Sage Journals: Discover world-class research

Abstract

Introduction: There is an increased injury risk during pointe training if dance students are not physically or technically prepared. The objective of this study was to find consensus between dance experts pertaining to the most reliable screening protocols when determining pointe readiness in young adolescent female dance students. Methods: Dance experts (10+ years of professional dance (pointe) experience/teaching pointe experience/clinician to dancers), were recruited through multiple dance teacher/science groups on social media. The Delphi method was utilized via Online Surveys and distributed in rounds until consensus was found. Questions were created, and subsequent rounds were devised based on analyzed data from the previous round. Descriptive and thematic analysis was used to collate, rank, and analyze data. Consensus was determined at 60% agreement between the dance experts’ answers. Results and discussion: Fifteen dance experts completed Round 3 with 80% consensus. The most important physical attributes were ankle alignment, pelvic stability, ankle strength, ankle stability, and lower limb alignment. Screening measures consisted of medical history, teacher assessment, heel raise test, single leg plié, plantarflexion. Functional skills tests were heel raise test, single leg sauté, holding passé relevé on demi-pointe, balance, and pencil test. All agreed that teacher assessment is more reliable than a test battery. Overall, responses corresponded with statistically significant evaluators yet were not conclusive. Conclusion: Contradictory responses meant providing reliable outcomes to the objectives was challenging. Further research projects are needed to indicate any association between testing and teacher assessment for pointe readiness.

Keywords

adolescent/children/pediatrics ankle/foot assessment ballet dance education dance science dance screening injury dance training

Key Points

Currently, there is no mandatory screening for determining dancers’ readiness for pointe.

Physical attributes, screening, and use of skills tests can provide insight into readiness, but may not be an accurate representation of readiness.

Research conducted to date has found some tests significantly better than others, but limitations of their methods’ design decrease the reliability.

Introduction

Classical ballet has an established historical tradition as a dance genre, with evidence of dancing en pointe dating back to the Renaissance.¹ Dancing en pointe is a progression in classical ballet training where dancers transition to a more advanced level of training that includes wearing pointe shoes (comprised of a leather sole/shank and a hard, flat-ended toe box, covered in satin)² that allow dancers to dance and balance on the toe ends³. This transition, for mainly female classical ballet students, usually occurs during early adolescence,^1,4
-10 coinciding with pubertal growth, and can potentially cause growth plate arrest in a dancer’s toe.⁷ The transition from soft ballet shoes to pointe shoes should be progressive and tailored to each dance student,¹¹ taking into account the vulnerabilities observed during pubertal growth.^10,12 Dancing en pointe places around 13 times the body weight of force on the ankle^13
-16 with approximately 150 N/cm² on the toes en pointe compared to 41 N/cm² barefoot.¹⁷ Bone strength is therefore important to cope with these stresses. In the general population the ossification centers in the epiphysis have closed,⁸ around 12 years of age,^1,4
-9 though complete ossification is not attained until 20 years old. Therefore, it would seem beneficial to wait until at least the epiphysis have closed before pointe training commences. Ossification could be delayed in pre-professional female dancers as their delayed menarche has an effect on bone health and development.^18,19

Physical factors that constitute readiness for dancing en pointe include foot strength, ankle range of motion, and stability and control whilst rising and lowering onto and from pointe.^8,20,21 These attributes are required to withstand the stress of pointe work on the body, particularly the ankles and feet.²² Posterior ankle impingement and ankle sprains are common in dancers en pointe, possibly associated with premature initiation of pointe training.^14,23
-25 Some reports have suggested that persistent plantarflexion trauma occurring in under-developed bones of young dancers can prevent the closure of ossification centers.^23,26,27 Moreover, young adolescent dancers who spend sixty minutes or longer a week en pointe have an increased incidence of foot and ankle tendinopathy and back injuries compared to those who do not;²⁸ with Leanderson et al²⁹ finding episodes of stress fractures in the metatarsals from dancing en pointe,²⁹ as reduced ROM can cause stress fractures in dancers who “over point” the feet en pointe.^30,31 Articles have suggested that pointe training should be discouraged in those dancers involved in one dance class a weak or have reduced range of motion (ROM) of the ankles and feet,⁹ as it is indicated that dancers who engage in more lessons may have a greater proprioceptive ability to cope with pointe training.^4,8,32

It is recommended that dancers are screened pre-pointe to determine their readiness for dancing en pointe, and this process should determine those dancers with the capability of advancing to pointe work. Richardson et al⁵ maintain that the most significant functional test for pointe readiness is the airplane test, with relevé and pirouette tests also being relevant indicators.^5,10,20 Attempts have been made to provide practitioners with assessment tools for pointe-readiness; however, chronological age is still the most common guideline used by teachers,¹ though others do incorporate some physical tests. Currently there is no mandatory regulation system for dance teachers and institutions to ensure pre-pointe evaluative screening measures.¹ Using the Delphi method, this study aimed to ascertain what screening methods best determine pointe readiness in young adolescent female dance students and what physical attributes are most important to transition safely to pointe.

