A Comparative Mechanical Analysis of the Pointe Shoe Toe Box An In Vitro Study Bryan W. Cunningham,* MSc, Andrea F. DiStefano,† PT, Natasha A. Kirjanov,‡ Stuart E. Levine,* MD, and Lew C. Schon,*§ MD From *The Orthopaedic Biomechanics Laboratory, Department of Orthopaedic Surgery, The Union Memorial Hospital, Baltimore, †Health South Spine Center, St. Joseph Hospital, Towson, and the ‡Ballet Theatre of Annapolis, Annapolis, Maryland ABSTRACT Dancing en pointe requires the ballerina to stand on her toes, which are protected only by the pointe shoe toe box. This protection diminishes when the toe box loses its structural integrity. The objectives of this study were 1) to quantify the comparative structural static and fatigue properties of the pointe shoe toe box, and 2) to evaluate the preferred shoe characteristics as determined by a survey of local dancers. Five different pointe shoes (Capezio, Freed, Gaynor Minden, Leo’s, and Grishko) were evaluated to quantify the static stiff- ness, static strength, and fatigue properties (cycles to failure) of the shoes. Under axial loading conditions, the Leo’s shoe demonstrated the highest stiffness level, and the Freed shoe exhibited the least strength. Under vertical loading conditions, the Leo’s and Freed shoes demonstrated the highest stiffness levels, and the Gaynor Minden and Freed shoes exhibited the highest strength. Fatigue testing highlighted the great- est differences among the five shoes, with the Gaynor Minden demonstrating the highest fatigue life. Dancers rated the top five shoe characteristics, in order of im- portance, as fit, comfort, box/platform shape, vamp shape, and durability and indicated that the “best” shoe is one that “feels right” and permits artistic maneuvers, not necessarily the strongest or most durable shoe. Appreciated for the artistry, grace, and elegance of the dancers, ballet is an art form that makes immense phys- ical demands on the body while requiring the production of aesthetic and graceful movements. From the 1581 in- troduction of ballet at the French Court (attributed to Catherine de Medici), the popularization of this art form by Louis XIV, and the 1661 creation of the Academie Royale de Danse, 2 the technique of ballet has become more demanding, requiring refinement of the dancer’s strength, technique, and tools. This was highlighted by Marie Taglioni, who, in 1832, was the first to dance en pointe. This was originally done with soft satin slippers contain- ing a leather sole. As pointe technique developed, the shoe also evolved to allow the ballerina to perform more exact- ing maneuvers. In time, the shanks became harder, the boxes became stronger, and the toe platform became wider. When dancing en pointe, today’s ballerina stands on her toes with little more than a papier-ma ˆ che ´ or cardboard shell to protect her forefoot. The pointe shoe, made up of the toe box, shank, and the outer material, is one of the most important tools of the dancer. The outer material is usually a soft, cotton-backed cloth called corset satin. The pointe material provides a relatively low-friction surface to permit spins while allowing for sufficient “grip” during standing or jumping. Although it is fairly durable, this covering will wear out, usually over the toe platform, and replacement will be necessary. The conical toe box consists of layers of burlap, cardboard, or paper, or a combination thereof, that have been saturated with glue. 3 It tightly surrounds the toes so that the dancer’s weight rests on the platform. The shank, made up of cardboard, leather, or a combination of the two, also helps to support the foot while en pointe by providing a certain degree of stiffness. The breaking-in process of the toe box softens the cardboard and conforms the shoe to the foot, but destroys the glue bonds. The optimum toe box shape lasts for only a short § Address correspondence and reprint requests to Lew C. Schon, MD, c/o Elaine P. Bulson, Editor, Union Memorial Orthopaedics, The Johnston Profes- sional Bldg., No. 400, 3333 N. Calvert Street, Baltimore, MD 21218. No author or related institution has received any financial benefit from research in this study. 0363-5465/98/2626-0555$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 26, No. 4 © 1998 American Orthopaedic Society for Sports Medicine 555