48. Supporting the Foot and Ankle with Andrea Zujko, DPT

Episodes have been transcribed to improve the accessibility of this information. Our best attempts have been made to ensure accuracy,  however, if you discover a possible error please notify us at info@bendybodies.org

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

00:16
Dr. Linda Bluestein
Our goal is to bring you up to date information to help you live your best life. 

00:20
Dr. Linda Bluestein
Please remember to always consult with your. 

00:22
Dr. Linda Bluestein
Own healthcare team before making any changes to your routine. 

00:26
Jennifer Milner
Our guest today is Andrea Zuko, physical therapist. Andrea, hello and welcome to Bendy Bodies. 

00:45
Andrea Zujko
Hi, Jennifer. Hi, Linda. Thank you so much for having me today. I'm really looking forward to this. 

00:52
Dr. Linda Bluestein
So are we. 

00:53
Jennifer Milner
We are looking forward to it, yes. So let me ask you, Andrea, before we dive in, we have a lot we want to talk about as we dive into the foot and ankle. But before we do, could you tell listeners a little bit about yourself? 

01:05
Andrea Zujko
Absolutely. Okay, so I am a physical therapist as well as a licensed Pilates instructor. I started this journey kind of in this field training as a dancer way back when. I like to say in the 19 hundreds. That does age me a little bit. Studied all different styles of dance, worked professionally when I was in my late teens and early twenty s. And unfortunately that stopped due to injury, which then opened up the next door for me in my life, which was getting into healthcare specifically for dancers via the Pilates world first, and then finally into the physical therapy world. So I'm currently practicing as a physical therapist. I do quite a few things. I am the clinic manager at Westside Dance Physical Therapy here in New York City. I'm also adjunct faculty at NYU Tish Dance Department. Let me just say that again. I'm adjunct faculty at NYU's Tish Dance Department and downtown, as I like to say, I teach anatomy courses to the BFA dance majors, and I also run an on site PT clinic for the dance majors. 

02:31
Andrea Zujko
And then finally, the third cap that I wear is I am the founder of Dance Medicine Education Initiative and that is a collaborative continuing education company that I launched formally in 2020. 

02:45
Jennifer Milner
So you do a lot and you work with several different organizations, which has enabled you to work with dancers, starting from the younger pre professionals through college students, all the way through professionals at all stages of their career. Great. We cannot wait to pick your brains on this. So let's start with the myth that hypermobile dancers all have banana feet. Can you have hypermobility without the crazy high arches? 

03:10
Andrea Zujko
Oh, yes, the banana feet. I show pictures of banana feet quite often to my dancers just to articulate exactly where movement can occur. If you have a lot of movement in your foot and ankle, you definitely are able to kind of tease that out from a visual perspective in somebody who has that type of foot range. Of motion and mobility. You can have hypermobility though, if you have a type of foot that might not look like a banana, that might be a little bit more of a flatter type of foot. It's actually what's called a flexible flat foot is very common in dancers with hypermobility. And what that means is that when you are standing on the floor, you're weight bearing. Your arches tend to lower, closer to the floor. So your foot has a flatter foot type of posture to it. However, when you rise up into demipoint and certainly all the way up into full point, the inside arch, the medial arch, which is what we're really looking at reappears, so you're able to, in a more non weight bearing position or a more pointed position, be able to achieve more of a pointed arch type of foot posture. 

04:33
Andrea Zujko
So not all dancers have hypermobile. Dancers have this kind of banana style of foot. Many have a flatter foot when they're weight bearing on the ground and then they have a beautifully pointed foot when their foot is up in the air. It's not weight bearing. Of course, there is the third type of foot posture, which is more of a stiffer type of flat footed posture. That's not necessarily going to change too much between when the foot is weight bearing on the ground or if the foot is not weight bearing, say. It's more in either a partial weight bearing demi point or even up as a gesture foot in the air. It's very important in terms of my work with dancers, especially the young dancers, the pre professionals and the collegiate dancers and the recreational dancers, that the banana foot really has its own issues in the tissues. 

05:25
Andrea Zujko
It is not like this ideal that does not have its own challenges, especially with somebody who has some hypermobility or a dance or with hypermobility. That type of foot can be very challenging to control when you're loading weight through it, especially if you're putting that type of foot into a point shoe, which we see often. You could find this type of foot posture anywhere via Instagram versus any company or a dance class. It's very challenging working with that type of foot. So, again, wonderful from an aesthetic perspective in terms of you really can appreciate the articulation of motion. But the real, I think, focus should be on control rather than trying to achieve a certain type of position or posture, maybe trying to certainly force the foot into a certain type of posture, maybe through rigorous stretching techniques that might not necessarily be so healthy for the feet. 

06:27
Dr. Linda Bluestein
So that's really fascinating because what's visually appealing may actually be more challenging in some ways than what is maybe considered less aesthetically desirable. And that makes me think about ankle sprains in particular and how some dancers can really struggle with that. So can you talk a little bit about ankle sprains, what that actually means and how that might impact future risk of ankle sprains. 

06:56
Andrea Zujko
Sure. So ankle sprain, we know it's when one or more ligaments here at the ankle are either partially or completely torn. It's very interesting. The really risk area or the risk range is when you are either in the process of rising up onto full point or when you are lowering yourself down off of full point. Now, that could be off of a point shoe or that could be coming down off of Demi point. So kind of that mid range position from when your foot is on the ground flat and when your foot is kind of locked up in the high point of its relevance. So you have this kind of precarious zone, if you will. And what happens is that you have this usually rapid shift of your center of mass of your body over this weight bearing foot. And what happens most often is that the lateral ligaments are injured as that ankle rolls outward, which causes the foot to twist. 

