Original Article

Functional Criteria for Assessing Pointe-Readiness

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.

Abstract chronological age, years of dance train- portant to consider, including lower
ing, and ankle joint range of motion. extremity strength, neuromuscular
The most popular criterion cited in the
control, and skill acquisition as de-

T
dance literature for advancement to
pointe work is attainment of the chrono- he question “When should scribed below.
logical age of 12 years. However, dancers a dancer begin training en
at this age vary greatly in terms of muscu- pointe?” is frequently asked of Traditional Factors
loskeletal maturity and motor skill devel- ballet instructors and dance medicine Chronological Age
opment. The purpose of this study was to professionals.1 Little is known about Pointe work traditionally begins just
investigate whether objective, functional the health implications associated prior to or during the onset of the ado-
tests could be used in conjunction with with pointe training, but millions lescent growth spurt, at approximately
dance teacher expertise to determine of children take dance lessons every 9 to 15 years of age.2-3 Ballet dancers
pointe-readiness. It was hypothesized year with the expectation of one day typically mature at the later end of this
that dynamic tests of motor control can rising onto pointe. A literature review
better indicate pointe-readiness than age spectrum4-5; thus, chronological
revealed very few evidence-based age alone seems an unreliable method
chronological age alone or in combina-
tion with static musculoskeletal measure- studies related to the physiological for determining skeletal maturation,
ments. Thirty-seven pre-pointe students requirements for successful participa- not to mention the physical and cog-
from two professional ballet schools were tion in pointe training. In the interest nitive skills needed for pointe work.
tested for muscular strength, ankle joint of addressing this void we undertook Nevertheless, in a survey of dance
range of motion, single leg standing the present study to determine how institutions across the United States,
balance, dynamic alignment, and turn- students’ performance on simple func- 96% of respondents identified age as
ing skill. In addition, the participating tional motor tests correlates with their the primary prerequisite for beginning
students’ ballet teachers independently teachers’ decisions regarding when to pointe training (with 39% specifically
graded each student on her readiness to begin pointe work. citing age 12).6
begin dancing en pointe. Performance on In the literature, three factors have
three functional tests (the Airplane test,
Puberty is defined as the stage in
traditionally been considered reason- human development when matura-
Sauté test, and Topple test) was closely
associated with teacher subjective rating able criteria for readiness to pursue tion occurs, in terms not only of
for pointe-readiness. It is concluded pointe training: chronological age, physical growth but also the attain-
that these tests may be more useful for years of training, and ankle plantar ment of cognitive and psychosocial
gauging acquisition of the skills required flexion range of motion. We propose skills.2 During this time, extra-uterine
for safe and successful performance than there are additional factors related to growth and biomechanical markers of
the traditionally accepted indicators of dancer functioning that are also im- bone turnover are at their peak,2,7 and
clinically significant adaptations in
strength, flexibility, and propriocep-
Megan Richardson, M.S., A.T.C., Marijeanne Liederbach, Ph.D., P.T., A.T.C., tion occur that influence both motor
C.S.C.S., and Emily Sandow, P.T., D.P.T., are at the Harkness Center for Dance control and psychological state.5,8,9 Of
Injuries, NYU Hospital for Joint Diseases, New York, New York. particular significance in the context
Correspondence: Megan Richardson, M.S., A.T.C., NYU Hospital for Joint of this study, there is a decrease in
Diseases, Harkness Center for Dance Injuries, 301 East 17th Street, New York, motor ability and dynamic balance
New York 10003; megan.richardson@nyumc.org. during adolescence resulting from the

