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Functional criteria for assessing pointe-readiness.

The question "When should a dancer begin training en pointe?" is frequently asked of ballet instructors and dance medicine professionals. (1) Little is known about the health implications associated with pointe training, but millions of children take dance lessons every year with the expectation of one day rising onto pointe. A literature review revealed very few evidence-based studies related to the physiological requirements for successful participation in pointe training. In the interest of addressing this void we undertook the present study to determine how students' performance on simple functional motor tests correlates with their teachers' decisions regarding when to begin pointe work.

In the literature, three factors have traditionally been considered reasonable criteria for readiness to pursue pointe training: chronological age, years of training, and ankle plantar flexion range of motion. We propose there are additional factors related to dancer functioning that are also important to consider, including lower extremity strength, neuromuscular control, and skill acquisition as described below.

Traditional Factors Chronological Age

Pointe work traditionally begins just prior to or during the onset of the adolescent growth spurt, at approximately 9 to 15 years of age. (2-3) Ballet dancers typically mature at the later end of this age spectrum (4-5); thus, chronological age alone seems an unreliable method for determining skeletal maturation, not to mention the physical and cognitive skills needed for pointe work. Nevertheless, in a survey of dance institutions across the United States, 96% of respondents identified age as the primary prerequisite for beginning pointe training (with 39% specifically citing age 12). (6)

Puberty is defined as the stage in human development when maturation occurs, in terms not only of physical growth but also the attainment of cognitive and psychosocial skills. (2) During this time, extra-uterine growth and biomechanical markers of bone turnover are at their peak, (2,7) and clinically significant adaptations in strength, flexibility, and proprioception occur that influence both motor control and psychological state. (5,8,9) Of particular significance in the context of this study, there is a decrease in motor ability and dynamic balance during adolescence resulting from the sensorimotor system's adjustment to rapid growth changes10; muscles may need to produce up to 30% more force in order to yield the same amount of bodily acceleration that occurred during the pre-growth spurt. (9)

It has been previously reported that during the pubertal years dancers cannot rely on formerly learned motor patterns. Instead, a period of adjustment for reacquisition of skills, both cognitive and physical, occurs due to the rapid growth-related changes taking place in the body. These rapid changes may raise safety concerns related to the young dancer's level of neuromuscular control relative to that which would be considered optimal for pointe work. There is tremendous variability among adolescent dancers with regard to musculoskeletal attributes, growth factors, and psychometric competencies, as well as socio-cultural features unique to each student's home environment and training exposure. (8,10-13) Thus, a central premise of this study is that a full array of health factors should be considered above and beyond chronological age when determining progression to pointe training.

Years of Training

Most dance educators and healthcare practitioners would agree that dancers need a minimum of 3 to 4 years of ballet training before they can acquire the technical skill and motor control necessary to begin pointe work. (14,15) In a study by Meck and colleagues,6 92% of surveyed dance school personnel used number of years of ballet training as a determinant for pointe participation. However, because duration of training does not necessarily produce a standardized level of proficiency among dance students, we suggest that objective indicators of readiness for pointe work based on individual performance outcomes should be used.

Ankle Plantar Flexion Range of Motion

Many dance medicine experts acknowledge that an important criterion for pointe-readiness is a supernormal range of ankle joint motion. (1,19,20) Professional women ballet dancers possess an average of 113[degrees] of ankle plantar flexion, compared to 48[degrees] among persons in the general population,16 and adolescent dancers have been reported to possess 10[degrees] to 20[degrees] more plantar flexion than age matched non-dancers. (1,4,17,18) Without this available range of plantar flexion dancers may compensate by coming out of neutral foot alignment into a "winged" (subtalar and mid-foot eversion) or "sickled" (subtalar and mid-foot inversion) position while en pointe, thus exposing the ligaments and tendons of the foot and ankle complex to increased stress loads. Several studies report an increased incidence of posterior ankle pain and injury among dancers who attempt pointe work without adequate ankle plantar flexion. (1,19,20)

