What Is Hypermobility and How Can It Impact Chronic Pain?
Image courtesy of Scott Broome via Unsplash.
Hypermobility is a broad term, but it simply means that your connective tissues are more elastic than average. This can be most easily observed in skin (which is usually soft, thin, and stretchy) and joints that move beyond the “normal” range due to more mobile / less rigid ligaments and tendons. It can present in other connective tissues too, which is where some of the more severe and seemingly unrelated signs and symptoms come from.
Hyper-mobile people are generally more prone to dislocations and subluxations (some recover fully, others do not and cause recurring injury due to unhealed micro-traumas), joint and or muscle pain (both acute and chronic), and hypertonic muscles (the muscles tighten up around joints that the body perceives as unstable).
Connective tissues of all kinds have to strike a fine balance between rigidity and elasticity so the body can move as freely as is practical, while still supporting its own weight and not falling apart at the seams. There are many things that can alter this balance:
You could simply produce tissues with a higher ratio of elastin (elastic connective fibers) than collagen (more rigid tissue).
You could have difficulty producing collagen for some genetic, physiologic, or nutritional reason.
You could have one or more connective tissues that have been injured over time and have not returned to their original strength or shape.
If you have one of the more general collagen / elastin issues, they can result in other, seemingly unrelated challenges such as hernias, weak blood vessels that lead to easy bruising and possible increased risk of stroke, mitral valve prolapse, leaky gut, and/or persistent, wide-spread pain and fatigue (it can be confused with chronic fatigue syndrome, complex regional pain syndrome, or fibromyalgia).
How can you tell if you’re hyper-mobile?
Hypermobility exists on a wide ranging spectrum. Mild cases of hypermobility are actually quite common and can exist in just some joints or in all joints. In many of these mild cases, it causes no problems at all, and in some cases can actually be beneficial—think dancers, gymnasts, or grease men in crime movies (I’m thinking of the Amazing Yen from Ocean’s 11).
Some milder cases do start to present issues. These are the cases that may not qualify as a diagnosable disorder, but still require some knowledge and special attention—and that’s why we’re talking about them here.
If you can do two or more of the following, then “hyper-mobile” probably describes you:
Extend your little finger back more than 90°
Flex your wrist so your thumb touches your forearm
Flex at you waist with your knees straight and put your palms on the floor
Extend your elbows and/or knees more than 180°
Ehlers-Danlos Syndrome (EDS)
Once we get into diagnosable hypermobility disorder territory, we’re talking about Ehlers-Danlos Syndrome. EDS is a series of 13 classified disorders in which one or more types of connective tissue form in a fragile or hyper-elastic way that makes it difficult or dangerous to perform normal tasks. These variations are usually due to inherited genetic mutations in one or more of 20 possible genes and can affect blood vessels, skin, bones, tendons, gut lining, and/or any other connective tissue. Many of these present in clearly defined and severe ways.
One form of EDS that is a little more common (about 1 in 50,000 people) is Hypermobility EDS. It is a condition of generally hyper-movable joints without signs of malformed bones or blood vessels. This one is a little more difficult to diagnose because there is no clear genetic marker or specific diagnostic criteria. It is usually diagnosed when general hypermobility becomes debilitating due to pain.
The line between Hypermobility EDS and generalized hypermobility is fuzzy at best. What usually tips the scales is when pain is involved. This can be joint pains from repeated micro-traumas and dislocations, and/or muscle aches from overactivity (commonly labeled complex regional pain syndrome or fibromyalgia).
OK. I know that was a lot of and/ors and variations, but here are the commonalities that you should know:
In all of these cases, there are joints that move beyond the “normal” range of motion (aka are hyper-mobile).
These joints often lack proper proprioception (body awareness / joint sense), and are prone to micro-traumas, aches, pains, and dislocations.
It is common for muscles around these joints to be hypertonic (overly tense) because the body is trying to use muscle tissue to stabilize the joint that it perceives as unstable.
It is also common for these joint hyper-mobilities to be accompanied by other hyper-elastic connective tissues such as skin, blood vessels, and gut lining.
Now that we know WHAT hypermobility is, what can you do about it?
Exercise
Types of workouts
Choose slower, steadier exercises to fast, erratic ones. Avoid things like CrossFit that encourage fast multi-joint exercises under load. These can put unnecessary strain on hyper-mobile joints. Olympic lifts (the class of movements including snatches and clean-and-jerks upon which CrossFit is built) are complex, fast-paced, multi-joint exercises designed to be done in single reps to demonstrate finesse of form. They are inherently challenging even with one rep in a person with stable connective tissues—and they can become exponentially less stable with repetition.
Normal high-intensity interval training (HIIT) workouts should be used with caution. HIIT workouts have a ton of benefits to your cardiovascular system and overall health, but can set you up for injury as you fatigue and your form gets messier.
Instead, focus on controlled exercises. Take 5 or more seconds per rep of each exercise. This lends itself very well to conventional weightlifting and bodybuilding programs. Not only will these challenge your muscles and help build stable connective tissues, but they will also work wonders for developing proprioception (body awareness) that is usually lacking in hyper-mobile people.
Stretch activated muscles
This is something that I learned from Yogic philosophy and now carry with me everywhere. Only stretch muscles that you are actively engaging as you stretch them. This will give you the neuro and lymphatic benefits of stretching without overstretching your already hyper-movable tendons and ligaments.