07:59
Andrea Zujko
And these ligaments on the outside of the ankle are overstretched and will tear depending on how much force is put through them. Certainly you could go a little bit further and you could actually have something called an evulsion fracture where there's a little piece of bone that is chipped off of the edge of the fibula, if you will. We're talking about the lateral ligaments of the ankle. So being in that plantar flex position, kind of transitioning in and out of it is a range or a zone of vulnerability to any dancer. Certainly if you are a dancer that has a hypermobile foot, which again can be to your advantage. Right. Certainly if you are dancing on point, you need to have some degree of hypermobility of your foot. But if you're working with a situation, whether you have a local hypermobility of your foot and ankle or you're dealing with more of like a general hypermobile body type, I think that, or at least what I've read and what I've experienced as a clinician is that you're a little bit more susceptible to ankle sprains based on maybe some proprioceptive challenges, some maybe being a little bit more at risk for strength imbalances at the foot and ankle. 

09:12
Andrea Zujko
And then putting that load and putting yourself into that position could predispose you to ankle sprains. Once you have ankle sprain, you can have healing, but usually the previous elasticity and the resilience of the ligaments rarely return. So again, if this happens, I definitely encourage my dancers that I work with to really take the time to heal because there's a lot of information out there about different case studies or even some research articles on if you go back too early, you will compromise sufficient ligament repair. And again, we're talking about not even necessarily being able to get back to 100%. 

09:56
Dr. Linda Bluestein
That was really important. So in terms of how much time for healing, I want to make sure that people really pause and think about this a minute too. It also depends on the degree of tear, right? That would also make a difference. 

10:14
Andrea Zujko
Yeah, correct. So in general, we grade ligament sprains on a scale of one to three and we can also consider how many ligaments are compromised. You can have a more severe injury in one ligament and a more minor injury in another ligament. So that again, is also going to affect the healing time and the plan. But we have to think about how the Collagen matures, the time that is needed for protection, the time that is needed for gradual loading and the time that is needed to continue to work on kind of regaining alignment. Control. Proprioceptive control. To be able to condition the body, to be able to handle the stresses that the dancer needs to be able to handle. This rehab can take you might not necessarily be in the clinic this long, but it can take months, if not up to a year. They have found some deficits lasting that long. 

11:16
Andrea Zujko
And you really don't want your dancers to become a coper. You want to try to do your best to try to avoid entering into that kind of category where you're just setting yourself up for potential future injury. And certainly multiple sprains over and over time can then lead to chronic ankle instability and then you just have what we call sometimes it's this loose bag of bones. It's very difficult to stabilize. And certainly layering on a hypermobility or hypermobile body type, I think can make things a bit more complicated. 

11:55
Jennifer Milner
And I think something that's important for people to hear out of all of this is that a lot of times when I see people with ankle sprains, they think that once it stops hurting, they're good to get back into the class or back into the dance studio. And there's so much more to it. As you said, with proprioception, with retraining, it retraining muscle strength that you aren't even aware that you lost because it's only been a couple of weeks. How bad could it be? But it really is something that takes a long time, especially with hypermobility, to regain that full sense and full use of that foot. So I appreciate what you said. I hope nobody hears that. Andrea is saying you have to be out of the studio for a year. But she is saying take your time getting back in and then when you get back in, you're going to still want to continue doing work with a physical therapist or someone who can help you continue to train and get you back to full speed. 

12:47
Jennifer Milner
It's not something you want to skip because is it not true that the biggest predictor of ankle sprain is if you've already had ankle sprain? 

12:56
Andrea Zujko
Correct. Yes, of course. Pain. We know that pain is a great motivator. It's true. It's true. For all of us. It's true for myself, once something, whatever injury I happen to be dealing with at the moment, once that pain goes away, sure, we all want to get back to what we're doing, right? Injuries are inconvenient. They never happen at a good time. We have the time to actually really make a plan in our schedule or open up that space. So, yes, no, you're not going to be out unless you're talking about having a major surgery where you maybe needed some kind of reconstructive procedure. You're not going to be out of the studio for a year. It's just about you got to think of the long game with this type of injury that you continue to check in with somebody or if you have the opportunities to work with a somatics practitioner, whether it be pilates. 

13:55
Andrea Zujko
Or Gyrotonic or someone that helps a trainer, someone that helps you with cross conditioning, they can continue to help you kind of build your program for a longer period of time, which has a lot of benefits for the rest of your body. So sometimes you're giving yourself that space to heal from an injury. Sometimes you really can wind up really benefiting in a lot of other ways from healing what you thought was just ankle or just a metatarsal or what have you, right. 

14:31
Jennifer Milner
That's so important and that's so true about so many injuries that we have moving to the talus. Talus is a great bone. So talk to us a little bit about the talus and why is it so important? And what happens when bones like the talus do not move correctly? Like, talk about optimal movement of the talus, what exactly is happening, all of that kind of thing. 

14:54
Andrea Zujko
The talus? Yes, the talus. I'm going to get really nerdy here. It's one of my favorite bones. 

14:59
Jennifer Milner
Bring it. 

15:02
Andrea Zujko
Maybe because I spend the most time with it in my practice. Helping. Helping it? Nourishing, it reeducating it's a central bone of the ankle. Okay. It's part of a group of bones which are collectively referred to as the tarsus. It articulates with the tibia and fibula, so that forms our ankle joint or the tallocrual joint if we want to get our anatomy terminology in there. It also articulates with the Calcaneous, which is our heel bone, and our navicular, which is a bone in more of the midfoot area. And I look at this region of bones and their articulations or their connections with each other as a real highway of information in terms of there's a lot of transmission of weight and force between the lower extremity and the foot occurring in this area. So really kind of looking at this area as a whole as something that needs to be well aligned, something that area that needs to be able to move adequately, but also to be very stable. 

