Supporting the Foot and Ankle with Andrea Zujko, DPT

[00:35] Jennifer Milner: Welcome back to Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility, focusing on dancers and other aesthetic athletes. This is co-host Jennifer Milner, here with the founder of the Bendy Bodies podcast, Dr. Linda Bluestein.

[00:51] Dr. Linda Bluestein: Our goal is to bring you up-to-date information to help you live your best life. Please remember to always consult with your own healthcare team before making any changes to your routine.

[01:01] Jennifer Milner: Our guest today is Andrea Zujko, physical therapist. Andrea, hello and welcome to Bendy Bodies.

[01:21] Andrea Zujko, DPT: Hi, Jennifer. Hi, Linda. Thank you so much for having me today. I'm really looking forward to this.

[01:23] Jennifer Milner: So are we. We are looking forward to it. Yes. So let me ask you, Andrea, before we dive in — we have a lot we want to talk about as we dive into the foot and ankle. But before we do, could you tell listeners a little bit about yourself?

[01:40] Andrea Zujko, DPT: Absolutely. So I am a physical therapist as well as a licensed Pilates instructor. I started this journey kind of in this field training as a dancer way back when — I like to say in the 1900s. It does age me a little bit. I studied all different styles of dance, worked professionally when I was in my late teens and early 20s, and unfortunately that stopped due to injury, which then opened up the next door for me in my life, which was getting into healthcare specifically for dancers via the Pilates world first and then finally into the physical therapy world.
[02:30] So I'm currently practicing as a physical therapist. I do quite a few things. I am the clinic manager at West Side Dance Physical Therapy here in New York City. I'm also adjunct faculty at NYU's Tisch Dance Department. I teach anatomy courses to the BFA dance majors downtown, and I also run an on-site PT clinic for the dance majors.
[03:01] And then finally, the third cap that I wear is I am the founder of Dance Medicine Education Initiative. That is a collaborative continuing education company that I launched formally in 2020.

[03:21] Jennifer Milner: So you do a lot, and you work with several different organizations, which has enabled you to work with dancers starting from the younger pre-professionals through college students, all the way through professionals at all stages of their career. Great. We cannot wait to pick your brains on this. So let's start with the myth that hypermobile dancers all have banana feet. Can you have hypermobility without the crazy high arches?

[03:45] Andrea Zujko, DPT: Oh yes, the banana feet. I show pictures of banana feet quite often to my dancers just to articulate exactly where movement can occur. You know, if you have a lot of movement in your foot and ankle, you definitely are able to kind of tease that out from a visual perspective in somebody who has that type of foot range of motion and mobility.
[04:12] You can have hypermobility, though, if you have a type of foot that might not look like a banana, that might be a little bit more of a flatter type of foot. What's called a flexible flat foot is very common in dancers with hypermobility. And what that means is that when you are standing on the floor, weight-bearing, your arches tend to lower closer to the floor. So your foot has a flatter foot type of posture to it. However, when you rise up into demi-pointe and certainly all the way up into full pointe, the inside arch — the medial arch, which is what we're really looking at — reappears. So you're able to, in a more non-weight-bearing position or a more pointed position, achieve more of a pointed arch type of foot posture.
[05:08] So not all hypermobile dancers have this kind of banana style of foot. Many have a flatter foot when they're weight-bearing on the ground, and then they have a beautifully pointed foot when their foot is up in the air and not weight-bearing. Of course, there is the third type of foot posture, which is more of a stiffer type of flat-footed posture. That's not necessarily going to change too much between when the foot is weight-bearing on the ground or if the foot is in either a partial weight-bearing demi-pointe or even up as a gesture foot in the air.
[05:47] It's very important in terms of my work with dancers — especially the young dancers, the pre-professionals, the collegiate dancers, and the recreational dancers — that the banana foot really has its own issues in the tissues. It is not like this ideal that does not have its own challenges, especially with somebody who has some hypermobility. That type of foot can be very challenging to control when you're loading weight through it, especially if you're putting that type of foot into a pointe shoe, which we see often. You could find this type of foot posture anywhere via Instagram or any company or dance class.
[06:33] It's very challenging working with that type of foot. So again, wonderful from an aesthetic perspective in terms of you really can appreciate the articulation of motion. But the real focus should be on control rather than trying to achieve a certain type of position or posture, or maybe trying to force the foot into a certain type of posture through rigorous stretching techniques that might not necessarily be so healthy for the feet.

[07:03] Jennifer Milner: That's really fascinating, because what's visually appealing may actually be more challenging in some ways than what is maybe considered less aesthetically desirable. And that makes me think about ankle sprains in particular, and how some dancers can really struggle with that. So can you talk a little bit about ankle sprains — what that actually means and how that might impact future risk of ankle sprains?

