Lukas Hinds-Johnson, Staatballett Berlin’s resident physiotherapist and owner of PhysioX Berlin
In this installment of Physio Talk, we’re uncovering what it takes to go en pointe, how pointe shoes come into play, and why you need to know what’s going on inside your pointe shoe–and even more when choosing the right pair, and a preview of what is in store for the future pointe shoe market.
We’ll dive into the feet anatomy, their biomechanics, plus how pointe shoes allow you to balance; how they support you in movements, like jumps and landing, and the transfer of weight that occurs from your arch to your toes.
Let us follow the journey of Alice, a young dancer who has dreamt of becoming a prima ballerina ever since watching her first ballet performance, The Nutcracker, on Christmas day. She was immediately captivated by the magic of the choreography, the costumes, and the emotions she felt from watching the dancers glide across the stage. Mesmerized by ballet from the get-go, she knew ballet was for her.
Alice was particularly drawn to Clara’s duet as her character rose up onto her toes en pointe, practically floating across the stage. She had an instant enchantment and desire to pursue ballet so that she could pass that same magic onto another child. Alice was 12 years old at the time.
From then on, Alice enrolled in a local ballet school where she took her first ballet lesson, impatient and eager to go en pointe just like Clara. However, Alice’s teacher taught her otherwise. Like first learning how to master the basic technique to strengthen and prepare your body for pointe work, because like all ballet movements, ballet requires strength and a solid foundation. Pointe work adds a layer of complexity because many things are happening simultaneously in the body to achieve and sustain balance en pointe. It means that the body has to cope with the strain on the ankles.
So, what happens when a dancer goes up en pointe? To answer that, we’ll take a closer look at the foot as a whole.
What’s In A Foot?
The foot is made up of 26 bones, each interacting with one other, enabling movement while maintaining balance.
The foot is divided into hindfoot, forefoot, and midfoot.
1. The Hindfoot The hindfoot is made up of the talus and calcaneus, forming the ankle. It is made up of an upper part, think pulling the foot up and pointing, and the lower ankle/subtalar. The hindfoot makes the complex movement of pulling the foot into inversion/adduction and eversion/abduction possible.
The hindfoot begins at the ankle joint and stops at the transverse tarsal joint. Located between the tibia and fibular, it forms the upper ankle joint.
The talus (Source: Ken Hub)
When you are en pointe, your upper ankle joint pulls the foot up and down and to its sides (slightly). The lower ankle joint connects the ankle bone to the tarsal bones and the calcaneus but is less mobile than the upper ankle joint. The lower ankle joint allows the foot to tilt slightly to the side and pivot inwards and outwards. Both the talus and the calcaneus connect to the bones of the midfoot.
2. The Midfoot
The midfoot is made up of 5 bones and lays between your two big ankle bones and the metatarsal, aka toe bones. These bones have a limited range in movement. They are responsible for more complex moves, such as adjusting your foot to uneven ground and working with the ankle to bring your foot in and outwards. Additionally, there are a lot of ligaments and tendons attached to it.
The midfoot begins at the transverse tarsal joint and ends where the metatarsals begin--at the tarsometatarsal (TMT) joint. The midfoot has several more joints than the hindfoot, and these joints have limited mobility. The five bones of the midfoot comprise the navicular, cuboid, and the three cuneiforms: medial, middle, and lateral.
3. The Forefoot
Metatarsals, phalanges, and sesamoids total 21 bones and make up the forefoot. It supports our toes en pointe when much force occurs. The bones that make up the forefoot are also the last to leave the ground when we walk. In terms of metatarsals, we have 5 total numbered 1 to 5. Number 1 forms our big toes to the 5th, our pinky toe. As more load goes through the first 3 toes, they are held more rigidly in place compared to the other two toes on the outside.
After a long year of dedication, Alice was finally able to go en pointe. She was overjoyed at the idea of getting her first pair of pointe shoes that she was not prepared for sore feet at the end of her first pointe class. Her teacher explained that the pain was due to the new load onto her foot and that it would be necessary to find the right pair of pointe shoes. While it made sense, Alice’s parents had just spent 60 EUR on her new pair of pointe shoes. It would be some time before they would be willing to pay for another new pair.
So Alice understood she would have to manage in the meantime with her existing pair and, hopefully, with more experience, experimentation, and time, she would somehow find the right shoes in the long run. For the time being, even with the pain, Allice was just happy to fulfill her dream of going en pointe.
So to explain the pain of going en pointe, now, let’s take a look at what happens in the foot when you go up on your toes.
