Hypermobility in dancers

Despite hypermobility being a topic that is frequently discussed in both dance and dance science circles, it was not an area I've ever had a great interest in. My focus has generally been on supplemental strength training and endocrinology, and anything that falls outside of that I've been reluctant to delve into too deeply. That is until I was diagnosed with hypermobility syndrome after my most recent injury. Being the type of person I am, I can't be told something is affecting my body without then poring over every piece of information on the subject that I can get my hands on. I've never considered myself to have above average flexibility compared with both my dancer and non-dancer colleagues, in fact, my lack of hip flexibility and subsequent limited turnout had been a bone of contention for most of my performing life. Sure I had to resort to my knees rotating and sneakily compensating for what my hips lacked (terrible idea by the way), but the rest of my flexibility levels were pretty good so I accepted you can't win them all and figured I was working from a pretty typical physical start-point. I therefore assumed hypermobility wasn't going to be a problem that affected me. Turns out I was wrong - I was blessed with both average flexibility and sub-par joints. Hypermobility syndrome affects the stability and range of motion of several of, although not necessarily all the body's joints and subsequently can have a substantial impact on posture, joint pain, physical performance and proprioception. 

Hypermobility syndrome is more common in dance populations than in the general public. Why? Probably because hypermobility can present above average flexibility levels in many affected individuals, and individuals with above average flexibility levels are more likely to succeed in dance than those with poor flexibility levels. It is not caused by dance training, however aggressive stretching practices are likely to exacerbate existing joint instability. 

Below is a brief overview of both hypermobility and hypermobility syndrome (note, they're not the same thing). Dance educators should be aware of the condition, of how it presents itself in dancers, and how to assist affected individuals in managing the condition and preventing injury. 


What is hypermobility?

Hypermobility refers to a condition where a joint has a higher range of motion than is usual. An individual may present hypermobility in a lone joint, in a number of joints, or may have a hypermobile joint on one side of the body and not the other. 

If the ligaments at a specific joint are lax, i.e. too loose or stretchy, their ability to stabilise the joint is compromised. Instability of the joints can predispose an individual to numerous injuries including sprains, strains and dislocations.  Even without the presence of a specific injury, the most commonly cited side-effect of hypermobile joints is chronic (longterm) pain. Hypermobility can be identified by means of the Beighton score.

The Beighton score

The Beighton score consists of a series of nine tests. A positive result on each test gives a score of 1 point. The tests are:

• Can the individual put their hands flat on the floor with knees straight? 
• Can the individual bend one or both of their elbows backwards (straightening beyond straight)? 
• Can the individual bend one or both of their knees backwards (straightening beyond straight)?
• Can the individual bend one or both of their thumbs back on to the front of your forearm? 
• Can the individual bend one or both of their little fingers to 90 degrees towards the back of the hand?

A score of 2 or less is considered normal, however an individual scoring 4 or more is considered hypermobile.


Hypermobility Syndrome

Hypermobility Syndrome is a medical condition wherein an individual presents hypermobile joints combined with other symptoms. Hypermobility Syndrome is diagnosed by the Brighton Criteria, which incorporates the Beighton score discussed above.


Brighton Criteria - Major Criteria

• A Beighton score of 4 or more
• Joint pain exceeding 3 months in duration in 4 or more joints

Brighton Criteria - Minor Criteria

• having a Beighton score of 1-3 
• having joint pain for longer than 3 months in 1-3 joints, back pain for longer than 3 months, spinal arthritis or spondylolisthesis 
• dislocating more than 1 joint or the same joint more than once
• having 3 or more injuries to your soft tissues, such as tenosynovitis or bursitis 
• having particular physical characteristics called Marfanoid habitus – this includes being tall and slim and having long, slim fingers
• having abnormal skin, such as thin and stretchy skin
• eye-related symptoms, varicose veins or a hernia 

An individual with 2 major criteria, 1 major and 2 minor, or 4 minor criteria may be diagnosed with hypermobility syndrome. 

