Are You Injured or Sore?

​You know exercise is good for you, but what if it causes pain and soreness?
 
People with hypermobility disorders benefit from exercise even more than others, but exercise also presents some additional challenges for their inherently less stable bodies. Hypermobility Spectrum Disorder (HSD) and Ehlers-Danlos Syndrome (EDS) are conditions caused by a disorder of collagen biosynthesis and structure that cause the  connective tissue in hypermobile bodies to possess less stiffness than normal connective tissue. This, both directly and indirectly, makes people with HSD and EDS more prone to musculoskeletal injuries. Injuries may be micro-injuries, i.e. microscopic injuries that tend to accumulate over time resulting in “wear and tear” on tissue and manifest as osteoarthritis, tendinosis and other forms of tissue breakdown. They may also be macro-injuries which, as the name implies, are frank injuries to tissue, such as a tear of a ligament or tendon, or fracture of a bone. There is also a grey area between the two, where gradual imperceptible changes in tissues cause findings that are often perceived as macro-injuries, as in rotator cuff tears and bulging discs.
 
Remember that exercise in and of itself, strictly speaking, strengthens muscle by causing “injury”, small micro-tears in muscle tissues. As these heal in the days following the exercise, the muscle builds itself back stronger than before in response to the load imposed on it. This process is completely natural and benign in the non-hypermobile body. Decreased joint stability and decreased tissue strength coupled with slower healing of tissue can make hypermobile people more susceptible to increased exercise-related soreness and pain. This is unfortunate, as hypermobile individuals may, if deterred by their experience, suffer more significant consequences of a sedentary lifestyle than their friends and partners with connective tissue of normal strength. In order to make it possible for hypermobile individuals to enjoy the many benefits of regular exercise, the exercise prescription for the individuals with HSD/EDS requires a thoughtful and gradual approach.
 
Delayed-onset muscle soreness (DOMS) is a phenomenon which, while not yet fully understood, is considered normal, and tends to occur after exercise. It is  especially likely when the exercise is intense, new, increased in load, duration or intensity or contains an eccentric component (muscle contraction during the muscle lengthening phase, as in walking or running down a hill, or slowly lowering a weight). Various phenomena such as lactic acid, muscle spasm, connective tissue damage, muscle damage, inflammation and the enzyme efflux theories have been proposed as underlying mechanisms, and in all likelihood DOMS may occur as a combination of any and all phenomena. When the hypermobile person experiences soreness or pain following exercise, it can be hard to distinguish between the more benign DOMS -- which, as mentioned, due to several factors may feel more intense in hypermobile individuals -- and actual injury to tissues, the latter of course requiring more attention and prevention than the former.
 
So how do you distinguish DOMS from injuries that you should be concerned about? DOMS tends to be more generalized, including muscles which may be sore both on movement and palpation. An injury to a joint or muscle is more often one-sided and more localized, and the pain may prevent movement in a more specific direction. For example, having exercised or in other ways been physically active in a way that included use of the arms may make you sore in the arms and shoulders in general. An injury --again, here we are excluding the benign microtrauma that beneficial exercise causes, even though it technically speaking is an “injury”-- to the shoulder joint may, as an example, present as pain with moving the arm upward or behind the body, but feel much better with the arm lowered and at rest. Another clue is the timeframe. DOMS usually eases within 2-4 days, having appeared with some delay, whereas an actual injury will still be present after a few days.
 
 
 
 
Preparation is protective 
 
Problems are best prevented, of course, and pain and soreness due to exercise is no exception. Exercise is one of the best treatments for the various manifestations of hypermobility, and problems associated with hypermobility are best addressed holistically, taking the entire body of the person into account, instead of addressing injuries one by one, as they occur.While high-quality studies on the effect of physical therapy on hypermobility conditions such as HSD and EDS are lacking we can extrapolate from what we know about rehabilitation of acquired hypermobility in single joints, and on the smaller studies that do exist, and conclude that over time, the decreased joint stability can be improved with training, and even decreased strength of muscles and tendons can be positively affected by the mechanical loads provided by regular exercise. 
 
