Understanding Lower Extremity Pain with Pradeep Chopra, MD

[01:16] Dr. Linda Bluestein: Welcome back, every bendy body, to the Bendy Bodies Podcast. I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD, here to provide you with accessible information and inspiration about hypermobility disorders like EDS, HSD, Marfan syndrome, and so much more. Combining my medical expertise and personal experiences and my passion for the science and clinical treatment of symptomatic joint hypermobility, I also treat patients and coach clients to optimize their quality of life. So let's get after it. As always, this information is for educational purposes only and is not a substitute for medical advice.
[01:54] Today we are so excited to have my friend and mentor, Dr. Pradeep Chopra, back with us for yet another great conversation. Before I welcome Dr. Chopra, let me introduce my friend and yours, Jennifer Milner, former professional ballet and Broadway dancer who trains hypermobile artists to work to their fullest potential. She knows a thing or two about being a bendy body. We are so fortunate to have Jen here today co-hosting this episode. Hey, Jen, it's so good to have you here.

[02:19] Jennifer Milner: Hey, always good to be here.

[02:24] Dr. Linda Bluestein: And Dr. Pradeep Chopra is a Harvard-trained anesthesiologist, double board certified in pain management and anesthesiology, director of the Center for Complex Conditions and assistant professor at Brown Medical School, with a special interest in chronic complex pain conditions and their associated coexisting conditions. Dr. Chopra, hello and welcome back to Bendy Bodies.

[02:47] Pradeep Chopra, MD: Thank you. Happy to be here again.

[02:49] Dr. Linda Bluestein: Wonderful. And we previously spoke with you about pain in the abdomen, the head, the neck, spine, chest, and upper extremities. I strongly encourage listeners to go check out those episodes as well. Today we're going to talk about pain in the lower extremities. So can you start out by telling us why this is an important topic for people with symptomatic joint hypermobility?

[03:13] Pradeep Chopra, MD: Pain anywhere is pain, and that can make anybody's life miserable. The problem with the legs is that they are weight-bearing joints — weight-bearing appendages. You can't do much if your joints in your legs have to not only be mobile, but also be able to tolerate the weight of your body. Your knee has to be mobile enough for you to walk, but at the same time be strong enough to support your weight. And you have to remember that when we walk, we don't walk on two feet. We walk on one leg at a time. So you put all your weight on the right leg first, and then you put all your weight on the left leg. Your knee joint on the right side — your knee, hip, and ankle — have to be able to bear your entire body weight, not half your body weight. And then your left side has to be able to bear all of that, all while you're moving and walking. That's the beauty of the human body — it's designed to do that.
[04:24] So with the legs, I like to start with the feet first, because if your feet and ankles are not stable, that makes your knees unstable. And most often your knees are unstable to start with, and then that throws your hips off, and then that throws your back off. It's like a Jenga tower. If one piece is missing or loose, then everybody else falls apart.
[04:51] So let's talk about the feet and ankles. Firstly, the feet. Almost — I would say almost 90% of people with EDS have flat feet. And remember, you look at whether your foot is flat or not when you're putting weight on it, when you're standing. I always get this argument: "But my feet have beautiful arches." Yes, that's when you're not standing on them. But the minute you stand, they're flat as a pancake. That's the difference.
The other thing about flat feet is your arch. Think of your arch as the bow part of a bow and arrow. It's got a springy action. When we walk, that springy action gives you that bounce and makes you take larger steps. Now if you don't have that — if the string on the bow is broken and you have flat feet — then you're just walking like Donald Duck. Splat, splat, splat, splat. That leads to its own problems.
[05:51] The other thing that happens in EDS is that the flatness is not just the arch. The flatness is also in the forefoot, the front of the foot. If a person with EDS looks at their feet, they'll see that when they stand, the front of the foot splays out. It looks like a spatula — it splays out and the arch disappears.
[06:15] Let me address the front-of-foot flatness real quick because that's easy. Whenever you buy shoes, make sure they're wide, because your shoes should have enough space for the front of your feet to spread out. Correcting the arch is not always necessary. I've learned this the hard way — I've insisted on correcting it and people have felt uncomfortable. Most shoe manufacturers now include a bit of an arch in their shoes. Brands like Asics, Brooks, and especially Hoka include an arch, and that makes them very comfortable. That's why they're so popular.
[07:06] If you have a shoe that doesn't have an arch, you can buy an insert and try it. You can buy an inexpensive brand from the pharmacy. It should make you feel good right away — it's not a question of getting used to it. As soon as you put it in your shoe and take that first step, it should feel good. If it does, great. If you need a shoe insert for your flat feet, one of the better brands I've found is called Pedag, P-E-D-A-G. It's a German brand. It's semi-custom built. You can find it on Amazon or on their website. They do last a while and they're not super expensive. The problem with these inserts is you have to change them on a regular basis — most people say once a year, but you can go longer. Once they become really mushy and flat, throw them away and get a new one. But like I said, most shoes nowadays have an arch built in, which is awesome.
[08:22] The other problem — when you have a flat foot — is that when you stand, it makes your foot curve outwards. If somebody looks at your ankles from the back when you're standing, you can see that the ankle curves outwards. That's where the problem is, because your weight comes down your leg and when it reaches the ankle, it should go straight down into the ground. But if your ankle is turned outwards, you're not getting proper weight transmission, and that leads to ankle problems.
[09:07] Just to recap: you check flat feet by standing on a hard, flat surface. You don't check it by eyeballing it — sitting down it's going to look great, but the minute you stand, it goes flat. There are two types. The front of the foot is flat, and for that you wear wide shoes. For the arch, you get an insert if your shoe doesn't already have one. It's really important to correct your flat foot because, as I said, a flat foot will turn outwards and cause the weight to be transmitted in an incorrect fashion, which leads to ankle damage.

