aspects of motor control that he suggests should be further researched.
* An unsuccessful attempt is defined by pelvic drop, hip adduction, hip internal rotation, knee valgus, or foot pronation during the movement


Topple test
'''<u>Note</u>:''' Slow motion analysis is necessary to assess all the criteria required to pass the test.<ref name=":7" /><ref name=":4" />
{{#ev:youtube|Q6NmwsfqbEM}}


The topple test assesses the dancer’s ability to perform a clean single pirouette. For the pirouette to be considered “clean” the dancer must demonstrate the following properties:  
==== 3. “Topple” Test<ref name=":3" /><ref name=":4" /><ref name=":6" /> ====
'''<u>Aim</u>:''' To assess a dancer’s ability to perform one clean pirouette.<ref name=":4" />


* 1. Proper beginning placement (square hips, the majority of weight on the forefoot, turned out, pelvis centered, and strong arms;
'''<u>Instruction</u>:''' A "clean" pirouette is defined as:<ref name=":4" />
* 2. Leg brought up to passé in one count;
#A proper beginning placement (i.e. square hips, the majority of weight is on the forefoot, a turned out position, the pelvis is centred, and the dancer has strong arms)
* 3. Supporting leg straightened;
#The dancer brings their leg up into passé in one count
* 4. Torso turned in one piece;
#The supporting leg is straightened
* 5. Strong, properly placed arms;
#The dancer turns their torso in "one piece"
* 6. A quick spot; and
#The dancer's arms are "strong" and must be properly placed
* 7. A controlled landing.  
#The dancer demonstrates a quick spot
#The landing must be controlled
In the Hewitt et al.<ref name=":4" /> study, one point was given for each criterion that was met. The best pirouette on each leg was given a score and a total score was given based on the scores from the right and left legs.<ref name=":4" />


The dancers were allowed three attempts on each leg. One point was given for each technical criterion that was met, and the best pirouette on each leg was scored. Right and left scores were combined for the total score. The test was recorded  and videos were replayed in slow motion to enhance precision of analysis
'''<u>Remember</u>:''' Dancers in the study by Hewitt et al.<ref name=":4" /> were given three attempts to complete the pirouette on each leg.


Single leg Heel rise test
'''<u>Note</u>:''' The tests should be recorded, so that videos can be replayed in slow motion for a more precise analysis.<ref name=":4" />
{{#ev:youtube|GDoFnUXd86c}}


* A heel rise test determines endurance of the calf musculature.
==== 4. Pencil Test – Plantar Flexion  ROM<ref name=":3" /> ====
* The dancers stand on one leg with the contralateral leg held in a parallel coupé. They performed as many relevés without plié as possible to a set beat of 120 beats per minute, or 30 heel raises per minute. The test ended when the dancer could no longer keep time with the metronome or chose to stop.
'''<u>Aim</u>:''' To determine the overall plantar flexion of the ankle-foot complex.<ref name=":3" />
* For practical considerations, if a dancer performed 75 relevés the test was stopped. Both left and right legs were tested and the number of relevés for both legs were added together for the total score.
* Another option of this test: Strength of the posterior calf muscles was measured by recording the number of parallel single-leg heel raises the dancer was able to perform while maintaining full pre-test relevé height on a straight leg. Because the dancers in this study were not yet adults, as was the sample group on whom the heel rise test has been validated, we defined “pass” as the ability to perform 20 or more heel raises
* Ninety degrees of plantar flexion is needed to lock the subtalar joint en pointe in order to avoid ankle ligamentous injury. Dorsiflexion was also included with a standard of 15°. In a study by Yocum et al, the heel rise test mean for 5 to 8 year olds was found to be 15.2 repetitions and 27.7 repetitions for 9 to 12 year olds


Single leg sauté test
'''<u>Instruction</u>:''' The dancer is positioned in long-sitting. A straight-edge level or a pencil is placed on the top of their dorsal talar neck. A dancer passes this test if they achieve sufficient plantar flexion (i.e. 90 degrees or more). This is achieved when the straight-edge clears the distal end of the tibia, just proximal to the malleoli.<ref name=":3" />


* The single leg sauté test was used to evaluate dynamic trunk control and lower extremity alignment. This test has been previously utilized in a pilot pointe readiness study.
'''<u>Remember</u>:''' A hypermobile individual will perform well in this test.<ref name=":7" />
* The dancers began in coupé derriere with the gesturing leg and standing leg turned out as if they had just completed a jeté ordinaire. Hands were placed on the hips. The participants then jumped into the air and had to demonstrate the following:  
** 1. A neutral pelvis;
** 2. An upright and stable trunk;
** 3. A straight standing leg in the air;
** 4. A pointed standing foot in the air
** 5. No movement in the leg maintaining the coupé; and
** 6. A controlled landing in plié, rolling toe-ball-heel through the foot.
* Participants attempted up to 16 sautés on each leg. The test was video recorded and replayed in slow motion for analysis. Each jump that met technical criteria was counted toward the total score. Right and left sides were then added together for the total score. A pass was at least 8/16 properly executed jumps


