Hypermobility and the Pelvic Floor

You might not think these two things are connected, but clinically I see this quite often, and the problems that show up in the pelvic floor might surprise you.

First Off, What is Hypermobility?

Hypermobility is when the joints have more mobility, or range of motion, than is considered normal.

For example: do your knees or elbows hyperextend when you lock them?

That is hypermobility.

There is a range of hypermobility. A person can be hypermobile and just one, or a few, joints, or they can have hypermobility throughout their body. They can have a diagnosis of hypermobility spectrum disorder, and one of the more severe diagnoses of hypermobility is Ehler's-Danlos syndrome.

One diagnostic criteria that is used to diagnosie hypermobility is the Breighton's scale. This is a test of a few movements such as:

-can your pinky finger bend back more than 90*

-can you touch your thumb to the wrist of the same arm

-do your elbows and knees hyperextend more than 10* past neutral

-can you touch your palms to the floor when you bend over from standing

To score this, a person would get one point for each positive (on each side) up to a total of 9 points.

An adult up to age 50 is considered hypermobile if they score at least 5/9. Above age 50 a positive is a score of at least 4/9. Children are considered hypermobile if they score anything 4/9 or higher.

You can read more about the test here: https://www.ehlers-danlos.com/assessing-joint-hypermobility/

What does this have to do with the pelvic floor?

People with hypermobility are found to have pelvic floor dysfunction and gastro-intestinal dysfunction more often than people without hypermobility (1).

Some common pelvic floor problems in people with hypermobility:

-prolapse

-bladder leakage

-pelvic pain

I find that my patients who have hypermobility most often have tight pelvic floor muscles, rather than weakness. This happens because the pelvic floor has to work harder to create stability for they hypermobile joints elsewhere in the body.

Prolapse is when a pelvic organ (bladder, uterus, rectum) is lower in the pelvis than they should be. This happens most often in pregnancy and postpartum, and people with hypermobility are more at risk of this because their ligaments are already more stretchy at baseline. I find even in these people that they often have tight pelvic floor muscles, so that is what we treat.

Many people think that prolapse and bladder leakage only happen when the pelvic floor muscles are weak, but these conditions can happen even with tight pelvic floor muscles.

How Do I Treat Patients With Pelvic Floor Dysfunction and Hypermobility?

I always treat what I find when I assess a patient in the clinic. That means if they have tight pelvic floor muscles, we work on getting those muscles to relax. That may be through manual therapy (hands on therapy directly to the pelvic floor muscles), breathing exercises and sometimes stretching.

Most patients with hypermobility don't need more stretching, but another thing that often helps them is strengthening the bigger muscles of the hips and pelvis like the glutes, quads and hamstrings. If those muscles can do their job more effectively, then the pelvic floor muscles can let go and relax a little easier.

One treatment method I like for strength training the other muscles outside of the pelvic floor for my patients who have hypermobility are exercises called Controlled Articular Rotations, also known as CARS. These come from a training called the Functional Range Systems training. It is basically taking a joint through its maximal range of motion in all directions, but with some self resistance throughout. This way we are creating some strength and stability in the hypermobile joints.

Treating Pelvic Floor Dysfunction is Always About Treating the Whole Person

This is very important in this patient population of people with hypermobility and pelvic floor dysfunction because just working on the pelvic floor muscles in isolation and never working with the hypermobility will rarely improve the pelvic floor for this (or most) people.

If you are hypermobile and pelvic floor therapy has not been successful because the therapist only did kegels or only did direct manual therapy on the pelvic floor muscles, you may need to try a different pelvic floor therapist who will assess your pelvic floor, but also look at that in connection with the rest of your body.

If you would like to schedule a virtual or in-person session with Dr. Carri, you can schedule here.

References:

1: Ewer ER, De Pauw R, Kazkazk H, Ninis N, Rowe P, Simmonds JV, De Wandele I. The Spider: A visual, multisystemic symptom impact questionnaire for people with hypermobility-related disorders—Validation in adults. Clinical Rheumatology. 2024;43(9):3005-17.