Chronic injuries: When too much flexibility is NOT your friend!
The signs and potential symptoms of Hypermobility Syndrome
While it’s wonderful to have a flexible body, what if you are a person who has so MUCH flexibility that it is a cause of pain, weakness, poor balance, clumsiness, ankle sprains and/ or slow to heal injuries.
This type of body is one with Hypermobility Syndrome where the joints exceed the normal expected movement for that joint. It is frequently an inherited disorder which renders the collagen found in our ligaments less firm than they should be. The job of ligaments is to perform as tight binders that hold our bones in stable contact with each other. The job of muscles is to move those bones for us. If the collagen is weaker, it is more elastic than it should be. This allows for excessive movement of the joints and may also affect any body part where collagen is found i.e. ligaments which suspend the bladder, heart valves, and walls of veins. The range of hypermobility is wide ranging from totally asymptomatic to total disability. People with hypermobility often spend years chasing their symptoms. Rather than chase symptoms it is best to understand the source of the problem and develop a treatment approach around this.
Hypermobility Syndrome is diagnosed on the basis of the Beighton Scale with the allocation of one point for each lax joint. See www.physio-pedia.com/Beighton_score for more details on this assessment.
It is present in about 20% of individuals in varying degrees and many have no symptoms at all.
The majority of patients we see at Trimetrics have had a history of chronic pain; recurrent injuries which do not seem to heal fully. This results in an inability to exercise effectively and a worry about exercising at all. Some have had careers as a dancer, a gymnast or in yoga. It is understandable that to some degree, hypermobile individuals are pre-selected for these activities on account of their “flexibility”.
Many present with a history of chronic knee, lower back or shoulder pain and instability. A frequent complaint we hear is “I have tried everything yet still I am in pain”. Hypermobility is often misdiagnosed by therapists, trainers and doctors. People with hypermobility respond to injury differently and do not always heal in the same way or in the same expected time frame, as those with normal collagen in their bodies.
The incidence of hypermobility is generally higher in women and highest currently in the U.K. where it is regarded as an important connective tissue disorder and children are routinely screened for it in elementary school. Many high scoring Beighton individuals that are under the care of a rheumatologist for life as they may experience gastro intestinal or auto immune symptoms in addition to painful joints. They do not respond to injury and healing in the same way as those with more normal collagen in their bodies and they may need specific medication for short periods or when newly injured.
An individual with this disorder also may live with chronic low grade joint pain as their joints are not as supported as they need to be. Inflammation due to chronic stress at the ligament’s attachment point on the bone (Enthesis) is often a source of pain. This can be extremely disabling when it occurs over many joints in the body resulting in severe chronic pain. For these reasons it is vital for an accurate diagnosis and specific treatment plan. Whenever possible, Trimetrics physiotherapists like to work closely with a rheumatologist, physiatrist or sports medicine specialist since more detailed medical evaluation and treatment may be needed depending on symptoms.
There can also be a psychological aspect to hypermobility. Anxiety is a common issue as a hypermobile person’s proprioception (awareness of where the body is in space) is not accurate. This results in poor balance, frequent falls or fear of falling, and chronic clumsiness. They never know quite where their bodies are in space and when an injury may occur with little provocation. As well as anxiety, stress and depression can also be experienced as a result of chronic pain, poor sleep patterns and decreased levels of function.
The desire to stretch!
Interestingly, one of the complaints hypermobile patients have is that they always feel “tight” and try to use stretching exercise, yoga etc. to get “relief “. This is the body’s attempt to stabilize the hypermobile joints with excessive tightening and gripping in the large global muscles i.e. quads, pecs, calf muscles etc. which is NOT effective in releasing the tightness and usually generates more pain and frustration!
The excellent news is that we at Trimetrics, have many years of experience of successful treatment and management of Hypermobility Syndrome due to the volume of referrals we receive from rheumatologists and sports medicine physicians. We have developed a very specific exercise approach based on where the patient is on the Beighton Scale, which is extremely beneficial for hypermobile patients. The aim is for strong muscles which is achieved with specific exercise safety guidelines and incorporating balance and coordination training. This combination makes a huge difference for hypermobile patients.
Children with Joint Hypermobility
10-50% of all children are hypermobile. A smaller percentage suffer from hypermobility syndrome. This is when a weakness in the muscles surrounding the hypermobile joint leads to the child suffering from pain as well as other symptoms. During adolescence these symptoms generally start to arise with the child complaining of painful, clicking joints along with the feeling of fatigue, abdominal pains and headaches.
Evidence shows that starting an exercise based treatment program along with reassurance and goal setting is the most effective management for children with Hypermobility syndrome. A progressive resisted training program, incorporating closed chain exercise along with proprioceptive retaining is the most effective approach for children and adolescents and we advise completion in 6 week blocks as needed.
“The Trimetrics Hypermobility Treatment Program”
- Reduce pain.
Knowledge is power. We ensure that our patients understand the nature of the issue and the reasons for their pain and recurring injuries. We explain the rationale for the effective treatment we as experienced physiotherapists can provide and the results we can expect. Where indicated, a patient’s physician or rheumatologist may prescribe medication in the short term to reduce painful inflammation. Medication may be required to allow the patient to get moving and to sleep since this is often affected.