Important points in testing
'''<u>Note</u>:''' It is important to correct excessive rounding of the foot.<ref name=":7" />


* It was important that the Single leg Sauté test not be preceded by the single leg heel rise test as they both involve primarily calf muscle strength.
==== 5. Single Leg Heel Raise Test <ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":6" /> ====
* It is also observed that it would be very difficult to correctly score any of the three tests (airplane, saute, topple) in real time and that slow motion analysis is necessary to capture the many criteria for each test–especially considering the Sauté test is 16 consecutive jumps with 6 different criteria.
'''<u>Aim</u>:''' To determine the endurance of the calf musculature.<ref name=":3" />


Double leg lower test
'''<u>Instruction</u>:''' The dancer stands on one leg. They hold their other leg in a parallel coupé. The dancer is asked to perform as many relevés without plié as they can to a beat of 120 beats per minute (i.e. 30 heel raises per minute). The test is ended if the dancer can no longer keep up with the beat or if they choose to stop. The test is also stopped if a dancer completes 75 relevés. Each side is tested and the total number of relevés are added together.<ref name=":4" />


* The DLL test is described by Kendall as an objective way to evaluate abdominal strength, and has been shown to have good inter-tester reliability.
This test can also be performed as follows: Posterior calf strength is measured by counting the number of parallel single-leg heel raises that the dancer can perform while maintaining the pre-test relevé height on a straight leg. A “pass” for this test has been defined as performing 20 or more heel raises.<ref name=":1" />
* The test is performed while the dancer is lying supine in a pelvic neutral position with both legs flexed to 90° at the hips and perpendicular to the testing surface. The dancer slowly lowers her legs to the testing surface while keeping both knees extended. The examiner monitors the stability of the pelvis and notes the angle of the LE’s at which the pelvis begins to tilt anteriorly, and a strength grade is assigned based on that angle.
* The dancer passed this test if her LE angle was less than or equal to 45° from the floor when pelvic motion occurred


Balance test
'''<u>Remember</u>:''' Batalden<ref name=":6" /> notes that at least 90 degrees of plantar flexion is needed for the subtalar joint to lock en pointe, thus helping to avoid ankle ligament injuries. In their testing, Batalden<ref name=":6" /> included dorsiflexion "with a standard of 15°".


* Dancers performed a modified “Romberg” test by assuming a single-leg parallel stance with arms crossed and eyes closed.
'''<u>Note</u>:''' For 5 to 8 year olds, the mean number of repetitions in the heel raise test has been found to be 15.2 repetitions. The mean number of repetitions in 9 to 12 year olds is 27.7.<ref name=":6" />
* The pass criterion was defined as the ability to surpass a 30-second balance without opening the eyes, touching the opposite foot down, or moving the standing foot on the floor.
{{#ev:youtube|CSHfBTXf484}}
* In accordance with the recommendation of Luke and Khan, we measured the dancer’s ability to perform a single leg balance while maintaining passé-relevé. To obtain a passing score dancers needed to maintain a neutral position of the pelvis while in full retiré of the gesture leg and full relevé on a straight support leg.


Timed plank test
==== 6. Double Leg Lower Test<ref name=":3" /> ====
'''<u>Aim</u>:''' To objectively evaluate abdominal strength.<ref name=":3" />


* A timed prone plank test was used to determine core endurance and ability to maintain the pelvis in a neutral position.
'''<u>Instruction</u>:''' The dancer lies supine. Their pelvis is in a neutral position and both legs are flexed to 90 degrees at the hips, so that they are perpendicular to the testing surface. While keeping both knees extended, the dancer is asked to slower lower their legs to the testing surface. The assessor looks at pelvis stability and records the angle of the legs when the pelvis begins to tilt anteriorly. A strength grade is given based on this angle.<ref name=":3" />
* Holding the core stationary with the pelvis in neutral is important for control and balance during barre and center work. This test has been previously used by researchers to measure core endurance in dancers. Our participants assumed a full plank position on the hands and toes and demonstrated proper pelvic alignment for the test to begin.
* Timing stopped when the dancer could no longer hold the pelvis in proper alignment, dropped to her knees, or timed out at 5 minutes (due to time constraints the test was called at 5 minutes)