82

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 dur-
ing 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 adjust-
ment 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 tremen-
dous variability among adolescent
dancers with regard to musculosk-
eletal 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 danc-
ers 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 per-
sonnel used number of years of ballet
training as a determinant for pointe
participation. However, because
duration of training does not neces-
sarily 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 ac-
knowledge that an important cri-
terion for pointe-readiness is a
Journal of Dance Medicine & Science • Volume 14, Number 3, 2010
supernormal range of ankle joint mo-
tion.1,19,20 Professional women ballet
dancers possess an average of 113°
of ankle plantar flexion, compared
to 48° among persons in the general
population,16 and adolescent dancers
have been reported to possess 10° to
20° 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 be-
coming 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 maintain-
ing a level pelvis and preventing femo-
ral adduction and internal rotation
during single leg stance.22,23 As the
base of support narrows, for example
during relevé en pointe, the dancer
will rely increasingly on proximal
control to maintain proper vertical
alignment and balance. Weak or
fatigued hip abductors have been as-
sociated 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.
83
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 popula-
tion, 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 train-
ing.
Skill Acquisition
The ability to control proper align-
ment 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 ado-
lescent dancers’ ability to control
their alignment and balance dur-
ing such tasks as jumping, turning,
plié, and passé relevé thus seems
reasonable for pointe-readiness as-
sessment.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 combina-
tion, 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 ± 2.2 years (range:
84 Volume 14, Number 3, 2010 • Journal of Dance Medicine & Science
9 to 17 years), and the average years
of ballet training was 6.5 ± 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 dif-
ferent 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 mus-
cular 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 Sauté
Test, Passé-relevé Balance Test, 14,35
“Topple Test,39,40 modified “Rom-
berg 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 ac-
cording 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.
Tests
“Pencil Test”
The Pencil test is a method for deter-
mining 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 (≥ 90°) 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 “Rom-
berg” 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 recommen-
dation of Luke14 and Khan,35 we mea-
sured the dancer’s ability to perform a
single leg balance while maintaining
passé-relevé. To obtain a passing score
dancers needed to maintain a neutral
position of the pelvis while in full
retiré of the gesture leg and full relevé
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 retiré and
the support leg fully extended, while
maintaining a vertical trunk and
demonstrating a controlled, deceler-
ated landing.40
Double-Leg Lower (DLL) Test
The DLL test is described by Kend-
all36 as an objective way to evaluate
abdominal strength, and has been
shown to have good inter-tester reli-
ability.42 The test is performed while
the dancer is lying supine in a pelvic
neutral position with both legs flexed
to 90° 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° 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 pliés on the standing leg,
attempting to touch the heel of her
opposite foot to the ground. Danc-
ers who demonstrate a pelvic drop,
Figure 1 Airplane
test.
 Journal of Dance Medicine & Science • Volume 14, Number 3, 2010 85

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 pliés 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, keep-
ing the pelvis square to the ground
(Fig. 1). The subject performs five
controlled pliés while horizontally ad-
ducting 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 pliés maintain-
ing neutral LE alignment.
Single-Leg Sauté Test
Dynamic trunk control and LE
alignment were assessed during 16
consecutive single-leg sauté 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 de-
fined 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 num-
ber of parallel single-leg heel raises
the dancer was able to perform while
maintaining full pre-test relevé 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 vari-
ables (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 depen-