16:21
Andrea Zujko
The talus bone is very unique in the sense that it lacks any direct muscular attachment so we're talking about stability of the talus is really created by the numerous ligaments that attach to it. And you have ligaments on the outside, you've got some of your lateral collateral ligaments, your deltoid ligament on the medial side. You can also think about ligaments that are attaching inferiorly, connecting with the Calcaneous and then from there into the midfoot, talking about the Navicular. And all of these ligaments really help to kind of, I think, tether or provide stability of this talus and really maintaining alignment of this joint, which is described often as a mortise joint, which is more of, I guess, a carpenter term in terms of one bone fitting in between the two. It depends on stability of the ligaments in terms of passive stability. But I think its stability, more dynamically depends on the rest of the lower extremity. 

17:31
Andrea Zujko
We don't even have to stop there. It can go up to the pelvic girdle, to the lumbo pelvic girdle, even to the thorax. So I find that alignment issues, or issues of impingement, issues of tracking of the ankle, a lot of times are driven by more proximal problems that are concerning the hip in terms of the musculature around the hip, which by and large part stabilizes the knee, right? And then we know that knee joint needs to be able to track adequately over the foot or correctly over the foot and adequately over the foot. And the efficiency of the hip musculature is really driven by the positioning and the control of the pelvis and the lumbar spine. So I know it's so cliche that one thing connects to the other, but it does. And a lot of times those issues in the tissues can lead to alignment problems at the talus in the absence of injury. 

18:44
Andrea Zujko
If we're talking about injuries, specifically going back down to the ankle, to the talicrual joint, usually that talus will get, if I can say we use words called we use words like subluxation, okay? That's very simply like some kind of abnormal force was placed or introduced into this ankle joint and it has disrupted its alignment, usually as a result of ligament injury. So we're talking about ankle sprain. So ankle sprain, your lateral ligaments, you end up rolling over your foot. Your foot is twisted into this inverted position, and that talus kind of gets knocked off its track a little bit, right? And if that is not reset back into place in terms of through any kind of necessary manual techniques, I find that then you start to run into kind of tracking problems. This is something that many dancers are familiar with. It's called a jammed ankle. 

19:49
Andrea Zujko
You can call it simply a jammed ankle. Exactly what's happening or talus is not tracking correctly in and out of the mortise, and you go to perform whatever it is. If it's closed chain dorsiflexion. So that's a plier or a closed chain plantar flexion that could be demi point relevant, full point relevant or even a tondu, you're potentially going to be pinching the soft tissue structures of that joint and that is going to become quite painful and problematic. 

20:22
Dr. Linda Bluestein
Interesting. And I feel like a lot of people that I've worked with and I have to confess I personally also deal with this when I plantar flex my feet, I get like a pretty loud clunking in my ankles. And I know that there is CO2 release right, in different parts of the body. So that may or may not mean anything. But can you maybe tell people how they might have a better idea if something is actually subluxing versus if there's just that CO2 release, if that makes sense? 

20:59
Andrea Zujko
I can give you personal anecdote because I certainly cannot tell you how other people feel in their bodies. Right. The difference is the quality of the sensation. There's a difference in the quality of a sensation between a joint making that cracking sound or popping sound versus let's say it's more of a soft tissue structure, like a tendon feeling, more like a rubber band that kind of snaps over or rubs over a bony prominence. You can have subluxation of your joints that especially if you have a body type that is hypermobile on a regular basis, you're kind of clicking around and things don't get stuck until they do. But a lot of that is not necessarily pathological. I wouldn't seek it out. I tell my dancers who have hypermobility that have the ability to clunk the hip and self manipulate their cervical spines and do all these other interesting self manipulations. 

22:13
Andrea Zujko
I caution them not to do too much of that. I find sometimes that is more of a manifestation of anxiety than it is a need to constantly adjust. But I also then explain to them, well, that could be a sign that maybe your muscular system is not doing its job or could do a little bit of a better job to help your body stabilize. So I hear you Linda, saying that you feel like if your talus kind of slips forward a bit, which is common. Certainly if you have a hypermobile foot that talus definitely can slide forward, it should go back. Sometimes it doesn't. There are ways that you can simply try to coaxic back in. I find that dancers with hypermobility, it's a lot of times I think that minor, more minor episodes of slipping out of place can really be worked out via self care. 

23:21
Andrea Zujko
Great. Fantastic. Other times self care doesn't work and you really need someone to help you restore the optimal alignment of your body. Like a physical therapist or even I've got know you Jennifer, I'm sure you've got a list of nice little list of items or techniques that you could help your dancers use to kind of get their joints back into place. That can be very beneficial. But self treating the foot and ankle in terms of subluxations in some situations can be very difficult. I'm all about advocating for self care and self treatment through movement restoration and movement reeducation and strengthening on top of that. But sometimes you just need help kind of restoring that and then you've got to like it's like the start again, start by stabilizing again. 

24:19
Dr. Linda Bluestein
That sounds like a very reasonable approach to take. And when it comes to the bones and stress fractures, can you talk a little bit about Taylor stress fractures and stress fractures in other parts of the foot and ankle? What kind of things you see in the hypermobile population, hypermobile dancers and what some important considerations might be? 

24:44
Andrea Zujko
Yeah, it's interesting that you're bringing up the Taylors. Is this because of any kind of specific what doesn't spike us taylor fractures are not that happen Jen's raising her hand. 

24:57
Dr. Linda Bluestein
But actually, I know I have patients and family members that have had stress reaction in the Taylors. 

25:06
Jennifer Milner
Yeah, and I have too. And I've had, I think, four or five of them, which seems like a really high number, but all but one of them, obviously I was not the primary point person for them. Right. But all but one of them were in hypermobile people. And so I started wondering what the relationship is between natalus that might be out like represented forward and they're sort of going through their day to day and not allowing it that full posterior glide and stress fractures. So, yeah, I think we both are interested in this and would like to know. 

