Original Article

J Dance Med Sci

ePub date: September 15, 2022 Investigation of the Relationship Between the
https://doi.org/10.12678/1089-313X.121522a
Copyright © 2022 J. Michael Ryan Publishing, Inc.
Morphology of the Toe Flexor Muscles in Ballet
All rights reserved.
To cite this article:
Dancers and the Postural Stability During
Ishihara H, Maeda N, Komiya M, Toshiro T, Urabe Y.
Investigation of the relationship between the morphology Standing on Demi-Pointe: A Cross-Sectional
of the toe flexor muscles in ballet dancers and the postural
stability during standing on demi-pointe: a cross-sectional Study
study. J Dance Med Sci. 2022;26(4):205-12.

Honoka Ishihara,1 Noriaki Maeda,1 Makoto Komiya,1 Tsubasa

Tashiro,1 and Yukio Urabe1

Abstract
Introduction: This study investigated how toe flexor muscles are related to postural stability in 11
ballet dancers and 12 non-dancers.
Methods: Toe flexor strength (TFS), cross-sectional areas (CSA) of the abductor hallucis, flexor
hallucis brevis, flexor digitorum brevis, flexor hallucis longus (FHL), and flexor digitorum longus,
and center of pressure (COP) displacement during single-leg demi-pointe were measured. Correlations
between toe flexor strength and COP displacement and between CSA and COP displacement within
each group were calculated using Pearson’s correlation coefficient or Spearman’s correlation coefficient.
Results: The dancers showed smaller COP displacement than the non-dancers (p < 0.05). Toe flexor
strength in dancers was moderately negatively correlated with COP displacement in the anterior-pos-
terior direction (r = -0.54, p < 0.01) and total COP displacement (r = -0.57, p < 0.01). Only the
CSA of the FHL in dancers exhibited a significant negative correlation with COP displacement in the
anterior-posterior direction (r = -0.42, p < 0.05) and total COP displacement (r = -0.52, p < 0.01).
Conclusion: The present study found a relationship between the toe flexor strength and COP
displacement and CSA of toe flexor muscles and COP displacement during one-legged demi-pointe
standing. These results suggest that the development of the toe flexor muscles may be involved in the
balance control of dancers.

Key Point
• Strengthening of toe flexor muscles, especially the extrinsic foot muscles across the ankle
joint, may be useful to control swaying in the AP direction during standing on demi-pointe.

Introduction
Ballet is an artistic physical activity that often involves the preservation of static
balance. The ability to maintain static balance plays an important role in various
ballet techniques. Additionally, classical ballet dancers are required to present some
specific and unique postures, such as the basic technique wherein ballet dancers
always maintain the pointe position when the foot is released from the floor and the
female dancers wear pointe shoes. Focusing on the feet, the demi-pointe position
is a characteristic position in ballet. In this position, the ankle joint is maximally
plantar flexed, and the metatarsophalangeal (MTP) joint extends 80° to 100° with
the weight of the body resting on the tip of the metatarsals and toes (Fig. 1).1 The
toes are the only part that keeps contact with the floor during demi-pointe standing.
1. Department of Sports Rehabilitation, Graduate It has been known that the body’s weightbearing ability in upright standing makes
School of Biomedical and Health Sciences, the force-generating capacity of the toe flexor muscles higher.2 Furthermore, the
Hiroshima University, Hiroshima, Japan.
maximum force produced by a muscle is dependent on the length of the muscle.3
Correspondence: When the ankle joint is in a plantar flexed position, as in the demi-pointe position,
Yukio Urabe the greater extension angle of the MTP joint provides a boost to the flexion exertion
yurabe@hiroshima-u.ac.jp
of the toe flexor muscles across the ankle joint and MTP joint. Specialization in
Funding Statement: The authors have no disclosures. a particular sport leads to adaptations in the muscles acting on the movements,
The authors report no conflicts of interest in regard
to the information presented in this work.
and their strength and morphology reflect the characteristics of the sport.4 Thus,
characteristic changes can be expected in the morphological structure and muscle

