Hypermobility part 2 (March 2012)
Hypermobility Syndrome – part 2
James Dodd
Part 1 of this article looked at giving readers a better understanding of Hypermobility Syndrome (HMS) and the implications it may have on the musculoskeletal system. Having a greater understanding of the common problems associated with hypermobility syndrome, how it is diagnosed and its relationship to other connective tissues disorders provides us with a solid base by which we can then go about developing a corrective exercise program. Part 2 aims to provide a more extensive look at assessing the hypermobile patient and taking a region specific approach to training. A detailed case history and screening process should alert you to any problematic areas or regions which may be predisposing, maintaining or aggravating your patient’s musculoskeletal problems. Static observation will help you to define any asymmetries in posture. Observation from all three views (frontal, lateral and posterior) will help you focus on areas of possible dysfunction. Functional testing in sagittal, frontal and transverse planes may highlight other areas of dysfunction
Muscle and Movement Testing
Carry out stretches and tests to identify weak, tight and shortened muscles. Take particular care in the hypermobile patient as range of movement may be much greater than expected. They are also good at ‘cheating’ to hide a dysfunctional area.
Assess functional activities such as gait, step up/down, lunge, squat, one leg stand and reach, anterior reach, posterior reach and push up for functional capability. Look for asymmetries, imbalances and glitches within the movement patterns to alert you to potential areas of dysfunction. Common causes of dysfunctional movements could be inhibited/over facilitated muscle activity in agonist/antagonist or synergistic muscles, tight and short or weak and lengthened muscles, hypo/hypermobile joints or body regions and balance, proprioception and coordination problems.
Always remember to seek advice from your patient’s general practitioner, osteopath or physiotherapist if you suspect any serious possible musculoskeletal problems or red flags.
A Regional Approach to Training the Hypermobile Patient
Common presenting features in the hypermobile patient include the following:
Shoulder, hip, neck, lower back, knee and foot pain
Poor body awareness, balance and proprioception
Flat, pronated feet
Hyperextended knees
Anterior pelvis
Clicking/popping joints
Hyperkyphotic or reduced movement in the thoracic spine. This could also be chronic muscle spasm
Tight and shortened hamstrings, gastrocnemius, iliotibial band, tensor fascia lata, pectoralis major/minor muscles
Weak anterior deep neck muscles, iliopsoas, core stabilizers and gluteals
Poor core stability
Upper rib breathing and poor diaphragmatic breathing
A good case history, observation and assessment should highlight any areas of dysfunction and will help you to focus on devising a program that will help restore optimal health and posture. Foam rollers, static stretching, active stretching and Muscle Energy Techniques (MET) are treatment strategies that can help stretch, activate and restore muscle balance. Remember to train the patient as a whole. The body works as one, and all systems are connected. Therefore, any one problem or area can predispose to a dysfunction elsewhere. The tissues are generally weaker and more vulnerable to injury than the non-hypermobile patient.
Hypermobility and the Lower Back
Poor overall functional stability is common among those individuals with lower back pain. In conjunction with poor stability, the hypermobile patient may also have poor kinesthesia and proprioception.
Focus training on:
Improving body awareness (anterior and posterior tilting of the pelvis)
Finding neutral spine
Teaching diaphragmatic breathing
Activating core muscles
Incorporating core muscle activation into functional activities
Balance, proprioception and coordination
Look for an ability to activate the core muscles:
Without co-contraction of more global muscles such as the rectus abdominis and external oblique muscles
Independently breathing
Diaphragmatic breathing? (often you will observe upper chest breathing)
Exercises that will be useful for the patient with core stability issues include:
Anterior and posterior tilting of the pelvis (standing, supine).
Core muscle activation (supine, prone, side-lying and four-point kneel).
Core muscle activation standing, seated.
Remember to isolate muscle activation and then integrate into functional activities.
Hypermobility and the Neck
Hypermobile patients may present with a history of neck complaints, ranging from the acute ‘wry’ neck to chronic neck pain. Individuals may present with an upper crossed syndrome pattern, which could be predisposed, maintained and aggravated by hypermobility, work and lifestyle postures such as sitting and slouching.
Look for:
Forward head posture (chin poking forwards)
Increased kyphosis (rounding) through the thoracic spine and Cervico-Thoracic C7/T1 region (base of the neck)
Reduced mobility through the thoracic and cervical spine
Tight upper trapezius, levator scapular, pectoral minor, sternocleidomastoid and scalene muscles
Weak rhomboids, lower trapezius and deep anterior neck flexors
Winging, elevated or protracted scapulars. Look for asymmetries in static
observation, movement and muscle weakness in shoulder stabilizers
Focus training on:
Lengthening short and tightened muscles
Strengthening weak muscles
Activating inhibited and de-facilitating over active muscles
Balance, proprioception and coordination
Exercises that will be useful for the patient with upper crossed syndrome and neck pain include:
Scapular retraction and setting
Ys and Ts exercise
Other useful exercises that aim to improve mobility of the neck, strengthen deep anterior neck flexors and increase body awareness include:
Chin tucks (similar to an emu neck movement)
Isometric neck flexion (using soft ball to push head against)
Isometric lateral neck flexion (using soft ball to push head against)
Pulling shoulder blades backwards and down, whilst lifting sternum to the roof
For more information on isometric neck exercises, see Paul Chek’s “How to Eat, Move and Be Healthy!”
