Episode 174: Interview with Linda Bluestein
Dr. Chelsea: Are you a flexible dancer or have easily hyperextended joints? Dancers with hypermobile joints might love the ability to show off tricks and skills as a dancer, but is it dangerous to be that hypermobile? I wanted to talk to a medical professional about this, hypermobile joints in dancers, and not just any doctor, but a doctor who was a dancer. She's now a dance medicine specialist, and she gets it because dancers usually enjoy being hypermobile. It's a good thing. But what if it's causing pain, or when should you be worried about it? My guest today is here to explain it all.
Dr. Linda Bluestein is renowned for her expertise in hypermobility disorders. As the founder of Hypermobility MD, she offers specialized medical care to individuals grappling with all these kinds of conditions. And Dr. Bluestein is the driving force behind Bendy Bodies, a worldwide coaching practice aimed at empowering and supporting individuals with hypermobility, many of whom are dancers. Dr. Bluestein is also the founder and host of a wonderful podcast, Bendy Bodies with Hypermobility MD, where she shares valuable insights and resources.
So today, I asked her all the questions I think dancers would ask, and dance teachers, in case you're hypermobile as well as an adult, or you can just be on the lookout for your own dancers’ health. Dr. Bluestein clarifies the difference between hypermobility and flexibility, when hypermobility is concerning and when it's not, and when and how to get help. She also shared why gut health and flat feet are often related to hypermobility, which I found really interesting, and she has very practical, helpful advice for dance teachers as well. So here's a crash course in hypermobility with Dr. Linda Bluestein. Let's listen in!
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Hi, I'm Dr. Chelsea, a former professional dancer and mental performance coach. I know what it feels like to be a passionate dance teacher who cares about your dancers, but you want to challenge them and help them be their best, and I also recognize that some traditions and teaching practices in the dance world are harmful. So I'm on a mission to change our dance industry by creating happier, more successful dancers using positive mental skills.
When you understand how to help your dancers with their confidence, how to find their own motivation, work together as a team and more, your dancers will unlock new levels of competitive success and happiness. And it's not just about them; you deserve the same. So we'll talk about how dance teachers can use positive mental skills to be more confident, resilient, and motivated as well.
Be sure to hit “subscribe” wherever you listen to podcasts. There are new episodes every Thursday, and each week you'll hear from me and my guests with advice and actionable tips for building mental toughness, covering topics about mindset, motivation, resilience, and building a community. Passion for Dance is a show designed to help dance educators like you have a positive impact on every dancer you teach.
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Dr. Chelsea: Welcome, Dr. Bluestein. I'm so happy to have you here!
Dr. Linda: Thank you so much for having me! I'm super excited.
Dr. Chelsea: Thank you. Will you share a little about yourself? I know you have your time in the dance world, but then what has led you to be the dance medicine specialist that you are today?
Linda’s Journey as a Dancer and What Led Her to Dance Medicine – 3:11
Dr. Linda: Growing up as a dancer, I started running into a lot of health problems, and the only answer I got from my doctors was, “Stop dancing,” and of course, as a dancer, that's the last thing you want to hear, right, is to stop dancing.
So, that was so incredibly frustrating, and of course, I had to come up with a plan B, which was to go into medicine, and I did enjoy my years as an anesthesiologist practicing in the operating room, very traditional-type practice, but then my health started to catch up to me again. And so, I had to come up with a plan C, if you will.
I realized along the way that I could combine my love of dance and my love of science, because I was starting to get really, really interested in joint hypermobility, which is when people have increased joint range of motion. And, of course, In dancers, that's a requirement basically.
Dr. Chelsea: Sure.
Dr. Linda: So I realized that I could combine those two things, and it's worked out very, very well because I feel like I can really help the dance population at the same time as helping, you know, of course, regular people as well, but really helping dancers at an earlier stage of their career when they really can take some small steps to help themselves feel good and dance as long as possible.
Dr. Chelsea: Yes, and I think that's the journey of a lot of us, like, “This is what I didn't have,” or “This is what, you know, didn't work for me in my life, and I want it to be better. So how do I make a difference?” So I love that you're helping dancers now.
Let's talk about joint hypermobility. Will you elaborate on that? Like, is that the same as just being flexible or what makes that different?
What is Joint Hypermobility? – 4:42
Dr. Linda: Right. So joint hypermobility means that a joint or a group of joints has greater than expected range of motion. So we have, like, norms in the population, and I get asked all the time about young children.
Dr. Chelsea: Mm-hmm.