Table 1 Pairwise Comparisons

Teacher -
Age Experience
< 12 years (N=9) ≥ 12 years (N=12) p value < 7 years (N=9) ≥ 7 years (N=12) p value
Tests mean (± sd) mean (± sd) mean (± sd) mean (± sd)
PF ROM 1.667 (.500) 1.833 (.389) .276 1.889 (.333) 1.667 (.492) .187
DLL 1.111 (.333) 1.250 (.452) .446 1.222 (.441) 1.167 (.389) .610
SLSD 1.111 (.333) 1.333 (.492) .367 1.111 (.333) 1.333 (.492) .367
Airplane 1.000 (.000) 1.417 (.515) .054* 1.000 (.000) 1.417 (.515) .054*
Saute 1.000 (.000) 1.583 (.515) .008* 1.111 (.333) 1.500 (.522) .149
Topple 1.111 (.333) 1.750 (.452) .006* 1.222 (.441) 1.667 (.492) .098
Heel Rise 1.778 (.441) 1.583 (.515) .556 1.889 (.333) 1.500 (.522) .097
Passe Releve 1.333 (.500) 1.583 (.515) .385 1.333 (.500) 1.583 (.515) .385
Romberg†
Teacher +
Age Experience
< 12 years (N=6) ≥ 12 years (N=10) p value < 7 years (N=7) ≥ 7 years (N=9) p value
Tests mean (± sd) mean (± sd) mean (± sd) mean (± sd)
PF ROM 1.833 (.408) 1.900 (.316) .820 1.714 (.488) 2.000 (.000) .129
DLL 1.167 (.408) 1.500 (.527) .158 1.429 (.535) 1.333 (.500) .870
SLSD 1.500 (.548) 1.500 (.527) 1.000 1.429 (.535) 1.556 (.527) .581
Airplane 1.167 (.408) 1.600 (.516) .122 1.286 (.489) 1.556 (.527) .589
Saute 1.333 (.516) 1.500 (.527) .625 1.143 (.378) 1.667 (.500) .050*
Topple 1.667 (.516) 1.700 (.483) .858 1.429 (.535) 1.889 (.333) .109
Heel Rise 1.667 (.516) 1.600 (.516) .886 1.714 (.488) 1.556 (.527) .668
Passe Releve 1.500 (.548) 1.900 (.316) .084 1.714 (.488) 1.778 (.441) .713
Romberg†
*Significant findings; †Statistics could not be calculated due to insufficient cell distribution.
86 Volume 14, Number 3, 2010 • Journal of Dance Medicine & Science
dent variables. The level of significance
was set a priori at 0.05. Univariate tests
identified which variables reached sig-
nificance, 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 sig-
nificantly different from one another.
Data were sorted by age (<12 or ≥12)
and by number of years of dance train-
ing (< 7 or ≥ 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 clas-
sification for pointe-readiness with
dancers’ age or experience, statistical
significance was not achieved. How-
ever, a trend toward significance (p
= 0.068) was seen for the effect of
experience, such that the less experi-
enced dancers were correctly classi-
fied 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 bet-
ter on the Sauté test (p = 0.05), and
dancers with the least years of experi-
ence 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), Sauté test (p = 0.01),
and “Topple” test (p = 0.01) were
correctly classified as not-ready for
pointe training by their dance teach-
ers (Table 1).
Discussion
The purpose of this study was to de-
termine if objective functional tests
that assess muscular strength, neu-
romuscular control, and dance skill
could aid the dance teacher, dancer,
parent, and healthcare practitioner in correlated with the teachers’ assess-
determining a student’s readiness for ments of pointe-readiness, a find-
pointe training. Our data indicate that ing that supports the prior work of
three functional tests that assess trunk Lopez-Ortiz,39 who found that skilled
control and dynamic LE alignment dancers possessed a greater ability than
can beneficially be used to comple- their lesser skilled counterparts to
ment teacher subjective assessment. control the “toppling effect” of a turn
The tests that were found to be by exhibiting greater acceleration, less
predictive of teacher ranking were head movement and body sway, and
the “Airplane” test, Sauté test, and longer landing phases.
“Topple” test. The “Airplane” test was The findings from this study sup-
the most sensitive for distinguishing port the assertion that specific dy-
between dancers identified by teachers namic tests of function are effective in
as ready or not-ready for pointe work. determining the adequacy of postural
The test’s horizontal positioning of the control, joint stability, and muscular
trunk and visual field demands signifi- power deemed necessary for success-
cant control not only of the tri-planar ful progression to pointe work.43 Tests
motion during the plié, but also of the that require dance specific postures
long lever arm of the trunk and leg in and tasks allow the examiner to test
the sagittal plane—a fundamental, integration of strength, control and
dance-specific technique requirement. alignment that express technical ac-
The Sauté test proved to be the curacy specific to the classical dance
strongest predictor of pointe-readiness artform.12,14 The tests that proved
classification overall, such that while significant in this study assess the
younger and less experienced dancers dancer’s ability to maintain neutral
did not have the strength and control alignment and center of mass over the
needed to perform the “Airplane” test, base of support while doing complex
the more experienced dancers could movement.
complete more jumps while main- There is growing evidence in the
taining proper trunk control and LE sports literature that core and LE con-
alignment and were most often classi- trol predicts which athletes will expe-
fied by teachers as ready to successfully rience injuries.24,25,28,44 Future studies
perform pointe work. should examine whether there is any
The “Topple” test was also closely relationship between performance on
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.

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 pointe-
readiness. 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 determin-
ing a dancer’s readiness to participate
in pointe training.
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 admin-
istrative assistance during this study.
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