Ankle Injury Prevention in Ballet Through Altered Pointe Shoe

RibbonsGracie Forbes and Emma Johnson

Background ● Ballet combines athleticism and

artistry

● Ballerinas experience high loads on

lower extremities

● Ankle injuries account for 15-22% of

all ballet injuries

● Female dancers show more ankle

injuries than male dancers as a result

of pointe shoes

Current Pointe Shoe and Ribbon Anatomy ● The box of a pointe shoe is made with

cardboard and glue

● Currently ribbons are just used to hold the

shoe in place and are sewn by hand

● There have been some shoes that use

elastomeric polymers as shock absorbers,

but no advancements to the ribbon

Ankle Moments During Pointe

Fig 1: Ankle Excursion Pattern

Fig 2: Ankle Angular Velocity Excursion Pattern

Fig 3: Ankle Moment Excursion Pattern

Previous Investigations● GRFs and peak plantar pressure were observed

during: saute, grande jeté, and standing en pointe

○ GRFs were measured by a piezoelectrical force platform

○ GRFs and joint angular variation were tested

● F-Scan insoles were used to collect peak pressure

for en pointe position

○ Peak pressures at 50 Hz for 8 seconds of standing en

pointe

● Results of one ballet dancer are presented

○ Presented in terms of mean values, standard deviations

and coefficient of variation

Results of Previous Investigations● Standing en pointe: peak pressure over the toes was higher than over the

forefoot

● Short jumps (sauté) produced greater peak pressure and higher loads over the

anterior part of the foot

● Vertical forces show that the ballet dancer deals with very high external loads

when wearing the pointe shoes

Biomechanics: Standing En Pointe● Walking in pointe shoes doubles the peak pressure acting on

the foot

○ Pointe shoes versus barefoot: (41 N/cm2 vs. 86 N/cm2)

○ Rising into releve position from a flat footed position increases

the peak pressure to 115 N/cm2

● Pointe shoes absorb some of the impact from jump landings,

but load greatly impacts the foot-ankle complex

○ A study found that the compressive strength of the shoes were

4300 N or less by testing 5 popular pointe shoe styles

○ A 60 kg ballerina landing on pointe from a height of one meter

creates an impact force that is about 4950 N

Problem ● Studies show the components that cause ankle injuries but nothing that

prevents ankle injuries

○ There are no current studies that are working on improving the pointe shoe ribbon and

strapping technique

○ Rate of reported injuries has increased from 67% to 95% among professional dancers

● Pointe shoe designs have remained unchanged

○ Lack support and shock absorption

● Previous study: tested the effects of textured insoles in ballet shoes to see if

the adjustment would improve ankle inversion moment discrimination

(AIMD)

○ Textured insoles decreased the likeliness of ankle injury

○ Problem: insoles cause arch discomfort which could limit the

shoes’ effectiveness, cause the dancers to not perform as well,

and create other injuries

Proposed Solution ● Ribbon integrated with a

material similar to kinesiology

tape

● Ribbon has a wider base and

is sewn into a different position

● New ribbon wrapping technique similar to ankle sprain

kinesiology taping technique

● Light pink colored tape with ribbon edges, so aesthetic is

kept

● Should lead to more stabilization

Significance of Design ● First change to pointe shoe ribbons

● Ankle injuries are the most common form of injury in female dancers, so a

product that can help decrease ankle injuries is essential

● Design will still look aesthetically pleasing

● Shoe itself is not changing, so the dancer’s movement integrity is not

compromised unlike previous investigations

● Ultimately, the design will be significant as it will increase ankle stability while

still allowing the dancers to perform at their best

Methods and Materials ● 4 test groups

○ Control- regular ribbons with no previous ankle injury

○ Regular ribbons with previous ankle injury

○ Re-designed ribbons with no previous ankle injury

○ Re-designed ribbons with previous ankle injury

● Test Dancer’s ankle moment through

wearable sensors

● Tests should show a decreased ankle moment

● Interview dancers to see if ribbons provide

more ankle stability and do not decrease

performance

● Observe both groups of dancers over long

term to see if ankle injuries decrease

Timetable of Research

Initial Moment Testing (1 Year)

Initial moment measurements will be taken for all dancers.

Final Moment Measurement (10 years)

Our research will end in 10 years. This will give us ample time to observe the effects of our ribbon over time to see if it really does decrease ankle moments among dancers. At the end of the 10 years, each dancer will be brought in for more testing.

