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Why do dancers wear pointe shoes?

The simplest answer is to look nice, but more importantly it allows them to dance on the tips of their toes. This extends the line of the legs, creates an illusion of lightness and a sense that the ballerina is floating in the air.

What are they made of?

The tip of the shoe is a rigid box made of densely packed layers of fabric, cardboard and glue (not wood or metal),  much like paper marché. The shank/sole is made of cardboard, glue and leather to provide hardness and support. The rest of the shoe is made of leather, canvas and covered in satin to give an aesthetically pleasing look. The shoe needs to be strong enough to support the dancer on pointe, yet malleable enough for the dancer to articulate the joints of the ankle and foot. Most parts of the shoe are hand-made, and no two pairs of pointe shoes are identical!

How do dancers prepare the shoes for dancing?

New shoes are pretty, but impossible to dance in as they are too rigid, thus dancers do various things to “break-in” the shoe to make them danceable. This includes sewing on ribbons and/or elastics to hold the shoe in place, with the ribbons usually being sewn at the highest point of the arch to help support the arch. They also darn the platform to create friction and protect the satin, followed by wearing and performing rises and releves to soften the box and shank in a natural way that will mould the shoe to the shape of the foot and arch.

When can dancers start dancing on pointe?

For young dancers, it is usually somewhere between the age of 11 and 13. This usually works out to about 5 years of ballet specific training, coincides with puberty, and the commencement of ossification of the soft bones in the foot. Many adult beginners or “returners” aspire to go on pointe as well, and while they are past the age of bone maturation, they should still ensure that they have a few years of good basic technique training before attempting pointe. Whether young or old, it is essential that the dancer have adequate flexibility in the ankle and foot, good strength in the lower limb and torso, good balance/proprioception, and good technique to handle the stress of dancing on her toes.

Without adequate ankle and arch flexibility, one would have problems getting up to the platform of the shoe in order to balance on pointe. This leads to either dancing on the edge of the shoe, or compensation to get on the platform. This is can be achieved by not straightening the knee, or scrunching from the toes or metatarsals. This discourages the use of the intrinsic muscles of the foot, and can lead to overuse injuries of the long toe flexors arising from the lower leg, also known as shin splints.

Without adequate strength of the plantarflexors and intrinsic foot muscles, one would find it hard to roll up onto the platform, causing one to “sit” or “sink” into the shoe. This puts excessive weight and pressure on the metatarsals, toes and toenails, which can lead to metatarsal stress fractures (usually 2^nd metatarsal), blisters and blackened toenails. For dancers with very flexible ankle joint and arch, all the more they need to be strong, to prevent them from falling over the shoe. Adequate strength of the medial (tibialis posterior, flexor hallucis longus) and lateral (peroneus longus and brevis) muscles of the foot is also essential to help stabilise the foot on pointe. This helps to prevent sickling in/out, which puts excessive strain on the tendons and ligaments of the lateral ankle/foot, leading to strains and sprains.

Not getting on the platform, correct, and falling over the platform

Sickling outwards putting excessive strain on the medial ankle, correct, and sickling inwards putting excessive strain on the lateral ankle.

Biomechanics of pointe

Dancing on pointe requires complete plantarflexion of the ankle and foot to a combined minimum of 90 degrees, to create a straight line down from the hips through the knees to the tip of the toes. The ankle joint is stable in this closed packed position as the posterior lip of the tibia locks onto the posterior talus and calcaneus. The vamp and sole of the shoe provides support to the lisfranc and metatarsals joints, stabilising the mid and forefoot on pointe. The toes are in a relatively neutral to slightly flexed position, allowing the toes to be perpendicular to the floor and not curl when on pointe.

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There are over 20 brands of pointe shoes, each with various models differing in shape of the toe box, vamp length, profile height, and shank strength. Combined with the length and width of the shoe, there are a few hundred options to choose from. Pointe shoe fitting requires a trained fitter, who is able to assess the foot and look for a shoe mostly closely fitted to the characteristics of the dancer’s foot. This is especially so for the novice who is just starting pointe and is not sure how pointe shoes should feel. Even professional dancers are encouraged to get re-fitted every few years as their feet may change.