So what do we use to decide?
'''<u>Remember</u>:''' This test is recorded as a pass if this angle is 45 degrees or less.<ref name=":3" />


* The young dancer asks, “When can I begin pointe work?” The answer usually given, almost without thought, is “at 12 years of age.” It would be better if the response were “What kind of dance student are you?”
'''<u>Note</u>:''' Watch for any biomechanical compensations further up the body.<ref name=":7" />
* Starting pointe at age 12 presupposes that the child is beginning her fourth year of ballet classes at a dance academy with a program designed to train professional ballet dancers. Acceptance to such a program would indicate that, at age eight or nine, the child had sufficient anatomic facility. The program itself would consist of classes progressively increasing in difficulty and frequency over the first three years
* By age 12 the student would be taking four classes per week. Her feet and ankles would be strong, her trunk and pelvic control would be good, and her proprioceptive skills would be properly developed. Pointe work would begin with 15 minutes of exercises at the end of each class.
* Simply put, there is no standardized method for assessing readiness for en pointe training, and importantly, no evidence to indicate current methods are appropriate to ensure a successful and safe transition to this dance form.
* Within the assessment tools that exist, the methodology lacks valid or reliable measurement. In addition, there has been little discussion in the literature regarding who is best qualified to conduct screenings.
* Once en pointe readiness has been assessed and any impairment identified, a pre-pointe training program is commonly introduced.
* no standardized program exists;


Guidelines direct from IADMS
==== 7. Modified “Romberg” Test<ref name=":3" /><ref>Agrawal Y, Carey JP, Hoffman HJ, Sklare DA, Schubert MC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190311/ The modified Romberg Balance Test: normative data in US adults.] Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2011 Oct;32(8):1309.</ref><ref name=":5">Ani KU, Ibikunle PO, Nwosu CC, Ani NC. [https://www.ingentaconnect.com/content/jmrp/jdms/2021/00000025/00000004/art00001 Are the Current Balance Screening Tests in Dance Medicine Specific Enough for Tracking the Effectiveness of Balance-Related Injury Rehabilitation in Dancers?] A Scoping Review. Journal of Dance Medicine & Science. 2021 Dec 15;25(4):217-30.</ref>====
'''<u>Aim</u>:''' To determine proprioception and falls risk.<ref name=":7" />


(international association of dance medicine and science)
'''<u>Instruction</u>:''' The dancer stands in a single-leg parallel stance. They cross their arms and close their eyes. A dancer passes this test if they can maintain this position for more than 30 seconds without: opening their eyes, touching the non-support foot down, or moving their stance foot.<ref name=":3" />


* To summarize the above discussion we offer the following guidelines for when to begin pointe training:
Please click on the link for more information on the [[Romberg Test]].  
** 1. Not before age 12.
** 2. If the student is not anatomically sound (e.g., insufficient ankle and foot plantar flexion range of motion; poor lower extremity alignment), do not allow pointe work.  
** 3. If she is not truly pre-professional, discourage pointe training.
** 4. If she has weak trunk and pelvic (“core”) muscles or weak legs, delay pointe work (and consider implementing a strengthening program).
** 5. If the student is hypermobile in the feet and ankles, delay pointe work (and consider implementing a strengthening program).
** 6. If ballet classes are only once a week, discourage pointe training.
** 7. If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training


En Pointe Dancing – Physio perspective
==== 8. Timed Plank Test<ref name=":4" /> ====
'''<u>Aim</u>:'''  To assess core endurance and the ability to maintain a neutral pelvis position.<ref name=":4" />


* Meeting the above criteria is very important to keep the dancers safe and to help prevent injury.
'''<u>Instruction</u>:''' The dancer starts in a full plank position on their hands and toes. They must achieve proper pelvic alignment before the test can start. The assessor times how long the dancer can hold this position. The test ends when the dancer can no longer hold the pelvis in the correct position or drops to their knees. It is also stopped after five minutes.<ref name=":4" />
* All students should get a pre point assessment with someone who specializes in working with dancers.
* Minimum age to commence pointe work is 12 years
* students must be attending a minimum of 3 classical ballet classes weekly in order to maintain the technique and strength required.