[09:51] Jennifer Milner: Can I put a hack in here?

[09:54] Pradeep Chopra, MD: Sure.

[09:55] Jennifer Milner: Because I work with a lot of people who do have flat feet — or high arches that collapse when their feet start moving — and they find relief with some sort of arch support, especially in my younger population, like teenagers and early 20s. They find relief even with just a drugstore sole insert, but they do not want to take the effort of moving the insert out of their Chucks and putting them into their Uggs or whatever the case might be. So I encourage them: the inserts are $15, buy three or four pairs, leave one in every single shoe you need them in. Because if you're not using them, you're wasting money anyway. If the only way you'll use them is if they're already in your shoes, then buy a few low-cost ones so you'll actually use them.

[10:45] Pradeep Chopra, MD: That actually is a great hack. Thank you. Agreed. That is a really good hack, because that's what I used to do — I used to keep moving my Pedag from shoe to shoe, but it's really not worth it. Just get a few. Plus they last longer because you're not putting all the weight on one pair. That's a really awesome hack.

[11:07] Jennifer Milner: Thank you.

[11:08] Pradeep Chopra, MD: That's going to be called the hack of the day.

[11:12] Jennifer Milner: Well, the podcast is early — we just started. So don't give away the prize.

[11:17] Pradeep Chopra, MD: I don't think I'll be able to beat that hack. So let's move up to the ankle. Ankle instability is common, and it's not just particular to EDS. I've seen a lot of adults with ankle instability. One of the advantages of waiting for a flight at the airport is that you sit down and watch people's ankles.

[11:42] Jennifer Milner: Oh yeah.

[11:42] Pradeep Chopra, MD: And you look and think, oh, that one has EDS, oh my goodness, those ankles. So it's common in non-EDS patients to have weak or unstable ankles. Ankles don't have any muscles padded around them. They are super weight-bearing joints, so they do tend to get unstable as life goes on. EDSers, of course, are born with unstable ankles. How do you know? Very simple. You lift up their foot and you can grab onto the sole and turn the ankle. Or you can just ask them: when you walk, do you ever find yourself rolling your ankles? And they'll say, oh yeah, I roll my ankles all the time. That is critical, because you don't want to roll your ankles — and I'll explain that in a second.
[12:39] Every time you roll your ankles, you are separating the bones of the lower leg. The lower leg has two bones: the tibia and the fibula. The tibia and fibula make a joint at the ankle end and also at the knee end. The relationship between these two bones is very parallel, almost parallel. When you roll your ankle, these two bones separate. There's a nerve near the knee joint at the top that gets hit by the fibula — that nerve is called the peroneal nerve. So the peroneal nerve gets hit every time you roll your ankle. The fibula separates more than the tibia, and when they separate, the fibula hits against the peroneal nerve just below the knee on the side.
[13:35] That nerve is responsible for two things: sensation down the leg into the ankle and foot, and more importantly, lifting your foot as you walk. When we walk, we do what is called the heel strike — we put down our heel and then lift the front of our foot up. That lifting is done by the peroneal nerve. If the peroneal nerve is injured by repeatedly rolling your ankle, it does not lift the foot properly. That's called foot drop. These patients will tend to stumble on their toes. You can ask them: have you ever noticed that after you've been walking for some time you stumble on your toes? And they'll all agree to that.
[14:47] The easiest way to treat an unstable ankle is to wear high-top shoes. High-top shoes with laces stabilize your ankle — they act like a brace, but they look nice. There are shoes that are supposed to be high-top but don't go very high above the ankle, and then you have ones that go a little higher than that. You want the ones that go higher. They should have laces so you can tighten them and stabilize the ankle. That avoids your ankles from rolling, which avoids you from tripping on your toes and also helps with pain in your leg.

