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

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Linda Bluestein, MD (00:19.985)

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 to the very end and you won't miss any of our special hypermobility hacks. As always, this information is for educational purposes only, and it's not a substitute for personalized medical advice today. I am so excited to have Lisa Ralston with me.

Lisa Ralston (00:21.718)

Thank you, everybody.

Linda Bluestein, MD (00:44.337)

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 Ralston (00:48.862)

then divided into four sections. And she graduated from Cal State one, then she got into the United States and produced the most important system in the United States.

specializes in treating LPC, Lapsic, Complicative and Fissure disorders to live the day to day as a whole person. In 2019, she has developed an infection-free medication, USA SDS, and world-level figure skaters. This was the physical therapy and two-day figure skating for the 2022 Richard Lippinc Foundation. This is the honor and founder of Walton Physical Therapy and Wellness Center, Colorado.

Linda Bluestein, MD (01:13.201)

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 has also licensed in California and offers virtual services. Lisa, hello, and thank you so much for coming on to Bendy Bodies.

Lisa Ralston (01:33.157)

Hi Dr. Linda, so excited to be here.

Linda Bluestein, MD (01:36.217)

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.

Lisa Ralston (01:42.71)

to watch this video. You're sitting in the front, Colorado, such a great place to be. I'm going to get my food. And there's more.

Lisa Ralston (01:51.494)

Yes.

Linda Bluestein, MD (02:05.697)

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?

Lisa Ralston (02:22.098)

Yes, absolutely. First, I want to also admit this is my first podcast. So, 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

Linda Bluestein, MD (02:33.58)

Mm.

Linda Bluestein, MD (02:40.813)

Mmm.

Lisa Ralston (02:48.982)

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 can have stiff areas, which we're gonna 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.

Linda Bluestein, MD (03:28.389)

That makes sense that I don't know that a lot of us think about posture as it relates to our feet.

Lisa Ralston (03:35.407)

Right. It's our foundation. And I think that also our patients and us, you know, we're seeing so many providers and there's so many important things, right, that we're dealing with GI issues and, you know, POTS and dysautonomia and headaches and cervical instability that the feet are sort of like, oh, we'll get there. You know? And so I think...

Linda Bluestein, MD (03:37.573)

Sure.

Linda Bluestein, MD (03:58.278)

Yeah.

Lisa Ralston (04:02.85)

Some of it is, it's just sort of a thing we don't get to because there's 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 to even help all those other things that we're trying to manage. That's so overwhelming.

Linda Bluestein, MD (04:21.541)

And I'm so glad you pointed that out because...

Excuse me. I'm gonna say the word mistakes. I don't forget to take this out. Not that we can't be on camera drinking water, but. So I'm so glad that you pointed that out because I think oftentimes we, 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. So cervical instability.

Lisa Ralston (04:27.644)

I don't know if that's the other word that's used.

Lisa Ralston (04:45.695)

that we're not. Right. And we don't realize that there are other things that could be.

Mm hmm. Could actually improve by working on a feed rate. Yeah. You wanna catch all the low-end food. Yes. Definitely don't wanna miss a relatively easy convention. Yeah. Like robotics and interest. I'm not saying that interest is easy, but you don't wanna miss.

Linda Bluestein, MD (04:52.265)

could actually be improved by working on our feet, right? And we wanna catch all the low-hanging fruit. We definitely don't wanna miss a relatively easy intervention like orthotics and addressing, I'm not saying that addressing feet pain is easy, but we don't wanna miss those lower risk type things.

Lisa Ralston (05:14.158)

Yeah, yeah, no, there are some very simple things we can do that help right away, that help us be able to stand longer, walk longer. Like one of my patients last week who is really cervical instability and has already had surgery for Chiari and severe headaches and just extreme fatigue and pain by some other things we did on the look with the low hanging fruit, pelvis and feet.

Linda Bluestein, MD (05:40.305)

Mm-hmm.

Lisa Ralston (05:40.63)

She was able, she's like, I was doing the dishes at eight o'clock last night. I'm so amazed. And so we were focused on the pain, but it was really the posture, the fatigue that was helped so much. And she, and then her brain was like, oh, I could do that. And so, you know, 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. So.

Linda Bluestein, MD (05:46.009)

Wow.

Linda Bluestein, MD (05:53.289)

Mm-hmm.

Linda Bluestein, MD (05:56.686)

Right.

Linda Bluestein, MD (06:07.545)

Mm-hmm. And it's all about function at the end of the day, right? We're addressing things that we can modify to improve function. So that's great. Fantastic. Can you run us through some common causes of foot pain in people that have joint hypermobility?

Lisa Ralston (06:12.374)

Yeah.

Lisa Ralston (06:17.386)

Yeah.

Lisa Ralston (06:27.554)

Yes, so as we talked about posture is number one and alignment so Alignment of the whole body is really important and when we have malalignment Anywhere up the chain from we could start with the feet or we could start with pelvis and knee hyperextension Femoral internal rotation You know

any kind of malalignment will set that posture off and contribute to increased load or things that cause pain. So and of course, we'll talk of excess pronation. So our foot, basically our foot has two jobs. So it is a little simple even though there's multiple joints and tissues. Our foot pronates to adapt to the ground and our foot needs to supinate.

Linda Bluestein, MD (07:11.055)

Hmm.

Lisa Ralston (07:24.686)

come back into supination where the arch comes up to push, to be stable, to push off the ground, to propel forward. And so, if, and 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. And so, that's one of my approaches, is even if we have too much pronation, or we're living there, or it's too fast, that's what we want to address, that function of pronation.

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, then we can address that. So I'd say those are the three most common, posture and alignment, excessive pronation, excessive supination. And also what I see probably more so with EDS is a hypermobile first ray. And I see very tight gastroc and soleus achilles.

Linda Bluestein, MD (08:18.13)

Mm.

Lisa Ralston (08:22.546)

And I don't know if there's 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 other directions. And so I think those can be causes.

Linda Bluestein, MD (08:22.578)

Mm.

Linda Bluestein, MD (08:27.293)

Heh.

Lisa Ralston (08:50.038)

posture and alignment, excessive pronation, excessive supination, a hypermobile first ray, meaning big toe where it actually looks like a high arch, but it's not, but that joint's hypermobile. Also, EDS patients tend to have more forefoot rotation. And so that's 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,

And I don't know why this is another research I'd want to see. It tends to be more the right foot in our dancers and skaters that are more hypermobile in the forefoot, forefoot varus or valgus and first ring. So there's some things that we can do to support that and not correct it, but just support it so that we can function better and be a little more stable. And then, of course, lack of proprioception, right?

Linda Bluestein, MD (09:23.822)

Interesting.

Lisa Ralston (09:46.238)

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. So I think all of those things. And then fatigue, right? So all the things that go with EDS, overall fatigue, pain contributes, even overall body pain contributes to foot pain, right? Because we have those days where you're just on the couch, you can't function, or you have a big setback.

Linda Bluestein, MD (10:10.097)

Right?

Lisa Ralston (10:15.606)

because we did too much. And then we're sort of immobile, and then we feel better, so we go do too much. Right? And so that contributes to pain as well. So.

Linda Bluestein, MD (10:28.165)

Yeah, definitely. I remember the first time that I heard the phrase pain begets pain, and I was dealing with my own EDS and

Lisa Ralston (10:36.522)

and that was really, I think it was well.

Linda Bluestein, MD (10:36.529)

really kind of like at a low point in my life at that point in time. So I've already finished my entire anesthesia residency and was, had been working for quite a while, but I was dealing with my own health issues. And when I heard that, I was like, 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,

Lisa Ralston (10:57.71)

Mm-hmm.

Linda Bluestein, MD (11:00.361)

they're more likely to get another pain problem. We do have lots of data to back this up. And so that's where it's to me 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. You know, and so we have such a huge responsibility in that we have a lot of young people that have pain. And sometimes there's that low hanging fruit there. So yeah, they need to see somebody

Lisa Ralston (11:19.332)

Yeah.

Lisa Ralston (11:24.952)

Yeah. Yes. Yeah.

Linda Bluestein, MD (11:30.361)

you know, sooner rather than later that can address the pain that they're having.

