Readiness for Pointe Shoes in Ballet: A Delphi Consensus Study

Readiness for Pointe Shoes in Ballet: A Delphi Consensus Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Readiness for Pointe Shoes in Ballet: A Delphi Consensus Study Haydee Ferguson, Rhiannon Snipe, Jason Bonacci, Dominique Condo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8644695/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background A ballet dancer’s first pair of pointe shoes marks a significant milestone in ballet training. Pointe shoes are synonymous with classical ballet and allow dancers to perform on the tips of their toes. Beginning pointe training is a multifactorial decision, but consensus is lacking regarding the abilities a dancer must demonstrate to progress to pointe training safely. Guidelines have been established by the International Association for Dance Medicine and Science, however, are largely broad and subjective. We aimed to establish a consensus on key factors a dancer should demonstrate before commencing pointe work via a scoping review and Delphi method. Results A scoping review identified existing criteria, followed by a three-round Delphi method with 21 experts (ballet teachers, health professionals and experienced researchers). Combining scoping review criteria with panel responses, three themes and 10 areas of assessment were identified, along with 22 reasons to complete a pointe readiness assessment. The panel rated their level of agreement for each criterion on a 4-point Likert scale (strongly-disagree to strongly-agree) to determine consensus (≥ 80% agreement). 48/99 of identified criteria to assess pointe readiness reached consensus. Single-leg heel-rise (SLHR) repetitions, balance and control and injury history reached the highest consensus in influencing the decision to progress a dancer to pointe. 18/22 reasons to conduct a pointe assessment reached an agreeable consensus. Conclusion This study provides a comprehensive evaluation of pointe readiness criteria and explores the differing perspectives of a range of stakeholders. It also offers a foundation for developing standardised, evidence-informed guidelines. Further research is needed to validate measures and improve the effectiveness of pointe readiness assessments. Pointe readiness assessment ballet pointe Delphi method Figures Figure 1 Figure 2 Introduction Ballet is an artistic dance form built on a structured repertoire of movements. It is recognised for its elegance, extensive range of motion and distinctive use of pointe shoes. Dancing in en pointe is an essential part of advanced ballet technique but also imposes substantial load on the lower limbs( 1 , 2 ). In female ballet dancers, most injuries occur during adolescence between the ages of 12 and 18( 3 ). As 12 is the typical age for initiating pointe training, it is important that clear guidelines are established to ensure dancers transition en pointe safely( 4 , 5 ). Multiple studies have reported 41.1–77% of ballet students will experience at least one injury during their pre-professional training with lower limb injury incidence up to 91%( 3 , 6 – 9 ). A substantial proportion of these injuries, particularly in the feet and ankles, are associated with dancing en pointe ( 4 ), highlighting the importance of ensuring dancers are physically prepared before starting pointe work. Despite potential risks of injury when dancing en pointe ( 10 ), there is a lack of consensus around what a dancer must demonstrate to be successful and safe when initiating pointe training( 4 ). The initiation of pointe training has traditionally been based on subjective opinions( 11 ). Historically, ballet teachers have determined when a dancer can start pointe work, but in recent years there has been a shift towards more objective evaluations conducted by health professionals (e.g. physiotherapists)( 12 ). Despite this, it has been suggested a teacher’s assessment of a dancer’s readiness may be more reliable than a battery of tests( 13 ). However, it remains unclear what criteria teachers prioritise or whether their expectations vary compared to health professionals. In 2009, the International Association for Dance Medicine and Science (IADMS) developed guidelines for initiating pointe work( 5 ). These included dancers being ≥ 12 years of age, having ‘sufficient’ ankle and foot range of movement (ROM), be training at a ‘pre-professional’ level, have strong core and leg muscles, controlled hypermobility, be participating in ≥ 2 ballet classes per week, and completed > 3 years of ballet training( 5 ). Despite having set guidelines, many of the criteria are subjective in nature thus leaving room for interpretation( 11 ). A recent consensus study found the assessments most used in practice by dance experts when evaluating pointe readiness were single-leg-heel-rise (SLHR) repetitions, ankle ROM and core stability and strength( 13 ). This study was limited by a high panel drop-out (33%), a low consensus threshold (60%), and no discussion of differences in opinion between stakeholder groups( 13 ). Despite providing some general guidance to their panel on what the dancer should demonstrate for each criterion to be considered pointe ready; it remains unclear whether these aligned with the panel’s real-world practice. Our study aimed to establish expert consensus on the key criteria a dancer should meet before beginning pointe training, as well as the reasons for conducting a pointe readiness assessment to support ballet teachers and health professionals in deciding when to progress a dancer en pointe . We sought to compare the criteria identified by the panel as important with the current IADMS guidelines and contrast to existing consensus studies to determine the extent to which these guidelines are being applied in practice. Our final aim was to establish criteria regarded as important by each expert group for assessing pointe readiness, thereby enabling a comparison of their respective priorities. Methods This study comprised two parts: (i) a scoping review; and (ii) a three round Delphi consensus panel. Ethics approval was granted from the university’s Human Research Ethics Committee (Project Number 2024/HE000106) for the Delphi panel component. Part 1: Scoping Review A scoping review was conducted to identify literature for determining pointe readiness, which were combined with the panel input from the Delphi process to create a comprehensive list of criteria used to determine pointe readiness. A systematic search of EBSCOhost databases (CINAHL, MEDLINE, Academic Search, SPORTDiscus, Scopus) was performed from inception until January 2025. Terms searched were ballet AND (pointe OR pre-pointe) AND (screen OR assessment OR readiness). Reference lists for selected studies were manually searched for additional relevant papers. Identified studies were exported to Covidence (Veritas Health Innovation 2025). After removing duplicates, two researchers independently screened studies by title and abstract, then full text against the eligibility criteria. Studies were included if they mentioned requirements for dancers to initiate pointe training or compared abilities of dancers at a pre-pointe level with those who had started pointe training. Given the limited number of peer-reviewed articles and the significant role of historical knowledge in assessing dancers, grey literature (e.g. magazine articles and blogs) was also considered. Criteria influencing the decision to progress a dancer to pointe were extracted if they: (i) determined readiness for initiating pointe training; (ii) differentiated between pre-pointe and en pointe dancers; or (iii) compared an objective test with a ballet teacher’s recommendation for starting pointe work. Part 2: Delphi Technique A three round Delphi consensus method was used to identify criteria that should be considered in allowing a dancer to initiate pointe training. The Delphi method was conducted between September 2024 and March 2025 using online Qualtrics (Qualtrics, Provo, USA) survey software. Expert panel Fifty participants were invited via email to join the expert panel. Participants were identified via contacting internationally recognised dance education organisations, dance specific healthcare centres and authors of dance research papers. To qualify for inclusion, participants had to be either a ballet teacher or health professional with > 5 years of experience assessing dancers' readiness to initiate pointe training, or a researcher with publications in the last 10 years related to pointe readiness, injuries associated with pointe training or ballet technique. Twenty-three people responded, of which 21 participants from three countries (Australia n = 18, New Zealand n = 2, England n = 1) met the eligibility criteria and were recruited to participate in the panel. This exceeds the reliability criteria of > 10 experts when using the Delphi method( 14 ). The panel included 11 registered health professionals (9 physiotherapists, 2 podiatrists), six ballet teachers with advanced training in the Royal Academy of Dance or Cecchetti syllabi, and four researchers. Health professionals had an average of 18.4 ± 8.2 years (range 8–32) of experience treating dancers and 15.6 ± 7.4 years (range 5–32) experience assessing dancers for pointe training. Ballet teachers had 40.6 ± 7.0 years (range 30–50) ballet teaching experience and 31 ± 13.1 years (range 5–47) experience progressing dancers en pointe . All panellists provided informed consent via an online electronic platform prior to participating in the first Delphi round. Panellists were given four weeks from the invitation date to complete each round of the online survey, with reminders provided after two and three weeks. Round 1 The panel were asked to provide an exhaustive list of what they believe important to consider before a dancer initiates pointe training and a list outlining the purpose of a pointe readiness assessment. Participants were not provided with criteria extracted from the scoping review to minimise response bias. Following the completion of round one, three members of the research group conducted an inductive content analysis of criteria identified from both the scoping review and the panel( 15 ). Unique items were categorised into major themes and subthemes. Round 2 Unique criteria identified in the inductive content analysis were listed next to a four-point Likert scale (1–strongly disagree, 2–somewhat disagree, 3–somewhat agree, 4–strongly agree) and presented to the panel. Panellists indicated their level of agreement on whether each criterion would influence their decision to allow a dancer to start pointe work. When panellists agreed with a criterion, they were asked to describe what they would expect to observe in a dancer ready to begin pointe training. Panellists were invited to list any additional criteria that may have been missed in round one. Consensus for or against each criterion was reached if ≥ 80% agreement (combined responses of somewhat and strongly-agree or somewhat and strongly-disagree) was achieved by the panel( 16 ). As the researcher sub-group of the panel consisted of only four participants, a consensus rate around 80% was not mathematically possible. Therefore, the consensus rate was lowered to 75% when considering sub-group level analysis. Round 3 A second round of agreement ratings, following the same process as round two, was conducted for criteria that did not reach consensus. Following this round, any criteria that did not reach the ≥ 80% threshold were deemed to have not reached consensus. Results Part 1: Scoping review Identification and selection of studies Through the database search, 409 records were identified. After removal of duplicates and eligibility screening, 13 research articles and nine grey literature articles remained (Fig. 1 ). Study quality and characteristics Nine of the 13 included articles used a cross-sectional design (Table 1 ), with the remaining four being commentary studies (Table 2 ). The nine cross-sectional studies( 4 , 12 , 17 – 23 ) were classified as level four evidence (low) and commentary studies( 5 , 24 – 26 ) classified as level five evidence (very low) as per the Centre for Evidence-Based Medicine hierarchy( 27 ). Forty-eight unique assessment criteria for pointe readiness were identified from the included articles. Criteria extracted included minimum age, ballet technique elements, range of movement (ankle plantarflexion, 1st metatarsophalangeal joint extension, hip external rotation), strength (core, calf), balance and control (airplane test, topple test), and training history (years of ballet). Due to the traditionally subjective decision and limited number of articles identified, nine grey literature articles from online magazines and blogs( 28 – 35 ) were also considered for review (Table 3 ). Similar findings of age, technique, ROM and strength were discussed through all grey literature. Other than a minimum age of 10–12 years to start pointe training, no other objective measures were identified( 29 , 30 , 34 – 36 ). Table 1 Summary of studies (n = 9) included in the review analysis Study Design Participants Age (years) Testing Outcome/Recommendations Review DeWolf et al. 2018 ( 12 ) Cross-sectional n = 49 pre-pointe n = 28 pointe n = 21 pre-pointe = 10.21 ± 1.17 pointe = 11.42 ± 0.81 Range of Motion • Non-weightbearing plantar flexion and dorsi flexion • Weightbearing lunge Muscular Capacity • Plantar flexion strength • Relevé endurance Balance • Airplane test • Star excursion balance test Pointe group performed significantly better in relevé endurance and airplane test repetitions. Findings suggested that 15 continuous single leg relevés and two quality repetitions of the airplane test may be useful in distinguishing the level of strength and proprioception required for successful pointe training. Erdman et al. 2024 ( 23 ) Cross-sectional Ballet instructors n = 31 43 ± 13.8 Questionnaire to assess the awareness and use of pointe readiness criteria Knowledge of existing pointe readiness criteria was low with only 30% aware of published guidelines. Dancer strength (100%), dance technique (94%) and age (87%) were rated as greatest indicators of pointe readiness. Guggenheim 1994 ( 22 ) Cross-sectional Directors of 11 ballet schools 10 out of 11 responded to all questions not reported Questionnaire addressing current practices of initiating pointe training 2–5 years of ballet training for pointe work Age to start pointe training 9–11 years First year of pointe training 5–10 minutes up to 2 hours per week Second year of pointe training two 15-minute sessions per week to four sessions per week of 30 minutes – 1 hour. 8/10 schools prohibited ‘obese’ dancers from starting en