Coaching The Hypermobile Athlete

Too much of a good thing

We all know that a certain degree of flexibility is important for all runners, with many of us noticeably limited in our range of motion around certain key joints. In runners and triathletes I find that lack of flexibility particularly becomes a problem around the hips and ankles. I know this is something I personally need to work continuously on!

This lack of available motion can cause the body to compensate through other less desirable movements in order to find motion from elsewhere, enabling the body get through the running gait cycle. As an example of this, I’d suggest taking a look at this article on restricted hip extension, and it’s impact on calf loading. In so many runners, a big problem is a lack of available motion around the hips areas.

However, there is a significant population of athletes where the problem isn’t too little motion, but too much motion being available. Without the neuromuscular control and strength through range to control this increased available movement, the athlete is potentially at increased risk of injury. These hypermobile runners present their own set of challenges when it comes to coaching and injury prevention.

The following is based on my coaching observations having worked with a number of hypermobile runners…

Physiotherapists (and anyone else for that matter) – feel free to add your thoughts in the comments section :)

Flexibility vs Hypermobility

Some runners are more bendy than others, for sure. Just because you are more flexible than your training partners, this doesn’t necessarily suggest that you are clinically hypermobile. Somewhere in the region of 4-15% of the population are thought to suffer from the genetically inherited Hypermobility Syndrome (HMS).

Sports Physio, Adam Meakins (@AdamMeakins) does a great job of explaining the two classification systems used in combination to diagnose HMS: Beighton Score and The Brighton Criteria.

The video below demonstrates the tests used to determine an athlete’s Beighton Score.

Adam describes Hypermobility Syndrome nicely in this blog post by stating:

It’s a syndrome that affects the connective tissue in our bodies, this is the stuff, the glue that holds our tissues and body’s together, it forms our ligaments, tendons, muscle, skin and most other things, there are different sub types and with hypermobility you have too much of a certain type and its disorganised in its structure, this is caused by a gene mutation and it is nothing that you can or could have prevented.

Due to this gene the connective tissue is very pliable or stretchy and so allows excessive movements of the body’s joints, this excessive movement and lack of control around a joint can then produce ‘arthralgia’ or joint pain believed to be from the shearing (side to side) forces that the joint experiences in day-to-day movements.

Challenges Faced By Hypermobile Athletes

I’m not going to get into the question of ‘What form of exercise is best for those with Hypermobility Syndrome?’. Needless to say, exercise is definitely the way forward compared to no-exercise. You will of course find that some forms of exercise are more or less stressful on the hypermobile body than others.

As this is a running blog, I’d like to focus more on what we as coaches and therapists can do to help hypermobile athletes become more resilient to the rigours of running. As 9 times out of 10, in my experience runners will run – hypermobile or otherwise.

Don’t run is rarely an acceptable long-term solution!

Having coached a number of athletes diagnosed with various degrees of Hypermobility Syndrome, there are a number of common challenges I notice. The good news is that if their training is adapted to take into account their HMS, their ability to train and compete successfully is noticeably improved.

Impaired Joint Proprioception & Control

When any athlete suddenly finds an increase in available range of motion at a joint, for example as an acute affect of PNF stretching around the hip, sometimes they find that they lack the neuromuscular ability to maintain dynamic control throughout this newly increased range of motion.

In the short-term, until their body learns to to control the new range, they struggle with proprioception and control at the joint while working through ‘new’ ranges of motion.

Now imagine this going across many joints throughout the body. All the time. That’s how I (without HMS) try to describe the proprioceptive and neuromuscular control challenges faced by athletes diagnosed with HMS, based on their feedback.

Where many non-HMS runners will need to spend time on range of motion exercises (various forms of stretching) – HMS athletes will instead need to spend time learning to control the often huge amounts of motion they already have.

Proprioception exercises for Hip, Knee and Ankle

Proprioception exercises for the Shoulder… for Swimmers and Triathletes

Flawed Movement & Muscular Activation Pattens

I’ve noticed that Hypermobile athletes have an outstanding capacity to ‘cheat’.

Not in a Lance Armstrong kind of way, of course – but the ‘using all the wrong muscles for a given exercise’ kinda way!

I’ll often find that in comparison to most athletes, those with HMS will find it difficult to feel the correct movement and muscular recruitment pattern. Their intrinsic feedback is often pretty poor. However, it seems to be a simple case of finding the right combination of cues and appropriate exercises to establish good firing patterns. The key is that the athlete needs to feel what it is to move with the correct pattern, and the correct muscles firing.

Athletes can often find a way to trick you into thinking that they’re doing the exercise right, by ‘going through the movements’. An important lesson learned by all new coaches or therapists at some point.

The point is that HMS athletes seem particularly good at this… and require constant attention initially to het the feedback going!

An example of coaching a simple Glute Bridge focusing on maintaining lumbar and pelvic position – rather than compensating through allowing excessive lumbar extension:

The Glute Bridge is a pretty obvious choice as an example – and a very basic exercise – but one I see preformed badly on a far-too-frequent basis.

If our athletes can’t get the patterning right here, who can we expect them to squat, lunge, swim, bike and run well?!

Muscle Activation Before Running

While this advice clearly isn’t restricted to hypermobile athletes, I’ve found that in many of those I’ve coached with HMS have benefitted greatly from getting into the routine of activating key running muscle groups before each running workout.

Routines like this resistance band routine and coach Jay Johnson’s Myrlt routine are great for priming key muscles before you run.

Don’t Stretch?

It would be all-too-easy for me to come out with the generic advice of telling hypermobile athletes not to bother stretching – as they have more than adequate range of motion. On the whole I’d stand by that advice, as strength and control must be the priority in HMS athletes.

Of course there will however always be the occasion where stretching a certain isolated area may be beneficial for a given acute or chronic complaint – take advice from your physiotherapist on this one…

Take Home Messages

Athletes with Hypermobility Syndrome need to spend significant time training their body to control the extra motion they have available to them. With mobility must come strength through range, neuromuscular control and stability.

Often hypermobile athletes require increased input and feedback to establish good movement patterns and feel the correct firing patterns.

From Twitter!

As I was putting this post together, these tweets came in…

Ellis and Jeff together sum it up nicely :)

About The Author

James has an academic background in Sport Rehabilitation and a special interest in Applied Biomechanics. He currently coaches a large number of Runners and Triathletes across all levels of ability and performance. He's grown a strong reputation for enabling athletes to improve their running performance and overcome running injuries through improving their Running Technique and developing Running Specific Strength.

 

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11 Comments

  • Excellent article, all three of my boys (8, 6, and 5) have been diagnosed as Hypermobile (all level 8). Is there anything specific we should be doing to harness the full potential as they all love running and biking and can’t wait to get into triathlons? Or should we just leave them be to develop with time?

    Many thanks.

    • Hi John,

      Thanks, I’m pleased to hear you enjoyed the article!

      Although I’ve done a great deal of youth coaching in the past (mainly in football) – to be honest, I haven’t worked with any truly hypermobile kids.

      That said, instinctively I’d lean towards playing lots of balance games with them. If you can help them develop awesome proprioception, strength will come with age. No doubt they will benefit from bodyweight strengthening exercises from early teens onwards – but for now I’d gravitiate towards lots of balance and proprioceptive work.

      I’d be interested to hear feedback from any Paediatric Physios who might be reading this…

  • That’s me!! I’m hypermobile, and would probably be at least a five. I also have spinal OA. Currently nursing a knee injury apparently caused by a laterally mobile joint. Can run if very strapped up, and spinning to build up strength around the joint, but not really recovering seven weeks after initial injury. Have been referred to NHS musculo-skeletal team. Hoping to compete in a 10k in about five weeks. Keep fingers crossed for me.

  • Thank you for this article, I’ve just been diagnosed as having hypermobility syndrome and haven’t run since Septmeber as have tendonitis in my foot/ankle as a result of bad posture while running. I am working with a physio and learning how to sit, stand and walk properly (learning the feedback as you talk about) so that eventually I’ll be able to run again. It’s a long, slow and boring process and I really wish that I’d know about it before. As it affects nearly 1 in 10 people I’m surprised that I’ve not yet met a yoga teacher, PT or running coach who has ever mentioned it, if they had I might well have been able to understand the condition and its effects years before it became such a debilitating issue. Thanks for publicising it.

  • I know I’m a bit late to this page, but just wanted to let you know how useful it is. I’ve been searcing for advice for running with hypermobility and I’m really pleased to see so much info in one place.

    I have Ehlers Danlos Type 3, which is HMS with some bonus pain and autonomic nervous system problems.

    The only plan that has ever helped my symptoms is the staying strong plan. I found out last year that I have osteoarthritis in one knee, so I’ve spent the last six months doing as much strengthening as possible and started running again three weeks ago. I’m back up to a 5k plod (so far, touch wood, etc.). I’ll give your pre-running advice a go and see where that leads.

    Thanks again for the work you’ve put into this.

  • Hi

    Love the Kinnetic Revolution materials = thank you.

    I have hypermbility around my right hip/SI joint. I also have weak knee(old injury) and anke (badly twisted ina fall a year ago) on right leg – and consequently weakness on my whole right side.

    I am recent convert to running but I LOVE to run.

    I struggle to do glute bridges correctly and I stuggle with single leg exercises that involve standing or jumping off my right leg. The biggest struggle I suppose is knowing what is “right”.

    Clearly my left side is stronger and I should focus on improvements on strength in rigtht core ankle, knee, hip back. But how do I achieve that and how do I know when i am doing exercises like glute bridge or balance exercises correctly?

    When I do the same exercise left leg or right leg it feels different.

    Many thanks

    Andrew

    PS – keep up the good work!

  • What I found that with hypermobility you need to listen to your body. A lot. And pay attention to anything that feels not quite right. Not quite straight… And address the issue without wanting. If you will build up muscles around that “not quite straight” joints than fixing the problem becomes much much harder job. You go to physio-Ostio- he’ll manipulate – your muscles will pull it back. Very single little thing in your life may cause this disballance – the way you sleep (don’t sleep on one side – :) ), the way you seat (don’t sit cross legged, especially with one dominant side), watch the way you drive – I found that my automatic car caused a lot of problems – one leg on a peddle, slightly rotated back…). Lots of problems with my upper body disappeared after I changed the way I hold stearing wheel (took only 15 years to figure that one out..). Yoga, actually, helped a lot, but in a very different way. I have my ‘body check’ yoga routine to establish if everything is straight.
    I also found that elliptigo helps a lot to get thogh the low impact miles and also align the body in a correct way.
    Yes, I gave up on doing marathons and iron man (at least at this point) – I don’t think my body will allow me, but the only one title I never hold is the AG world champion in sprint Tri (I was second though). That proves that with some limitations one can have reasonably successful sporting career – you just have to learn to know yourself and your boundaries

  • […] wondering if my hypermobility is the root of some of my injuries? THIS article and THIS article kind of points in that direction or at least it contributes to it. […]

  • Hi my 18 year old daughter has just been diagnosed with hypermobility syndrome. She is an athlete and does very well in her 100 &200m she is also doing level three personal trainer at college . She does have a talent in regards to her athletics, but this has brought a while new worry to her sports. What would you recommend for support for her knees an elbows as these are the Ares the consultant has said she has it . He knees stiffness and then she has to crack it to ease it .

    • Carol,
      last 7 month of my fight for my body was very hard and amazing the same time. I made it from not being able to walk to school to be able to do tri again. I learned so much that I want to study now to be able to help people with hypermobility.
      Very often, hypermobility is something that runs in the family and connected to other health problems, like, to say, IBS. It is connective tissue disorder. More, lots of people with hypermobility have a low muscle tone and struggle to activate big groups of muscles, like gluteus, which stabilises knee and foot. My feet and hands are the most affected.

      I wrote couple of articles for local running magazine about my journey – have a look
      http://tritb.blogspot.co.uk/2016/01/end-of-another-season.html
      and
      http://tritb.blogspot.co.uk/2016/02/in-search-for-body-balance-or-body-quest.html

      If you have private insurance she can try to get special physio.
      Not stretching is not right. She NEEDS to be sure that both sides of the body are the same. Foam rollers sometimes are the best to track knots.
      Then all depends on the level of hypermobility. If she dislocate joints – high impact and repetitive sport are really not recommended. I have to mix so many things in to be able to do triathlons again and I accepted that I never will be as good as I was.
      If she has other problems (guts, easily bruising etc. – google EDS hypermobility type) then it is likely to become worse in future when muscles will start weakening. Again, specific strength training will help. She will need to be clever – I mix some Pilates where I can control what is going on – and finally I can mix in some higher intensity classes (after I activated and learned to use major big muscles in the body). As I said above, very open hypermobile people have this ‘lazy’ look. or often they are clumsy. One of the physios (she was hypermobile herself) taught me a trick to … tap-smack – lazy muscle. I literally had to go through scanning my right and left side and finding what works on one side and doesn’t work on the other side and re-activate it.
      That journey was mostly taken alone as I didn’t find a specialist who will understand enough what was going on. Saying that, I met some amazing people on my journey who gave me courage and shared their knowledge.
      Sad thing, of cause, that there is 10-12% (estimated) who scientists think have hypermobility. And how many doctors run easy test? How many people with GERD disease were tested? I know few suffers and I had to open their eyes on the connection.
      Good luck with the hypermobility quest. I keep fingers crossed that you will find answers and methods to deal with it….

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