Is My Daughter Ready for Pointe Work? A Dance Medicine Physician Perspective

The decision to initiate pre-pointe training is a sentinel event in the progression of a young dancer. Dancing en pointe which involves full-weight bearing on the toes, is fundamentally rigorous, can lead to a variety of lower body injuries, and signifies a high level of commitment to ballet that should not be taken lightly.

Relying on reaching a certain to start (ie: "we start pointe at age 11") is not sensible and supported by many dance medicine authorities. Rather, there is the concept of developmental age which takes into account dance experience, mechanics, strength, commitment, and nutrition/sleep for a more individualized assessment of readiness.

Many wonderful musculoskeletal screening recommendations have been made by respected authorities, and I will definitely reference them below and do use them in my clinical practice.

Before moving the focus on movement patterns, I like to take a step back with dancers and families to discuss fundamental concepts emphasizing sufficient sleep, dance-specific nutrition and balance of dance classes and adequate time off for recovery. If a young dancer is not ready to accept these key foundations for success, then I'm not certain she is ready for the rigors and "sacrifices" of point work.  Jeff Russell has an amazing review of how psychosocial traits of dancers, nutrition and fatigue all can contribute to injury and I highly recommend the read.

• Dancers must accept the unique physical and mental demands of point work leading to a need for increased sleep (minimum 8-9 hours a night)
• Adequate calcium (1000-1500 mg/day) and iron (15 mg/day) needs can be best addressed by 4-6 servings of dairy foods and 3-4 servings of meat/protein per day
• Minimum of 1-2 days off a week from organized activities to enhance recovery

Returning to the discussion of musculoskeletal readiness, The International Association for Dance Medicine and Science (IADMS) proposes the following guidelines:

• Not before age 12.
• 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.
• If she is not truly pre-professional, discourage pointe training.
• If she has weak trunk and pelvic ("core") muscles or weak legs, delay pointe work (and consider implementing a strengthening program).
• If the student is hypermobile in the feet and ankles, delay pointe work (and consider implementing a strengthening program).
• If ballet classes are only once a week, discourage pointe training.
• If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training.

Prospective point dancers can benefit from a focused musculoskeletal screening examination, and the great team at Childrens Hospital of Kings Daughters has a nice visual which illustrates some of the following:

• Measuring range of motion of the ankle, foot and especially the great toe. 
  • Limitations in great toe range of motion can lead to injuries not only in the foot, but at the ankle and knee
  • The Pencil Test can measure foot plantarflexion
  • Loose tissues on the outside of the ankle, often from past ankle sprains, may not be able to handle the stresses of pointe leading to fractures of the talus (lower ankle bone) or 5th metatarsal bone on the outside of the foot
• Assessing strength and endurance of the "proximal" structures (hip, buttock, quadricep and hamstring muscles) where weakness leads to abnormal stresses on the inside of the knee, shin, and foot/ankle
  • The Airplane Test has been associated with readiness for pointe work
  • Single leg squat alignment, where hips, kneecaps, and 2nd toe should all stay in line, is a great measure of that proximal strength
    • Collapse of the knee inward, excessive internal rotation of the shin, or significant collapse of the arch/rolling in of the foot are problem findings that should be addressed before starting pointe.
• I also like to put dancers perform plie in 2nd position- ideally inside of knee should be lined up over 2nd toe with minimal rolling in of foot. 
  • Inability to maintain this alignment is another problem area that should be addressed before starting pointe.
• If there is any history of past injury, the dancer should have completed a full rehabilitation program culminating in unrestricted return to dance before contemplating pointe work. 
  • The biggest risk to future injury is under-rehabilitated or lingering past injury

In any type of injury prevention and readiness assessment, communication is the name of the game. The results of a thoughtful medical and musculoskeletal assessment from a dance medicine specialist can be discussed with instructors and this collaboration is a wonderful medium to best prepare a young dancer when she is ready for pointe work.