Foot Pain 101: Everything You Need to Know with EDS and HSD with Lisa Ralston, PT

[00:35] Dr. Linda Bluestein: Welcome back, every bendy body. This is the Bendy Bodies Podcast, and I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD. This is going to be a great episode, so be sure to stick around until the very end so you don't miss any of our special hypermobility hacks. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. I am so excited to have Lisa Ralston with me. Lisa is a physical therapist with over 30 years of experience in orthopedics, bendy bodies, and sports medicine. She graduated from Cal State Long Beach in 1990 and previously owned All Sports Physical Therapy in Parker for 16 years. While Ralston specializes in treating hips, feet, athletes, and complicated connective tissue disorders, she believes in taking care of the whole person. Since 2009, she has traveled internationally treating Team USA Olympians and world-level figure skaters. Lisa was the physical therapist for Team USA figure skating for the 2022 Winter Olympics in Beijing. Lisa is the owner and founder of Ralston Physical Therapy and Wellness in Arvada, Colorado, and she is also licensed in California and offers virtual services. Lisa, hello and thank you so much for coming on to Bendy Bodies.

[02:00] Lisa Ralston, PT: Hi, Dr. Linda. So excited to be here.

[02:03] Dr. Linda Bluestein: Wonderful, wonderful. And I want to acknowledge, if anyone's watching this on video, we are sitting in the Colorado sunshine and I have the sun shining in my face. So it's good for setting the circadian rhythm, not so good for recording video, but we'll get through it. So it's so great to chat with you. I have to admit that I personally have an interest in foot problems and orthotics and am super eager to dig into this topic with you. And so that's what we're going to talk about today — foot pain, orthotics, and really just kind of dig into your expertise. So can you start out by telling us why so many people with joint hypermobility have foot pain?

[02:49] Lisa Ralston, PT: Yes, absolutely. First, I want to also admit this is my first podcast, and it was actually some of my patients that encouraged me to talk about this because I do want to share. I have so many patients that come who have seen providers and nobody even put their hands on their feet and just handed orthotics, and there's so much we can do. But basically, because it's so dang hard for bendy bodies to hold their posture, and it takes so much effort. And so that's one of the reasons that the hypermobile body — and hypermobile bodies can have stiff areas, which we're going to talk about, that affect function — but basically it just takes so much effort to hold the posture. And so that really affects the load on our feet and our function. And so we have a lot of compensations and increased load on certain joints and tissues because our bodies are working so hard to hold a basic posture and alignment, which is key.

[03:55] Dr. Linda Bluestein: That makes sense. And I don't know that a lot of us think about posture as it relates to our feet.

[04:01] Lisa Ralston, PT: Right. It's our foundation. And I think also our patients — there are so many important things we're dealing with: GI issues, POTS and dysautonomia, headaches, cervical instability. The feet are sort of like, oh, we'll get there. And so I think some of it is just a thing we don't get to because there are so many other important appointments as well. But hopefully after today, we'll talk about some easy things to do that can help us feel better — things that can even help all those other things that we're trying to manage, which is so overwhelming.

[04:49] Dr. Linda Bluestein: Oftentimes the part of our body that hurts the most brings our attention, and we don't realize that there are other things like the feet that could affect that. Cervical instability could actually be improved by working on our feet, right? And we want to catch all the low-hanging fruit. We definitely don't want to miss a relatively easy intervention like orthotics. I'm not saying that addressing foot pain is easy, but we don't want to miss those lower-risk types of things.

[05:23] Lisa Ralston, PT: Yeah. There are some very simple things we can do that help right away — things that help us be able to stand longer, walk longer. Like one of my patients last week who has really significant cervical instability and has already had surgery for Chiari and severe headaches and just extreme fatigue and pain. By doing some other things with the low-hanging fruit — pelvis and feet — she was able to do the dishes at 8 o'clock at night. She said, "I'm so amazed." And so we were focused on the pain, but it was really the posture and the fatigue that were helped so much. And then her brain was like, oh, I could do that.
[06:02] And so it's fun for me because a simple little thing we do can sometimes have a big effect that we weren't even thinking of.

[06:19] Dr. Linda Bluestein: And it's all about function at the end of the day, right? We're addressing things that we can modify to improve function.

[06:37] Lisa Ralston, PT: Yes, absolutely.

[06:37] Dr. Linda Bluestein: Fantastic. Can you run us through some common causes of foot pain in people that have joint hypermobility?

[06:37] Lisa Ralston, PT: Yes. As we talked about, posture and alignment is number one. Alignment of the whole body is really important. When we have malalignment anywhere up the chain — we could start with the feet, or we could start with pelvis and knee hyperextension, femoral internal rotation — any kind of malalignment will set that posture off and contribute to increased load or things that cause pain.
[07:09] And of course, we'll talk about excess pronation. Our foot basically has two jobs. It pronates to adapt to the ground, and it needs to supinate — come back into supination where the arch comes up — to be stable, to push off the ground, to propel forward. Pronation is not a bad thing; these are not bad things or things that are wrong with us, it's just how we're made. So if there's too much pronation, or we're living there, or it's too fast, that's what we want to address. Or if somebody's living in a supinated position where all the weight's on the outside of the foot and the arch is up all the time and there's too much stress and load, we can address that.
[08:14] So I'd say the three most common causes are: posture and alignment, excessive pronation, and excessive supination. And also what I see probably more so with EDS is a hypermobile first ray. I also see very tight gastroc and soleus and Achilles. I don't know if there are studies on that — maybe you can tell me, I haven't seen them. But even if somebody has a lot of pronation, flat-footed or supinated, in EDS we tend to have tight calves. And I think that's the body's way to stabilize the back of the body because so much is unstable in other directions.
EDS patients also tend to have more forefoot rotation, which is something we'll talk about because that usually is not addressed with foot providers, in my experience with patients that come see me. And in the EDS population — I don't know why, this is another area where I'd want to see more research — it tends to be more the right foot in our dancers and skaters that are more hypermobile in the forefoot, with forefoot varus or valgus, and first ray hypermobility. There are things we can do to support that — not correct it, but just support it so that we can function better and be a little more stable.
[09:49] And then of course, lack of proprioception. Just because we have that range of motion doesn't mean that's where we should be functioning. So learning where joints are in space so that we can function with better joint alignment is really important.
[10:08] And then fatigue — all the things that go with EDS. Overall fatigue, pain contributes, even overall body pain contributes to foot pain. Because we have those days where you're just on the couch and can't function, or you have a big setback because we did too much, and then we're immobile for a while, and then we feel better so we go do too much again. And that contributes to pain as well.