[07:32] Andrea Zujko, DPT: Sure. So an ankle sprain — we know it's when one or more ligaments at the ankle are either partially or completely torn. The really risky area or risk range is when you are either in the process of rising up onto full pointe or when you're lowering yourself down off a full pointe. Now, that could be off of a pointe shoe, or that could be coming down off of demi-pointe. So kind of that mid-range position from when your foot is on the ground flat and when your foot is locked up in the high point of its relevé. So you have this kind of precarious zone, if you will.
[08:15] And what happens is that you have this usually rapid shift of your center of mass of your body over this weight-bearing foot. What happens most often is that the lateral ligaments are injured as that ankle rolls outward, which causes the foot to twist. And these ligaments on the outside of the ankle are overstretched and will tear depending on how much force is put through them. Certainly, you could go a little bit further and have something called an avulsion fracture, where there's a little piece of bone that is chipped off of the edge of the fibula — if we're talking about the lateral ligaments of the ankle.
[08:53] So being in that plantarflexed position, kind of transitioning in and out of it, is a range or a zone of vulnerability to any dancer. And certainly, if you are a dancer that has a hypermobile foot — which again can be to your advantage; if you are dancing en pointe, you need to have some degree of hypermobility of your foot — but if you're working with a situation where either you have a local hypermobility of your foot and ankle or you're dealing with more of a general hypermobile body type, what I've read and what I've experienced as a clinician is that you're probably a little bit more susceptible to ankle sprains based on maybe some proprioceptive challenges, being a little bit more at risk for strength imbalances at the foot and ankle. And putting that load and putting yourself into that position could predispose you to ankle sprains.
[09:53] Once you have an ankle sprain, you can have healing. But usually, the previous elasticity and resilience of the ligaments rarely return. So again, if this happens, I definitely encourage my dancers to really take the time to heal, because there's a lot of information out there — different case studies and even some research articles — showing that if you go back too early, you will compromise sufficient ligament repair. We're talking about not even necessarily being able to get back to 100%.

[10:32] Jennifer Milner: That was really important. In terms of how much time for healing, I want to make sure that people really pause and think about this a minute too. It also depends on the degree of tear, right? That would also make a difference.

[10:50] Andrea Zujko, DPT: Correct. So in general, we grade ligament sprains on a scale of 1 to 3, and we can also consider how many ligaments are compromised. You can have a more severe injury in one ligament and a more minor injury in another ligament. So that is also going to affect the healing time and the plan. But we have to think about how the collagen matures, the time that is needed for protection, the time that is needed for gradual loading, and the time that is needed to continue to work on regaining alignment control, proprioceptive control, to be able to condition the body to handle the stresses that the dancer needs to handle.
[11:40] This rehab can take — it might not necessarily be in the clinic this long — but it can take months, if not up to a year. They have found some deficits lasting that long. And you really don't want your dancers to become a coper. You want to try to do your best to avoid entering into that category where you're just setting yourself up for potential future injury. And certainly, multiple sprains over time can then lead to chronic ankle instability. And then you just have what we call sometimes this loose bag of bones. It's very, very difficult to stabilize. And certainly, layering on hypermobility or a hypermobile body type can make things a bit more complicated.

[12:31] Jennifer Milner: And I think something that's important for people to hear out of all of this is that a lot of times when I see people with ankle sprains, they think that once it stops hurting, they're good to get back into class or back into the dance studio. And there's so much more to it, as you said, with proprioception, with retraining it, retraining muscle strength that you aren't even aware that you lost — because it's only been a couple of weeks, how bad could it be? But it really is something that takes a long time, especially with hypermobility, to regain that full sense and full use of that foot.
[13:02] So I appreciate what you said. I hope nobody hears that Andrea is saying you have to be out of the studio for a year. But she is saying take your time getting back in. And then when you get back in, you're going to still want to continue doing work with a physical therapist or someone who can help you continue to train and get you back to full speed. It's not something you want to skip. Because is it not true that the biggest predictor of an ankle sprain is if you've already had an ankle sprain?

[13:31] Andrea Zujko, DPT: Correct, yes. And of course, pain — we know that pain is a great motivator. It's true for all of us. Once whatever injury I happen to be dealing with at the moment, once that pain goes away, we all want to get back to what we're doing, right? Injuries are inconvenient, they never happen at a good time. So no, you're not going to be out of the studio for a year unless you're talking about having a major surgery where you need some kind of reconstructive procedure. It's just about thinking about the long game with this type of injury.
[14:16] You know, if you have the opportunity to work with a somatics practitioner — whether it be Pilates or Gyrotonic or a trainer who helps you with cross conditioning — they can continue to help you build your program for a longer period of time, which has a lot of benefits for the rest of your body. So sometimes when you're giving yourself that space to heal from an injury, you can really wind up benefiting in a lot of other ways from healing what you thought was just an ankle or just a metatarsal or what have you.

[15:06] Jennifer Milner: Right. That's so important. And that's so true about so many injuries. Moving to the talus — the talus is a great bone. So talk to us a little bit about the talus and why it is so important. What happens when bones like the talus do not move correctly? Talk about optimal movement of the talus. What exactly is happening? All of that kind of thing.

[15:26] Andrea Zujko, DPT: The talus. I'm going to get really nerdy here. It's one of my favorite bones.

[15:35] Jennifer Milner: Yes, bring it.

