Managing Functional Instability in the Hypermobile Athlete

These days, we are quick to release muscles with various soft tissue techniques.  Whether it be rolling, smashing, cupping or massage guns, people always seem to be “releasing” something.  But not everyone is tight.  What about the hypermobile athlete? How do you intervene with the hypermobile athlete?  What kind of mobility work do they need?  They often feel the need to release tissue and get some relief from it, but is it really the best solution for them?

Functional instability is a common complication of joint hypermobility and most interventions focus on strengthening the muscles that cross the affected joint.  However, proprioceptive deficits and decreased neuromuscular control have a much greater impact on instability than strength.

If you are managing functional instability in the hypermobile athlete, your intervention needs to focus on proprioception, movement control and awareness as well as strength.

EXPLORING THE TERMS

The terms hypermobility and laxity are often used interchangeably.  Laxity refers to the amount of passive range of motion at a joint and different people have different degrees of laxity.  It is important to note that laxity is normal and does not always present a problem.  We could consider the terms laxity and hypermobility as quantitative.  Someone who has more laxity or is hypermobile has a greater amount of range of motion available at the joint.

The individual with more laxity or hypermobility can rely less on the passive stabilizing system: the ligaments, joint capsule, labrum, to stabilize the joint.  As such, they need a more efficient dynamic stabilizing system, essentially the neuromuscular system.  The dynamic stabilizing system provides functional stability.

Laxity or hypermobility then, could lead to instability if the individual is unable to dynamically stabilize the joint for proper control and movement

MANIFESTATIONS OF HYPERMOBILITY

While some people just have more laxity naturally, there are also several genetic connective tissue disorders that results in hypermobility such as Ehlers-Danlos syndrome, Loey’s-Dietz syndrome, and Marfan syndrome.

More often than not, you will be dealing more with hypermobility that is traumatic, following injury to a joint or to joint structures such as a shoulder dislocation or subluxation for example.

You may also come across occult instability, which is common in weightlifters (Olympic weightlifting) who have repeated episodes of subluxation or near-subluxation without trauma.  The athletes are unaware of this excessive movement at the joint until it results in some wear and tear and eventually, pain.

Dr. Shirley Sahrmann states that «the result of a joint moving more readily in a specific direction is the development over time of hypermobility of accessory motion or micro-instability».  Movement will always follow the path of least resistance, resulting in a specific direction of susceptible movement.  Extension and flexion movement biases in the lumbar spine are just one example of this, and I discuss these in my article Avoid Low Back Pain with the Right Training Plan.

FUNCTIONAL INSTABILITY

Injury to the joint structures results in deafferentation.  The peripheral joint mechanoreceptors responsible for conveying afferent information on joint motion (kinesthesia) and position sense (proprioception) are damaged affect the sensory input and in turn, the motor output.

There may also be proprioceptive impairments in individuals with hypermobility syndromes or higher levels of joint laxity, although the exact mechanisms behind this require further study.  In any case, a previously asymptomatic hypermobile individual who becomes involved in a new activity that requires working in extreme ranges of motion may run into problems.  Take the example of a previously sedentary individual who takes up CrossFit, a high-demand overhead sport.  Those who lack overhead mobility will struggle, as will those who have excessive mobility that they now need to control during overhead lifting.

Neuromuscular control is the efferent (motor) response to the various sensory information provided on joint motion and joint position sense.  As such, perturbations in proprioception result in decreased neuromuscular control and this in turn leads to functional instability.  As mentioned earlier, we can define functional instability as the inability to dynamically stabilize the joint for proper control and movement.

There are four crucial elements to restoring functional stability:

1- Proprioceptive and kinesthetic sensation

2-Dynamic joint stabilization

3-Reactive neuromuscular control

4-Functional motor patterns

PROPRIOCEPTIVE AND KINESTHETIC SENSATION

Peripheral joint mechanoreceptors are responsible for conveying afferent information on joint motion (kinesthesia) and position sense (proprioception).  Here is where some soft tissue work might actually benefit the hypermobile athlete.  For example, IASTM (instrument-assisted soft tissue mobilization) using rapid strokes can stimulate proprioception.  If you were dealing with an ankle injury, rolling the plantar aspect of the foot to stimulate the cutaneous receptors of the foot is also a good strategy, as the foot will convey important information for functional stability of the ankle.

Joint traction and compression also stimulate joint mechanoreceptors, so light intermittent traction or placing the joint under load is also a good strategy to increase proprioceptive input.  This is why closed kinetic chain exercises are often utilized for shoulder rehab. For one they provide compression through the joint for increased proprioception and second, they result in less translation of the humeral head, which can be important in the early stages of rehab.

That said, open kinetic chain exercises are quite useful for creating awareness.  When dealing with shoulder hypermobility, specifically for occult instability or excessive anterior humeral glide (Sahrmann), I like to use internal and external rotation control exercises.  Here the head of the humerus is supported anteriorly, a support which also provides feedback on the movement that needs to be controlled:

DYNAMIC JOINT STABILIZATION

Dynamic stabilization involves working preparatory agonist-antagonist coactivation to anticipate and react to joint loads.  Efficiency of coactivation allows for better distribution of joint forces to reduce both the load imparted to the static structures and excessive movement of the joint.  The same closed-chain kinetic exercises that stimulate joint proprioception also work to restore dynamic stability.  They can be progressed to involve a balance and/or plyometric component:

Balance:

Plyometric:

REACTIVE NEUROMUSCULAR CONTROL

Reactive exercises need to involve unanticipated joint perturbations in order to facilitate reflex muscle activation.  While we work with balance and unstable surfaces (BOSUs, stability balls, etc.) for dynamic stabilization to help stimulate pre-programmed muscle stiffness, joint perturbations that are not anticipated are important to decrease the response time to unexpected joint loads.  This requires perturbations that are much quicker and unexpected.  When you place your hands on a BOSU ball, you anticipate the instability that this will generate.

If we stick to our shoulder example, creating perturbation in the overhead position is a good way to improve reactive neuromuscular control:

FUNCTIONAL MOTOR PATTERNS

The goals here include restoring functional stability in specific movements.  This is where you would typically place your exercise variations (regressions and progressions) and manipulate intensity to progress the individual back to full performance.  Exercises should include positions where the joint is vulnerable, incorporating preparatory and reactive muscle activation in a controlled setting.

An example for a weightlifter would be to begin with a jerk recovery.  This allows him to get into the overhead position with the weight supported and then pick up the weight from there.  This still places the athlete in a vulnerable position but in a more controlled setting than a regular jerk.

PUTTING IT ALL TOGETHER

Rather than going through the elements independently, a great strategy is to target each of the components within a continuum.  The Mobilization-Activation-Integration sequence of the Movement Optimization Strategy is a great way to do this, as you can place elements of proprioception, dynamic stabilization, reactive control and functional movement within one intervention.

Not everyone is tight and requires soft tissue release in order to unlock mobility.  The hypermobile athlete who presents with functional instability needs to develop movement control and awareness so that they can develop and maintain strength and stability throughout this excessive range.

Strength is everything and is required for resilience.  However, deficits in proprioception and neuromuscular control will mitigate strength gains in the case of the hypermobile athlete.  In order to ensure your interventions are most effective, you need to include proprioception, movement control and awareness within your strategy in order to optimize strength potential.

The hypermobile athlete tends to go involved in soft tissue release just like everyone else.  While it can seem odd, they actually feel tight and releasing feels good.  However, letting them resort to only that without establishing a proper structure to improve the crucial elements for functional stability will result in chronic wear and tear and potentially, pain and injury.

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Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U