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Resource Paper

When Can I Start Pointe Work?


Guidelines for Initiating Pointe Training
David S. Weiss, M.D., Rachel Anne Rist, M.A., and Gayanne Grossman, P.T., Ed.M.

Abstract only taking ballet classes once per week, the child had sufficient anatomic
The initiation of pointe training for or who are not truly pre-professional, facility. The program itself would
dance students should be determined pointe training should be discouraged. consist of classes progressively in-
after careful evaluation of a number No student with insufficient ankle and creasing in difficulty and frequency
of factors. These include: the dance foot plantar flexion range of motion or over the first three years. By age
students stage of physical develop- with poor lower extremity alignment
should be allowed to do pointe work.
12 the student would be taking
ment; the quality of her (or his) trunk, four classes per week. Her feet and

T
abdominal and pelvic control (core ankles would be strong, her trunk
stability); the alignment of her legs he young dancer asks,
When can I begin pointe and pelvic control would be good,
(hip-knee-ankle-foot); the strength
and flexibility of her feet and ankles; work? The answer usually and her proprioceptive skills would
and the duration and frequency of her given, almost without thought, is be properly developed. Pointe work
dance training. For students who meet at 12 years of age. It would be bet- would begin with 15 minutes of
the requirements related to all of these ter if the response were What kind exercises at the end of each class.1-6
factors, began ballet training at age of dance student are you? Starting This student should be distin-
eight or later, and who are taking bal-
pointe at age 12 presupposes that guished from the child who began
let class at least twice per week, pointe classes at age five at a local dance
work should be initiated in the fourth the child is beginning her fourth
year of ballet classes at a dance acad- school and now, at age ten, takes
year of training. Students with poor one ballet and one tap class a week.
core stability or hypermobility of the emy with a program designed to
train professional ballet dancers. Ac- She is small for her age, with weak
feet and ankles may require additional
ceptance to such a program would feet and ankles. She is very loose-
strengthening to allow them to safely
begin pointe training. For those who are indicate that, at age eight or nine, jointed (hypermobile) in her spine,
knees, feet, and ankles. Her teacher
wanted her to start pointe work two
David S. Weiss, M.D., is at the Harkness Center for Dance Injuries of years ago, but the mother thought
NYU Hospital for Joint Diseases, NYU Langone Medical Center and in
the Department of Orthopaedic Surgery at New York University School of
she wasnt serious enough about her
Medicine, New York, New York, USA. Rachel Anne Rist, M.A., is Director dancing. Her cousin began pointe
of Dance at Tring Park School for Performing Arts, Tring Park, Hertfordshire, work at age ten and she wants to
United Kingdom. Gayanne Grossman, P.T., Ed.M., is at Temple University, know why she cant start now.
Department of Dance, Philadelphia, Pennsylvania, USA, and Muhlenberg
College, Department of Theatre and Dance, Allentown, Pennsylvania, USA. Growth and Development
Correspondence: David S. Weiss, M.D., NYU Langone Medical Center, 530
Can any one age be the correct
First Avenue, HCC Suite 5D, New York, NY 10016; david.weiss@nyumc.org. answer for all students? Are all
girls at the same stage of devel-
This Resource Paper was written under the auspices of the Education and Media opment at age 12? The answer
Committees of the International Association for Dance Medicine and Science. to both questions is No. There
Copyright 2009 by the International Association for Dance Medicine and may be significant differences in
Science. This paper may be reproduced in its entirety for educational purposes, girls physiologic development,
provided acknowledgment is given to the International Association for Dance depending on the onset and tempo
Medicine and Science. of puberty. After age five linear

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Journal of Dance Medicine & Science Volume 13, Number 3, 2009 91