Lisa Ralston (11:36.654)

Two things I thought of with that is one, absolutely, and I think there's research, but if somebody's pain is more than a five or six out of 10, we know that neurologically muscles shut down so that we don't load. And 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. So it's not always that we're weak, it's just things sort of shut down. So if we get the pain down,

Linda Bluestein, MD (11:49.801)

Mmm.

Linda Bluestein, MD (11:59.552)

Mmm.

Lisa Ralston (12:04.718)

what could be with support with manual therapy, you know, whatever lots of different treatment modalities, we get the pain down muscles fire, help with support and alignment that function improves. And that's key, you know, for the nervous system and, and all that. The second thing is, you know, after in my clinic, I was seeing a lot more children with hyper mobility problems. And

issues. And so probably from age seven up, I was seeing kids. And when I 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. And it might even be scoliosis, right? Because there's a scoliosis, scoliotic hypermobility, and kids are not even checked for scoliosis a lot anymore, right? And so

But there's also there are biomechanists and doctors who will tell parents that we should not put kids in orthotics. And so there are two opposing philosophies. In fact, I was at a meeting last week and a mother with her 11, 12 year old and she 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.

Linda Bluestein, MD (13:15.187)

Yeah

Lisa Ralston (13:30.542)

and the doctor said, oh no, don't do orthotics, you know. And so it's still out there, that belief, and I'm not saying orthotics are appropriate for every child, however, it is so cool when you see a child who's so malaligned because of hypermobility or other reasons, it could be an injury, or it could be an illness, for example. My daughter had leukemia when she was four, and she's a bendy body, she's now 23.

But during treatment and the steroids, she was so floppy. And I actually, so this was 20 years ago, I made little custom orthotics for her. We put them on and she ran around the kitchen island. And so that's so cool when you see a kid, cause they don't, it doesn't like the tech, they're usually really good with it. Like their bodies will just respond. They don't have 40 years of other stuff.

Linda Bluestein, MD (14:03.517)

Hmm

Linda Bluestein, MD (14:12.857)

Really? Wow.

Linda Bluestein, MD (14:26.845)

Hahaha

Lisa Ralston (14:29.626)

Um, I, that's one of the things I've sort of got back to from selling my practices. Um, I do enjoy working with kids and helping them to develop and learn about their bodies and their awareness and, and what the pain means and how to manage it. And nervous systems and all of that stuff, hydration and recovery, you know, all of that stuff to help their bodies feel better so they can go to school and do what activities they want to do.

Linda Bluestein, MD (14:58.845)

Yeah, absolutely. That's what we want. We want kids to be able to be as normal, you know, active and enjoying life and going to school and everything. So that's really great. And thank you for sharing that story about your daughter because yeah, that is a great, great example. And in terms of how you approach hypermobile patients, how do you approach them differently than non-hypermobile ones?

Lisa Ralston (14:59.362)

Yeah, absolutely. That's what we want. We want kids to be able to be more mobile, you know, and faster.

Lisa Ralston (15:09.91)

That's what it is.

Lisa Ralston (15:24.574)

Well, I love it when my hypermobile patients provide a thorough history for me. So even if they're coming to me with hip pain, knee pain, or foot pain, like a lot of times referred from another therapist or doctor or other patients, and it's for foot pain. However, I'm still thinking of the entire person and systems, all systems. And so like Dr. Lin, you have a page available, I think, for

people to help fill out a history. So I love it when patients send me a page ahead of time. I also have an EDS form where they can sort of check off, are they having headaches? Are they having dysautonomia, POTS, GI issues, skin issues? There are other injury history, ankle sprains, surgeries, all of that, I wanna know all of that.

And then what's important is when they come to see me, it's what's important to them at that point in time, because last week might be totally different than today. And so at that visit, we're addressing, okay, where are we now? Because it can be so overwhelming, even though I'm just treating the foot. I know if we do a few things, we can feel better all over. And so I address the hypermobile.

mobile patient with their entire systems first. Then I start with, you know, what's important to them, what activities they wanna do, where they at. One of my patients right now can only walk maybe a quarter mile, and our goal is to get her walking a mile, and I have a couple of patients who have gotten now to two miles with some support, and I don't see patients several times a week anymore. I see them maybe once a month.

Linda Bluestein, MD (17:02.13)

Mm-hmm.

Linda Bluestein, MD (17:12.164)

Mm-hmm.

Lisa Ralston (17:12.862)

And so it's not an involved process. It's just, so then I really start, I look at posture, entire body mobility. I might take into account Beighton score, but that's not really my focus because hypermobile bodies get stiff areas. And as we age, we have changes in our joint mobility, right? So.

Linda Bluestein, MD (17:36.054)

Mm-hmm. Yeah.

Exactly.

Lisa Ralston (17:42.098)

I'm going to look at spine and pelvis is very important. And so I check mobility of spine, especially lumbosacral L5S1 is really important and pelvis and hip range of motion. So if somebody is not moving in their L5S1 and their sacrum, their hip range of motion might be limited, which can affect their foot during gait. And so I'm going to check range of motion and standing. I'm going to look at alignment.

Linda Bluestein, MD (17:52.009)

Hmm, interesting.

Lisa Ralston (18:10.254)

And I can get a lot of information. And then we do a squat, single leg squat. I can also see proprioception and alignment when we're on one leg, because when we're walking, we're on one leg, you know, 60% of the time, we need to be able to stabilize on one foot and one leg, which is a problem for most of people, that most patients I see. They come in, they really can't stand on one leg because of pain, because of malalignment, because of instability, for example.

So we'll do a single leg squat that gives me information. I'm looking at the entire chain, their foot, does the navicular, the mid arch drop, is the femur rotating in, is their pelvis dropping? That tells me there's some weakness in the hip and core. And so I'm looking at all of that, even if I'm treating their big toe. And then of course, watching walk.

and then taking into account what shoe wears they are in and they like to wear. I'm not gonna, I don't want to push what I think they should wear, especially kids, right? They're gonna, I'm gonna try to fit what will help their function with what they like. And so, you know, I'm thinking of that ahead of time. And I don't think everybody needs orthotics. We can talk about like how I decide, but so I'm looking at function, both legs together, single leg.

Do they have a bend in their ankle, their subtalar joint, full squat with good alignment, or do they have to turn their foot out to do that? And then we go to hip range of motion, hip strength, hip stability. So I'm checking all the hip muscles, rotators, checking. Then I go to the foot and ankle. And here's where maybe the difference is from what my patients tell me is.

I'd say just real quickly I assess heel motion. So the heel needs to move not just one direction, but even three or four degrees. And if somebody's had a lot of ankle sprains, often they lose that rear foot valgus, even in a flat footed hypermobile foot. So that's probably the first thing I check. Then I come up the lateral side of the foot, the cuboid should move, and then the fourth and fifth metatarsal should be more mobile than two and three.

Linda Bluestein, MD (20:14.607)

Hmm.

Lisa Ralston (20:31.042)

So I check each metatarsal, they should move like piano keys. A lot of times two and three are stuck together, so then two gets loaded too much. And then I'll check first ray, big toe. Big toe is very important. How is that big toe hypo mobile, too stiff at the different joints? Or is it hyper mobile, one joint and hypo another joint? So I wanna know the function of that big toe because our big toe is big for a reason, right?

Linda Bluestein, MD (20:31.657)

Mm.

Lisa Ralston (21:00.81)

it's 60% bigger because we're supposed to push off the big toe, not our little toes. And so that's where the posture and function of the foot and just putting our hands on the foot to feel. And I'm also kind of treating and I'm explaining to the patient what, you know, about their foot, you know. And I might find this in a foot that's living in pronation and flat footed, and I might find it in a higher arch foot.

Linda Bluestein, MD (21:06.885)

Mmm.

Lisa Ralston (21:29.618)

I'm checking each joint to see what's going on. And so I would say that's, oh, and scoliosis. I'm going to look for scoliosis in kids. And we're going to look at shoes. What shoes are they wearing, for example? Like a hoca might be good for a stiff high arched foot. But a hoca could actually make a hypermobile, excessively pronated foot worse with knee hyperextension.

making knee hyperextension worse because it's too soft and it can also decrease our proprioception if it's too soft for some people. So not everybody I would want to put in a soft cushiony hoca, it actually could make their proprioception worse and their knee hyperextension worse.