The Journal of Dance Medicine & Science is the official publication of the International Association for Dance Medicine & Science | www.iadms.org 205
 Journal of Dance Medicine & Science • Volume 26, Number 4, 2022 206

surface electromyography was determined to be an inappropriate

way to evaluate toe flexor strength and, therefore, insufficient
to clarify the mechanism underlying the enhancement in the
function of toe flexor muscles observed in dancers.
Evaluation of the individual morphology of toe flexor mus-
cles using ultrasonography may be a useful method to evaluate
the development of each muscle. Ultrasonography has recently
been used to assess the cross-sectional area (CSA) of many
musculoskeletal structures.16-18 Morphology of muscles obtained
with ultrasonography can be employed to understand the
function of dancers’ toes and to explain the differences in foot
structure between dancers and non-dancers; however, data on
the morphology of each toe flexor muscle in dancers are lacking,
and the evidence for the relationship between toe flexor muscle
function and postural stability in dancers remains unclear. Char-
acterization of postural control strategies in dancers is required
as the foundational information for focused investigations on
dance performance; the findings could be used to design new
training methods for dancers.
Figure 1 The demi-pointe position. The ankle joint is flexed max- The present study aimed to determine the difference in the
imally, and the metatarsophalangeal joint extends 80° to 100°. The CSA of the toe flexor muscles between dancers and non-dancers
weight of the body is resting on the tip of the metatarsals and toes. and investigate the relationship between the strength and CSA
of toe flexor muscles and postural stability in demi-pointe to
strength in the toe flexor muscles of ballet dancers who train identify the features of postural control strategies in dancers.
in the demi-pointe position.
Dancers undergo repeated training from childhood to achieve Methods
the skill of maintaining postural stability on demi-pointe, and it The study protocols complied with the principles laid down
is a fundamental and important technique even for adult danc- in the Declaration of Helsinki and were approved by the Ethical
ers.5,6 Stabilometry has been a commonly used method to assess Committee for Epidemiology of Hiroshima University. All the
the static balance of dancers in previous studies.5,7,8 Measuring participants provided informed consent for their participation.
the center of pressure (COP) has been shown to be a reproduc- Eleven female ballet dancers and 12 female non-dancers
ible assessment for static balance.9 In previous studies, dancers participated in this study (Table 1). None of the participants had
showed a small COP displacement with single-leg support on acute ankle or foot injuries in the previous 6 months or a history
the force platform, which suggested that they had better balance of lower limb surgery. The inclusion criteria for dancers were as
ability than non-dancers.5,10,11 Michalska et al.12 reported that follows: 1. receiving classical ballet training for 10 years or more
professional dancers showed a higher ability of postural control and 2. having experience of wearing pointe shoes for at least 3
while performing simple balance tasks and high sensitivity to years. In contrast, the inclusion criteria for non-dancers were as
the subtle changes in comparison to non-dancers. Lin et al.6 follows: 1. never received ballet training and 2. no experience
stated that dance training possibly reduces postural instability playing any sports for more than 1 month continuously, except
by establishing a more accurate sense of position of the lower for school classes. Participants were recruited by displaying
extremities and a more advanced motor program. Rowley et posters inviting cooperation in the experiment at universities
al.13 considered that the toes contribute to maintaining the foot and ballet schools.
stability during heel-raising and holding the demi-pointe posi- The maximum circumference of the calf was measured at
tion in dancers and insisted that dancers have different muscle the thickest level between the medial tibial plateau and inferior
coordination strategies for the heel-raising task. Recent studies border of the medial malleolus using a tape measure.19 The rate
on the toe flexor muscles of dancers have focused on the flexor of the medial longitudinal arch in the sitting position (relatively
hallucis longus (FHL).13-15 The FHL is the primary active flexor non-weightbearing) was calculated based on the height of the
of the first MTP joint and a secondary flexor of the ankle and is navicular bone and foot length.20
considered as the foot stabilizer in the demi-pointe position.13,14 All procedures were conducted on 1 day. In order to eliminate
Measurement of muscle strength is one way to evaluate the flexor as much as possible any temporary effect of the activity of the
muscles of the toes, including the FHL. Toe flexor strength is at- toe flexor muscles on their morphology, measurement of the
tributable to both intrinsic and extrinsic flexor muscles; however, CSA of toe flexor muscles was conducted first. A 5-minute rest
it is impossible to determine the contribution of each muscle. was taken between each test.
Although electromyography is a way to measure the muscle
activity of each muscle individually, FHL and flexor digitorum Measurement of Toe Flexor Strength
longus (FDL) are deep calf muscles, and it is very difficult to The toe flexor strength was measured using a dedicated
measure their activity by surface electromyography. Therefore, device (Takei Scientific Instrument Co., Ltd., Niigata-City,
 Journal of Dance Medicine & Science • Volume 26, Number 4, 2022 207