• Firstly, the length of the shoe should be fitted to the longest toe. This should be assessed with the dancer in 2nd position in demi-pile as this is when the foot is the most spread out and the longest. The longest toe should be just touching the tip of the box, without the toes curling or pain from the pressure at the tip of the toe.
• Secondly, the toe box needs to be fitted to the shape/width of the dancer’s toes/forefoot. The toe box should be wide enough such that the foot can be flattened out fully when standing on flat, yet snug enough to provide support at the metatarsal heads when up on pointe.  A toe box that is too wide has too much “negative space”, allowing twisting and crumbling of the foot in the toe box when bearing the full body weight, and the foot to slide in and out each time they go up on pointe,. This leads to excessive weight being taken through the metatarsals and toes which can lead to stress fractures, and excessive friction causing the formation of blisters and calluses. Conversely, a shoe that is too tight can cause compression of the nerves between the metatarsals, also known as metatarsalgia.
• Thirdly, the vamp length needs to be fitted to the length of the dancer’s toes. A vamp that is too long does not allow the toes to extend, preventing the articulation of the foot through demi-pointe to full pointe, which discourages the use of the intrinsic foot muscles. On the other hand, a vamp that is too short will not support the metatarsal heads, causing the metatarsal heads to “pop” out of the shoe with a collapse of the transverse metatarsal arch, and excessive weight to be taken on the toes.
• Lastly, the stiffness of the shank needs to be fitted according to the ankle/arch flexibility and strength. Generally, a more flexible ankle/foot requires a harder shank for support, while a less flexible ankle/foot requires a softer shank to allow the dancer to articulate the feet in the shoe. A weaker ankle/foot may require a stronger shank to provide support, yet a softer shank may allow more strength training of the intrinsic muscles of the foot. A strong ankle/foot may be able to deal with a softer shank. Considerations also include the age and expertise of the dancer, and the current requirements for the shoe.

What is the best brand of pointe shoe?

It is not so much about the brand of the shoe, but whether the shoe fits the shape, strength and flexibility of the ankle and foot, as discussed above. Even within the same brand, most likely there will only be one model that fits each foot the best. Just because a prima ballerina is wearing a certain brand doesn’t mean that it will be good for you. If that was the case, wearing Puma shoes would make us all run like Usain Bolt.

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Running Shoes

Q: Is there one best brand of shoe?

A: It’s not so much the brand of the shoe but whether the shoe suits your activity, foot function, and fit. To use an analogy – think about cars. Is a Ferrari a good brand? Of course it is, however if you want to use the car to drive off road then would you want to have a Ferrari or a 4-Wheel Drive of a less well known brand. Similarly the shoe must firstly suit your activity (running shoes for either running or walking. Not tennis or casual shoes for running). Then the shoes should suit your foot function (neutral, overpronator), then the shoe must fit the shape of your foot eg. if you have a wider foot then the cut of New Balance may suit your foot better. Everyone’s different. Thus a shoe which may suit one person may not suit everyone; like the tennis racquet Serena Williams uses may not suit every female tennis player.

Q: But doesn’t Brand A make technical running shoes and the other brands don’t?

A: That’s like saying Mercedes is the only car brand that make luxury sedans. They themselves may imply so but implying so doesn’t necessarily make it so. All major shoe brands make different categories of running shoes just like all the major car manufacturers make different types of cars.

Q: When looking for a running shoe isn’t lighter the better?

A: The weight or lack thereof may be one of the considerations in choosing a shoe but it certainly is not the only consideration. There are other important considerations such as function and fit. If your foot is mechanically unstable then a lighter shoe may cause more problems. This is because a more stable shoe needs to be heavier. There’s always a trade off – the lighter the shoe the less stable it may be. So it really depends on what your foot requires. Different feet have different requirements. Again, what works for one person doesn’t necessarily work for another.

Q: You keep talking about function. How do I know how my foot functions? Is it really as simple as flat feet = severe overpronator, high arched feet = underpronator (actually there is no such word).

A: Firstly – no it is not as simple as that. Flat Feet or High Arched Feet are the description of the shape of the foot and overpronation or oversupination (not underpronation) are the movements of the foot. It is a gross generalisation to say all flat feet overpronate and all high arched feet oversupinate.

The most accurate way to determine the function of your foot is to visit either a Podiatrist (especially one who has experience in high performance sports), or a Sports Doctor, or a Sports Physiotherapist. Whilst most people may be reluctant to pay for a consultation just to determine how their foot functions but for those who are more serious or performance runners it is better not to be “penny wise pound foolish” as using the wrong type of shoe can lead to injuries (short and long term) and / or pain. I always liken a runners shoes their most important piece of their sporting equipment. Like a tennis player using the wrong tennis racquet or a golfer using the wrong type of golf clubs this could cause pain or injuries. The objective of sporting equipment is to maximise the athlete’s strengths and to minimise their weaknesses. I’ve seen many a patient waste money on the wrong type of shoes (which can be more expensive than a professional consultation). It is not just the money that one has to consider but also the possibility of pain and injury which could sideline the runner and cause them to miss the event they’ve been training so hard for.