[15:37] Andrea Zujko, DPT: Maybe because I spend the most time with it in my practice, helping it, nourishing it, reeducating it. The talus is a central bone of the ankle. It's part of a group of bones which are collectively referred to as the tarsus. It articulates with the tibia and fibula, which forms our ankle joint — or the talocrural joint if we want to get our anatomy terminology in there. It also articulates with the calcaneus, which is our heel bone, and our navicular, which is a bone in more of the midfoot area.
[16:20] I look at this region of bones and their articulations or connections with each other as a real highway of information — there's a lot of transmission of weight and force between the lower extremity and the foot occurring in this area. So really looking at this area as a whole as something that needs to be well aligned, something that needs to be able to move adequately but also to be very stable.
The talus bone is very unique in the sense that it lacks any direct muscular attachment. So stability of the talus is really created by the numerous ligaments that attach to it. You have ligaments on the outside — your lateral collateral ligaments, your deltoid ligament on the medial side. You can also think about ligaments attaching inferiorly, connecting with the calcaneus, and then from there into the midfoot, talking about the navicular. All of these ligaments really help to tether or provide stability of this talus and maintain alignment of this joint, which is described often as a mortise joint — one bone fitting in between two others.
[17:54] It depends on the ligaments for passive stability, but I think its stability more dynamically depends on the rest of the lower extremity. We don't even have to stop there — it can go up to the pelvic girdle, the lumbopelvic girdle, even to the thorax. I find that alignment issues, issues of impingement, issues of tracking of the ankle are a lot of times driven by more proximal problems concerning the hip, in terms of the musculature around the hip, which by and large stabilizes the knee. And we know that the knee joint needs to be able to track adequately over the foot. And the efficiency of the hip musculature is really driven by the positioning and the control of the pelvis and the lumbar spine.
[18:59] So I know it's cliché that one thing connects to the other, but it does. And a lot of times those issues in the tissues can lead to alignment problems at the talus in the absence of injury.
[19:21] Specifically going back down to the ankle, to the talocrural joint — usually that talus will get, if I can say, what we use words like subluxation for. That's very simply like some abnormal force was placed or introduced into this ankle joint and it has disrupted its alignment, usually as a result of ligament injury. With an ankle sprain, your lateral ligaments are injured, you end up rolling over your foot, your foot is twisted into this inverted position, and that talus gets knocked off its track a little bit. If that is not reset back into place through any necessary manual techniques, you start to run into tracking problems.
[20:19] This is something that many dancers are familiar with. It's called a jammed ankle — exactly what's happening is your talus is not tracking correctly in and out of the mortise. And when you go to perform whatever it is — if it's closed chain dorsiflexion, which is a plié, or closed chain plantar flexion, which could be a demi-pointe relevé, full pointe relevé, or even a tendu — you're potentially going to be pinching the soft tissue structures of that joint, and that is going to become quite painful and problematic.

[20:58] Jennifer Milner: Interesting. I feel like a lot of people that I've worked with — and I have to confess, I personally also deal with this — when I plantarflex my feet, I get a pretty loud clunking in my ankles. I know that there is CO2 release in different parts of the body. That may or may not mean anything, but can you tell people how they might have a better idea if something is actually subluxing versus if there's just that CO2 release?

[21:41] Andrea Zujko, DPT: The difference is the quality of the sensation. There's a difference between a joint making that cracking or popping sound versus a soft tissue structure like a tendon feeling more like a rubber band that kind of snaps over or rubs over a bony prominence.
[22:06] You can have subluxation of your joints — especially if you have a hypermobile body type — on a regular basis. Things click around and don't get stuck until they do. But a lot of that is not necessarily pathological. I wouldn't seek it out. I tell my dancers who have hypermobility and who have the ability to clunk the hip and self-manipulate their cervical spines and do all these other interesting self-manipulations — I caution them not to do too much of that. I find sometimes that is more of a manifestation of anxiety and a need to constantly adjust. But I also explain to them that could be a sign that maybe your muscular system is not doing its job or could do a better job to help your body stabilize.
[23:21] So I hear you, Linda, saying that you feel like your pelvis kind of slips forward a bit, which is common. Certainly if you have a hypermobile foot, that talus definitely can slide forward. It should go back. Sometimes it doesn't. There are ways that you can simply try to coax it back in. I find that dancers with hypermobility — a lot of times the more minor episodes of slipping out of place can really be worked out via self-care.
Other times self-care doesn't work and you really need someone to help you restore the optimal alignment of your body, like a physical therapist or even — I've got colleagues, and Jennifer, I'm sure you've got a nice little list of techniques that you could help your dancers use to get their joints back into place. That can be very beneficial. But self-treating the foot and ankle in terms of subluxations can be very difficult in some situations. I'm all about advocating for self-care and self-treatment through movement restoration and movement reeducation and strengthening on top of that. But sometimes you just need help restoring that. And then it's like the start again — start by stabilizing again.

[24:48] Jennifer Milner: That sounds like a very reasonable approach to take. And when it comes to the bones and stress fractures — can you talk a little bit about talar stress fractures and stress fractures in other parts of the foot and ankle, what kind of things you see in the hypermobile population and hypermobile dancers, and what some important considerations might be?

[25:19] Andrea Zujko, DPT: Yeah, it's interesting that you're bringing up the talus. Talar fractures are not that common. What is inspired by this question?

[25:31] Jennifer Milner: Jen's raising her hand — but actually I know I have patients and family members that have had stress reaction in the talus.

[25:36] Andrea Zujko, DPT: And I have too. I think I've had 4 or 5 of them, which seems like a really high number, but all but one of them — obviously I was not the primary point person for them — but all but one of them were in hypermobile people. And so I started wondering what the relationship is between a talus that might be presenting forward and not allowing that full posterior glide as they go through their day-to-day, and stress fractures. So I think we're both interested in this and would like to know.