pointe and 5 schools reported asking dancers to diet for the purpose of weight control. Anatomical variations were considered insignificant to pointe training Determinants for the initiation of pointe training varied greatly between schools. No physical or objective testing was discussed. Hewitt et al. 2016 ( 21 ) Cross-sectional female ballet students n = 29 pre-pointe n = 12 beginning pointe n = 7 intermediate pointe n = 10 all groups 13 ± 3 pre-pointe 10.8 ± 2.1 beginning pointe 13.7 ± 2.4 intermediate pointe 15.3 ± 2.2 Timed plank test Heel rise test Airplane test Topple test Single leg sauté test Teacher classification Significant difference found between pre pointe and intermediate group on the sauté test and the airplane test. A significant difference was also found on the topple test between the pre pointe group and the beginner and the intermediate pointe groups. Therefore, these tests may be useful in discriminating between p There was a maximum 12-year age gap between the pre-pointe and intermediate pointe groups and a difference of 13.5 years in ballet training. It is possible that the significant differences were related to development and experience rather than pointe readiness. Meck et al. 2004 ( 4 ) Cross-sectional 200 dance institutions invited responses n = 74 not reported Survey of 21 items used in pre-pointe evaluations: age, years of dance, menses history, present injuries, past injuries, x-ray, MRI, bone scan, spinal alignment, gait analysis, proprioception, muscle length, range of motion, manual muscle test, relevé, plié, port de bras, tendu, passé, developpé, upper body. Highest frequency of items used in pre-pointe evaluation: Age 95.9% Years of dance 91.9% Present injuries 87.8% Past injuries 82.4% Relevé 94.6% Plie 89.2% Tendu 77.0% Upper Body 79.7% Perhaps the presence or absence of health care professional has a greater influence on the pre-pointe evaluation than affiliation with professional dance company Richardson et al. 2010 ( 20 ) Cross-sectional pre-pointe n = 37 12.3 ± 2.2 Pencil test (PF range) Modified Romberg test Passé-relevé Topple test Double Leg Lower test Single Leg Step Down Airplane test Single leg sauté test Single leg heel rise test Teacher rating Airplane test, topple test and sauté tests were found to be most sensitive for predicting pointe readiness. Older/more experienced dancers performed better on tests than younger/less experienced dancers There were substantial differences between dancers with ages ranging from 9–17 years and experience from 1–12 years. 33 of the participants were in pre-professional training doing 5.5-9 hours per week, remaining 4 were from community level programs doing 1.5-3 hours per week. Teacher ratings on pointe readiness were provided by the dancer’s usual teacher which may contribute to bias due to personal relationship. No detail on why particular tests were chosen or why particular pass/fail criteria was chosen. Shah 2024 ( 19 ) Cross-sectional n = 17 en pointe or < 3 months en pointe 13.1 (range 10–17) Pilot study of PASSE screening tool for pointe readiness (Pointe Assessment Screen Shah Edison). Part 1 – questionnaire on dance history, bone health, injury and dance goals. Part 2 – physical examination of range of motion, core and strength testing, evaluation of dance technique. ‘PASSE’ assessment tool had 94% agreement across raters for determining pointe readiness (p = 0.0004). > 90° ankle plantarflexion, stability in grand plié and relevé balance had highest sensitivity for overall readiness thereby deemed necessary to advance to pointe. Relevé passé, airplane test and sauté test indicated lack of readiness. Wide range of ballet training hours per week ( 3 – 18 ) and range of years dancing ( 6 – 13 ) Teacher ratings on pointe readiness were provided by the dancer’s usual teacher which may contribute to bias. Unknown age and experience of dancers who were deemed ready to be en pointe . Solomon et al. 1993 ( 18 ) Cross-sectional n = 32 pointe n = 11 pre-pointe n = 11 controls (non-dancers) n = 10 pointe 11.01 ± 0.71 pre-pointe 9.83 ± 0.83 controls 10.35 ± 0.70 Passive range of motion at ankle (plantar flexion, dorsi flexion) Isokinetic strength at ankle (PF/DF) and knee (Fl/Ext) The pointe group demonstrated the greatest flexibility at the ankle, followed by the pre-pointe then control groups. The control group demonstrated greater peak torque across all muscle groups than dancers. Only lower limb muscles and joints were tested. Concluded that more items need to be included to determine pointe readiness. Noted that isometric testing may not be accurate indicator due to the eccentric nature of pointe movements. Veirs et al. 2023 ( 48 ) Cross-sectional n = 26 on the box n = 11 not on the box n = 15 14 (IQR = 13–16) on the box 15 (IQR = 2) not on the box 14 (IQR = 3) 10–15 repetitions of relevé in first position with 3D motion capture peak relevé en pointe position 6 variables captured Kinematic – ankle plantar flexion and first metatarsophalangeal relevé angle and C7 marker displacement Kinetic – ankle plantarflexion and hip mediolateral and hip anteroposterior net joint moments Dancers who were able to get ‘on the box’ had greater 1st MTP joint extension range (90deg) compared to dancers ‘not on the box’ (70deg). Dancers ‘on the box’ had greater ankle PF range, however not statistically significant. The dancers who were ‘on the box’ had twice as much pointe experience than those who were ‘not on the box’. This may indicate training experience influenced their technique. It is unknown if the dancer’s shoes contributed to their ability to get ‘on the box’. IQR: interquartile range, PF: plantarflexion, DF: dorsiflexion, MTP: metatarsophalangeal, Fl: flexion, Ext: extension, PASSE: Pointe Assessment Screen Shah Edison Table 2 Summary of commentary studies (n = 4) included in the review analysis Study Design Outcome/Recommendations Themes Lai, Kruse 2016 ( 26 ) Commentary study Age not a reliable indicator of readiness on its own Skeletal maturity – radiographs not recommended as complete ossification does not occur until 18yrs old Technique – proper turnout in 1st, 2nd and 5th positions Flexibility – ankle PF minimum 90deg Strength, proprioception and postural control – Airplane test, sauté test, topple test Training – assess on technical ability not necessarily years of training. Technique and skill Balance and control Technique and experience Range of motion Strength Age and maturity Shah 2009 ( 24 ) Commentary study Restricting age is more based on tradition than science. Needs adequate maturity and physical capability rather than specific age or years of training Technique – turnout control Flexibility – first MTP joint 80-90deg extension, ankle PF 90deg Strength, proprioception and placement – relevé passé, grand plié in 1st, 2nd, 4th and 5th positions, pirouette (topple test), airplane test, sauté test Training – 4 years of serious ballet training before starting en pointe Technique and skill Balance and control Training and experience Range of motion Strength Age and maturity Shah 2021 ( 25 ) Commentary study Age – usually 11-13yrs, but no requirement exists Growth Plates – low risk of damage, not a reason to delay starting en pointe Flexibility – 1st MTP joint 80-90deg extension, 90deg ankle PF Technique – Turnout control Alignment – torso control whilst using arms and legs Leg length difference can affect alignment Maturity – able to take and apply corrections Strength – core muscles, 25 relevés Proprioception – balance and control for pirouettes History - health, injury, sleep, etc Technique and skill Balance and control Range of motion Strength Alignment General health Age and maturity Injury history Dancer’s goals Weiss et al. 2009 ( 5 ) Commentary study Do not start pointe if: • < 12 years • Not anatomically sound (i.e. ankle foot PF, poor alignment) • Not truly at pre-professional level • Trunk, pelvic or leg muscles are weak (start strength program) • Hypermobile in ankle or feet (start strength program) • Only 1 ballet class per week Can start pointe if: • ≥ 4 years of ballet training if classes are x2 per week and none of above applies Technique and skill Training and experience Range of motion Strength Alignment Age and maturity Dancer’s goals PF: plantarflexion, MTP: metatarsophalangeal Table 3 Summary of grey literature (n = 9) included in the review analysis Author Publication Recommendations Themes Barringer 1995 ( 28 ) Dance Magazine Technique justifies it Pointe work takes more than developed muscles and understanding of placement Technique Alignment Strength Batalden 2020 ( 29 ) Orthopaedic Practice No tests to predict dancer ability to dance en pointe Typically start age 12 in the USA Duration of training does not produce standard level of proficiency 90deg ankle plantar flexion Difficult to assess tests (e.g. sauté test) without slow motion analysis and specific criteria Poor performance on satué test reflected low repetitions of heel rise test Age and level of achievement Technique and muscle development Range of motion and flexibility Training and experience Range of motion Age and maturity Brandt 2012 ( 30 ) Pointe Risk growth plate injury if start before age 11 Incentive to start between 11–13 as bones still malleable Technique readiness Turnout when rising Ankle stability and muscle tone Training intensity Metatarsal and intrinsic muscle work Hip and core strength for turnout Technique and skill Strength Age and maturity Brewer 2005 ( 31 ) European Dance News Feet, legs and hips are strong enough Hold passé on one leg on half pointe – should be strong enough for simple pointe work Relevé with knee straight and strong Good posture, understanding of placement, foot and ankle alignment, understanding of turnout Straight line from big toe joint to ankle Hypermobile child should start as late as possible Technique and muscle development Technique and skill Range of motion Strength Alignment Dekle 1994 ( 32 ) Dance Magazine Technical level Muscular strength Body structure Attitude Control of basic posture and alignment Technique and muscle development Physiological development Technique and skill Training and experience Strength Alignment Giguere 2020 ( 33 ) Dance Education in Practice Sufficient ankle strength Understanding and demonstration of alignment and turnout Intermediate level Training and experience Alignment Horosko 1997 ( 34 ) Dance Magazine Hold passé on demi pointe at the barre for 45 seconds Never before bones are sufficiently ossified Not before age 10 Not clenching or gripping toes when bare foot Teacher sufficiently experienced Technique and skill Balance and control Training and experience Age and maturity Sandall 2019 ( 35 ) Dance Magazine Not before age 11 No evidence that starting before 11 is damaging Chronological and biological age can differ significantly Teachers develop own pointe readiness indicators Functional ballet technique How introductory pointe classes are structured Training and experience Age and maturity Vogel 2004 ( 36 ) Dance Spirit Start around age 12 At least 4 years of solid training Strong and flexible calf and foot muscles Able to do repeated relevés away from barre and 4–8 single leg relevés Technique and skill Training and experience Range of motion Strength Age and maturity Table 1 : Summary of studies (n = 9) included in the review analysis Table 2 : Summary of commentary studies (n = 4) included in the review analysis Table 3 : Summary of grey literature (n = 9) included in the review analysis Part 2: Delphi Consensus During round one, panellists collectively listed 271 assessment criteria to be considered before a dancer initiates pointe training and 86 reasons for conducting a pointe readiness assessment. Three themes (skill and training, physical characteristics and health and wellbeing) were revealed with 10 areas of assessment (technique and skill, balance and control, training and experience, ROM, strength, alignment, general health, age and maturity, injury history and dancer goals) (Fig. 2 ). Ninety-nine unique criteria were identified for consideration in round two. Twenty-two reasons to complete a pointe readiness assessment were identified. No additional criteria were identified in subsequent rounds. Round two and three both had a 100% response rate. One health professional did not complete all responses in round 2, however their completed responses were included in the analysis. Pointe readiness assessment criteria Following round two of the Delphi, 39 of the 99 criteria to be considered in a pointe readiness assessment reached consensus (38 criteria for inclusion, 1 for exclusion). The 60 criteria not reaching consensus were re-rated in round three. Round three resulted in a further nine items reaching agreeable consensus. A total of 48 out of 99 criteria achieved consensus (47 criteria agreement for inclusion, 1 agreement for exclusion) on informing the decision to allow a dancer to start pointe training. Of the ten assessment areas, the agreement consensus rates for criterion inclusion were 100% for injury history (3/3), 84.6% for balance and control (11/13), 66.7% for strength (8/12), 61.5% for technique and skill (8/13), 62.5% for age and maturity (5/8), 53.8% for range of movement (7/13), 36.4% for training and experience (4/11), 10% for general health (1/10), 0% for alignment (0/11) and 0% for dancer’s goals (0/5). Individual assessment criteria of calf strength, ankle plantarflexion ROM, knee control, single-leg standing, chronological age, past injury history, present injuries and orthopaedic history each reached ≥ 95% agreement for inclusion, with demi-pointe position, calf endurance and the SLHR test each achieving 100% agreement. Criteria reaching consensus were analysed separately for teachers, health professionals and researchers (supplementary material, table S1 ). Teachers and researchers reached consensus on a higher proportion of criteria (74/99 and 67/99, respectively). In contrast, health professionals reached consensus for agreement on only 44/99 criteria. Researchers reached consensus that 26/99 criteria presented were not essential for assessing pointe readiness, compared to only 7 and 6 of the 99 criteria being deemed unnecessary by teachers and health professionals, respectively. Comments on requirements for criteria agreed upon by panel members are presented in supplementary material (table S2 ). Reasons for completing a pointe readiness assessment On completion of the Delphi,18 out of 22 reasons to conduct a pointe assessment reached an agreeable consensus (supplementary material, table S3 ). Six reasons (creating a baseline, providing an informed choice, assessing capacity to be successful en pointe , prescribing exercises, providing information to