Dr. Linda: And it’s like wait a second. It depends on the age, the sex, the ethnicity. There's like so many factors, and we don't have outstanding data for all of those variables. So in general, we really like to assess children post-puberty. It’s a little bit easier because we have better normative data post-puberty, so we have a better sense of what's normal.
Because the other challenge is, when you think about normal range of motion, in the dance studio most everybody does not have normal joint range of motion, right?
Dr. Chelsea: Right.
Dr. Linda: So it's very confusing, and it can be very difficult to tease that out because, of course, we know who the most crazy-flexible people are. And yes, flexibility and joint range of motion are two different things.
The joint range of motion, so for example, if you look at an elbow and does it hyper extend, then you would be thinking about, like, the bones and where they are in alignment with each other, and flexibility has to do with more, you know, are the muscles able to lengthen and access that joint range of motion? Because believe it or not, you can actually be hypermobile but inflexible and vice versa.
Dr. Chelsea: Yeah, okay.
Dr. Linda: So, yeah, we tend to think of them a lot together, but they are different.
Dr. Chelsea: Okay, that makes sense, that one being in the joint, one being in the muscle and would potentially be very different things. Okay, so, like you said, it's kind of the norm. Like we think of being usually flexible, but even people like, “My hyperextended — the knees, the elbows,” right? That’s just a norm in dance. I guess when you speak to, like, is that dangerous? Is that something dancers should look for? Are they concerned when they have that joint hypermobility?
What Dancers Should Look Out For with Joint Hypermobility – 6:39
Dr. Linda: So if a dancer has hypermobile joints, it is really important to think about why, why are the joints hypermobile? Because if you have joint hypermobility because you have an underlying connective tissue disorder, then over time you may run into more problems because you may have ligaments that don't heal well and, you know, rather than like a rubber band that nicely stretches and recoils it stops recoiling.
So, you know, I tend to think of the different phases of joint hypermobility. And this was one of my more popular posts that I did, and it was just my own conceptualization of what I've seen in not just myself but in tons and tons of patients and clients that I see. And there tends to be a fun phase where, you know, you can do all the things. And I used to do all kinds of party tricks and like, you know, do weird things with my hips or my legs, you know, and people think it's cool.
And then there tends to be, you know, kind of more — it can be the pain phase next or the mystery phase. But then you might start to run into some other problems and other symptoms, but you usually don't put them together as, “Oh, well, this pain that I'm having could be related to the fact that my joints are looser.”
Dr. Chelsea: Right.
Dr. Linda: You know, “I have lax joints or joint instability.” And a lot of times doctors don't put that together. I mean, I saw so many orthopedic surgeons and they would tell me, “Oh, you have really flexible joints –,” they would use that word, — “and a lot of joint laxity,” but they wouldn't say what that possibly meant or what the implications were. One, I was even having surgery, and he said, “Right now you have, like, 20 degrees of hyperextension in this elbow, and you will lose most of that after the surgery.” And I'm like, “I don't know what that means. Okay.”
Dr. Chelsea: “Okay.” Yeah.
Dr. Linda: So, it is very important for dancers to understand that the pattern of joint hypermobility makes a big difference. So joints can be hypermobile for a variety of reasons. So an underlying connective tissue disorder is definitely one of them.
So you think of the connective tissues as the tissues that connect everything to everything else. So this is all throughout our body. So if you have a connective tissue problem, then that can cause a lot of different symptoms. But, for example, if you have hip dysplasia (which it's not like that's a great thing to have either but that's a very shallow hip socket), you have incredible range of motion of your hips and your legs, but eventually you can start to run into problems with that. So it can be related to the shape of the bones. It can be related to another connective tissue disorder. It can be related to, you know, other genetic factors, temperature. Like, you know, first thing in the morning, of course, you're going to measure at less range of motion than later on in the day. So there's a lot of different factors. It can be a blessing and a curse. So it's definitely a dancer's incredible asset, but you also need to know how to handle it properly.
So one of the things that I really try to focus on is the things that are clearly of no benefit. So if I'm giving a talk, and I look around the room and there's a bunch of dancers leaning back on their elbows that are totally hyperextended, I call them out because I'm like there's no advantage to having hyperextended elbows. So, I mean, we want to have very beautiful upper body and all of that.
Dr. Chelsea: It's usually not the aesthetic line to have your elbow — yeah.
