A Study of Classical Ballet Injuries Caused By the Use of Pointe Shoes
Erika Cravath
In the mid-nineteenth century, Marie Taglioni rose on pointe for the first time, bringing a sensation across Europe and into America. Pointe work is magical, ethereal, and challenging. It inspires ballerinas to enhance their performance and fine tune their skills. Dancing on pointe is extremely detailed and difficult, yet provides breathtaking results. Pointe work adds an additional element of weightlessness and grace to the ballet, and has become the trademark of classical ballet and the dream of every young girl in a tutu. Although ballet was an art form for more than 200 years before the invention of the pointe shoe, pointe work is now standard in professional ballets. Modern ballets are now designed for women to be on pointe for the entire work. Pointe shoes, unique to ballet, add beauty and grace to any performance. Dancing on pointe is the zenith of classical ballet training and, therefore, aspired to by young ballerinas across the globe. Although, training in pointe strengthens the dancer’s feet dramatically, it also increases the chance for injury to the dancer. Pointe work produces both immediate and life-long effects in the human body including corns, blisters, tendonitis, and arthritic joints.
Pointe shoes are constructed intricately, often by hand, and vary in size, width, style, strength, and endurance. The shoe consists of a box, which supports and surrounds the toes while on pointe; a vamp, the upper sides of the box; and a shank, the hardened underside of the shoe supporting the arch of the foot. The toe box is made of cardboard, burlap, paper, or a mixture of these, and covered with satin or satin-like cotton. The base of the box, where the ballerina balances when on pointe, can be rounded or square. A square box supplies more even weight distribution while rounded boxes accommodate more varied toe lengths. The first pointe shoes were only heavily darned ballet slippers, and “…despite advancement in and implementation of materials science, the classical ballet pointe shoe has changed little mechanically since the 1600’s” (Stretanski, “Medical and Rehabilitation Issues in Classical Ballet” 385). However, hundreds of styles and makers of pointe shoes exist. Although styles and construction may vary, all pointe shoes are the means used to create the magical, weightless ballerina aesthetic.
In addition to being aesthetically pleasing, pointe shoes benefit the body both mentally and physically. Dancing on pointe brings confidence. A faculty member at Brigham Young University Brigham Young University
However, while there are benefits to pointe work, dancing on pointe can negatively affect the dancer mentally. Janalyn Memmott remarks, “Performing was really stressful because I had a lot of injuries” (Memmott). Injuries become a normalcy in a professional ballerina’s career. “Classical ballet is a career in which pain is a more or less permanent feature of the profession” (Wainwright 57). Because of the inevitability of injuries associated with dancing on pointe, most dancers do not treat their injuries properly. “Dancers, in general, regard injury and pain as a way of life and are reluctant to present to healthcare professionals, for fear of long-term immobilization and eventual unemployment” (Kennedy et al. 164). Dancers assume that pain must be a part of their dancing; otherwise, they are not dancing correctly.
As dancers learn to live and dance through the pain, they become entangled in the art form. Dancing becomes their life; the dancers live to dance. “An injury can therefore be a profound crisis, as it threatens his or her career, livelihood, artistic expression, and the very embodiment of his or her identity” (Air 114). Consequently, an injury that removes the ability to dance is not even considered an option. “If dancing is your life, then not dancing inevitably results in feeling lost and full of emptiness” (Wainwright 53). Dancers become so terrified of being without dance, that they neglect injuries and ignore pain. “Careers in ballet can be so entwined with an individual’s identity that the consequences of injury are not just threats to a career in dance, but they are also threats to one’s very identity as a person”(Wainwright 52). These mental negativities can only be avoided by proper and early treatment of injury and balancing dance with other activities and goals in a dancer’s life.
Pointe shoes create a negative impact on the physical body as well. “Partially responsible for the predominance of lower limb injuries [in classical ballet] is an archaic instrument of torture, or, depending on your perspective, an elegant piece of European footwear known as the ‘pointe shoe’” (Stretanski,“Classical Ballet: The Full Contact Sport” 392). Dancing on the tips of the toes in pointe shoes places significant and unique pressures on the foot. The pressures produced from pointe shoes cause injuries including blisters, hammertoe, calluses, corns, ingrown toenails, broken toenails, and tendonitis. At least one of these injuries is found in a majority of dancers on pointe. “It is estimated that up to 95% of dancers employed for more than one year will suffer a significant injury. Most of these physical injuries occur to the foot and ankle in female ballet dancers. Many of these injuries are as a result of dancing on the point of the toe” (Kennedy et al. 163).
