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Discussion in 'Biomechanics, Sports and Foot orthoses' started by paulm, Mar 26, 2012.

  1. paulm

    paulm Member

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    hi all received this from concerned parent
    advice welcomed

    Thank you very much for offering to look into this for us.

    Sylvie is 14 and she's been doing ballet for 9 years. She's now completed her Royal Academy of Dance Grade 5 and her ballet teacher thinks she is ready to go en pointe.

    She's been for 3 appointments at an NHS orthopeadic clinic, the first 2 were with the same doctor who took the view that if she went en pointe it would accelerate the development of her deformity in her big toes and trigger the need for a corrective operation. At the last appointment we saw a different doctor who thought that going en pointe would not make the condition any worse, and if it hurt that wasn't a reason not to do it, but it would mean that an operation would probably be necessary.

    Sylvie's ballet teacher can see nothing in Sylvie's posture or "turn out" to indicate there is a problem and she therefore thinks Sylvie is ok to go to this next stage with her dancing.

    Obviously my concern is that she'll do some lasting damage to her feet...]

    Sylvie came to see me 20months ago (approx), bilateral medial arch pain on dancing activities....applied semi compressed felt padding to medial arch aspect of footwear, also ballet shoes, this relieved symptoms, supplied rs off-the-shelf orthotics which worked well in relieving symptoms (these were of a ucbl design), these obviously did not fit in ballet shoes but by using them in everyday footwear sylvie has been free of discomfort.... im hoping the pictures her dad took load up given the information given by her Drs

    Attached Files:

  2. G Flanagan

    G Flanagan Active Member

    Juvenile Hallux Valgus.

    Truth is we don't really know if going en pointe will exaggerate / make the deformity worse personally i doubt it. By deformity I mean metatarsus primus varus / actual hallux valgus.

    However although we will really never know if her dancing will make the deformity worse (unless an RCT into hallux valgus development in ballet dancers is performed) I can take a guess that it will make them symptomatic.

    I do agree that she will need correction at some point, probably inevitable although maybe sooner if symptoms worsen with the ballet (obviously not until osseous maturity though).

    Anyway Sylvies ballet teacher seems to be dual qualified in musculoskeletal pathology, so let her deal with it :bang:

  3. G Flanagan

    G Flanagan Active Member

  4. kemplr

    kemplr Member

    Hi There,

    I can't tell you whether it would accelerate the progress of the bunion but it's obviously not the kindest to your feet.

    14 is at the later age for starting pointe. Does she want to make it her career? The main concerns for starting pointe are correct technique, appropriate strength, appropriate ankle and 1st MPJ flexibility, taking ballet class at least 3 times weekly. Their teacher is usually the most appropriate person to decide this.

    If she does decide to start pointe, it is very important to get correctly fitting pointe shoes. The wrong style can lead to the dancers foot sinking into the box and ultimately causing more stress to the toes, mets etc. A badly fitting shoe can cause a multitude of foot problems. If the box is too narrow it will impinge on the 1st MPJ. I would also suggest that she look at using a toe spacer between the 1st and 2nd toes - it alleviates a fair amount of pressure away from the 1st ray.

    Good Luck
  5. paulm

    paulm Member

    many thanks, and thank you George for the 2 references

  6. Hi Paul

    Treating circa 400 young dancers over a period of 2 years i noted a speculative increase in the proportion of young (mainly females) with Juvenile HAV and other lesser digit deformities than would typically be encountered in daily practice. Of course we know there are a miriad of variables and possibilities here, but it can be of no co incidence in my mind that Almost exclusively the older dancers and teachers all had severe HAV and lesser toe deformities.

    I have always advised against Pointe work, if there is no intended professional requirement, or when current foot pathology presents, that has the potential to be worsened by the activity. The risks outweigh the benefit in my mind when undertaken only for a limited time frame and for leisure.

    Of course this does not always go down well with all parties. Due to the commercial interests involved perhaps?

    Another aspect of daily dance training that seemed to be becoming more popular, but regionally variant, was the rejection of Soft Block training for a period of strengthening and acclimatization, prior to Pointe work starting. As a result a lot of the younger dancers would be presenting without the core strength required to "pull up and through" leading to poor foot posture through the foot and potentially increasing the risk of injury. I reached this conclusion as the poor subjects would be in pain whilst undertaking the task!

    Being involved in the shoe fitting side also, it was a constant struggle to fit a customer with the best, most comfortable and balancing shoe available for this task, as the dance schools would often prefer all students in the same shoe brand to keep the tone of pink and lines the same. The dancer could be collapsed into a Pointe shoe and in pain, but this could be a mute point if it looked the same as the others in the class/production.....Obviously there are a lot of good teachers/fitters and students, i am sure, but i mention my experience only :)

    It was interesting that when a sturdy young semi or professional dancer with 'block like feet' would attend....they would have minimal, or no discomfort and no digital pathology to note, bar the occasional blister. Made for the job always came to mind.