Present Study Factors Lower Extremity Strength and Neuromuscular Control

The importance of pelvic and trunk stability for proper lower extremity (LE) kinetics and kinematics is becoming increasingly clear as research emerges. Stabilization of the trunk and pelvis through activation of the core musculature has been identified as necessary for proper initiation of LE movement. (21) There is evidence that hip abductor and external rotator muscles, in combination with trunk control, are responsible for maintaining a level pelvis and preventing femoral adduction and internal rotation during single leg stance. (22,23) As the base of support narrows, for example during releve en pointe, the dancer will rely increasingly on proximal control to maintain proper vertical alignment and balance. Weak or fatigued hip abductors have been associated with increased postural sway and subtalar joint inversion during single leg stance, which can leave the dancer vulnerable to inversion ankle sprain. (22,24,25) Hence, one can logically speculate that muscular strength and endurance of the hip abductors is important for safe participation in pointe training.

In addition to proximal muscle strength, pointe work beginners must have adequate strength at the ankle in order to control the large range of ankle motion they possess. (4,16,18) Among persons in the general population, Lunsford and Perry26 established that the ability to perform 25 single leg heel rises is considered normal for human locomotion. Thomas and Parcell27 later found that the average number of single leg heel rises an adult dancer can perform is similar to the Lunsford and Perry sample. Thus, we propose that performance on the single leg heel rise test provides an objective measure of plantar flexion strength that may be telling in regard to a dancer's readiness for pointe training.

Skill Acquisition

The ability to control proper alignment and balance during dynamic tasks, such as turning and jumping, plays a critical role in prevention of LE injury. (28,29) Poor alignment and impaired balance performance are known risk factors for traumatic LE injury. (30,31) Balance-specific training has been shown to improve balance scores and decrease incidence of injury in athletes. (32,33) Testing adolescent dancers' ability to control their alignment and balance during such tasks as jumping, turning, plie, and passe releve thus seems reasonable for pointe-readiness assessment. (14,34,35)

In the present study, we set out to determine if a battery of functional tests that challenge dancers' strength, motor control, and technical skill could be used, alone or in combination, to effectively screen for readiness to begin safe and successful pointe training.

Materials and Methods Subjects

Thirty-seven pre-pointe students from two professional ballet training schools in New York volunteered for the study. All participants and their parents gave their informed consent to participate. The average age of the students was 12.3 [+ or -] 2.2 years (range: 9 to 17 years), and the average years of ballet training was 6.5 [+ or -] 2.4 years (range: 1 to 12 years). Thirty-three dancers were in a pre-professional track with 5.5 to 9 hours of ballet training per week, while the remaining four were in a community program with 1.5 to 3 hours of ballet training per week.

Procedures

The dancers were assessed for their performance on tests at several different functional capacity screening stations. Each station was supervised by a healthcare practitioner, and all evaluators graded students in a standardized fashion. The nine tests selected were designed to objectively measure key areas of motor activity, including abdominal and thigh muscular control, leg muscle strength, ankle joint range of motion, balance and turn ability, and dynamic LE alignment. Tests included the "Pencil Test,"20 Double-Leg Lower Test,36 Single-leg Bench Step-down Test,23,37 "Airplane Test,"38 Single-leg Saute Test, Passe-releve Balance Test,14,35 "Topple Test,39,40 modified "Romberg Test,"41 and Single-leg Heel Rise Test. (26,27) Each dancer's test result for each test outcome was categorized as a "fail" (1.0) or "pass" (2.0). The fail and pass criterion for each functional test is described below.

The students' dance teachers, who were blinded to the test outcomes, were asked to grade each student according to their personal perception of the student's technical skill and readiness to dance en pointe using a 4-point Likert-type scale, where 0 = poor and 4 = excellent.

[FIGURE 1 OMITTED]

Tests

"Pencil Test"

The Pencil test is a method for determining overall plantar flexion of the ankle-foot complex, as described by Novella. (20) The test is performed by having the dancer long-sit, while a straight-edge level or pencil is placed along the top of the dorsal talar neck. The dancer passed this test if adequate plantar flexion ([greater than or equal to] 90[degrees]) was detected as evidenced by the straight edge clearing the distal most part of the tibia just proximal to the malleoli.