Twenty to thirty percent of pressures caused by rising to pointe are directly on the toes. The remaining seventy to eighty percent are redirected through the shoe to the vamp and sole (Kadel 399). This weight distribution can cause compression in the phalangeal and metatarsal joints, bringing undue stress and possibly arthrosis of the joints later in life. The stress on the toes also contributes to broken and ingrown toenails, commonly found in ballerinas because toenails are not designed to be weight-bearing. “Dancers’ toenails take a beating, especially in ballet technique shoes en pointe…Acute injuries to the toenails include avulsions or subungual hematomas” (Prisk, O’Loughlin, and Kennedy 306). Avulsions can be infected and incredibly painful, while hematomas must be drained immediately. Hematomas can recur, becoming a lifelong injury resulting from the aesthetic found in pointe work.
Small, seemingly insignificant injuries regularly occur in the ballet classroom. “Although ballet injury can terminate a dancing career, injuries are accepted as an inevitable part of the vocation of ballet” (Wainwright 50). Almost every dancer that has ever danced on pointe has experienced some form of small injury which does not stop them from dancing. “Numerous foot problems including bunions, first metatarsophalangeal degenerative joint disease, and hammertoes plague dancers, particularly those who dance en pointe” (Teitz 216). These injuries, which do not completely remove the ability to dance, are often overlooked until they become permanent. Skeletal deviations such as hammertoe are caused by the pressures in pointe shoes. Janalyn Memmot remarks, “I still have really bad bunions and hammertoe [twenty years later]” (Memmott). “Acute or chronic trauma to the Distal Interphalangeal joint or extensor mechanism may result in a [hammer] toe, as when dancing en pointe” (Prisk, O’Loughlin, and Kennedy 316). While dancing, many ballerinas develop corns, calluses, and blisters. Former ballet dancer Emilee Wright comments, “I got blisters and I still have bunions…I have ugly dancer feet” (Wright). “Ballet dancers are very familiar with corns and calluses. This tough skin literally allows the dancers to tolerate and perform in pointe toe shoes…[However] infection can occur under a corn.” (Prisk, O’Loughlin, and Kennedy 316). Thus, ballet dancers must treat injuries immediately and consistently.
“Structural problems in pointe shoes, long strenuous classes and rehearsals, or poor placement caused by tired or weak muscles incapable of holding the feet in proper alignment may cause a variety of physical stresses and strains” (Barringer, The Pointe Book 1st ed. 133). In ballet specifically, most injuries occur within the foot and ankle region, partially because of the stresses placed on the metatarsals and phalanges of the foot by pointe shoes. These stresses are transferred up through the tarsus to the ankle, and any misplacement could place shearing stresses in the tarsus and ankle. “The most common sites of injury are within the foot and ankle…This predominance is thought to be related to the anatomic requirements of the five positions that form the basis of classical ballet and the use of pointe shoes” (Stretanski, “Medical and Rehabilitation Issues in Classical Ballet” 386). Pointe shoes also restrict the spiraling action of the foot used for shock absorption; the foot is less able to make small corrections to absorb stresses and correct a faulty landing. “Many female dancers’ problems stem from the lack of mobility caused by pointe shoes” (Barringer, The Pointe Book 1st ed. 136).
While most injuries from pointe are small, some dancers sustain serious, lasting injuries that can affect the dancer for life. “Ballerinas are susceptible to a unique stress fracture of the base of the second metatarsal that is rare in male dancers or other athletes. This suggests that major stresses occur at the base of second metatarsal resulting in stress fracture” (Kadel 394). Traditionally, only female dancers dance on pointe, therefore, one can deduce that this stress fracture is caused by usage of the pointe shoe. “Classical ballet training practices…can result in phalangeal stress fractures” (Prisk, O;Loughlin, and Kennedy 307). Dancers can also develop arthritis in the joints of the feet, causing every day walking and normal weight bearing to be painful. “When retired dancers are evaluated for degenerative joint disease, more than fifty percent have anthrosis of the metarsophalangeal joints” (Stretanski, “Medical and Rehabilitation Issues in Classical Ballet” 385). Additionally, consistent relevés on pointe can cause tendonitis in the Achilles tendon, with constant accompanying pain. “As the largest tendon in the body, the Achilles tendon incurs forces up to six times body weight during running and jumping. As such, the tendon is commonly injured in dancers either from repetitive overload or excess stress applied by poor technique” (Kennedy et al. 159). These painful injuries can affect a dancer’s life long after she has retired from performing.