Exercise examples
'''<u>Note</u>:''' Being able to keep the core still while maintaining a neutral pelvis is important for control and balance during barre and centre work.<ref name=":4" />


* 1. Plantar flexion stretching 3 repetitions, with 30-second holds
==== 9. Star Excursion Balance Test (SEBT)<ref name=":2" /><ref name=":5" />====
* 2. Dorsiflexion stretch in squat using a TheraBand on the tibia to exert a posterior force, knee positioned forward from toe and pressing hands down on knee 3 repetitions, with 30-second holds
[[File:SEBT.png|right|frameless]]
* 3. Box jump up with soft landing–3 sets of 10 jumps 3 times weekly
'''<u>Aim</u>:''' To measure dynamic balance.<ref name=":2" />
* 4. Box jump down with soft landing and correct knee position–3 sets of 10 jumps 3 times weekly
* 5. Single leg Romanian Deadlift (RDL) holding 5-10 lb. weights, 5 high quality repetitions per side, progress to 10-20
* 6. Quadruped bird dog hip against the wall, 5 high quality repetitions per side
* 7. Single heel raise-work up to 27 consecutive repetitions, three times weekly


Helpful Education concepts
'''<u>Instruction</u>:''' There are two versions of this test commonly used, both have links to pages describing the tests further. This course refers to a test known as the "[[Y Balance Test]]", in which the individual, balances on one leg and touches 3 different points on the floor with the non-weightbearing foot. The second test is referred to as the [[Star Excursion Balance Test|Star Excursion Balance Test (SEBT)]], as pictured along side. in this test four strips of athletic tape are cut (each strip is 6-8 feet long). Two pieces are used to create a '+' while the other two strips are used to create an 'x', which is positioned on top of the '+', thus forming a star shape. Each strip must be separated by a 45 degree angle.<ref name=":8">Olmsted LC, Carcia CR, Hertel J, Shultz SJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164384/ Efficacy of the star excursion balance tests in detecting reach deficits in subjects with chronic ankle instability.] Journal of athletic training. 2002 Oct;37(4):501.</ref> During the SEBT, the aim is to maintain single-leg stance while reaching the contralateral leg as far as possible along the points of the star.<ref name=":8" /><ref>Plisky PJ, Gorman PP, Butler RJ, Kiesel KB, Underwood FB, Elkins B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953327/ The reliability of an instrumented device for measuring components of the star excursion balance test.] North American journal of sports physical therapy: NAJSPT. 2009 May;4(2):92.</ref>


* 1. hip hinge in lumbar neutral–mirror and dowel for feedback
'''<u>Remember</u>:''' Complete the test in all required directions.
* 2. unilateral heel raise without anterior/posterior sway
* 3. identifying knee valgus in closed chain in mirror and with video feedback
* 4. identifying level pelvis with mirror
* 5. soft landing with jump up and jump down


References
==== Guidelines from the International Association of Dance Medicine and Science (IADMS)<ref name=":9">Weiss DS, Rist RA, Grossman G. [https://iadms.org/media/5779/iadms-resource-paper-guidelines-for-initiating-pointe-training.pdf Guidelines for Initiating Pointe Training.] Journal of Dance Medicine ci Science• Volunae. 2009;13(3):91.</ref>====
The IADMS provides the following guidelines for when to begin pointe training:<ref name=":9" />
#"Not before age 12.
#If the student is not anatomically sound (e.g., insufficient ankle and foot plantar flexion range of motion; poor lower extremity alignment), do not allow pointe work.
#If she is not truly pre-professional, discourage pointe training.
#If she has weak trunk and pelvic (“core”) muscles or weak legs, delay pointe work (and consider implementing a strengthening program).
#If the student is hypermobile in the feet and ankles, delay pointe work (and consider implementing a strengthening program).
#If ballet classes are only once a week, discourage pointe training.
#If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training."