[15:35] Jennifer Milner: It seems like just such a small thing. You can still sprain your ankle with high-top shoes, but it's much less likely, and it really does help a lot.

[15:48] Pradeep Chopra, MD: Yes. I was having a problem with my patients because I used to recommend ankle braces, which really looked ugly. And not only that, they had to buy a new pair of shoes because the brace would be thick. That's when I was sitting at the airport and watched a woman walk by with high-top shoes and said, well, that'll work for my unstable ankle patients. There are a few brands out there. Doc Martens is one, but almost all basketball sneakers are pretty high-top and any of those can work.

[16:25] Jennifer Milner: They are. But I will also say most of the high-top sneakers like basketball sneakers, and even the Doc Martens, do not have the built-in arch support that Hokas or some of those other brands would have. So that's where we go back to finding an arch support insert that you can use —

[16:44] Pradeep Chopra, MD: Right.

[16:44] Jennifer Milner: — best of both worlds.

[16:45] Pradeep Chopra, MD: Yeah. And then it can be hard to get the arch support in the high-top shoe too.

[16:49] Jennifer Milner: Right, right. So you have to make sure that if you find a pair of flat-soled high-top shoes, take an arch support with you to try them on, or make sure you can return them, because they will make a difference in how they fit. Every time I put an arch support in lace-up high-top sneakers, it starts to push on my arch where the laces are. So you've got to play around with that, but they definitely help.

[17:12] Pradeep Chopra, MD: Yes, absolutely. That's been my experience too. When you do buy high-top shoes, you have to figure out how tight those laces have to be. Some of those bindings may not have to be as tight, because after all the ankle joint needs to move. But you learn and you'll figure it out. And like I said, some shoes don't have arch support built in — that's when you buy them from Jennifer's shoe insert shop.

[17:45] Jennifer Milner: There you go. I'll start my own shoe insert shop.

[17:47] Pradeep Chopra, MD: I'm thinking — Doc Martens are really popular nowadays. I see people wearing them and they look dressed up, like they're going to the ballet. So it's cool that style-wise there are a lot more options. But for people who maybe that's out of their budget, don't you think that even wearing a more compressive-type sock might give you a little more proprioceptive input? It's not the same level of support, but maybe it might give you just a tiny bit of an advantage or make it slightly less likely to sprain your ankle compared to having nothing.

[18:30] Pradeep Chopra, MD: You're absolutely right, because one of the issues with EDS that I had in the beginning was compliance. I was completely blind to compliance. Guys are completely blind to fashion — they'll wear anything. But a lot of my EDS patients are girls, young girls and teenagers in their 20s, and they'd rather limp around than wear some ugly brace on their ankle. I can tell you that. So compliance became a big issue for me, and I had to look at something that would appeal to them. The high-top shoes just made a lot of sense. But I didn't realize — until a patient actually showed me a high-top shoe that wasn't really a high-top shoe, it was more of a mid-high-top — that you really need higher than that. So just be careful about that part.

[19:33] Jennifer Milner: Well, when we're talking about cost as well — I get it, I know fashion, some people love shoes and love to collect them. For me, because of my body, I would rather buy one really great pair of shoes that covers a few different uses than buy four different pairs of shoes for $30 that aren't going to be as supportive. Because I'll end up not wearing them — I'll wear them once, my feet will hurt, my ankles will hurt, and I'll put them aside. But if I spend what it costs on one good pair of Doc Martens, I look cool — or I probably don't look cool, but I feel cool. Spending good money on Hokas rather than buying a few pairs of cool-looking sneakers that aren't going to last as long and aren't going to give you support — yeah.

[20:23] Pradeep Chopra, MD: Converse. Let me just explain Converse. You just described Converse. Those are not shoes. Those are tarp wrapped around your feet. People do look at me weirdly when I say Converse is not a good idea, but Converse does make high-top.

[20:40] Jennifer Milner: And you put an arch support in.

[20:41] Pradeep Chopra, MD: I sort of compromised myself with that. I said, okay, Converse high-top will do.

[20:46] Jennifer Milner: Yes. There you go.

