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Footwear in classical ballet: a study of pressure distribution and related foot

injury in the adolescent dancer

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Footwear in Classical Ballet
A Study of Pressure Distribution and Related Foot Injury
in the Adolescent Dancer
Stephen J. Pearson, Ph.D., and Alison F. Whitaker, M.Sc.

Abstract
This study explores the relationship be-
tween dance shoe type and foot pressure
characteristics. During adolescence, while
the foot is still developing, limiting focal
pressure on the feet may help reduce the
risk of injury. In order to “condition” the
feet for advanced dance, where pointe
shoes are worn, it may be advisable to
first utilize demi-pointe shoes. Eight
female dancers were each tested in four
footwear conditions (barefoot, soft,
demi-pointe, and pointe shoes), and pat-
terns of foot pressure were compared. A
questionnaire was also distributed among
sixty-five adolescent females currently
training at vocational dance schools to
examine shoe use and injury rate before
and after the onset of pointe work. During
ballet-specific dynamic movement, soft
shoes and pointe shoes significantly vary
in the plantar pressures they impose on
the foot. Demi-pointe shoes provide an
intermediate pressure condition, which
may help the dancer adapt more gradually
to the pressure demands of pointe shoes.
Dancers who wore demi-pointe shoes
prior to starting pointe were found to be
less likely to sustain a ballet-related injury
or a lower leg, ankle, or foot injury (22%
compared to 30% in those who had not
worn demi-pointe shoes). The dancers in
this group were also older when they first
reported an injury.
Stephen J. Pearson, Ph.D., and Alison F. Whitaker, M.Sc., are from Centre for
Health, Sport and Rehabilitation Sciences Research, University of Salford, Greater
Manchester, United Kingdom.
Correspondence: Alison F. Whitaker, M.Sc., Centre for Health, Sport and
Rehabilitation Sciences, University of Salford, Greater Manchester M6 6PU,
United Kingdom; alison.f.whitaker@gmail.com.
A
dolescent dancers account
for the majority of injuries in
ballet,1 particularly overuse
injuries.2 These injuries tend to occur
after the onset of pointe work,2 pos-
sibly due to the increase in training
loads experienced when dancing in
pointe shoes. The transition to pointe
work requires much adjustment by
the young dancer, particularly if all
previous training has been done in
soft shoes.
Progressive training is desirable
so that the anatomical structures in-
volved can be gradually strengthened
in preparation for the greater loading
demands of pointe work. 3 Tissue
breakdown may occur, with a resul-
tant predisposition to overuse injury,
if the feet are exposed to repetitive
loads without adequate preparation
and sufficient recovery time.3,4 In this
regard, increased underfoot pressure
has been shown to be a strong predic-
tor of overuse injury in active young
people.5
Shoes used during high physical
demand on the feet generally incorpo-
rate shock absorbing materials, which
help increase flexibility of the sole, re-
ducing plantar pressure.6 Pointe shoes
require materials that are stiff and
durable in order to support the dancer
when balancing on the tips of her
toes. These materials have low shock
absorbent properties; consequently,
the demands on the foot structures are
heightened in comparison to training
in the flexible soft shoe.
The aim of this study, therefore,
was to examine the pressure character-
istics of different shoes used in ballet.
Specifically, the objectives were to 1.
compare the pressure profile of the
demi-pointe shoe with those of the
soft and pointe shoes, and 2. exam-
ine current practice in order to test
whether the use of demi-pointe shoes
may help prevent overuse injuries in
the adolescent dance community.
Materials and Methods
All procedures were approved by the
local Research Governance and Ethics
Committee, and all participants gave
their written informed consent. The
study conformed to the declaration
of Helsinki.
Pressure Distribution
Measurement
The study utilized a repeated measures
same subject design. Eight female
dancers (age: 19.63 ± 1.06 years;
height 163.00 ± 7.42 cm; weight
54.88 ± 8.95 kg) were recruited from
university undergraduate dance degree
programs. All had trained in ballet to a
level equivalent to RAD Intermediate,
with at least two years of experience