[10:37] Dr. Linda Bluestein: Definitely. I remember the first time that I heard the phrase "pain begets pain," and I was dealing with my own EDS and really at a low point in my life at that point. I had already finished my entire anesthesia residency and had been working for quite a while, but I was dealing with my own health issues. And when I heard that, I thought, oh, that's really interesting. But it does seem to really fit, whether it's people that have EDS or not. I've noticed in people that I know, it seems like if they get one pain problem, then they're more likely to get another pain problem. We do have lots of data to back this up. And so to me it's so important to try to do a better job with young people and try to help their pain as early as possible so that they don't develop other pain problems. We have such a huge responsibility in that. We have a lot of young people that have pain, and sometimes there's low-hanging fruit there. They need to see somebody sooner rather than later who can address the pain that they're having.

[11:46] Lisa Ralston, PT: Two things I thought of with that. One, absolutely — and I think there's research, but if somebody's pain is more than a 5 or 6 out of 10, we know that neurologically muscles shut down so that we don't load. So it's okay if we don't have zero pain, but we need to have pain that's low enough so our nervous system doesn't overreact and shut down muscles. It's not always that we're weak; things sort of shut down. So if we get the pain down — with support, with manual therapy, whatever treatment modalities we use — muscles fire, which helps with support and alignment, and function improves. That's key for the nervous system and for everything.
[12:30] The second thing is that in my clinic I was seeing a lot more children with hypermobility problems and issues, probably from age 7 up. And after working the Winter Olympics and with elite athletes, one of my loves I wanted to get back to was working with kids, because we can catch things early while they're developing. It might even be scoliosis, right? There's a scoliosis associated with hypermobility, and kids are not even checked for scoliosis much anymore. But there are also biomechanists and doctors who will tell parents that we should not put kids in orthotics. So there are two opposing philosophies. In fact, I was at a meeting last week and a mother with her 11- or 12-year-old said, "Oh, the doctor — I know my son, his feet are so flat like his dad's and he's having a lot of pain and he can't run." And the doctor said, "Oh no, don't do orthotics." So that belief is still out there. And I'm not saying orthotics are appropriate for every child. However, it is so rewarding when you see a child who is so malaligned because of hypermobility or other reasons — it could be an injury, or it could be an illness.
[14:03] For example, my daughter had leukemia when she was 4, and she's a bendy body. She's now 23, but during treatment and the steroids, she was so floppy. This was about 20 years ago — I made little custom orthotics for her, and we put them on and she ran around the kitchen island. That's so wonderful to see with a kid, because their bodies just respond. They don't have 40 years of other stuff layered on top. So that's one of the things I've got back to since selling my practices — I do enjoy working with kids and helping them develop and learn about their bodies and their awareness, what the pain means, how to manage it, nervous system regulation, hydration and recovery — all of that stuff to help their bodies feel better so they can go to school and do the activities they want to do.

[15:08] Dr. Linda Bluestein: Yeah, absolutely. That's what we want — we want kids to be as normal, active, enjoying life, going to school. So that's really great. And thank you for sharing that story about your daughter. That is a great example. And in terms of how you approach hypermobile patients, how do you approach them differently than non-hypermobile ones?

