Hypermobility Myths in Pelvic Health (And What to Do Instead)

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Transcript

Lindsey:

If you're an OT in Pelvic Health, you probably have had this client, or maybe you are this client. Postpartum, exhausted, living in leggings, carrying a baby more hours than you'd like to admit, trying to get back to moving in a way that feels like you again. And then there's the other layer.

Maybe you've always been bendy, or maybe you've been told you're hypermobile, or you've wondered if you are because you've got clicky joints, odd aches, some instability, and a body that feels different depending on the day. But now you're ready to return to running, something you've always loved, except you're leaking, or maybe you feel pelvic heaviness, or urgency ramps up the day after you do what you think is a normal workout. And somewhere in the middle of all of that, the internet, or a well-meaning professional, hands you a set of rules that basically sound like, be careful forever, don't lift heavy, never lock out your joints, fix your posture, and definitely don't run.

Today, I'm feeling spicy, and I want to pull that apart. Not in a dismissive way, because hypermobility can come with very real symptoms, but in a way that makes your body feel joyous again. And I want to give clear credit up front.

The core lens for this episode is adapted from a phenomenal conversation between Nikki Knob-Levy, Dr. Sarah Court and Laurel Beversdorf. Nikki is a nutritional coach who works with hypermobile humans, and she has a refreshing ability to say yes, the problems are real, and also the fear culture around hypermobility is not helping. So let's take these myths and translate them into pelvic health OT.

We're going to focus on postpartum, return to running, and incontinence. 

Intro:


Lindsey: 

Here's why this topic belongs in pelvic health.

In pelvic rehab, we're not just working with the pelvis as a standalone thing. We're working with an entire system, breathing mechanics, hips, feet, trunk control, recovery, sleep, stress physiology, and the nervous system's sense of safety, which is my favorite. Hypermobility, for some reason, changes the inputs into that system, not because they're broken, but because they have a more range available at joints and less consistent control or appropriate reception through that range.

And what I see clinically is that the problem often isn't they're too flexible. It's more like they have more range than their current capacity can manage. Definitely under fatigue, definitely under stress, and especially when we add impact.

Now layer postpartum on top of that. Postpartum is like the ultimate capacity versus recovery test. So you might have a client who is strong, motivated, and mentally ready to train, who technically has the capacity to do a lot, but their recovery is changed by night wakings, feeding demands, and the repetitive loads of baby care.

So symptoms become this confusing feedback loop. They do something that should be reasonable, and the next day their body says, absolutely not. And that's where the myths get really damaging, because if we interpret that as your body is unsafe, we're creating fear and avoidance.

But if we interpret it as we need a smarter dose and a better plan, we can make progress. Okay, we can't get too far into this episode without defining a few terms. So I'm going to keep this really practical.

I want you to be able to have language that you can use clients without scaring them. Words matter. So when I say hypermobility, I'm talking about joints that can move beyond what's typical.

It's often influenced by genetics and quality of connective tissue, ligaments and tendons especially. But here's an important distinction that Nikki highlighted. Hypermobility is not the same as flexibility.

Flexibility is more like, you know, can your muscle tendon system lengthen and allow you to access a range comfortably? Hypermobility is more like, does the joint have available range? Sometimes with less passive stability and sometimes with less consistent neuromuscular control. Add another nuance that matters a lot in pelvic health. People can be hypermobile and still feel stiff.

People can have one joint that's widely mobile and another that's guarded and restricted. It's not everything moves too much. It's often more like a patchwork.

 So now EDS versus HSD.

Okay, now let's talk about Ehlers-Danlos Syndrome versus Hypermobility Spectrum Disorder. OK, I'm not diagnosing anyone here. But clinically, what matters is lots of symptomatic people don't get a clean, quick diagnosis.

OK, it's such a long and complicated process to get evaluated that matches what many of us see in practice. People get told you're fine because blood tests look normal or because they look young, healthy, or they're just bendy. And for pelvic OOTs, the important piece is you can respect the diagnosis process while still treating the person in front of you seriously.

You can treat the symptoms, the capacity, the functional goals, the fear, the recovery constraints without needing a perfect label to justify care. One more. Forget that.