Dr. Linda: Yeah, exactly. Exactly. So don't be pushing your elbow into hyperextension, even if it doesn't hurt. If it doesn't hurt now, that's great. But the problem is, with a lot of these things, once they start to hurt, it's really hard to get it to not hurt. Because the damage has sometimes been done. It's like skin cancer. You know, by the time you get skin cancer, usually the damage has been done. So, I really — I'm trying to balance honestly that, like, I don't want to be too alarmist, but at the same time, it's really, really important, and we don't know the long-term effects yet because, really, going into these crazy, crazy end ranges is really a relatively new phenomenon. So we really don't know yet what's going to happen to dancers 20, 30, 40, 50 years later, especially when people are doing these things when they're really young. That's the thing that really worries me.
Dr. Chelsea: That makes sense, and it is becoming, you know, the wow factor, the, “Look what I can do!” And then once you become, like, known, you're the flexible one, then you demonstrate that flexibility in every routine you do and every day, and I assume it would probably correlate with overuse even too. You're doing the same hyper-mobile issue over and over and over because you can. Like you said, maybe it doesn't hurt, and it looks cool, and it's fun, and as a dancer, it's exciting. But then not knowing, yeah, where it could become a problem when you're older, that is a concern for sure.
So for the dancers out there who are known as the flexible one or have the hypermobile joints and maybe it is still in the fun phase, what would a dancer want to look for or be aware of when they might want to be worried about this hypermobile joint?
What Hypermobile Dancers Should Be Aware Of – 12:03
Dr. Linda: Sure, sure. So I would separate this into the musculoskeletal and non-musculoskeletal components. So from the musculoskeletal standpoint, it's important to think about, you know, “Have I been injured more often than my fellow dancers? Do I seem to heal more slowly? Do I get weird injuries? Do I seem to be in pain more than they are? Do I have sensitivity of parts of my body,” and things like that. So those are things that would be more worrisome, and if you don't have those things, that would be more reassuring.
From the standpoint of non-musculoskeletal things, again, if you think about the fact that connective tissues are all throughout your body, and that's the big thing that we want to make sure is, if you have a connective tissue disorder, that we understand that and that we support the dancer in every possible way that we can. So that's what we really want to identify. So really common things that we see with dancers that have a connective tissue disorder that are not musculoskeletal tend to be, first, gastrointestinal. So we see a lot of gastrointestinal problems, and it makes sense because we have connective tissue all throughout our gastrointestinal tract, and we have mast cells all throughout our gastrointestinal tract. So we see things that are not specific for these conditions.
That's the thing that's really tricky is it's not that if you have heartburn, it doesn't mean you have a connective tissue disorder, of course. But, you know, what do we do in medicine? We put patterns together, especially if it's a clinical diagnosis, right? If it's something that can be diagnosed by a lab test, different story. So we're looking for patterns. So it can start with a difficulty swallowing, reflux. They can have gastroparesis, which is when the stomach empties more slowly. We can see small intestinal bacterial overgrowth, which is something that happens in the small intestine. Constipation is quite, quite common because the tissues are more lax, so the colon can distend more, and then also it can be difficult to evacuate the stool. And we also can see, though, diarrhea because sometimes we can have problems, again, with the mast cells, which are part of the immune system. They can play a role, and so, we can run into problems there. And abdominal pain. Abdominal pain is a very, very frequent concern that people have and food intolerances.
So those are some of the GI symptoms that people can have. Again, they're not specific because, you know, you can have those for lots of other reasons. But if you have hypermobile joints and you have some GI problems, and then you start to think, “Oh, wait a minute. This is something systemic,” and so, we need to really be thinking about what could be going on here. And, of course, we want to look at the family history as well because that's very telling.
Okay, so besides the GI tract, we see constitutional symptoms. So we see fatigue, difficulty awakening in the morning. People tend to be very, very groggy. They don't feel restful when they wake up in the morning. That's very common. Disordered sleep is very common. So it could be difficulty falling asleep, staying asleep, awakening too early. It could be any of those. The fatigue is surprisingly significant, and it's shocking to hear sometimes from dancers because it's like, “Well, but you can do such amazing things.”
Dr. Chelsea: Yeah, “You can be so athletic.” Right. Yeah.
Dr. Linda: Correct. But they can just be just bone tired outside of class and rehearsals and just really be struggling with that. So the fatigue is a really, really big problem that a lot of people have.
Dr. Chelsea: Yeah. That is so interesting that you wouldn't think to put those together. Like when you understand the anatomy, it makes sense, but you're right. Your average layperson is like, “I have hyperextended knees, and a GI issue.” You wouldn't put that together at all and realizing that that could go together. Yeah.