Linda Bluestein, MD (22:06.761)

Mmm.

Linda Bluestein, MD (22:19.117)

Interesting. It's so interesting that you mentioned Hokas 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 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. Yes, yes. Love those. Love those. But I do also wear Hokas So I'm curious which what type of foot

Lisa Ralston (22:23.468)

Yeah.

Lisa Ralston (22:27.674)

Oh, uh-huh. Those are good. Yes. It's like a recovery sandal, kind of. Yeah, awesome. Yes.

Linda Bluestein, MD (22:47.453)

would benefit from a shoe like a Hoka.

Lisa Ralston (22:50.562)

And you know, Hoka has different ones out now, so I can't say all Hoka's. When they first came out, they were higher platform cushier. I can't remember which line, and they've changed now. So they have some that are not as cushy. So it really, that's where I would assess your foot. And your right and left foot could be different, but I would assess your foot mobility. And generally, Hoka's are better for a stiffer foot, somebody who needs more shock absorption.

Linda Bluestein, MD (22:54.79)

Right.

Linda Bluestein, MD (23:02.345)

Sure.

Linda Bluestein, MD (23:12.144)

Mm.

Linda Bluestein, MD (23:19.487)

Mm.

Lisa Ralston (23:20.266)

right? So maybe a higher arch, stiffer foot, joints are stiff, ankle stiff, and that gives you that aid in mobility. And so that's when that's the type of person banana foot as you talk to with the dancers, you know, basically a high arch supinated pes cavus, but I would be more likely to put in a hoca.

Linda Bluestein, MD (23:37.287)

Yeah.

Linda Bluestein, MD (23:43.385)

So you just used a lot of fantastic words in that last sentence. So and of course ballet dancers that are listening to this or dance medicine, physical therapists are going to know what you mean by a banana foot. I know what you mean by a banana foot, but can you distill that down for other people just so they know? Because I feel like that was really important what you just said.

Lisa Ralston (23:45.302)

I just use a lot of the last few words. I did. And of course, I have a lot of ideas. So, yeah, that is that. I'm going to know what you think about that. I know what you think about that. But can you...

Lisa Ralston (24:07.822)

So a foot that has the innate structure that is a high arch and 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, would be basically a high arch stiff foot versus somebody who's very flat footed. So if you step in the sand or in water, you see a flat.

Linda Bluestein, MD (24:14.255)

Mm-hmm.

Linda Bluestein, MD (24:20.627)

Mm-hmm.

Mm-hmm.

Linda Bluestein, MD (24:28.219)

Okay.

Lisa Ralston (24:36.458)

the banana foot, if you have water and you're by the pool, you're gonna see a huge space between your heel and toes. Yeah, and often the higher arch foot supinated will have more motion in forefoot valgus and the toe extensors work harder.

Linda Bluestein, MD (24:41.989)

Mm-hmm.

Linda Bluestein, MD (24:55.174)

Mm-hmm.

Lisa Ralston (24:56.962)

So if somebody, and I have, it seems like one out of every 10 patients will actually have a foot that is more pronated and then a foot that is stiff.

Linda Bluestein, MD (25:09.093)

Mm. Right, right.

Lisa Ralston (25:09.962)

And so they have one of each. And that's where, as we get into some orthotics, orthotics can fail because a lot of labs will make both kind of similar, whereas some labs could make it very different based on flexibility of the shell, contact with the foot. Um, but I do have patients and, uh, I don't know that it would be more with the EDS population, although maybe. That would be another study for somebody.

Linda Bluestein, MD (25:21.11)

Mm-hmm.

Linda Bluestein, MD (25:27.802)

Mm-hmm.

Linda Bluestein, MD (25:38.617)

Yeah, that would be a fascinating study. I honestly had not heard that before that the right and left foot, you know, can be that different. And for people that are listening to this, Lisa's doing a lot of different motions with her hands, which is great. And I would really encourage people to also watch this on YouTube so that they can see, you know, the different things that you're showing. And I know you're going to show some orthotics later as well. Before we move on. Good. No, no, you're good.

Lisa Ralston (25:47.191)

Yeah, you have to put it.

Lisa Ralston (25:51.786)

I was really...

Lisa Ralston (26:03.99)

Yeah, oh, and I was going to say was sorry, but with scoliosis, no, 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, one foot lifts up. So I would say scoliosis is the other time I would need to do a very different right and left foot orthotic to create a better posture.

Linda Bluestein, MD (26:10.96)

Oh.

Linda Bluestein, MD (26:23.773)

Mm-hmm. Sure, sure. That makes sense. And one other thing that I know that we had talked about when we're talking about shoes, about high tops, or I think you also called them like three-fourths tops. Could you just explain a little bit about that and what you suggest?

Lisa Ralston (26:31.092)

is talking about the high top. Yes. Could you just explain a little bit?

Mm-hmm. So somebody has a really hypermobile foot. Let's say they've had multiple ankle springs and there's some instability and they're like, well, you know, I don't really want surgery. We know there's ligament damage. We know there's inherent instability in that foot and ankle. We're trying strengthening. A lot of times the braces are too thick and cumbersome, right? And so I think with an orthotic, I would do a deeper heel cup.

Linda Bluestein, MD (26:47.123)

Mm-hmm.

Lisa Ralston (27:07.61)

and more contact and then in a high top shoe it just gives a little more external stability and feedback for that postural alignment and support so that you can it can improve that posture and you know shoes the other thing with you know a lot of newer shoes now if you squeeze I should go grab or if you have your shoe there might can I go grab my Brooks so okay.

Linda Bluestein, MD (27:30.693)

You can? You ca- Yes, please.

Lisa Ralston (27:38.55)

Thank you.

Lisa Ralston (27:45.175)

So a lot of the teenagers I work with, they like really cute tennis and Nikes but a lot of them do not have a firm heel counter. So if you take your tennis shoe above the heel and you squeeze the back, it's nice and firm. And this is a regular low cut. So if you're wearing a three quarter or high top, usually you don't have to worry about this. But in a tennis shoe or a regular fun shoe.

Linda Bluestein, MD (27:54.441)

Mmm.

Linda Bluestein, MD (28:01.434)

Mm.

Lisa Ralston (28:11.134)

If the heel counter is not firm, you're going to have less control with instability side to side. The other thing is look at the nice kind of wide wedge, which can give a little more stability. Years ago when Nike came out, some of them were very narrow here. I treated a lot of lateral sprains because... And so firm heel counter can give some support. That's pretty basic.

Linda Bluestein, MD (28:23.273)

Mmm.

Linda Bluestein, MD (28:31.926)

Mm-hmm.

Lisa Ralston (28:38.514)

little bit wider at the bottom and then you know a good test if somebody's hypermobile and not all shoes are made at the same factory. So if I have my Brooks and I go buy it at a discount store it's made at a different factory for a discount store. The foam can be different, the footbeds different, so go into I won't name a name brand discount store but you can think of one and take go find a sock in your Brooks.

Linda Bluestein, MD (28:59.057)

Really?

Lisa Ralston (29:08.414)

And see, it should just bend where my toe breaks easily, right? But a lot of those shoes, you can bend in half in like a pretzel. And so, you know, there's two, in the orthopedic and sports medicine world, there's a whole like, you know, oh, our shoes, there's a whole sort of trend now in the opposite direction of we're wearing shoes with too much support, that's why we're weaker. So I'd say this is different in the EDS population. I...

Linda Bluestein, MD (29:11.974)

Mm-hmm.

Linda Bluestein, MD (29:15.313)

Hmm.

Linda Bluestein, MD (29:32.456)

Mm.

Lisa Ralston (29:36.554)

For a patient that has some instability or hypermobility, I do want a midsole that gives support that is not bending the shoe in half and flexing. And so some orthopedic sports medicine providers have the theory that well, we just need to strengthen and we need to do all this. Well, some populations, that's true, but not all our patients. So

Linda Bluestein, MD (29:43.089)

Mm-hmm.

Linda Bluestein, MD (30:00.091)

Mm-hmm.