the ballet teacher and establishing what needs to be achieved before starting en pointe ) reached overall agreement of ≥ 95% for inclusion as reasons to complete a pointe readiness assessment. Discussion Our study sought to establish expert consensus from a range of stakeholders on the criteria a dancer should demonstrate prior to commencing pointe work. Although some criteria reached overall consensus, the responses varied for how each criterion should be measured and what the dancer should demonstrate to fulfil the criteria. This variability highlights the lack of standardised assessment methods for pointe readiness, potentially leading to inconsistent decision-making even when using the same criterion measures. Findings also identified differences in agreement and importance of individual criteria between professional groups of the panel. Further investigation into the reasons for this discrepancy is warranted. Our findings highlight the key criteria that should be considered and underscore the need for clearer objective guidelines to ensure safe and equitable progression to pointe work for ballet dancers. Findings also provide new insight into what each professional group deems important to consider when progressing a dancer en pointe and identifies certain criteria may be most appropriately assessed by teachers and health professionals independently. Comparison to IADMS Guidelines The IADMS guidelines for the initiation of pointe training were established in 2009( 5 ). The guidelines suggest dancers be ≥ 12 years of age, have enough range at the foot and ankle, be at a pre-professional level, have strong core and leg muscles, controlled hypermobility, be participating in ≥ 2 ballet classes per week and have > 3 years of ballet training before starting pointe( 5 ). The panel in our study broadly supported these recommendations. In addition to the IADMS guidelines, the panel also reached consensus on assessing injury history, SLHRs, and balance when determining a dancer’s readiness to progress to pointe. Age Agreeable consensus was reached for considering chronological age, with panellists predominantly recommending a minimum age range of 10–12 years, slightly below the IADMS guideline( 5 ). However, the relevance of chronological age has been questioned in both dance specific and general population literature due to developmental variability during adolescence( 24 , 37 ). Notably, no consensus was reached on assessing pubertal stage, menarche, growth velocity, or skeletal maturity. This may indicate a gap in understanding between chronological and developmental age or how developmental age impacts pointe readiness, warranting further education and investigation. Range of motion and lower limb alignment The panel reached consensus for the inclusion of foot and ankle ROM assessment, aligning with IADMS guidelines( 5 ). However, IADMS does not provide objective benchmarks, beyond requiring “sufficient range”( 5 ). Reflecting this lack of specificity, panel members employed varied standards and methods for assessing ROM (e.g. plantarflexion ranged between 160°-185°, discrepancy between medial or lateral goniometer measurement). While foot and ankle mobility and lower-limb alignment were clearly valued, assessment methods require further refinement for greater consistency and objectivity. In line with the IADMS guideline of assessing and ensuring appropriate joint control, the panel agreed that assessment of hypermobility should be included in a pointe readiness assessment. The Beighton scale with a score of ≥ 6, was most referenced (50% of panellists)( 38 ). Panellists agreed that hypermobile dancers may require additional strength and control training to transition safely to pointe. Pre-professional level of training In contrast to the IADMS recommendation that pointe work be limited to pre-professional dancers, the panel achieved consensus that the dancer’s goals would not inform their decision to progress a dancer to pointe training. Researchers and teachers did not consider goals as an essential consideration in readiness assessments, while health professionals reached no consensus on goal-related criteria. This divergence may reflect the increasing participation in recreational ballet( 39 ). Provided pointe readiness criteria are met, there may be no justification for excluding recreational dancers from starting pointe work. This finding may prompt future guidelines to acknowledge the growing diversity in ballet participation and reconsider the recommendation that pointe work be reserved solely for elite dancers. Core and lower limb strength IADMS guidelines suggest a strong core and lower limbs are required before beginning pointe training, however, do not provide objective criteria( 5 ). Despite agreement on the inclusion of core strength evaluation in a pointe readiness assessment, the assessment methodology and requirements varied across panellists. The variation in assessment and differences in what each test measured suggests a standardised approach is needed to define the criteria of core strength for pointe readiness. Agreement on inclusion of lower limb strength assessment was identified for the calves, hip external rotators, foot intrinsics and glutes. Again, a range of assessment methodologies were suggested. Poor core stability and decreased lower limb strength have been identified as an injury risk factor in dancers; however, its specific relationship to pointe training remains unclear( 40 ). Establishing clear, measurable strength guidelines that predict safe progression to pointe training would enhance consistency across assessors and contribute to safer, more evidence-informed decisions. Training The panel agreed training history should be considered before starting pointe work. However, they suggested a range of one to five years of prior training, compared with the IADMS recommendation of at least three years. The panel’s suggestion of a minimum of two classes per week aligned with IADMS guidance( 5 ), though they additionally recommended that each class be 60–90 minutes in duration. Currently, no literature supports these recommendations for class length or frequency, highlighting the need for further research into appropriate training volumes for pointe readiness. Highly rated criteria Calf endurance In agreement with previous studies, calf endurance, assessed by the SLHR test, reached unanimous consensus as an assessment criterion( 13 , 41 ). The panel defined proper execution as achieving demi-pointe with 90° metatarsophalangeal joint extension and 90° plantarflexion at peak height. However, the required number of SLHR repetitions varied greatly ranging from 10 to 35. Health professionals and researchers commonly recommended 20–25 repetitions. Teachers were less likely to specify a numeric criterion and prioritised technique over quantity. Although the Australian Ballet recommends ≥ 25 SLHRs, this benchmark is anecdotally based on adult company dancers( 42 ) and may not be applicable to younger dancers with lower training load and skill levels. Normative SLHR values in healthy 11 and 12-year-old females in the general population has been reported as 25.9 ± 4.6 and 27.7 ± 5.2 repetitions, respectively( 43 ). However, these values are unlikely to translate directly to ballet-specific SLHR due to greater technical demand( 41 , 44 ). Strength and endurance requirements of the calf complex for pointe work remain undefined ( 41 ). Although the panel unanimously agreed that SLHR should be used as a determining criterion for dancers’ progression to pointe training, further research is needed to establish normative strength thresholds and refine SLHR criteria. Injury History Knowledge of the dancer’s injury history reached unanimous consensus among panellists as an essential component of pointe readiness evaluation. The panel identified the evaluation of contributing factors to injury, patterns in injury type, frequency, completion of rehabilitation and confirmation of full recovery as critical components of the injury history assessment. Panellists unanimously agreed that dancers must be injury-free prior to commencing pointe work. This aligns with Hough-Coles et al.( 13 ) where ‘no recent injury’ was ranked as the top screening measure. While panellists agreed that a history of injury would not necessarily prevent a dancer from beginning pointe training, they emphasised it would warrant a more comprehensive physical evaluation. Although deemed important, the consideration of injuries remained general in nature. Prior injury tends to be a good predictor of subsequent injury ( 45 , 46 ), however it is unknown whether sustaining certain injuries (regardless of rehabilitation) may put a dancer at more risk of future injury if they begin pointe training. Balance and Control Agreement was established on including assessment of balance and control, with a specific focus on single-leg stability and knee alignment. The ‘Airplane’ and ‘Sauté’ tests for balance and control, identified as being good indicators for pointe readiness ( 13 , 20 ), were endorsed by the panel. However, the number of repetitions required for each test varied. For the ‘Sauté’ test (single-leg hops), Richardson et al.( 20 ) recommend a passing criterion of eight successful hops out of 16 performed in ‘neutral alignment’. Panellists suggested 3–16 successful repetitions, with three panellists recommending successful hops be consecutive. There was uncertainty about how the test should be performed, including whether to use parallel or turned-out alignment and whether a hop or jump was more appropriate. The ‘Airplane’ test involves a single-leg squat with the torso and unsupported leg held parallel to the floor( 20 ). Richardson et al.( 20 ) define a passing score as four out of five successful repetitions. In our study, panellists suggested dancers should demonstrate between three and eight successful attempts. Other studies have, however, not favoured this test for determining pointe readiness( 13 ). The assessment of single-leg balance was also identified as important determinant for pointe readiness by our panel. This agrees with existing work( 13 ), although no empirical evidence exists to support this. The panel, again, identified multiple methods of assessing single-leg balance including standing on a flat foot, balancing on rise, having eyes open or closed and time the position is held (suggested range 5-30seconds). Hough-Coles et al.( 13 ) reported single-leg balance on rise in the retiré position may be a more effective indicator of pointe readiness than the ‘topple test’ (single pirouette ) proposed by Richardson et al.( 20 ). However, balance time was not reported. Despite the panel’s agreement upon use in a pointe assessment, none of the tests (airplane, sauté , topple, retiré balance) have been validated for suitability in assessing balance and control in ballet dancers. Therefore, although there was agreement on the inclusion of the ‘airplane’, ‘sauté’ and single-leg balance tests, the variability in how these tests are administered and the range of passing criteria highlights the need for further validation studies to determine their appropriateness in assessing pointe readiness. Interdisciplinary Approach to Assessment Teachers and health professionals are the primary stakeholders involved in determining pointe readiness( 11 , 25 ). Eighty-five percent of panellists believed the ballet teacher should be involved in the pointe readiness assessment and 95% supported involvement of a health professional, with physiotherapists most preferred (85%). Teachers demonstrated broader consensus across all themes, placing importance on the assessment of technique, skill and overall postural alignment. Heath professionals favoured objective assessment of SLHRs, ankle and foot ROM and balance and control. This contrast highlights the variation in expertise, assessment focus, and priorities between the two groups. Hough-Coles et al.( 13 ) concluded that a ballet teachers’ assessment may be more reliable in determining pointe readiness than a battery of tests however, no detail on what a teacher’s assessment would consist of was provided. Our finding suggests that the agreement on a wider range of criteria among teachers may reflect their long-term relationships with students and ability to observe progression over time. In contrast, health professionals typically conduct assessments over one or two appointments and may be required to make decisions within limited timeframes. This discrepancy in the duration spent and context of engagement with the dancer, alongside varying expertise, suggests teachers and health professionals may be best suited to assess different aspects of pointe readiness. The discussion of interdisciplinary focus of our study extends on previous consensus work and highlights that a shared assessment framework may be necessary( 13 ). A more efficient approach may involve a shared assessment framework, wherein teachers evaluate components of technique, alignment, training history and maturity within their class setting, and health professionals focus their assessment on objective measures of strength, range of motion, balance and control as per their clinical expertise. The development of a standardised, collaborative assessment model may improve consistency and clarity in the pointe readiness decision-making process. Reasons to conduct a pointe readiness assessment There was strong agreement among panellists that a pointe readiness assessment should be used to evaluate a dancer’s current abilities, provide education to support informed decision-making, identify injury risk and guide appropriate intervention if required. The use of screening tools for injury prediction is not new within dance( 47 ). Although the panel agreed that a pointe readiness assessment should be used as an injury prevention tool, to date, no studies have demonstrated a that pointe readiness assessments reduce injury risk. Further research is needed to explore this potential association. While there was overall agreement that a pointe readiness assessment provides an opportunity for the dancer to develop a relationship with a health professional, health professionals did not reach consensus on this point. Consensus was not reached on using the assessment as a measure of technical ability or ballet aptitude despite agreement on the inclusion of multiple ballet technique elements. It remains unclear whether the inclusion of ballet-specific technical elements in the assessment were considered as indicators of ballet technique, or if these elements serve as surrogate indicators of functional strength and control. As such, further research is warranted to examine the validity