growth proceeds at approximately growth in the foot, they are less due stress on the leg, pelvic girdle,
5.5 cm/year (two inches/year). For exact in determining the stage of and trunk.
girls, the growth velocity increases bone maturation prior to closure of The child with hypermobile feet
sharply around age ten and reaches the epiphyses.7 and ankles is particularly at risk if
a peak of approximately 10.5 cm/ If bone growth in the foot is not placed on pointe too early. This
year (four inches/year) at age 12. complete at age 12, and if this is condition, commonly described as
Peak weight gain velocity of 8.5 kg/ a common age at which girls be- the over-arched or over-point-
year (18.7 pounds/year) is reached gin pointe work, is there medical ed foot, can be deceptive. These
at age 12.5 years, and quickly de- evidence for damage to the bones students have the suppleness to
celerates to less than 1 kg/year (2.2 of the growing foot resulting from achieve, or even exceed, the required
pounds/year) at age 15. 7 During training on pointe? Not to our pointe position, and thus they are
this rapid growth period there are knowledge: not from studies, an- more likely to be selected for ballet
inevitably significant differences ecdotes, or the authors collective in general and pointe work in par-
in development from one child to personal experiences. This is not ticular. However, they often lack the
the next. Mr. Justin Howse, retired to suggest that initiation of pointe required strength and postural con-
Consultant Orthopaedic Surgeon work before age 12 is harmless; trol to work safely on pointe. Prior
to the Royal Ballet Schools and indeed, by way of analogy, studies to beginning pointe work in these
the Royal Academy of Dancing involving gymnasts have established students all the muscles of the leg
(London, UK), says that the only the potential harm of repetitive must be strengthened, and adequate
factor which matters is the state of microtrauma to growing bones.11 proprioceptive control developed,
development of the child, and to If neither chronological age nor to facilitate correct alignment.
be dogmatic about an age does not bone maturation alone determines At the opposite end of the spec-
make any reference to the childs when to begin pointe work, what trum, the child with an inflexible
maturity or immaturity.8 other factors must be considered? In foot and ankle, resulting in insuf-
The completion of growth in a the fifth (and final) edition of her ficient plantar flexion range of mo-
tubular (long) bone is signaled by seminal book Anatomy and Ballet: tion, is also at risk. To ensure proper
the fusion or closure of the epiphy- A Handbook for Teachers of Ballet, alignment on pointe the line of the
ses (growth plates). This occurs in Celia Sparger writes: It cannot be metatarsals (represented by the top
the foot slightly earlier than in the too strongly stressed that pointe surface of the forefoot) should be
leg. The appearance of ossification work is the end result of slow and parallel to the line of the tibia (front
(bone formation) centers in the gradual training of the whole body, of the shin) when the foot is pointed
foot begins at age two months in back, hips, thighs, legs, feet, co- (combined ankle and foot plantar
utero. The last epiphysis to close in ordination of movement and the flexion). Attempting to perform
the foot does so at an average age placing of the body, so that the pointe work without such anatomic
of 16 years in boys and 14 years weight is lifted upwards off the feet, facility will place excessive stresses
in girls. From age five through age with straight knees, perfect balance, not only on the foot and ankle, but
12 the average girls foot grows 0.9 with a perfect demi-pointe, and also on the leg, pelvic girdle, and
cm (0.35 inches) per year, reaching without any tendency on the part of trunk. If there is hyperextension
an average foot length of 23.2 cm the feet to sickle either in or out or (sway-back) of the knees, even
(nine inches) at age 12. Thereafter the toes to curl or clutch. This mo- more ankle and foot range of mo-
the average girls foot growth rate ment will arrive at different times tion (plantar flexion) is needed to
slows to 0.8 cm (0.31 inches) per in different children, not only by assure proper alignment on pointe.
year for the next two years.9,10 The virtue of previous training but ac- Unfortunately, insufficient range of
completion of bone growth in the cording to their physical type, and motion may not improve with time,
feet is often given as a reason for in this may be included the growth and children with these restrictions
choosing the age of 12 for begin- of the bones.12 may never obtain sufficient flexibil-
ning pointe work. However, this ity for pointe work.
concept is basically erroneous, as Risks Associated with Starting
bone growth in the average girls Pointe Too Early Assessing the Pre-Pointe
foot is not complete at that age. As Spargers statement suggests, the Student
How far along in bone matu- potential dangers to the child from One of the factors affecting the de-
ration is any one girl at age 12? being placed on pointe before she velopment of muscular strength and
Knowledge of statistical averages is is ready have less to do with actual proprioceptive ability is the age at
not accurately predictive, as chrono- bone or joint damage (although which the child has begun studying
logical age does not necessarily these are real) than with inadequate ballet. Although movement classes
correlate with bone age. Although range of motion, strength, and sta- beginning at age four may be ben-
x-rays can show the completion of bility. These factors may cause un- eficial for other purposes, no proper
92 Volume 13, Number 3, 2009 Journal of Dance Medicine & Science