25:40
Andrea Zujko
Yeah, really interesting because statistically it's really not that common. But you know, I have a dancer, actually, right now that I'm working with who really suffered an impact injury to her talus. And I thought to myself, okay, maybe I'll speak about this a little bit. So a stress fracture, it's injury to the bone. It can be a small crack in the bone, it could be severe bruising within the bone. And most stress fractures are caused by overuse and repetitive activity. Certainly the ones I've seen. Yes, I've seen some acute traumas that have involved dancers colliding with pieces of scenery or suffering some kind of fall or something, absence on top of their foot. But that's been pretty rare in my practice. It's usually due to overuse and repetitive activity. And this is true of other athletes that are involved in constant repetitive forces. So things like walking, running, jumping dancers do it all. 

26:48
Andrea Zujko
But you do see stress fractures in other athletic populations, like runners, soccer players. And in the absence of acute trauma, you're usually dealing with a situation where you have this imbalance between bone formation and bone reabsorption, or reassorption, which is the removal of the bone. So when a bone is loaded or stressed during weight bearing exercise, it responds by increasing its bone turnover. So this is necessary for it to live up to the demands that we place on it. This is a normal part of the physiology of what happens with our skeletal system. So when stress is applied to the bone, the area of the bone can become damaged and these damaged areas of bone are then reabsorbed removed and replaced with new bone. So usually there's a nice balance, right? Everybody's happy in terms of this rate of turnover. But if the new bone formation is slower than the removal of the old bone, we can have weak points occurring at areas of stress within the affected bone. 

27:51
Andrea Zujko
So this can develop into a stress fracture if that weak area of the bone is repeatedly stressed. Usually this happens gradually over time sometimes and is worse during weight bearing activities. So oftentimes it's due to a change in training. And this could be frequency, duration, intensity, what type of surface you're dancing on, or your footwear. Maybe it's something you had a bad pair of point shoes or something like that. Or you can also have to take a look at your bone density. And certainly in adolescence we know that there is a period of where the bones are a little bit weaker because of the growth that occurs and we know that density is going to catch up a little bit later. So that's in a normal menstruating adolescent female, there is still this kind of period of time where the bones are not going to be as strong because they're grown in size, but their density has not caught up yet. 

28:51
Andrea Zujko
So I typically see more metatarsal stress fractures in my practice, but I have seen an injury to the talus. Well, it's actually a severe bruising of the talus. So there was no fracture of the bone, but there was a significant contusion of the talus. And this young woman that I've been working with, she's in musical theater and she has been dealing with a couple of very significant ankle sprains that have happened to her. I've known her now for, let's see, right before she went away to conservatory for college. So I've known her now for about five years and she during that time had suffered two significant sprains that I know of that really affected the mobility and stability of her ankle. But we took care of things as best as possible. Stabilize, good alignment, mindfulness, good recovery, rest days, everything was good until it wasn't. 

30:07
Andrea Zujko
And she was in a class and was maybe a little deconditioned but pushing herself a little bit and she went to do a soda shaw across the floor. And of course that involves really moving at a significant speed and landing one leg in a turned out position and things were not lined up well. She didn't sprain her ankle, but I think the forceful dorsiflexion that occurred really just I don't think her talus must have been out of alignment. I wasn't there at the time, but it just resulted in such a deep pinch and almost kind of a jamming sensation of her ankle that she had to limp out of the studio. So what do I think happened? I think that there was some alignment issue going on in her ankle before this happened. But what we have since discovered is that there's a lot of hip stability control issues that still creep up and we have to address and take care of, manage. 

31:23
Andrea Zujko
They go away, then they creep up again. So that's something, I think, that practitioners that work with hypermobile dancers have to consider, is that situations can arise again and maybe it's not the full fledged injury and that's great. But in terms of stability, it's like you need to do kind of a body check. And I found that I'm kind of looking at that more and more with my dancers with hypermobility. I mean, I like to think actually I do that with everybody. I try to take a holistic approach with my patients. So it's never just ankle, it's never just an elbow, it's never just your l five vertebrae. It's really the whole body in just assessing and treating up and down the chain as you see fit and continuing to monitor it because things can slip out. I'm sure you have dancers who tell you it feels like my body just kind of slips and slides out of place often. 

32:31
Andrea Zujko
And that's a normal occurrence for them. And that's where in many situations they can kind of get themselves integrated, reintegrated and put back together. And other times they need help, they need more hands on help, more directed help by somebody looking at their bodies, assessing their bodies, helping them find that place where they need to be. 

32:54
Dr. Linda Bluestein
I think taking that holistic approach is so important because if you're not addressing a contributing factor like that, like the hip stability, like the example that you gave earlier, then you're putting yourself at risk for re injury. And this is where I kind of go a little bit crazy with people if they're using their insurance for their physical therapy. Aren't you kind of caught sometimes with that? Or how does that work for you as a practitioner? 

33:24
Andrea Zujko
So I have to say that the work that I do is all out of network. That being said, I do have plenty of patients of mine that will submit to insurance. And insurance can get really bent out of shape if they see treatment for one area of the body when the prescription is for another area of the body. I have found that I have been able to get around that as long as I link all of my objective findings about, say, in the situation when I use the example of this dancer, the hip stability and control issues, if I link it down to the foot. Because there has been plenty of literature talking about the importance, let's say, of the gluteus medias and lateral ankle stability. So there you go. So you can kind. Of always put it in context of the body part that is so called you're authorized to treat and you are treating that and you're treating that because you're helping to balance out the leg, the lower extremity, so that the ankle will function better. 

