Hypermobility and Lower Back Pain in Dancers: hEDS, HSD and What Helps

Dancers are known for their flexibility, strength, control and ability to move through large ranges of motion. For some dancers, though, that extra joint mobility comes with pain and instability. If you are a dancer with hypermobility, hEDS or HSD and lower back pain, understanding how your body moves is a key part of managing symptoms and continuing to dance safely.

At AZ Physiotherapy Limited in Auckland, we have a special interest in hEDS, hypermobility spectrum disorders and hypermobility-related musculoskeletal problems. Physiotherapist Abdullah Abdullah works with people who have hypermobility-related pain, and has a particular interest in helping dancers with lower back pain build strength and movement control.

What are hEDS and HSD?

Hypermobile Ehlers-Danlos syndrome (hEDS) is a heritable connective tissue disorder associated with generalised joint hypermobility and a range of musculoskeletal and other features. There is currently no laboratory test that confirms hEDS. Diagnosis is based on clinical criteria, and other possible explanations need to be considered.

Hypermobility Spectrum Disorder (HSD) describes symptomatic joint hypermobility when the symptoms cannot be better explained by another condition. HSD can involve joint instability, pain, injuries and other symptoms.

Being flexible does not automatically mean you have hEDS or HSD. Many dancers and gymnasts are naturally flexible without having a disorder. Hypermobility becomes clinically important when it comes with pain, instability or functional problems. Our guide to the signs of hypermobility, EDS and hEDS explains the difference in more detail.

Why can hypermobility cause lower back pain in dancers?

Lower back pain in a dancer with hEDS or HSD is rarely caused by hypermobility alone. Strength, movement control, training load, fatigue, technique and repeated end-range positions all contribute.

Dance involves repeated:

• Back extension, such as arabesques and backbends
• Spinal rotation and side bending
• Hip extension and large hip ranges of motion
• End-range positions held or repeated many times
• Single-leg loading
• Jumping and landing
• Rehearsal and performance repetition

When these movements are repeated, especially when you are tired, the muscles around the trunk and hips have to work harder to control the spine and pelvis. For a dancer with symptomatic hypermobility, the demand on those muscles is greater.

This does not mean dancers with hEDS or HSD should avoid flexibility or dance. Rehabilitation focuses on building the strength, control and capacity to use the range you have.

How hypermobility affects the lower back

The spine, pelvis and hips work together in dance. A very mobile dancer naturally moves into large ranges, and for some, repeatedly using end-range spinal extension or rotation contributes to irritation, particularly with high training loads or not enough strength and control.

The lower back may also compensate when control is limited elsewhere. For example, if a dancer has a lot of hip mobility but struggles to control the pelvis, the lumbar spine may contribute more movement than intended.

This is why an assessment should not look only at the painful area. A physiotherapist may assess:

• Lumbar spine movement
• Hip mobility and strength
• Pelvic and single-leg control
• Trunk strength
• Balance
• Dance-specific movements
• Training load and previous injuries

The aim is to understand how the different parts of your body work together.

What is the Beighton score?

The Beighton score is a 9-point screening tool for generalised joint hypermobility. People sometimes call it the "Brighton score", but Beighton is the correct name. It looks at the little fingers, thumbs, elbows and knees on each side, plus forward bending of the spine.

Under the commonly used thresholds, 5 out of 9 or more is considered positive in adults up to age 50, with a higher threshold for children and adolescents and a lower one for adults over 50.

The Beighton score is not a diagnosis of hEDS. It also misses joints that matter for dancers, including the hips, shoulders, ankles and feet, so a broader clinical assessment is often needed.

Why strength matters for dancers with hEDS or HSD

Strength and muscular control are central to managing symptomatic hypermobility. Strong muscles give active support around joints and help you control movement through your full range. Guidance from The Ehlers-Danlos Society highlights strengthening and exercise as important parts of managing hEDS and HSD.

For a dancer, this may involve strengthening:

• Deep trunk and abdominal muscles
• Gluteal muscles and hip stabilisers
• Quadriceps and hamstrings
• Calf muscles
• The muscles that control the foot and ankle

The exercises should not just make you stronger in the gym. They should help you control the movements you need for dance, such as pelvic control in single-leg work, trunk control in extension and rotation, and lower-limb control when landing. See our guide to hypermobility exercises and physio for the general approach.

Managing lower back pain without giving up dance

A diagnosis or suspicion of hEDS or HSD does not mean you need to stop dancing. The goal is to understand what is contributing to your symptoms and gradually improve your ability to tolerate the demands of dance. That usually means looking at:

• Training load: sudden increases in rehearsals, classes or performances raise the physical demand.
• Recovery: enough recovery between sessions matters when the body is loaded repeatedly.
• Strength: progressive strengthening improves muscular capacity and control.
• Movement control: rather than reducing your range, rehabilitation focuses on controlling the range you already have.
• Technique: small changes in how a movement is performed can reduce unnecessary loading.
• Gradual progression: exercise and dance exposure are progressed according to your symptoms and capacity.

When should a dancer with hEDS or HSD see a physiotherapist?

Consider an assessment if you have:

• Recurrent lower back pain
• Pain during or after classes, rehearsals, backbends or extension movements
• Repeated muscle strains or joint sprains
• A feeling of joint instability
• Difficulty controlling certain dance positions
• Symptoms that increase as training volume increases
• Pain that keeps returning despite rest

You do not need a confirmed hEDS diagnosis to see a physiotherapist about symptomatic hypermobility.

Get checked promptly if you are a young dancer with back pain on backward bending that has lasted more than a few weeks, as this can occasionally be a stress injury to the spine that needs proper assessment. Seek urgent medical help for back pain with numbness in the groin or saddle area, changes in bladder or bowel control, or weakness in the legs.

How AZ Physiotherapy helps dancers with hEDS and HSD

We understand that dancers want to keep doing what they love while managing pain and avoiding recurring injuries. For a dancer with lower back pain, an assessment may cover:

• Your symptoms, injury history and hypermobility history
• The Beighton score where appropriate
• Spinal, hip and lower-limb movement
• Core and hip strength, balance and control
• Dance-specific movements
• Training and performance demands
• Your individual goals

Treatment is then tailored to you. It may include progressive strengthening, exercise therapy, movement retraining, education, load management and appropriate hands-on treatment. The aim is strength and control around your available range, not making you less flexible.

You can book directly at our Pakuranga clinic with no GP referral. Learn more about our EDS and hypermobility physiotherapy, read why a proper EDS, hEDS and HSD assessment matters, or see our general guide to lower back pain.

Sources

• The Ehlers-Danlos Society: 2017 international classification and Assessing joint hypermobility
• Ehlers-Danlos Syndromes Aotearoa NZ: NZ Hypermobility and EDS Guideline 2019
• Healthify (NZ): Ehlers-Danlos syndrome (EDS)