Methods

The study employed the Delphi method, a research approach fitting for research questions that cannot be answered with objective certainty but rather by the subjective opinions of a group of experts.³³ The Delphi method was developed at the RAND Corporation in the 1950s;⁵ a systematic method to structure discussion and reach a consensus from a group of independent experts through evaluating responses over multiple rounds³⁴ (each round’s question formation is based on the analyzed answers from the previous round until a consensus is formed), and is beneficial when a topic cannot be empirically studied.³⁵ In addition, by performing the study online, turnover can be faster, and experts from multiple countries can participate. Consensus was set at greater than 60% agreement within the group.^36,37 This study was approved by the lead author’s institution.

Sampling and Respondents

A broad range of dance experts (dance teachers, choreographers, company directors, physiotherapists, lecturers, and exercise specialists) were recruited through dance-related groups on social media (Facebook). The respondent inclusion criteria included: published peer-reviewed research in dance or 10+ years of professional dance (pointe) experience/teaching pointe experience/clinician to dancers. The experts were asked to participate in an online survey (Online Surveys) consisting of three rounds.

Survey Process

Pilot study

A pilot survey was carried out to generate interest in the study and refine the design of the survey.³⁸ Six dance teachers were invited to participate, and the results led to a slight adjustment to the questions (Table 1) before Round 1 was initiated.

Table 1.

Delphi Survey Questions (Pilot and Round 1).

Question	Detail
1	Demographic information?
2	Profession and location?
3	Please list what methods best test and determine pointe readiness?
4	What age should dancers progress en pointe?
5	Please list what physical attributes increase risk of pointe-related injury?

Round 1

The first round was based firstly on screening methods to best determine pointe readiness in young adolescent female dance students and secondly on physical attributes linked to pointe-related injuries. Respondents were sent an Informed Consent form for completion, and the link to Round 1 of the survey was given to respondents on return. Round 1 was open for three months. The survey consisted of two closed questions (demographic information and, profession and location) and three open-ended questions (Table 1). Follow-up messages were emailed to the respondents weekly and every other day for the final seven days before the deadline.

Round 2

The open-ended answers from Round 1 underwent thematic analysis and specific variables were discerned based on the frequency of the topic and their implied importance (Supplemental Table A). Respondents were asked to indicate the importance between two variables, for example “Based on your expertise, is turnout more important than pelvic tilt?” with a yes or no response. All variables were placed against each other through a series of question reiterations to allow ranking to occur. The link for Round 2 was disseminated directly to respondents by email, and the time scale was set to 28 days.

Round 3

This round was a repeat of Round 2 questions with the addition of the frequency of yes or no responses from all respondents and their own response from Round 2. The respondents were allowed to adjust their answers given in Round 2 in this round if needed. The link was distributed directly to respondents by email.

Data analysis

Once all data for each round was received, groups were categorized accordingly: dance practitioners, dance teachers, choreographers, professional ballet dancers, lecturers, and company directors; health professionals, physiotherapists, clinicians, doctors, and exercise specialists. The open-ended questions were thematically analyzed based on frequency and importance of variables related to screening methods and physical attributes³⁹ initially by the primary researcher (KHC) and reviewed by the other research team members (MW and NK). The data were grouped and formulated in Microsoft Excel (Version 16.76). The consensus was set at greater than 60% agreement by respondents.^36,37

Results

Pilot Study

Four out of the six invited respondents completed the pilot study. All respondents (n = 4) were female dance teachers in the private sector, aged above 30 years old, educated to a postgraduate level (dance) and located in Europe. Answers from all four respondents presented sixteen methods to determine pointe readiness and ten physical attributes that increase the risk of pointe-related injury. All (100%) answers related to the questions asked; though it was noted that questions 3 and 5 required the addition of “please list” as the pilot answers saw respondents trying to add more than one method/attribute per space provided.