Demi-Pointe To Pointe When you dance, you use open and closed kinetic chains. The foot is not weight-bearing and moves freely in the air in an open chain. It requires stability based on passive (ligaments, capsular, and shape of joint) and active structures (muscles and tendons), plus biomechanical mechanisms. Any joint in the foot can move without the upper ankle joint, meaning they aren’t always affected by movements of the ankle. Once you load your foot and make it weight-bearing, movements in any joint are connected to the others, creating a closed chain that follows biomechanical rules. It means what we describe above moves relative to the distal joint (underneath) bearing the weight. If the movement desired does not follow the rules dictated by the joint formation and normal muscular biomechanics of the foot in dance, then injuries (acute or stress-related) can occur. That’s because the bone structures, joint capsules, ligaments, muscles, and tendons are all under stress. So, listen up: it’s a matter of safety and comfort to examine your joint movements regularly, especially when injury or pain is present.
An unstable foundation or ankle can also cause issues around the foot, knee, hip, and pelvis, impacting the spine. Typically, your body will compensate somewhere along the chain, resulting in stress situations for the tissues around that area. Along those axes, the movement of the foot and ankle takes place. Between the talocrural (upper ankle), subtalar (lower ankle), the midfoot joints, and as well along the first (big toe) and 5th metatarsal (small toe), the axes of motion are running along, oblique to the body planes. The axes of motion are at an angle to three body planes. It enables us to do a combined movement of adduction, plantar flexion (demi-pointe & full pointe), and inversion.
When Relevé-ing During a relevé, the plantar fascia tightens up with an extension of the toes. It is the thick connective tissue (aponeurosis) that supports the arch on the bottom (plantar side) of the foot. When it is not aligned properly and forced into an unnatural turnout, the biomechanical action of the plantar structures will probably not work and sacrifice the normal movement pattern, resulting in a loose foot.
While executing the relevé, one must activate the glute muscles to stabilize the pelvis, hip, leg alignment and straighten the knees to secure the knee and transfer the forces of the movement. The thighs turn outwards while the heels are brought forward and together in the first position. Gait analysis of a normal heel raise shows that it is always connected with an inversion of the calcaneus with mid and forefoot activities. Resulting in a supination position (outward) of the subtalar joint while lifting the heel. When lowering the heels back to the ground, you need eccentric muscle activity in the external rotator muscles of the hip. You can see it’s a complex movement, and you should slowly but steadily progress from practicing demi-pointe into three quarters and fully pointe to gain solid control. It is especially true after an injury.
Strong and strengthened foot muscles are required to create and hold the foot arch. Difficulty going en pointe can be related to the tightness of the ligaments of the backside, joint capsule (particularly on the upper front side), issues of the upper ankle and muscles, tissues, or bursas on your backside. That means a lot of effort for your calf muscles (triceps surae/soleus and gastrocnemius), resulting in hypertrophy or tension.
During relevé, the entire weight shifts to the 1st and 2nd toes, as the whole lower extremity turns out. When the dancer is on full pointe in pointe shoes, even the 5th metatarsal is part of the support system assisting in balance. Support of the hip adductors is needed to direct the load onto the medial forefoot instead of letting the weight shift too much laterally. For this reason, the hip adductors also need to be well-trained and “connected” in relevé to control the chain. So if the dancer forces the foot too much with limited hip external rotation, the stress of moving is transferred onto the foot joints. Dancers need strong functioning glutes to keep the alignment and spiral dynamic. The subtalar joint is the first to absorb the shock weight-bearing caused by gravity.
A free range of motion is needed when doing a demi-plié, and one deep enough to achieve shock absorption in jump landings. Therefore, you need good ankle mobility and control to go into dorsiflexion; otherwise, you will load more forces on the knee and ankle. In a limited range of movement in dorsiflexion, the motion is transferred as compensation to the subtalar joint, leading to hyper-pronation and compromised medial knee alignment.
Early Pointe Work? A Big No-No. A dancer shouldn’t start pointe work too early. It’s a very complex movement with many forces going through the body. So starting pointe work before age 12 is most likely too early. One needs good foot-ankle mobility and control, a strong and stable hip and pelvis, and core muscles. So the more mobile you are, the more control you need.
Forces increase drastically when you dance on pointe. A study comparing the load on the foot in barefoot versus soft shoes, demi-pointe shoes, and pointe shoes concluded that areas of the foot got 3 times as much pressure in pointe shoes compared to being barefoot. The pointe shoe is like a brace, dictating where the forces are going through and aligning the axes of movement in a particular way.
Let’s get back to Alice. If we fast forward 14 years, Alice has experienced a long up path of many ups and downs with pointe shoes. Having dedicated years of sweat and tears to becoming a soloist, she has fulfilled her dream of being cast as Clara in The Nutcracker.
On the day of the premiere, she arrived early at the opera to start with her pointe shoe rituals and routines. She starts with her lengthy pointe shoe preparation.