Q: When should I change my running shoes?

A: Every 500 – 700kms or 1 year (whichever comes first). 1 year is even if you have never used the shoes. This is because the material in the midsole of the shoe deteriorates. The rate of deterioration is faster in a humid climate such as Singapore.

Also if the shoe is deformed – like in the photo below. Again, trying to save money when new shoes are due are “penny wise pound foolish” and can result in pain and injury.

Q: What are the basic key characteristics of a suitable running shoe?

A: The shoe must have

i) Firm Heel Counter – to give stability to the foot at heel strike.

ii) Laces are still the best – It allows to vary the fit of the shoe.

iii) Wide & Deep Toebox – too narrow can cause calluses or blisters, too shallow and it can cause subungual haematoma’s (painful blackened toenails)

iv) Midsoles are still the best. Recognised studies suggest running shoes with traditional midsoles over barefoot / minimalistic shoes.

Significant higher leg stiffness during stance phase was found in barefoot. Stride frequency, anterior-posterior impulse, vertical stiffness, leg stiffness & mechanical work were significantly higher in barefoot. For nearly the same Oxygen consumption, barefoot runners produce more mechanical work.” ¹

Barefoot runners used almost 4% more energy in each step than running in shoes.” ²

v) Durable outsole.

References:

1. Divert et al. Int’l Journal of Sports Medicine 2008;29:512-519
2. Kuran et al. Journal of Med Sci Sports & Exercise

We hope you have enjoyed the article! This is the first of our two-part series on Running Shoes and Orthotics. Be sure to check back for the second part on Orthotics next week!

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Q: Aren’t all Insoles the same?

A: There are 3 types of Insoles / Orthotics.

i) Over the Counter (OTC) Insoles. These are mass produced to a standard. General price range: $20 – $80.

ii) Prefabricated Insoles which can be modified. These are like OTC insoles but they can be modified either by heating them up and bending them in the desired shape. They can also be modified by adding external wedges and / or grinding them. Price range: $120 – $200.

iii) Prescription Custom Made Orthotics. These are the “Gold Standard”. They are the only ones which are “custom made”. How you can tell they are custom made is that they are either done by a Podiatrist or a Podiatrist run Orthotics Laboratory. It is a 15 – 20+ step process. The price range: $350 – $475.

Q: How can you tell if an Orthotic is really custom made as opposed to prefabricated and modified?

A: There are a few tell-tale signs

1. If the measurement of the foot for the orthotic is only done as a footplate / foot imprint (no matter how many pretty colours are used). I’m not an engineer but I fail to see how one can make a 3-Dimensional product (the orthotic) from a 2-Dimensional measurement (the foot pressure mat).

The proper measurement for a Custom-Made Orthotic is by one of 3 accepted ways.

1. A plaster of paris slipper cast
2. A foam impression box (see photo at right)
3. A 3-Dimensional foot scanner

Not one of these moulds are proven to be more accurate than the other as it is the skill of the Podiatrist of positioning the foot in the correct position when taking the mould that is paramount.

That leads me to the next tell-tale sign.

2. The measurement / mould of the foot should either be done with the patient lying down (non-weight bearing) or seated (partial weight-bearing) NEVER standing.

A lot of patients comment that since the orthotics are used when standing shouldn’t the mould be taken when they’re standing? Remember that the objective of the Orthotic is to position the foot in the most efficient position so when the patient is standing the patients foot assumes it’s compensated / incorrect position (think of someone taking the mould for a back brace when the patient is in a slouched position). When the Podiatrist is taking the mould he/she has to ensure that the foot is in the corrected position This can only be done accurately in either a non weight-bearing or partial weight-bearing position as the various muscles will be firing / activated when standing. Anyone who says that they can counter these firing muscles must be mighty strong – there are 26 bones, 33 joints and over 100 ligaments, muscles, tendons, & tissues in each foot.

3. If you take both the left and right sides of the Orthotic and place them mirrored together and they are exactly the same in all dimensions then there’s a pretty good chance that they are not custom made. No one has both their feet exactly the same so if the feet are different but the orthotics are exactly the same then ……..

4. The Prescription Orthotic should only be made by a Registered Podiatrist or a Podiatry Laboratory (btw: Orthotic Laboratory’s generally only accept prescriptions from Registered Podiatrists). How can you tell if it is a Registered Podiatrist. They will generally have their registration certificate from the country they graduated from or they will have their membership card from the Podiatry Association (Singapore). If the Podiatrist is unwilling to show you their Podiatry Registration then …..