Table 1 Participants’ Baseline Characteristics

Dancers Non-dancers
(n = 11, 22 legs) (n = 12, 24 legs) P-value d 95% CI
Age (year) 19.9 ± 1.8 20.9 ± 1.1 0.13 0.65 -0.33 to 2.34
Height (cm) 158.0 ± 6.9 155.5 ± 4.8 0.34 0.66 -5.05 to 5.88
Weight (kg) 49.7 ± 6.7 50.1 ± 5.3 0.43 0.41 -0.08 to 0.03
Body mass index (kg/m ) 2
19.8 ± 1.6 20.8 ± 2.4 0.31 0.43 -0.94 to 2.81
Dance training (years) 14.5 ± 2.2 N/A N/A N/A N/A
Calf circumference (cm) 30.3 ± 2.1 30.5 ± 1.7 0.17 0.10 -1.72 to 1.71
Rate of medial longitudinal arch (%) 16.9 ± 1.9 16.5 ± 2.1 0.09 0.42 -2.26 to 0.78
Data are presented as mean and standard deviation. CI, confidence interval; d, Cohen’s d; N/A, not applicable.

Japan). Measurement of toe flexor strength was performed in the FDB, the probe was placed perpendicular to the line from
an upright seated position with arms across the chest, and the the medial tubercle of the calcaneus to the head of the third
ankle joint was secured in a neutral position. Participants were metatarsal at the thickest portion of the muscle. The CSA of
instructed to place their barefoot on the device. The toe flexor the FDL was imaged on a transverse line drawn at 50% of the
strength was measured by griping the bar at the first proximal distance between the medial tibial plateau and the inferior
phalanx of the toes (Fig. 2). After at least two familiarization border of the medial malleolus on the medio-posterior aspect of
trials, the participants were instructed to exert maximal effort the tibia. The CSA of the FHL was measured at the same point
while gripping the bar with their toes. The participants were
blinded to the measured values during the performance to avoid
the value effect on their performance. The same procedure was
repeated three times, and the mean value was used for further
analysis. The average value was divided by body weight and
recorded as the toe flexor strength. A rest of at least 1 minute
was allowed between each trial.
Measurement of the CSA of Toe Flexor Muscles Using
B-Mode Ultrasonography
The CSA of the toe flexor muscles was acquired using an
ultrasound scanner (EXT-1H; TELEMED UAB, Vilnius,
Lithuania) with a linear probe (LF11-5H60-A3; 5.0-11.0.
MHz, TELEMED UAB, Vilnius, Lithuania). Five toe flexor
muscles, namely, the abductor hallucis (AbH), flexor hallucis
brevis (FHB), flexor digitorum brevis (FDB), FHL, and FDL,
were selected for this study. Each participant lay in the prone
position with the knee flexed at 90° for scanning the AbH, FHB,
and FDB and in the supine position with the knee extended for
scanning the FHL and FDL. The ankle joint was kept neutral
(0° position in both dorsiflexion and planter flexion) while all
scanning procedures were conducted.
Details of the probe position and orientation were in accor-
dance with previous studies that also reported the reliability of
the protocol used.21,22 Best contact was maintained between
the probe and the skin without applying excessive pressure. Figure 2 The single-leg demi-pointe posture during measurement
Measurements at each site were taken three times with the probe of center of pressure. Participants were instructed to stand bare-
removed between each recording. The intraclass correlation foot and make a posture of retiré in parallel with the heel raised
coefficient (ICC, 1.3) for the CSA of each toe flexor muscle was (demi-pointe), wherein the dancer raises the thigh with the knee
bent so that the foot is placed on the side of the supporting leg’s
evaluated using the three images to assess test-retest reliability.
knee. Participants were instructed to maintain their ankle joint at
Briefly, the CSA of AbH was acquired by placing the probe maximum plantar flexion and support the leg’s knee joint extension
along a line perpendicular to the long axis of the foot at the during the measurement. This measurement was performed with a
anterior aspect of the medial malleolus. The CSA of the FHB light touch on an adjacent wall with one finger. Participants were
was measured perpendicular to the shaft of the first metatarsal informed to employ the light touch to assist their balance and to
at the thickest portion of the muscle. To obtain the CSA of not lean against the wall.
 Journal of Dance Medicine & Science • Volume 26, Number 4, 2022 208