[26:12] Dr. Linda Bluestein: Yeah, really interesting, because statistically it's really not that common. But I have a dancer actually right now that I'm working with who suffered an impact injury to her talus. And I thought to myself, okay, maybe I'll speak about this a little bit.
[26:33] So a stress fracture — it's an injury to the bone. It can be a small crack in the bone. It could be severe bruising within the bone. And most stress fractures are caused by overuse and repetitive activity, certainly the ones I've seen. Yes, I've seen some acute traumas involving dancers colliding with pieces of scenery or suffering some kind of fall or something collapsing on top of their foot. That's been pretty rare in my practice. It's usually due to overuse and repetitive activity. And this is true of other athletes involved in constant repetitive forces — things like walking, running, jumping. Dancers do it all. But you do see stress fractures in other athletic populations like runners and soccer players.
[27:25] In the absence of acute trauma, you're usually dealing with a situation where you have this imbalance between bone formation and bone reabsorption or resorption — which is the removal of the bone. So when a bone is loaded or stressed during weight-bearing exercise, it responds by increasing its bone turnover. This is necessary for it to live up to the demands that we place on it — this is a normal part of the physiology of the skeletal system. So when stress is applied to the bone, the area of the bone could become damaged, and these damaged areas are then reabsorbed, removed, and replaced with new bone. Usually there's a nice balance in terms of this rate of turnover.
[28:16] But if the new bone formation is slower than the removal of the old bone, we can have weak points occurring at areas of stress within the affected bone. This can develop into a stress fracture if that weak area of the bone is repeatedly stressed. Usually this happens gradually over time and is worse during weight-bearing activities.
[28:39] So oftentimes, it's due to a change in training — and this could be frequency, duration, intensity, what type of surface you're dancing on, or your footwear. Maybe you got a bad pair of pointe shoes or something like that. Or you also have to take a look at your bone density. Certainly in adolescence, we know that there is a period where the bones are a little bit weaker because of the growth that occurs, and that density is going to catch up a little bit later. That's in a normal menstruating adolescent female — there is this period of time where the bones are not going to be as strong because they've grown in size but their density has not caught up yet.
[29:26] So I typically see more metatarsal stress fractures in my practice, but I have seen an injury to the talus — actually a severe bruising of the talus, so there was no fracture of the bone, but there was a significant contusion. This young woman I've been working with is in musical theater and has been dealing with a couple of very significant ankle sprains. I've known her now for — let's see — right before she went away to conservatory for college. So I've known her now for about 5 years. During that time, she had suffered 2 significant sprains that I know of that really affected the mobility and stability of her ankle. But things — we took care of things as best as possible. Stabilized, good alignment, mindfulness, good recovery, rest days. Everything was good until it wasn't.
[30:43] She was in a class, was maybe a little deconditioned but pushing herself, and she went to do a sauté de chat across the floor. And of course, that involves really moving at a significant speed and landing on one leg in a turned-out position. Things were not lined up well. She didn't sprain her ankle, but I think the forceful dorsiflexion that occurred — I don't think her talus was in alignment at the time — it just resulted in such a deep pinch and almost a jamming sensation of her ankle that she had to limp out of the studio.
[31:33] So what do I think happened? I think there was some alignment issue going on in her ankle before this happened. But what we have since discovered is that there are a lot of hip stability and control issues that still creep up. We have to address and manage them. They go away, then they creep up again. So that's something I think practitioners who work with hypermobile dancers have to consider — situations can arise again, and maybe it's not the full-fledged injury, and that's great. But in terms of stability, it's like you need to do a body check.
I find that I'm looking at that more and more with my dancers with hypermobility. I like to think I do that with everybody — I take a holistic approach with my patients. So it's never just an ankle, it's never just an elbow, it's never just your L5 vertebra. It's really the whole body, assessing and treating up and down the chain as you see fit and continuing to monitor it. Because things can slip out. I'm sure you have dancers who tell you it feels like their body just slips and slides out of place often, and that's a normal occurrence for them. That's where in many situations they can get themselves integrated, reintegrated, and put back together. Other times they need more hands-on help, more directed help by somebody looking at their bodies, assessing their bodies, helping them find that place where they need to be.

[33:30] Jennifer Milner: I think taking that holistic approach is so important because if you're not addressing a contributing factor like the hip stability — like the example that you gave earlier — then you're putting yourself at risk for reinjury. This is where I go a little bit crazy with people if they're using their insurance for physical therapy. Aren't you caught sometimes with that, or how does that work for you as a practitioner?

[34:00] Andrea Zujko, DPT: So I have to say that the work that I do is all out of network. That being said, I do have plenty of patients who will submit to insurance, and insurance can get really bent out of shape if they see treatment for one area of the body when the prescription is for another area. But I have found that I've been able to get around that as long as I link all of my objective findings about — in the situation I used, the dancer's hip stability and control issues — if I link it down to the foot. Because there has been plenty of literature talking about the importance of, say, the gluteus medius and lateral ankle stability. So you can always put it in context of the body part that you are so-called authorized to treat. And you are treating that, and you're treating that because you're helping to balance out the lower extremity so that the ankle will function better.
[35:11] So my notes tend to become pretty extensive documents over time. It's just part of — you have to look at your patient as a whole. You can't just say, okay, this is just an ankle, we're going to wrap you up and you're going to ice and then sit on the floor and do these TheraBand exercises and then put your shoes on and go back. Without considering anything else. I don't think many people do that these days, but I do think that especially when you're starting out and early in your career, really seeing those patterns and recognizing the importance of the integration of the whole body can be quite daunting as a new grad. But just stick with it, ask questions, get your mentorship, and look up the research that is available out there that is clinically useful. You'll start to really put it together.