[15:34] Lisa Ralston, PT: I love it when my hypermobile patients provide a thorough history. So even if they're coming to me with hip pain, knee pain, or foot pain — a lot of times they're referred from another therapist or doctor or other patients — I'm still thinking of the entire person and all systems. Like you, Dr. Bluestein, have a page available for people to fill out a history ahead of time. I also have an EDS form where they can check off things like whether they're having headaches, dysautonomia, POTS, GI issues, skin issues — their other injury history, ankle sprains, surgeries, all of that. I want to know all of that.
[16:25] And then what's important is when they come to see me: what's important to them at that point in time. Because last week might be totally different than today. So at that visit, we're addressing where we are now. It can be so overwhelming, even though I'm just treating the foot — if we do a few things, we can feel better all over.
[16:50] So I address the hypermobile patient with their entire systems first. Then I start with what's important to them, what activities they want to do, where they're at. One of my patients right now can only walk maybe a quarter mile, and our goal is to get her walking a mile. I have a couple of patients who have now gotten to 2 miles with some support. And I don't see patients several times a week anymore — I see them maybe once a month. So it's not an intensive process.
[17:27] Then I look at posture — entire body. Mobility. I might take into account Brighton score, but that's not really my focus because hypermobile bodies get stiff areas, and as we age we have changes in joint mobility. So I'm going to look at the spine and pelvis, which are very important. I check mobility of the spine, especially lumbosacral — L5-S1 is really important — and the pelvis. And hip range of motion. If somebody's not moving in their L5-S1 and their sacrum, their hip range of motion might be limited, which can affect their foot during gait.
[18:15] So I'm going to check range of motion in standing, look at alignment — I can get a lot of information that way. Then we do a squat, a single-leg squat. I can see proprioception and alignment when we're on one leg, because when we're walking, 60% of the time we need to be able to stabilize on one foot and one leg, which is a problem for most of the patients I see. They come in and they really can't stand on one leg because of pain, malalignment, or instability.
The single-leg squat gives me information about the entire chain — the foot, does the navicular drop, is the femur rotating in, is the pelvis dropping? That tells me there's some weakness in the hip and core. I'm looking at all of that, even if I'm treating their big toe.
[19:04] And then of course watching them walk, and taking into account what shoes they're wearing and like to wear. I don't want to push what I think they should wear, especially with kids — I'm going to try to fit what will help their function with what they like.
I'm also looking at function on both legs together, single leg — do they have full ankle and subtalar motion in a squat with good alignment, or do they have to turn their foot out to do that? Then hip range of motion, hip strength, hip stability — I check all the hip muscles and rotators.
[20:02] Then I go to the foot and ankle. And here's where, based on what my patients tell me, things are a little different from what they've experienced elsewhere. I assess heel motion first. The heel needs to evert 3 or 4 degrees. If somebody has had a lot of ankle sprains, they often lose that rear foot valgus, even in a flat-footed hypermobile foot. Then I come up the lateral side of the foot — the cuboid should move, and the 4th and 5th metatarsals should be more mobile than 2 and 3. I check each metatarsal; they should move like piano keys. A lot of times 2 and 3 are stuck together, so then 2 gets loaded too much.
Then I check the first ray — the big toe. The big toe is very important. Is it hypomobile, too stiff at the different joints, or is it hypermobile? It's possible to have one joint hypermobile and another hypomobile. Our big toe is big for a reason: it's about 60% bigger because we're supposed to push off the big toe, not our little toes.
[21:16] So that's where the posture and function of the foot comes in, and just putting our hands on the foot to feel — and I'm also kind of treating and explaining to the patient about their foot as I go. I might find these issues in a foot that's living in pronation and flat-footed, and I might find them in a higher arch foot. I'm checking each joint to see what's going on.
[21:49] Oh, and scoliosis — I'm going to look for scoliosis in kids.
Then we look at shoes. For example, a Hoka might be good for a stiff high-arch foot, but a Hoka could actually make a hypermobile excessively pronated foot worse. With knee hyperextension, it can make that worse because it's too soft. And it can also decrease proprioception if it's too soft for some people. So not everybody should be in a soft cushiony Hoka. It actually could make their proprioception worse and their knee hyperextension worse.

[22:29] Dr. Linda Bluestein: It's so interesting that you mentioned Hoka specifically because that's what I — I'm not wearing them right now. Right now I'm wearing my Oofos, which I just have to mention since we are recording video. I love these things. They have awesome arch support, they're nice and cushy. I have my indoor pairs and my outdoor pairs.

[22:47] Lisa Ralston, PT: Like a recovery sandal? Yes, love those.

[22:52] Dr. Linda Bluestein: But I do also wear Hokas, so I'm curious — what type of foot would benefit from a shoe like a Hoka?

[23:00] Lisa Ralston, PT: Hoka has different lines now, so I can't generalize across all of them. When they first came out, they were higher platform and cushier. They've changed, so now some are not as cushioned. So really, I would assess your foot. And your right and left foot could be different. But generally, Hokas are better for a stiffer foot — somebody who needs more shock absorption. Maybe a higher-arch stiff foot where the joints and ankle are stiff, and that gives you aid in mobility. That's the type of person — a "banana foot," as you say with the dancers — basically a high-arch supinated pes cavus foot. That's who I would be more likely to put in a Hoka.

[23:54] Dr. Linda Bluestein: You just used a lot of fantastic terms in that last sentence. Ballet dancers listening to this, or dance medicine physical therapists, are going to know what you mean by a banana foot. I know what you mean, but can you distill that down for other people? Because I feel like that was really important.

[24:17] Lisa Ralston, PT: A foot that has the innate structure of a high arch where the big toe can point down — you can make like a dome with your foot and it points easily — and the calf tends to be very tight. That would be basically a high-arch stiff foot, versus somebody who's very flat-footed. If you step in the sand or in water, the banana foot is going to leave a huge space between the heel and toes where you can see the arch clearly.
[24:50] And often the higher-arch supinated foot will have more motion in forefoot valgus, and the toe extensors work harder.
[25:37] I do have — it seems like 1 out of every 10 patients — a foot that is more pronated on one side and stiff on the other. They have one of each. That's where orthotics can fail, because a lot of labs will make both feet kind of similar, whereas some labs could make them very different based on flexibility of the shell and contact with the foot. I don't know that it would be more common in the EDS population specifically, although maybe that would be another good study.

[25:46] Dr. Linda Bluestein: That would be a fascinating study. I honestly had not heard that before — that the right and left foot can be that different. And for people listening to this, Lisa is doing a lot of different motions with her hands, which is great. I would really encourage people to also watch this on YouTube so they can see the different things being demonstrated. I know you're going to show some orthotics later as well.

[26:14] Lisa Ralston, PT: Oh, and I was going to say — with scoliosis, we might tend to see a different right and left foot because as the pelvis or spine side-bends and rotates, one foot drops down and one foot lifts up. So scoliosis is another reason I would need to do a very different right and left foot orthotic, to help create better posture.

[26:36] Dr. Linda Bluestein: That makes sense. And one other thing we had talked about regarding shoes — high tops, or I think you also call them 3/4 top. Could you explain a little about that and what you suggest?