Hypermobility in dancers

Due to the expectation of above average flexibility, hypermobility can often be seen as an advantage for a dancer. However joint instability is detrimental to performance and predisposes the dancer to injury,  due to increased likelihood of dislocation, as well as the negative effect it has on development of proprioception and balance.

Hypermobility often contributes to poor posture, with individuals slouching and "hanging" into their hypermobile joints. This may be due to these unusual positions feeling more stable for hypermobile individuals than correct posture.


Proprioception and hypermobility

A high degree of proprioception is essential in dancers. Proprioception refers to the awareness of the body in space - a "6th sense" of where the physical body is. If standing with the eyes closed and being asked to touch the left hand to the left ear, it is the sense of proprioception that allows us to guide our hand there without a visual cue. In dancers, this skill is essential for control of alignment, technique, choreography, and working with other dancers. 

Hypermobility can negatively effect the dancer's sense of proprioception. Hypermobile dancers may often appear more clumsy and be more injury-prone than dancers without the condition. Extra proprioceptive training is required for hypermobile dancers to gain greater control of their joints. 


Dance-specific issues caused by hypermobility

Swayback Knees

"Swayback" knees are commonly referred to in dance classes, when the knee appears to go past the stage of being straight. Teachers and choreographers should recognise this as a display of a hypermobile joint, not merely as a problem in alignment or technique.


Pulling up the quadriceps can help to correct the swayback of the knees, however extensive training may be required for the dancer to be able to identify between the sensation of correct and incorrect positioning.

Hyperextension of the knees

Pronation of the feet in 1st position

1st position can be especially problematic for hypermobile dancers. Instances of "rolling in" the feet are a common sign of hypermobility when standing in 1st position. Teaching increased activation of the quadriceps and adductors may help to correct the positioning, however pronation may need to be addressed by both podiatrist and physiotherapist if hypermobility is causing significant over-pronation.


Considerations in working with hypermobile dancers

When working with hypermobile dancers, the priority should be management of the condition, allowing the dancer to continue training and minimise likelihood of injury. Be aware that hypermobility syndrome may cause significant joint pain in certain individuals. Hypermobility causes a wide spectrum of problems, and while some individuals may suffer minimal joint pain, others may experience chronic pain at several joint sites. If a dancer suspects hypermobility to be the cause of chronic joint pain they should speak with a medical practitioner about pain management. While increases in stability achieved through strength training may control pain in some individuals, it is unlikely to be effective for those with more severe symptoms.

Correction of alignment and posture may be needed in several instances, and due to the high degree of ROM in certain joints, additional work may be needed to help the dancer learn the feel of correct positioning. For example, you may need to work to help the dancer relearn the correct alignment of standing in first position, to avoid pronation of the feet and the knees collapsing inwards. This internally rotated position may intuitively feel correct for the hypermobile dancer's body, and so retraining of the most simple positions may be required to ensure they are not allowing cause problems in technical alignment.

In order to decrease likelihood of injury in the hypermobile dancer, strength training is essential. Both alignment and control can be improved in hypermobile individuals through effective strength training programmes.  Improving strength levels is crucial in minimising the likelihood of the dancer developing minor soft tissue injuries, as well as major injuries such as joint dislocations as the muscle can compensate for ligament laxity. As strength training can improve the ability of the dancer to maintain and control correct alignment, it can also prevent the onset of muscle imbalances developed from prolonged training with incorrect posture. Minimising occurences of muscle imbalance further protects the hypermobile dancer from suffering injury. Unfortunately there is no guaranteed way of neutralising the problem of joint-hypermobility, and the hypermobile dancer will be more predisposed to injury than the non-hypermobile, however it is crucial that steps are taken to minimise risk wherever possible.

Be aware that hypermobility syndrome may also cause significant joint pain in certain individuals. Hypermobility causes a wide spectrum of problems, and while some individuals may suffer minimal joint pain, others may experience chronic pain at several joint sites. If a dancer suspects hypermobility to be the cause of chronic joint pain they should speak with a medical practitioner about pain management. While increases in stability achieved through strength training may control pain in some individuals, it is unlikely to be effective for those with more severe symptoms.