Balance Tests

Dancers performed a modified "Romberg" test by assuming a single-leg parallel stance with arms crossed and eyes closed. (41) 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.

In accordance with the recommendation of Luke14 and Khan,35 we measured the dancer's ability to perform a single leg balance while maintaining passe-releve. To obtain a passing score dancers needed to maintain a neutral position of the pelvis while in full retire of the gesture leg and full releve on a straight support leg.

"Topple" Test

In a study by Lopez-Ortiz,39 unskilled and skilled dancers were compared on their ability to perform single and double pirouette en dehors from fourth position. In the present study subjects passed this test if they were able to perform a single pirouette with the gesture leg in full retire and the support leg fully extended, while maintaining a vertical trunk and demonstrating a controlled, decelerated landing. (40)

Double-Leg Lower (DLL) Test

The DLL test is described by Kendall36 as an objective way to evaluate abdominal strength, and has been shown to have good inter-tester reliability. (42) The test is performed while the dancer is lying supine in a pelvic neutral position with both legs flexed to 90[degrees] 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 LE's at which the pelvis begins to tilt anteriorly, and a strength grade is assigned based on that angle. (36) The dancer passed this test if her LE angle was less than or equal to 45[degrees] from the floor when pelvic motion occurred.

Single-Leg Step Down (SLSD) and "Airplane" Tests

The SLSD and "Airplane" tests assess neuromuscular control of the LE. (23,37) During the SLSD test, the dancer assumes a single-leg stance on a nine inch step and plies on the standing leg, attempting to touch the heel of her opposite foot to the ground. Dancers who demonstrate a pelvic drop, hip adduction, hip internal rotation, knee valgus, or foot pronation receive a grade of "fail." "Pass" is defined as the ability to perform at least four out of five plies while maintaining neutral LE alignment.

The "Airplane test," as described by Liederbach,38 is an advanced version of the SLSD. In this test, the trunk is pitched forward and the non-support leg is extended to the back, keeping the pelvis square to the ground (Fig. 1). The subject performs five controlled plies while horizontally adducting the arms in order to touch the fingertips to the ground. The Airplane test is assessed with the same criterion as the SLSD test; "pass" was defined as at least four out of five plies maintaining neutral LE alignment.

Single-Leg Saute Test

Dynamic trunk control and LE alignment were assessed during 16 consecutive single-leg saute jumps. The dancer was graded on the ability to maintain a neutral pelvic position, upright and stable trunk, neutral LE alignment, proper toe-heel landing, and fully extended knee and pointed foot while in the air. "Pass" was defined as at least 8 out of 16 properly executed jumps.

Single-Leg Heel Rise 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 releve 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.

Data Analysis

A multivariate analysis of variance (MANOVA) was used to evaluate the effect of the independent variables (chronological age and years of dance experience) on the dependent variables (functional test outcomes) in relation to teacher classification of pointe-readiness. The F statistic and associated p value of the Wilks' Lambda variance ratio was used to test whether there were differences between the age and experience group means on the combination of dependent variables. The level of significance was set a priori at 0.05. Univariate tests identified which variables reached significance, and pair-wise comparisons of those variables were examined to determine differences between the age and experience conditions in order to identify which comparisons were significantly different from one another. Data were sorted by age (<12 or [greater than or equal to] 12) and by number of years of dance training (< 7 or [greater than or equal to] 7). All data were analyzed using SPSS v. 10 statistical software (SPSS, Chicago, Illinois).

