1. 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

2. 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?

3. 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…”

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

5. 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)

6. 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

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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. 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