[20:48] Pradeep Chopra, MD: Anyway, so we've talked about how to stabilize the feet and how to stabilize the ankles, and this should solve at least half the problems with your legs. Remember, your problems start with having unstable ankles and feet, which then goes on to your knees and then to your hips and then to your back.
[21:10] On the knee, there are only two issues. One is that knees hyperextend — they go backwards a lot. Not everyone, but most people do hyperextend a lot. The question is: if it hyperextends, should we correct it or not? The answer is no — unless it hurts. If it's painful, then you should consider correcting it. And there's a catch to how you correct it.
[21:41] What I tell patients is: fix your ankles and your feet first and see if it makes a difference to your knees. If that helps your knees, you're all set. If it doesn't, then let me know which knee hurts more. And here's the catch that physicians have to solve. A patient may come in and say, "My right knee hurts more than my left knee." But when you examine them, their left knee is much more hypermobile or hyperextended than the right. So what do you do? Your right knee doesn't hyperextend but it hurts. Your left knee hyperextends and is hypermobile. Which one are you going to treat?
[22:23] In this case, I choose treating the unstable knee even though it doesn't hurt — which would be the left knee. What's happening is that because the left knee is unstable, they tend to put more weight on the right side, and because they put more weight on the right side, the right knee hurts more. So you stabilize the left knee, which even though it's not hurting, is the root cause. That will take care of the right knee. They might say, "But I don't have any pain on the left knee." That's the problem — it's not coming from the left knee, but the left knee is making you so unstable that the right knee has to do all the work to stabilize you. So you stabilize the left knee, even though it's not hurting.

[23:11] Jennifer Milner: Well, isn't that something you see a lot with knee issues. As you said yourself, there's not a lot to talk about with the knee — it's either hyperextended or it's not, as far as pure hypermobility goes. But the knee is the joint caught in between the hip and the foot or the ankle. A lot of knee issues can come up that may not be a result of hypermobility in the knee itself, but are a result of hypermobility or biomechanical dysfunction because of hypermobility in the hip or in the ankle. I've had so many clients that go see a physical therapist and say, "My knee's bothering me," and the therapist says, "Well, let's look at your feet or your hips." And they say, "No, no, no, it's my knees that bother me." Well, the knee is just the poor kid stuck in between two fighting grown-ups, right? So it's really important to look at that.

[23:55] Pradeep Chopra, MD: Yes, absolutely. I've actually had people have back surgery and it didn't help. When they come into the office and you look at them and ask how long they've had the pain in their knee — and this is non-EDS — you find that the issue is actually a big bunion in their foot or their knee is completely off. Anyway, the tricky part is: you don't just treat what hurts. This is against the rule. The squeaky wheel gets the oil? Not here — the non-squeaky wheel gets the oil. The left knee is hypermobile compared to the right, but you still treat the left knee because you're transmitting all your weight to the other side.
[24:39] But from my experience, most people — when you fix their feet and ankles — their knees kind of behave themselves. There are a few exceptions where I've had to get a brace for the knee, and I don't like doing that because no one likes to wear a knee brace.
[24:55] What about people who have extremely mobile patellas? If they have patella alta or some other condition where they're dislocating their patella a lot — recurrent patellar dislocation and lateral release surgery seems like a not-uncommon thing with dancers or patients I've seen. I'd love to know your thoughts about that.
[25:27] So the patella is hypermobile in most patients with EDS — almost all of them. But it's not a problem at all. And if it is so hypermobile that it's causing a problem, it's an easy fix. You can get little braces or even little straps that will hold the patella in place. If you happen to wear a knee brace, almost all knee braces have a little donut hole in the middle that holds the patella in place. If you are not wearing a brace, there are very discreet little straps you can put around your kneecap to keep it in place.
[26:08] But most often, if the patella is going to be a nuisance, the problem will show up on the front of the thigh, not at the patella itself. Because the front of the thigh has four muscles — that's why they're called the quads. All four of them meet at the patella. So if your patella is swinging around from left to right, these muscles are being tugged. If your patella swings to the right, the left side of the quad gets pulled. If the patella goes to the left, the right side of the quad gets pulled. Oftentimes these patients will complain of pain in their thighs rather than at the kneecap itself. I haven't seen good relief from patellar release surgeries. The best thing is if it is a bother, you can get these little patellar bracing elastic straps to wear around the knee and they keep the patella in place.
[27:13] So just to recap on the knee: the term for hyperextended knees is banana knees.

[27:22] Jennifer Milner: That's a medical term.