[36:22] Jennifer Milner: Well, and the more people you see, the more bodies you have in front of you, the more patterns you start to see. You see one person with an ankle issue and maybe accidentally catch a hip thing. And then you see another one. And then the third one that walks in, you think, maybe I should look at their hip. So it becomes — you learn from them, right?
[36:41] One of the areas that I didn't originally start associating with hypermobility was bunions. But the more hypermobile people walked through the door — and of course most of whom I work with are pre-professional, still in the process of developing their bunions — I ask about family history, and we talk through all of that. Bunions don't have to occur, right? Sometimes they're genetic, sometimes you're predisposed to them, but sometimes it's an issue of technique not being correct or shoes that aren't working right and forcing the foot into poor alignment. So I'm wondering, have you seen a higher incidence of bunions in people with hypermobility?

[37:19] Andrea Zujko, DPT: That's a very interesting question, Jennifer. So are you talking about local hypermobility at the foot and ankle or more of a generalized hypermobility?

[37:30] Jennifer Milner: Well, certainly it could be localized. It could be generalized, but I'm thinking of that foot that's flatter in standing but has that highly compressible foot that goes into that long, lovely line when they go on pointe or on relevé. It's like their tissue is a bag, as we've talked about, that just gets stretched out and stretched out. And so they have to work even harder with their foot strength — which I think we'll talk about in a little bit with tendons. But without that support, if they pronate — which a lot of dancers do — well, then their feet can go into a much bigger range of motion. Their metatarsals can go into a much bigger range of motion perhaps than other people who might pronate. And so they might be more predisposed to that. That's just something I've noticed. I was wondering if you've seen a higher incidence of that in hypermobile dancers with mobile feet?

[38:21] Andrea Zujko, DPT: Yeah, it's interesting. The big question is, does hypermobility cause bunions, or did the bunion result in hypermobility? So there are thoughts out there. What are the predisposing and precipitating factors behind the etiology of a bunion deformity? This could be foot type, your shoes, do you have hypermobility, what are your genetics, is there any abnormal anatomy of the foot? But we don't really know what the true etiology of hallux valgus — which is the more medical term for a bunion — actually is. You're not necessarily going to get them from Grandma Pat. You could possibly develop them if you inherited the same type of foot type as Grandma Pat, but possibly not, because there are so many other reasons why you might develop this condition, which is really more of a subluxation of the first metatarsophalangeal joint, or MTP joint.
[39:39] It's very interesting if you start reading through some of the literature that podiatric surgeons write about in terms of bunion deformity and its causes. Quite a few as of late feel that the bunion deformity itself drives hypermobility in the foot. When they fix that bunion deformity, the hypermobility of the foot goes away — which I find to be very, very interesting.
[40:10] Now, on the flip side of that, what I've seen in clinical practice is that I have seen more issues of this hallux valgus in feet that have more of a flexible foot type than a rigid foot type, which leads me to think, okay, maybe there's this dynamic stabilization issue going on. Sometimes there are those out there who don't feel that foot and ankle exercises really help. In one sense, they probably don't — the extrinsic and intrinsic muscles of the foot really cannot support you passively. They can't create an arch that's not there. But what they can do is help you with dynamic control of the foot. So I definitely think that's where we can really start to address issues in a more flexible foot, a highly compressible foot that might not have that control, that is leading to excessive force on the first MTP joint, and over time, maybe that's leading to a little bit of breakdown.
[41:30] So it's all about how you load your big toe joint onto the floor. What is your strategy? Just to keep it simple — how do you put it down? How do you load? We have those two little sesamoid bones, those little two P-shaped bones underneath your first metatarsal. Those are like your train tracks — they're really going to be responsible for enabling you to successfully push off through your first ray. Your first ray is your medial row of bones that forms the medial longitudinal arch, which terminates in this first MTP joint. But how you put that foot down is going to pretty much dictate how you push off.
[42:18] I do see, in the dancers I work with who have symptomatic, painful bunions, loading problems during walking assessments and basic dance technique assessments. These really show an inability to control the excursion of the first ray and the stability and positioning of what happens to that big toe joint with load. So I do a lot of re-education in terms of teaching people how to walk. You know, who teaches who how to walk? We just kind of watch when we're little, we get up, we start walking. For the most part, we do pretty well. Well — we don't, right? Either it's because of an injury or we just get ourselves into these imbalances that then lead to abnormal forces being placed through the body. In this case, we're talking about the big toe joint.
[43:24] So again, in dancers that have that more flexible, mushy foot — the foot that maybe has a little bit too much pronation — pronation is a good word, it's not a dirty word. We need pronation of the foot to be able to load correctly and push off. But you want to make sure that that's controlled. And in a lot of dancers with bunion problems, I find that pronation is not controlled. How they put their foot down, how they load through their first ray is not controlled.
Going back up to the hip — a lot of them get really tight and restricted at the hip joint. They lose their internal rotation up at the hip, which you absolutely need for adequate push-off through that first ray. Those dancers — probably the younger ones — feel they need to walk in first position all the time.