    I guess we take our chance....My climbing shoes place an obvious and well felt pressure on my hallux in a similar manner, but i am an adult and make an informed choice on the subject. I always aimed to help parents and students make the best informed choice and apply a bit of common sense for themselves :)

    Best of luck

  7. Admin2

    Admin2 Administrator Staff Member

  8. Are her feet hypermobile? (Excessively so) and does she still have pain in the medial arch?

    As a trained dancer and a podiatrist - i have mixed views - ultimatley it does come down to whether sylvie is wanting to continue ballet as a career/or even for a few more years, i.e. if she doesn't go en pointe - her technique is never going to progress -and she won't be able to go any further in the syllabus.
    Good dance teachers should know when their pupils are strong enough to begin pointe work - throughout my training I saw many dancers denied the opportunity to begin pointe work until their feet, ankles, posture were strong enough. And there are numerous exercises specifically aimed at preparing girls for the pointe work.
    Her dance teacher will most likely have let her know - but there are so many types of pointe shoe that she can try (She would probably do well in a Bloch from the look of the shape of her feet - but as i can't see her dancing i may quickly change my mind with a few other pics!)- she should go try as many as possible in a known dance store to ensure her feet aren't cramped (contrary to what ppl may believe - there are comfortable pointe shoes!!) - once again her teacher should know the best ones in her area. - And there are lots of types of padding that can go in - I always found poron or sheeps wool worked best.

    It may be a possibility that she may eventually need intervention - but at 14 - I don't think anyone is going to be successful in telling her to stop dancing - best to aske her and her parent to keep an eye out for any changes/pains - and if so - to get in touch with you.
  9. Jenene Lovell

    Jenene Lovell Active Member

    I do agree with what Jessica says... I am also a podiatrist, dancer and a qualified dance teacher, specialising in ballet and contemporary.

    I guess it mainly comes down to whether her teacher is just saying that she is ready for going en pointe for the right reasons, not just because she thinks its about time. Yes, she is starting pointe work late compared to the "elite ballet scholls", I have heard cases of them starting at 8-9 years old which is completely wrong from the point that their feet are not ready structurally to handle the pressures that the pointe shoe places on the feet.

    But the major concern is whether sylvie is ready from a technical point of view, ie turned out properly (not faking it), core strength adequate ankle and 1st MPJ ROM and strength from the joints, etc, etc.

    If she still wants to continue, then her parents, and sylvie, have to make an informed choice... like stated before, that she might need correction later on in life, wearing some form of corrective device when not in pointe shoes, possibly needing a spacer between the 1st and 2nd digits to offload pressures and hopefully decrease the progression of HAV formation.

    Jessica is also right in saying that there are comfortably pointe shoes, and uncomfortable ones as well. If Sylvie does decide to continue with going en pointe, then she MUST try on lots and lots of different pointe shoes until she finds what is comfortable, And if she does decide to wear something in her shoes (eg a spacer between the toes), then I impore that she tries the pointe shoes on with them in the shoes.

    The big question... is it worth the possibilty of causing potential damage to her feet and pain later on in life if she is going to continue only for a couple more years?...
  10. petermac

    petermac Member

    I have a quick question as to what is adequate 1st MPJ flexion etc to start pointe. I have recently had a few pts come through asking me to assess their feet for advanced ballet/pointe work.

    I have typically looked at muscles strength and if there is severe joint deformity any where. These though are just guesses as to what is required - I often tell clients that I have no complete idea as I am not familiar with the stress of dancing.

    If anyone has a website or form that they refer to it would be greatly appreciated.
  11. kemplr

    kemplr Member

    Hi Petermac,

    Check out Lisa Howell's The Ballet Blog/ The Perfect Pointe Book.

    There is quite a lot to consider for pointe assessments. The student should be at least 11 years of age, has had at least two years of classes and regularly attends at least 3 classes per week.

    Also, the dancer should be able to maintain turnout when dancing, hold alignment when dancing, be able to do repeated releves in the centre without tiring or losing alignment, be aware of foot alignment e.g sickling or rolling in (especially if they are trying to force turn-out). You need to look at them in various positions e.g grand plie in centre (not holding onto a barre - they should be not losing balance, able to control core, not rolling the feet in), performing a tendu, releve and hold the position etc

    Ankle mobility is probably more of an issue than 1st MPJ mobility for pointe work. They need to have enough ankle mobility to be able to get over the platform/box of the shoe. Have a look at the patient on demi-pointe - this should give you an indication on whether they can fully get over on their forefoot (and will give you an indication on 1st MPJ and ankle mobility).

    A 'hypermobile' client may need strengthening exercises before going en pointe. This foot has no problems in getting over the box but can be quite weak sometimes.

    Does this help?

    Cheers, Lauren
  12. NewsBot

    NewsBot The Admin that posts the news.

    Premature Growth Plate Closure in a Ballet Dancer en Pointe.
    Shah, Selina MD, FACP
    Clinical Journal of Sport Medicine: August 05, 2016

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