Physical Therapy Performace Perspectives Podcast
Pre-Pointe Rediness by Maribeth Crupi
Why is it important to assess for pointe readiness?
- It provides an opportunity to possibly prevent injury
- Allows me to determine if there are areas of muscle weakness, muscle or joint tightness, excessive ligamentous flexibility (ligaments attach bone to bone and we want those to be tight), or postural deviations both in static standing and during movement transitions; all of which with my background as a physical therapist I have the opportunity to offer advice on and exercises to correct
- Provides an opportunity to educate dancer, parent and teacher, so it really goes beyond the just determining do they do or don’t they rise on pointe, allows them to really understand their dancer’s body
- Allows an objective means for the dancer to understand why they are or may not yet be ready to progress to this discipline. I am able to educate a dancer in my screening process in a manner where they can see how they may be struggling to meet a necessary movement, balance, or strength milestone. I explain that I am first and foremost committed to keeping them healthy, and it is a win/win situation, as the vast majority of advice I will give to promote optimal musculoskeletal health, also translates to improved dance technique. It is so much easier for the dancer to understand why more time is needed before they progress to pointe work when they can see or feel what it is they need to improve on and at the same time when they are given a means to work on their areas of need, they most often are not nearly as disappointed with the wait.
- Helps dancer (and parent) to understand why all dancers in a class do not necessarily rise on pointe at the same even if they have been training together for a number of years. In some instances, it may be that I have to give the advice that pointe work may not be a discipline they should pursue. While I don’t enjoy it, I am comfortable with being the one to have to share that message (thankfully not frequently) as I am referencing it around my concern for their health and that is usually much better received than potentially being told by their dance teacher they are not ready or able, which often gets translated to “I am not good enough.”
What elements do you include in a pointe-readiness screen?
- General health history, including menstruation (which we know is often delayed in dancers training intensely), nutritional habits, Vitamin D levels and this can offer a potential snapshot into the bone health of the dancer. For those listening who are not health care providers, it is important to understand that even if you have a calcium rich diet, if you do not have enough Vitamin D in your system, then you are not able to utilize the calcium you take in. Given the demands and forces being placed particularly on the lower limbs I want to be sure they may not be susceptible to boney stress injuries.
- What their aspirations are for dance/why pointe work…if they are not interested in pursuing pointe work as a long term goal, I remind them that they will be placing a lot of demands on their body and they should be sure they want to take on this rigorous discipline with that in mind.
- Ballet training history at least 3-4 years of training, at least 3 ballet classes/week
- Posture – position of feet, pelvic position, ribs, shoulders, head in midline
- And then I am looking at their ability to maintain adequate posture with dance gestures or movements
- Just observing how a dancer moves into a position of single leg balance in flat may start revealing any areas of weakness. For example are they clenching the floor with their toes, are their ankles wobbling, is their pelvis staying level.
- What is their hip external range of motion? The hip is where they should be deriving the vast majority of their turnout from. Is their active hip external rotation motion markedly less than what I can attain when I move the hip into its fullest range. If so, then exercise will be very helpful in their accessing fuller turnout safely.
- I assess for adequate ankle point and plie depth range of motion. You need adequate plie depth to absorb the shock of jump landings, and then certainly without enough pointe ROM the dancer will not be able to get fully on the toe box of their shoe. The “pencil test” is a great visual where a pencil is place on the top of the ankle, and if it lies flat the dancer has adequate point range.
- Strength assessment of core and lower extremities. Including passing basic milestones such as performing 20-25 single leg heel raises with ease and excellent midline position of the ankle, demonstrating 10 repetitions of single leg demi plie with level pelvis and vertical alignment of hip/knee/and foot.
- Ability to single leg balance with eyes closed w/o the legs touching
- 8 single leg sautes with optimal form
- the ability to perform a single pirouette from 4th position with optimal form and clean finish
- There are a number of specific tests that These and some other specific tests can be found in a wonderful research paper authored in the Journal of dance Medicine and Science by Megan Richards, MariJean Liederbach and Emily Sandow which offers research driven milestones for pointe readiness. Journal of Dance Medicine & Science Volume 14, Number 3, 2010
What are some common weaknesses that you see in young dancers that inhibit them from going up en pointe?
- Glute med w/compensatory over-activation of QL which prevents them from maintain adequate pelvic position
- Lower abdominal weakness which often means the are over strategizing at their ankles and feet and struggle to maintain balance in eleve, let alone on the tiny box of a pointe shoe
- Large posterior buttocks muscle weakness, the gluteus maximus, which contributes to tightness of hip flexors and in turn contributes to the dancer likely having a forward tilted pelvis
- Ankle weakness outer ankle muscles in particular which places them at risk for lateral ankle sprains in particular…sometime foot type will contribute to this. Dancers with sharply tapered toes will often face a greater challenge than those with a square foot type
- Improper balance and weight shift…for a PT this is simple physics, if the dancer doesn’t learn to balance on that single limb maintaining level pelvis and trunk placement, then everything becomes more challenging. That cascades into muscle strain and overuse which overtime usually becomes a painful condition.
Do you have suggestions as to how to make a dancer physically and technically stronger so that they are ready for pointe work?
- First of all, we as healthcare providers need to share our knowledge and open up as many opportunities to educate dance teachers on how to best prepare these developing bodies for dance
- Intrinsic foot work is so important, but I still find so lacking in dance training…getting those 4 layers of muscles that start and end in the foot only, “The intrinsic foot muscles, ”properly strengthened and engaged not only will add to improved balance and sense of grounding), it can help protect the foot in the pointe shoe as the toes will stay longer and stronger and potentially reduce the “snarly feet” that in the past have been considered the badge of pointe work. (Healthcare providers listening can look to the more recent work of Patrick Mackeon for this
- Along those lines, since most dancers are rising during adolescence they really need to work on balance and weight shift, as with their rapid growth during this time, balance is easily challenged by their center of balance moving further away from the floor and muscles becoming stiff as they elongate to meet the growth of the long bones of the limbs.