Round 1

Twenty-nine people expressed interest in the survey; twenty-three respondents logged onto the online survey; one participant agreed to the survey but provided no further answers, so was discarded, and one participant input the same answers twice. The duplicate response was removed from analysis (as the survey was blinded, it was deduced that both entries were the same person as all questions were answered with the exact wording within 5 minutes of each other); therefore, twenty-one surveys (n = 21) were included. The majority of respondents were female (n = 20); respondents were aged 50 to 59 years (n = 7), 31 to 39 years (n = 5), 30 years or younger (n = 3), 40 to 49 years (n = 3), and 60+ years (n = 3). Half (11/21) of the respondents were educated to postgraduate level, with the residual respondents to degree level (n = 6) or vocational dance teaching qualification (n = 4). Their professional backgrounds were divided into two main groups: teachers/lecturers (n = 11) and physical therapists/physiotherapists (n = 10). Lastly, most of the respondents were located in Australia (n = 10); the remaining locations included USA (n = 6), UK (n = 2), Greece (n = 1), South Africa (n = 1), Hong Kong (n = 1), and Canada (n = 1).

Thirty-seven physical attributes that increase the risk of pointe-related injury were recorded and thematically analyzed into six themes: flexibility, strength, alignment, stability, control, and medical (Table 2). Twenty-eight methods to test and determine pointe readiness were reported and thematically analyzed into five themes: flexibility, strength, alignment, tests, and behaviors (Table 2). Additionally, 52% of respondents (n = 11) reported the youngest age a dancer can progress onto pointe was 11 years old (33% age 12, 14% age 10, and 5% age 9).

Table 2.

Round 1 Respondents Responses—Best Methods.

Method to test and determine pointe readiness			Physical attributes associated with increased risk of pointe-related injury
Theme		Frequency (%)	Theme		Frequency (%)
Flexibility	Ankle flexibility	1 (5)	Flexibility	Plantar flexion	6 (29)
Strength	Ankle strength	1 (5)		Ankle	4 (19)
Alignment	Turnout	3 (14)		Hypermobility	4 (19)
	Pelvic Tilt	1 (5)		Dorsiflexion Minimum knee test 10 cm or <180º passive	3 (14)
	Functional performance	1 (5)		Dorsiflexion Minimum knee test 10 cm or <180º passive	3 (14)
	Foot shape	1 (5)		Gastrocnemius/soleus ROM (demi-plié restricted)	1 (5)
	Toe length	1 (5)		Gastrocnemius/soleus ROM (demi-plié restricted)	1 (5)
Tests	Relevé test—min. reps more than 20	10 (48)	Strength	Foot intrinsic muscle	7 (33)
	Relevé test—min. reps more than 20	10 (48)		Core	5 (5)
	Plantar flexion (180º medially)	9 (43)		Ankle	4 (19)
	Plantar flexion (180º medially)	9 (43)		Leg	2 (10)
	Teacher assessment	7 (33)		Hip	2 (10)
	Airplane	7 (33)		Overall	2 (10)
	Topple test	6 (29)		Calf	1 (5)
	Sauté test	5 (24)		Glute	1 (5)
	Holding passé relevé on demi-pointe	4 (19)		Grade 5 Kendal muscle test	1 (5)
	Single leg plié (pelvic control)	4 (19)	Alignment	Turnout	4 (19)
	Core strength—plank 30 seconds	3 (14)		Ankle/foot (pronation/supination)	3 (14)
	Core strength—plank 30 seconds	3 (14)		Foot/toe shape	3 (14)
	Tendu (toe strength)	3 (14)		Functional performance	2 (10)
	1st MTP range of 90º	2 (10)		Leg extension	2 (10)
	1st MTP range of 90º	2 (10)		Relevé	2 (10)
	Glute strength	2 (10)		Toe length	2 (10)
	Adductor strength	2 (10)		Lower limb (hip/knee/ankle)	1 (5)
	Medical/injury history	2 (10)		Lower limb (hip/knee/ankle)	1 (5)
	Grand Plié	2 (10)		Overall	1 (5)
Behavior	4 to 5 years previous dance training	5 (24)	Stability	Ankle	8 (38)
	4 to 5 years previous dance training	5 (24)		Core	2 (10)
	Student Maturity	4 (19)		Hip	2 (10)
	Attendance—3 classes a week	3 (14)		Pelvis	1 (5)
	Attendance—3 classes a week	3 (14)		Heel raise	1 (5)
	Pre-pointe training	3 (14)	Stability	Core	2 (10)
	Age 12+ years	2 (10)		Glute	2 (10)
	Age—not close to Peak height velocity	2 (10)		Hip	2 (10)
	Age—not close to Peak height velocity	2 (10)		Balance	1 (5)
			Medical	Underlying medical conditions	4 (19)
				Foot abnormalities	4 (19)
				Medical history (surgery)	2 (10)

