Understanding the Link Between Hypermobility and Pelvic Floor Dysfunction

It has recently come to my attention that there is somewhat of a correlation between hypermobility (excess flexibility) and pelvic floor dysfunction. This concept sort of led me down a path of discovery that I am pretty excited about in the sense that it has been really helpful for my clients. It has allowed me to better help them move forward out of this chronic cycle of pelvic pain. Let’s dive in!

Hypermobile Spectrum Disorders

First I want to address hypermobility. This is a broad topic in itself, but more specifically I want to discuss Ehlers Danlos Syndrome (EDS) and other hypermobility spectrum disorders. Hypermobile EDS is a subtype of EDS and it is a disorder of the connective tissue, our body’s passive support system. This includes ligaments, joint capsules, fascia, etc. and is what sort of holds us together in a passive manner.

There are a lot of subtypes of hypermobility but I don’t want to venture off too much. More so I want to narrow things down to two subtypes, Hypermobile EDS (H-EDS) and Hypermobility Spectrum Disorder (HSD).

Hypermobile EDS is one of the most common subtypes of EDS, but ironically enough, it’s the only subtype that does not have a clear genetic marker. Other forms of EDS can be diagnosed with a blood test, whereas this subtype of EDS cannot. H-EDS is diagnosed based on a certain set of criteria. Once the checkboxes for H-EDS have been met and all other connective tissue disorders have been ruled out, a patient will then be diagnosed with H-EDS.

Hypermobile Spectrum Disorder (HSD) on the other hand, is diagnosed when some does not check all of the boxes for H-EDS and other connective tissue disorders are ruled out.

Medical Limitations for Hypermobility Disorders

Symptoms of both of these diagnoses can be quite debilitating but I want to make a bit of a distinction between the two. People with HSD can have the same or even worse symptoms than someone who checks all of the boxes for H-EDS. Experts who treat these types of hypermobility syndromes tend to lump HSD and H-EDS together.

One of the major problems in treating these two is that the patient will often be sent to multiple different specialties throughout the medical community in an attempt to treat the symptoms. The issue with that is there is not really a specialty for connective tissue disorders so there are limitations in terms of resources for these clients resulting in these patients having chronic issues that aren’t necessarily remedied.

Another thing that happens unfortunately, is that there tend to be a little more dismissal of symptoms or medical gas lighting because of how limited the medical community’s understanding of these disorders is. This can lead to the patient feeling that they are crazy or their pain is all in their head. I’ve experienced first hand these patients who have a sort of PTSD from years and years of their symptoms not being validated and certainly not addressed because the root cause of the problem has not been solved.

Screening for Hypermobile Disorders

When screening for these disorders within my practice, I use the Beighton Scale that includes tests such as:

• Touch your palms to the floor without bending your knees

• Observe for elbow hyperextension

• Observe for knee hyperextension

• Can they bend their little finger past 90 degrees

• Can they touch their thumb to their forearm

The patient gets a point for each of the activities they can complete and then that helps to determine if hypermobility is present. This test provides what’s called an indication, not a confirmation to classify the patient as having a HSD.

Another test I do, especially with all of my new clients, is called the Five Point Questionnaire. This test takes into consideration not just where a patient is at today, because we know as we get older sometimes we get stiffer, but it also asks if you were able to do any of the specific tasks as a child. This allows us to be aware that previous hypermobility may be a driving factor for the patient’s current symptoms.

Disability in the Hypermobile Population

At this point, I want to touch on some of the common presentations or symptoms of these types of patients that walk in your door. Some of the things you might want to look for include repeated joint dislocation/subluxation, chronic pain around the joints, history of labral tears, repeated sprains and strains, and this is all because this population’s joints can go beyond what’s normal in range resulting in injury.

Chronic headaches and migraines are also common as a result of instability resulting in neck and shoulder tension.

This population will also have issues within the pelvic floor, as I mentioned before. Prolapse, pelvic pain, pain with intercourse, chronic constipation, heavy periods, painful periods, and infertility all fall into this category.