34:40
Andrea Zujko
My notes tend to become pretty extensive documents over time. It's just part of you have to look at your patient as a whole. You can't just say, okay, well, this is just ankle and we're just going to wrap you up and you're going to ice and then you're going to sit on the floor and do these TheraBand exercises and then, okay, fine, put your shoes on, go back without considering anything else. And I don't think many people do that these days. But I do think that at least when you're starting out and maybe you're early on in your career actually trying to really seeing those patterns and recognizing the importance of the integration of the whole body can be quite daunting as a new grad. But just stick with it. Stick with it and ask questions and get your mentorship and look up the research that is available out there that is clinically useful and you'll start to really put it together well. 

35:47
Jennifer Milner
And the more people you see, the more bodies you have in front of you, the more patterns you start to see. So you see one person with ankle issue and maybe accidentally catch a hip thing and then you see another one and then the third one that walks in, you think, maybe I should look at their hip. And so it sort of becomes you learn from them, right? One of the areas that I didn't originally start associating with hypermobility was bunions. But the more hypermobile people walked through the door. And of course, most of whom I work with is pre professional and they're still in the process of developing their Bunions. And I ask the family history and we talk through all of that. And not bunions don't have to occur, right? Sometimes they're genetic, sometimes you're predisposed to them, but sometimes it's an issue of technique not being correct or shoes that are not working right and forcing the foot in poor alignment. 

36:39
Jennifer Milner
So I'm wondering, have you seen a higher incidence of bunions in people with hypermobility? 

36:45
Andrea Zujko
Very interesting question, Jennifer. So are you talking about local hypermobility at the foot and ankle or more of like a generalized hypermobility? 

36:54
Jennifer Milner
Well, certainly it could be localized. I mean, it could be generalized, but they would be the foot. When I typically see that foot that's flatter in standing but has that highly compressible foot that goes into that long, lovely line when they go on point or on relevant and it's like their tissue is a bag, as we've talked about, that just kind of gets stretched out. And so they have to work even harder with their foot strength, which I think we'll talk about in a little bit with tendons, but without that support, they have tendency. If they pronate, which a lot of dancers do well, then their feet can go into a much bigger range of motion. Their metatarsals can go into a much bigger range of motion perhaps than other people who might pronate. And so they might be more predisposed to that. That's just something I've noticed. 

37:42
Jennifer Milner
I was wondering if you've seen a higher incidence of that in hypermobile feet. 

37:45
Andrea Zujko
Yeah, it's interesting. The big question is that does hypermobility cause bunions or did the bunion result in hypermobility? So there is the thoughts that are out there. What are these predisposing and precipitating factors that are behind the etiology of a bunion deformity? So this could be foot type, your shoes, do you have hypermobility? What are your genetics? Is there any kind of abnormal anatomy of the foot? But we don't really know what the true etiology of HALLEX valgus, which is the more medical term for a bunion. So you're not necessarily going to get them from like, Grandma Pat. You could possibly develop them if you inherited the same type of foot type as Grandma Pat, but possibly not because there's so many other reasons why you might develop kind of this condition, which is really more of like subluxation of this first metatarsal philangeal joint or MTP joint. 

39:03
Andrea Zujko
It's very interesting if you start reading through some of the literature that the surgeons, the podiatric surgeons write about in terms of bunion deformity and the causes of it. Quite a few as of late feel that the bunion itself, the deformity itself, drives hypermobility in the foot. And when they fix that bunion deformity, the hypermobility of the foot goes away, which I find to be very interesting. Now, on the flip side of that, what I've seen in clinical practice is I have seen more issues of this hallux valgus in feet that have that more of like a flexible foot type than a rigid foot type. Which leads me to think, okay, maybe there's this dynamic stabilization issue going on. Sometimes there are those out there that don't feel that foot and ankle exercises really help and in one sense they probably don't. So the extrinsic and the intrinsic muscles of the foot really cannot support you passively or they can't create an arch that's not there. 

40:26
Andrea Zujko
But what they can do is they can help you with dynamic control of the foot. So I definitely think that's where we can really start to address issues in a more flexible foot, in a really highly compressible foot that might not have that control, that is leading to kind of this excessive force on the first MTP joint. And over time, maybe that's leading to a little bit of breakdown. So I think it's all about how you load your big toe joint onto the floor. What is your strategy just to kind of keep it simple? How do you put it down? How do you let me have those two little sesame bones, those little two P shaped bones that are underneath your first metatarsal, right? Those are like your train tracks, okay? They're really going to be responsible for enabling you to successfully push off through your first ray. 

41:25
Andrea Zujko
What is your first ray? Your first ray is your medial row of bones that forms a medial longitudinal arch that kind of terminates in this first MTP joint. And you've got the distal part of the hallux there. But how you put that foot down is going to pretty much dictate how you push off. And I do see now again, is this chicken and egg in the dancers, that a situation where what came first, the dancers that I do see with these problems of symptomatic bunions, painful bunions I detect and kind of tease out loading problems during walking assessments, loading problems during basic dance technique assessments that really show an inability to really control the kind of excursion of the first ray and the stability and positioning of what happens to that big toe joint with load. So I do a lot of reeducation in terms of teaching you how to walk. 

42:26
Andrea Zujko
Who teaches who how to walk? Do we ever really learn how to walk? No, we just kind of watch when we're little, we get up and we start walking. For the most part, I think we do pretty well. We don't, right? Either it's because of an injury or we just get ourselves into these imbalances that then lead to abnormal forces coming being placed through the body. In this case, we're talking about the big toe joint. So again, in dancers that have that more kind of flexible mushy foot, that foot that maybe has a little bit too much pronation in terms of pronation is a good word. It's not a dirty word, it's a good word. We need pronation of the foot for us to be able to load correctly onto our foot and push off. But you want to make sure that's controlled. And so in a lot of dancers that have bunion problems, I find that pronation is not controlled. 

