Hypermobility & Soft Tissue Therapy

I have a number of clients who are hypermobile. Most of them know they are ‘double jointed’, but some do not, and there are different degrees of hypermobility in each client. I call these the ‘bendy people’ and as a Soft Tissue Therapist which incorporates and advances on sports & remedial massage more care is needed to treat them as many of the normal techniques for stretching tight muscles are not appropriate and can be counter-effective, causing more pain to the client after the treatment.

This is a brief article based on research and my experience from an increasing number of clients I see with this condition. Bendy people are particularly vulnerable to soft tissue injuries and the effects of overuse. My clients have often seen many different types of practitioners gaining no significant benefit before coming to see me.

Background

There is plenty of information regarding Hypermobility, eg Syndrome, Beighton score to screen hypermobility, problems with laxity of ligaments can run in families, increased susceptibility of women and children etc. but limited information available (web or books) regarding soft tissue massage treatment for the condition. The best book I found was “Hypermobility Syndrome – Recognition and Management for Physiotherapists” by Rosemary Keer and Rodney Grahame. This book was ok but gave me little “hands–on” soft tissue treatment advice.

Hypermobility can affect all joints of the body and it is common to find increased curvature in the spine (the lumbar region is particularly susceptible to back pain); pronation in the feet (flat footed); hyperextended knees with a sway back posture (note: females have a tendency to prefer resting at the end of their movement range as they normally have less muscle bulk than males); joints which are less stable and vulnerable to subluxation; lack of balance, and generally less stamina and/or more soreness after exercise.

The reason why the lumbar region is so susceptible to back pain is the sacroiliac (SI) joint, which is part of the pelvis and can be considered the ‘Achilles heel’ of some hypermobile people. The SI joint has fibrous triangles of ligaments and a limited range of movement. If these ligaments are loose various movements or postures such as sitting in a car for long durations can generate pain. The SI joint also depends on a collection of muscles including the six lateral rotators (piriformis etc), the gluteus maximus and the erector spinae (mainly by way of the thoracolumbar aponeurosis) for stability. How-ever stability is not their specific job, so while these muscles are doing other body movements they can move the sacrum out of its proper alignment with the spine and the pelvis.

Treatment

I have successfully treated many clients with hypermobility for their immediate problems and they leave with reduced or absence of pain. Postural assessment work is key in order to determine the areas to focus on and what needs strengthening. Muscle strength testing is very useful to highlight imbalances and helps to decide how to treat each client, also each treatment is unique and will vary dynamically according to what is found during the soft tissue / massage treatment.

As mentioned above during massage treatments more care is needed almost straight away, for example ensuring bolsters are positioned under knees while the client is lying on their back (prone), as knees will often hyperextend without them. (Although the client may not be aware and it does not cause pain, it is not advisable to keep clients in this position for long during massage. Similarly a stomach support can help with back alignment when the client is lying on their front. A more holistic body approach to treatment is needed to ensure all affected muscles and fascia that may need attention are treated, as hypermobile people use other secondary muscles to help the prime movers more often than normal.

Somewhat strangely, stretching is still helpful as part of the treatment to alleviate pain but needs to be undertaken in an even and controlled way to maintain muscle length and ensure that there is no increase to an already hypermobile range. A careful soft tissue release technique, with good pinning, focused at the muscle mid point / knotty area is very effective. Stretching normally works best at the end of the treatment session. I still rarely use Myofascial release techniques on hypermobile clients except on the thoracolumbar aponeurosis (lower back), and do not use friction techniques near any joint. I do favour Neuro Muscular Techniques (NMT), trigger points, deep transverse strokes in the deeper belly of the muscles which are more effective, but all clients are different so it follows that every treatment is different.

Kinesiology Taping

Kinesiology taping works well in aiding treatment, used for support, unloading tension and posture re-education and awareness but care should be taken to avoid dependency. I regularly use tape on my clients and probably the most common taping I do for hypermobile clients is at the back of the knees helping to reduce the sway back posture and also across the back to bring the shoulders to their correct position.

General Client Advice

Clients should consider the following:-

• Stop-if they are commonly and voluntarily subluxing shoulders or popping hips etc;
• Take regular breaks during daily activities eg even standing in one position at a cooker or sink can often induce pain;
• Watch or avoid pro-longed sitting positions;
• Avoid carrying heavy loads on one shoulder;
• Buy good foot-wear with arch supports;
• Use a good neck support pillow while traveling especially on overnight flights;
• Avoid sleeping face down with sustained rotation of the head (a softer mattress may be more help);
• Try to avoid static postures and resting at end of range – no locking knees into hyper-extension so body awareness and posture are very important.

Fitness & Strength Training

For long-term benefits I believe that fitness and strength training can be more helpful than frequent soft tissue treatments. Muscle strength promotes joint stability and together with posture awareness and correction is the starting point in improving symptoms. I encourage my clients to try exercise like swimming, cycling, dance, and Pilates as well as the other specific exercises below where relevant, and consider these to be an essential part of the long-term treatment.

Increasing gluteal muscle strength and tone in the maximus helps to reduce sway back posture. Other regular advice as appropriate includes: –

• Isometric back exercises;
• Strengthen-up weak iliopsoas and gluteus medius to help clicking hips;
• Pilates or specific exercises will switch on and strengthen the core, especially the transverse abdominals and obliques, and multifidis;
• Hyperextensions, controlled leg lifts and ‘superman’ exercises;
• Swiss ball work and standing on one-leg exercises.

Hypermobile clients need to be aware that they need to work their muscles harder to produce stability, as they are more likely to incorporate other secondary muscles to help in the task than someone who is not hypermobile. This can explain why hypermobile people tend to tire easily, lack good balance or their gait may be slightly different when they run.

Unfortunately it is likely, (but not always the case) that hypermobile patients will have recurrent problems throughout their lives so exercise and treatment may need to become a part of normal life. I can help with specific problems but hypermobile clients may take longer to heal than others. I can advise which muscles to strengthen, and help re-educate posture and gait. I sometimes advise or refer clients to an orthotics specialist in shoes but only after a few treatments to ensure muscle and skeletal balance are correct before proceeding with this option.

Summary

Soft Tissue Therapy which advances on Sports and Remedial massage is still effective for hypermobile clients experiencing pain provided the therapist fully understands the condition and that during treatment the client and therapist communicate well and treatment work is carefully thought out and slowed down. Advice around posture, use of tape and strengthening muscles may in the longer term be more beneficial.

Ps. If you are one of these bendy people and have a thumb similar to the picture, – I would not recommend becoming a Sports and Remedial Massage Therapist, (I know there are some good therapists around with this condition) but soft tissue work can be hard enough on your thumbs, muscles and joints without the complication of being bendy!

References
Hypermobility Syndrome. Recognition and Management for Physiotherapists. 2008 Rosemary Keer and Rodney Grahame.