but more posteriorly.16 The CSA was measured using ImageJ with one finger. Participants were told that this light touch
software (National Institutes of Health, Bethesda, Maryland, should only be used to assist with balance and to not lean
USA), and the region of interest was calculated along with the against the wall. Several practice sessions were conducted
fascial muscles. Three images of each muscle were obtained for to ensure familiarization, especially for non-dancers. If the
each participant and used to calculate the mean value. The ICC experiment was considered a failure, such as when the non-
(1.3) values for the CSA of AbH, FHB, FDB, FHL, and FDL stance leg touched the force platform or the supporting leg
showed excellent reliability (ICC = 0.96, 0.90, 0.97, 0.92, and lost stability and failed to maintain the position with the heel
0.98, respectively).23 raised, the trial was repeated. Data recording for 10 seconds
was initiated after determining that the participants’ balance
Measurement of the COP During Single-Leg Standing was stable for at least 5 seconds. The recording was repeated
on Demi-Pointe three times for each leg, and the mean value was used as the
The COP data during the single-leg standing on demi- representative value. Considering the direction in which the
pointe with eyes open were obtained with a force platform participants were facing during measurement, the data in the
(sampling rate, 120 Hz; Zebris FDM-S multifunction force AP (anterior-posterior) direction used the value expressed as
plate; Zebris Medical GmbH, Isny im Allgäu, Germany), and “Y” on Zebris, and the ML (medial-lateral) direction was ex-
direction-specific displacement, average velocity, and ellipse pressed as “X” on Zebris. Average velocity and ellipse area were
area were computed. The posture maintained during the mea- computed by Zebris and the value suggested by Zebris were
surements is shown in Figure 3. Participants were instructed used for the present study. We defined the ith COP coordinate
to stand on demi-pointe barefoot and adopt a posture of retiré as (Xi, Yi), ΔXi = Xi - Xi-1, ΔYi = Yi - Yi-1, and the total COP
in parallel, wherein the dancer raises their thigh with the knee displacement was calculated by the following equation: total
bent so that the foot is placed to the side of the supporting leg’s COP displacement = Σ ( √ ΔXi2 + ΔYi2 ).
knee. The position of retiré is extremely common in ballet,
especially when used in turning. In many cases, both the hip Statistical Analyses
joints are externally rotated in ballet. However, we judged that Statistical analyses were conducted with IBM SPSS Sta-
it is too difficult for non-dancers to externally rotate their hip tistics software version 20 (IBM, Armonk, New York, USA).
completely like dancers. To eliminate the additional effort in Prior to the analysis, the normal distribution of data was
maintaining the position with the external rotation at the hip confirmed using the Shapiro-Wilk test. Variables with normal
for non-dancers and align the condition of the body posture and non-normal distributions are presented as means and
during measurements, we selected to perform a parallel retiré standard deviations and as medians and interquartile ranges,
in this study. Participants were instructed to maintain their respectively. Participants’ baseline characteristics, toe flexor
ankle joint at maximum plantar flexion and support the leg’s strength, CSA of the toe flexor muscles, and measurements
knee joint extension during the measurement. This measure- obtained during single-leg standing on demi-pointe, includ-
ment was performed with a light touch on an adjacent wall ing COP displacement, average velocity, and ellipse area,
were compared between dancers and non-dancers by using
an independent samples t-test for normally distributed data
and a non-parametric Mann-Whitney U test for data with a
non-normal distribution. Lastly, the correlation between toe
flexor strength and COP displacement, CSA of the toe flexor
muscles, and COP displacement within each group were cal-
culated using Pearson’s correlation coefficient or Spearman’s
correlation coefficient. The level of statistical significance for
all comparisons was set at p < 0.05. Cohen’s d statistics and
eta-squared (η2 ) statistics were calculated as the effect size for
comparisons, and the post-hoc observed power was generated
by G*Power 3.1 (Kiel University, Kiel, Germany).
Results
The two groups showed no significant baseline differences
in any of the participant characteristics, including age, height,
weight, body mass index, calf circumference, and rate of the
medial longitudinal arch (p > 0.05; Table 1). The toe flexor
strength and CSA of all toe flexor muscles of dancers were sig-
nificantly higher than those of non-dancers (p < 0.01; Table 2).
Figure 3 Measurement of toe flexor strength. Participants were Center of pressure displacement in the AP and ML directions,
instructed to place their barefoot on the device. The toe flexor total COP displacement, and average velocity during single-leg
strength was measured by griping the bar at the first proximal standing on demi-pointe of dancers were lower than those of
phalanx of the toes. non-dancers (p < 0.05; Table 3).
 Journal of Dance Medicine & Science • Volume 26, Number 4, 2022 209