[26:50] Lisa Ralston, PT: Sure. If somebody has a really hypermobile foot — let's say they've had multiple ankle sprains and there's some instability and they're like, well, I don't really want surgery — and we know there's ligament damage and inherent instability in that foot and ankle, and we're trying strengthening, but a lot of the time braces are too thick and cumbersome. So I think with an orthotic, I would do a deeper heel cup and more contact. And then in a high-top shoe, it just gives a little more external stability and feedback for postural alignment and support.
[27:34] The other thing — a lot of newer shoes now, if you squeeze the back above the heel — that's called the heel counter. If you take your tennis shoe above the heel and squeeze the back, it should be nice and firm. This is a regular low-cut shoe. If you're wearing a 3/4 or high top, you usually don't have to worry about this as much. But in a tennis shoe or a regular casual shoe, if the heel counter is not firm, you're going to have less control with side-to-side instability.
[28:09] The other thing is look for a nice wide base at the bottom, which can give a little more stability. Years ago some Nikes were very narrow there, and I treated a lot of lateral sprains because of that. So a firm heel counter, a little bit wider at the bottom.
And here's another important point: not all shoes are made at the same factory. So if I have my Brooks and I go buy what says the same model at a discount store, it's made at a different factory. The foam can be different, the footbed is different. You can go find a Saucony or Brooks and see — a good shoe should just bend where the toe box is, right at the toe break, easily. But a lot of those discount-store versions you can bend in half like a pretzel.
[29:19] There's a whole trend now in the orthopedic and sports medicine world in the opposite direction — that we wear shoes with too much support, and that's why we're weaker. I'd say this is different in the EDS population. For a patient who has some instability or hypermobility, I do want a midsole that gives support and is not bending the shoe in half. Some orthopedic sports medicine providers have the theory that we just need to strengthen and that's it — well, for some populations that's true, but not for all our patients.
[29:59] Those are things I look for, and I check my patients' shoes and give them suggestions when they go shopping. Because even though it says the same brand name, it can be made at a different factory. And also, the right and left shoe of the same pair can even be made at different factories.

Dr. Linda Bluestein: Wait — really?

[30:15] Lisa Ralston, PT: Yes, really.

[30:18] Dr. Linda Bluestein: So if you buy your shoes from a regular store — like, there's one in Green Bay that I can't remember the name of, but it was amazing, all these incredible comfort brand shoes — if you go to a store like that, do you think you're more likely to have the right and left shoe made at the same factory?

[30:40] Lisa Ralston, PT: It's more about whether they're made for discount retail. Companies will have a line — just like a designer might have a line made for a discount store versus what they sell at Neiman Marcus. Shoes can be the same way. Running stores usually buy directly from New Balance or Brooks or whoever — they're buying direct and selling, and they're priced a little higher. But even on sale, I still test them with my hands: does it have a firm heel counter, where does it bend at the toe break, does it collapse in the midsole? For somebody who needs support and has hypermobility, I want that midsole to have solid support with some cushion.

[31:32] Dr. Linda Bluestein: Sure.

[31:33] Lisa Ralston, PT: And how we tie our shoes is important. That's another one.

[31:40] Dr. Linda Bluestein: You're blowing my mind right now.

[31:44] Lisa Ralston, PT: I'm sorry, all these things I didn't write down.

[31:47] Dr. Linda Bluestein: No, this is great.

[31:50] Lisa Ralston, PT: So treating kids, actually tying shoes becomes a thing.

[31:55] Dr. Linda Bluestein: Sure.

[31:56] Lisa Ralston, PT: Parents, here you go — shoes are tied for a reason, and we can use this. And this applies to skates, soccer shoes, cleats, hiking boots, anything. When we tie, we don't want to just pull to the outside — we want to pull that arch together. When I'm tying my shoe, I want to make sure I'm hugging my arch and not pulling out to the side. And there are a lot of kids now who never tie their shoes.

[32:39] Dr. Linda Bluestein: They just slide them on and off and ruin the heel part.

[32:42] Lisa Ralston, PT: Yes, exactly. In that situation, I'll approach the kid with whatever their goals are. If they're an athlete and they want to run, fine. But when they're doing conditioning and working with a trainer, they need to have appropriate support and tie their shoes. That simple little thing can make a difference for them.

[33:16] Dr. Linda Bluestein: Wow, that's really fascinating. And I'm curious to get your take on brands. I have a couple of dressier brands that I really love. One of them is Aetrex, spelled A-E-T-R-E-X. I love Aetrex. Vionic is also okay, but Aetrex is probably my favorite. Do you have any recommended brands for either bendy feet or just people with foot pain?

[33:40] Lisa Ralston, PT: For support? Yes. Obeo, Naot, Mephisto.

[33:43] Dr. Linda Bluestein: Oh yes, Naots are great.

[33:48] Lisa Ralston, PT: Yeah, I like Naot sandals. It kind of depends on the season because pre-March or April we're in sandals more. Vionic — I have used those, and the orthotics we'll talk about are actually made by Vasyli Vionic, although they've been sold and it's a different corporation now. So some of them don't have enough arch support in them anymore. But their slippers are good for around the house. And now there are so many more recovery shoes and slip-on shoes with arch support. Chaco is a good footbed sandal for a high arch. And Keens and Merrells are good.

[34:31] Dr. Linda Bluestein: Keens are nice and wide.

[34:37] Lisa Ralston, PT: Yeah, they have a good wide toe box. So Obeo, Aetrex — all of those are good options. And in our area I refer a lot of patients to a store that sells specialty shoes. A lot of them have a pedorthotist on site and they carry good supportive shoes. I'll try to give recommendations with their foot type and steer them in a direction to try.

[35:21] Dr. Linda Bluestein: Sure. Okay, great. And when you are finding and treating bendy feet — we talked about this briefly earlier, but if you could elaborate a bit more: are all bendy feet overpronated? Because of course that's something we see quite often — the rolling in. And does everyone have flat feet? Tell us more about that.

[35:46] Lisa Ralston, PT: No. I would say it's probably 75–80% flat feet, and then about 20–30% higher-arch stiff foot in the EDS population that I see. And then there's a small percentage that have one of each. In the general population, overpronation is probably around 95% — it tends to be more common anyway.
[36:16] In regards to treating kids and trying to catch things earlier: one of the things I tell parents is, if I see them around 8 or 9 years old, how they are orthopedically at that point — how flat-footed they are, for example — that's probably how they're going to be. So I'm pretty confident that starting a little bit of support around that age to create good alignment while they're developing and growing is appropriate. It's not correcting; we just want to support.
[37:05] And then some adults with EDS were more flexible and pronated as children, and then the arch can drop more after having kids, or just over time with injuries. Then you add other variables to a foot that was already maybe overpronated — a sprained ankle, which can cause stiffness, plantar fasciitis, pain under the big toe — and you start to avoid things, and then you're standing and loading in supination. So it can change. I don't see it as a static, specific diagnosis.