51
52 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science
A B
Figure 1 A, Demi-plié in first position, B, first position, and C, demi-pointe in first position.
dancing in pointe shoes and were free
of lower limb injury and abnormalities.
Pressure data were collected with an
emed®-x high-speed high-scan pressure
platform (Novel, Munich, Germany)
sampling at 100 Hz. Participants
were asked, while standing in first
position on the pressure platform, to
rise from demi-plié onto demi-pointe
(Fig. 1) in four footwear conditions:
barefoot, soft shoes (Sansha Tutu Split
– standard style across manufacturers),
demi-pointe shoes (Grishko 2007),
and pointe shoes (Grishko 2007).
The conditions were tested in random
order, and plantar pressure measure-
ments were taken from the demi-plié
to completion of the rise onto demi-
pointe (the participants were not re-
quired to go onto full pointe while in
pointe shoes, as these data would not
have supported the repeated measures
design required to compare each foot-
wear condition).
Pointe shoes were fitted to the
participants a week prior to data
collection by a trained fitter and
were sufficiently broken in to allow
the participants to feel comfortable
in them when rising through demi-
pointe to en pointe. While wearing
the shoes, rises and relevés with sup-
port were permitted. No toe pads
were used during testing, as they
might influence the observed differ-
ences in footwear.
After a 15 minute warm-up (con-
sisting of ankle circles, rises, relevés
and small jumps), contact area, peak
pressure, pressure time integrals, and
relevant force values were obtained in
each condition over four areas: total
foot, forefoot (consisting of the first
to fifth metatarsal heads and all toes),
midfoot, and hindfoot (heel).7 Mean
values were calculated for four trials
in each condition. The data were then
analyzed for statistical significance
(p < 0.05) with repeated measures
ANOVA and Bonferroni corrected
post hoc pairwise comparisons.
Questionnaire Data Collection
Sixty-seven female vocational dance
pupils (age 13.49 ± 1.42 years) were
recruited from vocational schools of
dance to complete a questionnaire
regarding dance training, injury,
and shoe use. These subjects had all
begun pointe work (mean starting
age = 11.15 ± 0.43 years), and their
main dance discipline was ballet.
Two questionnaires were discarded
due to incompletion. All reported
injuries were then categorized as either
relevant or irrelevant. “Irrelevant”
comprised any injury that was located
in the upper limb, had a non-dance-
C
related mechanism, or occurred prior
to the onset of pointe training. These
injuries were not used during further
analysis. A “Relevant” injury that
occurred or was first noticed during
ballet practice was designated as a
“ballet injury,” and any relevant injury
located below the knee, not inclusive
of the knee, came under the heading
“lower leg, ankle, and foot injury.”
Injury, age, training frequency, and
pointe experience (years since begin-
ning, and frequency of, pointe work)
were correlated with current shoe
use and shoes used for training prior
to pointe onset. Relationships were
explored between injury prevalence,
ballet-related injury, lower leg, ankle,
or foot injury, and shoes used prior to
the onset of pointe work, as well as the
shoes currently used.
Results
Pressure Data
Pressure and force data were obtained
for the total foot in each footwear
condition (Table 1), and pressure
was recorded for specific areas of the
underfoot for each shoe condition
(Table 2). Intraclass correlation values
for barefoot, soft shoe, demi-pointe
shoe, and pointe shoe data collec-
tion were 0.81, 0.78, 0.79, and 0.76,
respectively.
 Journal of Dance Medicine & Science • Volume 16, Number 2, 2012 53

Table 1 Pressure and Force Data with Variation of Footwear

Barefoot Soft Shoes Demi-pointe Shoes Pointe Shoes
Mean pressure (kPa) 249.41 ± 52.23* 240.94 ± 59.55* 279.50 ± 81.11 436.51 ± 152.69
Mean force (N) 567.06 ± 126.08 579.29 ± 119.10* 565.40 ± 113.72 524.99 ± 116.24
Mean contact area (cm2) 22.80 ± 2.57*† 24.84 ± 5.29* 20.84 ± 3.39* 12.93 ± 4.24
Pressure time integral (kPa.s) 747.36 ± 157.71* 722.82 ± 178.65* 838.49 ± 243.32 1309.50 ± 458.07
Force time integral (N.s) 1701.19 ± 378.24 1737.86 ± 357.30* 1696.20 ± 341.16 1574.97 ± 348.72
Total contact area (cm2) 216.38 ± 27.19*† 199.38 ± 21.76* 182.13 ± 19.19* 148.00 ± 19.25
*Significant difference to pointe shoe group (p ≤ 0.01). †Significant difference to demi-pointe shoe group (p ≤ 0.01).