43:25
Andrea Zujko
How they put their foot down, how they load through their first ray is not controlled. Again, going up to the hip, a lot of them get really tight and restricted at the hip joint. They lose their internal rotation up at their hip, which you absolutely need for adequate push off through that first ray. So those dancers, and again, these are probably the younger ones where they feel that they need to walk in first position all the time. 

43:57
Jennifer Milner
Right? So everybody needs to see it, or. 

44:01
Andrea Zujko
You just kind of get stuck there and that maybe is your default habit. I see other people do that as well. It's not just, I should sorry, pre pros out there, but you don't have to walk in first position. You shouldn't. You need internal rotation as much as you need external rotation. Those are things that I think are potentially driving problems at this joint that can lead to a bunion. Certainly having any kind of shoe wear that is not fitted properly to your foot is key. Certainly dancing with a point shoe, if you have a compressible foot, you cannot be in a shoe that is going to cause you to sink all the way down to the floor. I mean, that is going to really drive a lot of abnormal forces going through your entire foot. Fluting the big toe joint. So that is very important. 

44:56
Andrea Zujko
Walking reeducation is important. Technique reeducation is important. Looking at that ankle stability, looking at do you have a tendency to kind of fall into a winged and overly winged position when you're loaded into a demi point position? Again, we think those little sesame bones under the ball of the big toe, you're just kind of grinding them into a powder. I mean, you're going to sublux them and that's a big problem. It's so painful when that happens. And again, you want to have that really good alignment and integrity of the forefoot that you're really using the forefoot, the metatarsal philangeal joints, the ball of your foot as this beautiful platform that's equal opportunity. Okay. Maybe depending on the length of your little toe, you might not have as much weight bearing on that fifth toe, but you really need to have a nice balanced foot. 

45:54
Dr. Linda Bluestein
I'm glad you brought that up about the winging because I was wondering about that, and you see so many pictures on Instagram or wherever, and it looks like the entire weight of the foot is on the great toe. And I understand you want to avoiding sickling is important, and obviously there's a difference between doing a photo shoot and actually dancing that way. But I'm glad that you brought that up. 

46:19
Andrea Zujko
Yeah, I think you get into trouble with that. I'm all about if you want to wing your foot with your back foot when you're in an Arabesque ponche, what have you, go for it. If you're in that beautiful line, right? It's kind of like doing a cat eye with your eyeliner. 

46:39
Jennifer Milner
Right. 

46:40
Andrea Zujko
That swoop now you're getting me talking with my hands now, but it's not loaded. Right. It gets tricky. I think can put a lot of unnecessary stress through that big toe joint, which then potentially can lead to breakdown and this deviation that happens, which is really a progressive joint subluxation that doesn't reverse itself. 

47:12
Dr. Linda Bluestein
And if we can move from bones and those specific issues into tendons, maybe, because I would love to hear what you think about tendon problems that are most common in hypermobile dancers and how you treat them. What do you see there? 

47:29
Andrea Zujko
Tendons tendons are very difficult. I don't know. They're kind of cranky structures. And also the way that they heal in terms of how they respond to load really doesn't oftentimes coordinate well with a dancer who's working or a dancer who's actively training or someone who's in a collegiate program that can't take regular time off or kind of do this kind of on off loading cycle. So I definitely see a lot of tendinopathy. This ranges from kind of your acute reactive tendinopathy to more of like a chronic degenerative tendinosis type of problem. Typically, the more acute tendinopathies in the younger population, or maybe it's your first time around, or you have something like a peritendinitis where it's just a swelling kind of in the sheath of the tendon. If the tendon is a tendon that has a sheath, or in the older population, you have more of a tendinosis, kind of a chronic history of tendon problems. 

48:43
Andrea Zujko
We know that the repetitive motion and can drive some tendinopathy. But I tend to see more of issues coming. I find that issues come up when you're talking about overload. The most common scenario that brings dancers into see me with tendinopathy has to do with overload, sudden, rapid overload. So that I'm talking about a change in training, frequency, duration, intensity, or a dancer who's working that is coming off of a break. And they're coming from doing little nothing to very little to coming back to, like, a full workload tendons. Like to be you got to kind of stay in shape for your tendons, okay? Because if you don't, then what happens is that the tissue becomes a bit weaker and it's not able to handle the same amount of tensile load, and you can get back there, but it'll take time. We know that the body's tissues adapt to stress gradually, but we don't always have the time to do that. 

50:01
Andrea Zujko
Kind of getting into that pickle of a situation where you've had to rapidly load the body quickly. Your semester started. Your rehearsal period has started, and you went away for three weeks on a beach, and it was great, and you enjoyed yourself, but you got out of shape. Or especially during this time with COVID you were doing your classes in your bedroom, using your dresser as a bar, or you were trying to do some kind of center in your living room, and then all of a sudden, bam, you're right in the studio. And maybe you didn't have the guidance to kind of get back into shape before starting that. So all those factors kind of bring those tendon problems to me. And what I tend to see is I see a lot of Achilles tendinopathy, and then I see tendinopathy of your medial ankle tendons. 

50:53
Andrea Zujko
So your Tom, Dick and Harry's, all the physical therapists are going to know what I'm talking about. Of easy way to remember your medial ankle tendon so that's your tibialis posterior, your flexor digitorum longus, and your flexor halluses longus. So those are the most common tendons that I see in my practice that are affected. I would say the fourth one after that would be more of the perodus longus tendon. But if we stick with the Achilles and the medial ankle tendons, I find that dancers with hypermobility are susceptible to these types of injuries. Why that exactly happens is actually really interesting. So you can have injury or two overload of these tendons with very different foot postures or foot types, rather not foot postures, more arched types. Or you can have a high arched, more rigid cavis type of foot that doesn't have a lot of shock absorption. 

