The Hypermobile Athlete: Balancing flexibility for performance with joint protection and injury prevention.

For athletes whose performance relies on extreme range of motion—such as dancers, gymnasts, and swimmers—Generalized Joint Hypermobility (GJH) can seem like an asset. However, when this natural joint laxity is coupled with the systemic connective tissue vulnerabilities of Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (hEDS), the athlete is in a constant, elevated state of injury risk. Their ability to move further is often paired with a deficit in control.

The physical therapist’s mission is to guide the hypermobile athlete through a crucial transition: moving away from training for passive flexibility and toward training for dynamic stability and joint protection, thereby preserving their athletic advantage while mitigating long-term injury.

The Problem: When Flexibility Becomes a Liability

In competitive sports, the tendency is to push the body to its anatomical limit. For the hypermobile athlete, this limit is often determined by passive structures (ligaments and capsules) rather than active muscular control. This leads to several issues:

1. Micro-Trauma and Inflammation: Repeatedly pushing into the end range of motion causes chronic strain on lax ligaments, leading to persistent, non-traumatic joint and soft tissue pain.
2. Proprioceptive Confusion: The extreme range of motion provides poor sensory feedback, leading to delayed muscle reaction times and functional clumsiness—a key precursor to acute injury (sprains, subluxations).
3. Compensatory Overuse: Muscles work overtime to guard the joint, resulting in chronic hypertonicity, muscle spasms (e.g., upper traps, hamstrings), and fatigue.

Phase 1: Mindset, Education, and Safe Movement

Rehabilitation begins by fundamentally changing the athlete’s relationship with their joints.

1. The “Soft Joint” Rule

The single most important cue is training the athlete to consciously stop all weight-bearing and high-load movements just short of the joint’s maximal hyperextension lock-out.

• Intervention: Instruct the athlete to maintain “soft knees” or “unlocked elbows” during standing, planking, or landing jumps. This immediately transfers load from the passive ligaments to the active muscles (e.g., VMO, hamstrings, triceps), forcing them to engage as protective brakes.
• Application: In dance, practice pliés and jumps ensuring the knees are never snapped back. In gymnastics, practice handstands and vault landings with micro-flexion at the elbows.

2. Eliminate Passive Stretching

The hypermobile athlete should eliminate all passive, static stretching and high-velocity stretching (e.g., ballistic stretching) from their routine.

• Replacement: Replace static stretching with dynamic warm-ups that emphasize controlled, flowing movement within the actively controlled range. This keeps the muscles warm, strengthens the mid-range stabilizers, and prevents accidental overstretching of the ligaments.

Phase 2: Prioritizing Dynamic Stability

The core of the program focuses on building the stability necessary to control the extremes of motion required by the sport. This is achieved through high-frequency, low-load exercises that train endurance and reaction time.

A. Central and Proximal Control (The Anchor)

Building endurance in the inner core and girdle stabilizers is the prerequisite for all distal movement.

• Core Endurance: Focus on $30-60$ second holds of deep core exercises (e.g., bird-dog, planks, side planks) at $30-50\%$ maximum effort. The focus is on sustained endurance, not maximal force.
• Girdle Integration: Use light resistance bands (Therabands) for high-repetition exercises ($3$ sets of $20-30$ reps) targeting the gluteus medius and lower/mid-trapezius to improve pelvic and scapular endurance.

B. Reactive Control (Injury Prevention)

These drills train the neuromuscular system to react rapidly to unexpected forces, minimizing the time the joint spends in a vulnerable position.

• Rhythmic Stabilization: While the athlete holds a stable, closed-chain position (e.g., hand pressed against a wall), the therapist applies gentle, multi-directional pushes and pulls, forcing the rotator cuff and scapular stabilizers to fire rapidly to maintain joint centration.
• Balance & Perturbation: Practice single-leg stance on an unstable surface (e.g., foam or Bosu ball) while the athlete performs a secondary task (e.g., catching a light ball). This trains the ankle, knee, and hip stabilizers to react to the combined sensory and physical challenge.

Phase 3: Pacing and Systemic Management

The PT must address the non-musculoskeletal barriers to performance, primarily fatigue and poor recovery.

• Pacing and Scheduling: Teach the athlete to meticulously track their energy levels (using the Spoon Theory metaphor) and schedule high-intensity training days followed by low-intensity recovery days, rather than pushing until a crash occurs.
• Orthostatic Management: If POTS is suspected, emphasize sufficient hydration, salt intake (with physician approval), and rest breaks during high-heat or sustained standing activities to manage blood pressure regulation, which directly impacts training tolerance.
• Supportive Gear: Use judicious, temporary bracing or taping for high-risk joints (e.g., ankles, wrists) during competition only, but always reinforce that the primary support must come from the patient’s own musculature.

By intervening with targeted motor control and systemic management, Joint hypermobility physiotherapist Gold Coast enable the hypermobile athlete to achieve a state of controlled flexibility, transforming their unique connective tissue structure from a vulnerability into a stable, sustainable advantage.