[37:53] Dr. Linda Bluestein: Sure, definitely. I think that's one thing that I — I went to a course specifically about working with dancers, and I don't know if you've heard of the physical therapist Lisa Howell, but I took a couple of courses from her and they were really fantastic. For anyone who does dance medicine, I'll link that in the show notes. But she said something that has really stuck with me: "The body is in a constant state of reformation."

Lisa Ralston, PT: Yes, exactly.

[38:16] Dr. Linda Bluestein: And that gives us hope, because it tells us we can also make choices that will help how our body is realigning and reformatting itself.

[38:35] Lisa Ralston, PT: Yeah, absolutely. I took a course around 2011–12 at the Harkness Center for Dance Medicine, and that was really good. But yes, we're all changing and evolving. Even our nervous system can affect some of that, or our vascular system. I just meet people where they're at, and that's what we work on to get them to a better place.

[39:15] Dr. Linda Bluestein: Yeah, for sure. Awesome. So I want to talk about people who have quote "failed PT." I hear that from a lot of patients. I talk to them about going to physical therapy — and I'm a lifer, by the way. I've been in and out of physical therapy since I was a teenager and it's like the best tool for me. But a lot of people say to me, "It doesn't work for me." So let's talk about when people say that — what are some things that maybe need to be done differently? Of course none of us were there, so we don't know for sure, but what are your thoughts? And then let's talk about orthotics maybe after that.

[40:00] Lisa Ralston, PT: Yeah, I think it does roll together because I get a lot of people who come and have tried different orthotics that didn't work, and we'll talk about why.
[40:09] I think what's different with the hypermobile population is looking at all systems — including sleep, anxiety, sleep apnea, GI issues, the nervous system. Making sure the vagal tone is okay. If our nervous system threshold is up here, nothing I'm going to do is going to help. And if I give that patient a bunch of exercises and deadlifts and squats while their nervous system is at that level, or their pain is a 7 or 8 out of 10, I'm not going to strengthen them. So I think that's one mistake we make as providers. Our healthcare system makes it difficult in a 20- or 30-minute visit to address all of this. Part of my job is to take all this overwhelmingness and narrow it down to 1 or 2 things that are going to help my patient function.
[41:21] One of the biggest mistakes we do as physical therapists is — and there's also a trend right now toward higher-level strengthening. If you look at physical therapy clinics, they look like a big gym with big weights and equipment.

[41:37] Dr. Linda Bluestein: Oh, really? Interesting.

[41:39] Lisa Ralston, PT: That's the trend. And strengthening is really important, but we have to have our nervous system aligned and able to accept that training and firing of muscles first. So go slow and low load. That's probably not the first time everyone's heard this, but that's where I might start somebody on the reformer, or we literally just line things up and practice standing with correct alignment from the foot up. We forget about the feet. When we're working on proprioception and balance in a double-legged mini squat, we need to maintain our arch and not grip with our toes so that we're actually using our core and our pelvic floor.
[42:20] And then being able to modify. My patients tell me — because I'll ask them — that I'm able to help them modify. So let's say their low back and pelvis are giving them a lot of pain, and I give them a muscle energy technique, or their hip is pinching and I do a very gentle technique. If they're not able to do it the traditional treatment way, I modify it so that they can do this self-treatment without pain. That's the key. We have to modify by position, by load — so that the patient is in a safe place with their body and their nervous system, and then they'll respond.

[43:22] Dr. Linda Bluestein: That makes sense. The nervous system is so important. And I think a lot of people don't realize that when your nervous system is really ramped up, your muscles get really tight. And a lot of the pain in our bodies comes from our muscles. We might have arthritis and different things going on, but a lot of the pain may be coming from the muscles — from trigger points and things like that — rather than from the joints. So getting that nervous system calmed down is key.

[43:53] Lisa Ralston, PT: Yes. Like one of my patients last week who has a lot of issues — EDS, and really severe neck and shoulders and arm pain that had flared up. They have degenerative neck issues, some instability, stenosis — all the stuff you might see on an MRI. But I watched her breathe. She was trying to breathe to calm her nervous system. She knew she needed to do that. But when I watched her, all these accessory muscles were doing all the breathing. So we just slowed it down and got her into a position where she could relax those muscles, and she said, "Oh" — and then the air could move and her diaphragm could work, and then her arm pain went away.
Sometimes it's pretty remarkable, and that's where I think therapy might fail because we're so busy. We're doing our notes, dealing with insurance authorizations — if insurance companies are listening, I have a few things to say.

[44:58] Dr. Linda Bluestein: Me too. Me too.

[45:02] Lisa Ralston, PT: That's one reason I got out of the clinic setting — I just want to take care of patients and not be focused on all that. When you have 3 patients in an hour and you've got to document, you can't slow down and get a patient into a quiet, safe place so their body can actually do what it needs to do. I didn't even touch that patient to get her arm pain to go away. I did a little bit afterwards, but the nervous system piece was everything.
[45:32] So yeah, even if I'm treating the foot or someone is sent to me for orthotics, it's never just about the foot or the knee. And I think that's the other way our health system fails us — in a doctor's office, if you bring up another issue or body part, you've got to make another appointment and another copay.

[45:57] Dr. Linda Bluestein: Right.

[45:58] Lisa Ralston, PT: So that's where physical therapists tend to get it all. Physical therapy will fail when we don't meet the patient where they're at, help them get that pain down, get the nervous system down, address postural alignment, and help them feel safe to move. Because we can move no matter what state we're in, and we start to feel better when we feel okay to move.
[46:29] So I think finding a provider that you feel safe with — one who will push you a little when you're doing okay, and then knows when to back off and how to modify when you're not having a good day — is really key.

