Training with Hypermobility
Yoga, Personal Training, Mobility & Recovery
For years, hypermobility was a term that we didn’t hear much in the training world. It was understood people have various degrees of mobility, and some were naturally more flexible than others. Once in a while, you would come across the person that was double jointed, but trainers and coaches didn’t ponder the ramifications of this extra flexibility.
When I was going through yoga teacher training, we were required to observe classes. This was, actually, my favorite part of training because I find movement and the variability in movement fascinating.
As I sat in the back corner of the room and watched, I noticed most people in the room were fairly bendy. This makes sense; we tend to like what we are naturally good at, and bendy people are “good” at yoga. There were always a few people who, like me, weren’t naturally bendy, but were willing to take modifications and get into the poses as fully as they could. There were also usually one or two people with flexibility that could only be described as extreme. The teacher would cue fold forward and their chest would be on their legs, or she would ask everyone to raise their arms and not only would their arms go in the air, they would go backwards. These individuals reminded me of Gumby—highly pliable, with little glue holding them together.
Are You Hypermobile?
Individuals with extreme amounts of flexibility are often dubbed hypermobile. You can have a lot of flexibility and not actually be hypermobile—just ask world-class gymnasts and ballet dancers. To actually be classified as hypermobile, there is a test that assesses mobility at several joints called the Beighton Score.1
If you are curious whether you fall under the spectrum of hypermobility, ask yourself:
- Can you bend your thumb back to the front of your forearm? Check both sides. If you can do it on both sides, give yourself two points. If you can do it on one side, give yourself one point.
- Let’s move on to the little fingers. Can you bend them back to a ninety degree angle with the back of your hand? Give yourself a point for each side if you can do it.
- Can you bend your elbows and/or your knees backwards? (This is the hyperextension we are all used to seeing). Give yourself a point for each joint and side if you can do it. (The maximum total score for this section is four points.)
- Finally, from a standing position, can you fold forward and place your hands flat on the floor with the knees straight? If yes, you get one more point.
The maximum number of points available is nine. If your score was five or higher, you likely have joint hypermobility.
Hypermobility Isn't Bad
This isn’t necessarily a bad thing. People can have extremely flexible joints and no pain. At worst, these individuals might not know where they are located in space; at best, they will be the rock stars in yoga classes, pole classes, and anything else requiring large amounts of flexibility.
In fact, at the elite level, there doesn’t seem to be a whole lot of difference in terms of injury between those with hypermobility and those without. A 2017 study of elite female soccer players found there was no difference between injury risk and hypermobility classification.1 It is entirely possible these individuals have worked hard to gain active strength throughout their range of motion or wear things like knee braces to give them support. Regardless, their hypermobility doesn’t hinder their physical capabilities.
Pain with Hypermobility
At the other end of the spectrum are the hypermobile people that experience pain in their soft tissue or joints. Their ligaments (the connective tissue that holds bones in the socket), are lax, enabling shoulders to dislocate more readily and ankles to sprain more easily.3 Their extra mobility causes joint pain and discomfort. It’s a genetic issue you can thank your parents for, and it can make training a bit interesting.
One of the issues these individuals face is there often isn’t anything actually wrong in the joint, so even after seeing a medical professional, there still isn’t a definitive diagnosis or path of treatment. This can be extremely frustrating, and after they go through physical therapy, it isn’t unusual for the pain to move somewhere else. One of my hypermobile clients once described the pain as a spider, always prepared to crawl to the next vulnerable spot.
When I asked personal trainer and hypermobility specialist Catherine Cowey about this, she said the pain was like a wandering gnome, omnipersent, and sometimes vague in nature. Catherine, herself, is hypermobile and speaks about training with hypermobility from personal experience.
Training with Hypermobility
Much of the information regarding where our joints are located in space come from receptors located in ligaments. If you scored a five or above on the Beighton Scale, these ligaments are less taut. This affects proprioception, or the knowledge of where your body is located in space. “Proprioception in general usually isn’t great,” Catherine says. “It’s important to be able to feel where the joint is. The knee could be going way past the foot and you have no idea.”
The good news is we are extremely adaptable organisms, so despite the lack of sensory information from the ligaments, we can get the same feedback from the muscles, it just requires a little more work.
Take the shoulder, for instance. Catherine points out, "The shoulder already has so many degrees of freedom, so it already has inherent laxity. Target the rotator cuff, the proximal stabilizers before working the big movers.” These little muscles that support the joint are deep and let the brain know where the joints are located and how the arm is moving.
