How does hypermobility impact your Knees?

Estimated reading time: 5 minutesHyperextension of the knees in hypermobility is common. I used the adopt the strangest of standing postures, from simple knee locking to crossing one leg over the other, or actually wrapping one leg around the other one.

Knee pain is a frequent complaint I hear in our community. It has been reported that the knee was second only to the shoulder in terms of reported problematic joints in people with Ehlers-Danlos Syndrome (1). There are a number of strategies that can help support the knee joint including exercise, bracing and awareness training.

Knee hypermobility, sometimes referred to as a “double-jointed” knee, is also included in the Beighton score, a part of the 2017 diagnostic criteria for hypermobile Ehlers-Danlos Syndrome.  When the knee has greater than 10 degrees of hyperextension, 1 point is earned for each side.

Hypermobility can affect the knees in various ways

1. Increased Risk of Injury: The excessive range of motion associated with hypermobility can make the knee joint more susceptible to injuries such as dislocations, sprains, and strains. This is because the supporting ligaments and muscles may not provide adequate stability. When we lack control around the knee joint, we may lose control quickly under load or force causing injury.
2. Joint Pain: The knee joints may become sore and tired more quickly due to the extra movement and the effort required to maintain stability. Learning to stabilise the knee joint is key.
3. Osteoarthritis: Over time, the increased wear and tear on hypermobile knee joints can lead to early-onset osteoarthritis. The cartilage that cushions the knee may degrade faster, leading to pain, stiffness, and reduced function.
4. Patellar Instability: Hypermobility can lead to issues with the kneecap (patella), such as patellar instability or dislocation. This occurs when the patella moves out of its normal alignment, causing pain and discomfort.
5. Muscle Imbalances: like in any other part of a hypermobile body, the muscles around the knees may become imbalanced. Some muscles may overcompensate for the lack of joint stability, while others may weaken, leading to an increased risk of injury and pain.
6. Issues with proprioception: People with hypermobility often have impaired proprioception (the sense of joint position and movement). This can affect balance and coordination, making activities that require precise knee movements more challenging and increasing the risk of falls. The hyperextension of the knees that we frequently do can impair Proprioception but there are some great exercises to improve this.

What does the research have to say about knees and hypermobility and/or Ehlers-Danlos syndrome?

• Proprioception may be altered
  • An older (and small, n=10) study found hypermobile subjects have “poorer proprioceptive feedback” than controls (2)
• Gait may be altered
  • While one study on the gate pattern differences between people with joint hypermobility found it was not altered at the knee (3). However, a subsequent study from the same group enrolled more subjects and used different method of measuring gait parameters and did find significant differences in knee flexion and extension during gait (4).
• In athletes, generalized joint hypermobility is associated with an increased risk of injury to the knees (5)
  • Previous studies show a risk of knee injuries related to hypermobility in general. This was a meta-analysis (looking at 20 studies) and it found in men, joint hypermobility was associated with anterior cruciate ligament (ACL) injury. They found results were conflicting in women when it came to the ACL.
• There are alterations in tendon stiffness (reduced tendon stiffness) of the iliotibial tract that may be associated with knee problems (6)

What are the causes of the pain?

Knee pain can be caused by many factors. We are all different. My first occurrence of knee pain was when I was around 12 years old and a cross-country runner. I developed crippling pain under both kneecaps. Intense physiotherapy and quad-strengthening solved that issue. The knee is impacted by muscle weakness and ligament laxity in the surrounding tissues. It will also be subject to wear and tear due to faulty alignment of the bones.

Other things I see often that can contribute to knee pain:

• Patella tracking issues are common as well as subluxations and dislocations.
• The constant locking of knees is also going to pull the bones out of alignment placing them under more stress. Stress can cause irritation and inflammation causing further pain.
• The knee is the middle man – it will be impacted by foot alignment and pelvic alignment. This is why a whole-body approach to movement is key.
• Walking and climbing stairs can become really challenging if we are impacted by knee pain. I often coach my clients on how to load their joints when going up and down stairs. With proper technique, we can prevent loading the knee too much and reduce pain.

The good news is all of these can be addressed with movement therapy.

Why should we address knee hyperextension?

Before I learned about movement, gait, and hypermobility, standing with hyperextended knees was my natural position. Now that I know better I can share why I think we should avoid hyperextending our knees.

1. It can put pressure on the knee joint causing wear and tear.
2. When the knees lock, the muscles in the legs no longer have to work to support you. You are hanging off the hip and knee joints.
3. It puts the pelvis into a forward tilt which can cause low back pain as the muscles shorten at the back. Hamstrings will get tighter.
4. The glutes do not switch on in this position potentially leading to weak glutes which can be a contributing factor to walking issues.
5. The abs are pushed forward – again no muscle tone taking place.
6.  Body weight tends to come forward causing scrunching of toes to stop falling over. Not having an even weight distribution through the feet has implications for the rest of the body in terms of pain.
7.  The head follows the pelvis forward bringing us into a forward head posture. This can lead to neck pain and headaches.
8.  Ankles get tight and squashed, restricting mobility for walking.

We know that there should be a low level of muscle activity in standing. When the big bony structures of the head, ribs, and pelvis are out of alignment, the body is put under much more strain than is necessary.

Bringing these structures into alignment lets the body conserve energy and work less. Gravity is harnessed when our body weight is balanced.

With softened knees, you can bring those structures back into alignment. Start with the feet. It is important to get a sense of gravity by drawing the feet heavy into the ground. The knees will naturally soften. It is very difficult to lock out the knees when you are truly in your feet with balance front and back of the foot. Gravity is drawing your weight down. Have a play – it will take practice and will not fix overnight, but it’s definitely worth the investment in time.

Are braces any good for your knees?

I believe using braces to help support our joints, like the knee, can be helpful in alleviating pain. Braces can help with proprioception, alignment, and daily activities. In a study on treatment modalities used by people with EDS, 70% reported improvement in pain with the use of Occupational Therapy and Bracing (1). If we are using braces, we do still want to do movement and exercise to improve strength and stability around the knees.

I busted the myth that “braces are bad for EDS” in this video.

Best movements to alleviate the pain

I always start with Proprioception exercises before strengthening. There is no point strengthening a hyper-extended knee. We want to build awareness and knee joint control then introduce stability and strength. It takes time because if like me you’ve spent most of your life with hyperextended knees, the body will want to keep reverting back to that. Keep practising awareness and control will come.

In The Zebra Club we have a whole program or collection of classes dedicated to feet and the lower limb including one called Support the Knee Joint that can help address knee pain.

My live knee class takes us through some key knee exercises.

FAQ

Do knee supports help hypermobility?

Bracing and support can help alleviate pain in hypermobility. Braces can help with proprioception, alignment, and daily activities. At the same time, we will want to work on increasing strength and stability with exercise and movement.

How do you treat hypermobile knee pain?

With hypermobility, we can see an excessive range of motion and instability that may contribute to knee pain. We can use exercise to learn how to move our knees well, gain strength and stability, and relieve pain. Remember the knee is the middle man so I always look at the foot and hip when addressing knee pain too.

How to strengthen hypermobile knees?

To strengthen knees, we want to start with proprioception and control. Once we can control the range of knee movement we can introduce exercise for stability and strength. I have many of these on YouTube and even more in The Zebra Club app.

Jeannie Di Bon

Jeannie Di Bon is a movement therapist, educator and author specializing in hypermobility, Ehlers-Danlos Syndrome and chronic pain. She is the founder of The Zebra Club app and the creator of the Integral Movement Method.