Dr. Linda: Yeah, and there are a lot of other systems that are involved. Gastrointestinal is of course a big one, but also GU (genitourinary). It's like pelvic organ prolapse. That's more specific, especially if you're young or if you haven't had a baby and you have pelvic organ prolapse, that's when the bladder, the uterus, and/or the rectum start to push through that pelvic floor or they're starting to fall through the pelvic floor. So those are more specific findings, and there are other more specific findings for connective tissue disorders like joint dislocations and subluxations.
So it's one thing to have a joint that has greater range of motion, but it's another thing to have joints that are difficult to stay in proper alignment. So if you have difficulty with that, then you can have joint dislocations or a subluxation, which is when the joint doesn't fully dislocate but it partially dislocates. And the tricky thing about subluxations is, you know, I only know what my body feels like. You know what your body feels like, right?
Dr. Chelsea: Yeah.
Dr. Linda: But we don't know what's normal and not normal. So we can be subluxing our joints all the time and not realize that that's not normal.
Dr. Chelsea: Yeah, I think that's true of so many symptoms. You're like, “This is just how I've always been. I didn't think it was bad.” Yeah.
Dr. Linda: Right, right. Exactly, exactly. And some of the other musculoskeletal things that I should have mentioned that are more specific are scoliosis and that you can see flat feet. So especially dancers, they can have a beautifully arched foot, and then they stand on it and it collapses. So if you have flexible flat feet, that's another potential indicator, a high, narrow upper-arched palate and things like that.
Dr. Chelsea: So when I think about this now as a layperson, if I am now worried about this or I'm concerned, what kind of doctor am I looking for? I'm like, that's always my challenge, it's like, “Who do I ask about this? Who am I looking for?”
Doctors to See If You Think This May Be You – 17:59
Dr. Linda: So in terms of what kind of doctor to see, this is where it's really tricky because people with these conditions basically fall under the umbrella of, like, every specialist, right?
Dr. Chelsea: That's what you — when you were talking, I'm like, “I don't know who to see. I would see, like, six people.”
Dr. Linda: Right, right. And that's where I've had a lot of people refer to me as their quarterback because they go to the GI doctor and the GI doctor only wants to deal with their GI symptoms, and then they go to the orthopedic sports medicine doctor, and they only want to deal with their orthopedic concerns. And usually they're dealing with the tiny, little issue that's happening at that time and they're not looking at the big picture at all. So that's really challenging.
So I'm trained as an anesthesiologist and I do integrative pain medicine, which is a more holistic approach, but there's not very many people that are doing that. So if you can find that, that's good. Also physical medicine and rehabilitation or PM&R doctors, I think that's a really good fit because they are much more oriented to the function of the body. And so, I think that can be a really good fit as can a doctor of osteopathy. So if you go to someone that has DO after their name instead of MD, oftentimes in the osteopathic schools, they do learn more musculoskeletal medicine, and I think that they can take sometimes a more holistic approach. Now, some of them end up not using those manual skills. They actually learn hands-on manual skills like chiropractors do, and so, if you can find someone who's doing manual medicine who is a DO, that's often a really great fit.
Dr. Chelsea: Okay. Oh, that's really interesting. And there are always so many different specialists, and the specialists are great if you have a really special, specific issue, but when it crosses so many different domains —
Dr. Linda: Yeah, it gets complicated.
Dr. Chelsea: Thank you for explaining that.
Dr. Linda: Yeah.
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[Motivational Music]
Dr. Chelsea: Hey, coaches and teachers! If you are new to the show, it might be a little overwhelming to know which episodes to listen to. You can always go back to the beginning and binge listen, of course, but I also know we don't have a single spare minute in our days. So, to help you decide where to start, I have a short, five-question quiz that will tell you which episodes will help you with whatever is going on right now. It's kind of like a personality quiz, and after a few quick questions, you get a curated podcast list of the top five episodes that will help you most where you're at right now.
Maybe you need some motivation or inspiration, maybe your dancers need something to listen to for help, or maybe you're looking for a little boost of confidence. Whatever support you need, take the short quiz and find out. Go to www.chelseapierotti.com/podcastquiz to get started. Click the link in the episode’s show notes, if that's helpful, and thank you for being here. I'm so happy to have you as a part of this community!
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So one last thing with the dancers themselves, how can a dancer improve their performance if they're hypermobile, like if the hypermobility is actually, like we were talking about the elbow, not aesthetic, it's not actually helping.
