General Benign Hypermobility

If you observe people around you closely, you will see that some are naturally rigid and cannot touch the ground when bending over, while others seem as flexible as rubber, able to move their bodies into various positions that most people cannot even imagine. This characteristic is called congenital flexibility, and it varies for each of us. There is a whole range, from really stiff people to those who move as if they were made of rubber. This latter extreme is called general benign hypermobility and is a characteristic that is neither inherently good nor bad, just as green eyes are neither good nor bad. However, just as light-colored eyes are more sensitive to sunlight and other bright lights, hypermobility has its own drawbacks. So let’s proceed step by step.

Primary flexibility is determined by the properties of the connective system in the human body, which is ubiquitous, forming ligaments, permeating muscles and creating tendons, existing in subcutaneous tissue and fasciae around muscles and all organs in the human body, and in the joint capsules. These properties are directly dependent on the composition of connective structures, where an excess or deficiency of certain proteins determines their greater or lesser elasticity, and thus overall mobility, that is, greater or lesser flexibility or stiffness.
On average, women are more flexible than men. This is because, during adolescence, growth, and maturation, girls undergo a transformation into adulthood influenced by hormones, especially estrogen, which contributes to greater flexibility. The purpose of this flexibility is to prepare a woman’s body for its biological role in procreation. Without this flexibility, the typical changes of pregnancy and childbirth—such as the increase in abdominal volume and the enlargement of the birth canal through which the newborn enters the world—would not be possible. This type of flexibility is considered normal and desirable.

It’s a completely different story with increased flexibility of all joints unrelated to the aforementioned process in women, and this affects both sexes, though more commonly women. This refers to joint laxity, where movements beyond the physiological limits of joint structures are possible, making them inherently unstable. Such people are easily recognized by their ability to perform seemingly impossible movements, bending into positions that most cannot achieve, and sometimes even voluntarily dislocating joints (usually the shoulder) without any effort or pain.

It’s worth mentioning that flexibility can be increased through persistent exercise. This is most visible in certain sports or professions, such as gymnastics, swimming, or ballet. However, this increase has its genetic limitations and may or may not be related to the presence of natural laxity. In addition, these sports (and some unmentioned ones) tend to attract naturally flexible individuals, just as strength sports attract naturally large and strong people. Note that muscle size, whether congenital or acquired, does not mean a person cannot be hypermobile. We have seen many such athletes, as a combination of great strength and great flexibility, apart from gymnastics, can be a risk factor for developing specific injuries.

So, is general benign hypermobility inherently a risk for injury, especially to ligaments and joint structures, and an additional risk for damage to other tissues, such as cartilage and joints?It depends.

And it depends on how we use a hypermobile body. In everyday activities, there is no additional risk. In sports activities, especially those involving explosiveness, speed, and strength, hypermobility can increase the risk of injury. In simple terms, the body has three levels of protection against injuries. The first is muscles, which absorb forces during movement. When they are tired, the next line of defense is ligaments, which ensure joint stability. When they fail, the joints themselves and their structure provide the last line of defense against injuries. In sports activities involving explosiveness, speed, and endurance, training often occurs in a state of fatigue to stimulate adaptations that improve physical performance. For athletes with generalized laxity, there is an absence of full connective system protection in the fatigue zone, increasing the risk of injury. Therefore, most injuries among athletes with generalized benign joint laxity occur in strength, explosive, and endurance sports.

Thus, we can say that generalized hypermobility does not represent a restriction on participating in sports but rather a predisposition for sports in which it is desirable and sought after. Similarly, a certain height is a desirable predisposition for specific sports. That is why there are no seven-foot gymnasts and few short athletes in basketball. If we understand general hypermobility in this way, it’s similar to driving a new Ferrari. On the road, it is unmatched, and few cars can rival it. But if we drive it off-road, damage is inevitable.

For hypermobile athletes engaged in strength and explosive sports, specific preventive measures can reduce the risk of injury, but this requires an athlete’s understanding of the nature and specifics of their body, guidance from an experienced physiotherapist and strength coach, and consistency in implementing preventive measures, which broadly consist of:

–Recognizing fatigue and avoiding peak training loads in exhaustion zones
-Stimulating proprioception (reflex response) in the present
-Stimulating proprioception in the future
–Strength and endurance exercises for muscles whose primary task is joint stabilization in specific positions
-Modifying the training process, in consultation with the coach, by replacing high-risk training interventions with equally effective but less risky ones
-Other preventive measures specific to the sport and the athlete

As is evident from all of this, for hypermobile athletes in explosive and strength sports, communication within the sports-medical team and individualized training based on the experience of all involved in the training process is of great importance.

The tension model postulates that the stability of one segment depends on the stability of all other segments in the body. Thus, ligament laxity, which threatens ligament damage to the knee and ankle in soccer, is directly dependent on the function of the hip and the entire back. In this sense, injury prevention within this condition cannot be achieved only by exercising the knee or ankle muscles, but by conditioning large kinetic chains to ensure timely activation and prevent situations in which a joint or joints reach a zone beyond physiological limits. Simply put, we try to compensate for the lack of ligament tension with enhanced, accelerated, and timely muscle activation. For patients with generalized connective tissue laxity, this is an effort that lasts throughout their sports career.

Additionally, besides trauma, hypermobile athletes are at greater risk of developing certain overuse syndromes. Their prevention is carried out in the same way as for trauma. And finally, there are cases in which the body simply cannot compensate for the forces generated in a given sport. In such cases, we have no choice but to change sports. Just as a new Ferrari is not made for off-road driving, some bodies are simply not capable of participating in certain sports.