Are You Overly Flexibile? Hyperflexibility, Joint Hypermobility Syndrome and Generalized Joint Hypermobility
Over the last year or so, I have had more and more students asking me about “hyperflexibility” and more specifically if their excessive flexibility at certain joints could be dangerous in any way. Hyperflexibility has also been a topic of discussion in the teacher-training program where I teach experiential anatomy when we discuss “how much flexibility is enough?” To start, I always tell these students that it is fairly common for many people to have one or two joints that are more mobile than average, or hyperflexible. For these people, they might want to take care not to overstretch their hyperflexible joints (see my yoga recommendations below). However, if you have multiple (more than two) hypermobile joints, you may have joint hypermobility syndrome or generalized joint hypermobility, so it’s worth your while to learn more about these two conditions, especially because joint hypermobility syndrome is a commonly overlooked cause of chronic pain.
Inspired by these students as well as by some new information in a recent journal article for primary care doctors entitled Joint Hypermobility Syndrome: Recognizing A Commonly Overlooked Cause of Chronic Pain,, I felt it would be helpful to share what I have discovered about this joint hypermobility syndrome and the closely related condition generalized joint hypermobility. I will also discuss how these conditions, as well as hyperflexibility in one or two joints, might impact your personal yoga practice or the way you teach yoga to your students who have it.
Let’s start by looking at the differences between joint hypermobility syndrome and generalized joint hypermobility.
Joint hypermobility syndrome is condition that is typified by the presence of hyperflexibility of multiple joints (usually four or more, but this varies), joint pain (especially in the knees and ankles), and fatigue. It is based on your history and by examining your joints for hypermobility. (There is no blood test or X-ray that can confirm the diagnosis, which is why it is classified as a “syndrome.”)
Those with this condition also often have poor proprioception (for unclear reasons) that may contribute to joint injuries. They also have less muscle mass and strength, too, possibly due to the looseness of the tendons, but also maybe due to the fear of precipitating pain with activity that may have started as early as in adolescence, leading to a deconditioning effect on the muscles. In up to 75 percent of people, there are additional symptoms including anxiety and depression, postural hypotension (low blood pressure when changing posture), headaches, and GI and urinary complaints. The condition is considered by some (still some controversy on this point) to be an inherited condition that affects the connective tissue of the body, with a defect in the collagen. Interestingly, this condition is considered non-progressive and non-inflammatory. And as you age, and become somewhat stiffer, the symptoms may improve on their own. All right! A benefit to aging! However, the joint looseness in this condition can lead to increased chances of injuring the soft tissues of the joints, and also may lead to early osteoarthritis in the joints if your activities are not modified.
Joint hypermobility syndrome has some similarities to Elher-Danlos syndrome, another condition with hypermobile joints that we have written about on the blog, and some researchers even consider it to be on a continuum of conditions that includes EDS. Others consider joint hypermobility syndrome a stand-alone condition. (See my post on yoga and EDS Friday Q&A: Elher-Danlos Syndrome and Ram’s personal story Coming Out: My Personal Experience with Elher-Danlos Syndrome).
There is also is a much milder condition of increased joint mobility called generalized joint hypermobility. Those with generalized joint hypermobility have many joints that are more mobile than the average person’s. But according to one study of college students, even though people with this condition are more flexible, they are not at additional risk of injury from their extra movement or the other symptoms that affect those with joint hypermobility syndrome. Generalized joint hypermobility affects about 20% of the population, women much more frequently than men, and probably accounts for most of the students I see in class who are hyperflexible. Joint hypermobility syndrome, on the other hand, only affects about 3 percent of the population.
Especially because joint hypermobility syndrome can be an under-diagnosed cause of chronic pain, I encourage anyone who is hyperflexible and suffers from ongoing joint pain to see your doctor for an accurate diagnosis. They should rule out more serious diseases associated with hypermobility that can lead to early death, specifically, Marfan syndrome and Ehlers-Danlos syndrome, vascular type.
