Strength and fitness:

Regular exercise programs help with hypermobility and chronic pain problems such as fibromyalgia, osteoarthritis and rheumatoid arthritis.

With hypermobility syndrome it's important to develop and maintain a good fitness program matching your individual needs. This should to take into account your tissue strength and ability to withstand acute and repetitive stress without sprains, strains, tendinitis or bursitis.

If you fall into one of the more severe categories, you have to consider your vascular strength which may include risk factors for cerebral and aortic aneurysm. Talk to your primary care physician regarding this.

Contact sports or any high impact activity can be damaging. At the same time you want to maximize the strength of your tissues from muscles and tendons to ligaments and bones density. Cardiovascular health needs to be included as well. 

The program should be consistently followed to avoid back sliding and becoming discouraged as well as the difficulty and pain of restarting.

Developing proprioception (body awareness), balance, and reaction timing is critical for prevention of acute injuries and repetitive stress caused by poor coordination.  Maintaining balance and control is important beyond simply not falling down and hurting yourself. This is where exercises such as tai chi and yoga can play a big part – not in training you to stretch further and cross your legs and a weird fashion, but to stand on one foot and remain in control as you shift your weight to the side or to the front. The more hypermobile you are the less proprioceptive input you have regarding your position in the world. If your position sense is not good it's easy to overstress joints. If you're not stable standing on one foot and your ankle is wobbling back and forth you have to ask, what is happening when you're walking?

Overstretching, as in some forms of yoga and weightlifting, frequently produce unwanted symptoms and risk decreasing motor control. Never stretch beyond the range that you would normally use.

Isometric exercise avoids hyperextension and some overuse issues while contributing to strength.

Try to use free weights, body weight and closed chain exercises as opposed to machines when possible. Choosing dumbbells rather than machines in the gym prepares you better for everyday life since they are like real objects and promote better control and stabilization. Use of low impact elliptical training machines can replace high-impact running.

Running a 5K may be a reasonable option for some whereas half marathons are probably a bad idea for anyone who is hypermobile. If you choose to run be certain that you can do it with perfect form all the way down from knees to controlling ankle pronation.

Recovery is a critical component of your program. This includes at least eight hours of sleep. It's best to use undulating periodization to maximize the rest intervals so that you aren't exercising the same muscle groups in the same way too frequently.

Exercising in the pool is a reasonable recovery option but you have to keep in mind that we operate on dry land most of the time and need to maintain competence there. It is also difficult to maintain weight using only pool exercise. Pain-free swimming may require a kickboard or extra care to avoid hyperextending elbow and other joints.  Rotator cuff strength and scapular control are critical.

Lifestyle and ergonomic modification:

You need to protect yourself from impacts, move well, maintain excellent posture and be supported well by your furniture. Things that don't bother other people may bother you and things that don't feel uncomfortable to you may be very damaging to you.

Typing can reduce pain from writing. Alternating between different types of mice can help reduce wrist stress.

Voice control software or a more ergonomic keyboard can reduce pain from typing.

Bent knees or sitting can reduce pain from standing. Avoid shifting your hips forward into a swaybacked position.

Other treatments:

Chiropractors, massage therapists and physical therapists can be used as needed for specific circumstances.

It is counterintuitive to use treatments intended to increase mobility on a hypermobile person. The problem is you need your muscles to control the position of your joints but when painful they are unable to do a good job of this. Experienced massage therapists can help improve function.

When spinal joints are locked up and painful and you are unable to move properly you compensate and can overstretch other areas. Chiropractors and physical therapists can use gentle techniques including muscle energy techniques and mobilization to assist with this. They can also help you figure out your exercise plan and ergonomics.

A pain psychologist referral can be useful e.g. cognitive-behavioral therapy or other evidence-based care.

I highly recommend the following paper and have included some relevant selections below:

“Joint hypermobility syndrome, alternatively termed Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT), is likely the most common, though the least recognized heritable connective tissue disorder.” ~ Joint hypermobility syndrome (a.k.a. Ehlers-Danlos Syndrome, Hypermobility Type): an updated critique. Castori M

Frequently hypermobility syndrome is not recognized or is considered unimportant unless a family member has a brain or aortic aneurysm due to congenital collagen weakness. I see quite a few novice runners in the training team who have problems caused by hypermobility – more than would be expected in the general population.  It makes sense since I am looking at a subgroup that has problems.

There is a broad spectrum of hypermobility syndromes ranging from a little more than normal flexibility to named genetic syndromes that weaken multiple systems like Marfan Syndrome and Ehlers-Danlos Syndrome.

The term, “hypermobility syndrome” is old and has been replaced in much of the literature but is still in common use. The terminology is currently too nonspecific, lumping together some high risk systemic collagen problems along with more common situations that require only recognition of lower stress tolerance. 

People with hypermobility syndrome often seek our help for multiple problems. Some examples are:

-          Joint instability causing frequent sprains, muscle strains and overstress, tendinitis and bursitis. 
-          Increased injury by impacts in contact sports or accidents.
-          Fibromyalgia Syndrome (FMS).
-          Joint pain including wrists, shoulders, hips, knees, feet (bunions, pronation)
-          Early-onset degenerative joint disease (DJD) (Osteoarthritis)
-          Early, wide spread spinal disc degeneration
-          Temporomandibular Joint Syndrome (TMJ syndrome)
-          Carpal tunnel syndrome

The more severe conditions warrant monitoring the patient for vascular problems.  They also require chiropractors and PTs to be more selective and gentle with manipulation / mobilization, stretching and exercises. It generally takes more effort to develop an effective treatment program and more work and time on the patient’s part to manage the situation.