[46:42] Dr. Linda Bluestein: Yeah, I've definitely been to physical therapists who are really great at those modifications because I have various different problems, and others who are like, "Nope, this is the exercise." So I totally get what you're saying. And I think the same thing applies to my practice — it just takes a much longer period of time with the type of approach that I take. So it's probably a similar corollary.

[47:07] Lisa Ralston, PT: Yeah. And I refer out. So once I kind of see that a patient's pain is really driven by something else, I'm going to try to refer out. Or if the cardiovascular issue is really the big problem, I'm going to reach out to you or to Patty, or try to refer to the right place, so that patient can address those needs first. And I still give them a few things to help in the meantime — but acknowledging that it's not that they're crazy. It's just one thing we need to work on to get moving better.

[47:44] Dr. Linda Bluestein: Yeah, definitely. And tell us about orthotics and how some people have failed orthotics. I hear that too — "I tried that, it didn't work."

[47:55] Lisa Ralston, PT: So I've done custom orthotics for — I've been practicing 33 years, I think I've done orthotics for maybe 25 or 30 of those — using different labs and different types and different materials.
[48:09] A lot of orthotics fail because they're too hard. There are different materials, and there's also how we assess and decide on the orthotic, and then how the lab makes it. One reason they fail is that we need to assess and feel whether the foot and joints are hypermobile, stiff, or a combination — and what kind of support that foot needs to facilitate good posture. So I think the mistake is when a provider just looks at a foot, takes a cast, hands over an orthotic, and isn't looking at posture or flexibility in the foot.
[49:13] It also depends on what activities we're doing. If I have a runner, there's not a lot of heel contact. And yet, amazingly, corrections on the heel are still commonly prescribed for runners. Athletes like skaters or ballet dancers are not on their heels at all, so heel-based corrections fail for that reason as well.
Orthotics also fail based on materials — whether you choose shock absorption versus enough support to create good alignment. And the third thing is the way the lab makes the orthotic. Some people get casted in standing — you stand in a foam box. Well, if you're flat-footed and your navicular or arch is on the ground when standing, that's probably not the right casting technique for that patient. If you have a stable neutral foot and you stand there, it's probably okay — it's going to meet your foot. But for the hypermobile flat foot, that's a problem.
[50:14] The lab I've used for the last 23 years does total contact orthotics, which is different, and there's no correction. It's a partial weight-bearing cast with the joints in neutral. And then my job is to assess the flexibility in the foot. The podiatrist-engineer who created this system calls it a Gibb test, and I assess the rear foot, the midfoot, and give a foot flexibility assessment. The lab then calibrates for body weight, foot flexibility, and activity level and velocity. So if I have a skater versus someone who is just walking, I'm going to do something different because the load is different.
[51:02] With total contact, when your foot comes off the ground, the orthotic stays right with you. With traditional custom orthotics, you'll often see a gap under the arch. You can test this: if you have custom orthotics, sit down, place the orthotic under your foot, lift your heel up while keeping the orthotic under your foot, and see if there's a gap under your arch. If there's a big gap and then you load it in mid-stance while walking, it hits the orthotic abruptly — a lot of people find it doesn't help because of those forces. But if the orthotic stays with you, it maintains posture throughout gait, which is our goal. I don't want to correct; I just want to facilitate alignment and posture.
I also have semi-custom options. The Vionic or Vasyli line — these are the same company, out of Australia. There's one specifically for a high-arch supinated foot, and we can talk about specifics of that.
So many patients come to me with previously failed orthotics, and it's because the flexibility and hypermobility and stiffness of the foot wasn't addressed — they just took a mold, and right versus left wasn't addressed.
[52:45] Depending on foot flexibility, if the foot is really stiff, it can take a little longer to get used to the orthotic. Kids just adapt right away, unless they have some tactile sensitivities — and we don't want anything bugging them that way. So yeah, the difference is facilitating good posture and alignment, taking into account the foot's flexibility, and then putting the orthotics on and watching alignment in single-leg and double-leg stance and during walking.

[53:30] Dr. Linda Bluestein: That makes sense. And are there situations — cost being probably one of them — in which people might purchase something over-the-counter?

[53:32] Lisa Ralston, PT: Yes. And I want to add one more point about failed orthotics first. Besides the orthotic itself and the casting technique, what's really important is that the foot be functioning. If I have a tight Achilles or tight gastrocnemius, it can pull my heel in a certain direction. So if I just stick an orthotic in there without addressing the ankle bend, the tight Achilles, the movement of the metatarsals, that orthotic can fail because the body is not ready for that support.
It's like a knee brace — if we're trying to support knee hyperextension but we don't address tight hip flexors or the position of the knee, that brace is not going to help. So I think the assessment and the function and movement of the foot and lower leg need to be addressed so that the orthotic can actually support them. That's why so many fail. While we're waiting for the orthotic, we're doing foot mobility exercises with balls, getting the metatarsals to move, getting the cuboid to move, the heel to rock, massaging soft tissues — getting all of that ready for the orthotic.
So for over-the-counter options — if you know your foot is really flat-footed and flexible, the more support the better. You're going to want a nice deep heel cup. A good brand might be Sole or Vasyli. The Vasyli used to only be issued through providers, but now patients can go online. The blue Vasyli is about $45 to $55. You can find it on Rehab stores, Amazon. For average pronation, I would recommend the blue Vasyli. If it's a high-arch supinated foot, there's one called the Hoke — named after physical therapist Brian Hoke, H-O-K-E — and it has a deeper heel cup made for a supinated foot. If your Achilles is really tight, there's a little heel lift as well.
This brand also makes something called Easy Fit, which has a little heel cup and cutouts. I use that a lot for kids — it has a really nice arch and they can stick it in little Converse and different shoes. I've used them in cheer shoes too. The Vasyli Easy Fit you can just order and stick in different shoes. Super easy and inexpensive.
Sole has a website where you can answer questions about whether you're more of a supinator or pronator, and they help you decide which orthotic. I don't make money off any of these products — disclaimer.