How Hypermobile Dancers Can Improve Performance – 21:34
Dr. Linda: Mm-hmm. The biggest thing is strengthen, strengthen, strengthen. It is so, so important to get your muscles as strong as you possibly can because that will help support the joints, and that will support the ligaments which connect bone to bone and the tendons which connect muscle to bone. We want to support those tissues because ligaments and tendons have generally very poor blood supply. So if you injure them, they are very difficult to heal. So you hear people talk about tendonitis and you're like, “Oh, I've had tendonitis forever.” It really turns into a tendinopathy or tendinosis because it's not inflamed anymore, it just never healed. So some of those injuries are difficult to heal.
So number one, prevention is so much better than addressing something after the fact, and it's hard. If a dancer has never been injured, it's really hard to get them motivated about that.
So dancers love to stretch, and I think part of that is because we have such difficulty feeling end range that we keep wanting to do that, and it kind of feels good, and of course, you know, there's no dancer that's like, “I want to be less flexible, less mobile.”
Dr. Chelsea: Right.
Dr. Linda: So I think that it is really key to strengthen our muscles as much as we possibly can to support our joints, and that will support our ligaments and our joint capsules and the bursa and the tendons and all of the other important structures that are around that joint, and muscles are protective. So those muscles will help prevent future injury and help improve that alignment because joint laxity, or when the joint has difficulty being in proper alignment, that is relative to muscle strength or the ability of the muscles to control the joint and where the joint is and how things are aligned and how things move.
So, I think a lot of dancers, they don't necessarily want to. They're afraid they're going to get too bulky or whatever, but I really, really encourage dancers to strengthen but to do it gradually because you don't want to change the load too quickly. So that's where you run into problems.
So say if, you know, you've been on a break and you've been off for a week or a couple of weeks or something, and maybe you've done a couple of classes, but you've had a really low amount of activity, relatively speaking, and then you come back and you go right back to what you were doing before, that's when you're more prone to injury. So in general, you want to change the load on your body more gradually, and when you think about the strengthening of the muscles, you have to be able to generate enough force through the joint in order to put the muscle in a state of fatigue or failure in order for that muscle to then hypertrophy and get stronger for the next time because the muscle goes, “Oh, I better get stronger for the next time that this person is going to do this to me.”
So you want to do that when you are in a good, healthy place rather than waiting until things are not going well because then it's really hard to make up for all that lost ground. If you have a tendon injury or you have a ligament injury, it's a lot harder to put that amount of load through the joint in order to get the muscle to hypertrophy.
Dr. Chelsea: Oh, that makes sense. And I am all for strength training in every way. So many benefits, so many benefits.
Dr. Linda: Yes. Yes.
Dr. Chelsea: So as you've been talking about this, and I I'm thinking there's a really strong parallel with a lot of the mental skills that I work with in that when you're struggling, it's hidden. You can't see it, right? And so, you know, some medical things like you break your leg, you can see it. It's obvious. Everybody knows you're hurt, and you can see what's going on. With the mental skills and mental disorders, you don't see it, and it sounds like everything you're talking about, again, these dancers may be in a lot of pain and suffering, but they look normal.
Dr. Linda: Right? Yeah.
Dr. Chelsea: So you speak to that hidden disease part of this?
The Hidden Struggle of Hypermobility – 25:32
Dr. Linda: Oh, yes, that is such a great point, and I love how you describe that because I could not agree more. That is definitely a big part of the challenge. Dancers, we learned from a very early age that the outside appearance matters so much, right? And we want to please the teacher, the choreographer, the audience, right? We’re trying to make everything look effortless. So I think we are at the highest risk of hiding these things and not having them recognized. And then if you do mention it to a doctor or, you know, if you're a younger dancer, to your parents or something, oftentimes if they don't have an answer right away, they don't know what that means or what to possibly do about it, it gets kind of blown off. So yes, that is a huge, huge part of the problem.
And then not only do we get gaslit by other people, we gaslight ourselves. So we start to doubt our own physical pain and our own emotional pain, and I'm so glad you brought this up because that is, really, the number one reason why I'm doing what I'm doing is because I want to prevent, really more so, the emotional pain because that's the part that I feel like can be more avoided. Some of the physical sequelae may or may not be able to be avoided. But at the very least we should be able to avoid the psychologic impacts or at least minimize them. Of course, nobody likes to lose the ability to do certain things. So if you were a very high-level dancer and you're no longer able to do that, that's of course devastating. So you can't completely avoid that, right? But at least if you can validate that person and you can support them and you can show them that you care and they feel like they're not crazy, you know, all of those things matter.
Dr. Chelsea: Yeah. Oh, and it's so amazing that you have this knowledge but also have the dance background. Because like you shared at the top about your own dance experience, we're often just told, “Stop dancing,” and that is often certainly not the answer we're looking for.