The Centuries-Old Pointe Shoe After learning more about the foot anatomy, its muscle chains, and biomechanics, it’s time to take a closer look at what is inside a centuries-old traditional pointe shoe. The shoe comprises several components and materials and is made similar to paper mache. In theory, it’s a beautiful process; however, the demands of a dancer and the support they need run contrary to a shoe that breaks down in heat and sweat. With over 16 parts that make up a traditional pointe shoe, many dancers still experience issues and difficulties with their shoe, whether it be aesthetics, durability, comfort, performance–or all.
Anatomy of a traditional pointe shoe (Source: Bloch)
So, What Does A Pointe Shoe Do? The traditional pointe shoe was invented and designed to give the ballerina a unique connection to the floor and elongate the line. The platform idea is to create a more stable surface; but, in actuality, it adds more pressure to the toes. While the traditional pointe shoe was revolutionary for its time, we are now in 2022, and every human is different; this is no different for our feet.
We can define three different types of toes and foot shapes:
● Peasant foot: All toes are even in length. Probably the best type of foot to go en pointe as the load is distributed all over the toes. ● Grecian foot: When the second toe is the longest, you will most likely need a wide box to achieve the most comfort. ● Egyptian foot: Tapering toe length usually requires a narrower box.
Essentially, it doesn’t matter what foot shape you have because of the first phalange; the big toe will bear the most weight. It is why our biggest toe has different anatomy from the other toes.
When the box or shank of the pointe shoes becomes too soft, and the shoe loses its usefulness and performance ability, it puts the dancer at increased risk of injury. It is an underlying decades-long problem that continues today. Beyond shellack, jet glue, nails, and whatever short-term solution dancers have managed to save their shoes for one more class or performance. It is not a sustainable solution. Traditional pointe shoes do not last long, and it is inevitable when combined with heat and sweat that they break down.
That’s something that has bothered Alice ever since she increased her training hours and performances. Beyond the effort and time needed to prepare her shoes, in a time when climate change is real, Alice wants to reduce her carbon footprint, starting with the amount of trash produced by dead pointe shoes.
The magical memory of trying her first pointe shoe is overshadowed by the time, energy, pain, and costs she must spend on the preparation and breaking-in process. Alice wonders, what if things could be different? After all, dancers are athletes, and in any other sports profession, they would be treated as such. What if more innovation could be introduced into pointe shoes where health, durability, performance, sustainability, support, and aesthetics were prioritized and achieved simultaneously? And while Alice loves the idea of pointe shoes and the feeling she has on stage, she seeks a better solution.
And what if there was a solution?
Introducing the act’pointe
act’ble has developed a vastly improved pointe shoe alternative with leading dance medicine and research institutes. The act'pointes protect dancers' feet, legs, and overall health. Using innovations and technologies, such as 3D printing and scanning, make it possible to create unique geometry with materials that result in the pointe shoe lasting (up to 5x) longer.
General: ● The act’sole is made out of TPU and is fully recyclable ● The sole and the skin are interchangeable, making it a truly revolutionary and customizable shoe.
Sole: ● Due to the geometry, the act'pointes don't need breaking-in: they are ready to wear.
● The shoe provides stability and flexibility with a sole that has incisions (spine-like patterns), allowing the dancer to work through their feet in the shoe.
Skin: ● The shoe's skin-like upper provides compression and support simultaneously. ● It also adapts to the difference in length of the foot, compared from standing en pointe to flat.
● Additionally, the foot is held by specific act'laces, providing ample support and can be adjusted to personal needs and come in different sizes.
● They are replaceable and can be attached without hand-sewing.
Considering all things to do with feet anatomy, kinetics, and the above specifications of the new act’pointes, I see great potential and advantage of the act’pointes compared to traditional paper maché pointe shoes. With the new design and innovation of act’ble’s shoe, I believe they allow your feet more movement range within each foot. Because no one is built the same nor moves the same, the act’pointes function achieves both support and stability. Not to mention the shoe is made through 3D printing and scanning, meaning it is adapted specifically to your anatomy.
The second point is that the spine-shaped sole helps to effectively absorb the huge forces going through your foot instead of damming up forces in individual areas, which could avoid compensating movements along the kinetic chain, thus preventing stress or injuries of tissues. A healthier pointe shoe that protects the dancer will ultimately lead to a dancer prolonging her career. It is crucial because the foot is the base of your posture, and any small change can have a larger impact along the movement chain.
Another plus is the act’pointes’ sustainability, as you can exchange parts of the shoe and the material. Dancers are creative athletes, and it is time to break the old dogmas. It’s not about abandoning old traditions–but improving them and enhancing your ability to perform.