How to Handle the Hypermobile Client

Many Pilates clients fight to increase their flexibility. Some struggle to touch their toes, for instance, while others work hard to stretch their shoulders and some are barely able to sit cross-legged. But how do you handle the ones who are as pliable as Play-Doh and fight just to hold themselves in place?

You’ve seen the bendy-body signs: spines that seem to fold in half; knees or elbows that appear to bend backward; shoulders that look like they could pop out of their sockets. While flexibility is usually deemed a positive physical attribute enjoyed by a lucky few, many Pilates instructors don’t realize that hypermobility is more common than one might think and can be a root cause of chronic pain and postural issues (Hakim, Kerr & Grahame 2010). In fact, hypermobility can actually create symptoms of stiffness and tension and make sufferers vulnerable to a wide variety of physical issues and injuries, from tendinitis to damaged ligaments, pelvic-floor problems and sacroiliac joint instability (particularly during pregnancy) (Keer & Grahame 2003; Hakim, Kerr & Grahame 2010). Research even supports a connection between hypermobility and pain syndromes such as fibromyalgia (Acasuso-Díaz & Collantes-Estévez 1998).

If a client is hypermobile, it means he or she has a greater-than-normal range of joint movement, thought to be due to lax connective tissues. This can lead to movement impairments and muscle imbalances that stress joints, muscles and soft tissues (Keer & Grahame 2003; Simmonds 2000). Being hypermobile—in one or more joints—does not necessarily lead to negative symptoms. In fact, many people may not be aware that they are hypermobile, and the condition can even offer an advantage to dancers and gymnasts (though they may suffer injuries if not trained properly). When it does cause physical problems, however, it may be diagnosed as joint hypermobility syndrome (or, in extreme cases, it may be identified as a rare, genetic connective-tissue disorder such as Ehlers-Danlos syndrome) (Hakim, Kerr & Grahame 2010).

While formal data is lacking, experts believe hypermobility is far more prevalent in the general population than people realize and is under-recognized and misdiagnosed (Hakim, Kerr & Grahame 2010). The condition is far more common in females than males and tends to diminish with age. Signs to look for include hyperextended knees and/or elbows, extreme hip rotation, extreme plantar flexion of the feet, winged shoulder blades, supinated or pronated feet and a hyperflexible lumbar spine.

Ironically, some hypermobile clients may not present as particularly flexible and may complain of stiffness and tightness, says Rebekah Rotstein, a New York City–based Pilates instructor who has struggled with her own hypermobility issues. That’s because their muscles have to work overtime to stabilize and support the joints, and not in an efficient way, so they may go into a hypertonic state. “The key is to release the muscles that are gripping, while training others to kick in for support,” Rotstein explains.

Here are some tips on training the hypermobile client:

Lay off the stretching. A hypermobile student may constantly feel the need to stretch, but years of overstretching already-lax ligaments may mean muscles are actually lengthened to the max, like a stretched rubber band, says Marcy Schafler of Mind Over Movement, a Madison, New Jersey–based Pilates studio and teacher-training facility. “It’s an illusion of tightness,” she says. “It may feel good to stretch in the moment, but over the long term these clients need to find a sense of connection, internal support and structure.”

Do an initial assessment. Assessing a client’s posture and movement can offer telltale signs of hypermobility, says Lesley Powell, owner of Movements Afoot, a New York City-based Pilates and wellness studio. “Standing on one leg highlights compensations,” she explains. “[Hypermobile clients] may have trouble balancing, or their hips will move, or they’ll tuck.”

Other signs of hypermobility include difficulty holding neutral pelvis and lack of pelvic-floor control, according to Schafler. “You’ll see a lot of bearing down with no oppositional force of the abdominals.”

Stick with closed-chain exercises. Foundational work on the Pilates cadillac and reformer gives “tremendous feedback” thanks to the closed-chain elements involved, says Powell. This is important for hypermobile clients, who typically lack good proprioception. Quadruped exercises are similarly beneficial, adds Rotstein. “These get the transverse abdominals to work against gravity and the shoulders to work synergistically with the core, so hypermobile clients feel the connection,” she says.

Encourage breathing work. Hypermobile clients may generally have challenges with pelvic stabilization and deep core support. Both issues are greatly assisted by better breathing, says Schafler. “A proper diaphragmatic breath will keep them from bearing down and helps the diaphragm, abdominals and pelvic floor begin to work together.”

Help clients stay positive. Emotional frustration is common with hypermobile clients, who may have a hard time staying stable or even feeling that muscle work is happening, says Rotstein. “It’s important to help hypermobile clients have a positive movement experience, so they don’t leave feeling like they can’t do anything right,” she explains. “Finding exercises where they can really get connection and feedback is important. Keep checking in with them to find out how they’re feeling.”