Lisa Ralston (30:01.17)

Those are things I look for too, and I check my patient's shoes and give them suggestions when they go shopping because even though it says Saucony Brooks or whatever, it can be made and also the right and left foot can be made at a different factory.

Linda Bluestein, MD (30:15.944)

What?

Lisa Ralston (30:17.13)

Yes. Really? Yes.

Linda Bluestein, MD (30:18.821)

Really? So if you buy your shoes from a regular store, like a, say you go to a store where there's certain stores, there's one in Green Bay that I can't remember the name of, but it was amazing. I had all these like incredible comfort brand shoes. If you go to a store like that, do you think you're more likely to have the right and shoe, right and left shoe made at the same factory?

Lisa Ralston (30:42.742)

Well, it's more of the not made for discount. So companies will have a line, just like a designer might have a line that's made for a discount store versus what they sell at Neiman Marcus or whatever, for example, right? So shoes can be the same thing. And so I would just check it wherever, running stores usually buy directly from New Balance or Brooks or whatever, right? They're buying direct and selling.

Linda Bluestein, MD (30:46.736)

Okay.

Linda Bluestein, MD (30:54.533)

Mm-hmm.

Right.

Linda Bluestein, MD (31:08.392)

Right.

Lisa Ralston (31:12.298)

and they are priced a little higher. But even if you find, I still look for them on sale, but I test them with my hands. Does it have a firm heel counter? Where does it bend at the toe? Does it collapse midsole? And if it's somebody that needs support in hypermobility, I'm gonna want that midsole to have some good support with some cushion. And how we tie our shoes is important. There's another.

Linda Bluestein, MD (31:14.089)

Mm-hmm.

Linda Bluestein, MD (31:19.475)

Mm-hmm.

Linda Bluestein, MD (31:25.885)

Mm-hmm.

Linda Bluestein, MD (31:34.761)

Sure. Well.

Lisa Ralston (31:40.683)

So treating kids.

Linda Bluestein, MD (31:42.09)

You're blowing my mind right now, okay?

Lisa Ralston (31:46.01)

Oh my gosh, I'm sorry. All these things I didn't write down, right? No, right. So, you know, treating kids, actually tying shoes becomes a thing. So parents, here you go, I'm your advocate. Shoes are tied, you know, we have ties for a reason. And we can use this, and this applies to skates, soccer shoes, cleats, hiking boots, anything.

Linda Bluestein, MD (31:48.551)

No, don't, no, this is great.

Linda Bluestein, MD (31:57.625)

Uh huh, sure.

Linda Bluestein, MD (32:04.946)

Mm-hmm.

Lisa Ralston (32:14.678)

When we tie, we don't want to just pull to the outside. We want to sort of pull, we want to pull that arch together, right? So when I'm tying my shoe, I want to make sure that I'm, you know, pulling this way and not pulling out to the side. So I want to hug my arch. And there's a lot of kids that don't ever tie their shoes now.

Linda Bluestein, MD (32:23.529)

Mm.

Linda Bluestein, MD (32:34.694)

Mm, okay.

Okay.

Right. They just slide them on and off and ruin the heel part. Yeah.

Lisa Ralston (32:44.35)

Yes, yes, yes. So I, in that situation, I'll approach the kiddo with whatever their goals are. If they're an athlete and they want to run, I say, okay, fine, kick around, do that. But when you are doing like land, you know, conditioning and working with a trainer, you need to make sure you've got this appropriate support and tie your shoes.

Linda Bluestein, MD (33:08.26)

Haha

Lisa Ralston (33:10.294)

So I mean, treating kids, it's kind of, I mean, just that simple little thing can make a difference for them. But.

Linda Bluestein, MD (33:18.265)

Interesting. Wow, that's really fascinating. And I'm curious to get your take as we were talking about brands. I have some like a couple of dressier brands that I really love. One of them is Aetrex spelled A-E-T-R-E-X. I love Aetrex. Yep, I don't know how to pronounce that, right? Vionics 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 or... Yeah.

Lisa Ralston (33:32.674)

Yes, yes, yes. Yeah. Support. Abeo There's  Abeo and Naot too

Linda Bluestein, MD (33:51.031)

Oh yes, Naot that's a great.

Lisa Ralston (33:53.094)

Yeah, I like Naot sandals, you know, and so it kind of depends on season because you know pre-April, March we're in sandals more. Vionic I have used and I and the Orthotics we'll talk about are actually made by the Vasyli Vionic. Although they have sold, it's a different corporation now. So some of them are not, don't have as enough arch support in them.

But their slippers are good, like for around the house. But now there's so many more recovery shoes and slip-on shoes with our support. Chaco is a good footbed sandal for high arch. And that's a good one. And Keens and Merrells are good. Yeah, they have good forefoot. Yeah, yeah. So, yeah, I think all of those Abeo Aetrek Treks.

Linda Bluestein, MD (34:35.209)

Mmm. Keens are nice and wide. I love that.

Linda Bluestein, MD (34:47.645)

How do you spell, how do you spell O-B-O?

Lisa Ralston (34:47.658)

Neat, Mephisto.

I think it's OBEO. I have to look it up. I'm not sure. We'll have to look that up. So maybe a mistake. We'll check that.

Linda Bluestein, MD (34:53.261)

Okay, okay. I will. No, no, that's okay. I just want to make sure because I will have links to all of those in the show notes so people can find them more easily. Yeah, yeah.

Lisa Ralston (35:05.234)

Okay. And I would, you know, in our area, I refer a lot of our patients to a store that ship that sells specialty shoes. So this a lot of them have a pet orthotist on site and they carry good supportive shoes. I'll just try to give recommendations with their foot type and steer them in a direction to try.

Linda Bluestein, MD (35:15.099)

Mm.

Linda Bluestein, MD (35:19.741)

Mm-hmm.

Linda Bluestein, MD (35:25.253)

Mm-hmm.

Linda Bluestein, MD (35:28.797)

Sure, sure. Okay, great. And when you are finding and treating bendy feet, I know we talked about this briefly earlier, but if you could elaborate a little bit more about, do all bendy feet, are they all over pronated? Because of course that's something that we see quite often that the pronated, the rolling in, right? And does everyone have flat feet or tell us more about that?

Lisa Ralston (35:35.443)

I'm sure the internet is huge. I know it's a hedge fund, but it's a great place.

Lisa Ralston (35:47.502)

maybe people in the audience, right? And is it more half-foot, half-foot feet, or is it more about that? No, I would say it's probably 75%, 80% flat feet. And then I would say 20%, 30% higher arch stiff foot is what I see in the EDS population. And then there's a small percentage that have one of each.

Linda Bluestein, MD (35:59.994)

Mm-hmm.

Linda Bluestein, MD (36:05.539)

Mm-hmm.

Linda Bluestein, MD (36:10.865)

Mm-hmm.

Lisa Ralston (36:12.002)

So I'd say that's more common. And I think in the general population over pronation is probably 95%. You know, it tends to be more common anyway. And oh, I think in regards to that pronated or supinated with EDS, if we're looking at treating kids and trying to catch things earlier, one of the things I like and I tell parents, if I see them usually by around eight or nine years old, how they are orthopedically, meaning

Linda Bluestein, MD (36:21.374)

Mm-hmm.

Lisa Ralston (36:41.634)

how their legs and their feet are overpronated. If they're super flat-footed, their arches are on the ground. If they're like that at age nine, that's probably how they're gonna be. And so I'm pretty confident that if we start a little bit of support, we're not correcting, but we just wanna create good alignment for that child while they're developing and growing. I think it's okay around that age. That's a good time to sort of check that because

Linda Bluestein, MD (36:51.718)

Mmm.

Linda Bluestein, MD (37:02.596)

Mm-hmm.

Linda Bluestein, MD (37:09.041)

Mm-hmm.

Lisa Ralston (37:11.238)

As an adult, it's going to be more of that. And then some adults with EDS, they were more flexible as children, right? More pronated. And then either the arch can drop more, right? After having kids or just living, the arch can drop more or injuries. And so then you add on other variables to that foot that already was maybe over pronated or sprained ankle, which can then cause stiffness.

and so you avoid or plantar fasciitis so you avoid or pain under the big toe so you avoid and then you're standing and living in supination so it can change. I don't see it as like I don't know a specific like diagnosis sort of that makes sense.