[27:24] Pradeep Chopra, MD: They look like bananas. Knees generally behave themselves once you get the ankles and feet stabilized. If the patient comes back and tells me they did all this, they're wearing the high-top shoes, and their knee still hurts, I'll ask which knee, examine both sides, and then decide which side gets a knee brace.
[27:48] Now, a small hack on the knee brace. Most knee braces you have to pull up from your foot like a stocking all the way up to your knee. That's not an easy job — it's a tight strap, and with hypermobile fingers it's especially hard. There is one company that makes a knee brace you can wrap around your knee. It's called the Gripper. It's made by a company called Medspec, M-E-D-S-P-E-C.
[28:39] In any case, all knee braces should have a few features. One, it should have a strap on the top in the front and in the back. The leg is conical in shape — especially the thigh — so these braces tend to slip down. It should have a strap in the front and a strap in the back at the thigh level, and a strap in the front and a strap in the back below the knee — four straps total to keep the brace from slipping down. It has a little donut hole in the front that keeps the kneecap in place. It has a hinge on each side — usually a metal hinge — that keeps your knee from hyperextending. That's critical. And a good brand will make it adjustable. They'll give you a little Allen wrench so you can unscrew and set the right angle, because you should be able to flex the knee — you don't want it completely straight like Frankenstein walking around. So you can adjust it to whatever angle is best for you. I recommend the Gripper because you don't have to pull it up the leg — it just wraps around and has all the features I just talked about.

[30:15] Jennifer Milner: That's great. We should open up a hypermobility store. You have so many great tips from your years of working with people. You know all the good brands and things that work really well because it's been road-tested with your patients.

[30:27] Pradeep Chopra, MD: Actually, there is a hypermobility store. John Fuhrman from EDS Awareness — right, Dr. Bluestein?

[30:39] Dr. Linda Bluestein: Yeah, EDS Awareness, Chronic Pain Partners.

[30:40] Pradeep Chopra, MD: Chronic Pain Partners. If you go to their website, chronicpainpartners.com, he has a store with EDS-recommended items — recommended by EDSers. Different things. I don't know if he has these braces or not, but he does have some items there.

[31:01] Jennifer Milner: That's great.

[31:01] Pradeep Chopra, MD: Some of these — pillows and things like that — they do have them. These are all recommended by EDS patients.

[31:10] Jennifer Milner: That's great. Hey, before we leave the knee, I wanted to go back to something you said about how someone should stand in hyperextension — or not stand in hyperextension. You said if it's not causing any pain on either side, you don't necessarily correct it. But for me, when I see people standing in hyperextension, I usually see a compensatory strategy somewhere up or down the chain — they might be hanging forward on their Y ligaments in their hips, they might be jutting their head forward or something. Would you look at everything before you decided to let them hang in their hyperextension, or what do you usually do?

[31:53] Pradeep Chopra, MD: Yes, I'm glad you brought that up. If I see that they have no knee problems but I see a lot of hyperextension, it's the same rule. When you stand, always break your knee a little bit.

[32:06] Jennifer Milner: Okay.

[32:07] Pradeep Chopra, MD: So it's not tightly hyperextended.

[32:09] Jennifer Milner: Okay.

[32:10] Pradeep Chopra, MD: Just a tiny bit. That applies to the same rule about keeping your joints under your range of motion.

[32:21] Jennifer Milner: Under your range of motion.

[32:23] Pradeep Chopra, MD: If they're not squeaking, fine. If it's squeaking, then we have a different story. So that takes me to the hips. Hips in general are very stable joints inherently. They are deep socket joints with a ton of muscles around them. They don't have a great range of motion — hips move forward and backwards, just a little bit to the sides. The evolutionary idea was that if you're going to be chased by a saber-toothed tiger, you better run fast and you don't want your hips subluxing then. That was the idea of having strong hip joints.
[33:07] If a hip joint is subluxing, the culprit is usually somewhere else in the leg. That's the one we watch out for. In terms of bracing, there's no great brace for the hip. There is one — it's very elaborate, a pain to wear, and it really doesn't help a lot. It's almost like shorts that stabilize the hip joint, but they're not really helpful. If a super stable joint like the hip is subluxing, the problem is somewhere else in the leg — either the ankle or the knees or something like that.
[34:01] I don't know if this is common, but there's a condition called FAI — femoroacetabular impingement.

[34:08] Jennifer Milner: I think it is common.

