Yoga and Hypermobile Joints

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Information for teachers and students

Dr Rowena Nicholson
MB, BS, MRCGP, DRCOG, Dip PCouns, Dip NSpH, Dip THY&R.

I find that there are generally two different reactions when people hear that I practice yoga and have hypermobile joints: either they think I must find it really easy, or that I shouldn’t be doing yoga because I’m too flexible anyway and I’ll make it worse! Both are wrong, and these opinions ignore some of the issues of hypermobile joints and the valuable help that yoga can be in this condition.

There are a number of different medical conditions associated with joint hypermobility, but there is usually a defect in the collagen, with most causes being considered ‘genetic’. Although many people may have hypermobility in some joints, only a minority will have Hypermobility Syndrome, in which symptoms such as arthralgia (joint pain) and dislocation or subluxation occur. The problems associated with hypermobile joints are still not widely known and I have spotted several people in my yoga classes who have not been diagnosed. I remember as a child being repeatedly told that I had growing pains. It was not until the age of 20, when I was a medical student who was unable to walk up stairs or keep up on the ward round that I found out what the problem was. Yoga Therapy and particularly Aqua Yoga have played a very important part in achieving health and fitness for me. I teach Transformation Hatha Yoga, and the asana names used here apply to this form of yoga only.

Hypermobility does not always affect all of the joints. It may be spine only, all joints apart from the spine, or particular joints only.

People with hypermobile joints usually have poor joint position sense, and will be out of alignment without being aware of it. For example, if someone’s elbows hyperextend (i.e. bend backwards a bit), they may go into hyperextension when asked to hold their arms out straight. Yoga is very good at re-educating the body, so that the student becomes more aware of their alignment, and can use their body without unconsciously hyperextending.

Balance can be a challenge when the ankles, knees and hips are hypermobile; the joints can all ‘wobble’, as there is not the ligamentous strength to hold them. Thus, someone may be able to achieve the heron from a flexibility point of view, but be unable to take their weight on one leg without wobbling over. Balance can be improved through yoga, which in turn reduces injuries and falls. Some students may need to practice balance asanas with a hand on the wall until strength and balance is improved. Use of a balance pad can be effective if teaching one-to-one. Balance pad work usually begins with simply standing in good posture, then balancing on one leg, followed by tiptoes, progressing to knee bends on flat foot and tiptoes. The ski roll is also useful on the balance pad for some students. The arc asana is also particularly effective, as the foot is never far from the floor; students should start this on terra firma, but as they advance, they may be able to use this asana on a balance pad. I would not recommend the use of a pad in a class situation, as more individual attention is needed.

When teaching good posture or earth-sky, be aware that the student may find it difficult to know when their knees are ‘straight’, and that the pelvic tilt can be over-done, causing a complete loss of a lumbar lordosis (i.e. making the back flat), which is counterproductive.

An important aspect of yoga is knowing yourself. Through slow controlled movements students can improve their alignment and position awareness, further their own understanding as to their needs and develop their intuition. In hypermobility, it is all too easy to go into more extreme stretches without being aware of how much the joints are being stressed, until experiencing pain the next day. In most people, the ligaments prevent undue stress being placed on a joint, but in hypermobility, this safety mechanism is not effective. It is therefore important to make sure that the new student errs on the side of caution until they (and the teacher) have more awareness of what movements work or don’t work for them. It is also important to avoid allowing a rapid progression to a more advanced class because of student’s physical flexibility. It is more likely that a student with hypermobility would benefit from a longer period of time in a stage 1 class; indeed they may not need to do stage 2 at any point, but this is an individual decision. A student would have to have developed a high degree of awareness and shown that they have the wisdom to be able to practice within their safe limits, before stage 2 should even be considered. Some of the stage 2 work including breathing and extending in position may be completely inappropriate. For example, when I extend, I can feel my joints separating. Extension is designed to encourage a student further into an asana, but in hypermobility there is no benefit and considerable potential for harm.

Some stretching and releasing is important for people with hypermobility. Students can still experience a feeling of stiffness and muscle tension despite a wide range of movement. The skill is in doing this without joint stress.

It is important to remember that people with hypermobile joints may have had injuries or dislocations which have led to a reduced range of movement in that particular joint.

