049: Hypermobility Part 2

hypermobility Sep 26, 2021

This post is the second part of a continuing series on the subject of joint hypermobility. You can read the previous instalment by clicking here.

One of the biggest misconceptions about hypermobility is that people presenting with symptoms of a hypermobility syndrome (HS) were born with abnormally high levels of joint flexibility.

Sure, many people living with a HS first realised they were "extra bendy" at a young age, and more than 75% of people with a HS start showing signs before the age of 15 (Kirk et al., 1967).

The vast majority of people living with a HS are those assigned female at birth, with the hips, knees and ankles being most affected (this genetic predisposition to hypermobility may explain why females are naturally more flexible than males).

It's important to understand however that HS symptoms may simply be co-morbidities that arise  because of some other pathology or dysfunction.

Once a clinician has completed differential diagnosis, a true HS is the root cause of a patient's issues in less than 2% of cases (Ansell, 1972).

In many instances, a doctor may diagnose a HS simply because the patient demonstrates a higher than normal level of flexibility with little regard for lifestyle and training factors, which results in the patient walking around wearing "hypermobile" as a label.

This can have profoundly negative effects on the individual's self-esteem and could possibly lead to catastrophisation and central sensitisation, which can trigger and sustain long periods of idiopathic chronic pain - so physicians need to be very careful what labels they assign and to whom.

People lacking awareness of hypermobility will often refer to themselves as being 'double-jointed,' but keep in mind that there is no such thing as double-jointedness.

What they do have is naturally high levels of flexibility caused by a connective tissue disorder, abnormal joint geometry (e.g., uncommonly shallow hip sockets, even for a female, which makes performing moves like the splits effortless), or both.

Such individuals may feel drawn to sports and activities that prize flexibility, such as dance or gymnastics, and so this self-selection might account for why the majority of participants in these disciplines are female.

However, we need to be mindful of survivorship bias when associating physical disciplines and natural flexibility levels of the participants.

Since we never see the naturally inflexible people who drop out in the beginning of training, probably because the the regimen is difficult and fruitless (who wants to stick with something they're not good at?), it's easy to say "all dancers/gymnasts are naturally flexible" because we mostly see the naturally flexible ones who made it through the rigours of training.

But this isn't always the case, and the training itself produces high levels of flexibility even in those without a HS, especially when trainees start at the age when it is still possible to (relatively) safely increase the length of ligaments and manipulate the shape of the skeleton.

While disciplines like dance and gymnastics do have a higher proportion of people living with a HS than other sports, it's almost impossible to tell just by looking who was gifted with good genetics and who had to develop their flexibility with practice.

Therefore, it is inaccurate and unfair to claim that dancers, gymnasts, and others from a similar background are not valid flexibility coaches "because they are hypermobile," since without more information, we cannot know who is or isn't hypermobile, or how hard a given person worked for their flexibility.

Unfortunately, the health and fitness space is filled with assholes making exactly those types of claims as a way to build an air of superiority around their system or method of training, as though not being hypermobile is a badge of honour or something they even had any control over.

Whether or not someone is hypermobile has no bearing on their ability to coach flexibility; what matters is their ability to effectively communicate how to perform an exercise, how to progress and regress it, and how to actively listen to the student/client so they know when and why to modify it.

References

Ansell, B. M. (1972) Hypermobility of Joints. Modern Trends in Orthopaedics volume 6, pages 419-425.

Kirk, J. A. et al. (1967) The Hypermobility Syndrome: Musculoskeletal Complaints Associated with Generalised Joint Hypermobility. Annals of Rheumatological Disorders volume 26, pages 419-425.