Enhancing Physician Assessment of the Dancer The “Pointe” Question Lauren Elson, MD Director of Dance Medicine, Spaulding Rehabilitation Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA

Controversies When can a dancer start to work on pointe? ▪ Age? ▪ Level? ▪ Who decides? Dancer, parent, teacher, school director? ▪ What is the health practitioners role?

Controversies When can a dancer start to work on pointe? Balanchine: “When she can do something once she’s up there.” Dr. David Weiss: For those… who are not truly pre-professional, pointe training should be discouraged.” C Sparger; “Anatomy and Ballet: A Handbook for Teachers of Ballet. “…pointe work is the end result of slow and gradual training of the whole body… coordination of movement and the “placing” of the body so that the weight is lifted upwards off the feet… perfect balance, without tendency of the feet to sickle… or toes to curl/clutch… This moment will arrive at different times in different children, not only by virtue of previous training but according to their physical type…”

Controversies What is the health practitioners role? ▪ Education ▪ Facilitate injury prevention ▪ Work with teachers/schools

Pointe Readiness Dancer Specific!!!!! Stage of physical development Quality of trunk, abdominal and pelvic control Leg alignment Foot alignment/flexibility Foot strength Technical acumen (duration/frequency of training)

Pointe Readiness Dancer Specific!!!!! “12 years old” Assuming dancer has completed 3 years of training with a program designed to train professional ballet dancers Taking 4 classes/week Feet/ankles strong Good core strength (trunk/pelvic control) Good proprioception Pointe work should begin with 15 minutes of exercises at the end of each class

Pointe Readiness Dancer Specific!!!!! Alignment Foot ankle flexibility

Pointe Readiness Trunk Control; Core strength (Harkness Tests) balance in relevé-passé for 5 seconds maintain form and balance while performing a pirouette en dehors from 4th to 4th maintain good form while performing single leg sauté for at least 7 of 16 continuous reps perform at least 3 of 5 “Airplane” up/down maneuvers without loss of balance or form (maintain level pelvis, aligned hip knee, and no foot collapse)

Pointe Readiness Modern studio reality Multiple styles of technique classes Focus on performance/competition, not technique Students advanced based on age Full pointe technique classed right away Parental/student wishes vs teachers recommendations

Pointe Readiness Risks of starting too early If struggling on pointe, may have difficulty developing other aspects of technique May be prone to decreased confidence and poor self-esteem if unable to execute movements required to dance on pointe Risks of improper alignment Less bone/joint “damage”; more stress higher in the kinetic chain Hypermobile feet need increased trunk/leg control Inadequate ankle flexibility can cause compensatory lumbar lordosis

Physical Exam of the Dancer Turn out Hips Knees Ankle Forcing turnout contributes to overuse injuries Pronation, FHL tendonitis Hip external rotation can not be used to predict functional turnout 1st position may be useful as a guide or functional turnout for the other positions

Physical Exam of the Dancer Ankle ROM- pencil test <90 degrees PF is inadequate for pointe work Dancer weight bears on calcaneus Posterior impingement Symptomatic os trigonum Posterior tendon irritation Dancer “cheats” with lateral weightbearing Increased risk of ankle sprain LCL overload

Physical Exam of the Dancer Knee Hyperextension Desired aesthetic in ballet Causes relative PF stance with chronic anterior glide of the talus Leads to anterior impingement and increased force during jumps Needs increased PF to compensate

Physical Exam of the Dancer Strength Testing Adductors Functional abductors Lower abdominal muscles Sahrman, Kendall “Dance Exam” Plie Passe Develope Rapid footwork Small jumps www.abt.org - Dance glossary

Workshop Stations Alignment: Strength testing Pre-pointe Turnout assessment in first position Ankle/toe flexibility Strength testing Lower abdominals Functional abductor Pre-pointe Trunk control Balance Jump technique