[57:54] Dr. Linda Bluestein: Neither do I.

Lisa Ralston, PT: Then there's Superfeet — for kids, or for something a bit milder. They give a little pronation control. They make some for skates too. They have kid sizes.
[58:11] And the custom ones — I don't know if you want to know what I charge?

[58:24] Dr. Linda Bluestein: Sure. Yeah, it'd be great to know.

[58:26] Lisa Ralston, PT: For evaluation, follow-up visit, and one pair of orthotics, it's $425. You don't pay for an extra visit for the follow-up — that's included. So the first visit usually includes evaluating, treating while I'm talking, casting, one pair of orthotics, and your follow-up visit. Then I usually give some things to work on at home and follow up by phone or email as needed.
[58:55] You can go on the Sole Supports website and look for providers in your state or area. I would still recommend finding a provider who's good with treating feet — someone who will put their hands on you and assess the foot. I get it, there aren't as many as there should be. But whether it's a therapist or another kind of provider, someone who can address the foot, move the foot, and treat it. And there are a lot of videos now with self-treatment of feet.

[59:51] Dr. Linda Bluestein: What if a person comes to see you and does the evaluation and everything, but they want a second pair of orthotics — how does that work?

[59:58] Lisa Ralston, PT: I do not charge any extra for that visit. If they're doing well and want a second pair — maybe for a dress shoe that's more narrow, for a skate, or for a soccer shoe — the second pair is $195, and they do not have to come in. I can just order it and trim it to fit their shoe.
[1:00:32] Some people, if they have a lot of extra mobility in their forefoot, I add something called a sesamoid balance pad, and that can make a big difference, especially if the toes are overworking trying to balance. With proprioception, it just aligns that posture from the rotation of the foot, or I might need to add a metatarsal pad if there's one very painful metatarsal, or if somebody has a Morton's neuroma — burning and pain in between the toes. You can order these pads online to add under your shoe insert to unload those metatarsals and relieve that nerve pain.

[1:01:23] Dr. Linda Bluestein: I have a lot of people who have had problems with their sesamoids, so I'm fascinated about how you might adapt the orthotic for that.

[1:01:34] Lisa Ralston, PT: Sometimes I use a dancer pad. There's also a sesamoid balance pad made by a company called Human Locomotion — that's the website, humanlocomotion.com, you can check it out. A dancer pad I put underneath the big toe and across the metatarsals, and it unloads those sesamoids — it gives more support so it catches some of that load and decelerates it before those sesamoids hit the ground. I've used that a lot with dancers and skaters. The sesamoid balance pad I use when there's significant hypermobility with forefoot rotation — it tends to work better in that case. It positions like this: here's your foot, big toe here, and it sits under the fifth metatarsal side.
[1:02:31] So if you go to Human Locomotion, you can see that online.

[1:02:37] Dr. Linda Bluestein: Excellent. And again, I definitely encourage people to watch the YouTube video if they can, because there are great visuals there. In terms of over-the-counter orthotics — is it best if people can go to a store so they can choose from a few varieties and get their hands on them?

[1:02:58] Lisa Ralston, PT: Yeah. Running shoe stores carry a lot more now and their staff are more knowledgeable. A lot of them carry Superfeet, Sole, some Vasyli, and even Birkenstock makes some cork footbeds that are pretty nice. The shoe store person doesn't necessarily know your foot type, so they don't always know what to recommend. But if you know you have a flat foot, the companies will generally guide you. I would say look for a nice heel cup — that's probably one of the first things I would check for hypermobile patients.

[1:03:47] Dr. Linda Bluestein: Okay. As we're getting close to the end here, can you talk a little about self-mobilization of feet? I think that's something you mentioned.

[1:03:56] Lisa Ralston, PT: Oh yes. We all get so stiff in our metatarsals with pain or whatever. So I'll take a little kitty ball — like a small firm rubber ball, like a cat toy — and if you're seated, you place that ball under your foot under the metatarsals and gently press down to mobilize. You can move that ball back by the cuboid, under the lateral side of the foot, in front of the heel, and use the ball to mobilize the joints up and down. You can also use it to massage the plantar fascia. You can put your heel on a ball and rock the heel to get mobility that way. And you can use the ball to stretch by placing your toes on the ball and spreading your toes to create space around it.
There are some really nice foot mobility exercises. And even with EDS, what I find is that we work a lot on mobility because there are areas that are painful and stiff.

[1:05:00] Dr. Linda Bluestein: Yeah.

[1:05:04] Lisa Ralston, PT: Addressing those stiff, painful areas is really helpful.

[1:05:09] Dr. Linda Bluestein: What's that ball called again?

[1:05:12] Lisa Ralston, PT: It could be a little kitty ball — like the ones cats play with, a little firm rubber ball. Not a marble, that's too painful, but just a small bouncy ball, something that has a little bit of give. Usually about a quarter-size or a little bigger so you can get each joint separately. Then there's a slightly bigger ball where you spread your toes around it. You can get inexpensive balls on Amazon, Target, or any department store. Anything that spreads and moves those bones in your feet can be really helpful.
[1:05:52] And then after you mobilize, the next step is to work on stability and proprioception. Once the foot can move, it's important to know your foot's tripod — your heel, your big toe, and your little toe. And I'm going to work on proprioception and balance while maintaining my arch with that tripod under my foot. After mobilizing, I want to work on some proprioception and balance in the correct alignment and posture of my foot — meaning arch up, not rocking out to the side, not collapsing in, trying to maintain neutral — without clenching my toes, and while using my core. All those good things together.