Failing these I don’t think many professionals such as Doctors, Physiotherapists, Lawyers etc will set upbooths in shopping malls to ply their trade.

*Be careful of terminology

What some claim to be “custom-made” or “customised” or “custom-fitted” is really just prefabricated insoles modified or “altered” insoles.

Think of when you buy some pants and the length is too long – what do you do? You “alter” the length to fit your measurements ….. but altering the length is not the same as tailor made pants is it? However, these companies will argue that “since I’ve changed the insole to fit your feet then it is “custom-made / customised / custom-fitted” to your feet. Is it really the same?

Note: Podiatrists do use modified prefabricated insoles BUT professionally they should inform you that these insoles are NOT Prescription Custom-Made Orthotics. They should also charge accordingly and NOT as a Prescription Custom-Made Orthotic.

Q: Since some running shoes already are built for overpronators doesn’t that mean that using a Prescription Orthotic will overcompensate?

A: No. Prescription Orthotics work complementary with the shoe. The foot will still move (overpronate) in the shoe. Thus the Prescription Orthotic will position & guide the foot whilst it is in the shoe and then the shoe will position and guide the foot and the orthotic against the interface of the ground.

Q: So, do that mean I can use any type of shoe if I have a Prescription Orthotic?

A: They work best together. If you use an unsuitable shoe then the shoe will cause the orthotic and the foot to be unstable.

Q: How come OTC insoles have a higher arch than some Prescription Orthotics (the “Gold Standard”)? Isn’t the arch the most important part of the insole?

A: That’s where the misconception lies. The arch is NOT the most important part of the insole. The objective of any insole / orthotic is to enable the foot to work in the most efficient mechanical way. This is done by controlling the excessive movements (eg. overpronation) and to enable proper synchronisation of correct movements at the correct timings during the stance phase of gait. Thus it is not as simple as increasing the arch height. That’s like saying the optometrist should give a higher power on my spectacles. It not only is the wrong principle but it can be dangerous.

The definition of Prescription Custom-Made Orthotics is:

“Custom made insoles to support, align, prevent or correct deformity or to modify position or motion and improve the function of the moveable parts of the body.” ¹

Q: How come Podiatrists make Prescription Orthotics in a short (3/4 length) and a Full length version. What are the differences?

A: All Prescription Orthotics can be made either 3/4 length or Full Length. This is because the main area of control in the Prescription Orthotic is the rear-foot and the mid- foot. Remember – the objective of the orthotic is to control the mechanics of the foot.

The differences –

If there is no forefoot pain or injuries then the function between the 3/4 length and Full length orthotic is exactly the same. The main is difference is practicality – if you want to use the orthotic in only 1 shoe or shoes which are very similar shape & size then a Full Length Orthotic is suitable, however if you do want to move it from shoe to shoe then a 3/4 length is more versatile.

Q: What types of conditions can Prescription Orthotics help and what evidence is there to  support Orthotic use.

A: Prescription Orthotics can help many conditions from those in the feet to the ankles, legs, knees, and even lower back. However, for those conditions in the knees and lower back they only help conditions where there is a mechanical contributing factor, and they (prescription orthotics) are best used in conjunction with other treatment modalities eg. Physiotherapy.

Some of the more common conditions that Prescription Orthotics can help are

Feet

• Plantar Fasciitis (heel pain):
• “Patients in the present study demonstrated the best compliance with the use of custom-made orthoses, which may indicate that orthoses provide the best long-term results.” ²

Growing Pains

• In 90 percent of the children in our studies who had lower extremity symptoms and some degree of overpronation of the feet, treatment with foot orthoses relieved the majority of “growing pains.” ³

Running Related Injuries

• “Foot orthotic devices are used to treat a variety of running-related injuries. In terms of pain relief, success rates between 70% and 90% have been cited.” ⁴

Lower Back Pain

• “77% of patients demonstrated 50% to 100% improvement over a 2-year follow-up period when custom-made foot orthoses were used to cor- rect subtle aberrations in their gait style.” ⁵

Ankle Instability

• “Foot Orthoses have been shown to have a positive influence on subjects who have recently experienced an ankle sprain and on subjects with chronic ankle instability.
•  There is evidence that foot orthoses can influence multiple levels of neuromuscular control of the ankle.” ⁶

Q: Whilst there is evidence that Prescription Orthotics are effective for certain conditions, are they a miracle cure for everything?

A: No. Orthotics WILL NOT:

• Make your child smarter
• Make you grow taller
• Make your child have better posture
• Improve respiratory function
• Improve blood circulation
• Improve the appearance of cellulite
• Tone your legs & buttocks

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