and reliability of ballet technique assessment in comparison to standardised objective measures. The broad range of reasons reaching consensus indicates panellists agree a pointe readiness assessment is both valuable and informative. Longitudinal studies may provide insight into the effectiveness of pointe readiness assessments in addressing their intended purpose and rationale. Strengths and Limitations The scoping review component of this study has several limitations. The lack of standardised measures within dance medicine may have led to relevant studies being overlooked despite comprehensive search strategies. The inclusion of grey literature, while necessary due to the limited volume of peer-reviewed research on pointe readiness, introduces variability in the quality and reliability of sources. A key strength of our study was the inclusion of diverse stakeholders involved in supporting the safe transition of young dancers to pointe training in the Delphi study. Comparing consensus rates between teachers and health professionals offered insight into the priorities of these key groups and whether they value the same criteria when deciding if a dancer is ready for pointe. Involving researchers actively engaged in developing current evidence in this field also enabled an assessment of the extent to which emerging research is being translated into practice. Including qualitative responses from panellists further strengthened our study by demonstrating the diversity of methodologies and expectations, even when they agreed on including specific criterion. Our study had a 100% retention rate of panellists, further strengthening the findings. However, as 86% of panel members were based in Australia, the findings may reflect region-specific practices and not fully represent those in other countries, limiting generalisability outside of Australia. Conclusion Our study presents the most thorough evaluation of pointe readiness assessment criteria and should be used as a framework to develop further objective guidelines in conjunction with IADMS guidelines and other consensus panels( 5 , 13 ). The panel’s consensus on pointe-readiness criteria shows strong alignment with multiple IADMS guidelines. Additional criteria of SLHRs, balance and control, and injury history were identified as important considerations. While consensus on many criteria was reached, our findings highlighted a lack of consistency in the methodology and requirements used across these criteria. These findings emphasise the need for additional research to validate measures used in pointe readiness assessments. Such validation should consider the dancer’s stage of maturation and development, the expected duration of pointe training per week once initiated, and the assessment’s effectiveness in reducing injury risk once pointe work begins. Abbreviations IADMS International Association for Dance Medicine and Science ROM Range of Movement SLHR Single Leg Heel Raise Declarations We confirm that the manuscript, including related data, figures, and tables has not previously been published and is not under consideration by another journal. All authors have approved the manuscript and agree with its submission to Sports Medicine Open. Ethics Approval: Ethics approval was granted from the university’s Human Research Ethics Committee (Project Number 2024/HE000106). Data availability statement: Data supporting the findings of this study are available within the paper and its Supplementary files. Original data are available upon reasonable request. Access to the data will be subject to approvals by the Principal Investigator with a requirement to sign a data access agreement. Competing interests: The authors declare that they have no competing interests. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Author contributions: HF and AF were responsible for project conceptualisation. HF was responsible for all data collected and wrote the manuscript (review and editing). AF, JB, RS and DC all provided critical revision of the manuscript. AF provided supervision, analysed data and assisted with writing and revision of the manuscript. Acknowledgements: Not Applicable References Russell JA, Yoshioka H. Assessment of female ballet dancers’ ankles in the en pointe position using high field strength magnetic resonance imaging. Acta radiol. 2016;57(8):978–84. Li F, Adrien N, He Y. 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Supplementary Files SupplementaryTable1criteria.docx SupplementaryTable2qualitativecomments.xlsx SupplementaryTable3reasons.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Minor Revision 10 Mar, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 27 Jan, 2026 Editor invited by journal 22 Jan, 2026 Editor assigned by journal 21 Jan, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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It is recognised for its elegance, extensive range of motion and distinctive use of pointe shoes. Dancing in \u003cem\u003een pointe\u003c/em\u003e is an essential part of advanced ballet technique but also imposes substantial load on the lower limbs(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn female ballet dancers, most injuries occur during adolescence between the ages of 12 and 18(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As 12 is the typical age for initiating pointe training, it is important that clear guidelines are established to ensure dancers transition \u003cem\u003een pointe\u003c/em\u003e safely(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Multiple studies have reported 41.1\u0026ndash;77% of ballet students will experience at least one injury during their pre-professional training with lower limb injury incidence up to 91%(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A substantial proportion of these injuries, particularly in the feet and ankles, are associated with dancing \u003cem\u003een pointe\u003c/em\u003e (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), highlighting the importance of ensuring dancers are physically prepared before starting pointe work. Despite potential risks of injury when dancing \u003cem\u003een pointe\u003c/em\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), there is a lack of consensus around what a dancer must demonstrate to be successful and safe when initiating pointe training(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe initiation of pointe training has traditionally been based on subjective opinions(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Historically, ballet teachers have determined when a dancer can start pointe work, but in recent years there has been a shift towards more objective evaluations conducted by health professionals (e.g. physiotherapists)(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite this, it has been suggested a teacher\u0026rsquo;s assessment of a dancer\u0026rsquo;s readiness may be more reliable than a battery of tests(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, it remains unclear what criteria teachers prioritise or whether their expectations vary compared to health professionals. In 2009, the International Association for Dance Medicine and Science (IADMS) developed guidelines for initiating pointe work(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These included dancers being \u0026ge;\u0026thinsp;12 years of age, having \u0026lsquo;sufficient\u0026rsquo; ankle and foot range of movement (ROM), be training at a \u0026lsquo;pre-professional\u0026rsquo; level, have strong core and leg muscles, controlled hypermobility, be participating in \u0026ge;\u0026thinsp;2 ballet classes per week, and completed\u0026thinsp;\u0026gt;\u0026thinsp;3 years of ballet training(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite having set guidelines, many of the criteria are subjective in nature thus leaving room for interpretation(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A recent consensus study found the assessments most used in practice by dance experts when evaluating pointe readiness were single-leg-heel-rise (SLHR) repetitions, ankle ROM and core stability and strength(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This study was limited by a high panel drop-out (33%), a low consensus threshold (60%), and no discussion of differences in opinion between stakeholder groups(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Despite providing some general guidance to their panel on what the dancer should demonstrate for each criterion to be considered pointe ready; it remains unclear whether these aligned with the panel\u0026rsquo;s real-world practice.\u003c/p\u003e \u003cp\u003eOur study aimed to establish expert consensus on the key criteria a dancer should meet before beginning pointe training, as well as the reasons for conducting a pointe readiness assessment to support ballet teachers and health professionals in deciding when to progress a dancer \u003cem\u003een pointe\u003c/em\u003e. We sought to compare the criteria identified by the panel as important with the current IADMS guidelines and contrast to existing consensus studies to determine the extent to which these guidelines are being applied in practice. Our final aim was to establish criteria regarded as important by each expert group for assessing pointe readiness, thereby enabling a comparison of their respective priorities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study comprised two parts: (i) a scoping review; and (ii) a three round Delphi consensus panel. Ethics approval was granted from the university\u0026rsquo;s Human Research Ethics Committee (Project Number 2024/HE000106) for the Delphi panel component.\u003c/p\u003e \u003cp\u003e Part 1: Scoping Review\u003c/p\u003e \u003cp\u003eA scoping review was conducted to identify literature for determining pointe readiness, which were combined with the panel input from the Delphi process to create a comprehensive list of criteria used to determine pointe readiness. A systematic search of EBSCOhost databases (CINAHL, MEDLINE, Academic Search, SPORTDiscus, Scopus) was performed from inception until January 2025. Terms searched were ballet AND (pointe OR pre-pointe) AND (screen OR assessment OR readiness). Reference lists for selected studies were manually searched for additional relevant papers. Identified studies were exported to Covidence (Veritas Health Innovation 2025). After removing duplicates, two researchers independently screened studies by title and abstract, then full text against the eligibility criteria. Studies were included if they mentioned requirements for dancers to initiate pointe training or compared abilities of dancers at a pre-pointe level with those who had started pointe training. Given the limited number of peer-reviewed articles and the significant role of historical knowledge in assessing dancers, grey literature (e.g. magazine articles and blogs) was also considered. Criteria influencing the decision to progress a dancer to pointe were extracted if they: (i) determined readiness for initiating pointe training; (ii) differentiated between pre-pointe and \u003cem\u003een pointe\u003c/em\u003e dancers; or (iii) compared an objective test with a ballet teacher\u0026rsquo;s recommendation for starting pointe work.\u003c/p\u003e \u003cp\u003ePart 2: Delphi Technique\u003c/p\u003e \u003cp\u003eA three round Delphi consensus method was used to identify criteria that should be considered in allowing a dancer to initiate pointe training. The Delphi method was conducted between September 2024 and March 2025 using online Qualtrics (Qualtrics, Provo, USA) survey software.\u003c/p\u003e\n\u003ch3\u003eExpert panel\u003c/h3\u003e\n\u003cp\u003eFifty participants were invited via email to join the expert panel. Participants were identified via contacting internationally recognised dance education organisations, dance specific healthcare centres and authors of dance research papers. To qualify for inclusion, participants had to be either a ballet teacher or health professional with \u0026gt;\u0026thinsp;5 years of experience assessing dancers' readiness to initiate pointe training, or a researcher with publications in the last 10 years related to pointe readiness, injuries associated with pointe training or ballet technique. Twenty-three people responded, of which 21 participants from three countries (Australia n\u0026thinsp;=\u0026thinsp;18, New Zealand n\u0026thinsp;=\u0026thinsp;2, England n\u0026thinsp;=\u0026thinsp;1) met the eligibility criteria and were recruited to participate in the panel. This exceeds the reliability criteria of \u0026gt;\u0026thinsp;10 experts when using the Delphi method(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The panel included 11 registered health professionals (9 physiotherapists, 2 podiatrists), six ballet teachers with advanced training in the Royal Academy of Dance or Cecchetti syllabi, and four researchers. Health professionals had an average of 18.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 years (range 8\u0026ndash;32) of experience treating dancers and 15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 years (range 5\u0026ndash;32) experience assessing dancers for pointe training. Ballet teachers had 40.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 years (range 30\u0026ndash;50) ballet teaching experience and 31\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 years (range 5\u0026ndash;47) experience progressing dancers \u003cem\u003een pointe\u003c/em\u003e. All panellists provided informed consent via an online electronic platform prior to participating in the first Delphi round. Panellists were given four weeks from the invitation date to complete each round of the online survey, with reminders provided after two and three weeks.