Let's talk about one of the loudest myths. If you're hypermobile, you should never lock out your joints.

OK, this shows up everywhere. Yoga, Pilates, strength training, even rehab cues. We might say something like micro bend your elbows or never lock your knees.

And it's usually taught with this tone of if you do it, you're going to hurt yourself. Right. And Nikki's take on this is basically the answer no one wants because it's not Instagram friendly.

The answer is it depends. We know that answer in OT. Right.

Because locking out can mean different things. There's a difference between an active straight joint where you, you know, you have that muscular control and you're stacked and stable. And a passive hang where you're slamming into end range and resting on ligaments because your system is tired and it doesn't know where it is in space.

And here's where pelvic health comes in. In pelvic rehab, we're often dealing with people who already feel like their body is unpredictable. Right.

They have symptoms that flare sometimes for no obvious reason. If we then add a rule that says your joints are dangerous and you have to constantly monitor them, we create hypervigilance and hypervigilance is not neutral. It changes breathing.

It changes movement. It changes threat perception and it amplifies symptoms. So in clinic, the question I care about isn't, is your knee straight? The question is, are you in control? Is this dose appropriate? Are symptoms stable? And if I see a postpartum client stand up from a chair and they snap into knee hyperextension at the top, I'm not going to sprint over and say, stop dangerous.

Right. I'm going to treat it like information. I'm going to say something like, hey, can we try something? Stand up and pause before the very top and tell me how stable that feels.

Or you could say something like, you know, what happens if you stand tall but thinking about keeping some energy in the front of your thighs and glutes? Does that feel different? And if they say, oh, my gosh, my legs feel like they're working and I feel less wobbly, then we've learned something. We didn't catastrophize. We explored.

We stayed curious. But I also want to say something. You can't make someone afraid of end range for the rest of their life.

Bodies go there. Life goes there. Parenthood definitely goes there.

You will reach, twist, lunge to catch a falling toddler. So instead of teaching avoidance, we teach capacity. Now, let's connect that to return to running, right, because running is not a controlled environment where you can monitor elbow micro bends.

Right. It's impact, repetition and variability. So if someone is returning to running postpartum and they're hyper mobile and their entire strategy is don't lock anything out.

Well, what happens is they stiffen everywhere, they brace, their breathing gets funky and their pelvic floor is guarded. And efficiency drops. So instead, I like the cue.

We're looking for control, not perfection. We're looking for active straight rather than hanging, and we're going to build a strength that makes impact feel less like roulette. I remember the first time I learned about some of these cues of like not hanging.

It was really from my training with Lauren O'Han and Restore Your Core. She very, you know, straightforwardly talks about the fact that she is a hyper mobile person. And it was really one of the first times.

And it was so refreshing for me to hear a fitness professional talk about cues that weren't often said that made such a difference for my clients. OK, the next myth is that posture and alignment are more important for hyper mobile people. Right.

It's like the rules of pain and biomechanics somehow change if you are hyper mobile. This shows up in pelvic health in a very specific way, especially postpartum. Right.

People get told things like your rib flare is the reason you have symptoms or your pelvic tilt is the reason you leak. You're hanging on your joints and therefore you need constant posture correction. Here's where I want to be careful.

I'm not saying posture is irrelevant. I'm also not saying that biomechanics don't matter. What I'm saying is posture is not a simple one to one cause of pain or pelvic floor symptoms.

And fixing alignment is not the guaranteed solution. People are promised. I think the antidote to much of this is that hyper mobile people are people, too.

I know that sounds silly. Right. But they have muscles and bones and a nervous system.

Their connective tissue quality may be different. Their range may be larger. Their control demands may be higher, but the fundamentals are still there.

So, I mean, in preparing for this episode, I just kept coming back to why do some hyper mobile clients seem to do better when you coach stacking or change posture? And I think it comes down to the fact that we're giving them options. You're giving them another piece to live. You're giving them another place to live besides the end range they've been resting in.

You're reducing repetitive tissue stretch and changing low distribution. Right. And of course, you're improving proprioception input.

And that's so important because you're increasing their sense of safety and control. And that's very different from your posture is wrong and you're broken.