Linda Bluestein, MD (37:38.291)

Mm-hmm.

Linda Bluestein, MD (37:41.745)

Yeah.

Linda Bluestein, MD (37:46.839)

Right.

Linda Bluestein, MD (37:57.949)

Mm-hmm. Sure, sure. Yeah, definitely I think that's one thing that I was, I went to a course that was 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, really fantastic for anyone that does dance medicine. I'll also link that in the show notes. But she said something that has really stuck with me. And she said, the body is in a constant state of reformation.

Lisa Ralston (38:17.323)

Awesome.

Lisa Ralston (38:24.974)

you can cut the space around the ocean. Mm-hmm. Yes. And then.

Linda Bluestein, MD (38:28.409)

sake. Yeah. And that gives us hope because that tells us we can also make choices that will help how our body is, you know, reformatting itself and realigning itself.

Lisa Ralston (38:40.947)

Yeah. Yeah, absolutely. I took, gosh, 2011-12, I went to the Harkness Center for Dance Medicine course years ago, and that was really good. I enjoyed that. So, but yeah, no, absolutely. We're all changing and evolving. And, you know, even our nervous system can affect some of that, or our vascular system.

Linda Bluestein, MD (38:52.445)

Oh! Mm-hmm.

Lisa Ralston (39:07.946)

You know, and so I just see people meet people where they're at. And that's where we're and that's where we're at that day. And that's what we work on to get them to a place that's better.

Linda Bluestein, MD (39:14.539)

Mm-hmm.

Linda Bluestein, MD (39:22.501)

Yeah, yeah, for sure. Awesome. So I want to talk about people who have quote failed PT. I've had a lot of patients say to me, you know, I talked 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 I have a lot of people who say to me, it doesn't work for me. So let's talk about when people say that.

Lisa Ralston (39:27.138)

So, I want to talk about people who have more mail than me. And yeah, that is the same thing. I talk to them about my physical therapy. I'm a lifer, I think. I think, you know, I control myself. I was a teenager. And I get like the fix about what I do. But I have a lot of physical therapy. So I want to talk about that.

Linda Bluestein, MD (39:51.121)

Like what are some things that maybe need to be done differently or that have happened in the past? Of course, none of us, you weren't there, I wasn't there, we don't know for sure, but like thoughts about that. And then and then let's talk about orthotics maybe after that, unless if that kind of rolls into this question. Yeah.

Lisa Ralston (39:52.816)

that they need to be done differently or.

Lisa Ralston (40:00.295)

Yeah, right.

Lisa Ralston (40:08.286)

Yeah, I think it does because I get a lot of people that come and they've tried different orthotics and they didn't work and we'll talk about why. Yeah, I mean I really, I mean my patients tell me because they've been to all the providers, so I think what's different is looking at all systems and it might be including sleep and anxiety, sleep apnea, GI issues, nervous system.

making sure vagus nerve is, you know, if our threshold of our nervous system is up here, nothing I'm going to do is going to help. And if I give that patient whose nervous system is up here, a bunch of exercises and deadlifts and squats, we're, I'm not going to strengthen or if my pain is a seven, eight, I'm not going to strengthen. So I think that's one mistake we make as providers is

Linda Bluestein, MD (40:58.857)

Mm-hmm.

Lisa Ralston (41:04.234)

And you know, you've talked about this, our healthcare system makes it difficult in a 20 minute visit or 30 minute to address all this. So part of my job is to sort of take all this overwhelmingly and narrow it down to one or two things that are gonna help us function, help my patient function. And so.

Linda Bluestein, MD (41:11.986)

Yeah.

Lisa Ralston (41:27.602)

I think one of the biggest mistakes we do as physical therapists is, and because there's also a trend towards higher level strengthening right now. So if you look at physical therapy clinics, they look like a big field, a gym, and big weights and equipment. Oh yeah, so that's the trend. And that strengthening is really important. Well, it is, but we have to have our nervous system and our system aligned and...

Linda Bluestein, MD (41:37.753)

Mm.

Linda Bluestein, MD (41:44.477)

Oh really? Interesting.

Lisa Ralston (41:56.358)

able to accept that training and firing of muscles. And so low load, probably not the first time everybody's heard this, but go slow and low load. And so that's where I might start somebody on the reformer or we literally just line things up and practice standing with correct alignment from our foot, our arch. We forget about the feet, right? So 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.

Linda Bluestein, MD (42:00.199)

Yeah.

Linda Bluestein, MD (42:08.undefined)

Yeah.

Linda Bluestein, MD (42:19.397)

Yeah, exactly.

Lisa Ralston (42:26.306)

so that we're using our core and our pelvic floor. And so I think, and then being able to modify. So my patients tell me, because I'll ask them, I just, I'm just with my patients. I don't really think about what I do. And they tell me that I'm able to help them modify. So let's say their low back and pelvis, they're having a lot of pain and I give them maybe a muscle energy technique or their hip is pinching.

I do a very gentle technique and if they're not able to do it the traditional treatment way, then I modify it so that they can do the self-treatment without pain. That's the key. We have to modify. We have to either modify by position, by load, by... So maybe, you know... And so it's modification so that patient is in a safe place with their body and their nervous system.

Linda Bluestein, MD (43:05.118)

Mm, right.

Lisa Ralston (43:24.778)

and then they'll respond.

Lisa Ralston (43:30.07)

I guess that's.

Linda Bluestein, MD (43:30.313)

That makes sense. The nervous system is so important. And I think a lot of people don't realize. And I think part of that too is when your nervous system is really, really jacked up, your muscles get really, 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 it's possible that the pain is coming a lot from the muscles and not as much from the joints.

Lisa Ralston (43:33.996)

Yeah.

Lisa Ralston (43:40.226)

really late jacked up. That will get really, really tight. And a lot of a baby's body comes in a puzzle. You might have a front end.

Linda Bluestein, MD (43:56.857)

and trigger points in the muscles and things like that. So getting that nervous system, yeah.

Lisa Ralston (43:58.643)

Yeah, yeah, like, yeah, like one of my patients last week that has a lot of issues, EDS, and just really neck and shoulders and arms flared up. And they have degenerative neck issues, some instability, stenosis, right, all that stuff that you might see on an MRI. But I watched her breathe. And when she was, she was trying to breathe to calm her nervous system, like she knew she needed to do that.

Linda Bluestein, MD (44:08.837)

Mm-hmm.

Linda Bluestein, MD (44:19.285)

Mm.

Linda Bluestein, MD (44:24.252)

Mm-hmm.

Lisa Ralston (44:24.322)

But when I watched her breathe, all these accessory muscles were doing all the breathing. And so we just slowed it down and we got into a position where she could relax these muscles and she was like, oh, and then the air and her diaphragm could move and then her arm pain went away. So sometimes it's pretty, you know, and that's where I think therapy might fail because we're so busy and we're trying to.

Linda Bluestein, MD (44:27.677)

Hmm. Yeah.

Linda Bluestein, MD (44:40.849)

Mm-hmm.

Lisa Ralston (44:53.014)

do our notes and deal with insurance authorizations and we're like, oh, you know. Sorry, insurance companies, if you're listening. Me too, me too. But that's one reason, I mean, I got out of my clinic because I just wanna take care of patients and not be focused on it. So I think when we get in a setting where there's three patients in that hour and.

Linda Bluestein, MD (44:56.199)

Yeah.

Yeah.

Linda Bluestein, MD (45:03.839)

Well, if they're listening, I have a few things to say. Ha ha ha.

Lisa Ralston (45:21.474)

You've got to document and I was able to just slow down and get this patient in a quiet, safe place so that they could actually get their body to do it and relax and get the pain to go away. I didn't even touch them. I did after I did a little bit, but so yeah, the nerve is even if I'm just training the foot or where the patient sent to me for a thought it's, it's never just about the knee, the foot, right?

Linda Bluestein, MD (45:35.145)

Mm-hmm. Right.

Linda Bluestein, MD (45:48.11)

Mm-hmm, right.