Dr. Linda: Right.
Dr. Chelsea: There may be times when, whatever's going on, that is the only answer, but it's like, “Can we look at every other option first?” I can imagine, you know, even a teenager but a child looking at them and saying, “Oh, my stomach hurts and I have this abdominal pain and I have hyperflexible joints,” but again, “I'm not going to talk about those as like symptoms together,” and just think that there is something you should go see. It's going to feel more like, “Well, I'm just uncomfortable, but I can still dance, so I'm just going to keep going and I'm going to keep doing this and not say anything.”
Dr. Linda: Yeah, and that's an excellent point because I think the assumption that if a dancer is dancing they must be fine —
Dr. Chelsea: Exactly.
Dr. Linda: — is definitely — yeah.
Dr. Chelsea: Yeah, and it's hard to get past that too. Like you said, it's always the show must go on. It's like, “Well, I can still perform, so there's no need to go pursue this.” So thank you so much for explaining all of this and what to look for and how to help. That's wonderful.
I want to pivot a little bit to the teacher, because I think a lot of my audience are teachers and the dance teachers who might be someone to notice some of this more than someone else as well. So for any of those dance teachers listening that maybe either like they haven't heard of this before, have not experienced this, didn't realize it was something beyond just being flexible, what would you want dance teachers to know about hypermobility?
What Dance Teachers Should Know About Hypermobility – 29:00
Dr. Linda: I love talking to dance teachers so much because I think it's really important to let them know that this is not their responsibility because we're asking them to do so many things, right? Now you need to teach dance and you need to screen for all of these things.
Dr. Chelsea: Right.
Dr. Linda: We're not going to ask you to, like, go and calculate everyone's Beighton Score, which is when you measure, like, the elbow hyperextension and things like that. We're not going to ask you to do that. But in the course of teaching your classes, you will be making observations, because that's just part of what you do, and you will know which students tend to be more flexible or more hypermobile than other students. So the people who are being asked to be, you know, front and center doing the needle or the scorpion or any of those kind of things, right, those kids you really want to keep an eye on and especially if they are saying that they have pain, if they are saying that their tummy hurts or, you know, any other complaints that they're tired. I should have mentioned ADHD and autism are extremely common with people who have joint hypermobility.
Dr. Chelsea: Oh, interesting.
Dr. Linda: Yeah. So when you have dancers that have more difficulty focusing in class, that also can be a clue. And another really important clue as a dance teacher is proprioception. So we know that dancers with joint hypermobility have less than optimal proprioception, and that's knowing where your body is in space without looking.
So if you give the same cue to a dancer over and over and over again, and you're like, “Oh my gosh, why can't they do this?” It could be ADHD, they're not able to focus and pay attention. It could be that they can't feel it in their body, and they truly don't think that their elbow is hyperextended.
So those are some things that the dance teacher can be paying attention to, and it's not necessarily that the most hypermobile person in the dance class is the most likely to have these conditions because it definitely can be somebody who you wouldn't necessarily have thought of because sometimes the muscles are also holding on for dear life. And so, you might have a dancer who, maybe they're struggling in other ways, and you're like, “Hmm, not so sure.” But if they have other complaints, I think it's really, really important to talk to the parents.
Dr. Chelsea: Yeah.
Dr. Linda: When in doubt, always talk to the parents because they may be very unaware of what's going on, and you might be much more in tune with what's going on with that dancer.
Dr. Chelsea: Right. Yeah, I could see the parent is seeing the fatigue or the stomach issues and the dance teacher is seeing the hypermobility, but you're not necessarily going to see both sides of that, you know, or see all of it.
Dr. Linda: Right. Right.
Dr. Chelsea: And like you were saying before, how the flexibility, the muscle flexibility is different, so having those kinds of potentially conflicting cues in front of you of like hypermobile joints but struggling to have full splits or struggling to have high battements or something, we would be like, “No, but they're not that flexible.” But they could still have the joint hypermobility. They don't necessarily have to be together, right?
Dr. Linda: Right, right. And I interviewed Moira McCormack, who was the lead physiotherapist for the Royal Ballet. She was a dancer with the Royal Ballet, and she's amazing, and she wrote some of the earliest work on joint hypermobility in dancers. And we talked about, like, what are some of the things to look for, and she said, “These dancers appear to have difficulty organizing their bodies.”
Dr. Chelsea: Oh, yeah. Yeah, I can see that, right, where it's just — but again, to the dancer, they may not know that that challenge is above and beyond your average person's ability to organize their body. Like they wouldn't realize that this is an abnormal level of challenge.