[44:31] Jennifer Milner: Right. So everybody needs to see it.

[44:36] Andrea Zujko, DPT: Or you just kind of get stuck there, and that maybe is your default habit. I see other people do that as well. Sorry, pre-pros out there, but you don't have to walk in first position. You shouldn't. You need internal rotation as much as you need external rotation.
[44:55] But those are things that I think are potentially driving problems at this joint that can lead to a bunion. Certainly, having any kind of footwear that is not fitted properly to your foot is key. If you have a compressible foot, you cannot be in a pointe shoe that is going to cause you to sink all the way down to the floor — that is going to really drive a lot of abnormal forces going through your entire foot, including the big toe joint. That is very, very important.
[45:32] Walking reeducation is important. Technique reeducation is important. Looking at that ankle stability — do you have a tendency to kind of fall into a winged and overly winged position when you're loaded into a demi-pointe position? Think about those little sesamoid bones under the ball of the big toe — you're just kind of grinding them into a powder. You're going to sublux them, and that's a big problem. It's so painful when that happens.
[46:02] You want to have really good alignment and integrity of the forefoot, really using the metatarsophalangeal joints. The ball of your foot is this beautiful platform that's equal opportunity. Okay, maybe depending on the length of your little toe you might not have as much weight-bearing on that fifth toe, but you really need to have a nice, balanced foot.

[46:29] Jennifer Milner: I'm glad you brought that up about the winging, because I was wondering about that. You see so many pictures on Instagram or wherever, and it looks like the entire weight of the foot is on the great toe. I understand you want to avoid sickling, and obviously there's a difference between doing a photo shoot and actually dancing that way. But I'm glad you brought that up because you can get into trouble with that. I'm all about — if you want to wing your foot with your back foot when you're in an arabesque, penché, what have you, go for it. If you're in that beautiful line, it's kind of like doing a cat eye with your eyeliner, right?

[47:14] Andrea Zujko, DPT: That beautiful swoop.

[47:17] Jennifer Milner: Now you're getting me talking with my hands. But it's not loaded. It's tricky. It can put a lot of unnecessary stress through that big toe joint, which then potentially can lead to breakdown and this deviation, which is really a progressive joint subluxation that doesn't reverse itself.
[47:39] And if we can move from bones and those specific issues into tendons — I would love to hear what you think about tendon problems that are most common in hypermobile dancers and how you treat them. What do you see there?

[48:05] Andrea Zujko, DPT: Ah, tendons. Tendons are very difficult.

[48:08] Jennifer Milner: They're very difficult.

[48:08] Andrea Zujko, DPT: They're kind of cranky structures. And also the way that they heal in terms of how they respond to load really doesn't oftentimes coordinate well with a dancer who's working, or a dancer who's actively training, or someone who's in a collegiate program that can't take regular time off or do this kind of on-off loading cycle.
[48:36] So I definitely see a lot of tendinopathy. This ranges from your acute reactive tendinopathy to more of a chronic degenerative tendinosis type of problem. Typically, the more acute tendinopathies in the younger population — or maybe it's your first time around — or you have something like a paratendinitis where it's just the swelling in the sheath of the tendon if the tendon has a sheath. Or in the older population, you have more of a tendinosis, a chronic history of tendon problems.
[49:18] We know that repetitive motion can drive some tendinopathy. But I tend to find that issues come up when you're talking about overload — sudden, rapid overload. The most common scenario that brings dancers in to see me with tendinopathy has to do with overload, a change in training frequency, duration, intensity, or a dancer who's coming off of a break — coming from doing little to nothing, to coming back to a full workload.
[50:08] Tendons like to be — you've got to kind of stay in shape for your tendons. Because if you don't, then the tissue becomes a bit weaker and it's not able to handle the same amount of tensile load. You can get back there, but it'll take time. We know that the body's tissues adapt to stress gradually. But we don't always have the time to do that. So you get into that pickle of a situation where you've had to rapidly load the body — your semester started, your rehearsal period has started, and you went away for 3 weeks on a beach and it was great and you enjoyed yourself, but you got out of shape.
[50:54] Or especially during COVID, you were doing your classes in your bedroom using your dresser as a barre, or you were trying to do some kind of center work in your living room, and then all of a sudden you're right in the studio, and maybe you didn't have the guidance to kind of get back into shape before starting that.
[51:14] So all those factors bring those tendon problems to me. What I tend to see — I see a lot of Achilles tendinopathy. And then I see tendinopathy of your medial ankle tendons — your Tom, Dick, and Harry's. All the physical therapists are going to know what I'm talking about. It's just an easy way to remember your medial ankle tendons. So that's your tibialis posterior, your flexor digitorum longus, and your flexor hallucis longus. Those are the most common tendons that I see in my practice. The fourth one would be more of the peroneus longus tendon.
[51:59] But if we stick with the Achilles and the medial ankle tendons — I find that dancers with hypermobility are susceptible to these types of injuries. Why that exactly happens is actually really interesting. You can have injury or overload of these tendons with very different arch types. You can have a high-arched, more rigid, cavus type of foot that doesn't have a lot of shock absorption. And you can have a more flexible, flatter foot that has a lot of shock absorption but not a lot of propulsion and is lacking medial ankle support.
[52:48] With the dancers I see that have hypermobility and a more high-arched cavus type of foot, I find that's often coupled with more knee hyperextension. And more knee hyperextension, I find, sometimes drives a habit where it's almost as if there's a lack of control of the talus coming forward when they plantarflex their foot — they just kind of hit the position without really working through the foot. Does that make sense?