[34:10] Pradeep Chopra, MD: I've seen it in EDSers. I've not seen it in non-EDS patients, but I can't say for sure if it's completely an EDS thing. Essentially, the head of the femur is too big for the socket — that's what it boils down to. The treatment is surgical, and it does work well if done by an orthopedic surgeon familiar with FAI surgeries and the nuances of EDS. But not just because you have an FAI should you get surgery done. If you have an FAI and it's causing pain — that's when you consider surgery. The philosophy in medicine is you treat the patient, not the MRI. If you see an FAI on an MRI but the patient has no hip problems, you don't touch it.
There are three types of FAI, but basically it boils down to the head of the femur not fitting properly into the acetabulum. From that you have a few different problems. Usually it's hip pain. Hip pain shows up in many different places — it can show up in your groin, on the side of your thigh, or in the middle of your buttock. If you have pain in any of these areas and you don't know if it's the hip or just a muscle, and if walking makes the pain worse, then it's probably the hip. If you walk and you limp a little towards that side, then it's probably hip joint pain.
[36:08] And I think to just wind up on the lower extremity, I'm going to touch base on the sacroiliac joint — the SI joint.

[36:18] Jennifer Milner: Yes, please.

[36:18] Pradeep Chopra, MD: The pelvis is made up of three joints that connect to each other to form a ring. In the middle of the ring live all the organs — the urinary bladder, the uterus, and so on. On the outside of this ring is the socket for the hip joint. The SI joint, or sacroiliac joint — there are three bones. The one bone in the middle of your lower back, almost in your bum, is called the sacrum. The sacrum makes a joint with the bone on the left and a joint with the bone on the right. These are the two joints that start to hurt.
[37:07] Sacroiliac joint pain is not peculiar to EDS — it is common in non-EDS patients also. Most often seen in women, because the pelvis expands for childbirth and then goes back in place. But in EDS, it may not go back and fuse as well after childbirth. So they're left with SI joint pain. It can also happen with pain from your leg. If one leg is painful, it can make your pelvis uneven — it seems like one leg is shorter than the other, which tilts the pelvis slightly, and the sacroiliac joints start to hurt.
[37:54] There are three ways to treat it. One is to look for why there is SI joint pain — is there something wrong in the knee, foot, or hip that's causing the pelvis to tilt? If you can't find that, you look at the SI joint itself. It could be that the SI joint is just inflamed, in which case a couple of steroid injections into the sacroiliac joints could help. If it really hurts a lot and you've tried everything and nothing's making a big difference, then you look at an SI joint brace. And here I need to explain: there is an old brace called the SI belt. Do not use that. That's a useless piece of junk. There is a German company that has come out with a combined brace for the waist and the SI joint, designed for women because women's pelvises are different. It holds the pelvis in place, but holding the pelvis in place is not the best solution, because the pelvis needs to have some movement in it.

[39:18] Jennifer Milner: Excuse me — are you referring to the Bauerfeind sacral lock or something different?

[39:22] Pradeep Chopra, MD: Yes, I'm talking about Bauerfeind — not the sacral lock, but the lumbar.

[39:27] Jennifer Milner: Oh, okay. My sacral lock is sitting just a few feet from me, so I was curious.

[39:31] Pradeep Chopra, MD: The sacral lock is another one you can use. What Dr. Bluestein is referring to is a company called Bauerfeind — B-A-U-E-R-F-E-I-N-D. It's a German company. They make really great braces. They have a design called the Lumbo Lady that stabilizes the lower back and the SI joint, and it's designed for women.
[40:02] Now, there are some orthopedic surgeons who think that putting a screw into the SI joint will fix the problem. That is by far the worst idea I have ever seen. As we walk, the SI joint needs to have some movement — it should rock a little. You cannot fuse it. Once you do that, it throws the mechanics of your entire spine off. You start developing lower back pain, your hips start to hurt, everything starts to hurt. I have never seen good outcomes from that. There are just a few people who have no clue what they're doing who will fuse it.

Dr. Linda Bluestein: Yeah, there are people that are still doing it, and I had somebody recently.

[41:00] Pradeep Chopra, MD: There are. Are we allowed to swear on the podcast?

[41:04] Jennifer Milner: Go for it.

[41:06] Pradeep Chopra, MD: We can always take it out. There are some orthopedic surgeons who will say, "Oh, your SI joint is causing pain and it's loose, let me go get some screws and fix your SI joint and you'll be good to go." And then they show up in our office: "Doc, my back hurts, my knee hurts, everything hurts." And you're like, oh, the SI joint got fused. And there's not much you can do about it once it's been fused.