Round 2

Seven respondents did not return for Round 2, leaving 14 respondents. A consensus was achieved in questions 1 to 12 and ranged from 64% to 100% agreement (Supplemental Table A). Additionally, the respondents ranked question 13 to 16 answers from Round 1 (physical attributes, screening tests, functional skills tests, and the tests they used personally to determine pointe readiness).

The top 5 ranked physical attributes for pointe readiness were ankle alignment, pelvic stability, ankle strength, ankle stability, lower limb alignment (NB: as experts provided the answers, it was conceived that alignment indicated bone alignment, stability the ability to keep the bones supported and hold positions, and strength to support and enable stability and mobility). Additionally, the top 5 screening tests were medical history (no recent injury), teacher assessment, heel raise test (>20 repetitions), single leg plié (pelvic control), and plantarflexion range 180° (measured medially). Furthermore, the top 5 functional skills tests were heel raise test, single leg sauté, holding passé relevé on demi-pointe, balance (modified Romberg test), and pencil test (180° plantarflexion). Finally, participants ranked the top 10 tests used personally to determine pointe readiness as heel raises, single leg sautés, holding passé relevé, pencil test/plantarflexion, grand plié, airplane, balance, teacher assessment, turnout (passive vs active), and core stability and strength.

Round 3

There was a return of one respondent for Round 3 (from Round 1) of the Delphi. This round was a repeat of questions from Round 2, where participants were offered the chance to review and adjust answers, yet all acknowledged they did not change their answers. However, it was noted that for questions 1, 2, 4, and 9 there was a slight increase in the conviction of response, and answers were more positive or negative (Supplemental Table A). Consensus was achieved in all questions, ranging from 60% to 100% agreement.

Questions 13 to 15 found that 80% of the respondents agreed with the top 5 ranked physical attributes for pointe readiness, screening measures, and functional skills test responses from Round 2 (Table 3) which contrasted with the ranked measures in questions 1 to 12 (Supplemental Table A).

Table 3.

Most Important Physical Attribute, Screening Measures, Functional Skills Tests for Pointe Readiness (Round 3).

Rank	Q. 13 Physical attribute	Q. 14 Screening measures	Q. 15 Functional skills tests
1	Ankle alignment	Medical history—No recent injury	Heel raise test
2	Pelvic stability	Teacher assessment	Single leg sauté
3	Ankle strength	Heel raise test (more than 20 reps.)	Holding passé relevé on demi-pointe
4	Ankle stability	Single leg plié (pelvic control)	Balance (modified Romberg test)
5	Lower limb alignment	Plantarflexion range 180° measured medially	Pencil test (180° plantarflexion)

When asked what tests they currently used for pointe readiness (Table 4), 80% of the respondents agreed with the ranked top 10 tests from Round 2; interestingly, there was a slight change in rank order of the top 10 tests between Round 2 and 3 with grand plié moving from fifth to tenth, core strength tenth to third, and teacher assessment eighth to fourth. However, when asked if the top 10 responses include the most important tests/assessments to determine pointe readiness, all respondents agreed that the list (Table 4) did not accurately represent pointe readiness assessment, and ultimately, all agreed that teacher assessment is more reliable than a test battery. Subsequently, respondents were asked what tests/assessments they would add to or take from this top ten list as a primary factor when determining pointe readiness. Their responses indicated that toe strength, full knee extension, ankle ROM, previous history, training year, peak height velocity, age, and maturity should be added, but grand plié and overall test battery should be removed. However, each change was suggested by only one respondent for each proposed test.

Table 4.

Round 2 and 3 Ranked Tests/Assessments Used by Dance Experts in Practice.