Table 2 Peak Pressure and Contact Area of the Different Sections of the Foot with Variation of Footwear
Barefoot Soft shoes Demi-pointe shoes Pointe shoes
Forefoot
Peak pressure (kPa) 306.88 ± 130.49‡ 379.38 ± 166.29 372.50 ± 246.69 493.75 ± 166.56
Total contact area (cm2) 59.88 ± 9.34*‡ 55.50 ± 5.88‡ 52.88 ± 9.00 43.38 ± 6.05
Midfoot
Peak pressure (kPa) 63.75 ± 28.00‡ 107.50 ± 34.12‡ 141.25 ± 33.57 236.25 ± 125.58
Total contact area (cm2) 22.88 ± 12.25 33.13 ± 13.81 35.13 ± 8.69 32.88 ± 7.59
Hindfoot
Peak pressure (kPa) 436.25 ± 70.29 373.13 ± 99.42 418.13 ± 182.87 709.38 ± 294.59
Total contact area (cm2) 132.75 ± 17.35‡§ 110.50 ± 18.42‡ 93.88 ± 11.08‡ 71.13 ± 11.13
Total foot
Peak pressure (kPa) 462.50 ± 60.83‡ 449.38 ± 134.36† 543.13 ± 241.56 764.76 ± 321.22
Total contact area (cm2) 216.38 ± 27.19‡§ 199.38 ± 21.76‡ 182.13 ± 19.19‡ 148.00 ± 19.25
*Significant difference to demi-pointe shoe group (p = 0.03); †Significant difference to pointe shoe group (p = 0.02); ‡Significant difference to
pointe shoe group (p ≤ 0.01); §Significant difference to demi-pointe shoe group (p ≤ 0.01).

Significant differences in pressure

were found between barefoot and
pointe shoe (p ≤ 0.01) and soft and
pointe shoe conditions (p ≤ 0.01).
No significant pressure difference
was found between demi-pointe and
pointe shoes or demi-pointe and soft
shoes, indicating overall that the de-
mi-pointe shoe provides a transitional
stage in pressure between soft shoes
and pointe shoes. Progression can be
observed from soft to demi-pointe to
pointe shoes, the latter having signifi- Figure 2 Barefoot: pressure and center Figure 3 Soft shoes: pressure and center
cantly higher pressure values. Except of gravity. of gravity.
at the midfoot, the shoe conditions
significantly (p ≤ 0.01) decrease in
contact area progressively from bare-
foot to soft shoes, to demi-pointes,
to pointe shoes (Table 2). Figures 2-5
illustrate the pressure distribution in
each of the conditions. Differences in
force can also be observed in Table 1
between soft shoes and pointe shoes.
Questionnaire Results
Each participant was grouped as either
1. an individual who wore demi-
pointes prior to starting pointe (N = Figure 4 Demi-pointe shoes: pressure Figure 5 Pointe shoes: pressure and
9), or 2. one who did not wear demi- and center of gravity. center of gravity.
54 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science

A B
Figure 6 A, Age at first related injury with wearing demi-pointe shoes prior to pointe work. B, Age at first related injury without
wearing demi-pointe shoes prior to pointe work.

A B
Figure 7 A, Previous shoe use in relation to injury incidence. B, Current shoe use in relation to injury incidence.

pointes prior to starting pointe (N =
56). Participants were also grouped
according to their current shoe use
during ballet class: soft shoes (N =
12), demi-pointe shoes (N = 34), or a
combination thereof (N = 19).
Of the sample, 82% (53) had
trained in demi-pointe shoes (mean
starting age 11.96 ± 0.91yrs), and of
those individuals, 83% (44) did so
after the onset of pointe work (mean
starting age 11.18 ± 0.46 years).
Dancers who wore demi-pointes
before starting on pointe were more
likely to report their first dance-related
injury at an older age (Fig. 6A) than
those who did not wear them before-
hand (Fig. 6B), the occurrence of
which had a distinct peak at age 13.
Relevant injury was reported by
55% (36) of the total sample (65).
Forty-two percent (21) of injuries
reported were localized to the ankle,
foot, and lower leg: 20% (10), 12%
(6), and 10% (5), respectively. Forty-
five percent (21) of injuries occurred
during ballet class, 17% (8) in other
dance classes or exercise, and 38%
(18) were reported as “unsure.” An
individual was found to be more likely
to sustain a ballet-related injury or
a lower leg, ankle, or foot injury, if
she had not worn demi-pointe shoes
prior to starting pointe work (Fig.
7A). This was also the case with those
who currently wore demi-pointe shoes
during class rather than soft shoes or a
combination of soft and demi-pointe
shoes (Fig. 7B).
Discussion
Pressure time integrals, peak, and
mean pressures recorded demon-
strated a consistent contrast among
the various footwear conditions. Soft
shoes impose the least pressure on the
plantar surface of the foot and pointe
shoes the most, with demi-pointe
shoes between the two. In addition,
a reverse trend was found to be sig-
nificant with regard to contact area
of each of the shoe conditions: pointe
shoes had the least contact and soft
shoes the most.
The pressures recorded in pointe
shoes were significantly greater than
the other footware conditions (Tables
1 and 2), an indication of much
greater demands of the foot and
related structures in this condition.
Similar to pointe shoes, but to a
far lesser extent, demi-pointe shoes
impose greater plantar pressures than
in the barefoot condition, unlike soft
shoes. The structure and stiff nature
of the pointe shoe materials contrib-
ute to the restricted contact area and
therefore heightened pressure in this
condition. The less resilient materials
used for the soft and demi-pointe
shoes result in larger contact areas and
reduced pressures in comparison. This
illustrates the potential advantage of
demi-pointe shoes over soft shoes in
preparation for pointe work. It has
already been established that high
plantar pressure is a strong predictor
of exercise-related lower leg pain, spe-
cifically overuse injury in adolescents.5
It follows, then, in the context of bal-
let footwear, that one way to decrease

