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Hypermobility, Hamstrings, and Hashimotos, oh my!

At Urban Wellness Clinic, we spend most of our days treating patients who have low back or neck pain, jaw pain, or headaches.

These symptoms are the bread and butter of what we treat as a chiropractors.

But some of these patients also experience hypermobility syndrome, when the joints move easily beyond the normal range. These patients may feel double jointed, like they have loose joints, or feel off their center.

Most chiropractors would overlook the systemic signs and symptoms that can come with hypermobility, such as fatigue, dark circles under the eyes, depression, and a positive Beighton Test and treat for tightness anyhow. And that’s a shame.

Thank goodness we’re not “most chiropractors,” because they’re not providing hypermobile patients with the type of therapy they need. But we are. What’s the real story?

yogi in deep hamstring stretch

Movement Experts Understand Hypermobility

We are movement experts, and we’re obsessed with how the body overcompensates for various health issues. I can’t emphasize this enough: When you have pain or hypermobility in one area, it’s often caused by a deficiency, illness, or injury elsewhere.

We know that hypermobile patients need strength and stability. Sure, they may need an adjustment here or there, but for the most part, the adjustment, or osseus manipulation, is the ultimate destabilizing move, and hypermobile patients especially need joints that feel like they are stable. So often times we don’t adjust our hypermobile patients.

Here’s the deal: Hypermobility causes joints that hyperextend beyond the normal range, including elbows that need to bend when you’re in a plank or downward dog, or thumbs you can push down to the wrist. These are the positive signs of a Beighton test.

Beighton Score

When you are hypermobile, you may be able to extend your pinky to 90 degrees and touch your palms to the floor without bending your knees. It’s like you have a looseness, which is fun to show off like a circus acrobat, but it can lead to injury if you don’t take steps to stabilize your joints during movement.

But many hypermobile patients often also have fatigue, dark circles under the eyes, light, pale skin, and a hard time maintaining muscle mass or losing weight. Sometimes, they also experience constipation, depression, memory loss, hair loss, brittle nails, or sensitivity to cold.

yogi doing a lunge stretch

That’s not all: If you have some combination of these symptoms, you may have thyroid dysfunction, such as Hashimoto’s disease, or an autoimmune disease, such as Lupus. Most autoimmune diseases are also collagen diseases with increased tissue laxity, muscle atrophy, and tendon weakness, which all cause skeletal muscle fiber tissue changes. These patients also have a harder time healing and repairing tissue and may experience more muscle strains and tendinitis.

But the average chiropractor often doesn’t recognize these important issues. Why does this matter? Because a chiropractor that doesn’t understand movement and doesn’t determine how illness affects mobility will just go ahead and adjust your body as though your only complaint is low back or neck pain, jaw pain, or headaches.

With each adjustment, that chiropractor would probably bounce off hypermobile joints because it’s hard to find the end range or tension on them. You’d then feel sore for the next two days.

If you were to complain, your chiropractor might tell you this is a normal side effect of body work, that your body should feel sore, like you do when you start a new workout at the gym. That’s what we learned in chiropractic school, but there’s a better way.

The bottom line is that as movement experts, we know that hypermobile patients with a sluggish thyroid may describe themselves as “clumsy” and “unathletic,” reporting that they trip a lot. This is not their fault. Joints with loose connective tissue feel less stable, making it difficult to find your center. We find these patients often feel anxious and ungrounded. They tend to be chest breathers, which exacerbates their anxiety as a result of feeling “off their center.” They need more than the average chiropractic adjustment. A great doctor will know when to refer out. We often collaborate with functional medicine doctors to help work on the underlying thyroid issues and we work on the hypermobile tissue from a strength perspective.

One of the major areas we see this hypermobility is in the hamstrings. So let’s break this down.

But can I stretch my Hamstrings daily?!?

There are four hamstring muscles, three cross the knee joint, one does not. Here’s a little anatomy deep dive.

The 2 medial hamstring muscles insert to the medial side of the tibia, these are the semimembranosus and semitendinosus and they originate at the ischial tuberosity.

The lateral hamstring, bicep femoris long head and short head both insert onto the fibular head.

But the biceps femoris long head originates at the ischial tuberosity and the short head originates on the linea aspera on the posterior shaft of the femur.

A picture is worth a thousand words so here you go:

anatomy pictures of hamstring muscle

Studies show that extreme stretching injuries, such as dancing, leads to injury of the semimembranosus (87% of the time) most commonly. These injuries typically occurred when the hip was fully flexed and the knee was fully extended.

Studies also show that the injuries like running at high speed more often lead strain of the bicep femoris on the lateral side more often than the medial hamstring muscle group. These sprinting injuries usually tear where the muscles meet the tendon.

Athletes with a stretch injury take almost 2x as long (43 days) to return to sport than sprint injuries (23 days). What does this all mean?!?!

The hamstrings are our anchors to the pelvis to hold us up in the world. In the worst case scenario, a person with a full hamstring tear can barely load that leg while walking, sitting is unbearable, or if you fully tore both, you would not be able to hold yourself upright.

In more mild cases, hamstring strains lead to an anterior tilted pelvis and an inability to push off efficiently while walking. Our patients with hypermobile (or hypostable) hamstrings, Yogi’s I’m talking to you, have a pelvis that likes to sit into an anterior pelvic tilt which can jam the SI joints, compresses the facet joints in the low back, and destabilizes the deep intrinsic core.