Lisa Ralston (45:49.618)

And I think that's the other way our health system fails because we have to, you know, in a doctor's office, you might see, oh, well, if you bring up another issue or body part, you've got to make another appointment and make another copay, right? So that's for physical therapists, we tend to get it all. So I think physical therapy will fail when we don't meet the patient where they're at.

Linda Bluestein, MD (46:03.545)

Right, right, yep.

Lisa Ralston (46:18.278)

and help them get that pain down, nervous system down, postural alignment, and for them to feel safe to move. Because we can move no matter what state we're in. And we start to feel better when we feel OK to move. And so I think finding your provider that you feel safe with that you know will maybe push you a little bit when you're doing OK and then knows when to back off and how to modify when you're at a place where it's not a good day.

Linda Bluestein, MD (46:30.343)

Mm-hmm.

Linda Bluestein, MD (46:34.098)

Yeah.

Linda Bluestein, MD (46:49.949)

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

Lisa Ralston (46:56.748)

Yep.

Lisa Ralston (47:00.626)

Mm-hmm. Yeah.

Lisa Ralston (47:14.598)

Yeah, yeah, and I refer out. So once I kind of see if I think, well, their pain is really due to some other things, I'm going to try to refer out, or if the cardiovascular issue is really the big problem. You know, I'm going to ask you or Patty, you know, I'm going to try to refer out so that patient can address those needs first, and still give them a few things to help with, you know, what we're working on. But acknowledging that, you know,

Linda Bluestein, MD (47:21.886)

Mm-hmm.

Linda Bluestein, MD (47:35.677)

Mm-hmm.

Lisa Ralston (47:45.502)

You know, they're not crazy, right? It's just, it's just one thing we need to work on to get moving better.

Linda Bluestein, MD (47:51.205)

Yeah, yeah, definitely. And tell us about orthotics and how some people have failed orthotics. You know, I hear that too. I know I tried that it didn't work. Yeah.

Lisa Ralston (47:58.414)

Yeah, yes, yeah. So I've done our custom orthotics for, let's see, I've been practicing 33 years. I think I've done orthotics for, I don't know, maybe 25-30 years. And using different labs and different types and different materials in the old days, and a lot of orthotics failed because they're too hard. So there's different materials. And there's also how

Linda Bluestein, MD (48:20.57)

Mm.

Lisa Ralston (48:24.798)

we assess and decide the orthotic, and then there's also how the lab makes the orthotic, right? So when I'm, one, not everybody needs an orthotic, but the one reason they fail is because we need to assess and feel is the foot and joints hypermobile, or is it stiff, or is it a combination, and what kind of support does that foot need to facilitate good posture?

Linda Bluestein, MD (48:29.584)

Mm.

Linda Bluestein, MD (48:36.177)

Yeah.

Lisa Ralston (48:54.146)

So I think that's the mistake is if we go to a provider that just like looks at a foot, cast, gives an orthotic, and they're not looking at posture or flexibility in the foot, they're going to fail. And if we just put like a correction on the bottom or whatever, and we don't address the body's posture and the forces, they're going to fail. And it also depends on what activities we're doing.

So if I have a runner, there's not a lot of heel contact. It's crazy, but this is still done all the time. We don't need corrections on the heel and a runner for most runners. So anyway, an athlete's like a heel or a skate or a ballerina, they're not on their heel. So they fail for that reason. They fail with materials that are picked, shock absorption versus enough support to create good alignment.

The third thing is the way the lab makes the orthotic. And sometimes we cast, like some people get casted in standing. So you stand in the foam. Well, if you're flat-footed and that navicular or your arch is on the ground and you're 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 OK. It's going to meet your foot.

Linda Bluestein, MD (50:14.248)

Yeah.

Lisa Ralston (50:20.994)

But so the lab that I've used the last 23 years is a total contact, which is different. And there's no correction. So basically it's a partial weight bearing with the joints in neutral. And then my job's to assess the flexibility in the foot. So this podiatrist engineer created, he calls it a gib test. And so I assess the rear foot and the mid foot, and I give it a foot flexibility.

Linda Bluestein, MD (50:34.525)

Mm-hmm.

Lisa Ralston (50:50.57)

assessment. And then the lab calibrates body weight, the flexibility in the foot, and the activity level, the velocity. So if I have a skater or if I just have somebody walking, I'm going to do something different because the load is different. And so with total contact and calibrating how the foot is, the body weight.

Linda Bluestein, MD (50:51.678)

Mm-hmm.

Linda Bluestein, MD (51:01.605)

Mmm.

Lisa Ralston (51:19.918)

When it's total contact, I don't know if you can see this, when your foot comes off the ground, the orthotic stays right with you. Traditional custom orthotics, you'll see a gap. And you can test that, so for those of you listening, if you have custom orthotics and you're seated, put your orthotic under your foot and just lift your heel up and keep that orthotic under your foot and see if there's a gap under your arch. So if there's this big gap here,

Linda Bluestein, MD (51:22.649)

Mm-hmm.

Linda Bluestein, MD (51:27.122)

Mm.

Linda Bluestein, MD (51:30.477)

Mmm.

Linda Bluestein, MD (51:45.33)

Mmm.

Lisa Ralston (51:47.798)

And then you load and you're walking mid-stand, and then it hits this orthotic. A lot of people, it doesn't help, because you've still got these forces sort of going like that. But if it stays with you, it's maintaining that posture throughout the gait, which is our goal. I don't want to correct, I just want to facilitate good alignment and posture.

Linda Bluestein, MD (51:54.992)

Mm.

Linda Bluestein, MD (51:59.557)

Mmm.

Lisa Ralston (52:11.17)

So that's how it's different. That's what I do that's a little bit different. I do have semi-custom as well. We'll talk about the Vionic or Vasili. These are the same company, but out of Australia, this is for a high arch supinated foot. And we can talk about specifics of that. And then, so I have so many patients that previous orthotics have failed. And it's because...

Linda Bluestein, MD (52:27.339)

Mm-hmm.

Lisa Ralston (52:38.978)

the flexibility, the hypermobility and stiffness of the foot wasn't addressed. They just took a mold and, and right versus left wasn't addressed. So there is there, you know, depending on the foot flexibility, if the foot is really stiff, it can get, be a little bit longer to get used to, cause you're putting something on a stiff foot. Um, kids, they just go right away. Um, unless they have some tactile issues and we, you know, we don't want.

Linda Bluestein, MD (52:43.845)

Yeah.

Linda Bluestein, MD (52:58.067)

Mm-hmm.

Linda Bluestein, MD (53:02.897)

Eh.

Lisa Ralston (53:08.338)

anything bugging them that way, you know. So yeah, that's, that's the difference, I think, is facilitating that good posture and alignment, taking into account the foot's flexibility and posture. And then I want to put them on and look and see how that alignment looks when they're on one leg, double leg, how they walk.

Linda Bluestein, MD (53:33.907)

Mm-hmm.

Lisa Ralston (53:37.808)

on that kind of thing.

Linda Bluestein, MD (53:40.093)

sure that makes sense. And are there situations in which I mean, obviously cost is probably one situation in which people would purchase a, you know, something over the counter kind of a thing. Could you talk a little bit about a little bit more about that?

Lisa Ralston (53:47.885)

business.

Lisa Ralston (53:51.435)

Yeah.

Lisa Ralston (53:57.118)

Yes, and I just had another thought. Yes, the different orthotics. Hang on. So, mistake. Let me, um, I just thought about something when you were asking that I was going to... Oh! When you're talking about failed orthotics, besides the orthotic and casting, what's really important is that the foot be functioning. So, with the orthotic, it's important to go to a provider that feels and assesses the function of the foot.

For example, if I have a tight Achilles, tight gastrocnemius it can pull my heel a certain direction, right? So if I just stick an orthotic in there and I haven't addressed the bend at the ankle, the tight Achilles, the movement of the metatarsals, that orthotic can fail, right? Because the body's not ready for that support.

So I think it's an important point is the assessment and the function and movement of the foot needs and lower leg needs to be addressed so that the orthotic can support them. Just like a knee brace, if we're trying to support knee hyperextension, but we don't address tight hip flexors or whatever, or position of the knee, that brace is not gonna help. And also we want that brace to have good contact if it's a supportive brace.