the likelihood of this type of injury
is to introduce the demi-pointe shoe
prior to pointe work, so as to achieve
a load progression from that of a soft
shoe.
Young dancers train using one of
three shoe progression scenarios:
1. Wearing soft shoes only prior to
the onset of pointe work, then
continuing to practice in soft
shoes only when not in pointe
shoes;
2. Wearing soft shoes, then demi-
pointe shoes for a period prior to
the onset of pointe work; or
3. Wearing soft shoes only prior
to the onset of pointe work and
then, at onset or shortly thereaf-
ter, also training in demi-pointes.
The results of this study’s ques-
tionnaire support the suggestion that
when demi-pointe shoes are worn
prior to the onset of pointe work (pro-
gression 2), the relevant soft tissues
are strengthened through exposure
to a gradually increasing load and
therefore are less likely to become
injured once pointe work begins.
However, many dancers begin to wear
demi-pointes at the same time as, or
shortly after starting pointe training
(progression 3). This further increases
training loads rather than creating the
desired transitional step, as the dancer
must withstand the additional load
of training in both demi-pointe and
pointe shoes after previously wearing
only soft shoes.
It is likely that, due to the structural
similarities of demi-pointe and pointe
shoes, proprioceptive training may
also be developed in advance of pointe
training to help the dancer become
accustomed to pointe shoes. However,
it has not been determined whether
the dancers in this study who wore
demi-pointes prior to starting pointe
work were better adapted, stronger,
had better proprioceptive awareness,
or sustained fewer injuries as a result
of having done so. Such findings were
beyond the scope of the questionnaire,
as the preparatory pointe training
regimen of the participants was not
in all cases at their vocational school
and therefore could not be accurately
Journal of Dance Medicine & Science • Volume 16, Number 2, 2012
assessed by this method. Further con-
sideration and research are required in
these areas.
As may be anticipated, older danc-
ers who participated in the present
study reported a higher training fre-
quency and were more experienced in
pointe work. When correlated with
injury, training frequency was gener-
ally lower among injured dancers,
which would be the expected result of
time lost to recovery. The lower inci-
dence of ballet and lower leg, ankle, or
foot injuries reported among dancers
who currently train in a combination
of soft and demi-pointe shoes may be
due to the flexibility of the soft shoe.
This possibly allows for better recovery
from stress in the tissues surrounding
the sites of potential overuse injury.3
The pressures recorded in the dif-
ferent sections of the foot indicate
that the footwear conditions’ pressure
was highest in the hindfoot; however,
in soft shoes the highest pressure
recorded was in the forefoot (Table
2). This difference in the focus of
pressure relative to footwear condi-
tion may well influence shoe choice
to protect the local structures of the
forefoot and hindfoot during daily
training. This is particularly relevant
during busy training periods and
injury rehabilitation, when load is of
specific concern. Similarly, the lower
pressures throughout the foot in soft
shoes in comparison to demi-pointe
shoes is relevant to injury prevention
and rehabilitation, as use of the soft
shoe may help to offload the forefoot
and hindfoot when necessary.
Compared to previous injury
surveys with reports of ankle and
foot injuries accounting for 53%,1
54%,7 and 65%8 of all injuries, the
corresponding figures obtained in this
study were low. Those other studies
all investigated injury occurrence
in professional dancers, who were
unquestionably exposed to a greater
number of previous training hours
and therefore more likely to have
sustained a training-related injury.9
The peak of first reported injury
at 13 years of age (Fig. 6) may be ex-
plained by a combination of factors.
This time frame coincides with the
55
rapid adolescent growth spurt among
females; however, when compared