Table 2 Comparison of Toe Flexor Strength and Cross-Sectional Area of Toe Flexor Muscles Between Dancers and Non-
Dancers
Dancers Non-dancers
(22 legs) (24 legs)
Mean ± SD Mean ± SD P-value d 95% CI
Toe flexor strength (kg/BW) 0.43 ± 0.11 0.25 ± 0.04 0.001 0.44 -0.08 to -0.02
CSA (cm2)
AbH 2.37 ± 0.28 2.15 ± 0.18 0.003 0.58 -0.26 to -0.15
FHB 2.84 ± 0.09 2.74 ± 0.11 0.002 0.48 -0.17 to -0.03
FDB 1.97 ± 0.20 1.81 ± 0.15 0.003 0.74 -0.23 to -0.02
FHL 3.01 ± 0.18 2.83 ± 0.18 0.001 0.73 -0.28 to -0.02
FDL 2.15 ± 0.28 1.92 ± 0.20 0.004 0.46 -0.28 to -0.08
Data are presented as mean and standard deviation and medians and interquartile ranges. AP, anterior-posterior; CI, confidence interval; COP, center of pressure; d,
Cohen’s d; ML, medial-lateral; AbH, abductor hallucis; FHB, flexor hallucis brevis; FDB, flexor digitorum brevis; FHL, flexor hallucis longus; FDL, flexor digito-
rum longus.

