Pre Pointe Assessment

Original Editor - Carin Hunter based on the course by https://members.physio-pedia.com/course_tutor/michelle-green-smerdon/

Top Contributors - Carin Hunter, Jess Bell, Kim Jackson and Ewa Jaraczewska

Introduction

• 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.
• 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

• 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
  • 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)

Best predictors

• “Airplane” test
• Sauté test
• “Topple” test

Second study, Hewitt et all 2016

• The participants completed five tests, used to measure physical attributes important to pointe training.
  • Heel rise
  • 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

• Six dependent variables were evaluated
  • : non-weightbearing (NWB) plantar flexion (PF) and dorsiflexion (DF) range of motion (ROM);
  • 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:

ROM (NWB PF and DF, WBL),

muscular capacity (relevé endurance, PF isometric strength),

and balance (Airplane, SEBT).

• 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).
• 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.
• In conclusion, the relevé endurance test and the Airplane test are appropriate for use in differentiating between pre-pointe and pointe dancers  

.

Tests used as deciding criteria

• 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.
• 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.
• 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.
• 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.
• 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

• The Pencil test is a method for determining overall plantar flexion of the ankle-foot complex
• 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.
• 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

Airplane test

• The airplane test measures control of the lower extremities , core and balance.
• 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

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:

• 1. Proper beginning placement (square hips, the majority of weight on the forefoot, turned out, pelvis centered, and strong arms;
• 2. Leg brought up to passé in one count;
• 3. Supporting leg straightened;
• 4. Torso turned in one piece;
• 5. Strong, properly placed arms;
• 6. A quick spot; and
• 7. A controlled landing.

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

Single leg Heel rise test

• A heel rise test determines endurance of the calf musculature.
• 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.
• 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

• 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.
• 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

• 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.
• 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.

Double leg lower test

• 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.
• 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

• Dancers performed a modified “Romberg” test by assuming a single-leg parallel stance with arms crossed and eyes closed.
• 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.
• 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

• A timed prone plank test was used to determine core endurance and ability to maintain the pelvis in a neutral position.
• 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?

• 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?”
• 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

(international association of dance medicine and science)

• To summarize the above discussion we offer the following guidelines for when to begin pointe training:
  • 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

• Meeting the above criteria is very important to keep the dancers safe and to help prevent injury.
• 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

• 1. Plantar flexion stretching 3 repetitions, with 30-second holds
• 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
• 3. Box jump up with soft landing–3 sets of 10 jumps 3 times weekly
• 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

• 1. hip hinge in lumbar neutral–mirror and dowel for feedback
• 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

1. Batalden L. Pointe-Readiness Screening and Exercise for the Young Studio Dancer. Orthopaedic Practice. volume 32 / number 1 / 2020  
2. 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
3. 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
4. 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
5. Glumm S A. FUNCTIONAL PERFORMANCE CRITERIA TO ASSESS POINTE-READINESS IN YOUTH BALLET DANCERS: A Thesis in Kinesiology. The Pennsylvania State University,  2017
6. 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
7. 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
8. 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
9. 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
10. 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