Nervous System Deficits with Hypermobility Spectrum Disorders

These patients will also have what’s called dysautonomia, or difficulty regulating heart rate and blood pressure. They also have difficulty regulating their fight or flight vs. rest and digest responses.

A more specific disorder in this category of dysautonomia is called POTS, or Postural Orthostatic Tachycardia Syndrome. These patients will have an elevated heart rate upon standing and they might experience symptoms of heart palpitations, dizziness, passing out, exercise intolerance, brain fog, or excessive fatigue. In terms of correlation, about 70% of people struggling with hypermobility will also be diagnosed with POTS.

Mental Health and Hypermobility Spectrum Disorders

Mental health disorders also can come into play with this population. This may be somewhat obvious, but these patients experience increased anxiety after years of searching for answers they can’t find, symptoms of chronic fatigue, chronic pain, and an overactive sympathetic nervous system.

Because of an overactive sympathetic nervous system, they may also struggle with Attention Deficit Hyperactivity Disorder.

Proprioception Impairments in Hypermobility Disorders

Patients with hypermobility will also have impaired proprioception, or the awareness of their body in space. They may report feeling clumsy or “floppy” because their tissues don’t pick up the same sensory stimulation that others’ tissue would. For example, when I extend my arm I receive feedback from mechanical receptors within the tissues telling me that they are on stretch.

These receptors will also alert me when I am reaching the point of maximal stretch to prevent injury. Someone who is hypermobile does not have the same healthy response and can take their joints to an extreme position without pain or discomfort, resulting in injury.

You’ll also see these patients experience chronic muscle tension and pain likely drawing them to something like the practice of yoga. They choose yoga because they feel they need to stretch tight muscles, but in reality, this may do more harm than good.

Because of their hypermobility, their muscular system is already working overtime to try and stabilize their tissues because they are not receiving that passive stability from the connective tissues. The muscle tension they feel is really the muscles working to try and stabilize and compensate for the deficits in the connective tissues.

Chronic Pain in the Hypermobility Population

This overcompensation of the muscular system can oftentimes lead to tense, tight, and overworked muscles resulting in muscle fatigue and muscle pain - which then diagnoses like fibromyalgia come into play.

Fibromyalgia is the widespread tenderness throughout the body and it is also often associated with fatigue and difficulty sleeping. To simplify this diagnosis even more, this happens when the nervous system starts to generate pain responses, even when they’re not warranted resulting in a chronic state of pain

Chronic fatigue syndrome is also another common diagnosis within the hypermobile population. This is characterized by extreme fatigue greater than 6 months in chronicity that is not relieved by rest and that cannot be explained by any other medical condition.

Mast Cell Activation Disorder, another common diagnosis, is an autoimmune disorder that impacts the mast cells of a person’s immune system. The mast cells are one of the first lines of defect for immunity, but this dysfunction happens when the mast cells release their inflammatory molecules even when not warranted. This release of mast cells often occurs in response to stress and anxiety, exercise, and extreme temperatures.

Hypermobility individuals often also have digestive issues like Irritable Bowel Syndrome, leaky gut, and chronic constipation. You might see them have food sensitivities and be on a restrictive diet because of these sensitivities.

Taking a Holistic Approach to Treating Hypermobile Patients

To bring things together, sometimes a patient may be hypermobile and not have any of these chronic conditions. Knowing that they are hypermobile may help to explain some of their chronic symptoms and put them on a path to successful recovery. These indicators are important because it helps us to provide these clients with a path forward. We are better equipped to modify exercises and make referrals when necessary if we feel that these patients need further testing or better treatments.

Without taking into consideration the full picture of the patient, including hypermobility, we can sometimes get stuck in a rut and not be able to solve the problem. My goal with this information is to bring awareness to clinicians and patients, and if someone is struggling with any of these symptoms, or haven’t been able to find answers, then it might be necessary to consider these connective tissue disorders.

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