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRound 1\u003c/h2\u003e \u003cp\u003eThe panel were asked to provide an exhaustive list of what they believe important to consider before a dancer initiates pointe training and a list outlining the purpose of a pointe readiness assessment. Participants were not provided with criteria extracted from the scoping review to minimise response bias. Following the completion of round one, three members of the research group conducted an inductive content analysis of criteria identified from both the scoping review and the panel(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Unique items were categorised into major themes and subthemes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRound 2\u003c/h3\u003e\n\u003cp\u003eUnique criteria identified in the inductive content analysis were listed next to a four-point Likert scale (1\u0026ndash;strongly disagree, 2\u0026ndash;somewhat disagree, 3\u0026ndash;somewhat agree, 4\u0026ndash;strongly agree) and presented to the panel. Panellists indicated their level of agreement on whether each criterion would influence their decision to allow a dancer to start pointe work. When panellists agreed with a criterion, they were asked to describe what they would expect to observe in a dancer ready to begin pointe training. Panellists were invited to list any additional criteria that may have been missed in round one. Consensus for or against each criterion was reached if\u0026thinsp;\u0026ge;\u0026thinsp;80% agreement (combined responses of somewhat and strongly-agree or somewhat and strongly-disagree) was achieved by the panel(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). As the researcher sub-group of the panel consisted of only four participants, a consensus rate around 80% was not mathematically possible. Therefore, the consensus rate was lowered to 75% when considering sub-group level analysis.\u003c/p\u003e\n\u003ch3\u003eRound 3\u003c/h3\u003e\n\u003cp\u003eA second round of agreement ratings, following the same process as round two, was conducted for criteria that did not reach consensus. Following this round, any criteria that did not reach the \u0026ge;\u0026thinsp;80% threshold were deemed to have not reached consensus.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePart 1: Scoping review\u003c/p\u003e\n\u003ch3\u003eIdentification and selection of studies\u003c/h3\u003e\n\u003cp\u003eThrough the database search, 409 records were identified. After removal of duplicates and eligibility screening, 13 research articles and nine grey literature articles remained (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy quality and characteristics\u003c/h2\u003e \u003cp\u003eNine of the 13 included articles used a cross-sectional design (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with the remaining four being commentary studies (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The nine cross-sectional studies(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) were classified as level four evidence (low) and commentary studies(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) classified as level five evidence (very low) as per the Centre for Evidence-Based Medicine hierarchy(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Forty-eight unique assessment criteria for pointe readiness were identified from the included articles. Criteria extracted included minimum age, ballet technique elements, range of movement (ankle plantarflexion, 1st metatarsophalangeal joint extension, hip external rotation), strength (core, calf), balance and control (airplane test, topple test), and training history (years of ballet). Due to the traditionally subjective decision and limited number of articles identified, nine grey literature articles from online magazines and blogs(\u003cspan additionalcitationids=\"CR29 CR30 CR31 CR32 CR33 CR34\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) were also considered for review (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Similar findings of age, technique, ROM and strength were discussed through all grey literature. Other than a minimum age of 10\u0026ndash;12 years to start pointe training, no other objective measures were identified(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of studies (n\u0026thinsp;=\u0026thinsp;9) included in the review analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTesting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutcome/Recommendations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeWolf et al. 2018 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;49\u003c/p\u003e \u003cp\u003epre-pointe n\u0026thinsp;=\u0026thinsp;28\u003c/p\u003e \u003cp\u003epointe n\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003epre-pointe\u0026thinsp;=\u0026thinsp;10.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003cp\u003epointe\u0026thinsp;=\u0026thinsp;11.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRange of Motion\u003c/p\u003e \u003cp\u003e\u0026bull; Non-weightbearing plantar flexion and dorsi flexion\u003c/p\u003e \u003cp\u003e\u0026bull; Weightbearing lunge\u003c/p\u003e \u003cp\u003eMuscular Capacity\u003c/p\u003e \u003cp\u003e\u0026bull; Plantar flexion strength\u003c/p\u003e \u003cp\u003e\u0026bull; Relev\u0026eacute; endurance\u003c/p\u003e \u003cp\u003eBalance\u003c/p\u003e \u003cp\u003e\u0026bull; Airplane test\u003c/p\u003e \u003cp\u003e\u0026bull; Star excursion balance test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePointe group performed significantly better in relev\u0026eacute; endurance and airplane test repetitions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFindings suggested that 15 continuous single leg relev\u0026eacute;s and two quality repetitions of the airplane test may be useful in distinguishing the level of strength and proprioception required for successful pointe training.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErdman et al. 2024\u0026nbsp;(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBallet instructors n\u0026thinsp;=\u0026thinsp;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQuestionnaire to assess the awareness and use of pointe readiness criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKnowledge of existing pointe readiness criteria was low with only 30% aware of published guidelines.\u003c/p\u003e \u003cp\u003eDancer strength (100%), dance technique (94%) and age (87%) were rated as greatest indicators of pointe readiness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuggenheim 1994\u0026nbsp;(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDirectors of 11 ballet schools\u003c/p\u003e \u003cp\u003e10 out of 11 responded to all questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003enot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQuestionnaire addressing current practices of initiating pointe training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u0026ndash;5 years of ballet training for pointe work\u003c/p\u003e \u003cp\u003eAge to start pointe training 9\u0026ndash;11 years\u003c/p\u003e \u003cp\u003eFirst year of pointe training 5\u0026ndash;10 minutes up to 2 hours per week\u003c/p\u003e \u003cp\u003eSecond year of pointe training two 15-minute sessions per week to four sessions per week of 30 minutes \u0026ndash; 1 hour.\u003c/p\u003e \u003cp\u003e8/10 schools prohibited \u0026lsquo;obese\u0026rsquo; dancers from starting \u003cem\u003een pointe\u003c/em\u003e and 5 schools reported asking dancers to diet for the purpose of weight control.\u003c/p\u003e \u003cp\u003eAnatomical variations were considered insignificant to pointe training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDeterminants for the initiation of pointe training varied greatly between schools.\u003c/p\u003e \u003cp\u003eNo physical or objective testing was discussed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHewitt et al. 2016\u0026nbsp;(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale ballet students n\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e \u003cp\u003epre-pointe n\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003cp\u003ebeginning pointe n\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003cp\u003eintermediate pointe n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eall groups 13\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e \u003cp\u003epre-pointe 10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003cp\u003ebeginning pointe 13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003cp\u003eintermediate pointe 15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTimed plank test\u003c/p\u003e \u003cp\u003eHeel rise test\u003c/p\u003e \u003cp\u003eAirplane test\u003c/p\u003e \u003cp\u003eTopple test\u003c/p\u003e \u003cp\u003eSingle leg saut\u0026eacute; test\u003c/p\u003e \u003cp\u003eTeacher classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSignificant difference found between pre pointe and intermediate group on the saut\u0026eacute; test and the airplane test. A significant difference was also found on the topple test between the pre pointe group and the beginner and the intermediate pointe groups. Therefore, these tests may be useful in discriminating between p\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThere was a maximum 12-year age gap between the pre-pointe and intermediate pointe groups and a difference of 13.5 years in ballet training. It is possible that the significant differences were related to development and experience rather than pointe readiness.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeck et al. 2004\u0026nbsp;(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200 dance institutions invited\u003c/p\u003e \u003cp\u003eresponses n\u0026thinsp;=\u0026thinsp;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003enot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey of 21 items used in pre-pointe evaluations: age, years of dance, menses history, present injuries, past injuries, x-ray, MRI, bone scan, spinal alignment, gait analysis, proprioception, muscle length, range of motion, manual muscle test, relev\u0026eacute;, pli\u0026eacute;, port de bras, tendu, pass\u0026eacute;, developp\u0026eacute;, upper body.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHighest frequency of items used in pre-pointe evaluation:\u003c/p\u003e \u003cp\u003eAge 95.9%\u003c/p\u003e \u003cp\u003eYears of dance 91.9%\u003c/p\u003e \u003cp\u003ePresent injuries 87.8%\u003c/p\u003e \u003cp\u003ePast injuries 82.4%\u003c/p\u003e \u003cp\u003eRelev\u0026eacute; 94.6%\u003c/p\u003e \u003cp\u003ePlie 89.2%\u003c/p\u003e \u003cp\u003eTendu 77.0%\u003c/p\u003e \u003cp\u003eUpper Body 79.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePerhaps the presence or absence of health care professional has a greater influence on the pre-pointe evaluation than affiliation with professional dance company\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRichardson et al. 2010\u0026nbsp;(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003epre-pointe n\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.3 \u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePencil test (PF range)\u003c/p\u003e \u003cp\u003eModified Romberg test\u003c/p\u003e \u003cp\u003ePass\u0026eacute;-relev\u0026eacute;\u003c/p\u003e \u003cp\u003eTopple test\u003c/p\u003e \u003cp\u003eDouble Leg Lower test\u003c/p\u003e \u003cp\u003eSingle Leg Step Down\u003c/p\u003e \u003cp\u003eAirplane test\u003c/p\u003e \u003cp\u003eSingle leg saut\u0026eacute; test\u003c/p\u003e \u003cp\u003eSingle leg heel rise test\u003c/p\u003e \u003cp\u003eTeacher rating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAirplane test, topple test and saut\u0026eacute; tests were found to be most sensitive for predicting pointe readiness.\u003c/p\u003e \u003cp\u003eOlder/more experienced dancers performed better on tests than younger/less experienced dancers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThere were substantial differences between dancers with ages ranging from 9\u0026ndash;17 years and experience from 1\u0026ndash;12 years. 33 of the participants were in pre-professional training doing 5.5-9 hours per week, remaining 4 were from community level programs doing 1.5-3 hours per week.\u003c/p\u003e \u003cp\u003eTeacher ratings on pointe readiness were provided by the dancer\u0026rsquo;s usual teacher which may contribute to bias due to personal relationship. No detail on why particular tests were chosen or why particular pass/fail criteria was chosen.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShah 2024\u0026nbsp;(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e \u003cp\u003e\u003cem\u003een pointe\u003c/em\u003e or \u0026lt;\u0026thinsp;3 months \u003cem\u003een pointe\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.1 (range 10\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePilot study of PASSE screening tool for pointe readiness (Pointe Assessment Screen Shah Edison).\u003c/p\u003e \u003cp\u003ePart 1 \u0026ndash; questionnaire on dance history, bone health, injury and dance goals.\u003c/p\u003e \u003cp\u003ePart 2 \u0026ndash; physical examination of range of motion, core and strength testing, evaluation of dance technique.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lsquo;PASSE\u0026rsquo; assessment tool had 94% agreement across raters for determining pointe readiness (p\u0026thinsp;=\u0026thinsp;0.0004).\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;90\u0026deg; ankle plantarflexion, stability in grand pli\u0026eacute; and relev\u0026eacute; balance had highest sensitivity for overall readiness thereby deemed necessary to advance to pointe. Relev\u0026eacute; pass\u0026eacute;, airplane test and saut\u0026eacute; test indicated lack of readiness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWide range of ballet training hours per week (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and range of years dancing (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTeacher ratings on pointe readiness were provided by the dancer\u0026rsquo;s usual teacher which may contribute to bias.\u003c/p\u003e \u003cp\u003eUnknown age and experience of dancers who were deemed ready to be \u003cem\u003een pointe\u003c/em\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSolomon et al. 1993\u0026nbsp;(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e \u003cp\u003epointe n\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003epre-pointe n\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003econtrols (non-dancers) n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003epointe 11.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003cp\u003epre-pointe 9.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003cp\u003econtrols 10.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePassive range of motion at ankle (plantar flexion, dorsi flexion)\u003c/p\u003e \u003cp\u003eIsokinetic strength at ankle (PF/DF) and knee (Fl/Ext)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe pointe group demonstrated the greatest flexibility at the ankle, followed by the pre-pointe then control groups.\u003c/p\u003e \u003cp\u003eThe control group demonstrated greater peak torque across all muscle groups than dancers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOnly lower limb muscles and joints were tested.\u003c/p\u003e \u003cp\u003eConcluded that more items need to be included to determine pointe readiness.\u003c/p\u003e \u003cp\u003eNoted that isometric testing may not be accurate indicator due to the eccentric nature of pointe movements.