Q. 16 What tests/assessments would/do you use to determine pointe readiness?	Round 2 ranked	Round 3 ranked
Heel raises	1	1
Temps levé/single leg sautés	2	5
Holding passé relevé	3	6
Pencil test/plantarflexion	4	2
Grand plié	5	10
Airplane	6	7
Balance	7	9
Teacher assessment	8	4
Turnout (passive vs active)	9	8
Core stability and strength	10	3

Discussion

This study aimed to evaluate the views of dance experts on what screening protocols are most important and best determine pointe readiness in young adolescent female dancers. Consensus was achieved in Round 3 of the Delphi. Dance experts from this study agreed that ankle alignment, pelvic stability, ankle strength, ankle stability, and lower limb alignment as the top five most important physical attributes required for successful pointe training. Logic would suggest that dancers who do not have the required joint stability and muscle coordination to dance en pointe may be predisposed to musculoskeletal changes and injury. Pointe readiness tests determine when a dancer is “ready” to begin pointe training.^5,10,40 However, the validity and reliability of these tests are yet to be determined.⁵ Respondents from this study also found consensus that the best determinants of pointe readiness include medical history, heel raise, teacher assessment, single leg sauté, holding passé relevé, single leg plié, Romberg (balance), and pencil test (plantarflexion). Nevertheless, respondents’ consensus did not favor the topple test in any of the outcomes, despite studies suggesting it as a significant predictor,^5,13 and the evidenced airplane test was not in their top 5 tests.⁵

Respondents from this study agreed the pencil test (which measures plantarflexion by laying a pencil on top of a pointed foot at 180°) as the fifth most important screening measures and functional skills tests to best determine pointe readiness and was ranked as second in the tests used in practice. Although no literature supports the use of the pencil test as a statistically significant predictor of pointe readiness, there is theoretical underpinning to support that dancers require adequate 90° to 100° of plantarflexion at the ankle during relevé^1,10,14,41 for a successful transition to pointe. Therefore, the pencil test offers measurable means for determining adequate plantarflexion. However, it is worth noting that this “test” has no current validity and the respondents in this study favored relevé as more reliable over the pencil test; possibly due to relevé being active and involves moving the body mass of the dancer, rather than the passive range of movement of the pencil test, which may be a more reliable test for determining if a dancer has the physical range of movement in the ankle joint to be capable of training en pointe.

The consensus of the respondents from this study supports research by Schoene,⁶ DeWolf et al,⁴² Richardson et al,⁵ and Hewitt et al¹³ on the importance of heel raises, relevé, and abdominal strength tests. In addition, adequate strength, balance, and alignment of the lower extremities are essential.⁶ Meck et al¹ and DeWolf et al⁴² suggested that relevé endurance is the most frequently used musculoskeletal measure in pre-pointe screenings by dance and health professionals. However, there is no relevant research to indicate what number or duration of relevés delivered would quantify pointe readiness. DeWolf et al⁴² determined that students performing 15 relevés were “more likely” to be successful at pointe as they performed better statistically than pre-pointe students in the relevé endurance test. They also found a statistically significant difference (P < .01) between the number of relevés completed and successful pointe students.⁴² Additionally, Hewitt et al¹³ and Richardson et al⁵ suggested that heel raise and plank tests should be used supplementally for training purposes. It is important to note that relevés were seemingly expressed as heel raises by Hewitt et al.¹³ Heel raises (from flat, rise on the balls of the feet with 180° alignment at the ankle to hip) and relevés (starting in plié, snatching onto the ball of one foot with 180° alignment from ankle to hip, with the other foot in retiré position at the knee) are not the same, so stating relevés as heel raises leaves uncertainty surrounding these conclusions. Nevertheless, respondents from this study concluded that heel raises are more reliable than the sauté test (sixteen single leg sautés or hops with a pointed toe utilizing correct form for at least eight) and was ranked third in the top 5 most important screening measures, first in the top 5 most important functional skills tests, and first in the top 10 assessments used in their practice. Lastly, although holding passé relevé (holding and balancing in relevé position for a number of seconds) was not found to be a statistically significant test in past studies,⁵ dance experts from this study agreed it is more reliable than the topple test (single pirouette en de hors) and was third in the top 5 most important functional skills tests to best determine pointe readiness, and sixth in the top 10 assessments used in practice by dance experts. Shah⁴³ noted dancers should demonstrate appropriate levels of balance by completing passé relevé and holding without support. The lack of reported grading criteria for this test may be indicative of its unreliability. Therefore, value of both the heel raise and relevé tests are acknowledged. Additional research is required to substantiate findings behind all heel raise and relevé test studies.

