Pre Pointe Assessment

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

Introduction

Dance injuries associated with pointe work are highly prevalent within the dance community, particularly in a young dancer who is growing at the same time as repeatedly learning motor patterns in a period of skill acquisition. Pre-pointe assessments are used to determine whether a ballet dancer is safe to progress to dancing en pointe. This transition often occurs around 12 years of age.

Basic evaluation protocols have not yet been standardised, but attempts have been made to identify musculoskeletal variables between pre-pointe and novice pointe students to ascertain readiness. Previously, chronological age, years of dance training, ankle plantar flexion, and correct execution of relevé was the only indicator of readiness, but studies suggest that a combination of biomechanical assessment, assessment of the entire kinetic chain, muscle imbalance, compensation, or other postural issues is more useful to gauge safe and successful performance.

There is much debate as to who does a pre-pointe assessment for the dancer, it it thought that a healthcare provider has the greatest influence over the pre-pointe assessment.

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 an adequate evaluation for determining when a dancer is ready to begin pointe work.

General criteria used:

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 contribute to growth plates being more at risk for injury.
2. 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.
3. Injuries
   • The presence of newly acquired injuries, or injuries that have not fully healed, will cause the student to compensate for the injury.
4. Relevé alignment and stability
5. Plie alignment and stability
6. Tendu
7. Upper body alignment and stability
8. Technique requirements and skill acquisition
   • The correct execution of movements such as relevé, plie, and tendu were the most commonly reported technique requirements.
   • Ankle plantar flexion range of motion

Recommended Testing

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. With the repetitive nature of ballet, a major factor for injuries when training for pointe work is chronic fatigue of the muscles crossing the joints in the feet.

Lower Extremity Strength and Neuromuscular Control

When assessing lower extremity strength, it is important to look at the kinetic chain as a whole, as 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, and this will give them the control needed to execute the necessary movements.

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 narrowed even further by rising up onto pointe. The compensations can be seen further up the kinetic chain in the form of increased postural sway. this can also cause a dancer to have an increased risk of inversion sprains.

Recommended Testing

As mentioned above, there are generally advised indicators of pointe readiness. While there is no gold standard, there are a few evidence based tests that are advised for use, when determining safe and successful performance.

Performance on a single leg heel rise test can provide an objective measure of plantar flexion strength that may assist with assessing a dancer’s readiness for pointe training. The ability to perform 25 single leg heel rises is considered normal for human locomotion. . It has also been advised that the best cut-off levels when using single-leg relevés and the airplane test as part of a pre-pointe screening protocol was 15 continuous single-leg relevés and two repetitions of the airplane test.

Dynamic motor control, such as controlling alignment during ballet specific tasks, can assist in the evaluation for pointe work. The Airplane test, topple test and saute test discriminated between dancers of varying levels, whether it be pre-pointe, beginner pointe and intermediate pointe and may be useful for determining pointe readiness. The relevé endurance test and the Airplane test are appropriate for use in differentiating between pre-pointe and pointe dancers These three tests also discriminated between dancers of different skill levels, integrating both technique and physical ability.

1. “Airplane” Test

Aim: Measures control of the lower extremities, core and balance. 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.

Instruction: The dancer stands with feet 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. 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.

Remember: Test both right and left sides

Note: An unsuccessful attempt is defined by pelvic drop, hip adduction, hip internal rotation, knee valgus, or foot pronation during the movement

2. Sauté Test

Aim: evaluate dynamic trunk control and lower extremity alignment.

Instruction: 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

Remember: Single leg Sauté test not be preceded by the single leg heel rise test as they both involve primarily calf muscle strength

Note: slow motion analysis is necessary to capture the many criteria

3. “Topple” Test

Aim: assesses the dancer’s ability to perform a clean single pirouette

Instruction: 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

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.

Remember: The dancers were allowed three attempts on each leg.

Note: The test was recorded  and videos were replayed in slow motion to enhance precision of analysis

4. Pencil Test – PF ROM

Aim: determining overall plantar flexion of the ankle-foot complex

Instruction: 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.

Remember:

Note:

5. Single Leg Heel Raise Test

Aim: determines endurance of the calf musculature

Instruction: 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

Remember: 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°.

Note: 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

6. Double Leg Lower Test

Aim: an objective way to evaluate abdominal strength

Instruction: 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 lower extremities at which the pelvis begins to tilt anteriorly, and a strength grade is assigned based on that angle

Remember: The dancer passed this test if her lower extremity angle was less than or equal to 45° from the floor when pelvic motion occurred

Note:

7. Modified “Romberg” Test

Aim: assuming a single-leg parallel stance with arms crossed and eyes closed

Instruction: 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.

Remember:

Note:

8. Timed Plank Test

Aim: used to determine core endurance and ability to maintain the pelvis in a neutral position

Instruction: 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.

Remember:

Note: Holding the core stationary with the pelvis in neutral is important for control and balance during barre and center work

9. Star Excursion Balance Test (SEBT)

Aim:

Instruction:

Remember: Complete the test in three directions

Note:

So what do we use to decide?

• 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. 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
• 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 remity 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

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
8. Balance-specific training has been shown to improve balance scores and decrease incidence of injury in athletes

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