The physical therapy principle of “proximal stability before distal mobility” holds immense significance for the hypermobile client. In conditions like HSD and hEDS, the ligaments—the body’s natural restraints—are lax, forcing the muscular system to take over the primary role of joint protection. If the proximal stabilizers (the core, hips, and shoulder girdles) are weak or unresponsive, the distal joints (knees, hands, feet) are left vulnerable to recurrent subluxation, micro-trauma, and chronic pain.

Therefore, the rehabilitation sequence must prioritize establishing a stable, robust trunk and girdle foundation before allowing the distal extremities to move under load.

The Rationale: Why Proximal First?

Hypermobile joints are often highly mobile due to the failure of passive constraints. This high mobility demands a higher degree of co-contraction and endurance from the stabilizing muscles to maintain the joint’s “mid-range” of safety. If a client attempts to strengthen their knee (distal) without activating their hip and core (proximal) stabilizers, they simply reinforce faulty movement patterns that place shear forces on the knee joint.

Proximal stability serves three critical functions in hypermobility:

1. Shock Absorption: A strong core dissipates ground reaction forces, preventing them from traveling up the kinetic chain to fragile peripheral joints.
2. Optimal Lever Arm: Stable scapulae and hips provide a firm anchor, allowing the muscles controlling the distal limbs to generate force efficiently.
3. Proprioceptive Hub: The deep core musculature contributes essential feedback for posture and balance, compensating for the inherent proprioceptive deficits in the loose connective tissue.

The Sequential Approach to Stability

Effective proximal training follows a layered, sequential approach, starting with the deepest stabilizing unit and progressing outward.

1. The Inner Core Unit (Deep Stability)

Training must begin with the inner core unit, which acts as a pressure-regulating cylinder that stabilizes the lumbar spine and pelvis. These muscles must be trained for endurance and activation, not power.

• Muscles: Transversus Abdominis (TA), Pelvic Floor (PF), Diaphragm, and Multifidus.
• Initial Focus: Diaphragmatic Breathing and Co-Contraction. Teach the patient to integrate gentle TA and PF activation during quiet, three-dimensional breathing. This establishes the foundation for intra-abdominal pressure regulation and postural control. Start in non-weight-bearing positions (e.g., hook-lying or supine).
• Progression: Integrate the TA/PF co-contraction during simple limb movements (e.g., heel slides, controlled arm reaches).

2. The Hip and Pelvic Girdle (The Power Anchor)

The hip musculature, particularly the gluteal complex, stabilizes the sacroiliac (SI) joint, controls femoral rotation, and prevents excessive stress on the knees and low back.

• Muscles: Gluteus Medius, Gluteus Maximus, and Deep External Rotators.
• Focus: Gluteal Endurance and Control. Exercises should emphasize isolation and low-load activation rather than heavy lifting. Use band work (clam shells, side-lying abduction) or bridge variations.
• Progression: Advance to functional, weight-bearing activities (e.g., single-leg stance, mini-squats) while maintaining pelvic neutrality, ensuring the core (Layer 1) is active before the hips fire.

3. The Scapular and Shoulder Girdle (The Upper Anchor)

The scapular stabilizers are vital for preventing shoulder subluxation and reducing neck/upper back tension.

• Muscles: Mid and Lower Trapezius, Serratus Anterior, and Rotator Cuff.
• Focus: Postural Endurance and Dynamic Stabilization. Train the patient to maintain retracted and depressed scapular positions during movement. Use low-load, high-repetition exercises like prone T’s and Y’s or wall-focused serratus punches.
• Progression: Integrate controlled weight-bearing activities (e.g., modified plank on knees, stability ball push-ups) and progress to rhythmic stabilization drills, where the therapist applies light, unpredictable pressure to the shoulder while the patient maintains a static arm position.

Principles of Load and Repetition

When training the hypermobile core and girdles, Joint hypermobility physiotherapist Gold Coast must adhere to connective tissue principles:

• Low-Load Endurance: Connective tissue adapts slowly. Strengthening should focus on holding static positions for longer durations (isometric endurance) rather than maximizing weight.
• Form is King: The moment the client loses form or compensates with global muscles (e.g., bracing with external obliques or anterior shoulder muscles), the exercise must stop. Repetition should never compromise joint protection.
• Functional Integration: The final stage is integrating the stable proximal base into dynamic activities (e.g., lunges, carrying, gait training). The client must learn to recruit their stabilizers before the prime movers engage.