Your brain and spinal cord know where all your parts are and how they are moving by way of sensory input.  Much of this is from stretch sensation which is diminished in very flexible people. If your central nervous system does not know your joint and body position instantly and there is a delay due to increased stretching, it can move farther before reacting.  This increases damage during impact and also during walking and running.  It forces your muscles to tighten on both sides of a joint during motion to stiffen it and provide information.  This creates tight sore muscles and tendinitis or bursitis. These muscles and tendons as well as ligaments and joint capsules can overstretch as well, which promotes further displacement especially in the ankle and foot.

Diagnosing HMS

I test single leg standing on almost all of my patients.  Their ability to balance with minimal ankle wobbling is important.  When I test patients with eyes closed and, in the extreme, with their head tilted back, they are prevented from relying on vision or inner ear for balance.  They are then forced to rely on information from their foot and the rest of their body to determine where they are and maintain balance.  Eyes closed is a good reflection of how stable you are with the lights off or when texting while standing or walking.

I look at their posture for knees that go backward (Genu recurvatum) and elbows that hyper extend or thumbs that can easily reach their wrist.  Excessive ankle pronation with arch flattening and bunions is an indication of overstretch and excessive shearing motion at the big toe.  These are indications that their collagen is not supporting their structure well.

Female hormones (just before their period) and to a much greater extent, during later pregnancy, greatly increase mobility.  Pregnant women have run Marathons but the question as to whether it is good for them or the baby remains controversial. Children are often more mobile.  There also seems to be a difference between ethnicities around the world. This needs to be taken into account when determining whether the patient is normal or hypermobile and what activities are appropriate. 

Since July 2000, hypermobility has frequently been diagnosed using the Beighton criteria.  The Beighton criteria incorporate the Beighton score along with other symptoms.

The Beighton score: Add 1 point for each of the following:
-          Placing flat hands on the floor with straight legs
-          Left knee bending backward (passive knee hyperextension over 10°)
-          Right knee bending backward (passive knee hyperextension over 10°)
-          Left elbow bending backward (passive hyperextension of the elbows over 10°)
-          Right elbow bending backward (passive hyperextension of the elbows over 10°)
-          Left thumb touching the forearm (passive flexion of the thumbs to the flexor surface of the forearms)
-          Right thumb touching the forearm (passive flexion of the thumbs to the flexor surface of the forearms)
-          Left little finger bending backward past 90 degrees (Passive dorsiflexion of the fifth finger of the hands over 90)
-          Right little finger bending backward past 90 degrees (Passive dorsiflexion of the fifth finger of the hands over 90)

HMS is diagnosed in the presence of two major criteria, one major and two minor criteria, or four minor criteria. The Beighton criteria have not been very well supported in the literature in that the minor criteria do not add much to the correlations.

Major criteria:
-          A Beighton score of 4/9 or more (either current or historic)
-          Arthralgia in four or more joints for more than three months.
-          Criteria major 1 and minor 1 are mutually exclusive as are major 2 and minor 2.

Minor criteria
-          A Beighton score of 1, 2 or 3/9 (0, 1, 2 or 3 if aged 50+)
-          Arthralgia (> 3 months) in one to three joints or back pain (> 3 months), spondylosis, spondylolisthesis/lysis.
-          Dislocation/subluxation in more than one joint, or in one joint on more than one occasion.
-          Soft tissue rheumtism. > 3 lesions  (eg. Epicondylitis, Tenosynovitis, Bursitis)
-          Marfanoid  habitus (tall, slim, span/height ratio >1.03, upper: lower segment ratio less than 0.89, arachnodactyly; positive Steinberg thumb / Walker wrist signs).
-          Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring.
-          Eye signs: drooping eyelids, myopia or antimongoloid slant (Palpebral slant)
-          Varicose veins or hernia or uterine/rectal prolapse.


Check back tomorrow for part two: Managing HMS

Image courtesy of Ambro at FreeDigitalPhotos.net

We know some measures that can be taken to protect runners from excessive eccentric loading.

When running downhill, keep your stride short and avoid excessive heel strike. This protects your anterior tibialis which is keeping your toes from slapping down as well as protecting your quadriceps, psoas, and gluteus medius that are stabilizing and controlling your speed.

When you are fatigued to the point that you cannot train with good form any longer, it is time to quit because you're treating compensation instead of good form. You are also increasing stress that will cause you to have to recover longer before you can train again.

At the end of a long training run your hamstrings are fatigued and not decelerating your leg when it swings forward. This increases your stride length, causing heel strike. At the same time you're glutes are fatiguing and not controlling hip sway which is then controlled eccentrically by the TFL - IT. Your glutes are external rotators and when they are fatigued the deep external rotators such as the piriformis have to become overactive to compensate.

Look at the attached study if you are interested in further information. I have edited and reorganized the paper to make it more readable. The paper in its entirety is available for free on pub med. See appendix A at the end of the paper for their walk run program.

I like this paper because they attempt to find cues that were effective in changing behavior rather than simply stating an analysis which as we know frequently does not change what is performed. The fact that this group of subjects had this particular problem is a good indication that they probably have running form issues that are either causative or at least contributory. We do see this problem and problems with similar mechanisms a lot in our novice runners.

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