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVeirs et al. 2023\u0026nbsp;(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e \u003cp\u003eon the box n\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003enot on the box n\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (IQR\u0026thinsp;=\u0026thinsp;13\u0026ndash;16)\u003c/p\u003e \u003cp\u003eon the box 15 (IQR\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003enot on the box 14 (IQR\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;15 repetitions of relev\u0026eacute; in first position with 3D motion capture peak relev\u0026eacute; \u003cem\u003een pointe\u003c/em\u003e position\u003c/p\u003e \u003cp\u003e6 variables captured\u003c/p\u003e \u003cp\u003eKinematic \u0026ndash; ankle plantar flexion and first metatarsophalangeal relev\u0026eacute; angle and C7 marker displacement\u003c/p\u003e \u003cp\u003eKinetic \u0026ndash; ankle plantarflexion and hip mediolateral and hip anteroposterior net joint moments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDancers who were able to get \u0026lsquo;on the box\u0026rsquo; had greater 1st MTP joint extension range (90deg) compared to dancers \u0026lsquo;not on the box\u0026rsquo; (70deg). Dancers \u0026lsquo;on the box\u0026rsquo; had greater ankle PF range, however not statistically significant.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe dancers who were \u0026lsquo;on the box\u0026rsquo; had twice as much pointe experience than those who were \u0026lsquo;not on the box\u0026rsquo;. This may indicate training experience influenced their technique.\u003c/p\u003e \u003cp\u003eIt is unknown if the dancer\u0026rsquo;s shoes contributed to their ability to get \u0026lsquo;on the box\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eIQR: interquartile range, PF: plantarflexion, DF: dorsiflexion, MTP: metatarsophalangeal, Fl: flexion, Ext: extension, PASSE: Pointe Assessment Screen Shah Edison\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of commentary studies (n\u0026thinsp;=\u0026thinsp;4) included in the review analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutcome/Recommendations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLai, Kruse 2016\u0026nbsp;(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommentary study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge not a reliable indicator of readiness on its own\u003c/p\u003e \u003cp\u003eSkeletal maturity \u0026ndash; radiographs not recommended as complete ossification does not occur until 18yrs old\u003c/p\u003e \u003cp\u003eTechnique \u0026ndash; proper turnout in 1st, 2nd and 5th positions\u003c/p\u003e \u003cp\u003eFlexibility \u0026ndash; ankle PF minimum 90deg\u003c/p\u003e \u003cp\u003eStrength, proprioception and postural control \u0026ndash; Airplane test, saut\u0026eacute; test, topple test\u003c/p\u003e \u003cp\u003eTraining \u0026ndash; assess on technical ability not necessarily years of training.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eBalance and control\u003c/p\u003e \u003cp\u003eTechnique and experience\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShah 2009\u0026nbsp;(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommentary study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRestricting age is more based on tradition than science.\u003c/p\u003e \u003cp\u003eNeeds adequate maturity and physical capability rather than specific age or years of training\u003c/p\u003e \u003cp\u003eTechnique \u0026ndash; turnout control\u003c/p\u003e \u003cp\u003eFlexibility \u0026ndash; first MTP joint 80-90deg extension, ankle PF 90deg\u003c/p\u003e \u003cp\u003eStrength, proprioception and placement \u0026ndash; relev\u0026eacute; pass\u0026eacute;, grand pli\u0026eacute; in 1st, 2nd, 4th and 5th positions, pirouette (topple test), airplane test, saut\u0026eacute; test\u003c/p\u003e \u003cp\u003eTraining \u0026ndash; 4 years of serious ballet training before starting \u003cem\u003een pointe\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eBalance and control\u003c/p\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShah 2021\u0026nbsp;(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommentary study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge \u0026ndash; usually 11-13yrs, but no requirement exists\u003c/p\u003e \u003cp\u003eGrowth Plates \u0026ndash; low risk of damage, not a reason to delay starting \u003cem\u003een pointe\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFlexibility \u0026ndash; 1st MTP joint 80-90deg extension, 90deg ankle PF\u003c/p\u003e \u003cp\u003eTechnique \u0026ndash; Turnout control Alignment \u0026ndash; torso control whilst using arms and legs\u003c/p\u003e \u003cp\u003eLeg length difference can affect alignment\u003c/p\u003e \u003cp\u003eMaturity \u0026ndash; able to take and apply corrections\u003c/p\u003e \u003cp\u003eStrength \u0026ndash; core muscles, 25 relev\u0026eacute;s\u003c/p\u003e \u003cp\u003eProprioception \u0026ndash; balance and control for pirouettes\u003c/p\u003e \u003cp\u003eHistory - health, injury, sleep, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eBalance and control\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAlignment\u003c/p\u003e \u003cp\u003eGeneral health\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003cp\u003eInjury history\u003c/p\u003e \u003cp\u003eDancer\u0026rsquo;s goals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeiss et al. 2009\u0026nbsp;(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommentary study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDo not start pointe if:\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;12 years\u003c/p\u003e \u003cp\u003e\u0026bull; Not anatomically sound (i.e. ankle foot PF, poor alignment)\u003c/p\u003e \u003cp\u003e\u0026bull; Not truly at pre-professional level\u003c/p\u003e \u003cp\u003e\u0026bull; Trunk, pelvic or leg muscles are weak (start strength program)\u003c/p\u003e \u003cp\u003e\u0026bull; Hypermobile in ankle or feet (start strength program)\u003c/p\u003e \u003cp\u003e\u0026bull; Only 1 ballet class per week\u003c/p\u003e \u003cp\u003eCan start pointe if:\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ge;\u0026thinsp;4 years of ballet training if classes are x2 per week and none of above applies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAlignment\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003cp\u003eDancer\u0026rsquo;s goals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePF: plantarflexion, MTP: metatarsophalangeal\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of grey literature (n\u0026thinsp;=\u0026thinsp;9) included in the review analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecommendations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarringer 1995\u0026nbsp;(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDance Magazine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTechnique justifies it\u003c/p\u003e \u003cp\u003ePointe work takes more than developed muscles and understanding of placement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique\u003c/p\u003e \u003cp\u003eAlignment\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBatalden 2020\u0026nbsp;(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopaedic Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo tests to predict dancer ability to dance \u003cem\u003een pointe\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTypically start age 12 in the USA\u003c/p\u003e \u003cp\u003eDuration of training does not produce standard level of proficiency\u003c/p\u003e \u003cp\u003e90deg ankle plantar flexion\u003c/p\u003e \u003cp\u003eDifficult to assess tests (e.g. saut\u0026eacute; test) without slow motion analysis and specific criteria\u003c/p\u003e \u003cp\u003ePoor performance on satu\u0026eacute; test reflected low repetitions of heel rise test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge and level of achievement\u003c/p\u003e \u003cp\u003eTechnique and muscle development\u003c/p\u003e \u003cp\u003eRange of motion and flexibility\u003c/p\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrandt 2012\u0026nbsp;(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePointe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRisk growth plate injury if start before age 11\u003c/p\u003e \u003cp\u003eIncentive to start between 11\u0026ndash;13 as bones still malleable\u003c/p\u003e \u003cp\u003eTechnique readiness\u003c/p\u003e \u003cp\u003eTurnout when rising\u003c/p\u003e \u003cp\u003eAnkle stability and muscle tone\u003c/p\u003e \u003cp\u003eTraining intensity\u003c/p\u003e \u003cp\u003eMetatarsal and intrinsic muscle work\u003c/p\u003e \u003cp\u003eHip and core strength for turnout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrewer 2005\u0026nbsp;(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEuropean Dance News\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFeet, legs and hips are strong enough\u003c/p\u003e \u003cp\u003eHold pass\u0026eacute; on one leg on half pointe \u0026ndash; should be strong enough for simple pointe work\u003c/p\u003e \u003cp\u003eRelev\u0026eacute; with knee straight and strong\u003c/p\u003e \u003cp\u003eGood posture, understanding of placement, foot and ankle alignment, understanding of turnout\u003c/p\u003e \u003cp\u003eStraight line from big toe joint to ankle\u003c/p\u003e \u003cp\u003eHypermobile child should start as late as possible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and muscle development\u003c/p\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAlignment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDekle 1994\u0026nbsp;(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDance Magazine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTechnical level\u003c/p\u003e \u003cp\u003eMuscular strength\u003c/p\u003e \u003cp\u003eBody structure\u003c/p\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003cp\u003eControl of basic posture and alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and muscle development\u003c/p\u003e \u003cp\u003ePhysiological development\u003c/p\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAlignment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGiguere 2020\u0026nbsp;(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDance Education in Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSufficient ankle strength\u003c/p\u003e \u003cp\u003eUnderstanding and demonstration of alignment and turnout\u003c/p\u003e \u003cp\u003eIntermediate level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eAlignment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHorosko 1997\u0026nbsp;(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDance Magazine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHold pass\u0026eacute; on demi pointe at the barre for 45 seconds\u003c/p\u003e \u003cp\u003eNever before bones are sufficiently ossified\u003c/p\u003e \u003cp\u003eNot before age 10\u003c/p\u003e \u003cp\u003eNot clenching or gripping toes when bare foot\u003c/p\u003e \u003cp\u003eTeacher sufficiently experienced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eBalance and control\u003c/p\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSandall 2019\u0026nbsp;(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDance Magazine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot before age 11\u003c/p\u003e \u003cp\u003eNo evidence that starting before 11 is damaging\u003c/p\u003e \u003cp\u003eChronological and biological age can differ significantly\u003c/p\u003e \u003cp\u003eTeachers develop own pointe readiness indicators\u003c/p\u003e \u003cp\u003eFunctional ballet technique\u003c/p\u003e \u003cp\u003eHow introductory pointe classes are structured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVogel 2004\u0026nbsp;(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDance Spirit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStart around age 12\u003c/p\u003e \u003cp\u003eAt least 4 years of solid training\u003c/p\u003e \u003cp\u003eStrong and flexible calf and foot muscles\u003c/p\u003e \u003cp\u003eAble to do repeated relev\u0026eacute;s away from barre and 4\u0026ndash;8 single leg relev\u0026eacute;s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnique and skill\u003c/p\u003e \u003cp\u003eTraining and experience\u003c/p\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003cp\u003eStrength\u003c/p\u003e \u003cp\u003eAge and maturity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Summary of studies (n\u0026thinsp;=\u0026thinsp;9) included in the review analysis\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Summary of commentary studies (n\u0026thinsp;=\u0026thinsp;4) included in the review analysis\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e: Summary of grey literature (n\u0026thinsp;=\u0026thinsp;9) included in the review analysis\u003c/p\u003e \u003cp\u003ePart 2: Delphi Consensus\u003c/p\u003e \u003cp\u003eDuring round one, panellists collectively listed 271 assessment criteria to be considered before a dancer initiates pointe training and 86 reasons for conducting a pointe readiness assessment. Three themes (skill and training, physical characteristics and health and wellbeing) were revealed with 10 areas of assessment (technique and skill, balance and control, training and experience, ROM, strength, alignment, general health, age and maturity, injury history and dancer goals) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Ninety-nine unique criteria were identified for consideration in round two. Twenty-two reasons to complete a pointe readiness assessment were identified. No additional criteria were identified in subsequent rounds. Round two and three both had a 100% response rate. One health professional did not complete all responses in round 2, however their completed responses were included in the analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePointe readiness assessment criteria\u003c/h3\u003e\n\u003cp\u003eFollowing round two of the Delphi, 39 of the 99 criteria to be considered in a pointe readiness assessment reached consensus (38 criteria for inclusion, 1 for exclusion). The 60 criteria not reaching consensus were re-rated in round three. Round three resulted in a further nine items reaching agreeable consensus. A total of 48 out of 99 criteria achieved consensus (47 criteria agreement for inclusion, 1 agreement for exclusion) on informing the decision to allow a dancer to start pointe training. Of the ten assessment areas, the agreement consensus rates for criterion inclusion were 100% for injury history (3/3), 84.6% for balance and control (11/13), 66.7% for strength (8/12), 61.5% for technique and skill (8/13), 62.5% for age and maturity (5/8), 53.8% for range of movement (7/13), 36.4% for training and experience (4/11), 10% for general health (1/10), 0% for alignment (0/11) and 0% for dancer\u0026rsquo;s goals (0/5). Individual assessment criteria of calf strength, ankle plantarflexion ROM, knee control, single-leg standing, chronological age, past injury history, present injuries and orthopaedic history each reached\u0026thinsp;\u0026ge;\u0026thinsp;95% agreement for inclusion, with demi-pointe position, calf endurance and the SLHR test each achieving 100% agreement.