Intermittent Check- Ins

Check in on the dancers periodically. These check-ins will include a survey for them to complete. If a dancer has an ankle injury while using our designed straps we will bring them back to the lab for more moment testing. We will analyze if we can change the strap positioning or material so the dancer will have more support.

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Funding● Redesigned ribbon material

● Wearable motion sensors

● Force plate

● Facility

● Research staff

○ Graduate students

○ Dance specialist

○ Physical Therapist

Possible Complications ● Design improves ankle support but not ankle

strength

○ Dance specialists recommends exercises for every

dancer on pointe

○ Cross training and injury prevention techniques could

be incorporated to improve overall strength and

stamina

● Skin may degrade if a dancer wears the straps

for too long

○ Prolonged wear of the tape-like material could cause

the dancer to lose the mechanoreceptor input that

could come from the skin

○ Dancers need to allow resting time for their feet and

skin so they can “breathe”

Future Directions ● Mass produce the ribbon

● Create an easy tutorial that is accessible for dancers to learn how to

properly tie our new and improved ribbon design

● Investigate adding different textures to the ribbon

● Research insole and toe box materials that could decrease ankle injuries and be

generally more comfortable for the dancers

○ Toe box provides balancing support while dancing:

improvements and adjustments could help improve the overall pointe shoe

Summary ● Ankle injuries account for 15-22% of

all ballet injuries

● Wearing pointe shoes doubles the

peak pressure exerted on the foot

● There are currently no studies that are working on the improvement of ballet

shoes/ ribbons in order to lessen ankle injuries

● Our solution is to create a ribbon which is integrated with kinesiology tape and

wrapped in a new manner in order to support the ankle, and thus reduce ankle

moment

● Testing will occur over the span of 10 years, with four different test groups

● Ultimately, our product will allow dancers to maintain their artistic integrity

while decreasing ankle injuries

References 1. Dance Anatomy and Kinesiology, 2E. (n.d.). Retrieved from https://books.google.com/books?id=qI3jCgAAQBAJ&pg=PA379&lpg=PA379&dq=Ankle

biomechanics of ballet Dancers in relevé en pointé

dance&source=bl&ots=5djr_pkRIY&sig=BDFtgJHl3y7_YmsUbsKK0Nh2zx0&hl=en&sa=X&ved=2ahUKEwi0nYL2vtLeAhVEZN8KHUujCeIQ6AE

wBHoECAUQAQ#v=onepage&q=Ankle biomechanics of ballet Dancers in relevé en pointé dance&f=false

2. Pointe shoes complicate biomechanics of ballet. (n.d.). Retrieved from

https://lermagazine.com/article/pointe-shoes-complicate-biomechanics-of-ballet

3. How to Apply Kinesiology Tape to a Sprained Ankle #TapeTuesday. (2017, January 24). Retrieved from

http://blog.performancehealthacademy.com/2017/01/24/how-to-apply-kinesiology-tape-to-a-sprained-ankle-tapetuesday/

4. Picon, A. P., Costa, P. L., Sousa, F. D., Sacco, I. D., & Amadio, A. C. (n.d.). BIOMECHANICAL APPROACH TO BALLET MOVEMENTS: A

PRELIMINARY STUDY. Retrieved from https://ojs.ub.uni-konstanz.de/cpa/article/view/2402/2256

5. University of Delaware College of Health Sciences. (2016, October 26). Ballerinas on point studied in motion capture. Retrieved from

https://www.youtube.com/watch?v=S2gcYaTbVhc

6. Steinberg, Waddington, Adams, Karin, & Tirosh. (2016). The effect of textured ballet shoe insoles on ankle proprioception in dancers. Physical

Therapy in Sport, 17, 38-44.

7. Ankle sprains and taping. (2013, October 31). Retrieved from https://alysserina.wordpress.com/2013/10/31/ankle-sprains-and-taping/

8. Pointe Shoe Toe Box. (n.d.). Retrieved from https://www.russianpointe.com/perfect-fit/pointe-shoe-toe-box/

9. Injury in Ballet: A Review of Relevant Topics for the Physical Therapist. (1994). Journal of Orthopaedic & Sports Physical Therapy, 19(2), 121-129. doi:10.2519/jospt.1994.19.2.121

10. Byhring, S., & Bø, K. (2002). Musculoskeletal injuries in the Norwegian National Ballet: a prospective cohort study. Scandinavian journal of medicine & science in sports, 12(6), 365-370.

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