# Batalden L. Pointe-Readiness Screening and Exercise for the Young Studio Dancer. Orthopaedic Practice. volume 32 / number 1 / 2020  
== Ballet Terms Explained ==
# WEISS D S, RIST R A, GROSSMAN G , WITH THE IADMS DANCE EDUCATORS’ COMMITTEE, 2019. Guidelines for Initiating Pointe Training. IADMS. RESOURCE PAPER FOR DANCE TEACHERS, 2019
{{pdf|PAglossary.pdf|Glossary of Ballet Terms}}
# Altmann C, Roberts J, Scharfbillig R, Jones S. Readiness for En Pointe Work in Young Ballet Dancers Are There Proven Screening Tools and Training Protocols for a Population at Increased Risk of Injury? Journal of Dance Medicine & Science • Volume 23, Number 1, 2019
# DeWolf A, McPherson A, Besong K, Hiller C, Docherty C. Quantitative Measures Utilized in Determining Pointe Readiness in Young Ballet Dancers. Journal of Dance Medicine & Science • Volume 22, Number 4, 2018
# Glumm S A. FUNCTIONAL PERFORMANCE CRITERIA TO ASSESS POINTE-READINESS IN YOUTH BALLET DANCERS: A Thesis in Kinesiology. The Pennsylvania State University,  2017
# Shayla Hewitt, M.S., Michael Mangum, Ph.D., Brian Tyo, Ph.D., and Clayton Nicks. Fitness Testing to Determine Pointe Readiness in Ballet Dancers. Journal of Dance Medicine & Science • Volume 20, Number 4, 2016
# ROSE E. TAYLOR-SPANN. CLASSICAL BALLET PRE-POINTE EDUCATION: AN ANALYSIS OF THE PEDAGOGY FOR THE TRAINING OF YOUNG DANCERS A THESIS SUBMITTED TO THE GRADUATE FACULTY in partial fulfillment of the requirements for the Degree of MASTER OF FINE ARTS IN DANCE. 2016
# Megan Richardson, M.S., A.T.C., Marijeanne Liederbach, Ph.D., P.T., A.T.C., C.S.C.S., and Emily Sandow. Functional Criteria for Assessing Pointe-Readiness. Journal of Dance Medicine & Science • Volume 14, Number 3, 2010
# David S. Weiss, M.D., Rachel Anne Rist, M.A., and Gayanne Grossman. When Can I Start Pointe Work? Guidelines for Initiating Pointe Training. Journal of Dance Medicine & Science • Volume 13, Number 3, 2009
# Meek C,  Hess R A, Helldobler R,  Roh J. Pre-Pointe Evaluation Components Used by Dance Schools. Journal of Dance Medicine and Science: Volume 8, Number 2, 2004


== References ==
[[Category:Plus Content]]
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]
[[Category:Foot - Assessment and Examination]]
[[Category:Ankle - Assessment and Examination]]
[[Category:Ankle]]
[[Category:Foot]]

Latest revision as of 19:05, 22 January 2023

Original Editor - Carin Hunter based on the course by Michelle Green-Smerdon
Top Contributors - Carin Hunter, Jess Bell, Kim Jackson and Ewa Jaraczewska

Introduction[edit | edit source]

Dance injuries associated with pointe work are highly prevalent within the dance community,[1] particularly in young dancers who are growing and, at the same time, having to learn motor patterns and technically demanding skills.[2] Pre-pointe assessments are used to determine whether a ballet dancer is safe to progress to dancing en pointe. This transition often occurs at around 12 years of age.[1][2][3]

Basic evaluation protocols have not yet been standardised [4], but attempts have been made to identify musculoskeletal variables between pre-pointe and novice pointe students to ascertain readiness.[3] Previously, chronological age, years of dance training, ankle plantar flexion range, and correct execution of relevé were the only indicators of readiness. However, research suggests that a combination of a biomechanical assessment, and an assessment of the entire kinetic chain, muscle imbalance, compensation, and other postural issues is more useful to gauge safe and successful performance.[2] Similarly, there is a lack of research regarding pre-pointe training programmes. While a programme is often introduced and is very beneficial, there is no gold standardised programme.[5]

There is much debate over who should complete the pre-pointe assessment for the dancer, but it is thought that a healthcare provider has the greatest influence over the pre-pointe assessment.[6] It has also been suggested that functional tests which examine core stability, strength and flexibility of the feet and ankles, lower extremity alignment and postural control may be adequate to determine when a dancer is ready to begin pointe work.[7]

Please see the glossary at the bottom of this page for definitions of any unfamiliar ballet terms.

General Criteria Used[edit | edit source]

  1. Age
    • Dancers are often encouraged to start pointe work between 11 and 12 years of age. There is a large variation in musculoskeletal and motor development at this age. There are regular, rapid growth spurts which can heighten the risk of growth plate injuries[5]
  2. Years of dance
    • It is assumed that by 12 years of age, a dancer will have participated in at least 3 or 4 years of classical ballet training, and therefore, will have the necessary cognitive ability, strength, technique skill, alignment, coordination, bone development and motor control to begin pointe work[8]
  3. Injuries
    • Dance students will compensate for newly acquired injuries, or injuries that have not fully healed
  4. Relevé alignment and stability
  5. Plié alignment and stability
  6. Tendu
  7. Upper body alignment and stability
  8. Technique requirements and skill acquisition
    • When assessing a dancer, commonly technique in carrying out certain movements is assessed. According to Meck,[9] the most valuable input with regards to requirements of technique were to focus of assessing a relevé, plié, and tendu.
    • The requirement of sufficient ankle plantar flexion range of motion is essential for pointe work

Strength Testing[edit | edit source]

Intrinsic Muscle Strength[edit | edit source]

When a dancer moves to full pointe, the intrinsic muscles of the foot work 2.5 to 3 times harder than the other muscles in the foot.[10] Because of the repetitive nature of ballet, chronic fatigue of the muscles which cross the joints of the foot are a major factor in injuries associated with pointe work.[5]