Postpartum makes this more intense because people are often, quite frankly, bracing their core all day. They're trying to hold themselves together and they're trying to be a good client. They're trying to do it right.

But that constant bracing can create a pressure management strategy that's rigid instead of adaptable. So if someone is leaking on a run and we respond by telling them to pull their ribs down, tuck their tail, engage their core, squeeze their pelvic floor for the entire duration of the run. 

Gosh, that sounds awful, Just saying it out loud. We may be creating a strategy that is not sustainable under impact or fatigue. They end up holding their breath over recruiting and the whole system, the whole system becomes less reflexive, less springy and really less responsive.

So the way I use posture in clinic is more like, let's see if this changes anything. Posture is an experiment, not a diagnosis. And then we keep what helps, discard what doesn't and keep building capacity.

OK, myth number three, only lightweights go slow high reps. OK, this section of our episode today is probably the most important for returning to running with incontinence because there's a common belief that hypermobile people should strength train in a very specific way. Keep loads light.

Keep everything slow. Do lots of reps. Let's keep it safe.

I'm going to translate this into pelvic health first. Hypermobile bodies still adapt to load. So strength principles still apply.

The problem is not that they can't get strong. It's that they've been taught to train in a way that produces tons of fatigue, tons of soreness and inconsistent control. One of the most interesting points that Nikki made is that light loads can be too little input.

If someone has reduced proprioception, you know, like a tiny weight that can feel, A tiny weight can feel like nothing, so they can't find their joint position. 

They can't organize the movement well and they end up doing a high number of reps with poor control. That combo low feedback plus high reps can flare people and postpartum is already a state where recovery is changed.

Right. And add high rep training. It's easy to create a pattern where someone doesn't feel good and then they stop.

Capacity drops and everything feels harder. So here's the framework I want us to consider. It's simple and very compassionate.

Train to your window of tolerance, not your window of capacity. 

Capacity is what you can do when you're motivated or running on adrenaline. Tolerance is what you can do and recover from without your symptoms escalating.

And postpartum clients, especially high drive clients like I saw in New York City and Paris, will almost always overestimate tolerance because they miss their old body. So how do we apply that to return to running with incontinence? We build tissues and the systems that manage impact. This means lower body strength, trunk strength, foot and calf capacity, graded plyometric exposure and a running progression that respects recovery.

This is where I'll say something very directly. For a lot of postpartum leakage with running, doing more Kegels is not the main lever. It's not the pelvic floor strength doesn't matter.

Of course it does. Right. But impact incontinence is reflexive.

It's timing. It's stiffness. It's load transfer.

It's the whole system. So how might programming look different for a hypermobile postpartum runner? 

OK, instead of a giant circuit of 15 exercises, three rounds and 15 reps, what I often prefer is fewer movements, repeated consistency with enough load to feel and not so much volume that symptoms flare. A very quick practical example might be two short strength sessions per week, one short plyo prep session, something like this.

Right. So a hinge pattern, a step or squat pattern, a row or a carry, and maybe some calf raises. And that's it.

Not because they're fragile, but because we're respecting tolerance and recovery and then progress. Right. We don't exile them to three pound weights forever.

Bonus if they're pink. We find a starting point that feels safe and doable and we stair step. All right.

What about the part of going slow? Look, slow reps can be great early, especially to teach control. But if the goal is running, eventually you need force development. You need spring.

You need to absorb and produce force quickly. So the rule is go only as fast as you can control and gradually expand the speed range. Also, right, symptom monitoring matters more than perfection.

I personally care less about whether it looked ideal and more about whether they leaked, heaviness showed up, urgency spiked, pelvic pain flared or fatigue lasted for days. So there's no dosage signals, not failure signals. And if a client tells me I did a workout and the next day I felt pelvic pressure, I don't say then you can't lift.

I say, great. Your body gave us data. Let's adjust variables.

Maybe let's look at volume or load or rest or exercise choice or look at your weekly schedule. What do you have going on that week? Because the goal is to keep them training consistently, not heroically. 

OK. let's talk now about tightness, because this definitely confuses me. Hypermobile people can still be extremely tight.

And the way I like to say it is this tight is often an experience, not a measurement. Right. So a hypermobile person may have a nervous system that creates stiffness in certain areas because it's trying to generate stability.