Core strength and alignment^4,32 are considered requirements to perform en pointe successfully and safely. Interestingly, although claimed to be the most significant functional test for pointe readiness, the airplane test^{5,10,13,20,42} (weight bearing on one foot, neutral pelvis, the body levered forwards to a “T” position, and completing five single-leg pliés—at least three with correct form) was not ranked among this study’s respondents’ top 5 most important screening measures or functional skills tests. However, it was deemed more important than the plank test for core strength and was ranked number seven in the top 10 tests respondents used personally. Therefore, it is unclear whether the airplane test is an accurate determinant for pointe readiness, or it is used by dance teachers because of the research from past studies. DeWolf et al⁴² noted that although statistically significant, when conducting the airplane test the number of up-down maneuvers lacked consistency between participants. The authors suggest that two quality repetitions may indicate adequate proprioception and trunk stability for a safe transition to pointe training. While the difference between the two pre-pointe and pointe groups was reported as statistically significant, the mean difference between the two groups was one (n = 1) repetition. Richardson et al⁵ found that the airplane test (along with the topple and sauté tests) was a significantly better evaluator for pointe readiness, than a series of other tests including heel rise, passe relevé, Romberg (balance on one leg, eyes closed and arms crossed on chest timing loss of control), and the pencil test. Although DeWolf et al⁴² suggest that the recommendation by Richardson et al⁵ is four successful repetitions, the methodological limitations demonstrated by Richardson et al⁵ (small cohort, cross-sectional design) indicate that their results should be treated with caution. Within this study, respondents did not corroborate the use of the airplane test as a “important” test for pointe readiness and further research is required to determine how accurate the airplane test is and if it necessitates being tested during screening for pointe readiness or whether it be used as a supplementary pre-pointe training exercise.

Despite this study’s respondents indicating that bone maturity is more important than chronological age, 67% of them (n = 14) indicated the youngest age dancers should go en pointe was below 12 years old. However, measuring bone age is expensive and exposes the dancer to unnecessary radiation; testing bone health is not cost-conducive for dance teachers when factoring bone maturity for pointe readiness.¹ Respondents agreed that 4 to 5 years of dance experience is more important than pre-pointe training, which is supported by previous research. DeWolf et al,⁴² Hewitt et al,¹³ Richardson et al,⁵ and Solomon et al,⁴⁴ found that younger, pre-pointe dancers with fewer years of experience performed statistically significantly worse in the sauté test,^5,13 airplane test,^5,13,42 topple test,^5,13 relevé endurance,⁴² isometric strength,⁴² isokinetic strength,⁴⁴ and star excursion balance test in three directions.⁴² Richardson et al⁵ suggested functional tests should be used alongside chronological age, years of dance experience, maturity status, commitment to dance, and medical history. Hence, a collaboration of traditional methods and functional test measures may be a more accurate assessment for dance teachers and health professionals to determine a dancer’s readiness for pointe.⁵

This study’s respondents were unanimous that teacher assessment is more reliable than a test battery. It was ranked second in the top 5 most important screening measure for determining pointe readiness yet was ranked fourth in the top 10 tests used by respondents, which shows discrepancies between answers. The consensus in this study adds value to prior research, where findings illustrate that while dancers successful en pointe performed better than pre-pointe dancers on the quantitative tests, teacher evaluation aligned and statistically correlated with relevé,⁴² airplane,^5,42 topple,^5,13 and sauté^5,13 tests. This leaves questions to whether test battery is necessary if teacher assessment offers the same merit. Therefore, both prior research and the consensus from this study inadvertently highlight the need for future research to review the use of test battery and teacher assessment, to provide reliable outcomes and support when determining a dancer’s readiness for pointe training.

Overall, the importance of this study is illustrated when evaluating what test procedures best determine pointe readiness, as the research presented is limited or contradictory. Pre-pointe screening protocols are required to minimize the associated injury risk factors and ensure that dancers have the desired strength and stability of the pelvis and lower limbs, particularly during adolescence.

Limitations

The authors recognize a number of limitations within this study; there was a disparity in respondents between the rounds with an initial high dropout rate (33%); although consensus was achieved, there were conflicting viewpoints between rounds, and this may have been due to the time between Rounds 1 to 2 and 2 to 3, leading to recall bias; the addition of one respondent between Rounds 2 and 3 created a discrepancy in the data which couldn’t be rectified due to the respondents being anonymous. The use of social media to attract experts increased the recipient pool but also potentially reduced the expertise. More explicit inclusion criteria of the invited respondents might have demonstrated the outcomes more clearly. Lastly, conceptual understanding of testing procedures determined by the experts was presumed, which may have led to a bias of responses during ranking due to those who may have lacked understanding of tests suggested by other respondents. Yet, there was no correspondence with the researchers to state a lack of understanding of terminology or tests.