Lower Extremity Strength and Neuromuscular Control[edit | edit source]

When assessing lower extremity strength, it is important to look at the kinetic chain as a whole. This is because the kinetics of the lower limb are largely dependent on pelvis and trunk stability. To gain stability of the pelvis and trunk, a dancer needs to activate their core muscles. This helps provide them with the control needed to execute the necessary movements.[11]

In single-leg stance, a dancer relies heavily on their hip abductor and external rotator muscles to maintain a level pelvis. This becomes increasingly challenging when the base of support is further decreased (i.e. when rising up onto pointe). Compensations can be seen further up the kinetic chain in the form of increased postural sway. This can also increase a dancer's risk of inversion sprains.[5]

Evidence-Based Tests[edit | edit source]

While there is no gold standard, certain evidence-based tests may give an idea of pointe readiness and are recommended in a pre-pointe assessment.[5]

The single leg heel rise test can provide an objective measure of plantar flexion strength and it can be used to help determine a dancer’s readiness for pointe training. Performing 25 single leg heel rises is considered normal for human gait.[12] [13]

DeWolf et al.[3] also advise that 15 continuous single-leg relevés and 2 cycles of the airplane test should be considered "cut-off levels" when performing pre-pointe assessments.

Evaluating dynamic motor control, such as controlling alignment during ballet specific tasks, can also be useful in the pre-pointe assessment.[14] The airplane test, topple test and sauté test were able to distinguish between dancers of varying levels (i.e. pre-pointe, beginner pointe and intermediate pointe) and may be useful for determining pointe readiness.[3][14][15]

The relevé endurance test and the airplane test can both be used to distinguish between pre-pointe and pointe dancers.[3] These tests also discriminated between dancers of different skill levels, integrating both technique and physical ability.[3][14][15]

1. “Airplane” Test [3][14][15][16][edit | edit source]

Aim: To measure control of the lower extremities, core and balance. Hewitt et al.[15] have found that this test is a useful way of determining a dancer's ability to hold their pelvis in a neutral position.

Instruction: The dancer stands with feet parallel on one leg. They bend over at the waist and extend the non-support leg backwards, until the leg and the trunk are parallel to the floor. In this position, the dancer is facing down towards the floor. Here, they lift their arms beside their torso in the shape of a “T.” Once the torso and leg are parallel with the floor, the dancer bends their supporting leg. At the same time, while keeping the trunk and non-support leg parallel to the floor, they bring their arms down towards the floor (elbows extended) until the fingertips make contact with the floor in front of their face. The dancer then extends their knee and arms to return to the starting position. The test is stopped if the dancer moves their supporting foot, falls out of the position, or chooses to stop. The number of completed repetitions on both sides are added together for a total score.[15]

Remember: Test both right and left sides.

Note: An attempt is considered unsuccessful when there is pelvic drop, hip adduction, hip internal rotation, knee valgus, or foot pronation during the movement.[15]

2. Sauté Test [14][15][16][edit | edit source]

Aim: To evaluate dynamic trunk control and the alignment of the lower limb.[15]

Instruction: The dancer begins in coupé derriere. Their gesturing leg and standing leg are turned out and they place their hands on their hips or across their chest. The dancer jumps into the air and must achieve the following:[15]

  • Neutral pelvis
  • Upright / stable trunk
  • Straight standing leg in the air
  • Pointed standing foot in the air
  • The leg holding the coupé must not move
  • Their landing into plié must be controlled (i.e. they roll through the foot from toe to ball to heel)

Participants in the study by Hewitt et al.[15] attempted as many as 16 sautés on each leg. They added scores from the right and left sides together to find the total score. A pass was a minimum of 8/16 correctly performed jumps.[15]

Remember: The single leg sauté test should not follow the single leg heel raise test as both tests primarily evaluate calf muscle strength.[5]

Note: Slow motion analysis is necessary to assess all the criteria required to pass the test.[5][15]

3. “Topple” Test[14][15][16][edit | edit source]

Aim: To assess a dancer’s ability to perform one clean pirouette.[15]

Instruction: A "clean" pirouette is defined as:[15]

  1. A proper beginning placement (i.e. square hips, the majority of weight is on the forefoot, a turned out position, the pelvis is centred, and the dancer has strong arms)
  2. The dancer brings their leg up into passé in one count
  3. The supporting leg is straightened
  4. The dancer turns their torso in "one piece"
  5. The dancer's arms are "strong" and must be properly placed
  6. The dancer demonstrates a quick spot
  7. The landing must be controlled

In the Hewitt et al.[15] study, one point was given for each criterion that was met. The best pirouette on each leg was given a score and a total score was given based on the scores from the right and left legs.[15]

Remember: Dancers in the study by Hewitt et al.[15] were given three attempts to complete the pirouette on each leg.