Hypermobility and the Shoulder
The shoulder is the most unstable joint in the body, and often the hypermobile person will have a glenohumeral joint and/or scapulothoracic joint dysfunction. Problems may develop due to poor neuromuscular control, increased laxity of the capsule and rotator cuff weakness. Individuals may also present with subacromial impingement signs and symptoms. In some circumstances, your patient may require referral to an osteopath or physiotherapist to rehabilitate and teach correct scapulothoracic setting and glenohumeral positioning before commencing an exercise program. Focus training on:
Scapulothoracic setting
Rotator cuff strengthening
Stretching tight and shortened muscles i.e. pectoralis major and minor
Strengthening weak muscles i.e. serratus anterior, rhomboids, lower trapezius
Training functional exercises which address adjacent areas (cervical, thoracics, lumbars and hip/pelvis), muscular slings, synergistic and agonist/antagonist muscles
Hypermobility and the Hip
Like the shoulder, the hip is a ball and socket joint that has a large range of movement. It is essential that the neuromuscular, active and passive systems are working effectively to allow adequate movement and yet stabilize the region sufficiently. The hypermobile person is more likely to suffer from clicking/popping hip. The exact cause of this could vary from an intra to extra articular causes such as a tight iliopsoas to a labral tear or loose body. It may or may not be associated with pain. In those individuals presenting with extreme or constant pain, refer them off to the GP, sports medical doctor, osteopath or physiotherapist for further assessment. Typically, hypermobile patients will have poor control of their hip, pelvic and lumbar regions, and these often need to be addressed to correct any imbalances and prevent further problems developing.
Focus training on:
Lumbar (lower back) stability
Hip stability
Weak iliopsoas
Weak gluteus medius and maximus
Tight hamstrings, iliotibial band, tensor fascia lata
Balance, proprioception and coordination
Hypermobility and the Knee
Patellofemoral problems are common in hypermobile individuals. The cause of patellofemoral problems can be both structural and non-structural related. Common causes include a variable Q angle, genu varum, increased foot pronation and biomechanical and muscle imbalances.
Focus training on:
Tight iliotibial band, tensor fascia lata, hamstrings, gastrocnemius
Weak vastus medialis, gluteal muscles
Pronation and supination foot
Balance, coordination and proprioception
Exercises that will be useful for the client include:
Seated heel presses (helps to activate vastus medialis)
Foam rolling ITB and quadriceps muscles
Exercises that will be useful for the patient include:
Seated heel press (helps to activate vastus medialis)
Lunge – Forward
Lunge – Multiplanar
Squat – Against Wall with SB
Squat Touchdown – 1 Leg
Step Up to Balance – Frontal Plane
Hypermobility and the Foot
Pronated (flat) feet is common in the hypermobile patient. Over pronating can lead to problems with the subtalar joint, mid and forefoot, possibly causing plantar fasciitis and other problems up the biomechanical chain. Over pronation will cause internal rotation of the tibia and fibula, therefore potentially creating dysfunctions further up the chain at the knee, hip/pelvis and lower back. Individuals with flat feet may benefit from an exercise program or orthotics prescription.
Focus training on:
Tight plantar fascia, gastrocnemius and soleus muscles
Activation and control of tibialis anterior, peroneal muscles
Tight iliotibial band and weak gluteal muscles
Balance, coordination and proprioception
Exercises that will be useful for the patient include:
Active plantarflexion and dorsiflexion of the foot
Rolling feet inwards (pronation) and outwards (supination)
Single leg balance (stable to labile surface i.e. wobble board, bosu ball)
Swiss ball squat with ball between the knees finishing with standing on toes
Exercises that will be useful for the patient include:
Side to Side Hip Swing (Hip)
Balance Hold 1 Leg – Overhead Anterior Reach
Balance Hold 1 Leg – Overhead Posterior Reach
Hypermobility and Balance and Proprioception
Hypermobile individuals are likely to have poor balance, proprioception and kinesthesia. Exercises that challenge these components will translate over to improvement of general daily activities and reduce the likelihood of injury.
Exercises that will be useful for the patient include:
1 Leg Balance
1 Leg Balance Reach (anterior, posterior, lateral)
Balance Hold 1 Leg – Overhead Anterior Reach
Balance Hold 1 Leg – Overhead Lateral Reach
Step Up to Balance – Frontal Plane
Equipment such as wobble boards, Bosu Balls, cones, Airex Balance Pad, Swiss ball, Theraband, etc. can be added to further challenge balance and proprioception.
References:
Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.
Gray, G. Functional Video Digest Series
Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.
Janda, V. Muscle Function Testing, Butterworths, London, 1983.
Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.
Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.
Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.
Osar, E. Complete Hip & Lower Extremity Conditioning.
Osar, E. Complete Shoulder & Upper Extremity Conditioning.
Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.
Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism
Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.
Resources:
www.ehlers-danlos.org <http://www.ehlers-danlos.org>
www.hypermobility.org <http://www.hypermobility.org>
www.marfan.org <http://www.marfan.org>
www.marfanssyndrome.net <http://www.marfanssyndrome.net>
www.medicinenet.com/hypermobility_syndrome <http://www.medicinenet.com/hypermobility_syndrome>
http://medlineplus.gov/
www.oif.org <http://www.oif.org> (Osteogenesis Imperfecta)
www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http://www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html>
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