Table 3 Comparison of Center of Pressure Displacement During Single-Leg Standing on Demi-Pointe Between Dancers
and Non-Dancers
Dancers Non-dancers
(22 legs) (24 legs)
Mean ± SD Mean ± SD
Median (IQR) Median (IQR) P-value d 95% CI
COP displacement (mm)
AP direction* 81.80 ± 19.59 107.14 ± 44.05 0.01 0.82 6.13 to 68.07
ML direction* 38.08 ± 13.49 55.85 ± 35.78 0.03 1.12 8.22 to 64.86
Total* 97.02 ± 20.58 129.13 ± 58.34 0.02 0.89 11.7 to 77.43
Average velocity (mm/s)† 4.86 (4.33 to 5.90) 6.55 (3.71 to 10.10) 0.03 0.62 1.24 to 7.67
Ellipse area (mm )† 2
6.50 (4.60 to 11.90) 5.73 (4.98 to 14.30) 0.09 0.04 -4.12 to 28.78
Data are presented as mean and standard deviations and medians and interquartile ranges. *Samples followed a normal distribution. †Samples did not follow a
normal distribution. SD, standard deviation; IQR, interquartile range; AP, anterior-posterior; CI, confidence interval; COP, center of pressure; d, Cohen’s d; ML,
medial-lateral.

The toe flexor strength of dancers showed a moderate neg- for controlling the COP displacement while holding the demi-
ative correlation with COP displacement in the AP direction pointe position in dancers. Furthermore, the main findings
and total COP displacement (r = -0.54, p < 0.01; r = -0.57, p of the present study indicate that dancers’ toe flexor strength
< 0.01, respectively; Fig. 4). and CSA of the FHL were negatively correlated with COP
Only the CSA of the FHL in dancers showed a significant displacement in the AP direction, indicating that these results
moderate negative correlation with COP displacement in the AP are of key importance for dancers who are required to maintain
direction and total COP displacement (r = -0.42, p < 0.05; r = optimal postural stability.
-0.52, p < 0.01, respectively). There was no significant correla- First, the toe flexor strength of dancers showed higher values
tion between other CSA measurements and COP displacement, than that of non-dancers, consistent with a previous study.24
including the CSA of the FHL and the COP displacement in Furthermore, the CSAs of the toe flexor muscles of dancers
the ML direction in dancers (Table 4). were larger than those of the non-dancers in this study, which
may contribute to the differences in the strength output. The
Discussion dancers had been trained since childhood to perform repeated
This study investigated the relationship between toe flexor standing on demi-pointe, maintaining a pointe position in the
strength and COP displacement and CSA of toe flexor muscles air, and jumping at various speeds and in different directions.
and COP displacement during one-legged demi-pointe stand- This training is included in the dancers’ usual practice in order
ing. To the best of our knowledge, this is the first study to show to perform choreography containing a variety of techniques,
that toe flexor strength and CSA of FHL have a relationship which may have resulted in specialized activities and structural
with the postural stability in single legged demi-pointe, and it changes for adaptation of the toe flexor muscles.24-26 Second,
may provide the clue that the toe flexor muscles are important the dancers’ toe flexor strength and COP displacement, as well
 Table 4 Correlation Coefficients for Cross-Sectional Area and Center of Pressure Displacement in Each Direction
AbH FHB FDB FHL FDL
Observed Observed Observed Observe Observed
r p Power r p Power R p Power r p Power r p Power
Dancers
AP‡ -0.31 0.16 0.56 0.21 0.33 0.29 -0.11 0.62 0.11 -0.42* 0.04 0.84 -0.10 0.09 0.10
ML§ 0.35 0.10 0.67 0.12 0.60 0.12 -0.41 0.06 0.82 -0.20 0.38 0.26 -0.13 0.57 0.13
Total‡ -0.10 0.65 0.10 0.29 0.19 0.50 -0.35 0.08 0.67 -0.52† <0.01 0.96 -0.16 0.61 0.18
Non-dancers
AP‡ 0.31 0.16 0.56 0.33 0.12 0.62 -0.01 0.67 0.05 0.91 0.05 -0.07 0.75 0.07
ML§ 0.22 0.30 0.31 0.13 0.55 0.13 0.08 0.70 0.08 -0.14 0.53 0.15 -0.05 0.81 0.06
Total‡ 0.33 0.17 0.62 0.29 0.17 0.50 0.09 0.68 0.09 -0.09 0.72 0.09 -0.12 0.57 0.12
*p < 0.05; †p < 0.01. ‡Each variable was tested using Pearson’s correlation coefficient. §Each variable was tested using Spearman’s rank correlation coefficient. AbH, abductor hallucis; AP, anterior-posterior; FDB, flexor
digitorum brevis; FDL, flexor digitorum longus; FHB, flexor hallucis brevis; FHL, flexor hallucis longus; ML, medial-lateral; r, correlation coefficient; p, p-value.

medial-lateral, **p < 0.01.