- Challenge their balance by performing SLB exercises on slightly unstable surfaces and adding leg or arm gestures, balance on one leg while you are brushing your teeth, studying for school, etc.
- Local cores stability work is so important. In my practice we use the Australian Physiotherapy Pilates approach with all our dancers and patients in general to assure that all exercises we teach start with a stable and engaged group of deep core muscles
- Dedicated ankle strengthening and be sure to specifically strengthen the deep calf muscles, too often dancers will do heel raises and strengthening only with their knees straight, they need to strengthen with a bent knee as well
- Hip girdle strengthening with exercises such as simple clams
- Do not force turnout and make sure some of your exercises have you turning in too!
- Cardio (fatigue is a precursor to injury)
- Proper nutrition and hydration
- Proper warm up and cool down
What are some of the consequences of putting a dancer up on pointe too early?
- Overuse injuries- FHL, Achilles, posterior impingement, potential bony stress injuries
- If they are hypermobile w/o adequate strength and stability they are at even greater risk of injury
- Psychologically can be damaging as they will really struggle to progress
At what age or level do you start screening dancers for pointe-readiness?
- Dancers from conservatory programs are often coming at 11-12 years of age
- those from recreational studios tend to be coming 12-14 years of age on average
- the difference is usually related to the amount of ballet training they have had
- one thing to keep in mind, is that chronological age and physiological age may differ significantly. In other words you may have a dancer who is 14 but not yet menstruating and is physically at a developmental level of a 12 year old.
- Age, within reason of course, is not as significant as the ability to demonstrate meet the milestones we have already discussed.
Are PTs the only people who can screen a young dancer for pointe shoe readiness or can a dance teacher perform this assessment?
- I feel a collaborative approach can best. If you think about it, dance teachers have been placing dancers on pointe a lot longer than PTs! But certainly now with the benefit of organizations such as IADMS, and the growing body of research in dance medicine, there is a greater base of knowledge to allow for the safest progression to pointe work. While a dance teacher can certainly be trained to make the observations and learn how to spot “red Flags with regard to suboptimal movement or posture, they likely do not have the knowledge of anatomy and kinesiology (the study of human body movement) to allow them to make the best recommendations for correcting technique faults rooted in musculoskeletal weakness or the unique anatomical features of a particular dancer. For example, sometimes a dancer will have a twisting (called a torsion) of their lower leg bone, the tibia. Thus the foot of that dancer may be slightly turned out due to that bony change. If a dance teacher instructs that dancer to stand in parallel position based on the position of their feet and not their hips and knees, they will in essence have them standing with a turned in hip. At the same time, the components of artistry needed for best execution of pointe work are often best taught by the dance teacher, who has the wonderful vocabulary necessary to create the beautiful movements we see in the classroom or on stage. I am fortunate that I have a number of dance teachers who as they are preparing their students for pointe work will refer them to me for further screening if they have any concerns. This allows me to determine more specifically where the difficulty may lie and create an exercise program or recommendation to the teacher that will allow the milestone needed to be met. I truly have only found dance teachers to be hugely receptive and appreciative of the knowledge I can offer and I appreciated learning from them as well. I feel it is a missed opportunity to expand the knowledge of best dance practice if we do not try to do this in a collaborative manner. Right now I am fairly certain there are many more dance teachers than physical therapists who specialize in dance, so we need to make this information more universal.
If there was one thing you could tell young dancers about going up on pointe, what would it be?
It is an individual process and to transition to this discipline with the greatest joy and ease they need to meet the proper milestones for this discipline. Do not be discouraged if one of you peers rises en pointe before you. For both best health and best dance practice you should progress to this discipline based on your individual strengths and objective measures. To quote George Balanchine: There is no reason to get a young dancer on full pointe if she cannot do anything when she gets there.”
Tell us your favorite story of treating a dancer.
- Sure, as a prelude I will offer that I frequently say to my patients that my goal is to put myself out of business! In other words, I want the dancers to become so knowledgeable about how to care for themselves, that they do not feel they need to rely on me to stay well. I get great satisfaction from stories dancers share of how they used the knowledge I offered them to overcome a problem or painful condition. I will share two quick examples
- I treated a pre-professional ballet dancer who was extremely hyper mobile and we had worked through a number of injuries over two years due to her weakness combined with her hyper mobility. She finally was pain free, strong and attending summer program at CPYB. She emailed me twice during her intensive. Once to share how frequently she was complimented on her strength, and then again to say she was complimented for best demonstrating how to stay out of knee hyperextension. This was particularly gratifying, as I know I drove her crazy correcting that in session, and more importantly it was exciting to now hear that from the artistic end they were also concerned about the dancers not hyperextending as well!
- Then one of my patients who is a multi-disciplinary dancer was at a dance competition. She was having some stiffness in her ankle and did not have her theraband to do the self mobilization I had taught her, so she improvised with a pair of tights! I thought that was really inventive and now share that advice with other patients in a pinch. But even better, that same day this dancer was watching another dancer getting ready to perform and she was struggling taping her ankle. The first dancer knew the technique as I had taught it to her for a prior ankle sprain. As she was helping the second dancer apply the tape, they came to discover they were both my patients. It was so gratifying to see the trickle down of learning and sharing from one of my patients to another!
Take care, Marissa and Jenna