[53:30] Jennifer Milner: Yeah.

[53:30] Andrea Zujko, DPT: Kind of like that nice juicy tendu on the floor, where you really take your time and it's kind of luxurious — you really see all that articulation, you give yourself that time to really work through the foot. I find that dancers with this combination of knee hyperextension with a cavus foot — it's really easy, and any kind of training on top of that that might advocate for that, if I say that diplomatically — that kind of leads to that rapid pushing of that foot and of that ankle anteriorly, that talus anteriorly. I find that can lead to some trauma to the back of the ankle. And of course, at the back of the ankle, we have the Achilles and we have the 3 medial ankle tendons.
[54:15] I also find that in that type of scenario — and again, if you have this, dancers, it's totally fine, it's a beautiful line of the leg — you just have to make sure that you are really taking the time to recruit the musculature around the foot and ankle adequately, so you can really feel your calves working. Because you have that plantar flexion mobility, you have the picture, you have the end result. What was your journey? What was your strategy to actually get there? You want to make sure that your calf attended the party. So that you're not really jamming the back of the calcaneus up to the back of the talus with the Achilles getting trapped, or — if you're not adequately contracting your calf — using your deeper plantar flexors of your ankle and foot a bit too much.
So this gives us things to work on in terms of trying to inhibit the overuse of the Tom, Dick, and Harry tendons and really making sure we get adequate gastrocnemius-soleus activation. We do things like relevé reeducation, standing with the toes off the edge of a book and all that, to really teach you how to use your calves if that's something you're finding challenging. But also looking at that timing — they dance quickly, but still, it's the path you took to get there.
[55:55] In a dancer that has a more flexible type of foot that maybe doesn't have as much medial arch control, oftentimes that can result in what we call a heel valgus — your calcaneus bone is a little bit more rolled in toward the medial side. That can really affect how much load and force is being put through the Achilles tendon as well as the medial ankle tendons. And that sometimes leads to increased overload of those tissues and the result of tendinopathy.
[56:34] Again, go proximal and look at different issues going on with knee alignment, hip alignment, internal rotation control, adduction control up at the hip and the knee, that could potentially be driving even more force going through that medial column of the foot.

[57:01] Jennifer Milner: Well, something I'm hearing you say over and over again is that a lot of times people end up at a physical therapist because something has come up, because something is wrong. And unfortunately, you guys get them when they've hit that point and then you have to work backwards to fix it. But what a lot of my clients don't understand right away — because I see them before, hopefully, they end up with a physical therapist — when I say, hey, your feet are really pretty flexible, let's make them stronger, they're like, no, they're plenty strong, see? And they look so pretty, right? And I work on reeducating that tendu over and over and over again.
[57:32] And I think that's something that hypermobile people hear, and it's certainly something we say on this podcast over and over again — whatever joints you've got that are hypermobile, it's so easy to lock into it. Like you were saying, to lock into the knee and to lock into the ankle. People with hypermobile shoulders, it's so easy to lock into the shoulder and the elbow. But what muscular reeducation can we do to make that joint more stable and to give it all of that dynamic support that it needs, so it's not just that passive support as you were saying?
[58:03] So it's not just going to see someone when there's a problem, but finding someone who can help you before there's a problem — make you stronger and make you a more efficient dancer who can use all of that beautiful loveliness.
[58:21] So if someone is not in New York City and can't go see Andrea Zujko, how can they find someone who can help them with this? How would an artistic athlete find that medical professional or that really qualified trainer or somatic practitioner who can understand hypermobility and the high demands on an artist's career?

[58:40] Andrea Zujko, DPT: That's a really good question with not a simple answer. This profession is growing exponentially, which is wonderful, because for so long there were just people in New York and then a few people in California and not very many in other places in this country. So it's continuing to grow. That being said, it can be very challenging trying to find a dance medicine specialist.
[59:09] A couple of things to start you on your hunt: certainly ask your teachers, ask around. Don't — there's this whole culture of injury where we have to hide it, it's this dark dirty secret, we have to be perfect and pain-free 100% of the time. That's changing for the better. Hopefully this is something you can feel comfortable speaking to teachers about, or parents could ask who they see, who have they seen for any injuries they might have been dealing with. That would be something to consider.
[59:55] You could also try to find a practitioner through some of the professional organizations. The big one that I'm a part of — as well as you are too — is the International Association of Dance Medicine and Science, IADMS for short. If you go to iadms.org, I do believe they have a resource page that allows you to search for a practitioner in your area. That could be another way to see if there's somebody in your area to work with.
You could also look at who's teaching Pilates in your area, who's teaching Gyrotonic in your area. A lot of practitioners in those two professions are former dancers. So again, a little bit of networking — seeing who they're working with.