Dr. Linda: Right, right, right.
Dr. Chelsea: Yeah, oh, that’s super interesting. Thank you. I think you have shared such great advice for what to look for and what this might feel like for dancers and, as we've said a few times, how we're often told to just stop dancing, but we don't want dancers to stop dancing.
So will you talk a little bit about how someone who has this, you know, joint hypermobility can still be a strong athlete? Like, that doesn't mean that they have to stop dancing or should be worried about pursuing a career if that's their dream? Can you have this and keep dancing?
Tips for Hypermobile Dancers Following Their Dreams – 33:37
Dr. Linda: So I'm so glad you asked the question that way because I should point out these are very heterogeneous conditions. So two people can have the same diagnosis and present very, very differently.
So first off, and I know you say this all the time on your podcast, and I see you saying this on social media, and it's so important. It's one of those things that’s easier to say than to do, but we definitely all should strive to do this: not to compare.
Dr. Chelsea: Right.
Dr. Linda: So, you know, if I know that I have EDS or Ehlers-Danlos Syndrome (hypermobile EDS), and I know another dancer has hypermobile EDS, please don't compare yourself like, “Well, we have the same condition, but she's doing so much better than me and she's able to rehearse all day and she's able to do these harder parts.” And, you know, please don't compare yourself because there are no two bodies that are the same. And so, just focus on what you can do to get your own body as strong as possible.
And to that end, what I like to do is I have a mnemonic that I use for my treatment approach and it's MENSPMMS and that stands for movement, education, nutrition, sleep, psychosocial modalities, medications, and supplements.
Dr. Chelsea: That’s a mouthful but so good.
Dr. Linda: Yeah, it's a mouthful, but you'll notice that there's a couple of letters that are repeated. But like for the Ms, there's a reason why movement is before modalities, which is before medications. Unfortunately, most doctors can write a prescription pretty quickly, but they don't have the time to really do the detective work that is often needed with these conditions. That's really what a lot of people need is a detective. They need somebody to really dive deep and figure out what are the variables that are affecting their quality of life, how do we improve those things, how do we find the low hanging fruit and make it so that they can dance as long as possible in as close to the capacity that they want as feasible, really.
Dr. Chelsea: Yeah.
Dr. Linda: So yeah. So those are the parts of my comprehensive treatment plan.
Dr. Chelsea: That makes sense, and I'm glad you said that about comparison because it's a danger in every way. But I think when you're talking about a medical diagnosis, that's a bigger issue to be aware of. Like your journey is your journey and being able to be your best self is, like, stay with kind of blinders on and focus on your own journey and your own health.
Dr. Linda: Yeah. Yeah.
Dr. Chelsea: Is there anything I didn't ask or anything like you would just want people to know about this joint hypermobility that you think is important to share?
Syndromes Associated with Hypermobility to be Aware Of – 36:23
Dr. Linda: I'm glad you asked that because I think it's important for people to be aware of Mast Cell Activation Syndrome and Postural Orthostatic Tachycardia Syndrome. So I'm going to start with Postural Orthostatic Tachycardia Syndrome, which is one of the dysautonomias.
So anybody, if they're a little behind on fluid or they’ve had the flu or something like that, when they go from laying down to sitting up or sitting up to standing, they're going to get dizzy, right? We know that that happens if you, you know, don't have enough blood flow going to your brain. Sometimes that happens a lot, it happens really regularly. So if that's happening a lot, then it's possible that a person has one of these conditions of dysautonomia. And unfortunately, COVID can be a trigger for this. Any kind of infection can be a trigger. And sometimes you kind of go through a period where you are more dizzy, you have more heat intolerance, cold intolerance, etcetera, and then it kind of resolves. And other times it just does not go away. So that's another set of symptoms that people can have, and that can affect the GI tract that can affect your, like I said, heat and cold intolerance, and that affects your ability to have upright posture.
So if you're a dancer or if you're a dance teacher and you have dancers that are complaining of this, it's very important. And some people will faint and that's more Neurocardiogenic Syncope, and some dancers will feel faint and that's more POTS or Postural Orthostatic Tachycardia Syndrome. So you don't have to faint because some people get that confused. They probably are two different conditions. One is more of a fainting disorder and the other one is a feeling faint disorder. So that's very important.
The other is Mast Cell Activation Syndrome. So a lot of people who have a connective tissue disorder, they are at much higher risk of having Mast Cell Activation Syndrome, and mast cells are part of your immune system, and we expect them to be there and react when we get an infection and when we're exposed to pathogens or chemicals in the environment, that's appropriate. But sometimes they get trigger-happy, and they release chemicals too easily, and they can cause a whole host of problems all throughout the body.
