The hypermobile athlete: what you need to know

Joint hypermobility has been associated with increased risks of injuries over the years, but is this true for all joints? Should you avoid any types of exercises? And what can you do to reduce your risk of injury? A special thanks to my brother, Dr Ryan Koay, for finding out what the latest and most agreed research says. Find out in this article!




What is joint hypermobility?


Joint hypermobility is defined as having a range of motion beyond normal within a joint. You can find a list of normal ranges here. Think of people bending their fingers back 90 degrees or hyper-extending their knees and elbows so that they go beyond a straight line.


Although it’s not a medical condition, it does carry an increased risk of injury with certain types of exercises and ultimately osteoarthritis, the wear and tear version of arthritis.


If you want to check whether you have hypermobile joints, most physiotherapists and clinicians will screen you for hypermobility using the 'Beighton Score', where you will be asked to perform 5 manoeuvres which you will be scored on.


If your JH is a cause of long-term (chronic) pain, instability, or other features seen in this list, then you might want to discuss with your clinician the possibility of having Joint Hypermobility Syndrome (JHS). This is categorised separately from joint hypermobility and is important to distinguish as it comes with a need for more expert input from your clinician and physiotherapist to exercise safely.



Who gets joint hypermobility?


Joint hypermobility can be inherited or acquired and its prevalence has been estimated at somewhere between 10–30% and varies by country (more common in those of Asian and African descent than Caucasians). It’s also approximately three times more likely to affect females than males.


Inherited (most common)

The majority of people with joint hypermobility will have inherited it from their parents and these are often associated with disorders affecting the protein matrix of your connective tissue, which is the protective tissue that helps to keep your organs and joints safe. They majorly contribute to structures such as your cartilage, ligaments, tendons and bone to name a few. Those with joint hypermobility will actually have greater laxity in their ligaments and tendons.


There are many different heritable conditions which can make it more likely to have hypermobility such as Marfans Syndrome, Ehlers-Danlos (hypermobile variant), Downs Syndrome, and Osteogenesis Imperfecta. However, not everyone with these conditions will necessarily have hypermobility.


Acquired

JH can also be acquired, and you can see it in individuals with injuries such as those with ligament ruptures, i.e. anterior cruciate ligament (ACL).


It can even be trained, for instance, those that wish to be more flexible in specific joints may undergo training from childhood such as for gymnastics, ballet dancing or combat sports.


You can also temporarily increase your flexibility i.e. a progressive stretching and warming up period. A study on Olympic athletes with normal flexibility could temporarily increase their flexibility beyond normal for a short duration through progressive stretching.



What are the risks involved with joint hypermobility?


Unfortunately, the majority of the literature agrees that joint hypermobility increases the risk of both upper and lower extremity injuries. With one of the major reported injuries is with the knees and is normally associated with team-based sports, especially those involving a lot of contact, such as Rugby and American Football.


This is likely due to the fact that people with joint hypermobility tend to have difficulty keeping their joints in a neutral resting position and maintaining stability during motion, especially those with high-impact (running and jumping etc), cutting motions (quickly changing direction when running) or involving heavy weights.


One reason for this is that ligament laxity in joint hypermobility can affect your joint proprioception (knowing the position and movement of a body part), where your muscles will normally respond to correct a body position or to reduce the force going through it. As such, any disruption to your proprioception can result in you placing your joints in more strenuous, and even dangerous positions when you exercise. This is made much worse when your muscles are tired, so pay close attention to this!


The majority of studies agree that joint hypermobility increases your risk of injury, however, a much smaller number of studies have suggested no difference, and even less injury on some joints when compared to a control group. The ankle joint seems to be far less reported to become injured with hypermobility than other joints.



Are there any advantages of having joint hypermobility?


The advantages of joint hypermobility are strongly associated with sports where high levels of flexibility is a desired attribute, such as gymnastics, acrobatics and ballet.


A study by Grahame and Jenkins concluded that there was a selection bias by the Royal Ballet School and the Royal Ballet Company to pick individuals with joint hypermobility. A snapshot at the time showed that of all their dancers, 95% of females and 82% of males had joint hypermobility.


There have also been some observed advantages in sports where flexibility and power are needed in combination. For instance, bowlers in cricket may generate more speed with increased flexibility in their wrists and shoulders. Additionally, benefits have also been seen in swimmers where having increased hip and shoulder flexibility can be beneficial for breaststrokes.



How do I reduce my risk of injury?


You can’t ‘cure’ hypermobility, but you can take some steps to help avoid injury.


Work on your proprioception

This involves working on your balance, coordination and agility in a variety of ways. Exercises such as balancing on one leg, single-leg squats and controlled hops all help improve your proprioception.


Strengthen your muscles

Having stronger and more muscle bulk around your joint, can help stabilise the joint, and also share some of the forces running through the joint during exercise.


You’ll want to strengthen the muscles surrounding your problematic joint, including the muscles above and below it. This is because your joints work together along with your ligaments, bones, muscles and nerves to make sure they’re working smoothly, and positioned correctly in movement.


When doing strength exercises, it’s important to focus on good form, control every part of the movement and build up the resistance gradually. You may find working with a personal trainer helps to build up your ability and confidence.


Improve your fitness

Fatigue is linked to an increased risk of injury which is why it’s essential to work on your aerobic fitness and conditioning of your muscles. Building this up will help stave off fatigue and allow you to exercise for longer.


Build sports-specific resilience for high-risk activities

For the vast majority of people with joint hypermobility, the benefit of exercising far outweighs the risk but you should take more care with the type and intensity of exercise you do. It’s worth noting that these types of activities may carry a bigger risk for you:

  • Team-based sports — especially if it involves changing direction and collisions

  • High-impact sports — those that typically involve running, jogging, or jumping

  • High-load sports — powerlifting or gymming with poor form

If you regularly get injured in a sport that you love, it’s worth working with a physiotherapist to identify possible issues that you can address that can get rid of or prevent this from occurring. From there, I’d recommend keeping up a training programme to build and maintain specific sport-related resilience to reduce your risk of injuries and pains. Your future self exercising into your 90s will thank you for it.


Consider avoiding high-risk activities

Professionals generally won't tell you to give up the sport or activity you love, but it’s important to realise that these are all risk factors that increase your chances of injuring your joints and developing osteoarthritis at an earlier age. If the risk of the injury is not worth the reward of the sport for you, then consider alternative forms of exercise, like cycling, swimming and strength exercises in the gym.



Should I be concerned about my joint hypermobility?


There’s no need to be concerned about joint hypermobility if you are not experiencing regular injury or pain. Most people with hypermobile joints can lead very active lives!


If you are concerned that your joint hypermobility is causing various injuries and pains, then do visit a physiotherapist for advice and you can work with a fitness professional to help build your strength and reduce your risk of injury.



References
  1. https://journals.lww.com/acsm-csmr/fulltext/2013/09000/joint_hypermobility_and_sport__a_review_of.7.aspx

  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196975/

  3. https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04249-x

  4. https://www.cdc.gov/ncbddd/jointrom/index.html

  5. https://pubmed.ncbi.nlm.nih.gov/15273185/

  6. https://www.nhs.uk/conditions/joint-hypermobility-syndrome/#:~:text=A%20GP%20will%20usually%20test,any%20other%20conditions%20like%20arthritis.&text=A%20doctor%20will%20also%20use%20more%20detailed%20criteria%20to%20help%20their%20diagnosis.

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