[1:06:45] Dr. Linda Bluestein: All those good things. We know that you work a lot with ice skaters, and I just wanted to mention — if people are listening and would like to hear an episode specifically about hypermobile ice skaters, please send me an email or a voicemail on my website, or make a comment on one of the posts about this episode. That's something we've thought about doing — an episode about hypermobility in ice skaters — and it would be great to have Lisa back to talk about that.
[1:07:17] So you talked a lot about other factors that can influence foot pain and foot stability, like stability in the pelvis. Are there other things you do to address that?

[1:07:27] Lisa Ralston, PT: Yes. During my assessment, when I have somebody stand and do a single-leg squat, I'm looking at the arch — is it collapsing? The alignment of the leg, the pelvis, and how much pain they're having. If they're having a lot of pain and looking really unstable, I'll often have them try an SI belt. SI-Lok is one brand, or Serola. We put on the belt and retest the single-leg balance or single-leg squat. If they're more stable and it lessens their pain, then that becomes a tool we use for external support to aid in better posture and improve function. And at the same time, I'm looking at what the foot is doing. So maybe I don't need as much foot support if they're able to stabilize better with the pelvis supported.

[1:08:17] Dr. Linda Bluestein: And do you use any of the Bauerfeind products for that?

[1:08:24] Lisa Ralston, PT: I tend to use the SI-Lok or Serola. Serola is a little smaller. The SI-Lok helps with a little more stability, and it's pretty remarkable. Patients just go, "Wow" — they can stand on one leg more easily, it's easier to go from sit to stand, they have less hip pain or back pain. You know pretty immediately whether it's going to help or not. And I take that into account with what we're doing with the feet — maybe we don't need as much postural support at the feet if we have good postural support at the pelvis, which can also help the neck.

[1:08:55] Dr. Linda Bluestein: It's all connected. That's the bottom line. Okay, last question before the wrap-up — do you have any favorite hypermobility hacks?

[1:09:12] Lisa Ralston, PT: I have quite a few, but let's go to a foot one. Especially in a higher-arch, dome-type foot, people complain of numbness, particularly when walking or in certain shoes. And it's very simple — you can just change the lacing so that you skip a hole where the nerve is close to the skin. The nerve on the top of the foot sits right near the surface. What I do is crisscross below that bump, skip a hole, and crisscross above it. That creates a space for that nerve and you don't get the numbness on top.

[1:09:50] Dr. Linda Bluestein: Oh, that's brilliant.

[1:09:54] Lisa Ralston, PT: I've had quite a few patients who have gone to all these providers and I just change the lacing and they go hiking and come back and say, "That worked."

[1:10:04] Dr. Linda Bluestein: That's incredible.

[1:10:04] Lisa Ralston, PT: That's an easy one.

[1:10:07] Dr. Linda Bluestein: I love little hacks like that. That's amazing. Okay, so just to recap — you basically skip a hole. Can you show us with the shoe?

[1:10:17] Lisa Ralston, PT: Yeah. So if I have a prominent bump right here and I'm getting numbness in my toes and foot, I would skip this cross. So you put the shoe on, feel where the bump on top of your foot is where it's kind of tender, then unlace and skip a hole, crossing above and below that bump. You're unloading the spot right there because a lot of shoes have this lace strap that pushes down right on the top of the foot, and that can aggravate it. It just depends on where the bump in your foot is — usually right where that lace crosses. So if we just cross below and above, we unload that lace from pushing on the nerve at the top of the foot.

[1:11:11] Dr. Linda Bluestein: Fantastic. I love that one. Okay, where can people find more about you online?

[1:11:18] Lisa Ralston, PT: I no longer have a website because I'm working part-time this past year. You can find me at lisaralstonpt.janeapp.com — it's a scheduling platform. I can also be emailed at [email protected]. Those are probably the two best ways.

[1:11:43] Dr. Linda Bluestein: Okay, great. We'll make sure to have that information in the show notes. Well, Lisa, thank you so very much for coming on the Bendy Bodies with the Hypermobility MD podcast today. This has been so incredibly informative. I know so many people are impacted by foot problems, so they're going to really enjoy all of the pearls of wisdom that you shared. Thank you so much.

[1:12:09] Lisa Ralston, PT: Well, thank you for asking me. It was fun. I love talking about feet, obviously. I was worried I wasn't going to have enough to say.

[1:12:16] Dr. Linda Bluestein: I don't think we ran into that problem.

[1:12:22] Lisa Ralston, PT: Okay, good.

[1:12:23] Dr. Linda Bluestein: Well, thank you so very much again, and I will see you soon.

[1:12:27] Lisa Ralston, PT: Thank you. And thanks for all you do for all the patients and all the work and time that you put into this. It's just amazing.

[1:12:34] Dr. Linda Bluestein: You're very welcome. You're very welcome.

[1:12:36] Lisa Ralston, PT: Have a great day.

[1:12:40] Dr. Linda Bluestein: Thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. Visit our new website at bendybodiespodcast.com where you can now view guest profiles and show notes with links to products and journal articles. Leave me a comment, sign up for updates, leave a review or a voicemail, and access the podcast on your favorite player, all directly from our website. You may hear your voicemail in a future episode where we answer your question or dive into your gracious feedback. Follow us on Instagram at @bendy_buddies. We love seeing your posts and stories, so be a buddy and engage our community by using the hashtag BendyBuddy — that's hashtag B-E-N-D-Y-B-U-D-D-Y. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, Twitter, or LinkedIn at HypermobilityMD. Visit hypermobilitymd.com for information about medical services and one-on-one coaching. 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. Do not disregard or delay obtaining medical advice for any medical condition you have. Opinions shared are that of the guest and do not necessarily represent the views of the host or any particular organization. Sponsorship of the podcast does not necessarily mean an endorsement. Thank you for being a part of our community, and we'll catch you next time on the Bendy Bodies Podcast.