Practical and Clinical Applications and Implications

Although there was consensus in the three strands of top 5 physical attributes, screening measures, and functional skills tests, this study demonstrates the diversity of opinion of how readiness for pointe can and should be measured; as when cross referencing the strands, contradictory outcomes were found.

Conclusion

This study found consensus among dance experts on the best screening methods and functional skills tests to determine pointe readiness in young adolescent female dance students, and the physical attributes dancers need to safely transition to pointe. Although respondents felt that teacher assessment was more reliable than a test battery, there is no evidence or literature to support this. It seems that pointe-readiness cannot be assessed empirically; therefore, a collaboration of traditional methods (teacher assessment) and functional test measures may be a more accurate means of assessment for dance teachers and health professionals to determine a dancer’s readiness for pointe.

Supplemental Material

sj-docx-1-dmj-10.1177_1089313X251339220 – Supplemental material for Screening Protocols for Pointe Readiness in Young Adolescent Female Dance Students: A Delphi Study

Supplemental material, sj-docx-1-dmj-10.1177_1089313X251339220 for Screening Protocols for Pointe Readiness in Young Adolescent Female Dance Students: A Delphi Study by Kelly Hough-Coles, Matthew Wyon, Nico Kolokythas and Shaun M. Galloway in Journal of Dance Medicine & Science

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kelly Hough-Coles

Matthew Wyon

Nico Kolokythas

Supplemental Material

Supplemental material for this article is available online.

References

Meck

Hess

Helldobler

Roh

Pre-pointe evaluation components used by dance schools. J Dance Med Sci. 2004;8(2):37-42.

Barringer

Schlesinger

The Pointe Book: Shoes, Training & Technique. Elysian Editions; 2004.

Nunes

Haddad

Bartlett

Obright

KD.

Musculoskeletal injuries among young, recreational, female dancers before and after dancing in pointe shoes. Pediatr Phys Ther. 2002;14(2):100-106.

Altmann

Roberts

Scharfbillig

Jones

Readiness for en pointe work in young ballet dancers are there proven screening tools and training protocols for a population at increased risk of injury?

J Dance Med Sci. 2019;23(1):40-45.

Richardson

Liederbach

Sandow

Functional criteria for assessing pointe-readiness. J Dance Med Sci. 2010;14(3):82-88.

Schoene

. Dance: lower extremity biomechanics and considerations in the evaluation of the dancer. In: Werd

Knight

, eds. Athletic Footwear and Orthoses in Sports Medicine. Springer; 2010:295-352.

Shah

Premature growth plate closure in a ballet dancer

en pointe. Clin J Sport Med. 2017;27(5):e69-e71.

Toledo

Akuthota

Drake

Nadler

Chou

LH.

Sports and performing arts medicine. 6. Issues relating to dancers. Arch Phys Med Rehabil. 2004;85:75-78.

Weiss

Rist

Grossman

When can I start pointe work? Guidelines for initiating pointe training. J Dance Med Sci. 2009;13(3):90-92.

10.

Shah

Determining a young dancer’s readiness for dancing on pointe. Curr Sports Med Rep. 2009;8(6):295-299.

11.

Roemmich

Rogol

AD.

Physiology of growth and development: its relationship to performance in the young athlete. Clin Sports Med. 1995;14(3):483-502.

12.

Malanga

Ramirez-Del Toro

JA.

Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am. 2008;19(2):347-371.

13.

Hewitt

Mangum

Tyo

Nicks

Fitness testing to determine pointe readiness in ballet dancers. J Dance Med Sci. 2016;20(4):162-167.

14.

Lai

Kruse

DW.

Assessing readiness for en pointe in young ballet dancers. Pediatr Ann. 2016;45(1):e21-e25.

15.

Fong Yan

Hiller

Smith

Vanwanseele

. Effect of footwear on dancers: a systematic review. J Dance Med Sci. 2011;15(2):86-92.

16.

Spilken

TL.

The Dancer’s Foot Book: A Complete Guide to Footcare & Health for People Who Dance. Dance Horizons; 1990.

17.

Teitz

Harrington

Wiley

Pressures on the foot in pointe shoes. Foot Ankle. 1985;5(5):216-221.

18.

Amorim

Metsios

Flouris

, et al. Endocrine parameters in association with bone mineral accrual in young female vocational ballet dancers. Arch Osteoporos. 2019;14(1):46.