[41:34] Jennifer Milner: So leave it alone. And this is such an interesting conversation to have because the discussion about the SI joint has come such a long way. When I started out 20-some-odd years ago, there were people who would stand on a hill and say the SI joint's not a joint because it doesn't have any movement — they couldn't even come up with a name for it. And now everybody agrees it's a joint, even though it has what, five to ten degrees of motion. It's not a lot of motion, but it's critical motion.
[42:04] Looking at how the SI joint moves, how it coordinates with the rest of your spine, and more importantly — what we've talked about in earlier discussions about the upper extremities — what is muscle tightness trying to protect? When I have people come in with low back pain, I look at what's tight, what's going on. They'll have really tight glutes that may be super hypertonic but not really efficient, or they might have one piriformis that's really strong and one that's really weak. Figuring out what's trying to hold on is much better than, as you said, sticking a screw in it and hoping for the best. It's usually a sign that there is some imbalance of too much looseness versus too much tightness, and one will usually follow the other. So it's a really important conversation to have because it affects so much of the body — that SI joint and that sacrum movement.

[43:01] Pradeep Chopra, MD: Jennifer, I am blown away by what you just said, because the glutes and the piriformis are so annoying. Especially the piriformis — it's a really annoying muscle. The degree of pain it causes relative to what it actually does makes it just not worth having. If I had a way to send a request to whoever designs human beings: the next set of human beings you create, can we just get rid of the piriformis muscle?
[43:37] You're absolutely right. Just because somebody has back pain, you don't just assume it's the SI joint or the disc or whatever. No one has a normal MRI — there's no such thing as a normal MRI. You look at the muscle. You palpate the muscles, you push around, and all of a sudden they're going to jump up and say, "Yeah, that hurts a lot." You can feel a knot there. And that's because your muscles are trying their best to stabilize your joints as you move around.
[44:09] The piriformis muscle is super annoying. I especially hate it because I've had piriformis pain myself, and it's not fun. It's a muscle deep down in the buttock. It connects your sacrum — the bone in the middle of your butt — to the hip joint. There's one on each side. It's called piriformis because it's pyramid-shaped. The problem is that muscle goes into a spasm because either you moved your hip the wrong way or overstretched the piriformis, and now it's excruciatingly painful. This pain is usually in the buttock.
[44:51] The other problem is that just behind the piriformis muscle is the sciatic nerve. So when it goes into a spasm, it presses on the sciatic nerve, and now you have pain shooting down your leg. That is excruciating. Disc pain also causes pain down the leg, but it's not half as bad as piriformis-induced sciatica.
Over the years I've found that when you walk into the room, you'll see the patient sitting on one buttock, leaning to one side. You can right away say something, and they'll tell you: "My back hurts, doc. I have this disc herniation and I have sciatica going down my right leg." You do a couple of maneuvers to aggravate the piriformis muscle, and there you have it. The diagnosis is really simple, and the treatment is equally simple.
[45:47] I can do some injections into the piriformis muscle to break the spasm and stretch it. Otherwise, you can sit on a golf ball or a tennis ball depending on the size of your buttock. The way to stretch it is to bring the affected ankle — let's say it's the right side — you bring the right ankle onto your left knee, the unaffected knee, and just lean forward. You'll feel that pain in your buttock. Hold it for two seconds and then straighten back up, all the while keeping that golf ball or tennis ball underneath. When you put pressure on it, it's like a pressure point, and the pressure loosens and breaks the spasm, and then you stretch it. Eventually it will let go. That's the way to do it.
[46:53] If it's super painful and you want relief right away, lie on your back and move the affected leg away from you about 20 degrees away from the midline to the side, and turn the foot outwards. After about 10 to 15 minutes, the muscle will start to let go. But that's not the cure — that's just temporary.

[47:16] Jennifer Milner: Just temporary. Yeah. I will add to that, that when someone comes in to me with SI joint pain and says they really feel the pain on the right side, I'll go through a few different things. There are lots of different places where they could be really tight, but I would say 70% of the time, one of the most effective things I can do is strengthen the left piriformis — the non-painful, non-squeaky wheel side, as you've said about the knees — and get it to start working. I'll do a little bit of release for the right piriformis, but then I will largely ignore the right piriformis and strengthen other muscles like the deep rotators, make sure the hamstrings are doing the extension work they need to on the right side, to try to get the right piriformis to feel safe and like it can release and let go. So strengthening the opposite piriformis from where there's pain, and then strengthening the muscles around it so the piriformis doesn't feel quite so alone — that is often a great first step for people with those issues.

[48:16] Pradeep Chopra, MD: That's a really great idea. I never thought of that. This condition is very painful. This is the one that drives a lot of people to the emergency room. Disc pain is not this painful. This pain causes pain down the leg and all that, but it's not as acute as piriformis pain, because it's both a muscle spasm and sciatic nerve pain at the same time.
[48:44] I think — do you have anything else on our lower extremities?

[48:49] Jennifer Milner: I have a question in the pelvis, and I think Dr. Bluestein wants to get back to the ankle in a second. But really quickly — because I have seen this a few times — can you talk about the pubic symphysis? I see it especially in pregnant women, and I've seen it in a few of my athletic dancer clients with a subluxation of the pubic symphysis due to hypermobility.