We may begin by releasing the chronically tight, painful, OVER dominant muscles. Ideally using myofascial release – foam roller and / or IMS / Functional Dry Needling (http://www.trimetricsphysio.com/imsdry-needling-and-acupuncture-whats-the-difference/ ). These are effective techniques in releasing the old muscle gripping patterns that are very energy expensive for the patient, and itself a cause of painful trigger points. We address the tightness where it actually is, in the muscles. This treatment approach feels wonderful to a hypermobile person! We do NOT routinely stretch joints!
- Realign the pelvis and spine.
This is essential so that correct exercise information is messaged to the brain. We know from research that a misaligned pelvis is not a good basis for a balanced symmetrical core strengthening program.
- Pilates based spine and core strengthening
Specific exercise used to stabilize and to build strength from the powerful deep inner spine muscles and progress to the outer system (arms/ legs etc.). This exercise is progressive so we are adding demand in all movement directions, as the patient’s body strengthens week by week.
A hypermobile body responds really well to an equipment based (Reformer/ Chair / Cadillac) Pilates program which delivers exactly the type of experience the hypermobile body needs: i.e. the sense of safe, stable and progressive exercise, which will not generate any additional pain.
We use a “closed chain” approach meaning that we use the equipment to bombard the nervous system with posturally stimulating information which assists the patient to pull their strength from the deep spine / core muscles. This is the system of deep muscles we want to use to stabilize the spine and limbs rather than use and over use, the big and often over dominant global muscles. Closed chain means that hands, feet, knees are always in contact with a hard surface, small ball, magic circle etc.
A feeling of safety is very important for hypermobile patients. We begin in the safest positions (supine, side lying and prone) so that the patient can learn where their bones are and how to access their core muscles, without the stress of gravity.
- Real Time Ultrasound
Not required for every individual. However, if feeling or accessing the deep core system is hard for the patient, we use a Real Time Ultrasound test so that the patient and therapist can clearly see the abdominal muscles, and cue their activation with the ultrasound… our patients love this tool.
- Progressing the exercise and the challenge
As goals are mastered, we increase the challenges in kneeling, sitting, standing and jumping drills on the Reformer, Chair and Cadillac. We incorporate balance and proprioception training into each exercise using Pilates discs and Bosu. Tactile cues and imagery are very powerful tools in eliciting deeper postural and muscular reactions. A program of one to one Pilates training, twice a week over a 6-week period generates excellent results. We guide our patients to exercise and sports which will reinforce their new patterns so that core strength, balance and coordination are always being progressed for continued fitness, endurance and…. the painless enjoyment of life!
* Please note that a person may also experience a single joint as being loose or lax after an injury: for example, a person has a fall and dislocates a shoulder: this shoulder may well remain hypermobile due to ligament damage in that particular incident. We treat this as a one- off joint problem with appropriate and effective rehabilitation targeted to that specific joint.
Please check out these excellent links for more information regarding hypermobility:
For initial 60 minute assessment and treatment with a Registered Physiotherapist, please call us at 604 982 0366 or email [email protected].
After years of several debilitating experiences with misaligned pelvis and unsuccessful treatments my family doctor, Dr Zeineddin, referred me to see Siobhan O’Connell at Trimetrics Physio who she said was “ the best “.
Siobhan assessed me thoroughly and I was made aware that these repeated incidents were caused by my general body hypermobility, with particular laxity in my right sacroiliac (SI) joint. I underwent a series of treatments on and off to stabilize my spine and build my core strength.These were partially successful but ultimately Siobhan recommended that I explore prolotherapy for a more long-term solution and my doctor made the referral to rheumatologist, Dr. Jean Gillies.
I have since been treated with a course of prolotherapy in conjunction with my physio program and have recovered remarkably well. My program of core strength with my stable pelvis allows me to do everything I was previously unable to do (including flying / travelling to see my family) For this successful collaboration between Siobhan’s treatment and my doctors I am most grateful.
Three years ago I was a fit active 23 year old when I was in a car accident that has left me with chronic debilitating neck pain. I have seen multiple doctors/specialists, chiropractors, RMTs, physiotherapists, and the list goes on. I have always been “flexible,” and since I retained my flexibility after the accident, many doctors took this as a sign that I had no injuries, and so quickly the pain I suffered from daily was dismissed and undiagnosed. I was no longer playing sports, going to the gym, skiing, surfing, or hiking, I spent most days lying on the couch, exhausted from the soreness.
I saw little to no progress for three years and was really beginning to struggle with the mental side of long-term injury. It was when I began researching various approaches to treating chronic injuries that Google introduced me to Trimetrics. When I first came to Trimetrics four months ago, I was fatigued, unhappy, sleep deprived and in pain. Within the first thirty minutes of meeting Siobhan, she discovered that I have joint hyper mobility syndrome, a diagnosis that has drastically changed my treatment plan.
We have focused on releasing my overtight muscles, strengthening my weak muscles, relieving pain and realigning the pelvis to promote healing. Understanding the type of body I have has made a huge difference to my recovery and fitness. Thanks to my new treatment plan, I have noticed an immense reduction in pain, improvement in my sleep pattern and an increase in strength that has allowed me to introduce my much-loved physical activities back into my life. Moreover, the positive and supportive approach that physiotherapists Siobhan and Niamh consistently deliver has helped me become optimistic and confident during this healing process.