Journal of Dance Medicine & Science • Volume 26, Number 4, 2022

rior-posterior; BW, body weight; COP, center of pressure; ML,

and center of pressure displacement in each direction. AP, ante-
210

Figure 4 Correlation coefficients between toe flexor strength

 Journal of Dance Medicine & Science • Volume 26, Number 4, 2022 211

as the FHL CSA and COP displacement in the AP direction, those obtained from other athletes performing various sports
were negatively correlated in this study. This suggests that toe activities.
flexor muscles might contribute to stabilizing the demi-pointe Ballet is a combination of art and sport. It is important for
position in dancers. The results of this study provide new ev- dancers to have a high level of postural stability control, not
idence that toes muscles may facilitate the control of sway in only for reducing the risk of musculoskeletal injuries but also for
the AP direction during demi-pointe in dancers. achieving an optimum aesthetic level of dance performance.34,35
Additionally, Rowley et al.13 emphasized that dancers relied Examination of the strategies used by dancers to maintain
on toe flexor muscles more than non-dancers to perform heel postural stability could lead to a better understanding of the
raises and maintain balance during demi-pointe. The ballet maintenance of postural stability. Moreover, suggestions to
technique of standing on demi-pointe for a few seconds requires improve the ability to maintain postural stability based on this
the ability to hold the center of mass and COP in a small base of understanding would be beneficial to dancers and instructors.
support.5,6,10 Focusing on the dancer’s feet, the ideal demi-pointe This study indicated that dancers with stronger toe flexor
position in ballet is to stand on the toes with maximum plantar strength and larger FHL CSA showed better postural stability
flexion of the ankle joint and 80° to 100° extension of the MTP during single-leg standing on demi-pointe. Strengthening of
joint.27 The repetitive action of standing on demi-pointe places toe flexor muscles, especially the extrinsic foot muscles across
a high demand on the FHL.28-31 The FHL, which straddles the ankle joint, may be useful to control swaying in the AP
both the ankle and MTP joints, is loaded 2.5 to 3 times more direction during standing on demi-pointe.
than the muscles acting only on the plantar flexion of the ankle
joint due to the repetitive demi-pointe in the position where Conclusion
the MTP joint is greatly extended.32 Additionally, Ferris et al.33 In summary, the present study found a relationship between toe
reported that if the FHL does not act in demi-pointe, the floor flexor strength and COP displacement and CSA of toe flexor
contact area under the toes and the ground reaction force are muscles and COP displacement during one-legged demi-pointe
significantly reduced, which in turn increases the metatarsal standing. In particular, the toe flexor strength and CSA of the
contact area. In other words, activation of the FHL is necessary FHL were negatively correlated with the COP displacement
to hold the demi-pointe position with a large MTP extension in the AP direction during holding the demi-pointe standing
and load on the toes. position. These results suggest that the development of the toe
Furthermore, the role of the FHL in reducing pressure on flexor muscles may contribute to increasing balance control
the metatarsal heads may help prevent injury in dancers who of dancers.
frequently stand in demi-pointe.33 However, in their daily
lives, non-dancers are rarely required to stand on their toes Acknowledgments
the same way as dancers. Therefore, non-dancers may not have The authors are grateful to all participants for their cooperation
acquired the strategy of using their toe muscles when standing in this study.
on their toes, which is why no significant relationship was
observed among the toe flexor strength, CSAs of toe flexor References
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