Results

When the entire battery of nine tests were analyzed together using MANOVA to correlate teacher classification for pointe-readiness with dancers' age or experience, statistical significance was not achieved. However, a trend toward significance (p = 0.068) was seen for the effect of experience, such that the less experienced dancers were correctly classified as not ready for pointe training by their dance teachers. When each of the functional tests was looked at independently, three of the nine tests were significantly predictive of teacher classification for pointe-readiness as follows: dancers with the most years of experience who the teachers classified as ready for pointe training performed significantly better on the Saute test (p = 0.05), and dancers with the least years of experience who teachers classified as not ready for pointe training performed significantly worse on the "Airplane" test (p = 0.04). Differences were also found with respect to age, such that younger dancers who performed significantly worse on the "Airplane" test (p = 0.05), Saute test (p = 0.01), and "Topple" test (p = 0.01) were correctly classified as not-ready for pointe training by their dance teachers (Table 1).

Discussion

The purpose of this study was to determine if objective functional tests that assess muscular strength, neuromuscular control, and dance skill could aid the dance teacher, dancer, parent, and healthcare practitioner in determining a student's readiness for pointe training. Our data indicate that three functional tests that assess trunk control and dynamic LE alignment can beneficially be used to complement teacher subjective assessment.

The tests that were found to be predictive of teacher ranking were the "Airplane" test, Saute test, and "Topple" test. The "Airplane" test was the most sensitive for distinguishing between dancers identified by teachers as ready or not-ready for pointe work. The test's horizontal positioning of the trunk and visual field demands significant control not only of the tri-planar motion during the plie, but also of the long lever arm of the trunk and leg in the sagittal plane--a fundamental, dance-specific technique requirement.

The Saute test proved to be the strongest predictor of pointe-readiness classification overall, such that while younger and less experienced dancers did not have the strength and control needed to perform the "Airplane" test, the more experienced dancers could complete more jumps while maintaining proper trunk control and LE alignment and were most often classified by teachers as ready to successfully perform pointe work.

The "Topple" test was also closely correlated with the teachers' assessments of pointe-readiness, a finding that supports the prior work of Lopez-Ortiz,39 who found that skilled dancers possessed a greater ability than their lesser skilled counterparts to control the "toppling effect" of a turn by exhibiting greater acceleration, less head movement and body sway, and longer landing phases.

The findings from this study support the assertion that specific dynamic tests of function are effective in determining the adequacy of postural control, joint stability, and muscular power deemed necessary for successful progression to pointe work. (43) Tests that require dance specific postures and tasks allow the examiner to test integration of strength, control and alignment that express technical accuracy specific to the classical dance artform. (12,14) The tests that proved significant in this study assess the dancer's ability to maintain neutral alignment and center of mass over the base of support while doing complex movement.

There is growing evidence in the sports literature that core and LE control predicts which athletes will experience injuries. (24,25,28,44) Future studies should examine whether there is any relationship between performance on these pointe-readiness tests and injury occurrence.

Conclusion

Findings from this study indicate that three functional tests that measure dynamic core and LE control proved to be good indicators of pointereadiness. Although single screening tests are never foolproof determinants of success or risk, they may provide general benchmarks that promote wellness and enhanced performance. The outcome of these screening tests may be used along with the dancer's chronological age and maturity status, years of experience, medical history and commitment to dance to guide parents, school administrators, and healthcare practitioners in determining a dancer's readiness to participate in pointe training.

Key Points

Dancer

Dancers should bear in mind that dancing en pointe successfully requires a high level of core and LE control.

Dance Teacher

Dance teachers and artistic staff" are encouraged to include the three simple functional tests described in this study when considering which students may be ready to advance to a higher level class that includes pointe work.

Dance Scientist

Additional research in this area is needed. Specifically, it would be useful to know if and how proficiency in these functional tasks and ranking by teachers correlate with injury occurrence.

Healthcare Professional

Doctors and other healthcare specialists working with young dancers can benefit from including functional criteria, such as the tests described above, in their assessments of dancers' ability to handle the physical demands of dancing en pointe.

Acknowledgments

The authors would like to thank the staff of the Harkness Center for Dance Injuries at the NYU Hospital for Joint Diseases and the faculty and artistic teams at Ballet Hispanico and Dance Theatre of Harlem for their administrative assistance during this study.