[1:00:54] Jennifer Milner: Well, and as you said, and we've had so many people say before in different areas — you just have to find that one person, right? You find the teacher who knows somebody, or a parent who has somebody that works with their child, or you find something in IADMS that may not be the exact fit for what you need but they could recommend someone. It's finding that one person and then having that entire network that can come from knowing that one person.

[1:01:21] Andrea Zujko, DPT: Andrea, you were talking a little bit earlier about overstretching and how dancers don't necessarily need to do that because hypermobile dancers already have that range. And as soon as you said that, I was thinking about foot stretchers — is this a good idea for dancers to use, or does it depend, or what is your thought on foot stretchers?

[1:01:46] Jennifer Milner: Ah, foot stretchers. It's kind of like the black market device, right? Anytime a dancer mentions to me that they're using a foot stretcher, they kind of look like they've got their tail between their legs, afraid of what I'm going to say. I get why they were designed, and I can understand why a dancer would want to use them. And certainly when you start using a foot stretcher, you're usually preadolescent or adolescent.
[1:02:27] I find that foot stretchers are used more often by dancers who have a stiffer type of foot — a foot that doesn't really have a lot of plantar flexion available at the talocrural joint, which is the first area that you should plantarflex in. You should plantarflex at the talocrural joint first, followed by the midfoot, and then finally down at the metatarsophalangeal joints. So if you don't have that range of plantar flexion, your point looks a lot less arched or curved. And of course, a lot of dancers are self-conscious about that or unhappy about having that as their line. So they seek out the use of these foot stretchers.
[1:03:30] I have a big problem with that because a lot of times the reason why they don't have as much plantar flexion at their ankle has to do with the design of their foot. And you're not necessarily going to get a copious amount of plantar flexion at your ankle as a result of using the foot stretcher. What I find happens is that the stress or the stretch that the foot stretcher introduces is more at the midfoot. And it results in excessive force being placed at the midfoot. The midfoot, where your transverse arch is, needs to be an area of really, really good stability. So if you're starting to put an excessive amount of force through that midfoot, it could potentially hurt you in terms of developing problems along the way — more of a midfoot breakdown.
[1:04:29] Also, if you are trying your best to force your foot into this plantarflexed position at your ankle joint, you could potentially be damaging the structures in the posterior aspect of the ankle as you're trying to really push that calcaneus up and forward. I've had quite a few dancers over the years develop problems with posterior impingement — that can be just a bruised styloid process, or that could be an os trigonum from using a foot stretcher.
[1:05:03] There are ways to safely stretch your feet. I've taught many dance teachers how to safely stretch their students' feet. I certainly work on that as a PT. But your foot and body will adapt to the forces you place through them over the course of dance training. You're going to continue to be working on your range of motion — hopefully in a very sound way — as you go through your training. You don't need to force the foot into this extreme position that it might not be built for.

[1:05:46] Andrea Zujko, DPT: That makes perfectly good sense. Be very careful.

[1:05:48] Jennifer Milner: That is all an excellent amount of advice for people to be able to take away with them. So thank you very much for all of that.

[1:06:02] Andrea Zujko, DPT: You're welcome. Thank you.

[1:06:02] Jennifer Milner: Thank you. You have been such a wealth of knowledge today on the whole topic of the foot and ankle. I know it's so easy to do a deep dive on it and to keep talking about it because there's so much — it's such a complicated structure, especially for artistic athletes. Where can people find you if they want to get in touch with you?

[1:06:25] Andrea Zujko, DPT: Well, you can find me — I manage the clinic called West Side Dance Physical Therapy here in New York. So if you want to look up the website, it's westsidedancept.com. You can find me there listed under the staff section. You can email me at [email protected]. Or for those of you who want to know more about the collaborative dance medicine education that I do, you can look me up via my company, Dance Medicine Education Initiative, and the website is dancemedei.com. I'm also on Instagram at DanceMedEI, and I'd be happy for you to follow me there and see what I'm up to.

[1:07:13] Jennifer Milner: Excellent. Thank you so much, Andrea. You have been listening to Bendy Bodies with the Hypermobility MD. Today we have been speaking with Andrea Zujko. Andrea, thank you so much for sharing your expertise with us today.

[1:07:21] Andrea Zujko, DPT: Thank you, it was my pleasure. Thanks so much.

Jennifer Milner: Bye.

[1:07:25] Dr. Linda Bluestein: Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other aesthetic athletes. If you found this information valuable, please share it with a colleague or friend and leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes.
[1:07:51] If you want to follow us on Instagram, it's @bendy_bodies, and our website is www.bendybodies.org. If you want to follow Bendy Bodies founder and co-host Dr. Bluestein on Instagram, it's @hypermobilitymd, all one word, and her website is www.hypermobilitymd.com. If you want to follow co-host Jennifer Milner on Instagram, it's @Jennifer.Milner, M-I-L-N-E-R, and her website is www.jennifer-milner.com.
[1:08:28] Thank you for helping us spread the word about hypermobility and associated conditions. We want to hear from you — please email us at [email protected] to share feedback. The thoughts and opinions expressed on this podcast are solely of the co-hosts and their guests. They do not necessarily represent the views and opinions of — we'll catch you next time on the Bendy Bodies Podcast — and do not constitute medical advice and should not be used in any legal capacity whatsoever. This information is not intended to diagnose, treat, cure, or prevent any disease, as this information is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for all medical concerns.