Stretching the Limits: Managing Hypermobile Joints

By Claudia Bauer

December 1, 2013, PUBLISHED BY IN DANCE

Proper care of a hypermobile body can mean the difference between a fulfilling career and sidelined dreams.

We know it when we see it: the hyperextended line of an arabesque, the back arched fluidly over a partner’s arm, the ankle raised behind the head during a stretch. Such acrobatic flexibility seems perfectly normal to many dancers; for some, it’s a basic job requirement. But often dancers are unaware that the flexibility we prize isn’t normal—it signals the presence of joint hypermobility, a systemic connective-tissue condition with worrisome risks and lifelong implications. Fortunately, with awareness and active self-care, we can protect our hypermobile bodies, and dance longer and stronger.

The Flip-Side of Flexibility
Joint hypermobility is a relatively new area of research, and scientists and practitioners only recently began consolidating their knowledge. Consequently, descriptions of the condition vary and names for it range from “hypermobile joint disorder” to “benign hypermobility syndrome”; in keeping with common, if imprecise, parlance, this article uses “joint hypermobility syndrome” (JHS). Thought the science is in flux, what’s certain is that JHS affects slightly more women than men, tends to decline with age, and is benign only in that it has no effect on vital functions like breathing or metabolism. It affects people from all walks of life, but is such an asset to dancers that it is much more prevalent among them than in the general population. “Many [dancers] think hypermobility is a blessing,” says Dr. Selina Shah, a physician at St. Francis Memorial Hospital’s Centers for Sports Medicine in San Francisco and Walnut Creek. “But the word of caution is that it is not, necessarily.”

A dancer and competitive athlete herself, Dr. Shah is the company physician for Liss Fain Dance, San Francisco Ballet School and Diablo Ballet. She understands the catch-22 that JHS represents. “There is the ideal to have 180 degrees of turnout, to développé a leg to 180 degrees, whether it is front, side or arabesque position,” she says. “Dancers that are hypermobile often have a capability to do so, but…pushing those limits continuously without adequately strengthening can lead to injury.” Indeed, the trade-off for that effortless, ethereal flexibility is an increased risk of strains, sprains, tears, cartilage wear and chronic joint pain.

“[JHS] is basically an abnormality in the collagen fibers,” she explains. Because collagen is found in cartilage as well as in every muscle, tendon and ligament, JHS affects the entire body, including the jaw, shoulders, arches, vertebrae—any point of flexion, large or small. In extreme cases, the effects of JHS can be devastating. According to a 2011 study published in the British Medical Journal, complications may include hernias, organ prolapse, premature osteoarthritis and severe immobility (BMJ 2011; 342:c7167). And we thought we were just stretching.

Savvy Diagnosis, Strategic Management
Practitioners use a simple test called the Beighton score (see sidebar) to diagnose joint hypermobility. If a patient meets the criteria, Shah’s next step is a thorough evaluation to exclude other arthralgic conditions such as rheumatoid arthritis, or potentially life-threatening disorders that have joint hypermobility as a sign, such as Ehlers-Danlos syndrome and Marfan syndrome.

It’s worth seeking out a practitioner who is familiar with hypermobility. Even experienced orthopedists can misdiagnose it, and some take the term “benign” literally and downplay the potential outcomes. While it’s true that some people with JHS will experience no negative symptoms, the heavy demands on a dancer’s body mean that the elevated risks of injury, repeated injuries at the same site and slowed healing can have far-reaching effects. “When you have a hypermobile dancer that continues to overstretch, they sometimes worsen the problem, leading to more weakness,” Shah observed, “and you combine that with overuse, with constantly pushing the limits of range of motion.” Proper care of a hypermobile body can mean the difference between a fulfilling career and sidelined dreams.

Once she makes diagnosis of JHS, absent of other diseases or conditions, Shah prescribes any needed dietary changes to ensure balanced nutrition, plus physical therapy, strengthening exercises…and lifetime maintenance. Unfortunately, JHS doesn’t go away with treatment; it can only be managed. Here again, practitioners who understand JHS, and are familiar with dancers’ special needs, can create a safer, more efficient recovery and maintenance plan.

Alameda physical therapist Dr. Suzanne Martin treats hypermobile patients using a range of modalities, from Pilates and Floor Barre to TheraBand and Yamuna balls. A dancer, teacher and choreographer, as well as a master Pilates instructor, she is the lead physical therapist with Smuin Ballet and has presented papers on hypermobility at International Association for Dance Medicine and Science conferences.

Dr. Martin emphasizes strengthening the core and deep skeletal muscles to create a stable foundation for all movement. “You want to learn how to hold your muscles while you’re stretching so that you’re not just pulling your joints apart,” she cautions. “If you can learn how to hold yourself inside yourself, then you get a more accurate muscular stretch.” Normal, non-lax joints are protected by their own relative stiffness, which prevents the extreme range of motion that hypermobile people can achieve. Properly supported stretching helps compensate for those bendy but inherently dangerous biomechanics.

She is also a proponent of compression tools like Yamuna balls and foam rollers to help loosen the fascia, a connective tissue that surrounds many body structures, including the muscles. “Lots of times the fascia will tighten up on a hypermobile person, because something has got to hold you together,” she says. “The more you jump, the more your fascia is going to tighten up against the impact, especially if your joints can’t hold you.” Rolling is especially helpful for gluteal muscles and hamstrings, while the compact Yamuna ball allows gentle but deep access to hip rotators.

Both doctors recommend weight training to further stabilize the joints. “You can continue to stay lean and have the dancer’s ideal physique without bulking,” Shah says, “and get that additional assistance that you can’t really get from Pilates.” When patients worry that lifting weights might reduce their range of motion, Dr. Shah reminds them that their predisposition to hypermobility means they can maintain that extreme flexibility and have strong joints. It’s up to every hypermobile person, as Dr. Martin puts it, to “know that this is my body type, this is a dancer body type, and come to terms with that. It’s not going to just go away if I don’t pay attention to it.”

The Beighton Score
Score one point for each yes answer, up to a total of 9 (one for each task or right/left side). A score of at least 4 is required for a preliminary diagnosis of hypermobility. See a medical professional for additional tests to confirm the diagnosis and rule out other conditions.
1.  Can you bend your pinky fingers backwards beyond 90 degrees?
2.  Do your elbows hyperextend when you straighten your arms?
3.  Do your knees hyperextend when you straighten your legs?
4.  Can you bend your thumbs down to touch your forearms?
5.  Can you place your palms on the ground when bending over with your legs straight?

JHS is a complex condition, and this article touches on the basics. Here are resources for learning more and getting an accurate diagnosis and treatment.

For further reading
Most reputable medical websites have useful basic information about JHS.
The Hypermobility Syndromes Association:
British physician Dr. Rodney Grahame has written extensively on hypermobility; his books can be found on

Suzanne Martin, DPT:
Dr. Selina Shah / Center for Sports Medicine: (San Francisco: 415-353-6400, Walnut Creek: 925-934-3536)

Wellness tools

This article appeared in the December 2013 issue of In Dance.

Claudia Bauer is a freelance writer. She covers dance for the San Francisco Chronicle, Dance Magazine, Pointe Magazine, Dance Teacher Magazine and