\u003c/p\u003e \u003cp\u003eCriteria reaching consensus were analysed separately for teachers, health professionals and researchers (supplementary material, table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Teachers and researchers reached consensus on a higher proportion of criteria (74/99 and 67/99, respectively). In contrast, health professionals reached consensus for agreement on only 44/99 criteria. Researchers reached consensus that 26/99 criteria presented were not essential for assessing pointe readiness, compared to only 7 and 6 of the 99 criteria being deemed unnecessary by teachers and health professionals, respectively. Comments on requirements for criteria agreed upon by panel members are presented in supplementary material (table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eReasons for completing a pointe readiness assessment\u003c/h3\u003e\n\u003cp\u003eOn completion of the Delphi,18 out of 22 reasons to conduct a pointe assessment reached an agreeable consensus (supplementary material, table \u003cspan refid=\"MOESM3\" class=\"InternalRef\"\u003eS3\u003c/span\u003e). Six reasons (creating a baseline, providing an informed choice, assessing capacity to be successful \u003cem\u003een pointe\u003c/em\u003e, prescribing exercises, providing information to the ballet teacher and establishing what needs to be achieved before starting \u003cem\u003een pointe\u003c/em\u003e) reached overall agreement of \u0026ge;\u0026thinsp;95% for inclusion as reasons to complete a pointe readiness assessment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study sought to establish expert consensus from a range of stakeholders on the criteria a dancer should demonstrate prior to commencing pointe work. Although some criteria reached overall consensus, the responses varied for how each criterion should be measured and what the dancer should demonstrate to fulfil the criteria. This variability highlights the lack of standardised assessment methods for pointe readiness, potentially leading to inconsistent decision-making even when using the same criterion measures. Findings also identified differences in agreement and importance of individual criteria between professional groups of the panel. Further investigation into the reasons for this discrepancy is warranted. Our findings highlight the key criteria that should be considered and underscore the need for clearer objective guidelines to ensure safe and equitable progression to pointe work for ballet dancers. Findings also provide new insight into what each professional group deems important to consider when progressing a dancer \u003cem\u003een pointe\u003c/em\u003e and identifies certain criteria may be most appropriately assessed by teachers and health professionals independently.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComparison to IADMS Guidelines\u003c/h2\u003e \u003cp\u003eThe IADMS guidelines for the initiation of pointe training were established in 2009(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The guidelines suggest dancers be \u0026ge;\u0026thinsp;12 years of age, have enough range at the foot and ankle, be at a pre-professional level, have strong core and leg muscles, controlled hypermobility, be participating in \u0026ge;\u0026thinsp;2 ballet classes per week and have \u0026gt;\u0026thinsp;3 years of ballet training before starting pointe(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The panel in our study broadly supported these recommendations. In addition to the IADMS guidelines, the panel also reached consensus on assessing injury history, SLHRs, and balance when determining a dancer\u0026rsquo;s readiness to progress to pointe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAge\u003c/h2\u003e \u003cp\u003eAgreeable consensus was reached for considering chronological age, with panellists predominantly recommending a minimum age range of 10\u0026ndash;12 years, slightly below the IADMS guideline(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, the relevance of chronological age has been questioned in both dance specific and general population literature due to developmental variability during adolescence(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Notably, no consensus was reached on assessing pubertal stage, menarche, growth velocity, or skeletal maturity. This may indicate a gap in understanding between chronological and developmental age or how developmental age impacts pointe readiness, warranting further education and investigation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRange of motion and lower limb alignment\u003c/h2\u003e \u003cp\u003eThe panel reached consensus for the inclusion of foot and ankle ROM assessment, aligning with IADMS guidelines(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, IADMS does not provide objective benchmarks, beyond requiring \u0026ldquo;sufficient range\u0026rdquo;(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Reflecting this lack of specificity, panel members employed varied standards and methods for assessing ROM (e.g. plantarflexion ranged between 160\u0026deg;-185\u0026deg;, discrepancy between medial or lateral goniometer measurement). While foot and ankle mobility and lower-limb alignment were clearly valued, assessment methods require further refinement for greater consistency and objectivity. In line with the IADMS guideline of assessing and ensuring appropriate joint control, the panel agreed that assessment of hypermobility should be included in a pointe readiness assessment. The Beighton scale with a score of \u0026ge;\u0026thinsp;6, was most referenced (50% of panellists)(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Panellists agreed that hypermobile dancers may require additional strength and control training to transition safely to pointe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePre-professional level of training\u003c/h2\u003e \u003cp\u003eIn contrast to the IADMS recommendation that pointe work be limited to pre-professional dancers, the panel achieved consensus that the dancer\u0026rsquo;s goals would not inform their decision to progress a dancer to pointe training. Researchers and teachers did not consider goals as an essential consideration in readiness assessments, while health professionals reached no consensus on goal-related criteria. This divergence may reflect the increasing participation in recreational ballet(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Provided pointe readiness criteria are met, there may be no justification for excluding recreational dancers from starting pointe work. This finding may prompt future guidelines to acknowledge the growing diversity in ballet participation and reconsider the recommendation that pointe work be reserved solely for elite dancers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCore and lower limb strength\u003c/h2\u003e \u003cp\u003eIADMS guidelines suggest a strong core and lower limbs are required before beginning pointe training, however, do not provide objective criteria(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite agreement on the inclusion of core strength evaluation in a pointe readiness assessment, the assessment methodology and requirements varied across panellists. The variation in assessment and differences in what each test measured suggests a standardised approach is needed to define the criteria of core strength for pointe readiness. Agreement on inclusion of lower limb strength assessment was identified for the calves, hip external rotators, foot intrinsics and glutes. Again, a range of assessment methodologies were suggested. Poor core stability and decreased lower limb strength have been identified as an injury risk factor in dancers; however, its specific relationship to pointe training remains unclear(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Establishing clear, measurable strength guidelines that predict safe progression to pointe training would enhance consistency across assessors and contribute to safer, more evidence-informed decisions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTraining\u003c/h2\u003e \u003cp\u003eThe panel agreed training history should be considered before starting pointe work. However, they suggested a range of one to five years of prior training, compared with the IADMS recommendation of at least three years. The panel\u0026rsquo;s suggestion of a minimum of two classes per week aligned with IADMS guidance(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), though they additionally recommended that each class be 60\u0026ndash;90 minutes in duration. Currently, no literature supports these recommendations for class length or frequency, highlighting the need for further research into appropriate training volumes for pointe readiness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eHighly rated criteria\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eCalf endurance\u003c/h2\u003e \u003cp\u003eIn agreement with previous studies, calf endurance, assessed by the SLHR test, reached unanimous consensus as an assessment criterion(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The panel defined proper execution as achieving demi-pointe with 90\u0026deg; metatarsophalangeal joint extension and 90\u0026deg; plantarflexion at peak height. However, the required number of SLHR repetitions varied greatly ranging from 10 to 35. Health professionals and researchers commonly recommended 20\u0026ndash;25 repetitions. Teachers were less likely to specify a numeric criterion and prioritised technique over quantity. Although the Australian Ballet recommends\u0026thinsp;\u0026ge;\u0026thinsp;25 SLHRs, this benchmark is anecdotally based on adult company dancers(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) and may not be applicable to younger dancers with lower training load and skill levels. Normative SLHR values in healthy 11 and 12-year-old females in the general population has been reported as 25.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 and 27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2 repetitions, respectively(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). However, these values are unlikely to translate directly to ballet-specific SLHR due to greater technical demand(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Strength and endurance requirements of the calf complex for pointe work remain undefined (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Although the panel unanimously agreed that SLHR should be used as a determining criterion for dancers\u0026rsquo; progression to pointe training, further research is needed to establish normative strength thresholds and refine SLHR criteria.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eInjury History\u003c/h2\u003e \u003cp\u003eKnowledge of the dancer\u0026rsquo;s injury history reached unanimous consensus among panellists as an essential component of pointe readiness evaluation. The panel identified the evaluation of contributing factors to injury, patterns in injury type, frequency, completion of rehabilitation and confirmation of full recovery as critical components of the injury history assessment. Panellists unanimously agreed that dancers must be injury-free prior to commencing pointe work. This aligns with Hough-Coles et al.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) where \u0026lsquo;no recent injury\u0026rsquo; was ranked as the top screening measure. While panellists agreed that a history of injury would not necessarily prevent a dancer from beginning pointe training, they emphasised it would warrant a more comprehensive physical evaluation. Although deemed important, the consideration of injuries remained general in nature. Prior injury tends to be a good predictor of subsequent injury (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), however it is unknown whether sustaining certain injuries (regardless of rehabilitation) may put a dancer at more risk of future injury if they begin pointe training.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBalance and Control\u003c/h2\u003e \u003cp\u003e Agreement was established on including assessment of balance and control, with a specific focus on single-leg stability and knee alignment. The \u0026lsquo;Airplane\u0026rsquo; and \u003cem\u003e\u0026lsquo;Saut\u0026eacute;\u0026rsquo;\u003c/em\u003e tests for balance and control, identified as being good indicators for pointe readiness (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), were endorsed by the panel. However, the number of repetitions required for each test varied. For the \u003cem\u003e\u0026lsquo;Saut\u0026eacute;\u0026rsquo;\u003c/em\u003e test (single-leg hops), Richardson et al.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) recommend a passing criterion of eight successful hops out of 16 performed in \u0026lsquo;neutral alignment\u0026rsquo;. Panellists suggested 3\u0026ndash;16 successful repetitions, with three panellists recommending successful hops be consecutive. There was uncertainty about how the test should be performed, including whether to use parallel or turned-out alignment and whether a hop or jump was more appropriate. The \u0026lsquo;Airplane\u0026rsquo; test involves a single-leg squat with the torso and unsupported leg held parallel to the floor(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Richardson et al.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) define a passing score as four out of five successful repetitions. In our study, panellists suggested dancers should demonstrate between three and eight successful attempts. Other studies have, however, not favoured this test for determining pointe readiness(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The assessment of single-leg balance was also identified as important determinant for pointe readiness by our panel. This agrees with existing work(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), although no empirical evidence exists to support this. The panel, again, identified multiple methods of assessing single-leg balance including standing on a flat foot, balancing on rise, having eyes open or closed and time the position is held (suggested range 5-30seconds). Hough-Coles et al.