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[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, 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 plantarflexion, and correct execution of relevé were the only indicators of readiness, but studies suggest that a combination of biomechanical assessment, assessment of the entire kinetic chain, muscle imbalance, compensation, and other postural issues is more useful to gauge safe and successful performance.[2]

There is much debate over who should do a pre-pointe assessment for the dancer, but it is thought that a healthcare provider has the greatest influence over the pre-pointe assessment.[4] 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 an adequate evaluation for determining when a dancer is ready to begin pointe work.[5]

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[6]
  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 possess adequate cognitive ability, strength, technique skill, alignment, coordination, bone development and motor control considered necessary to begin pointe work[7]
  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
    • The correct execution of movements such as relevé, plié, and tendu were the most commonly reported technique requirements[8]
    • Ankle plantar flexion range of motion

Recommended 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.[9] 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.[6]

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.[10]

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.[6]

Recommended Testing[edit | edit source]

While there is no gold standard, certain evidence-based tests can give an idea of pointe readiness and are recommended in a pre-pointe assessment.[6]

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.[11] [12]

DeWolf et al.[3] also advise that 15 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.[13] 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][13][14]

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][13][14]

1. “Airplane” Test [3][13][14][15][edit | edit source]

Aim: To measure control of the lower extremities, core and balance. Hewitt et al.[14] have found that it is a useful test to determine 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 made contact with the floor in front of their face. The dancer then extends their knee and upper extremities 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 the total score.[14]

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[14]

2. Sauté Test [13][14][15][edit | edit source]

Aim: To evaluate dynamic trunk control and the alignment of the lower limb.[14]

Instruction: The dancer begins in coupé derriere i.e. their gesturing leg and standing leg are turned out and they place their hands on their hips. The dancer jumps into the air and must achieve the following:[14]

  • 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
  • The 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.[14] 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.[14]

Remember: The single leg sauté test should not follow the single leg heel rise test as both tests primarily assess calf muscle strength.[6]

Note: Slow motion analysis is necessary to capture the many criteria.[6][14]

3. “Topple” Test[13][14][15][edit | edit source]

Aim: To assess a dancer’s ability to perform one clean pirouette.[14]

Instruction: A "clean" pirouette is defined as:[14]

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

In the Hewitt et al.[14] study, one point was given for every criterion that was met. The best pirouette on each leg was given a score and the total score was recorded based on the scores from the right and left legs.[14]

Remember: Dancers in Hewitt et al.[14] were allowed to attempt the pirouette three times on each leg.

Note: Tests should be recorded, so that videos can be replayed in slow motion for a more precise analysis.[14]

4. Pencil Test – Plantar Flexion ROM[13][edit | edit source]

Aim: To determine the overall plantar flexion of the ankle-foot complex.[13]

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 is able to pass this test if they achieve sufficient plantar flexion (i.e. 90 degrees or more). This is evidenced if the straight-edge clears the distal end of the tibia, just proximal to the malleoli.[13]

Remember: A hypermobile individual will perform well in this test.[6]

Note: It is important to correct excessive rounding of the foot.[6]

5. Single Leg Heel Raise Test [3][13][14][15][edit | edit source]

Aim: To determine the endurance of the calf musculature.[13]

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[13][edit | edit source]

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: Watch for any biomechanical compensations further up the body.

7. Modified “Romberg” Test[16][13][17][edit | edit source]

Aim: To determine the proprioception and falls risk in an individual

Instruction: 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.

Remember: Please click on the link for more information of the Romberg Test

8. Timed Plank Test[14][edit | edit source]

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.

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) [3][17][edit | edit source]

SEBT.png

Aim: A measure of dynamic balance. Instruction: Four strips of athletic tape will need to be cut to a length of 6-8 feet each. Two pieces will be used to form a ‘+’, with the other two being placed over top to form an ‘x’ so that a star shape is formed. It is important that all lines are separated from each other by a 45° angle.[18] The goal of the SEBT is to maintain single leg stance on one leg while reaching as far as possible with the contralateral leg.[19]

Remember: Complete the test in all four directions

Guidelines direct from International Association of Dance Medicine and Science (IADMS)[20][edit | edit source]

With regards to the tests listed above, methodology lacks valid or reliable measurement. There has been little research to indicate the most appropriate individual to conduct a Pre-Pointe Assessment. This results in a lack of standardization.

Once en pointe readiness has been assessed and any impairment identified, a pre-pointe training program is commonly introduced. The following are guidelines offered from the IADMS 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[6][edit | edit source]

  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[6][edit | edit source]

  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[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 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 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. ↑ Russell JA. Preventing dance injuries: current perspectives. Open access journal of sports medicine. 2013;4:199.
  5. ↑ Glumm SA. Functional Performance Criteria to Assess Pointe Readiness in Youth Ballet Dancers.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Green-Smerdon M. Pre-Pointe Assessment Course. Physioplus. 2022.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ Barreau X, Gil C, Thoreux P. Ballet. Injury and Health Risk Management in Sports 2020 (pp. 725-731). Springer, Berlin, Heidelberg.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 13.12 Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. Journal of Dance Medicine & Science. 2010 Sep 1;14(3):82-8.
  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 14.17 14.18 14.19 14.20 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.
  15. ↑ 15.0 15.1 15.2 15.3 Lynn Batalden PT. Pointe-Readiness Screening and Exercise for the Young Studio Dancer. Orthopaedic Physical Therapy Practice. 2020;32(1):48-50.
  16. ↑ 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.
  17. ↑ 17.0 17.1 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ Weiss DS, Rist RA, Grossman G. Guidelines for Initiating Pointe Training. Journal of Dance Medicine ci Science• Volunae. 2009;13(3):91.
Retrieved from "https://www.physio-pedia.com/index.php?title=Pre_Pointe_Assessment&oldid=306997"