The slow movements of yoga allow the student to build muscle strength around the joints, without straining them. This muscle strength helps to support and hold the joint, so that the joint itself has less strain upon it. Some years ago when my joints were most problematic, I found that Aqua Yoga was very beneficial. The water resistance enhanced the strengthening, whilst the water created a non-weight bearing environment, which placed even less strain on the joints themselves. However, I would recommend that if a student is new to yoga, they have some stage 1 or individual lessons first, as it is more difficult for both the teacher and student to be aware of alignment in the water.

If the student has symptoms associated with their joints, they may need some creative modifications or alternatives. It is important for the teacher to take a very good history of which particular movements hurt or don’t feel good. People with hypermobile joints can get a feeling that a joint doesn’t ‘feel right’ without there being pain, and can feel protective or vulnerable when attempting movements that could predispose to dislocation. Hypermobile students can be challenging to the teacher, because they may be able to do some ‘difficult’ asanas very easily, whilst having a problem with a ‘straightforward’ one, and they sometimes don’t know until they start an asana that it is going to be a problem. I have found it helpful to not think of any asana as being easy or difficult, but rather to consider every asana in the light of what it is going to achieve for the individual. Also, the usual questions from a teacher such as “can you do this movement?” may not apply, as often the student can do a particular movement, but perhaps not when weight bearing, or not without pain (which the student may be used to experiencing and ignoring). When there are problems in a number of joints, remember that it is sometimes the combination that is difficult. In any class there should be an emphasis on going as far as is right for the individual. This is even more important for hypermobile students, who may have to learn just how far this is. Bear in mind also, that everything can fluctuate, and what a student can do one week may not be possible the next, depending both on their joints and what else they may have been doing that week. The only way to teach successfully is with an intuitive, creative and open-minded approach.

Because of the range of joint problems, the range of affected joints and individual variability, there are no hard or fast rules to guide the teacher. However, it may be helpful to be aware of the pointers given below.

General Guidelines

Avoid breathing and extension in position
Watch alignment
As muscles get tired, may get joint pain, so consider less repetitions
Sequences can be particularly challenging, due to the number of modifications required and lack of assimilation/rest time between asanas.
Do not encourage or praise hyperextension or hold it up as an example to the class, as this can encourage the student to push themselves to harmful limits.
Avoid constant comments about a student’s alignment in class, it’s easy for them to feel picked on; Rome wasn’t built in a day!
Remember balance can be challenging and students are vulnerable to injuries.
Most hypermobile students will be more comfortable with an extra thick mat, but these can make balance even more difficult by increasing the ‘wobble’ factor. Consider recommending a thin non-slip mat on top of a thicker mat, and pulling the thin mat over to use alone for standing balance work.
Make sure warm-up is thorough, with particular attention on joint circles to increase synovial fluid production.

Specific Joint Guidelines

Knees

Often associated with tight hamstrings.
Forward bend type movements may force knees into hyperextension, so best to do with slightly flexed knees, or avoid. Lying Chimp gives same stretch with more knee control
The knees can hyperextend when sitting with legs out; may be more comfortable with a blanket or thin cushion under knees to avoid this.
May need a roll under knees during relaxation in pose of tranquillity; may prefer a prone or non-standard relaxation position.
Hypermobile knees are prone to patella dislocation, and the patella may be subluxated. Kneeling may be painful, but not always
Watch for hyperextension of the knees in all standing positions.
Earth sky- Students may need to have feet slightly turned out from the midline if discomfort in the knee.
Important to build strength in the quads.

Shoulders

May be a history of dislocation; ask student what movements cause this.
Injury/dislocation can sometimes lead to restricted movements

Elbows

Watch for tendency to rotate and hyperextend joint when arms out at shoulder height
May have increased carrying angle (-when arms by sides, forearm angulated away from body). No problem, can’t ‘correct’!

Wrists

May have reduced mobility due to subluxation or injury.
May be problems taking the weight through the wrist, though this might only be in some positions - Don’t assume, ask.
Alternative hand positions (e.g. weight through knuckles/fist rather than palm) may help, but are less stable and more sore on the fingers, so avoid prolonged use.
Doing the wrist stretch with the hands on the floor can force hyperextension; better to do the same stretch in the air, rather than braced between floor and body weight.

Ankles

May be painful. Injury and fall prone.
Important to strengthen the muscles around the ankle to improve stability and balance. Consider use of balance pad .

Spine

Avoid excessive spine extension; take care of neck extension.
Be aware of posture and spinal curves.

The Centre For Balanced Medicine