There are several factors we can take into account before exercising that can decrease the risk or intensity of DOMS and injury-related pain.  When planning to start a new type of activity, it's best to first analyze -- usually with expert help -- what the requirements are for safely performing the activity in question. As an example, if you'd like to be able to walk, run, zumba or dance for exercise, you will need trunk stability, hip strength and stability, a full range of motion especially in your hips and your big toe, and good foot strength and movement form. All of these can be acquired prior to starting the desired form of exercise. A would-be runner or dancer could engage in a lighter version of the activity -- walking or working on slow dance steps  -- while working to improve the aforementioned basic requirements for safely performing the activity.
A common mistake is to assume that the activity itself will help you develop the requisite stability, mobility and strength needed for this. There are two problems inherent in this assumption. First, what will protect you during your exercise until you have acquired these skills? Second, this expectation is based on the somewhat faulty assumption that the body during movement will recruit weak muscles to perform the activity, when stronger muscles are available to compensate. Think of the body more as a survival machine than a self-rehabilitating organism. We are much more likely to instead develop compensatory movement patterns that in the long run lead to subpar performance and even pain and injury, than to spontaneously develop good, balanced strength and perfect form while performing a new activity. This makes perfect evolutionary sense. What would have been a greater priority to our ancient forebears, running away from the risk of becoming someone’s next meal as fast as possible, even though some injury might have left us with decreased strength in some area, or jog away a bit more slowly using all muscles ideally needed for the escape, including weak ones to make sure that (in the unlikely event that we survived using this strategy) we would once again develop a balanced body?
Keep in mind the time it takes (usually longer than normal in hypermobile people) for your body to respond to exercise and to progress. Do your best to add load very slowly when you’re challenging your body to grow, allowing it to respond fully to the previous level of exercise before you progress. 
One factor that may lead us to try to progress faster than we should is the fact that the exercise itself decreases the perception of pain during the activity. This phenomenon is referred to as exercise-induced hypoalgesia. While this mechanism may be reduced or altered in chronic pain, a single bout of aerobic or resistance exercise typically leads to a generalized reduction in pain and pain sensitivity that occurs during the exercise itself and for some time afterward, so that you may feel fine while exercising, only to realize afterwards that you exposed your body to too much, too soon.
When in pain…
Once exercise soreness has set in, there are still things you can do to improve the situation. While pain can feel scary, and while you might, understandably,  want to avoid the very thing that  brought it on, the best strategy is to avoid complete physical inactivity. Try to remain physically active, but with a much lesser intensity and duration. A short walk can ease the sensation of stiffness and soreness along with the regret of having overestimated your capability. Cooling nerves slows their conduction velocity (the speed at which they send signals to the brain) so applying a cold pack can decrease pain significantly. Apply it over a damp washcloth to any area that hurts, for 20 minutes at a time. Allow the skin to return to a normal temperature before reapplying in order to avoid frostbite. Icing will, however,  not positively affect the rate at which you heal, and you actually do not need to do anything to make DOMS subside, as it is a natural phenomenon and will pass on its own. 
There is also some data suggesting that gentle stretching can modulate the inflammation causing the pain and stiffness. Remember that in this context stretching means coaxing muscles to relax, not forcing them to lengthen.
While you’re feeling sore you can still exercise other parts of the body than the involved ones. If you suspect actual injury, you should of course seek help. If you're simply experiencing DOMS (delayed-onset muscle soreness) gentle movement is helpful. Pain intensity is affected by our beliefs and this means that how you perceive pain affects how much you suffer from it. Reminding yourself of the fact that exercise soreness is a natural, benign and self-limiting phenomenon helps alleviate any concerns that you may have and will make it more likely that you’ll sail through DOMS without suffering needlessly. 
Since hypermobility may lead to greater than average exercise-induced soreness, as well as slower post-exercise recovery, it is also important to gauge whether the intensity of the soreness is greater than ideal. When in doubt, in the presence of HSD/EDS it is usually a better idea to progress slowly and carefully in order to avoid the dreaded boom and bust- phenomenon; advancing too quickly only to be sidelined by an injury. With hypermobility, impatience is the enemy of progress, and patience is your secret superpower!