Upper Extremity Exercise Considerations with Hypermobility

Published October 9th, 2024 by OrthoSport Performance Therapy

Hypermobility Spectrum Disorder (HSD) and Hypermobility Ehler-Danlos Syndrome (hEDS) clients require multifaceted considerations with exercise due to varying levels of joint hypermobility (general, peripheral, localized, historical), pain, joint instability, presence of osteoarthritis, presence of dysautonomia, cervical instability, temporomandibular dysfunction, presence of mast cell activation diseases, etc. The following are highlighted considerations with selection of upper extremity exercises for asymptomatic or symptomatic HSD and hEDS. Due to the complexity of HSD and hEDS, professionals should have the training and ongoing continuing education to provide care safely and effectively for those with these conditions.

1. Always consider, respect, and honor subjective feedback from clients, as they understand their bodies more than anyone and will have to endure symptom exacerbations brought on from poor exercise selection and over exertion. A symptomatic hypermobility client will present the same as asymptomatic so reports of pain should be respected and not based on your visual perspective. Respect the client and professional boundary when they say they can’t do a specific exercise or prefer not to do it.

2. Assess and utilize the information to determine the exercise intervention that will be appropriate to strengthen or restore and enhance function to meet specific performance goals or activity of daily living. Important assessments and items to consider are:

Beighton Scale - Watch Video

Posture

Forward head

Breathing mechanics could be altered
Under and overactivity of scapular stabilizers could be present
Could alter scapular mechanics leading to increased stress to the shoulder
Neck range of motion deficits may be present

Rounded shoulders

Often leads to tight pectorals leading to mobility deficits.
Can cause increased anterior translation of humeral head with shoulder internal rotation
Alters positioning of the scapula

Excessive Lumbar Lordosis

Can alter shoulder flexion mechanics and mobility from restrictions in the latissimus dorsi musculature and anterior pelvic tilt

Thoracic Kyphosis (postural vs structural)

Can alter breathing mechanics and scapular positioning
May restrict mobility

Rib Flare

Breathing mechanics could be altered
Could lead to muscle weakness and restrictions

Scapular Positioning

Proper scapular positioning is essential to facilitate the role of the rotator cuff for dynamic stabilization of the glenohumeral joint. With hypermobility clients glenohumeral joint stability is essential for preventing dislocations and subluxations

Shoulder Mobility Assessment

Be aware of compensatory strategies

Strength Assessment
Screen for Dysfunctional Breathing Pattern

Can cause kinetic chain issues with compensatory adaptations

3. Be aware of history of cervical instability.

4. Clients with dysautonomia will need to avoid/limit orthostatic stress.

Supine, sidelying, reclined, and seated tend to enhance client tolerance
Be prepared to monitor heart rate, oxygen levels, and blood pressure and have plan in place to address issues such as fainting, nausea, difficulty breathing, etc.
May do better with machines
Activity pacing is essential
Hydration and nutrition prior to session is important
If you are working with patients who are hypermobile and have dysautonomia or POTS, you should refer to a qualified professional unless you have the training to safely work with these conditions

5. Open versus Closed Chain Exercises

Hypermobility clients may have finger, wrist, and elbow pain that may limit closed chain exercises
Be careful with certain open chain upper extremity exercises as it could put them in positions of instability that could facilitate dislocations/subluxations
Clients should have the prerequisite mobility and strength for the exercise gained from proper progressions and regressions that has prepared them for the intervention
It is very important to be prepared with regressions and progressions of exercises so you can meet the needs of the client without provoking symptoms

6. Grip Tolerance

Gloves, handles, straps, tape, and braces may improve tolerance with grip intolerance

7. Proprioception and Correct Motor Patterning are essential for Hypermobility

Clients often will access more range of motion than what is needed for the exercise or targeted joint or already be in a rested hyperextended position (elbows as an example)
Visual cues and tactile/external feedback can assist client with proprioception and feeling the targeted muscles working
Utilize time under tension and isometric holds to facilitate motor control/proprioception, muscle activation, and bring awareness to the client of the targeted musculature

8. May benefit from kinesiotaping while exercising for joint proprioception, stabilization, and pain.

9. Warm-up should focus on activation and targeted trigger point release.