My Personal Hamstring Journey:

I started doing yoga in chiropractic college in Portland, Oregon about 15 years ago to decompress from my 14 hour days sitting in lecture halls and studying. I would dive deep into a standing forward fold, reach long into triangle pose, and work my way into full hanumanasana aka the yoga the splits. My left hamstring was always more mobile and open so I would work deeper into the pose on that side because it felt “good” not necessarily for my practice but for my ego. I was experiencing low back pain and compression through my SI joints.

yogi in downward dog pose
Fast forward 2 years later, I was training for a half marathon and getting left lateral knee pain. MRI was negative but I could barely bend or extend my knee more than 20 degrees in either direction. I went into surgery thinking it was a meniscus tear that wasn’t picked up on the MRI. They didn’t find anything under the knife but I started rehab afterwards with a focus on quad and hamstring strength, releasing of the popliteus and functional movement to start to integrate my overstretched hamstrings. Lucky to say, that with a solid posterior chain program of glute bridges, deadlifts, and kettlebell swings, my hamstrings are back to their normal length and knee pain is gone.

How to assess the Hamstrings:

Standing Forward Lumbar Flexion:

Passive SLR:

Active SLR with core brace:

How can hamstrings compensate for weakness elsewhere?

Hamstrings neurologically tighten down if the deep intrinsic core is not stabilizing well. When we are not moving from our deep intrinsic core, we recruit other muscle to move us through the world. We also find the hamstring inhibited if the gluteus max is not firing efficiently. In the anatomy lab, the gluteus maximus fibers are intertwined with the high hamstring muscle and you literally have to peel them away from one another.

Got tight hamstrings? It could be because they are short, there is scar tissue in the hamstring, or possibly they are simply weak.

Young attractive woman practicing yoga, sitting in paschimottanasana exercise, Seated forward bend, working out, wearing sportswear, grey pants, bra, indoor full length, home interior, living room

 

How to Improve Quality of Life for Hypermobile Patients

At Urban Wellness Clinic, we offer a package of treatments and services to help hypermobile patients feel stronger and more stable. How do we do that?

Breathing work: Hypermobile patients have problems with pelvic stabilization, which can be assisted with diaphragmatic, not chest, breathing. We teach you to help your diaphragm and deep intrinsic core muscles to work together during breathing.

Avoid static stretching: Even hypermobile people can feel tight. That’s because the ligaments and tendons surrounding a hypermobile joint can overcompensate to protect it. When you stretch a hypermobile joint, you risk further instability and injury. Try a strength move instead to help decrease that “tight” feeling.

Proprioception: When your joints hyperextend, it’s crucial to know about your proprioception, the fibers that tell your body where it is located in time and space. Without that knowledge, your knees or elbows may be hyperextended during exercise and you wouldn’t know it. That can lead to injury. We help show you where your joints are during training and advise you on ways to correct overextension.

Bracing: We teach you how to maintain a neutral spine to avoid overextending your lower back and how to stabilize your core. That sets the foundation for all of your exercises. Take a breath down into the belly, as you exhale try to keep the belly tanked up with the breath by at least 50% this is a brace. Your brace shoulder match your load so a light brace if you are picking up a pencil and a stronger brace if you are picking up your toddler or a heavier load. like a deadlift.

Stacked exercises: It’s important to keep your body stacked when weightlifting so that hypermobile joints stay stable. Stacked is having your diaphragm stacked and parallel over your pelvic floor and ears over shoulders over hips. If we sway our low back or flare our lower ribs in the front, which happens when we are more hypermbile, we lose our stacked and compress the low back. We call this Extension Compressions Compensation. See below:)

Extension compression compensation: We teach you how to avoid the end ranges of hypermobility through compensation during push-ups and hip hinging to stabilize your joints. This helps you avoid injury from swaying your low back  or flaring your ribs while enjoying the benefits of exercise.

Deadlifts: We love these to turn on your posterior chain like your hamstrings and gluteus maxius. These help create integration when we stand and walk so we are not sway back.

Front squat vs back squat: Back squats place the load on the spinal extensors like the lumbar erectors – right down the spine. Front squats, on the other hand, put the load on the quads and deep core  forcing you to concentrate on staying Stacked.

Here are some specific exercises (with demo videos) which will help:

DNS 6 Month Supine to Get Good Deep Intrinsic Core Stability

6 month supine exercise video

Hamstring SLR with Weight Overhead

Kettlebell single leg raise

Beast to Bear

beast to beat

Pallof Press

Paloff Press

Hip Hinge to Wall

Hip hinge to wall

Deadlift

Hex bar deadlift

Single Leg Deadlift

Single leg kettlebell deadlift

What if the hamstring stretch is part of your cool down after working out?

We see this deep hamstring overstretch at the end of a workout during the cool down phase. If your trainer does this, don’t let them. If you are a trainer, don’t do this please, unless your clients goals are to join Cirque Du Soleil.

trainer stretching a personal training client

What’s the point of the cool down?

To calm the down nervous system back to the rest and digest parasympathetic state. We don’t want our clients walking out of their workout all amped up in what we call “extension compression compensation” and a sympathetic fight or flight state.

We have enough of that state every day just being a rushed go go go New Yorker.

Here is what it looks like, swayed in the low back, dropping out the core, jutting the chin and overextending the neck. Ouch!

The bottom line is that the average chiropractic adjustment won’t help with all of your signs and symptoms of hypermobility. It takes movement expertise to ensure that you build strength and stabilize hyperextended joints. Let’s collaborate with a multi-disciplinary approach, we build the strength and integrity of the joints, and a great functional medicine doctor helps regulate the thyroid. Our patients get better, faster when collaborate in this manner.

If you’re experiencing the signs and symptoms of hypermobility, we can help you stabilize and strengthen. Call us at 212-355-0445, email us at hello@urbanwellnessclinic.com or click ‘Book Appointment‘ above.

We’re here for you!

Best in Health,

Dr Emily Kiberd