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Megan Richardson, M.S., A.T.C., Marijeanne Liederbach, Ph.D., P.T., A.T.C., C.S.C.S., and Emily Sandow, P.T., D.P.T.

Megan Richardson, M.S., A.T.C., Marijeanne Liederbach, Ph.D., P.T., A.T.C., C.S.C.S., and Emily Sandow, P.T., D.P.T., are at the Harkness Center for Dance Injuries, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Megan Richardson, M.S., A.T.C., NYU Hospital for Joint Diseases, Harkness Center for Dance Injuries, 301 East 17th Street, New York, New York 10003; megan.richardson@nyumc.org.
Table 1 Pairwise Comparisons

                                 Teacher -

                                   Age

                                     [greater than or
                                    equal to] 12 years
                < 12 years (N=9)          (N=12)         p value

Tests          mean ([+ or -] sd)   mean ([+ or -] sd)
PF ROM         1.667 (.500)         1.833 (.389)         .276
DLL            1.111 (.333)         1.250 (.452)         .446
SLSD           1.111 (.333)         1.333 (.492)         .367
Airplane       1.000 (.000)         1.417 (.515)         .054 *
Saute          1.000 (.000)         1.583 (.515)         .008 *
Topple         1.111 (.333)         1.750 (.452)         .006 *
Heel Rise      1.778 (.441)         1.583 (.515)         .556
Passe Releve   1.333 (.500)         1.583 (.515)         .385
Romberg
  ([dagger])
                                 Teacher +

                                   Age

                                     [greater than or
                                    equal to] 12 years
                < 12 years (N=6)     > 12 years (N=10)   p value

Tests          mean ([+ or -] sd)   mean ([+ or -] sd)
PF ROM         1.833 (.408)         1.900 (.316)         .820
DLL            1.167 (.408)         1.500 (.527)         .158
SLSD           1.500 (.548)         1.500 (.527)         1.000
Airplane       1.167 (.408)         1.600 (.516)         .122
Saute          1.333 (.516)         1.500 (.527)         .625
Topple         1.667 (.516)         1.700 (.483)         .858
Heel Rise      1.667 (.516)         1.600 (.516)         .886
Passe Releve   1.500 (.548)         1.900 (.316)         .084
Romberg
                                Teacher -

                               Experience

                                     [greater than or
                                    equal to] 7 years
                 < 7 years (N=9)          (N=12)         p value

Tests          mean ([+ or -] sd)   mean ([+ or -] sd)
PF ROM         1.889 (.333)         1.667 (.492)         .187
DLL            1.222 (.441)         1.167 (.389)         .610
SLSD           1.111 (.333)         1.333 (.492)         .367
Airplane       1.000 (.000)         1.417 (.515)         .054 *
Saute          1.111 (.333)         1.500 (.522)         .149
Topple         1.222 (.441)         1.667 (.492)         .098
Heel Rise      1.889 (.333)         1.500 (.522)         .097
Passe Releve   1.333 (.500)         1.583 (.515)         .385
Romberg
  ([dagger])

                                 Teacher +

                                Experience

                                     [greater than or
                                    equal to] 7 years
                 < 7 years (N=7)           (N=9)         p value

Tests          mean ([+ or -] sd)   mean ([+ or -] sd)
PF ROM         1.714 (.488)         2.000 (.000)         .129
DLL            1.429 (.535)         1.333 (.500)         .870
SLSD           1.429 (.535)         1.556 (.527)         .581
Airplane       1.286 (.489)         1.556 (.527)         .589
Saute          1.143 (.378)         1.667 (.500)         .050 *
Topple         1.429 (.535)         1.889 (.333)         .109
Heel Rise      1.714 (.488)         1.556 (.527)         .668
Passe Releve   1.714 (.488)         1.778 (.441)         .713
Romberg
  ([dagger])

* Significant findings; ([dagger]) Statistics could not be
calculated due to insufficient cell distribution.
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Title Annotation:Original Article
Author:Richardson, Megan; Liederbach, Marijeanne; Sandow, Emily
Publication:Journal of Dance Medicine & Science
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2010
Words:4864
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