51:59
Andrea Zujko
And you could have a more flexible, flatter foot, if you will, that has a lot of shock absorption but not a lot of propulsion and is lacking maybe more medial ankle support. With the dancers that I see that have hypermobility and have a more high arched cavis type of foot, I find that's often coupled with more knee hyperextension and more knee hyperextension, I find sometimes drives a habit of dancers almost how should I say this? It's almost as if there's lack of control of the talus coming forward when they plant or flex their foot it's they just kind of hit the position without really working through the foot. Does that make sense? Yeah. Kind of like that nice juicy tondu on the floor right, where you kind of like it's really luxurious. You really see all that articulation, you give yourself that time to really work through the foot. 

53:07
Andrea Zujko
I find that dancers with this kind of combination of knee hyperextension with a Cavist foot, it's really easy. Again, and then any kind of training on top of that might advocate for that. If I say that diplomatically, that kind of leads to that kind of rapid pushing of that foot and of that ankle anteriorly, of that talus anteriorly, I find can lead to some trauma to the back of the ankle and of course the back of the ankle. We have the Achilles and we have the three medial ankle tendons. I also find that sometimes in that type of scenario, again, if you have the stancers, it's totally fine. It's a beautiful way like line of the leg. You just have to make sure that you are really taking the time to recruit the musculature of the round the foot and ankle adequately so you can really feel your calves working because you have that plantar flexion mobility, you have the picture, you have the end result. 

54:09
Andrea Zujko
What was your journey? What was your strategy to actually get there? And you want to make sure that your calf attended the party so that you're not kind of really jamming the back of the calcanias up to the back of the talus, the Achilles getting trapped. Or if you're not adequately contracting your calf, you might be using your deeper plantar flexors of your ankle and foot a bit too much. And so this gives a lot of work being done in terms know, let's make sure that we're kind of really trying to inhibit the overuse of the Tom, Dick and Harry tendons and really making sure we get adequate gastrocue. These things where you're going to do relevant reeducation standing with the toes off the edge of the book and all that stuff to really teach you how to use your calves, if that's something that you're finding it to be a challenge. 

55:13
Andrea Zujko
But again, also looking at that timing, dance quickly, but still it's the path that you took to get there in a dancer that has a more flexible type of foot that maybe doesn't have as much medial arch control, oftentimes that can result in a heel. We use a term called valgus. Your heel or Calcaneous bone might be a little bit more in a valgus position. It's basically kind of rolled in toward the medial side. That can really affect how much load and force is being put through the Achilles tendon as well as the medial ankle tendons. And that sometimes leads to increased overload of those tissues and the results of tendinopathy. Again, go proximal. And look at different issues going on, either with knee alignment, with hip alignment, with internal rotation control, with adduction control up at the hip and the knee that could potentially be driving increased even more force going through that medial column of the foot. 

56:25
Jennifer Milner
Well, and something I'm hearing you say over and over again, a lot of times people end up at a physical therapist because something has come up because something is wrong, right? And that's just sort of unfortunately, you guys get them when they have hit that point and then you have to work backwards to fix it. But what a lot of my clients don't understand right away because I see them before, hopefully they end up with a physical therapist when I say, hey, your feet are really pretty and flexible, let's make them stronger. And they're like, no, they're plenty strong. See, and they look so pretty, right? And I work on Reeducating that Tondu over and over again. And I think that's something that hypermobile people hear and it's certainly something we say on the podcast over and over again. Whatever joints you've got that are hypermobile, it's so easy to lock into it like you were saying to lock into the knee and to lock into the ankle. 

57:15
Jennifer Milner
People with hypermobile shoulders, it's so easy to lock into the shoulder and the elbow. But what muscular reeducation can we do to make that joint more stable and to give it all of that dynamic support that it needs? So it's not just that passive support, as you were saying. So it's not just going to see someone when there's a problem, but it's finding someone that can help you before there's a problem. So make you stronger and make you a more efficient dancer who can use all of that beautiful loveliness. So if someone is not in New York City and can't go see Andrea Zucco, how can they find someone who can help them with that. How would an artistic athlete find that medical professional or that really qualified trainer or somatic practitioner who can understand hypermobility and sort of the high demands on an artist's career? 

58:05
Andrea Zujko
That's a really good question with not a simple answer. This profession is growing. It's growing exponentially, which is wonderful because for so long it was just a lot of people in New York and then you had a few people in California and know not very many in other places in this country. So it's continuing to grow. That being said, sometimes it's very challenging trying to find a dance medicine specialist. So a couple things to kind of start you on your hunt to try to find somebody. Certainly ask your teachers, ask around. Don't be this whole culture of injury that we have to hide it and we can't talk about it, and it's this dark little dirty secret, and we have to be perfect and pain free 100% of the time. That's changing for the better, right? And hopefully this is something you can feel comfortable speaking to teachers about, asking them or maybe parents could potentially ask who do they see? 

59:13
Andrea Zujko
Who have they seen? For any injuries that they might have been dealing with. That would be something that you could consider. You could also try to find a practitioner through some of the professional organizations. So the big one that I'm a part of, as well as you are as well, is the International Association of Dance Medicine and Science, Iatoms, for sure. So if you go to Iadoms.org, I do believe they have resources that you can a resource page that allows you to search for a practitioner in your area. So that could be another way to see if there's somebody in your area to work with in terms of who's teaching Pilates in your area, who's teaching Gyrotonic in your area. A lot of practitioners who are in those two professions are former dancers, a little bit more networking, seeing who are they working with. 