For example: When you’re using a doorframe stretch for your pecs, rather than completely relaxing your chest and shoulders to get more range of motion, give a slight push into the doorframe to activate your pecs while you stretch. When you’re stretching your hamstrings, either do it from a standing position or push your heels down into the floor as you stretch to activate all of the muscles in the back of your legs.
Allow yourself more active recovery time between workouts than the average Joe.
This means walking, light yoga, qui-gong, tai chi, or something similar on your days away from the gym. The movement is needed to stimulate repair, stability, and growth of proprioceptors (position sensors). Just resting without movement and joint loading will actually prevent the joints from repairing themselves properly which can increase mobility in your already hyper-mobile joints.
Injuries
If you have joint injuries (as many hyper-mobile people do) I highly recommend working with a specialist (physiotherapist, personal trainer, chiropractor) who can help you figure out the right types of movement for you. There is a fine balance between stimulating an injured area enough to grow and overworking it to make it worse. Only experience can really help you find that balance point.
Nutrition
The big thing here is protein. In order to create any connective tissues, you need to eat enough protein—at least 1 gram of protein per kilogram of body weight every day. (This equals out to about 1/2 a gram of protein per pound of body weight—when is America finally going to switch to the metric system!?) That’s 75g of protein for a 150-pound human.
If you’re actively trying to heal from an injury (or recover overall joint stability), I’d recommend eating up to 1.5x that amount just to make sure your body has the resources it needs.
Bone broth and collagen supplements are great sources of the proteins needed for connective tissue growth (proline, hydroxyproline, alanine, and glycine, just in case you were curious). These types of protein are rare in muscle meat.
This may be a little controversial, but I feel the need to say it: It is my professional opinion that if you are trying to grow healthy connective tissues, eating ethically sourced animal products is essential. There is not a practical plant substitute for the components necessary for building healthy connective tissues (or many hormones, but that’s a whole other can of worms.) The ethics and science behind raising and eating animal products are way, way beyond the scope of this article. I’ll definitely swing back and dive into it in the future, but for now I’m going to ask you to take my word for it.
In addition, make sure you’re getting enough vitamin C and A. Both of these are present in sufficient amounts if you eat a few servings of vegetables and fruits every day, and are getting enough protein. If you seem to be struggling, ask your doctor for lab work that can measure the vitamin C and A levels in your blood.
One of the keys with this nutrition is that eating the right things is not enough. You have to eat the right things, and then tell your body what to do with those building blocks. This means YOU HAVE TO MOVE. You do that by using the joints and muscles that you want your body to focus on. If you don’t use the joints and prompt their growth, your body will use those valuable proteins and vitamins somewhere else
Joint repair is a lot of effort for your body. There are many easier things that it can do with those proteins and vitamins—maintain muscles, maintain gut lining, make neurotransmitters and hormones, etc.
Water intake
You need to drink at least your body weight in pounds divided by two in ounces every day (that’s 75 oz. for a 150-pound person). I’d challenge you to drink a gallon a day no matter your body weight.
Remember tendons and ligaments do not get direct blood flow. They rely on the fluid around them being packed with nutrients that they can absorb to grow. Not only does this mean that enough fluid needs to be there (hence drinking the water), but it also means that the process of growth and repair takes more time—weeks to months for lasting results. Translation: These are not one-and-done behaviors. They are lifestyle choices.
Pain Relief: Medications and Over-the-Counter Options
Lay off the anti-inflammatory drugs
NSAIDS (the most common of which is ibuprofen) are a common staple in the at-home care for joint pain. Recent research has shown that they are detrimental to the healing and maintenance of bones, ligaments, and tendons. It turns out that they block signaling pathways that your body relies on for recognizing injured tissues and sending the resources to repair them.
If you must take something, drugs like acetaminophen (though they have detrimental effects on your gut and liver) have not been shown to have this decreased healing effect.
You can also substitute these for turmeric and/or dark cherry extracts. While they don’t have immediate pain-killing effects, both have very potent long-term, anti-inflammatory effects, and are much less detrimental than their drug-based counterparts with extended use.
Other anti-inflammatory foods that you can include in your regular repertoire are fatty fish (for the omega 3s), dark berries, dark leafy greens, and dark chocolate (70% cacao or more).
Be cautious of steroids
Corticosteroid injections (namely cortisone) have become very popular for treating intense chronic pain in joints. While they often do provide significant immediate pain relief, they are very detrimental to the connective tissues around them. They prevent the repair of the surrounding tendons and ligaments by disrupting the signaling to and function of the fibroblasts (collagen forming cells).
There is a time and place for steroid injections. It is up to you and the orthopedic doctor you’re working with to determine if they are right for you. When my patients decide that steroid injections are right for them, here’s the advice I give: Take full advantage of the reduced pain and move. Walk every day, start weight training, work with a personal trainer, a physiotherapist, a chiropractor, anyone who can get you moving well to stimulate repair. Otherwise, that steroid injection is going to end up doing more harm than good in the long run.
If you think you might have hypermobility and you’re looking for a partner who can help get you some pain relief and create a treatment plan, reach out to me. I’d love to be part of your team!
Additional Hypermobility Resources