Anatomy of the Pointe Shoe

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

Introduction

The pointe shoe is a complex and vital piece of equipment for the dancer, which should not be overlooked when assessing injuries in dancers. There are many different styles and types of pointe shoes. Examples include:

• Freed
• Capezio
• Teplov
• Grishko
• Gaynor Mindens

Parts of the Pointe Shoe

The main parts of a pointe shoe are as follows:

• Drawstring

• Binding
• Toe box
  • Consists of compressed layers of paper, fabric, and glue
• Sides or wings
• Pleats - plantar surface
• Platform
• Inner sole
• Outer sole
• Shank
  • Variations include thickness, length and amount
  • Adapted according to the dancer's preference
• Waist seams on left and right
• Back seam
• Accessories - i.e. the ribbons or elastics used to secure the shoe to the dancer's foot
  • Looking at the accessories can provide therapists with various insights, including:
    • Dancer preference
    • Amount of experience
    • Potential or current injuries
    • The way in which accessories are attached can also cause injuries (e.g. stitching might rub on tendons / bony prominences)
• Toe caps
  • Provide comfort, mouldability, shock absorption, impact, sweat absorption, cushioning
  • Can be made of material or silicone:
    • Silicone - breathable, malleable, better compressibility, longer lasting
    • Material - hardens with sweat from dancing

Important Measurements

• Vamp - the length of the toe box
• Crown, or profile - the height of the toe box

• 

  Vamp Measurement

• 

  Crown Measurement

Breaking in Pointe Shoes

The term "breaking in" mostly refers to when the ballet dancer breaks or cuts off the shank of the shoe:

• The purpose of this is to help mould the shoe to the foot of the dancer for comfort
• Shank strength will depend on the dancer's arch type and arch flexibility
• The natural arches of the foot should line up with where the shank is broken in
  • As a basic rule of thumb, if a shoe has an extensive bend, the ballerina often presents with a high arch; if the shoe is stiff, the ballerina tends to have a low arch
  • The dancer needs to be comfortable in their shoe with their feet flat, in demi-pointe and en pointe
• Physiotherapists can assist with breaking in the shank by marking on the dancer's shoes where their natural arches are - the dancer can then line up the break in the shank with these markings

The toe box must also be broken in. To break in the toe box, dancers might:

• Wear the shoe
• Dance in the shoe
• Do barre work in the shoe
• Compress the toe box with the palm of their hand or heel of their foot
• Hit the plantar surface of shoe on the floor
• The toe box of the pointe shoe must be strong enough to support the dancer en pointe, but also malleable enough to allow articulation of the joints of the foot and ankle

Foot Shape

There are three foot types:

• Square
• Tapered (also referred to as Egyptian-type toes)
• Somewhat tapered (or Morton's foot type)

Because there is so much variation in both feet and shoes, a ballet shoe needs to be professionally fitted. Variations within a pointe shoe include: different shank length, height, and width, different vamp length, toe box length, wing height, platform height and crown height.

Effect of Toe Type on Postural Stability

Kizawa et al. examined ballet dancers with Egyptian-type toes (or tapered toes) and with square type toes. They found that there was no significant difference in postural stability between these two toe types in dancers standing and in a demi-pointe position. However, dancers with square-type toes were more stable en pointe than dancers with Egyptian-type toes.

In dancers with square-type toes, Kizawa et al. found that similarities in toe length enabled more simultaneous loading of the toe-tips. As this creates a greater surface area to support the body / load, the balance ground reaction force can be more evenly transmitted between the two toe-tips. Thus, there is a smaller centre of pressure displacement in dancers with square-type toes than those with Egyptian-type toes.

Correct Shoe Fit

• The shank strength will depend on the dancer's arch type and arch flexibility
• Heel height and width will have an influence on the heel section of the pointe shoe
• The vamp length will depend on the ability of the toes to be compressed, the length of the toes and the flexibility of the arch
• The shoe profile height depends on the arch type and flexibility, the box shape and width, toe length and foot profile height

Why Does Fit Matter?

The correct shoe fit is essential as toe type and compressed toes will have an effect on the correct load bearing points of the feet. Complications associated with overly compressed toes include: Morton's neuroma, bunions and hallux valgus. Toe type and postural stability are essential when correctly fitting a pointe shoe. The pointe shoe is designed to assist the dancer while they are in plantarflexion, protecting the feet from impact forces and stabilising the performer.

What should physiotherapists look out for in a pointe shoe?

• Getting “over the box” - look for wear and tear on the platform of both shoes
• There should be central wear - wear should not be more to the left or the right sides
• Stitching around the platform can give proprioceptive feedback about where the dancer is on the toe box
• Consider the type of shank - dancers with weak ankles might need a rigid shank and they should be weary of a flexible shank
• The shanks should curve in towards each other so there are no gaps between the dancer's feet in 5th position as shown in the images below
• Toes should be straight in the pointe shoe (no bend)

There is no “ideal” foot structure for en pointe:

• Ankles that are less prone to injury have the following features:
  • Toes of equal length
  • High instep
  • Flexible ankle
  • High arches IF they are very strong
• Ankles more prone to injury have the following features:
  • Uneven toe length
  • Inflexible / rigid ankle
  • Low instep or flat arch - flat arches mean that the dancer will need to work on flexibility, although they usually present with good strength

Assessing the Shoe

The following might indicate an inexperienced dancer:

• Shank not “broken in”
• Elastic is placed on the heel to keep the shoe on
  • More experienced dancers will either have a proper shoe fit or may sew the elastic along the inside seam to provide stability and reduce the risk of injuries

According to Bickle et al., a pointe shoe will last for approximately 20 hours of dancing. A worn pointe shoe has been shown to increase mid-foot flexion and ankle plantarflexion when en pointe. The impaired structural integrity of the used pointe shoe is thought to be a contributing factor to biomechanical changes which can lead to pain and injury. Professional ballet dancers are encouraged to change their pointe shoes multiple times during a show because the high demand placed on the shoes quickly reduces their structural integrity.

Injuries Related to Pointe Shoes

The pointe shoe is an intricate piece of equipment used by the dancer to showcase their feet. However, some common problems occur when a pointe shoe is worn out, such as:

• Reduced structural integrity
  • This can lead to an increased risk of muscle fatigue, ankle sprains or falls
• Increased flexibility
  • This may mean that the shoe provides little or no support in the extreme end range of plantarflexion, which is achieved during pointe work
  • Can lead to excess plantarflexion at the talocrural joint, as well as excessive mid-foot flexion
• Poor condition or support from the shoe
  • This can result in overuse and acute injuries

• A lack of sufficient shock absorbing material
  • A newer shoe can decrease the ground reaction forces

The joints and ligaments of the foot are not designed to accept excessive repetitive loading at the most extreme ranges. This type of training can lead to the compression of soft tissue structures and strains in the midfoot ligaments.

Take-Home Points

• All professional dancers are required to see a professional fitter
• Beginner dancers who are experiencing recurring injuries or who would like to advance in their discipline should be encouraged to see a professional fitter
• The phrase "too much, too soon" applies to moving on to pointe work
  • A dancer's body should be ready to accept the load with the correct shoe, and have adequate range of motion and strength through range before pointe work is even considered
  • The dancer needs to be able to move through their range from flat foot, to demi-pointe, and pointe, and be able to reverse the movement