Maybe you're that person whose shoulder dislocated doing something benign, like reaching at an odd angle for a water bottle. Or perhaps your shoulder simply feels unstable, like it could pop out of the socket at any time. The lack of confidence in your body’s ability to keep you safe further alters proprioception. The best way to combat this is through prolonged physical therapy and general strength and conditioning.4
One way to effectively warm-up the shoulder and establish a connection between the brain and the muscular system is through isometric contractions at different angles.5 Keep the holds short, 10-15 seconds is usually sufficient to begin establishing a sense of connection between the body and the brain, Catherine advises.
Isometrics are exercises that are performed by generating tension without actually moving. Planking is an isometric exercise most of us are familiar with.
Try this: with your right elbow by your side, bend your arm so your forearm faces across your body (like you are halfway through a hammer curl). Take your left hand to the outside of the right wrist. Press your wrist into your hand and your hand into your wrist. Can you feel the work in your right shoulder? Now, take your left hand to the inside of your right wrist and press your hand into your wrist and your wrist into your hand. Can you feel the work in a different part of your shoulder?
Not only do isometrics provide a sense of stability in the shoulder joint, they also increase a general awareness of the joint, leading to a higher degree of confidence in the area. Isometrics also seem to have an analgesic effect. Basically, they are a natural pain killer.6 It’s always nice to go into your exercise session feeling good. This also explains why even if you feel a little achy before your exercise session, you usually feel better afterwards. Muscles, it appears, like to be used.
As I mentioned above, improving your sense of where your limbs are located in space is important for people with extra flexibility. In fact, proprioceptive training appears to be an effective way to reduce pain and increase strength in individuals with benign joint hypermobility syndrome.7 Plus, it improves balance, making exercise of any type a little more enjoyable.8
An easy way to do incorporate proprioceptive training into your routine is to have a reference point. When you lie down on the floor, for example, the pressure of your body on the floor provides a lot of information regarding where your limbs actually are.
Tools like yoga straps, plyo boxes, and the wall can inform body awareness and improve your sense of space. Incorporating this type of training into your workouts can give you a better overall sense of stability and awareness.
Another way to improve proprioception is through perturbation training. Perturbations are unexpected disruptions that your body has to stabilize against. If someone came up and unexpectedly pushed you, that would be a perturbation. Your response would be to stiffen in order to stay upright. Because perturbation training is reactive and you aren’t really quite sure where the stimulus is coming from, it tends to have high carryover into the ability to maintain balance say, when a curb appears out of nowhere.9 This type of training is obviously a little more complex. As a result, Catherine suggests adding in perturbation training after you have become comfortable with isometric holds and controlling the joint throughout its range of motion.
It can be a little hard to implement perturbation training on your own. An example of how this type of training can be performed solo is by using a tool such as an earthquake bar or taking a strong Dynaband and wrapping it through the handle of a moderately heavy kettlebell. Holding on to the dynaband, start bouncing it up and down. Once it’s moving up and down on its own, perform a squat. The weight of the kettlebell against the band will provide movement that your body will have to react to in order to stabilize. For the more adventurous, my favorite form of perturbation training is slacklining.
One of the things I noticed when I began training more hypermobile clients is they get tired. This makes sense; it takes more muscular energy to, say, sit cross legged on the floor than it does for the average person. The inherent stiffness that keeps the less flexible of us from bending too much also provides a level of passive support on which we can rest.
What does this mean for training? Catherine notes, “Fatigue is such a huge factor. With myself, I am always trying to find the minimum effective dosage. Can you get a good amount of strength twice a week?”
Research shows that lifting weights once or twice a week is enough to improve overall strength.10, 11 Three days a week might improve your strength a little bit more. If you fall into the hypermobile category, lifting heavy twice a week and complimenting your strength work with more stability based exercises might be a good balance. “Do lighter stuff on the off days or rehab stuff on the off days, like old school rehab drills for the shoulders and hips,” Catherine suggests. Things like external and internal rotation for the shoulders, planks, and clam shells, while not sexy, are effective ways to focus on the stabilizing muscles of the hips and shoulders. Additionally, they are usually performed slowly, with quite a bit of control. To begin increasing strength throughout the range of motion, introduce holds in various positions. This provides a better sense of control in the joint.
Because anxiety is common in this group and the nervous system is sensitive, restorative sessions and breathing work is best done in the evening.12 If fatigue is improved, recovery will be better, which means your workouts will be more epic. Because epic workouts are the goal, right?