01:00:18
Jennifer Milner
Well, and as you said, and we've had so many people, say before in different areas, you just have to find that one person, right? You find the teacher who knows somebody or a parent who has somebody that works with their child or you find something in NIA Adams that may not be the exact fit for what you need, but they could recommend someone to you. So it's finding that one person and then having that entire network that can come from knowing that one person. 

01:00:45
Dr. Linda Bluestein
Andrea, you were talking a little bit earlier about overstretching and how dancers don't necessarily need to do that know, they kind of have the hypermobile dancers. They have that range usually, and so it may be defeating the purpose. And as soon as you said that, I was thinking about foot stretchers. And is this something that is a good idea for dancers to use, or does it depend or what is your thought on foot stretchers? 

01:01:11
Andrea Zujko
Foot stretchers? It's kind of like the black market device, right? Anytime a dancer mentions to me that they're using a foot stretcher, they kind of look like they got their tail between their legs, afraid of what I'm going to say. So I get why they were designed and I can understand why a dancer would want to use them. And certainly when you start using a foot stretcher, you're usually pre adolescent. So again, maybe having that self reflection and analysis why you're doing something, maybe you need a little bit of guidance on that. I find that foot stretchers are more often sought by dancers, are used by dancers, is what I want to say. So foot stretchers are used, in my opinion, more often by dancers who have a stiffer type of foot, more of a foot that doesn't really have a lot of plantar flexion available at the tallocrual joint, which is the first area that you should plantar flex in, right? 

01:02:22
Andrea Zujko
You should plantar flex at the talacrual joint first, followed by the midfoot, and then finally down at the metatarsal philangeal joints. So if you don't have that excessive range of plantar flexion, then your point looks a lot less arched or curved. And of course, a lot of dancers are self conscious about that or unhappy about having that as their line, so they will seek out the use of using these foot stretchers. I have a big problem with that because a lot of times the reason why they don't have as much plantar flexion at their ankle, it has to do with the design of their foot. And you're not necessarily going to get a copious amount of plantar flexion at your ankle as a result of using the foot stretcher. What I find happens is that the stress, or the stretch, if you will, that the foot stretcher introduces is more at the midfoot and it becomes results in excessive force being placed at the midfoot and the midfoot where your transverse arch is. 

01:03:33
Andrea Zujko
That needs to be an area of really good stability. So if you're starting to really put an excessive amount of force through that midfoot, I think it could potentially hurt you in terms of developing problems along the way, more of like a midfoot breakdown. Also, if you are trying your best to kind of force your foot into this platter flex position at your ankle joint, you could potentially be damaging the structures that are in the posterior aspect of the ankle as you're trying to really push that Calcaneous up and forward. And I've had quite a few dancers over the years develop problems with posterior impingement that can be just a bruised state of process that could be an ostragonum from using a foot stretcher. There are ways to safely stretch your feet. I've taught many dance teachers how to safely stretch their students feet. I certainly work on that as a PT, how to safely stretch the foot and ankle if it's needed. 

01:04:43
Andrea Zujko
But I find that it's going to happen as a result of dance training. Over time, your body will adapt to the forces that you place through it. So you're going to continue to be working on your range of motion, hopefully in a very sound way, as you go through your training. You don't need to force the foot into this extreme position that it might not be built for. 

01:05:12
Dr. Linda Bluestein
That makes perfectly good sense. 

01:05:14
Andrea Zujko
Be very careful. Right. 

01:05:18
Jennifer Milner
That is all an excellent amount of advice for people to be able to take away with them. So thank you very much for all of that. You're welcome. 

01:05:27
Andrea Zujko
Thank you. 

01:05:28
Jennifer Milner
Thank you for you have been such a wealth of knowledge today on the whole topic of the foot and ankle. I know it's so easy to do a deep dive on it and to keep talking about it because there's so much about it. It's such a complicated structure, especially for artistic athletes. Where can people find you if they want to get in touch with you? 

01:05:49
Andrea Zujko
Well, you can find me. So, again, I manage the clinic called Westside Dance Physical Therapy here in New York. So if you want to look up the website, it's Westsidedancept.com, so you can find me there. I'm listed under the staff section. You can email me at andrea@westsidedancept.com. Or for those of you who want to know more about the collaborative dance medicine education that I do, you can look me up via my company Dance Medicine Education initiative and the website is dancemedi.com. And I'm also on Instagram at EI, and I'd be happy for you to follow me there and see what I'm up to. 

01:06:37
Jennifer Milner
Excellent. Thank you so much, Andrea. You have been listening to bendy bodies with the hypermobility MD. Today we have been speaking with Andrea Zucco. Andrea, thank you so much for sharing your expertise with us today. 

01:06:49
Andrea Zujko
Thank you. It was my pleasure. 

01:06:51
Dr. Linda Bluestein
Thanks so much. 

01:06:53
Jennifer Milner
Bye. 

01:06:54
Dr. Linda Bluestein
Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other aesthetic athletes. If you found this information valuable, please share it with a colleague or friend and leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes. If you want to follow us on Instagram, it's at bendy underscore Bodies, and our website is WW bendibodies.org. If you want to follow Bendy Bodies founder and co host Dr. Bluestein on Instagram, it's at hypermobilitymd all one word. And her website is WW dot hypermobilitymd.com. If you want to follow cohost Jennifer Milner on Instagram, it's at jenniferperiodmilner Milner and her website is www.jennifermillner.com. Thank you for helping us spread the word about hypermobility and associated conditions. We want to hear from you. Please email us at info@bendibodies.org to share feedback. 

01:08:03
Dr. Linda Bluestein
The thoughts and opinions expressed on this. Podcast are solely of the co host and their guests. They do not necessarily represent the views and opinions. And we'll catch you next time on The Bendy Bodies. Podcast constitute medical advice and should not be used in any legal capacity whatsoever. This information is not intended to diagnose, treat, cure or prevent any disease, as this information is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for all medical concerns.