Linda Bluestein, MD (55:09.458)

Yeah.

Linda Bluestein, MD (55:13.255)

Mm-hmm.

Linda Bluestein, MD (55:18.319)

Mm-hmm.

Lisa Ralston (55:18.398)

And so that's where that contact of the orthotic. So, okay. So I just wanted to add that in that that's why the assessment's so important with the orthotic and not just getting an orthotic. And I think that's why so many fail. So while we're waiting for the orthotic, we're doing some foot mobility exercises with balls. We're getting the metatarsals to move. We're getting the cuboid to move the heel to rock. We're massaging soft tissues. We're getting all that ready for that orthotic.

Linda Bluestein, MD (55:27.944)

Mm-hmm.

Lisa Ralston (55:48.511)

So, yeah. Okay, so different orthotics, right? Is that your question? Yeah. Okay. So, yeah. Okay. So, different orthotics, right? Is that your question? Yeah.

Linda Bluestein, MD (55:54.586)

Yes, yes, because I know some people they either can't come to see you to get orthotics or they might not be able to afford getting custom orthotics. So what do you suggest in that situation?

Lisa Ralston (56:03.181)

Right.

So, of course I'd want to assess, if you know your foot is really flat footed and flexible, the more support the better. So if it's an over the counter, you're gonna want a nice deep heel cut. So a good brand might be S-O-L-E or Vasili. You can see the name. This is actually a thin one for like a high shoe heel.

This is for a higher arched supinated foot, has a deep heel cup, and it has a little more support laterally for the foot that has so much motion this way. So, Vasili used to only be issued through providers, but now my patients can just go online. So, the blue Vasili, that's just kind of looks like this, and they're about 45, $55. And we do heat mold them a little bit, but you don't really have to.

You can go online and find those stores are selling them rehab Amazon and so it just kind of Average pronation I would recommend the silly the blue one If it's a high arch supinated foot there's it's called the hokey. Is that named after Brian? Hokey is a physical therapist. Okay, and It has a deeper heel cup. It's made for a supinated foot

If your Achilles is really tight, there's a little heel lift as well. This brand makes something called Easy Fit and it has a little heel cup and it has cutouts. So I use that a lot for kids. It has a really nice arch and they can stick it in little converse in different shoes. I've used them in cheer shoes, like small. So Vasily makes one called Easy Fit that you can just order and stick in different shoes. That's super easy and inexpensive.

Linda Bluestein, MD (57:49.225)

Mm.

Lisa Ralston (57:58.446)

SOL I mentioned has on their website you can sort of put answer questions if you're more supinator and pronator and they can help you decide which orthotic. And by the way, I don't make money off of any of these products. Disclaimer. I've sold a ton of them. And then super feet like, you know, for kids for some for something kind of mild, they're super feet. They give a little bit of pronation control. They make some for skates.

Linda Bluestein, MD (58:04.424)

Mm.

Linda Bluestein, MD (58:13.533)

Neither do I.

Lisa Ralston (58:27.894)

that sort of thing. And then the custom ones I charge, oh and kids, they have kids sizes too. And there's some different ones. The custom for what I, I don't know if you wanna know what I charge or if people wanna know. So for evaluation, follow-up visits, one pair of orthotics is $425. So you don't pay for an extra visit with follow-up, we issue.

Linda Bluestein, MD (58:43.529)

Sure, yeah, it'd be great to know.

Lisa Ralston (58:57.634)

and communicate. So the first visit usually includes, you know, it includes evaluating, sort of treating while I'm talking, casting, one pair of orthotics, and your follow-up visit. And I usually give some things to work on at home. And then just follow up by phone or email if we need to. And you can go on Soul Support's website and look for providers in your state or area. I don't know about out of the country. And again, though, I would

it could be a provider that doesn't put their hands on you, right? I don't know. Even though you're orthotic, I would still recommend finding a provider who's good with treating feet or who, um, and I don't know why there's not more. I get, you know, people are like, Oh, you know, I've treated so many stinky hockey feet, but it doesn't even faze me. But I, you know, just, I think of, um, either a therapist or,

Linda Bluestein, MD (59:45.649)

Yeah.

Linda Bluestein, MD (59:48.937)

That's funny.

Lisa Ralston (59:55.178)

It could be any kind of provider that can address the foot and moving the foot and that kind of thing. And there's a lot of videos now with self-treatment of feet.

Linda Bluestein, MD (01:00:06.363)

Mm-hmm.

Okay, I just, I'm going to say the word mistake here. I just heard the dog bark. And I want to make sure not to not to miss any of that because that was fantastic. So, but, but trying to go back, I think, is going to be too hard. So we'll just, we'll just keep going. Okay, I had a follow up question to that. Oh, so what if a person comes to see you and they do the one on one evaluation and everything, but they want a second pair of orthotics. How does that work?

Lisa Ralston (01:00:14.214)

Oh.

Lisa Ralston (01:00:18.318)

mistake. Okay.

Lisa Ralston (01:00:37.146)

Mm-hmm. I do not charge any extra for that. If they're doing well and they like it, I can make any modifications. Like, let's say they want a second pair for a dress shoe that's more narrow or for a skate or something, or, you know, a soccer shoe. Second pair is 195 and they do not have to come in. I can just order it. I trim, so I pick different amounts of top covers or cushions. These are very old, by the way. And so...

Linda Bluestein, MD (01:01:00.798)

Mm-hmm.

Lisa Ralston (01:01:05.014)

They can just order a second pair. I trim them to fit in their shoe. Some people, if they have a lot of extra mobility in their forefoot, I add a balance called a sesamoid balance pad. And that can make a big difference, especially if toes are overworking, trying to balance, and with proprioception, it just sort of aligns that posture from this rotation the other way. And...

Linda Bluestein, MD (01:01:16.59)

Oh.

Lisa Ralston (01:01:31.902)

You know, or I might need to add a metatarsal pad if there's one very painful metatarsal or if somebody has neuroma Morton's neuroma where they have burning and pain in between their toes. You can go to Oh, I gotta think of the site motion. Human. Mistake. Oh, look up this. I'll give it to you, but you can order these pads online.

Linda Bluestein, MD (01:01:41.373)

Mm-hmm.

Lisa Ralston (01:02:01.927)

to add under your shoe insert to unload those metatarsals and that nerve pain. So.

Linda Bluestein, MD (01:02:12.273)

So I have a lot of people that have had problems with their sesamoids. So I'm fascinated about how you might adapt the orthotic for that.

Lisa Ralston (01:02:16.831)

Thank you.

Lisa Ralston (01:02:21.538)

So sometimes I use a dancer pad. This is actually a sesamoid balance pad made by the, I'm just going to click on this and see. It's called Human Locomotion is the website. And you can check that out. A dancer pad I put underneath a big toe and across metatarsals, and then it unloads those sesamoids. So it gives more support so that it's sort of

Linda Bluestein, MD (01:02:25.67)

Mmm.

Lisa Ralston (01:02:50.954)

catches some of that load and decelerates it before those sesamoids hit the ground. And so I've used that a lot with dancers and skaters. The sesamoid balance pad I use if there's just so much hypermobility with rotation this way. That tends to work better. And it goes like, here's your foot, it goes like that, there's your big toe. And this is under the fifth metatarsal.

Linda Bluestein, MD (01:03:16.489)

Okay.

Okay, that's very helpful.

Lisa Ralston (01:03:19.682)

So if you go to human locomotion, you can see that online.

Linda Bluestein, MD (01:03:25.593)

Okay, excellent. And again, I definitely encourage people to watch the YouTube if they can, because that's a great visual there. So, and in terms of the over-the-counter orthotics, is it best if people go to a store if they can, and that way they can maybe choose from a few varieties and be able to get their hands on them and that kind of thing?

Lisa Ralston (01:03:26.894)

I just gotta get out of here.

I can't.

Lisa Ralston (01:03:47.006)

Yeah, you know running shoe stores carry a lot more now and they're more knowledgeable. So a lot of them running shoe stores will carry super feet, SOL, some Vasily, Birkenstock even makes some cork footbeds that are pretty nice. So they could go do that again, you know, the shoe store person doesn't know your foot type and so they don't necessarily know what to recommend.