with other sport training in this age
group, it appears to be only among fe-
male dancers that this injury peak oc-
curs.2 The present study suggests a spe-
cialized explanation for this anomaly.
It found that the majority of young
dancers had not worn demi-pointe
shoes prior to pointe work; however,
after the onset of pointe, they mainly
used demi-pointe shoes for class work.
The mean pointe onset age is 11.18 ±
0.46 years, and for demi-pointes it is
11.96 ± 0.91 years. Thus, dancers who
had worn demi-pointe shoes prior to
starting pointe were somewhat older
than those who had not. When they
first sustained an injury, however, the
peak at 13 years was still present in
this group. For both groups, the time
lapse to the injury peak at 13 years
corresponds with the amount of time
required for consistent sub-maximal
gradual loading to produce the related
microfailure of structures that may be
above the tolerated threshold in some
individuals.10 This may be attributed
to the increased demand of accepting
the additional loads of wearing both
demi-pointe and pointe shoes without
prior progression, possibly leading to
overuse injury.
In addition, it was seen that a num-
ber of dancers had started pointe prior
to beginning vocational training (i.e.,
at their local dance schools). As should
be apparent by now, in these authors’
opinion, it is particularly important
that demi-pointes be worn at this stage
of a young dancer’s career in order to
potentially reduce the risk of lower
limb overuse injury, and such was
likely not the case with these dancers.
After the onset of pointe work danc-
ers are most likely to benefit from
wearing a combination of soft and
demi-pointe shoes for class work.
Conclusion
This study identifies a possible con-
tributing factor to overuse injuries
in adolescent female dancers and
proposes an applicable approach to
dancers’ training aimed at reducing
the injury rate. The study suggests that
demi-pointe shoes have a clear impact
 56 Volume 16, Number 2, 2012 • Journal of Dance Medicine & Science
on injury risk, and their use should be
a consideration in dance practice and
injury research. A progressive integra-
tion of appropriate footwear at the
onset of pointe training in adolescent
females may not only reduce injury
in individuals but also promote more
efficient and accurate technique.
Acknowledgment
We thank Amanda Hill at IDS/
Grishko for her kind support.
References
1. Gamboa JM, Roberts LA, Maring
J, Fergus A. Injury patterns in elite
preprofessional ballet dancers and
the utility of screening programs to
identify risk characteristics. J Orthop
Sports Phys Ther. 2008;38(3):126-36.
2. Micheli L, Fehlandt AF. Overuse
View publication stats
injuries to tendons and apophyses in
children and adolescents. Clin Sports
Med. 1992;11(4):713-26.
3. Page P. Dosing of elastic resistance ex-
ercise. In: Page P, Ellenbecker T (eds):
The Scientific and Clinical Application
of Elastic Resistance. Champaign, IL:
Human Kinetics Publishers Inc.,
2003, pp. 21-36.
4. Wang J, Iosifidis M, Fu H. Biome-
chanical basis for tendinopathy. Clin
Orthop Relat Res. 2006;443:320-32.
5. De Clercq D, Willems T, De Cock
A, Wityrouw E. The use of plantar
pressure measurements in the detec-
tion of gait related risk factors for
exercise-related lower-leg pain in
sports active young adults. J Bio-
mech. 2006;39(1):S191-2.
6. Nyska M, McCabe C, Linge K,
et al. Effect of the shoe on plantar
foot pressures. Acta Orthop Scand.
1995;66(1):53-6.
7. Brinson P, Dick F. Fit to Dance? Sum-
mary of the Report of the National In-
quiry into Dancers’ Health and Injury.
London, UK: Calouste Gulbenkian
Foundation, 1996.
8. Ramel E, Moritz U. Self reported
musculoskeletal pain and discom-
fort in professional ballet dancers
in Sweden. Scand J Rehabil Med.
1994;26(1):11-16.
9. Nunes NMA, Haddad J, Bartkett
DJ, Obright KD. Musculoskeletal
injuries among young, recreational,
female dancers before and after danc-
ing in pointe shoes. Pediatr Phys
Ther. 2002;14(2):100-6
10. McPoil TG, Hunt GC. Evaluation
and management of foot and ankle
disorders: present problems and
future directions. J Orthop Sports
Phys Ther. 1995;21(6):381-88.