Monitoring fatigue and stress levels will help you scale the workout for the day. If you are feeling more tired than usual and are having a day that is high on the stress scale, dial it back a little bit. If, after a thoughtful warm-up and a few light sets, you are feeling ready to conquer the world, increase your load. If you are still feeling crummy, stick with an easier day. Your body will thank you for it later.
One of the best ways create a sense of superhuman strength, whether you are hypermobile or not, is to get strong throughout the joint’s entire range of motion in a lot of different ways and emphasize controlling your movement. As Catherine says, "Work on getting strong in all those crazy ranges you have. You may be able to passively go into the splits, but do you have any control or strength of your adductors (groin muscles) in that position?”
Take the bodyweight squat, for example. Can you move slowly into the squat and slowly out of the squat? Can you hold at various positions on the way down? And on the way up?
If the answer to those questions is yes, what happens if you change your foot position? Can you take one foot slightly back and do the same thing? Or make your feet wider? Or more narrow? What happens if you turn your feet out? All of these small changes enable you to get strong in a variety of contexts. Strength in multiple ways leads to a sense of resiliency, of trust in your body and its capabilities.
Make Strength a Priority
Hypermobility can be both a blessing and a curse. If you are hypermobile, make strength training a priority. Establish strength throughout your range of motion, and learn how to isolate moving at one joint while keeping the rest of yourself still. When you feel the need to stretch, see if you can find a way to tap into strength instead. Because strength, after all, is what keeps you stable.
There are other, more serious former of hypermobility syndromes such as Ehlers Danlos.1 For the purpose of this post, I am only going to discuss benign joint hypermobility. However, if you think you might have Ehler’s Danlos, I highly suggest seeking the help of a physical therapist or medical doctor.
1. Cattalini, M., Khubchandani, R., & Cimaz, R., (2015). When flexibility is not necessarily a virtue: a review of hyper mobility syndromes and chronic or recurrent musculoskeletal pain in children. Pediatric Rheumatology Online Journal, 13(40).
2. Blokland, D., Thijs, K.M., Backx, F.J., Goedhart, E.A., & Huisstede, B.M., (2017). No effect of generalized joint hyper mobility on injury risk in elite female soccer players. American Journal of Sports Medicine, 45(2), 286-293.
3. Jindal, P., Narayan, Am., Ganesan, S., & McDermid, J.C., (2016). Muscle strength differences in healthy young adults with and without generalized joint hyper mobility: a cross-sectional study. BMC Sports, Science, Medicine, & Rehabilitation. 8(12).
4. Wolf, J.M., Cameron, K.L., & Owens, B.D., (2011). Impact of joint laxity and hyper mobility on the musculoskeletal system. Journal of American Academy of Orthopedic Surgery, 19(8), 463-471.
5. Mootz, R.D., & McCarthy, K.A., (1999). Sports Chiropractic. Aspen Inc: Gaithersburg, Maryland.
6. Rio, E., van Arm, M., Docking, S., Moseley, G.L., Kidgell, D., Gaida, J.E., van den Akker-Scheek, I., Swerver, J., & Cook, J., (2017). Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Jounral of Sports Medicine, 27(3), 253-259.
7. Sahin, N., Basket, A., Cakmak, A., Salli, A., Ugurlu, H., Berker, E., (2008). Rheumatology International, 28(10), 995-1000.
8. Yong, M-S., & Lee, Y-S., (2017). Effect of ankle proprioceptive exercise on static and dynamic balance in normal adults. Journal of Physical Therapy Science, 29(2), 242-244.
9. Freyler, K., Krause, A., Gollhofer, A., & Ritz, A., (2016). Specific stimuli induce specific adaptations: sensorimotor training vs. reactive balance training. PLoS One, 11(2).
10. Braith, R.W., 1989. Comparison of 2 vs 3 days/week of variable resistance training during 10- and 18-week programs. International Journal of Sports Medicine, 10(6), 450-454.
11. Thomas, M.H., & Burns, S.P., (2016). Increasing lean mass and strength: a comparison of high frequency strength training to lower frequency strength training. International Journal of Exercise Science, 9(2), 159-167.
12. Mallorqui-Bague, N., Bulbena, A., Roe-Vellve, N., Hoekzema, E., Carmona, S., Barba-Muller, E., Fauque, J., Pailhez, G., & Vilarroya, O., (2015). Emotion processing in joint hyper mobility: A potential link to the neural basis of anxiety and related somatic symptoms in collages anomalies. European Psychiatry, 30(4), 454-458.