Note: The tests should be recorded, so that videos can be replayed in slow motion for a more precise analysis.[15]

4. Pencil Test – Plantar Flexion ROM[14][edit | edit source]

Aim: To determine the overall plantar flexion of the ankle-foot complex.[14]

Instruction: The dancer is positioned in long-sitting. A straight-edge level or a pencil is placed on the top of their dorsal talar neck. A dancer passes this test if they achieve sufficient plantar flexion (i.e. 90 degrees or more). This is achieved when the straight-edge clears the distal end of the tibia, just proximal to the malleoli.[14]

Remember: A hypermobile individual will perform well in this test.[5]

Note: It is important to correct excessive rounding of the foot.[5]

5. Single Leg Heel Raise Test [3][14][15][16][edit | edit source]

Aim: To determine the endurance of the calf musculature.[14]

Instruction: The dancer stands on one leg. They hold their other leg in a parallel coupé. The dancer is asked to perform as many relevés without plié as they can to a beat of 120 beats per minute (i.e. 30 heel raises per minute). The test is ended if the dancer can no longer keep up with the beat or if they choose to stop. The test is also stopped if a dancer completes 75 relevés. Each side is tested and the total number of relevés are added together.[15]

This test can also be performed as follows: Posterior calf strength is measured by counting the number of parallel single-leg heel raises that the dancer can perform while maintaining the pre-test relevé height on a straight leg. A “pass” for this test has been defined as performing 20 or more heel raises.[2]

Remember: Batalden[16] notes that at least 90 degrees of plantar flexion is needed for the subtalar joint to lock en pointe, thus helping to avoid ankle ligament injuries. In their testing, Batalden[16] included dorsiflexion "with a standard of 15°".

Note: For 5 to 8 year olds, the mean number of repetitions in the heel raise test has been found to be 15.2 repetitions. The mean number of repetitions in 9 to 12 year olds is 27.7.[16]

6. Double Leg Lower Test[14][edit | edit source]

Aim: To objectively evaluate abdominal strength.[14]

Instruction: The dancer lies supine. Their pelvis is in a neutral position and both legs are flexed to 90 degrees at the hips, so that they are perpendicular to the testing surface. While keeping both knees extended, the dancer is asked to slower lower their legs to the testing surface. The assessor looks at pelvis stability and records the angle of the legs when the pelvis begins to tilt anteriorly. A strength grade is given based on this angle.[14]

Remember: This test is recorded as a pass if this angle is 45 degrees or less.[14]

Note: Watch for any biomechanical compensations further up the body.[5]

7. Modified “Romberg” Test[14][17][18][edit | edit source]

Aim: To determine proprioception and falls risk.[5]

Instruction: The dancer stands in a single-leg parallel stance. They cross their arms and close their eyes. A dancer passes this test if they can maintain this position for more than 30 seconds without: opening their eyes, touching the non-support foot down, or moving their stance foot.[14]

Please click on the link for more information on the Romberg Test.

8. Timed Plank Test[15][edit | edit source]

Aim: To assess core endurance and the ability to maintain a neutral pelvis position.[15]

Instruction: The dancer starts in a full plank position on their hands and toes. They must achieve proper pelvic alignment before the test can start. The assessor times how long the dancer can hold this position. The test ends when the dancer can no longer hold the pelvis in the correct position or drops to their knees. It is also stopped after five minutes.[15]

Note: Being able to keep the core still while maintaining a neutral pelvis is important for control and balance during barre and centre work.[15]

9. Star Excursion Balance Test (SEBT)[3][18][edit | edit source]

SEBT.png

Aim: To measure dynamic balance.[3]

Instruction: There are two versions of this test commonly used, both have links to pages describing the tests further. This course refers to a test known as the "Y Balance Test", in which the individual, balances on one leg and touches 3 different points on the floor with the non-weightbearing foot. The second test is referred to as the Star Excursion Balance Test (SEBT), as pictured along side. in this test four strips of athletic tape are cut (each strip is 6-8 feet long). Two pieces are used to create a '+' while the other two strips are used to create an 'x', which is positioned on top of the '+', thus forming a star shape. Each strip must be separated by a 45 degree angle.[19] During the SEBT, the aim is to maintain single-leg stance while reaching the contralateral leg as far as possible along the points of the star.[19][20]

Remember: Complete the test in all required directions.