I think about it like this. It's like the body saying, I don't trust this joint to hold me. So I'm going to grip somewhere else and grip it does.

So when someone says my hip flexors are so tight and then we drop into a massive lunge stretch, that would make a yoga teacher cry tears of joy. Both can be true. They can feel tight and still have a lot of range.

So stretching feels very good. I am not anti stretching. Right.

I'm anti stretching as the only long term plan when the real driver is low control and low strength through range. Because what often happens is the client stretches. Right.

They feel a ton of relief. And the next day, the tightness is back and they feel like they have to stretch more. And now stretching is a management job.

But strength done thoughtfully can reduce the protective tightness over time, all because the nervous system starts to believe, oh, we can control this. We're safe here. I also want to address the right muscle, wrong muscle narrative, because in pelvic health, we actually bump into this constantly.

People are told you're using your hip flexors, you're using your upper traps, your glutes aren't firing or your pelvic floor is compensating. 

And I know that language is meant to be helpful, but with hypermobility, especially postpartum, especially with anxious clients, it can become another way the client can mistrust their body. So I translate it into something a little bit different. I say something like, let's change the setup so a different strategy is easier.

Or let's find a version where symptoms are quiet or let's build the strength so that you have more options. 

All right, let's talk about flare planning now, that's a mouthful, flare planning, because this is one of the most useful pieces from Nikki's framework. If you're postpartum and hypermobile or just postpartum, you're going to wake up and feel like you're in a different body sometimes.

I know I did. Right. Maybe you slept.

Maybe you didn't. Maybe you carried the baby for two hours while making dinner. Maybe you had a stressful day.

Symptoms shift. The mistake people make is deciding what to do in the middle of the flare, because when you're flared, you have less cognitive bandwidth. You feel discouraged.

So. Here's what Nikki says to do as the framework using red, orange, green framework, and I think it's brilliant. On a green day, you do your normal plan, right? Normal, normal plan on an orange day.

Maybe you have a built in modification. Maybe you do half the volume or lighter loads or more rest or swap the run for a walk. On a red day, you have a minimum plan that keeps you from the all or nothing spiral.

And I want to say something important to postpartum listeners. A red day is not a moral failure. It's not a sign you're not healing.

It's often just the math of recovery. On a red day, your plan might be like a five to 10 minute walk around the house, maybe like a gentle mobility sequence, maybe nothing. Right.

What matters is that you don't turn a red day into a red week because you panic and guilt. Your plan keeps you tethered to consistency. OK, let's put all of this into a return to running scenario.

Imagine a postpartum client who's hypermobile, right? She's leaking on runs, terrified because someone told her if you'll run, you'll make your prolapse worse. Or if you're hypermobile, you shouldn't do impact. Here's what I want her to hear instead.

We're going to earn running, not avoid it forever. Or we're going to build a system that can handle impact. Or we're going to do it in a way that doesn't flare you, but supports you.

Practically, that means we're going to look at her current strength baseline, symptom behavior across like probably like 48 hours, her recovery constraints. So sleep, feeding, work and stress. And then we're going to progress gradually.

And yes, pelvic floor rehab tools are part of it. So coordination, relaxation, pressure management strategies, bladder habits. Right.

But they're not the only pillar. Incontinence with running usually improves when lower body strength improves. Calf foot capacity improves.

Running exposure is graded. And most importantly, the nervous system stops treating impact as threat. And for hypermobile folks, sometimes it's even more important that the plan is steady and not chaotic.

Because novelty and high volume can be flare triggers, whereas consistency and progression can be medicine. OK, let's close with a few anchor statements that you can carry into your clinic or your own postpartum journey. 

OK, hypermobility isn't a sentence, It's a variable, a meaningful variable. You don't need to be coached into fear. You need to be coached into capacity.

Thank you so much for listening to today's episode. I would so appreciate if you head over to Apple, review, like, star, whatever, whatever it is you do at podcasts. It really does help more OTs find this work, find what it means to be a pelvic floor therapist.

And at the end of the day, raises the bar for our profession and also lets clients know that we're out there and we're ready to serve them. Thank you so much for listening.