by: heather boynce and julianne swafford - home | the university
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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.
References cont. 11. Bowling, A. (1989). Injuries to dancers: prevalence, treatment, and perceptions of causes. Bmj, 298(6675), 731-734.12. Kadel, N. J. (2006). Foot and ankle injuries in dance. Physical Medicine and Rehabilitation Clinics, 17(4), 813-826.13. Lee, Hsing-Hsan, Lin, Chia-Wei, Wu, Hong-Wen, Wu, Tzu-Chuan, & Lin, Cheng-Feng. (2012). Changes in biomechanics and muscle activation in injured ballet dancers during a jump-land task with turnout (Sissonne Fermée). Journal of Sports Sciences, 30(7), 689-697.14. Johansson, L. (2011). Musculoskeletal injuries in young ballet dancers. Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA., 19(9), 1-5.15. Hopper, Alderson, Elliott, & Ackland. (2015). Dance floor force reduction influences ankle loads in dancers during drop landings. Journal of Science and Medicine in Sport, 18(4), 480-485. 16. Steinberg, Waddington, Adams, Karin, & Tirosh. (2016). The effect of textured ballet shoe insoles on ankle proprioception in dancers. Physical Therapy in Sport, 17, 38-44.17. Lin, C., Su, F., & Wu, H. (2005). Ankle biomechanics of ballet Dancers in relevé en pointé dance. Research in Sports Medicine, 13(1), 23-35.18. Ritter, S., & Moore, Marjorie. (2008). The Relationship Between Lateral Ankle Sprain and Ankle Tendinitis in Ballet Dancers. Journal of Dance Medicine & Science, 12, 23-31.19. Fong, D. T. P., Hong, Y., Chan, L. K., Yung, P. S. H., & Chan, K. M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports medicine, 37(1), 73-94. (This is a potential reference for the report, but it is not covered in the outline.)
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