Guidelines from the International Association of Dance Medicine and Science (IADMS)[21][edit | edit source]

The IADMS provides the following guidelines for when to begin pointe training:[21]

  1. "Not before age 12.
  2. If the student is not anatomically sound (e.g., insufficient ankle and foot plantar flexion range of motion; poor lower extremity alignment), do not allow pointe work.
  3. If she is not truly pre-professional, discourage pointe training.
  4. If she has weak trunk and pelvic (“core”) muscles or weak legs, delay pointe work (and consider implementing a strengthening program).
  5. If the student is hypermobile in the feet and ankles, delay pointe work (and consider implementing a strengthening program).
  6. If ballet classes are only once a week, discourage pointe training.
  7. If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training."

Ballet Terms Explained[edit | edit source]

Glossary of Ballet Terms

References[edit | edit source]

  1. ↑ 1.0 1.1 Altmann C, Roberts J, Scharfbillig R, Jones S. Readiness for en pointe work in young ballet dancers are there proven screening tools and training protocols for a population at increased risk of injury?. Journal of Dance Medicine & Science. 2019 Mar 15;23(1):40-5.
  2. ↑ 2.0 2.1 2.2 2.3 Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 DeWolf A, McPherson A, Besong K, Hiller C, Docherty C. Quantitative measures utilized in determining pointe readiness in young ballet dancers. Journal of Dance Medicine & Science. 2018 Dec 1;22(4):209-17.
  4. ↑ Cantergi D, Moraes LR, Loss JF. Applications of Biomechanics Analysis in Dance. InScientific Perspectives and Emerging Developments in Dance and the Performing Arts 2021 (pp. 25-44). IGI Global.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Green-Smerdon M. Pre-Pointe Assessment Course. Plus. 2022.
  6. ↑ Russell JA. Preventing dance injuries: current perspectives. Open access journal of sports medicine. 2013;4:199.
  7. ↑ Glumm SA. Functional Performance Criteria to Assess Pointe Readiness in Youth Ballet Dancers.
  8. ↑ McCormack MC, Bird H, de Medici A, Haddad F, Simmonds J. The physical attributes most required in professional ballet: a Delphi study. Sports medicine international open. 2019 Jan;3(01):E1-5.
  9. ↑ Meck C, Hess RA, Helldobler R, Roh J. Pre-pointe evaluation components used by dance schools. Journal of Dance Medicine & Science. 2004 Jun 1;8(2):37-42.
  10. ↑ Barreau X, Gil C, Thoreux P. Ballet. Injury and Health Risk Management in Sports 2020 (pp. 725-731). Springer, Berlin, Heidelberg.
  11. ↑ Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2005 Sep 1;13(5):316-25.
  12. ↑ Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy. 2017 Dec 1;103(4):446-52.
  13. ↑ Thomas KS. Functional eleve performance as it applies to heel-rises in performance-level collegiate dancers. Journal of Dance Medicine & Science. 2003 Dec 15;7(4):115-20.
  14. ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 14.11 14.12 14.13 14.14 14.15 14.16 Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 15.12 15.13 15.14 15.15 15.16 15.17 15.18 15.19 15.20 15.21 15.22 15.23 15.24 Hewitt S, Mangum M, Tyo B, Nicks C. Fitness testing to determine pointe readiness in ballet dancers. Journal of Dance Medicine & Science. 2016 Dec 15;20(4):162-7.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Batalden L. Pointe-Readiness Screening and Exercise for the Young Studio Dancer. Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.
  17. ↑ Agrawal Y, Carey JP, Hoffman HJ, Sklare DA, Schubert MC. The modified Romberg Balance Test: normative data in US adults. Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2011 Oct;32(8):1309.
  18. ↑ 18.0 18.1 Ani KU, Ibikunle PO, Nwosu CC, Ani NC. Are the Current Balance Screening Tests in Dance Medicine Specific Enough for Tracking the Effectiveness of Balance-Related Injury Rehabilitation in Dancers? A Scoping Review. Journal of Dance Medicine & Science. 2021 Dec 15;25(4):217-30.
  19. ↑ 19.0 19.1 Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the star excursion balance tests in detecting reach deficits in subjects with chronic ankle instability. Journal of athletic training. 2002 Oct;37(4):501.
  20. ↑ Plisky PJ, Gorman PP, Butler RJ, Kiesel KB, Underwood FB, Elkins B. The reliability of an instrumented device for measuring components of the star excursion balance test. North American journal of sports physical therapy: NAJSPT. 2009 May;4(2):92.
  21. ↑ 21.0 21.1 Weiss DS, Rist RA, Grossman G. Guidelines for Initiating Pointe Training. Journal of Dance Medicine ci Science• Volunae. 2009;13(3):91.
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