You're probably thinking, “Well, wait. All of these things cause problems all throughout the body.” So yes, it gets very confusing very quickly. There's a great Venn Diagram from one of the journal articles that shows like, “Yeah, these more specific musculoskeletal things are more likely related to EDS or connective tissue disorder.” The flushing and the hives, those are more likely related to Mast Cell Activation Syndrome and the postural orthostatic intolerance is more likely Dysautonomia. But there's this overlap area in the middle.
So it does get complicated pretty quickly, but that's where, again, it's so hard because if dancers are having multiple different things going on, they have nasal allergies, they have asthma, they have eczema, they have, you know, GI issues, and they're still able to dance through all these things. They're having some random joint pain, or they get injured more often. Nobody else is putting all of this together, but they really are all related.
Dr. Chelsea: Okay. Yeah, that's what I was going to — it's like, this feels so disjointed, but actually — sorry, no pun intended. So ironically, they are not related, but they are actually coming from one root cause, and I could see how, you know, yeah, you're going to go see doctors that will give you your allergy meds, and then that doctor is going to help with the GI thing, and nobody's going to see the full picture. So I'm so glad you're laying this out to help people. Again, know your body, know your symptoms, and try to see what you feel. And if any of this is ringing a bell for you, being able to look for the right kind of doctor to help you put it together. That's so helpful!
Dr. Linda: Mm-hmm. Yeah, and it's funny that you said that because I actually contributed two chapters to a book called Disjointed: Navigating the Diagnosis and Management of Hypermobile EDS and HSD.
Dr. Chelsea: That’s what this feels like! Yes.
Dr. Linda: Yeah, yeah, yeah, exactly!
Dr. Chelsea: Okay, I did it on accident, but that's great. I love it!
Okay, so you've had such good advice. Thank you so much. Will you please share how people can find you and learn more from you and your work?
Connect with Linda – 40:35
Dr. Linda: Sure. So I have two main websites. One is www.hypermobilitymd.com, and I do have patients — if people can come to see me in person in Colorado or Wisconsin, which are the two states that I'm licensed to practice medicine in. If they can come see me in person for the first appointment, then I can do follow-ups usually virtually for about a year. So I do take patients, and that website is a good place to start if you're interested in that. My practice is very, very small, as you can imagine. My initial appointments range from one-and-a-half hours to three-and-a-half hours, and even the three-and-a-half hours, we often can't get to everything.
Dr. Chelsea: Yeah.
Dr. Linda: So it's a lot.
Dr. Chelsea: But you're asking all the questions and trying to put it together. Like you're taking the time. That's wonderful.
Dr. Linda: Yeah. Yeah. So I have that website, and you can get information about other services. For example, I do workshops, and I love to teach to dance schools, groups of dance teachers and things like that because, exactly like what we're talking about here, they are the front line, you know? And there's a great study that showed that dancers will go to their dance teacher before they will go to a doctor.
Dr. Chelsea: Anybody else, yep.
Dr. Linda: Yeah, they'll talk to their teacher about what's going on with their body. So really important. Okay so that website has the information about becoming a patient and also about becoming a coaching client. If you can't travel to see me in person or if you are out of the country, I do offer sessions online where it's more I give you information. I don't give you specific advice because you're not becoming a patient, but It's still personalized to you.
And then the last thing is my podcast called Bendy Bodies with Hypermobility MD, and on that podcast I give lots of information about how to manage these conditions, and I interview experts that are in various different niches. So they're usually very, very highly specialized topics. The first, about, three seasons were very focused on the performing artist. And then now it's a little bit more of a deep dive in this fifth season into medical topics, but we're still doing episodes that are dance or medicine related but trying to just get as much information out there as possible.
Dr. Chelsea: That's so good. I will make sure everything is linked in the show notes. Thank you so much, Dr. Bluestein, for being here and sharing your knowledge! I learned a lot, and I am so grateful for your time. Thank you!
Dr. Linda: Thank you so much for having me. It was great to chat with you!
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Thank you for listening to Passion for Dance! You can find all episode resources at www.chelseapierotti.com/podcast, and be sure to follow me on Instagram for more high-performance tips at @dr.chelsea.pierotti. This podcast is for passionate dance teachers and coaches who are ready to change the dance industry by creating happier, more successful dancers. I'm Dr. Chelsea and keep sharing your passion for dance with the world.
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