Practicing with Hyperflexibility
After you have been diagnosed with joint hypermobility syndrome or if you have generalized hypermobility syndrome without any present joint pain, how should you proceed with your yoga practice? Let’s start with a look at what is usually recommended by your doctor.
In the western medical system, lifestyle modification is considered the most important treatment option for joint hypermobility syndrome and possibly generalized joint hypermobility (the jury is still out on whether this second condition can lead to first), although studies confirming the benefits of this are lacking at this time. They include the following recommendations, which I list here due to their direct relevance to yoga asana:
- Avoid excessive joint movement (due to risk of injury to joint structures).
- Exercise regularly while being careful not to over train, and avoid focusing on increases in flexibility.
- Increase strength to stabilize specific joints.
- Stretch specific tight muscles in a way that does not affect the joints, as this may reduce symptoms and may also improve balance and control.
- Focus on improving proprioception (with activities that combine strength, balance and agility), which may also lessen symptoms.
I suspect as you were reading this list, you were already thinking of all the ways yoga could address these recommendations! Here are mine.
1. Increasing Strength
Even with my students who are simply hyperflexible (and don’t have joint hypermobility syndrome or generalized joint hypermobility), I have been emphasizing strengthening over deeper stretching for some time now. So, in general, I recommend that you focus on adding more strengthening poses into your practice, such as Warrior 1 and 2, Hunting Dog pose, Plank pose, Side Plank pose, Boat pose and any other pose that requires strength more than flexibility.
You can even work on strength building in poses you’d typically think of as flexibility poses. For example, with Reclined Leg Stretch pose, instead of having a student with obviously flexible hamstrings go deeper in the pose by bringing the lifted leg closer to the chest, I have them pull the strap on their foot back in the direction of the head while pushing the lifted foot and leg in the opposite direction, creating an isometric contraction of the muscles in the back of the leg. I apply this idea to as many poses as possible, so that even though the student does not go as deep into the stretch as they could, they start to develop more strength in the muscles around their lax joints to support more joint stability.
2. Avoiding Excessive Joint Movement
To avoid excessive joint movement, practice stretching poses as I described above. Also, use of props in any pose to help avoid excessive joint movement and generally avoid going into extremes in poses. Many poses, such as Warrior 3, require a combination of strength and flexibility. For poses like these, I often suggest that hypermobile students only go to 75-80% of their maximum range of motion in their hypermobile joints.
Another way to do avoid excessive joint movement is to isometrically contract the muscles around a very mobile joint before you head into a deeper range of motion and maintain that contraction while you are in the pose. This will both stabilize the joint more and decrease the range of motion through which you can more it.
3. Stretching Tight Muscles
When stretching specific tight muscles, which even someone with joint hypermobility syndrome may have in certain areas, I encourage students to look for sensation of stretch in the center of the muscle body and not near the joints, and become familiar enough with “normal” joint movement that they can visually check to make sure they are not going beyond it. This might require working with a teacher who can give you feedback about healthy range of motion of your hypermobile joints.
4. Exercising Regularly
If you establish a regular yoga asana practice, it can serve as a consistent form or regular exercise. The caution to those with joint hypermobility syndrome is to avoid taking advantage of their extra joint mobility in order to do advanced poses that may increase your chances of joint injury. Focus instead in your asana practice on building good strength around your hypermobile joints and improving the feeling of joint stability when you are in your poses, especially standing poses where you might normally feel wobbly.
5. Improving Proprioception and Balance
You can use your yoga practice to improve both balance and proprioception See Techniques for Improving Balance ) But because your proprioception may initially be off quite a bit in both of these conditions, I suggest you also get visual confirmation (use those eyes or a mirror!) as you do your poses that your body parts are where you intend them to be and adjust to safer alignment if you see that the joints are off at all.
6. Cultivating Equanimity
To help your fatigue, anxiety, headaches, and GI or urinary symptoms associated with joint hypermobility syndrome, I recommend practicing stress management (see Stress Management for When You’re Stressed) and equanimity practices (see 7 Ways to Cultivate Equanimity with Yoga) as these practices can help you accept and manage your condition and reduce stress-related symptoms.