This one's for the bendy girls

While many of us struggle to touch our toes or scratch our own backs, there are some who have never had an issue folding in half, doing the splits, or dropping into a backbend. A lot of people with these skills find themselves dancing, ice skating, doing gymnastics, cirque, or yoga. Despite their graceful appearance and stretchy superpowers, there can be underlying disadvantages, such as pain and heightened risk of injury. This excessive joint flexibility is what we call “hypermobility” in the Physical Therapy world, hyper meaning above or beyond and mobility referring to the ability to move.  

Hypermobility Spectrum Disorder (HSD) is thought to occur in 1 of every 4 people and is an umbrella term to describe that includes more specific conditions, including: Ehlers-Danlos, Marfan Syndrome, Hypermobility Spectrum Disorder, and Osteogenesis Imperfecta.  

Let’s discuss a little anatomy to understand how hypermobility can lead to pain. Joints articulate our bones together with connective tissue, including ligaments that are tough bands that hold bones together. Joints are home to many nerves and rich blood supply, while ligaments assist to stabilize the joints and contain receptors that are responsible for how we perceive joint position, movement, and speed.  

In individuals with hypermobility, the composition of collagen in the joints and ligaments are more easily lengthened and not as supportive, which can lead to instability of the joints if there is not sufficient muscle strength to provide the lack of support. This can lead to nerve injury in the joint, inflammation from internal and external stresses on the joint, dislocations, subluxations, muscle fatigue from working “overtime” to generate support, changes in body mechanics due to poor awareness of where the body is in space, and joint degeneration. Not everyone with hypermobile joints experiences pain, however many do at some point in their lives.

Aside from pain, other common symptoms associated with hypermobility include:  

  • stiffness in the joints
  • fatigue
  • joint clicking
  • dizziness
  • trouble regulating blood pressure
  • more susceptible to bruising
  • gastrointestinal disturbances
  • depression, anxiety
  • thin skin

Here’s the thing, if this has been happening your entire life and you have nothing to compare it to, then this pain is “normal” for you and becomes chronic. Consequently, pain receptors and pain messages to your brain adapt and become accustomed to these signals, sometimes triggering pain from unrelated stimuli. These amplified pain signals can intensify with emotional and physical stress, disrupted sleep, depression, anxiety, or abnormal hormone levels.

So, let’s put a practical perspective into this. Say Sarah has been a competitive soccer player her entire life, since she was a little girl, and never thought twice about her hypermobile joints. She’s had repetitive ankle sprains, kneecap subluxation, shoulder dislocations from contact, and bilateral hip pain. Soccer is a demanding sport that requires complex movement. You need to constantly cut, or quickly shift directions, kick a ball at high velocities with one leg while keeping multiple joints stable, loading multiple joints at once on the standing leg when you kick the ball, and sprinting in multiple planes. On top of this, you need coordination and balance!

In this classic scenario, Sarah, like many elite athletes, started playing soccer at a young age and transitioned to both high school and club soccer to increase competence. This typically translates into minimal cross training, or otherwise, over-utilizing and stressing the same muscle groups repetitively. In addition, many youth athletic programs neglect the importance of strength training, which is even further essential if you exhibit hypermobile joints. This is where correcting form and biomechanics is advantageous. With hypermobility, there is less awareness of where our bodies are in space, allowing excessive or high velocity movements beyond the load a joint can withstand. This means people with hypermobility are more prone to injuries like sprains, dislocations, subluxations, sports hernias, and muscle and tendon strains.  

How can Physical Therapy help manage pain and avoid injury in those with hypermobility?  

Movement Analysis

Habits and our daily movement patterns can contribute to pain since they are frequent and repetitive. For example, a volleyball player with hypermobility may experience pain from hyperextending their shoulder while hitting. Cuing the player to generate more power from trunk rotation, core recruitment, and using the momentum from loading the lower extremities can decrease the stress of the shoulder.  

Manual Therapy

Muscle pain in hypermobility can originate from muscles overworking in trying to help stabilize joints. Muscle fibers can also overly elongate with high velocity movements, causing soft tissue damage and inflammation. In hypermobile individuals, it can be difficult to feel a stretch due to the extensibility in their collagen. The joints may be able to move way beyond a “normal” end-range, but the muscles are still stiff and tight. Soft tissue mobilization is an intervention that can reduce muscle tension by improving direct blood flow and oxygenation of the muscle and increasing mobility of the fascia that encases these muscle fibers, while moving fluid contributing to inflammation and pain.

Balance Training

Balance training in Physical Therapy can be advantageous to increase postural control, decrease risk of injury by promoting safe fall strategies and corrective reflexes, and strengthening normally underutilized muscle groups. A recent study analyzed the effects of balance training on chronic ankle instability in a population with hypermobility and revealed a lower incidence of recurring ankle sprains immediately and 3 months afterwards than the control group without hypermobility.  

Strength Training

Multiple studies have been published that compared populations with hypermobility syndrome to control groups, revealed significantly less muscular strength, endurance, and performance. At the first visit, a Physical Therapist can assess which muscle groups are weak and determine which exercises can promote optimal function. For example, the rectus femoris (aka your quad/thigh muscle) may need more strengthening if your knee is buckling when going downstairs.  

How can you find out if you are hypermobile or have hypermobile spectrum disorder?

  • Beighton Score Testing: This test uses a 9-point scoring system, which tests 5 physical maneuvers, including how far you can bend your thumb or knees backwards, and asks 5 questions regarding your medical history. The test is positive if you score 5 or more points in the physical portion, with a history of pain in at least 4 joints for the past 3 months, and if you meet at least 2 of the medical history criteria.  

If you are interested in further testing your hypermobility you can check these out:

  • Lower Limb Assessment Score (LLAS): This is a 12-point scoring system that is a more detailed test and specific to the lower body. This test examines the quality of movements, including how loosely the thigh drops towards the patient’s chest while bending the hip or how the ankle affects the arches of your feet in weight-bearing. This test is positive with a score of 7 or more points.
  • Upper Limb Hypermobility Assessment Tool (ULHAT): This is also a 12-point scoring system similar to the LLAS that looks at the upper body. The examiner looks for movements such as how far your shoulder can separate from the socket and how far can your elbow deviate to one side or the other. Testing is also positive if there is a score of 7 points or more.

There are a multitude of other tests that include physical examination and questionnaires, including (not all mentioned):

  • Carter and Wilkinson Scoring System
  • Modified Line Drawings
  • Sasche Scale
  • Kapandji Index
  • Hakim and Grahame Questionnaire  
  • Rotes-Querol Criteria

Whether you are “officially” diagnosed with hypermobility spectrum disorder or you’re suspicious and feel like this might be you, the key takeaway from this is to increase awareness of options available to those who experience pain or injuries with suspected hypermobility. And just because your body is bendy, does not mean that it is bad. It just means you need to give it the love and literal support it needs.  

If you would like more resources we recommend checking out this website in their “patient” section to learn more 😊  

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