ballet training can be accomplished work. As Howse notes: There are eton Book Co., 2004, pp. 136-157.
before age eight (both Cecchetti and certainly well-known dancers who 2. Grieg V. Inside Ballet Technique.
Balanchine agreed on this). Another were not strong enough to start Princeton, NJ: Princeton Book Co.,
factor is the frequency with which their pointe work until they were 1994, pp. 104-106.
the child takes ballet class. In gener- over the age of sixteen and this 3. Guggenheim CL. A survey of elite
professional ballet schools regard-
al, students taking ballet class once a has proved no handicap in their ing the initiation of pointe work
week will progress more slowly than career.8 in children. Med Probl Perf Art.
those taking twice a week. Those 1994;9:15-7.
taking four ballet classes a week will Guidelines 4. Huwyler JS. The Dancers Body: A
progress fastest, but this frequency To summarize the above discussion Medical Perspective on Dance and
is usually found only in professional we offer the following guidelines for Dance Training. Germantown, MD;
schools or academies. when to begin pointe training: International Medical Publishing,
Within any given class of 13 1999, pp. 115-119.
1. Not before age 12. 5. Solomon R, Micheli LJ, Ireland
year olds there will be girls in dif-
2. If the student is not anatomically ML. Physiological assessment to
ferent stages of pointe work, just as
sound (e.g., insufficient ankle determine readiness for pointe
there will be a variety of physiques
and foot plantar flexion range work in ballet students. Impulse.
and abilities. This places a heavy
of motion; poor lower extremity 1993;1(1):21-38.
responsibility on the dance teacher. 6. Watkins A, Clarkson PM. Dancing
alignment), do not allow pointe
The growth and development of Longer, Dancing Stronger. Princeton,
work.
each student needs to be considered NJ: Princeton Book Co., 1990, p.
3. If she is not truly pre-profession-
when determining readiness to be- 69.
al, discourage pointe training.
gin pointe work. Teachers should 7. Roemmich JN, Rogo, AD. Physiol-
4. If she has weak trunk and pelvic
perform their own pre-pointe ogy of growth and development: its
(core) muscles or weak legs, relationship to performance in the
assessment to ascertain whether
delay pointe work (and consider young athlete. Clin Sports Med.
the student has proper postural
implementing a strengthening 1995;14(3):483-502.
control (with good abdominal and
program). 8. Howse J. Dance Technique and In-
trunk support), sufficient lower leg
5. If the student is hypermobile in jury Prevention (3rd ed). London: A
strength, and appropriate leg (hip-
the feet and ankles, delay pointe & C Black, New York: Routledge,
knee-ankle-foot) alignment to begin 2000, pp. 59-60.
work (and consider implement-
or continue working on pointe. 9. Blais MM, Green WT, Anderson M.
ing a strengthening program).
Communication with parents is es- Lengths of the growing foot. J Bone
6. If ballet classes are only once a
sential to explain the reasons behind Joint Surg Am 1956;38(5):998-
week, discourage pointe training.
every decision, thereby preventing 1000.
7. If ballet classes are twice a week,
misunderstandings. 10. Sarrafian SK. Anatomy of the Foot
and none of the above applies, and Ankle: Descriptive, Topographic,
Finally, we offer two observations
begin in the fourth year of train- Functional (2nd ed). Philadelphia:
that emphasize the importance of
ing. Lippincott, 1993.
making a proper assessment of
when to start pointe work. First, the George Balanchine, master of 11. Zetaruk MN. The young gymnast.
Clin Sports Med. 2000;19(4):757-
dancer who is struggling to work on choreography on pointe, has been 80.
pointe may have difficulty develop- credited with having created the 12. Sparger C. Anatomy and Ballet: A
ing other aspects of her ballet tech- baby ballerina. He is reported to Handbook for Teachers of Ballet (5th
nique; second, due to inability to have said that there is no reason to ed). London: Adam & Charles
execute the movements required to get a young dancer up on full pointe Black, 1970, pp. 74-8.
dance properly on pointe, she may if she cannot do anything when she 13. Hamilton WG. Ballet. In: Reider B
be prone to psychological problems, gets there!13 (ed): Sports Medicine, The School-Age
including decreased confidence and Athlete (2nd ed). Philadelphia: W.B.
poor self-esteem. Hence, we suggest References Saunders, 1996, pp. 543-581.
that it is wise to be conservative 1. Barringer J, Schlesinger S. The Pointe
in choosing when to begin pointe Book (2nd ed). Princeton, NJ: Princ-