Understanding Hypermobility Foot Mechanics and Pain Management

I always start at the feet.

There are two major foot movements that we need to be able to do for healthy foot mechanics – pronation and supination. Pronation sees a flattening of the foot and internal rotation of bones. Supination sees a lifting of the arches and external rotation of bones. Research shows that people with joint hypermobility syndrome can have multiple alterations in walking patterns including reduced walking speed, altered stepping patterns, and stiffened joint movement when walking (probably an effort to avoid pain or protect the joint) (2). This points to a need for gait training and learning how to effectively move our feet.

Importantly, the muscles in the foot can be deconditioned just like any other muscle in the body. The good news is we can learn how to work these muscles to support balance and posture and rehab our bodies from the foot up. We need to find a way to give our feet structure and support whilst maintaining foot mobility.

Introduction to Foot Health

“When the foot hits the ground, a whole body reaction occurs.”

Gary Ward, What The Foot

The feet are so important. Ideally, for healthy foot positioning, we want to aim to stand on a tripod or a neutral foot. The tripod is made of the heel bone, big toe pad, and little toe pad. This makes up the support structure of your foot. In a neutral position, the three points will be in contact with the ground.

When we walk we push off the big toe bone or first metatarsal. It gives us the power to push off and activate the whole posterior chain to move through the step. We need to pronate when we walk. When we step into the foot we lengthen and widen to allow the foot to move and adapt to the impact of the ground. If we didn’t, there would be too much stress going through the joints.

So many of us have issues around many of the joints and foot structures that can lead to altered gait patterns, altered posture with standing, and pain.

Anatomy of the Foot

The foot is made of 26 bones, 33 joints, and more than 100 muscles, tendons, and ligaments. Feet are made for movement!

The bones of the feet are:

• Talus – the bone on top of the foot that forms a joint with the two bones of the lower leg, the tibia and fibula.
• Calcaneus – the largest bone of the foot, which lies beneath the talus to form the heel bone.
• Tarsals – five irregularly shaped bones of the midfoot that form the foot’s arch. The tarsal bones are the cuboid, navicular, and medial, intermediate, and lateral cuneiforms.
• Metatarsals – five bones (labeled one through five, starting with the big toe) that make up the forefoot.
• Phalanges (singular: phalanx) – the 14 bones that make up the toes. The big toe consists of two phalanges – the distal and proximal. The other toes have three.
• Sesamoids – two small, pea-shaped bones that lie beneath the head of the first metatarsal in the ball of the foot.

Common Foot Problems and Their Causes

Ankle instability

Perhaps unsurprisingly to many of us, people with joint hypermobility have a higher risk of re-sprain and persistence of complaints following an ankle sprain (3). Ankle instability and sprain is something I see often in my clients and a common complaint in The Zebra Club community.

One research group set out to assess balance training as a treatment for chronic ankle instability. They compared their balance training protocol in a group of people with chronic ankle instability (based on MRI) and split them into two groups – one considered to have generalized joint hypermobility which they categorized as having a Beighton score greater or equal to 4.

They found that patients with generalized joint hypermobility had even better outcomes with balance training than the less hypermobile group. They found an improvement in sprain recurrence, balance control, and muscle strength (3). Balance is a key tenant in my Integral Movement Method, I have a whole chapter devoted to the foot and balance in my book Hypermobility Without Tears. I believe balance is essential for everyday life and love seeing this improve in my clients when we work together.

Plantar fasciitis

Plantar Fasciitis is a painful foot condition I often see in my hypermobile clients. The plantar fascia is a thick band of connective tissue that provides support to the arch and helps provide structure for propulsion and energy for stepping (4). This is a painful condition occurring at the bottom of the feet, that is often worse in the morning or after long periods of rest. This is thought to be due to issue with where the plantar fascia connects with the calcaneus (heel bone)(5).

Here is a short video on how to manage this condition.