[49:08] Pradeep Chopra, MD: That's actually pretty painful.

[49:10] Jennifer Milner: Yeah.

[49:11] Pradeep Chopra, MD: So what Jennifer is asking about is the pubic symphysis. Remember the ring — the pelvis is a ring. On the back it meets the sacrum and the tailbone. But in the front, the bones meet together right at the pubic area. Oftentimes — well, when you're as old as I am, they actually fuse. But in EDS, they can actually separate. When that separates, it causes pain in the back because it throws the whole pelvic ring off. It causes pain in the SI joint area. This usually happens when there's something severely off with the hip joints or the legs. To solve this problem, you really need a brace. I don't know if surgery is necessarily a good option. But just thinking of the mechanics, if the separation is so severe that you can't bring it together or keep it together, then surgically treating it might be the way to go. Otherwise, the Bauerfeind Lumbo Lady or even the Sacro Lock will do the job.

[50:34] Jennifer Milner: That's great. Thank you.

[50:35] Pradeep Chopra, MD: That makes sense.

[50:36] Jennifer Milner: Absolutely. Well, this whole conversation about the lower extremity has just been so interesting. I keep thinking about what you said at the very beginning — how the lower extremities not only have to function well for themselves, but also have to bear the load of our entire body. We have to be able to stand on one leg and bear the load of our body, and we have to do it as efficiently as possible. Going through it joint by joint and seeing how closely connected they are — the ankle affects the knee, the knee affects the hip, the hip affects the foot, and the pelvis sits in there going, I'm sorry for everything that's happening. You have given us some really great hacks and we are so grateful once again for you sharing your knowledge with us and for continuing this series as we talk through the whole body with you. Thank you so much once again, Dr. Chopra, for being on the Bendy Bodies Podcast with us.

[51:24] Pradeep Chopra, MD: Thank you for inviting me. It's a pleasure to be able to help your listeners and give them some guidance on what to do and what not to do, because there's not a whole lot of help out there. And it's nice to be able to do that. Setting up a podcast is not an easy job — it's an expensive venture — and I really appreciate you doing that out of the goodwill of your hearts. May God bless you for doing that, because the information I give here is not something I cooked up last week. It's 30 years of treating EDSers and figuring out solutions. Because when I started out, there were no solutions. EDS was very rarely diagnosed and all they said was, "They have loose joints, period," and then moved on to the next condition. And so it was an invention of many, many treatments over the years.

[52:27] Jennifer Milner: And that's why we're so grateful that you've shared your amassed wisdom with our listeners. We really appreciate it.

[52:31] Pradeep Chopra, MD: Oh yeah, I am just oozing with wisdom.

[52:44] Jennifer Milner: You are, you are.

[52:44] Pradeep Chopra, MD: You joke, but you are.

[52:47] Jennifer Milner: I need to wear earplugs now.

[52:51] Pradeep Chopra, MD: Keep all that wisdom in. Right, right.

[52:53] Jennifer Milner: Linda, we need to beat my hack of the day. I set the bar too high.

[53:00] Pradeep Chopra, MD: You set the bar too high. You guys are going to have to come up with a better hack.

[53:03] Jennifer Milner: Yeah, we'll have to come up with a better hack. I'm going to be thinking between now and then — trying to think of as many hacks as I possibly can.

[53:20] Pradeep Chopra, MD: Just hack your way through till our next podcast.

Jennifer Milner: Right.

[53:21] Pradeep Chopra, MD: Any one of those could end up being the highest hack. We've got to beat Jennifer's. She set the bar way too high.

[53:27] Jennifer Milner: You've got to. Yeah, I set a high bar. That's right, I did. Well, everybody, make sure you tune in to our next podcast to hear who wins the hack of the day. Until then, we will see everybody later.

[53:40] Dr. Linda Bluestein: Thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. Help us spread the word about joint hypermobility and related disorders by leaving a review and sharing the podcast. This helps raise awareness about these complex conditions. Visit bendybodiespodcast.com and follow us on Instagram @bendy_bodies. We love seeing your posts and stories, so please tag us using #bendybody. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, Twitter, and LinkedIn, all with the ID @HypermobilityMD. This podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. This is not intended to be a substitute for medical diagnosis or advice. Do not disregard or delay obtaining medical advice for any medical condition you have. The opinions shared are that of the guest and do not necessarily represent the views of the hosts or any particular organization. Thank you for being a part of our community, and we will catch you next time on the Bendy Bodies Podcast.