There is a growing appreciation in both medicine and in manual therapy (osteopathy, chiropractic, physiotherapy) of the role that excessively flexible ligaments can play in spinal and joint issues, and even in general health.
First, some background. The body is built of connective tissue, which is comprised mainly of strands of protein, especially a protein called collagen. Fat can be stored in connective tissue (e.g. tummy fat) but is an entirely different thing from connective tissue. Carbohydrates are used for fuel or stored in the liver or muscles for energy reserves, but again, are different from connective tissue.
Collagen itself comes in different types and organises itself into various forms of connective tissue. Joint ligaments, the skin and the connective tissue that folds around and supports organs such as the heart are all examples of connective tissue.
Now, this is simplifying it a bit, but it is genes that largely determine how stretchy and how strong are your ligaments compared to someone else. I believe we over-estimate how much we lengthen ligaments through regular stretching (I suspect the benefits from proper stretching come from other mechanisms).
(As an aside, bear in mind that ligaments connect bones to other bones – to help keep the joints together – whereas muscles connect to tendons (at either end of the muscle) and those tendons connect to bones).
Osteopaths are very interested in understanding how stretchy people are. We categorise people as having;
- normal or stretchy ligaments (another word for stretchy could be ‘lax’)
- normal or low muscle mass/bulk
- normal or low muscle tone (think of tone as the background ‘rpm’ of your muscles – are they floppy at rest, or are they quite taught?)
For example, ballet dancers are likely to have loose ligaments (to allow a fantastic range of joint motion) but also need to be quite muscular with ‘firm’ muscle tone.
What would the ‘best’ combination be for long-term health and joint prospects? Probably normal or tight ligaments, and plenty of taut/tonic muscle.
The worst? I’m sure you’ve figured that out: loose ligaments, and low muscle mass with a low level of background tone (floppy musculature).
Why? Because the first way to protect joints from excessive or abnormal motion is to have nice tight ligaments. The second, to have fast, accurate and powerful muscles that can quickly control joints to stop them getting into trouble.
If you have the opposite of the above, then your joints can be more vulnerable. This vulnerability can be because of the joint moving further than it should, causing the joint to become irritated or the muscles that control the joint to ‘spasm’, or because the ligament itself gets injured through too much movement.
The above is all a bit of a simplification, and the modern understanding of these issues is filling in quite a few gaps, but it does help.
So you can now see why the general medical term to describe this issue is hypermobility.
It’s quite likely, given all the studies and research to date, that up to 30% of females may have some form of this condition, and up to 10% of males. It is not uncommon!
So what clues might indicate that you or your children have loose ligaments?
Perhaps the most obvious is how bendy are your joints? For example, do your knees or elbows bend backwards, ‘the other way’. There are some tests and protocols for this. The Beighton Score is widely used in research and clinical testing, although leading researchers see it as a little simplistic.
However, there are other clues. If regular everyday movements make you click and pop a lot, or if you have the need to click yourself to relieve tension and aches, then this raises the chance you have some form and degree of hypermobility.
If you find your body does not like exercises that place your joints at an end-of-range position (for example yoga, or lunges in the gym) that’s another clue.
Perhaps your skin is prone to stretch marks? Are your joints causing problems, which is then blamed on early osteoarthritic change by the doctor?
Do you keep getting plantar fasciitis or achilles tendon problems – in both feet?
When you were a kid did your knees give you problems?
It’s a simplification, but if you have normal ligament / connective tissue stretchiness, then you can kind of get away with getting less fit from a muscular point of view. Everyone should keep fit and active, of course, but at least in your case, you have your normal ligaments to ‘hold things together’.
However, if you have hypermobility? Then you have no choice but to work on low impact, predictable, muscle strengthening and toning work to help look after your joints. For example, pilates, or gym weights, swimming or running (but only on level ground).
Over the last ten years or so, the whole issue of what was previously called joint hypermobility syndrome has been folded into a general medical term for a type of connective tissue disorder called Ehlers-Danlos Syndrome.
We should now see joint hypermobility as being part of this spectrum of connective tissue disorders. Indeed, it is now considered the most common sub-type of Ehlers-Danlos.
This new classification is very useful for many reasons, the most important being that having loose ligaments (hypermobility) is unlikely to be something you have in isolation.
Other disorders (for example, chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and even anxiety are more likely to be present in forms of Ehlers- Danlos syndrome (EDS) and even in the sub-type of EDS we used to call joint hypermobility syndrome.
The mechanisms that link these apparently unrelated symptom clusters are beginning to be understood.
So if you or your child keep getting problems with your spine and joints, don’t only think about posture, or exercise, or sleep, or health, but also deliberately and carefully consider this issue. It might answer many questions.
Although GP’s are now strongly encouraged to be on the lookout for this condition, it would be sensible for you to be aware of this very useful ‘toolkit’.