Flat feet and high arches

In a flat foot, like we often see in hypermobility, there is going to be a tendency for the bones to rotate inwards, causing the ‘knock knee’ look or X legs. The thigh bones then roll inwards which tends to lead to an anterior tilt of the pelvis. You can work at trying to fix the anterior tilt, but unless you also look at the mechanics of the foot upwards, it probably won’t be successful. You have got to take a global look at the body. The Letter X on the A to Z of hypermobility looks at this X leg issue and how to correct it.

Different studies have found both a higher prevalence of flat feet (pes planus)(6) in hypermobility and a higher prevalence of high arches (pes cavus) in hypermobility (7). I tend to see more flat than high arches, but what is important is this can be changed and worked on to improve mechanics.

Here are some other foot issues you may have experienced:

• Blisters
  • If we have imbalances in how we walk and stand, friction can cause blisters
• Bunions
  • Or Hallux Valgus is commonly seen in Ehlers-Danlos Syndrome (8)
• Neuroma (nerve tumor or Morton’s neuroma)
  • If the metatarsals move too much due to hypermobility, friction on the interdigital nerves can occur which could lead to a neuroma.
• Ingrown toenails
  • The nail grows into the toe, usually the big toe.
• Corns and calluses
  • Friction and imbalance can cause these to develop. I can always tell a lot about how my clients walk by looking at the calluses on their feet.
• Overuse injuries and strains
  • This is very common in hypermobility. Mechanics and gait improvements can help prevent this.
• Heel pain
  • Working on developing a tripod can prevent excessive heel pressure and pain.
• Clawed toes
  • I was guilty of this. I would claw my toes as a form of stability. The feet are often the last resort when all other stabilisers have failed. It also meant I was very front-body dominant, which I see a lot in my clients.
• Arthritis
  • While hypermobility itself doesn’t cause arthritis, it can contribute to joint wear and tear, potentially increasing the risk of developing arthritis over time, especially in weight-bearing joints (Arthritis UK)
• Athletes foot
  • A common fungal infection that affects the feet. It can be treated with creams and sprays. The symptoms can cause itchiness, inflammation of the skin, blisters, and stinging. These will all impact our correct walking patterns so it is important to have these infections looked at as soon as possible.
• Delayed wound healing
  • We know that EDS wounds tend to take longer to heal, which will impact proper gait mechanics due to pain.
• Small fiber neuropathy
  • This is beginning to be found commonly in people with hEDS (9). This may feel like burning feet or pins and needles.

Hypermobility and Foot Pain

Foot pain is common, but as I mentioned above, foot issues can cause pain all the way up the body. Walking may result in pain, and not just in the foot. The gait can impact the whole body.

Some reasons you may be experiencing foot pain with hypermobility:

• Alignment & Posture
  • Alignment of the bony structures is key.
• Laxity of joints
• Structure
  • Structural issues can lead to conditions like bunions and neuromas.
• Gravity
  • This is pulling us down and potentially flattening our feet
• Environment / Job / Home / Stress
  • Do I exercise my feet enough? Do I wear shoes all day so they are not moving naturally?
• Spinal / Pelvic Instability
  • The feet impact the pelvis and vice versa. If I have a twisted pelvis, that is going to cause more weight in one foot than the other.
• Immobility in other areas
  • Such as knees or hips – if something does not move well, like your knees, the feet may take up the load and have excess movement.
• Proprioception & Motor Control
  • Lack of proprioception in the feet has been found in people with EDS (10)
  • Check out this video
    to learn more about proprioception
• Balance
  • A super important part of any EDS / HSD training programme is to work on balance. The act of walking is, in fact, a balancing act. My Letter B for Balance and Breath gives you some simple exercises to try.
• Breathing
  • If we more frequently use high up chest breathing – This can disrupt our balance. We need to get weight down into the feet, but without collapsing into them.

The good news is there are things we can do to address so many of these issues and improve your pain.

Footwear and Support

Custom orthotics and proper footwear can go a long way in improving foot pain. One study assessed the use of custom orthotics in people with EDS and found wearing custom insoles for 3 months (7 hours a day) led to improvements in foot pain, foot functionality, fatigue(!), and mental-health-related quality of life. This was based on questionnaires filled out by participants the day the orthotics were received and 3 months later (11).

Sophie Roberts and Alan Hakim also state orthotics help improve proprioception, help with ankle stability and recurrent sprains, and help with issues further up the kinetic chain (knees, hips, back) by changing foot kinematics (or motion of the foot) (1).

The orthotics mentioned in both publications were created by podiatrists who had an awareness of EDS, which is sadly not always our experience. Working with EDS-aware podiatrists like Sophie Roberts can guide you in shoe and orthotic selection working with your individual patterns and gait. The Zebra Club members can watch a past presentation from Sophie Roberts in the Resources Section of the App (Presentations > September 2023).

Some favorite shoe brands of The Zebra Club members include Hokas, Brooks, and Oofos

Therapeutic Exercises for Feet

When I address the foot with my clients these are some of the main things I focus on:

• Mobility
  • The ability to start to move pain-free
  • Try this: foot mobilization exercises with a spikey ball
• Stability
  • Finding stability without guarding or bracing
  • Try this: standing on one leg whilst holding on
• Calming of nervous system
  • This can help with pain sensitisation
  • Try this: breathing exercises
• Strength
  • To support the body and mind
  • Try this: foot strengthening exercises

You can find classes to address each of these aspects in The Zebra Club app

In this video, I dive into all things feet, and the issues we face in hypermobility, and how we can address these issues with movement.

Literature Review/Research by Catherine Nation, MSc, PhD

Works Cited

1. Roberts & Hakim (2024). Chapter 75: Painful heels, and tired and clumsy feet Poor biomechanics in the feet causing localized pain, poor gait, and fatigue when walking. Symptomatic Editors: Clair A. Francomano, Alan J. Hakim,
2. Lansdale G.S. Henderson, Fraser C. Henderson Sr.
   Alsiri et al. (2020). Gait biomechanics in joint hypermobility syndrome: a spatiotemporal, kinematic and kinetic analysis. Musculoskeletal Care.
3. Hou et al. (2023). Balance training benefits chronic ankle instability with generalized joint hypermobility: a prospective cohort study. BMC Musculoskeletal Disorders.
4. Cutts et al. (2012) Plantar Fasciitis. Annals of The Royal College of Surgeons England.
5. Petraglia et al (2017). Plantar fasciitis in athletes: diagnostic and treatment strategies. A systematic review. Muscles Ligaments and Tendons Journal.
6. Berglund et al. (2005). Foot pain and disability in individuals with Ehlers – Danlos syndrome (EDS): Impact on daily life activities. Disability and Rehabilitation.
7. Cimolin et al. (2014). Foot type analysis based on electronic pedobarography data in individuals with Joint Hypermobility Syndrome/ Ehlers-Danlos Synfrome Hypermobility type during upright standing. Journal of the American Podiatric Medical Association.
8. Vermeulen et al (2022) Altered multi-segment ankle and foot kinematics during gait in patients with Hypermobile Ehlers-Danlos Syndrome/Hypermobility spectrum disorder. A case-control study. Arthritis Care Research.
9. Igharo et al (2022) Skin biopsy reveals generalized small fibre neuropathy in hypermobile Ehlers–Danlos syndrome. European Journal of Neurology.
10. Robbins et al (2019) Neuromuscular Activation Differences During Gait in Patients With Ehlers-Danlos Syndrome and Healthy Adults. Arthritis Care and Research.
11. Reina-Bueno et al (2020). Custom-Made Foot Orthoses Reduce Pain and Fatigue in Patients with Ehlers-Danlos Syndrome. A Pilot Study. International Journal of Environmental Research and Public Health.