19.

Amorim

Metsios

Wyon

, et al. Bone mass of female dance students prior to professional dance training: a cross-sectional study. PLoS One. 2017;12(7):e0180639.

20.

Russell

JA.

Preventing dance injuries: current perspectives. Open Access J Sports Med. 2013;4:199.

21.

Fuller

Peirce

Screening practices in dance: applying the research. In: Proceedings of the World Dance Alliance Global Summit 2008: Dance Dialogues, Brisbane, Australia, 13-18 July 2009. University of Southern Queensland; 2009:1-8.

22.

Pearson

Whitaker

AF.

Footwear in classical ballet: a study of pressure distribution and related foot injury in the adolescent dancer. J Dance Med Sci. 2012;16(2):51-56.

23.

Moser

BR.

Posterior ankle impingement in the dancer. Curr Sports Med Rep. 2011;10(6):371-377.

24.

Russell

Kruse

Koutedakis

McEwan

Wyon

MA.

Pathoanatomy of posterior ankle impingement in ballet dancers. Clin Anat. 2010;23(6):613-621.

25.

Katakura

Kedgley

Shaw

, et al. Epidemiological characteristics of foot and ankle injuries in 2 professional ballet companies: a 3-season cohort study of 588 medical attention injuries and 255 time-loss injuries. Orthopaed J Sports Med. 2023;11(2):1-8.

26.

McDougall

The ostrigonum. J Bone Joint Surg Br. 1955;37(2):257-265.

27.

Peace

Hillier

Hulme

Healy

MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clin Radiol. 2004;59(11):1025-1033.

28.

Ramey

Yin

. Epidemiology of injury in the young dancer. In: Solomon

Solomon

Micheli

, eds. Prevention of Injuries in the Young Dancer: Contemporary Pediatric and Adolescent Sports Medicine. Springer; 2017:1-13.

29.

Leanderson

Wykman

Strender

Johansson

Sundquist

Musculoskeletal injuries in young ballet dancers. Knee Surg Sports Traumatol Arthrosc. 2011;19(9):1531-1535.

30.

Albisetti

Perugia

De Bartolomeo

Tagliabue

Camerucci

Calori

GM.

Stress fractures of the base of the metatarsal bones in young trainee ballet dancers. Int Orthopaed. 2010;34(1):51-55.

31.

Howse

. The young ballet dancer. In: Ryan

Stephens

, eds. Dance Medicine: A Comprehensive Guide. Pluribus Press; 1987:107-114.

32.

Hinkamp

Morton

Krasnow

, et al. Occupational health and the performing arts. J Occup Environ Med. 2017;59(9):843-858.

33.

Trevelyan

Robinson

Delphi methodology in health research: how to do it?

Eur J Integr Med. 2015;7(4):423-428.

34.

Nair

Aggarwal

Khanna

Methods of formal consensus in classification/diagnostic criteria and guideline development. Semin Arthritis Rheum. 2011;41(2):95-105.

35.

Haven

Errington

Gleditsch

, et al. Preregistering qualitative research: a Delphi study. Int J Qual Methods. 2020;19:1-13.

36.

Diamond

Grant

Feldman

, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-409.

37.

Hsu

Sandford

BA.

The Delphi technique: making sense of consensus. Pract Assess Res Eval. 2007;12(1):10.

38.

Kraemer

Mintz

Noda

Tinklenberg

Yesavage

JA.

Caution regarding the use of pilot studies to guide power calculations for study proposals. Arch Gen Psych. 2006;63(5):484-489.

39.

Cohen

Manion

Morrison

Research Methods in Education. Routledge; 2002.

40.

Hough-Coles

Wyon

Determining pointe readiness in young adolescent female dancers: A systematic review. J Dance Med Sci. 2022;26(4):213-225.

41.

Hamilton

Marshall

Molnar

A profile of the musculoskeletal characteristics of elite professional ballet dancers. Am J Sports Med. 1992;20(3):267-273.

42.

DeWolf

McPherson

Besong

Hiller

Docherty

Quantitative measures utilized in determining pointe readiness in young ballet dancers. J Dance Med Sci. 2018;22(4):209-217.

43.

Shah

Readiness for dancing en pointe. Dance Med Issue Phys Med Rehabil Clin N Am. 2021;32(2021):87-102.

44.

Solomon

Micheli

Ireland

Physiological assessment to determine readiness for pointe work in ballet students. Impulse. 1993;1(1):21-38.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB