Many talented yogis seem to be blessed with bodies that are able to perform a myriad of different and for others seemingly impossible yoga postures. However, after more than 30 years of teaching my observation and personal experience is that it is often these ‘talented’ very flexible yogis who are much more vulnerable to injury and thereby have more physical problems than their stiffer colleagues.
Not surprisingly yoga attracts these flexible bodies. Often this natural flexibility is in fact joint hypermobility due to a generalised laxity in connective tissue. Hypermobility is different to flexibility. Mobility is a quality of joints whereas flexibility is a quality of muscle. However, it is your connective tissue that allows both mobility and flexibility and is a big determinant as to what degree these can occur. The shape of our bones, which form and determine the structure of our joints, are our set foundation in determining much of our range of motion. However, the length and laxity of the tissues connecting, surrounding and stabilising these joints will dictate to what degree we will have freedom of movement at these joints. Often, without complex advanced imaging it is difficult to determine exactly how much of this movement is dependent on boney structure and how much on connective tissue laxity.
Connective tissue includes the ligaments that connect bone to bone, the joint capsules around the joint, the muscle tendons that are actually the filum terminale of the multitude of layers of fascia that both invaginate and surround every muscle, as well as the superficial layer of fascia beneath our skin that unifies the entire body like a fascial wet suit. Undoubtedly, even the deepest layers of fascia that act as organ trusses and sacs (eg: the meninges around the spinal cord and brain, the pericardium around the heart and the peritoneum around the abdominal organs) also affect our levels of trunk flexibility. Connective tissue, as the name suggests, is what connects everything in our body into the single cohesive, unitary physical and mechanical system we inhabit!
Therapists often use a scale to determine a person’s general flexibility. The most common is the Beighton 9-point scoring system. With this scale you receive one point for each elbow and knee that hyperextends to 10 degrees or more; one point for each thumb that can oppose/flex down to the inside of your forearm; one point for each little finger that can dorsiflex to 90 degrees or more; and one point for being able to flex forward to touch your hands flat to the floor without bending your knees. A score of four or more in males and five or more in females is considered suggestive of marked generalised hypermobility. Although this system is the major tool used in epidemiology research in this field it obviously lacks specificity to the many other joints of the body as well as the person’s actual symptoms.
Joint Hypermobility (JHM) is common and of itself is neither a disease nor a disorder. It is three times more prevalent in females coupled with the fact that joints are looser with the pre-menstrual phase of the menstrual cycle and during menstruation. This is due to the spike of the hormone progesterone, which causes increased tissue laxity. JMH may be associated with mechanical injury but equally confers an advantage to any yogi. As our ligaments, joint capsules and fascia act as our body’s passive stabilisation system, the support that is missing from these in JHM needs to be made up for with extra strength of our active stabilisation system, i.e. our muscles. In this way repeated focal, regional or widespread injury can be avoided. However, when hypermobility is responsible for a wide range of chronic pain symptoms including musculoskeletal pain it may indicate the presence of one of the heritable disorders of connective tissue (HDCT). The most common of these is joint-hypermobility syndrome (JHS).
JHS classifies people based on more than articular or joint laxity. The Brighton Criteria for the diagnosis of JHS has two major criteria and eight minor criteria that need to be met. The two major criteria are: 1) A Beighton score of 4/9 or more and 2) Joint pain or arthralgia for longer than three months in four or more joints. The eight minor criteria are: 1) A Beighton score of 1, 2, or 3/9 in aged 50+; 2) Arthralgia in 1-3 joints or back pain or spondylosis/spondylolysis/spondylolisthesis; 3) Dislocation in more than one joint or in one joint more than once; 4) Three or more soft tissue injuries (eg, tendonitis, bursitis, epicondylitis); 5) Exceptionally tall, slim build with unusually long, slender fingers (Marfanoid habitus); 6) Skin striae, hyperextensibility, thin skin or abnormal scarring; 7) Drooping eyelids, short-sightedness or slanting eyes; 8) Varicose veins or hernia or prolapse of the uterus or rectum. The diagnosis of JHS is made when either two major, or one major and two minor, or four minor criteria or two minor criteria with a first degree relative with confirmed JHM are present.
As well as a vulnerability to injury, those with JHS often experience the following symptoms: pain after routine sport or exercise, excessive clicking of joints, excessive fatigue from sport or activity, acute wry neck, frequent headache, flat feet, “restless leg syndrome”, “growing pains”, scoliosis, constipation or “irritable bowel syndrome” poor posture (hanging off their joints), poor muscle tone, fatigue, anxiety, dizziness, a tendency to fainting especially after standing for long periods, back and pelvic pain and/or premature rupture of membranes and labour during pregnancy, chronic widespread pain or fibromyalgia. The latest research explores the association of JHS with fibromyalgia, chronic fatigue syndrome, gastrointestinal disorders and chronic pain syndromes. Their many overlapping symptoms often leads to misdiagnosis.
It is proposed that hypermobile joints have an increased incidence of injury because of altered joint proprioception, especially in extreme ranges of motion. This poses a higher risk for yogis who are consistently playing the edge of extreme ranges of motion. One role of proprioceptors is to help provide congruity of our joints. Unprotected excess mobility can be likened to wearing shoes that are too large. The laxity of the fit means excess movement between your foot and shoe and is akin to loose ligaments, joint capsule and fascia. Any misalignment, imbalance or dysfunction of joints will cause the surrounding muscles to tighten in an attempt to stabilise and protect that area.
This leads to the less expected phenomenon that people with JHS actually FEEL stiff and gain much relief through stretching. What is important here is to use stretching as a therapeutic tool rather than as an indiscriminate way to become even more flexible. Additionally what is needed in the case of hypermobility is adequate strength surrounding the core of these joints. Muscle co-contraction and high resistance partial range training are excellent ways to achieve this.
Whether hypermobility is genetic or self-induced it does increase the risk of injury due to destabilisation of the joints. It is important for yogis to exercise care and protect themselves when demanding greater flexibility at their end range of movement. It is this destabilisation of joints that leads to the unnecessary recurrence of injuries. It is challenging and fun to be able to do all sorts of wonderful if not weird things with our bodies. However if we damage ourselves at the same time we need to question our motives. It is a misconception to believe that every different body can or should be able to eventually perform all complex or flexibility-demanding postures given adequate practice. This may be suitable for those so inclined by boney structure or being loosely held together. My question is: How flexible is flexible enough? If you think you can never be flexible enough, you are embarking on a dangerous path. The accurate saying goes: “God will forgive you but your body won’t”. Excess flexibility is not an end in itself and certainly will never lead to lasting happiness let alone spiritual freedom! Practice yoga to sustain a healthy body by working with awareness, sensitivity and intrigue.
Chek P, Equal But Not the Same. C.H.E.K. Institute, 2011.
Hakim AJ, Keer R and Grahame R, Hypermobility, Fibro- myalgia and Chronic Pain. Churchill Livingston, 2010.
Risley Physiotherapy Pty Ltd, Benign Joint Hypermobility Syndrome. Perth, 2012.
Potsdam Fibromyalgia Support Group Newsletter. Clarkson University and Canton-Potsdam Hospital, 2005.
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