And so that's where sort of the specifics come in. But if you know you have a flat foot, the companies will generally kind of guide you. I would say look for a nice heel cup. That's helpful for control and stability. I'd say that's probably one of the first things I would check for hypermobile patients.

Linda Bluestein, MD (01:04:36.013)

Okay, and as we're getting close to the end here, can you talk a little bit about, I think one of the things that you had mentioned was self-mobilization of feet?

Lisa Ralston (01:04:37.879)

as we're getting close to the end.

Lisa Ralston (01:04:44.942)

Oh, yeah. So one of the things we do is we all get so stiff in our metatarsals, right, just with pain or whatever. And so take like a little kitty ball, like a little foam ball. And if you're sitting, you place that ball under your foot under those metatarsals and you just 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 sort of mobilize the joints up and down. And then of course you can use it to massage plantar fascia. You can put your heel on a ball and rock the heel to get mobility that way. You can also use the ball to sort of stretch by putting your toes on the ball and spreading your toes to create space around the ball. And so there's some just really nice foot mobility exercises.

Linda Bluestein, MD (01:05:34.677)

Mm.

Lisa Ralston (01:05:41.958)

you know, even with EDS, what I find is we work a lot on mobility because there's some areas that are painful and are stiff. And so maybe that's kind of one of the big differences is addressing those stiff painful areas is really helpful.

Linda Bluestein, MD (01:05:46.12)

Mm-hmm.

Yeah.

Linda Bluestein, MD (01:05:57.353)

Sure. And what's that ball called again?

Lisa Ralston (01:06:01.002)

Well, it could be a little kitty ball. Like, cats play with like a little fur rubber ball. Kittens, cat, like a, or, or like, just a small rubber ball. You don't want to use a marble, that's too painful. But just like a small bouncy ball, something that has a little bit of give, a little rubber ball. But usually, you know, kind of a quarter size or a little bigger, you can get each joint separately.

Linda Bluestein, MD (01:06:07.001)

Mm, okay. Gotcha.

Linda Bluestein, MD (01:06:18.621)

Mm-hmm. Okay.

Linda Bluestein, MD (01:06:30.174)

Mm-hmm.

Lisa Ralston (01:06:30.206)

And then we do a little bigger ball where you spread your toes around it. And you can buy inexpensive balls on Amazon or Target, you know, department stores. And anything that sort of spreads and moves those bones in your feet can be really helpful. And then after you mobilize, then the next step is to work on stability and proprioception. So once our foot can move.

Linda Bluestein, MD (01:06:48.137)

Sure.

Linda Bluestein, MD (01:06:53.353)

Mm-hmm.

Lisa Ralston (01:06:56.13)

Then the next important phase is to know your foot's a tripod. So you have your heel, your big toe, your little toe. And I'm gonna work on proprioception and balance and maintaining my arch.

with that tripod under my foot now that my foot has, I can load it everywhere, right? So after I mobilize, I want to work on some proprioception and balance in that correct alignment and posture of my foot, meaning arch, you know, not rocking out to the side, not collapsing in. I want to try to maintain that neutral. That's a great exercise without clenching my toes and using my core, all those things.

Linda Bluestein, MD (01:07:20.066)

Mm-hmm.

Linda Bluestein, MD (01:07:37.89)

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 if they 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 or something on one of the posts about this episode because that's something that we've thought about doing, doing an episode about.

Lisa Ralston (01:07:46.undefined)

Yeah

Lisa Ralston (01:07:50.763)

Please send me emails and a face mail on what site you're in.

Lisa Ralston (01:08:00.887)

So, I'm going to go ahead and start the presentation.

Linda Bluestein, MD (01:08:02.601)

hypermobility in ice skaters. And that would be great to have Lisa back to talk about that. So, okay. Last couple of questions here. First of all, what do you wish that I had asked you and how would you have answered?

Lisa Ralston (01:08:16.009)

Okay, last couple questions here. What, first of all, what do you wish that I had asked? And how would you do it? Let's see, what do I wish? I hadn't thought of that. Well, the total contact, and then I think treating kids, which you did, we ended up getting to. So I can't think of anything else.

Linda Bluestein, MD (01:08:32.589)

Okay. Okay, no problem. No problem. Okay, so last question besides the wrap up here. Do you have any favorite hypermobility hacks?

Lisa Ralston (01:08:34.74)

I think you got it.

Lisa Ralston (01:08:48.654)

I have quite a few, I think, but we'll go to foot. When I see, especially in a higher arch kind of dome foot, people complain of numbness, especially like if they're walking or in certain shoes. And so it's very simple. You can just change the lacing where you crisscross. So if you feel the bump on the top of your foot and if that lace hits right where that nerve, the nerve is close to the skin.

Linda Bluestein, MD (01:08:49.929)

Ha ha!

Okay.

Lisa Ralston (01:09:16.746)

And so what I do is we crisscross below, skip a hole, crisscross above it, and then you create a space for that nerve and you don't get the numbness on top.

Linda Bluestein, MD (01:09:17.04)

Mm.

Linda Bluestein, MD (01:09:22.173)

Mmm.

Linda Bluestein, MD (01:09:26.982)

Oh, that's brilliant.

Lisa Ralston (01:09:29.87)

So I've had quite a few patients and I've gone to all these providers and I just changed the lacing and they go hiking and they're like, that's good. Or they go walk on the treadmill. So that's an easy one.

Linda Bluestein, MD (01:09:37.27)

Wow. That's incredible. I love little hacks like that. That's amazing. Okay, so just to recap that when you're saying that you basically skip... Actually, Kaia, can you show us with the shoe?

Lisa Ralston (01:09:53.31)

Yeah, so like in my foot, if I have, I'm real prominent right here and I'm getting numbness in my toes and foot, I would skip this cross. So you put the shoe on, you feel where that bump on top of your foot is, where it's kind of tender. And then you unlace and then skip a hole and cross above and below that bump in your foot. So you're unloading that spot right there, because a lot of shoes have this, right, where we have the lace goes in.

Linda Bluestein, MD (01:10:00.659)

Mm-hmm.

Linda Bluestein, MD (01:10:17.662)

Mm-hmm.

Lisa Ralston (01:10:21.434)

in that little strap there, then it pushes down on the top of the foot. Sometimes that can make that worse. So it just depends on where the bump in your foot is. Usually it's kind of right here, right where that lace crosses. And so if we just cross below and above, we can unload that strap pushing, that lace pushing on the nerve where that top of the foot is.

Linda Bluestein, MD (01:10:23.305)

Mm-hmm.

Mm. Mm-hmm.

Linda Bluestein, MD (01:10:34.373)

Mm-hmm.

Linda Bluestein, MD (01:10:44.169)

Mm-hmm. Okay. Fantastic. I love that one. Okay. Where can people find more about you online?

Lisa Ralston (01:10:54.062)

So I no longer have a website because I'm kind of this working part time this last year. You can find me at lisasralstonpt.janeapp.com. So it's a scheduling platform. I can be emailed at lisasralstonpt@gmail.com. And I'd say that's probably the two ways.

Linda Bluestein, MD (01:11:19.233)

Okay, great. And we'll make sure to have that information in the, in the show notes. So, 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 and find this so helpful. So thank you so much.

Lisa Ralston (01:11:25.846)

Okay. Well, we've been built. So we're excited to be coming on the KB Live presentation. I'm really looking forward to it. I can't today, but I'm so excited to be talking to you about this. I know so many of you want to learn about the KB Techs and the problems, so it's really a joy. Also, I'm so excited to be able to share and try to do this. Well, thank you for asking me. It was fun. I love talking about feet, obviously. So.

Linda Bluestein, MD (01:11:48.934)

Yeah!

Linda Bluestein, MD (01:11:52.729)

It's a very important topic. I don't think we ran into that problem. So well, thank you so very much again, and I will see you soon.

Lisa Ralston (01:11:52.762)

I was worried I wasn't going to have enough to say. Okay, good. Thank you and thanks for all you do for all the patience and all the work and time that you put into this is just amazing.

Linda Bluestein, MD (01:12:09.945)

Oh, you're very welcome. You're very welcome. You too.