Although faulty technique is the cause of many pointe injuries, “even with optimum technique dancers who wear pointe shoes are bound to experience wear and tear on their feet” (Barringer, The Pointe Book 1st ed. 133). Pointe shoes are an integral part of classical ballet; without them, the art form would significantly change. “It is classical ballet that requires the longest formal training and places the greatest functional demands on the dancer’s musculoskeletal system”(Stretanski, “Medical and Rehabilitation Issues in Classical Ballet” 383). These demands can overstress the muscles and skeletal system resulting in pain and injury. In a study of two groups of dancers, a pointe group and a non-pointe group, researchers calculated the number of painful sites on a dancer’s body. “The number of painful sites was significantly different between the pointe and non pointe groups; this was…only explained, in part, by the number of years each individual had participated in ballet classes” (Nunes 103). The length of time one takes ballet classes directly correlates with whether or not she wears pointe shoes; therefore the pointe shoe itself may be the cause of pain.
The best way for a ballerina to avoid injury is to pick the correct shoe. “Ill-fitting shoes can cause a range of ailments: for example, too-narrow shoes can cause neuromas, buildups of scar tissue that pinch the nerve between the third and fourth toes and can cause loss of sensation or pain” (De Silva 112). The support found in a point shoe, measured by the shape and strength of the box and shank, influences amount and severity of pointe injuries. “Selection of a pointe shoe with adequate support may limit susceptibility to stress fracture of the second metatarsal base in ballerinas” (Kadel 394). Proper shaping of the box of the pointe shoe is also important and unique to the individual. “Posterior impingement—a bone-on-bone jam in the back of the anklebone—is also common among dancers without strong arches or sufficient relevé. Make sure these ballerinas fit pointe shoes so the tip of the box is square to the ground (rather than rounded) when in relevé, so that they don't point beyond their range of motion”(De Silva 112). Properly fitted shoes are the best and easiest method to avoid injury.
As pointe shoes continue to dominate advanced and professional ballet classes, one must be aware of the injuries that can occur simply from wearing even a properly fitted pointe shoe. In intermediate and recreational classes, however, another factor must be considered with pointe injuries. “Many of the injuries…in nonprofessional patients occur because their body types are not suited to ballet” (Barringer, The Pointe Book 2nd ed. 184). In America
A teacher of pointe must also measure maturity level and technical prowess before putting a child in pointe shoes. “Starting [pointe work] before the child is physically and technically ready is potentially very harmful”(Howse 59). Beginning pointe before the bones are sufficiently ossified can create bowing of the long bones and other skeletal deviations including hammertoe and clawtoe. Janalyn Memmot comments, “I started dancing on pointe at nine, and because of incorrect training I knuckled over in my shoe which caused hammertoe that I still have. I had to essentially start over my training at age thirteen at a new studio” (Memmott). “In addition to natural ability, motivation, and dedication, a dancer must have a supple body and feet, natural turnout, healthy knees, and excellent training geared to developing proper technique in order to survive the rigors of pointe work”(Barringer, The Pointe Book 2nded. 183). Beginning pointe work when the child is sufficiently strong and mature greatly reduces injuries in pointe work resulting both from faulty technique and the shoe itself.
With the predominance of injury so apparent in dancers on pointe, one questions the ethics of the art form. Wearing pointe shoes does not seem to be any better than binding the foot as the Chinese did centuries ago. Young children see ballerinas on pointe and aspire to dance on pointe themselves without learning of the risks and dangers involved. These dangers have become so commonplace in the dance world that they are completely expected and accepted. It is unlikely that pointe will ever be removed from ballet. Pointe work is a tradition difficult to break and a beauty that is loved by dancers and audiences alike. Like any other sport, risk is known to be involved, but unlike many sports, dancers lack a helmet or protective gear. They use little more than cardboard wrapped with satin to protect and support their feet.
However, one can take many protective measures to reduce the risk of injury. Proper technique and training drastically reduce injuries. Also, teachers and parents should be wary of pushing a child into pointe shoes before she is physically ready. Not all girls are ready to dance on pointe at twelve. Some are ready at nine and some are not ready until sixteen (Barringer, The Pointe Book 2nd ed. 176). Once a dancer sustains an injury, she can greatly help herself by treating it immediately. Often, ignoring the injury and dancing on it simply aggravates the injury.
Pointe work lends a beauty and grace to ballet. It is the breathtaking element of the art form. Dancing on pointe has many downsides, yet parting from the art would be detrimental to ballet. Pointe work attracts dancers and audiences alike. There is nothing quite like watching a ballerina complete fouettés on pointe as if it was as easy as walking out to the mailbox. “Unfortunately, the ‘cruel little slipper’,that is, the ‘en point shoe’, as well as the physical demands of the dance itself, have left many dancers with significant injuries and permanent deformities” (Kennedy et al. 164). Dancing on the tips of the toes affects the body in unique ways, both strengthening and injuring the feet, ankles, and tendons. It is a feat for the dedicated ballerina, whose desire to dance overrules all doubts relating to injuries and pain.
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Provo, UT: March 9, 2009
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