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) reported single-leg balance on rise in the \u003cem\u003eretir\u0026eacute;\u003c/em\u003e position may be a more effective indicator of pointe readiness than the \u0026lsquo;topple test\u0026rsquo; (single \u003cem\u003epirouette\u003c/em\u003e) proposed by Richardson et al.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, balance time was not reported. Despite the panel\u0026rsquo;s agreement upon use in a pointe assessment, none of the tests (airplane, \u003cem\u003esaut\u0026eacute;\u003c/em\u003e, topple, \u003cem\u003eretir\u0026eacute;\u003c/em\u003e balance) have been validated for suitability in assessing balance and control in ballet dancers. Therefore, although there was agreement on the inclusion of the \u0026lsquo;airplane\u0026rsquo;, \u003cem\u003e\u0026lsquo;saut\u0026eacute;\u0026rsquo;\u003c/em\u003e and single-leg balance tests, the variability in how these tests are administered and the range of passing criteria highlights the need for further validation studies to determine their appropriateness in assessing pointe readiness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eInterdisciplinary Approach to Assessment\u003c/h2\u003e \u003cp\u003eTeachers and health professionals are the primary stakeholders involved in determining pointe readiness(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Eighty-five percent of panellists believed the ballet teacher should be involved in the pointe readiness assessment and 95% supported involvement of a health professional, with physiotherapists most preferred (85%). Teachers demonstrated broader consensus across all themes, placing importance on the assessment of technique, skill and overall postural alignment. Heath professionals favoured objective assessment of SLHRs, ankle and foot ROM and balance and control. This contrast highlights the variation in expertise, assessment focus, and priorities between the two groups. Hough-Coles et al.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) concluded that a ballet teachers\u0026rsquo; assessment may be more reliable in determining pointe readiness than a battery of tests however, no detail on what a teacher\u0026rsquo;s assessment would consist of was provided. Our finding suggests that the agreement on a wider range of criteria among teachers may reflect their long-term relationships with students and ability to observe progression over time. In contrast, health professionals typically conduct assessments over one or two appointments and may be required to make decisions within limited timeframes. This discrepancy in the duration spent and context of engagement with the dancer, alongside varying expertise, suggests teachers and health professionals may be best suited to assess different aspects of pointe readiness. The discussion of interdisciplinary focus of our study extends on previous consensus work and highlights that a shared assessment framework may be necessary(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A more efficient approach may involve a shared assessment framework, wherein teachers evaluate components of technique, alignment, training history and maturity within their class setting, and health professionals focus their assessment on objective measures of strength, range of motion, balance and control as per their clinical expertise. The development of a standardised, collaborative assessment model may improve consistency and clarity in the pointe readiness decision-making process.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eReasons to conduct a pointe readiness assessment\u003c/h2\u003e \u003cp\u003eThere was strong agreement among panellists that a pointe readiness assessment should be used to evaluate a dancer\u0026rsquo;s current abilities, provide education to support informed decision-making, identify injury risk and guide appropriate intervention if required. The use of screening tools for injury prediction is not new within dance(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Although the panel agreed that a pointe readiness assessment should be used as an injury prevention tool, to date, no studies have demonstrated a that pointe readiness assessments reduce injury risk. Further research is needed to explore this potential association.\u003c/p\u003e \u003cp\u003eWhile there was overall agreement that a pointe readiness assessment provides an opportunity for the dancer to develop a relationship with a health professional, health professionals did not reach consensus on this point. Consensus was not reached on using the assessment as a measure of technical ability or ballet aptitude despite agreement on the inclusion of multiple ballet technique elements. It remains unclear whether the inclusion of ballet-specific technical elements in the assessment were considered as indicators of ballet technique, or if these elements serve as surrogate indicators of functional strength and control. As such, further research is warranted to examine the validity and reliability of ballet technique assessment in comparison to standardised objective measures. The broad range of reasons reaching consensus indicates panellists agree a pointe readiness assessment is both valuable and informative. Longitudinal studies may provide insight into the effectiveness of pointe readiness assessments in addressing their intended purpose and rationale.\u003c/p\u003e \u003cp\u003eStrengths and Limitations\u003c/p\u003e \u003cp\u003eThe scoping review component of this study has several limitations. The lack of standardised measures within dance medicine may have led to relevant studies being overlooked despite comprehensive search strategies. The inclusion of grey literature, while necessary due to the limited volume of peer-reviewed research on pointe readiness, introduces variability in the quality and reliability of sources. A key strength of our study was the inclusion of diverse stakeholders involved in supporting the safe transition of young dancers to pointe training in the Delphi study. Comparing consensus rates between teachers and health professionals offered insight into the priorities of these key groups and whether they value the same criteria when deciding if a dancer is ready for pointe. Involving researchers actively engaged in developing current evidence in this field also enabled an assessment of the extent to which emerging research is being translated into practice. Including qualitative responses from panellists further strengthened our study by demonstrating the diversity of methodologies and expectations, even when they agreed on including specific criterion. Our study had a 100% retention rate of panellists, further strengthening the findings. However, as 86% of panel members were based in Australia, the findings may reflect region-specific practices and not fully represent those in other countries, limiting generalisability outside of Australia.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study presents the most thorough evaluation of pointe readiness assessment criteria and should be used as a framework to develop further objective guidelines in conjunction with IADMS guidelines and other consensus panels(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The panel\u0026rsquo;s consensus on pointe-readiness criteria shows strong alignment with multiple IADMS guidelines. Additional criteria of SLHRs, balance and control, and injury history were identified as important considerations. While consensus on many criteria was reached, our findings highlighted a lack of consistency in the methodology and requirements used across these criteria. These findings emphasise the need for additional research to validate measures used in pointe readiness assessments. Such validation should consider the dancer\u0026rsquo;s stage of maturation and development, the expected duration of pointe training per week once initiated, and the assessment\u0026rsquo;s effectiveness in reducing injury risk once pointe work begins.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIADMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Association for Dance Medicine and Science\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRange of Movement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSLHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSingle Leg Heel Raise\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eWe confirm that the manuscript, including related data, figures, and tables has not previously been published and is not under consideration by another journal. All authors have approved the manuscript and agree with its submission to Sports Medicine Open.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e Ethics approval was granted from the university\u0026rsquo;s Human Research Ethics Committee (Project Number 2024/HE000106).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eData supporting the findings of this study are available within the paper and its Supplementary files. Original\u0026nbsp;data are available upon reasonable request. Access to the data will be subject to approvals by the Principal Investigator with a requirement to sign a data access agreement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eHF and AF were responsible for project conceptualisation. HF was responsible for all data collected and wrote the manuscript (review and editing). AF, JB, RS and DC all provided critical revision of the manuscript. AF provided supervision, analysed data and assisted with writing and revision of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRussell JA, Yoshioka H. Assessment of female ballet dancers\u0026rsquo; ankles in the en pointe position using high field strength magnetic resonance imaging. Acta radiol. 2016;57(8):978\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi F, Adrien N, He Y. Biomechanical risks associated with foot and ankle injuries in ballet dancers: a systematic review. Int J Environ Res Public Health. 2022;19(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. 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J Sci Med Sport. 2009;12(6):594\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinch CF, Cook J. Categorising sports injuries in epidemiological studies: the subsequent injury categorisation (SIC) model to address multiple, recurrent and exacerbation of injuries. Br J Sports Med. 2014;48(17):1276\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenny SJ, Palacios-Derflingher L, Shi Q, Whittaker JL, Emery CA. Association between previous injury and risk factors for future injury in preprofessional ballet and contemporary dancers. Clin J Sport Med. 2019;29(3):209\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmstrong R, Relph N. Screening Tools as a Predictor of Injury in Dance: Systematic Literature Review and Meta-analysis. Sports Medicine - Open. Volume 4. Springer; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeirs KP, Rippetoe J, Baldwin JD, Fagg A, Haleem A, Jeffries L, et al. Effects of dancer-specific biomechanics on adolescent ballet dancers\u0026rsquo; posture en pointe and factors related to pointe readiness: A cross-sectional study. Med Probl Perform Art. 2023;38(3):155\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pointe readiness, assessment, ballet, pointe, Delphi method","lastPublishedDoi":"10.21203/rs.3.rs-8644695/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8644695/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eA ballet dancer\u0026rsquo;s first pair of pointe shoes marks a significant milestone in ballet training. Pointe shoes are synonymous with classical ballet and allow dancers to perform on the tips of their toes. Beginning pointe training is a multifactorial decision, but consensus is lacking regarding the abilities a dancer must demonstrate to progress to pointe training safely. Guidelines have been established by the International Association for Dance Medicine and Science, however, are largely broad and subjective. We aimed to establish a consensus on key factors a dancer should demonstrate before commencing pointe work via a scoping review and Delphi method.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA scoping review identified existing criteria, followed by a three-round Delphi method with 21 experts (ballet teachers, health professionals and experienced researchers). Combining scoping review criteria with panel responses, three themes and 10 areas of assessment were identified, along with 22 reasons to complete a pointe readiness assessment. The panel rated their level of agreement for each criterion on a 4-point Likert scale (strongly-disagree to strongly-agree) to determine consensus (\u0026ge;\u0026thinsp;80% agreement). 48/99 of identified criteria to assess pointe readiness reached consensus. Single-leg heel-rise (SLHR) repetitions, balance and control and injury history reached the highest consensus in influencing the decision to progress a dancer to pointe. 18/22 reasons to conduct a pointe assessment reached an agreeable consensus.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study provides a comprehensive evaluation of pointe readiness criteria and explores the differing perspectives of a range of stakeholders. It also offers a foundation for developing standardised, evidence-informed guidelines. Further research is needed to validate measures and improve the effectiveness of pointe readiness assessments.\u003c/p\u003e","manuscriptTitle":"Readiness for Pointe Shoes in Ballet: A Delphi Consensus Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 17:15:48","doi":"10.21203/rs.3.rs-8644695/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor Revision","date":"2026-03-10T22:08:12+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2026-01-29T23:02:49+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T20:11:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Sports Medicine-Open","date":"2026-01-22T22:42:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T06:05:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Sports Medicine-Open","date":"2026-01-20T17:00:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"42fad87e-e486-43ae-b26d-c5c0784ad697","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T04:55:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 17:15:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8644695","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8644695","identity":"rs-8644695","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}