Generalized Hypermobility

By: April Kirkner, DPT, ATC

Generalized joint hypermobility is an abnormal increase in multiple joint range of motion from the normal values of the population.  The prevalence of joint hypermobility is higher in children and is seen more in females than males.  Joint hypermobility syndrome is diagnosed when the person has musculoskeletal symptoms including pain in 4 or more joints for >3 months in addition to the hypermobility.  Generalized joint hypermobility is determined in children by use of the Beighton score.  The Beighton score is a valid measure and involves determining if 9 items (pictured and described below) are positive or negative.  If 5 of the 9 items (using both extremities) are positive then the individual has generalized joint hypermobility.

Hypermobility 1

Hypermobility 2

Hypermobility 3

Hypermobility 4

Hypermobility 5Reference:

  1. Smits-Engelsman B, Klerks M, Kirby A. Beighton score:  a valid measure for generalized hypermobility in children.  Journal of Pediatrics 2010; 158:119-123.
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Sun and Skin Damage

By: Michael Mosciano, ATC

Many factors go into an athlete’s training. Rest, diet and proper equipment are all essential to success in their sport. But, with the long hours spent practicing outdoors, there is the associated danger of long term sun exposure. While a sun burn may only seem like short term issue, continued skin damage has long reaching consequences from premature wrinkles to the development of skin cancer. So, what are the types of skin cancer and what steps can you, as an athlete, take to help decrease the impact of the suns UV rays?

Skin Cancer

Skin cancer has become the most common type of cancer in the United States, with close to 1 million new cases diagnosed each year. Ultraviolet (UV) radiation from the sun damages the outermost layer of the skin. The damage to the skin over time creates small breaks in the DNA of the skin cells, which ultimately may lead to the formation of cancer. Warm weather athletes are at an even greater danger according to Dr. Brain Adams, MD, MPH, FAAD. “When you perspire, you are more susceptible to burn.” Perspiration on the skin lowers the amount of UV exposure needed to turn the skin pink.

Basal Cell Skin CancerThe most common type of nonmelanoma skin cancer is basal cell skin cancer. This type of cancer is most commonly found on the head and cervical region, but can occur anywhere on the body. It is a slow growing cancer, rarely spreads, and the most curable if found early. Continued daily exposure to UV rays during workouts increase the athlete’s chance of getting basal cell skin cancer.

A second type of skin cancer is malignant melanoma, and while it may be less common, it is more aggressive and accounts for close to 75% of all related skin cancer deaths. Melanomas may develop in a mole or may look like a mole. Some physical risk factors for developing melanoma include red hair, blue eyes, fair skin, a family history of melanoma, and a history of multiple blistering sunburns. Some of the physical features of a melanoma lesion is the uneven or irregular borders and uneven coloration within the lesion. Treatment of a melanoma lesion usually requires surgical excision, which may include some removal of healthy skin to ensure the entire lesion was removed.

Mole BordersProtective Steps

There are many steps that dermatologists recommend to help reduce an individual’s sun exposure and they include the following.

Be aware of the UV Index, developed in 1994 by the National Weather Service and the Environmental Protection Agency. It is used to provide a forecast of the expected risk of over exposure to UV radiation. It also provides a guide to how long an individual can be in the sun before skin damage would occur. For example if the UV index is 1, then a fair skinned person would expect to be able to stay in the sun without any protection for 60 minutes before getting sun burned. But if the UV index is an 8, then that same person would get burned after only 15 minutes.

Adjust your training time to early morning or closer to dusk and try to avoid the peak UV levels between 12 pm and 4 pm. One tip to use is the shadow rule; if your shadow is taller then you then UV exposure will be less than if you shadow is shorter. An added benefit of rescheduling your training time is that temperatures are usually cooler during these times.

Wear some sort of protective clothing to prevent skin exposure, which may include a hat, pants, long sleeved shirt and sun glasses to help protect the areas around your face. Look for clothing that is made of a breathable material, which can help wick away sweat and allow for cooling and still provide you with protection. There are also laundry additives that can be used to add UV protection into clothing

Use sunscreen on areas of your body that are most likely to get burned during your workout. The sunscreen protection factor (SPF) is a measure of the level of protection the lotion gives over the skin. The Skin Cancer Foundation recommends that the sunscreen has an SPF of at least 15. A SPF of 15 would indicate that your skin would have the same exposure amount in 15 hours that unprotected skin would have in 1 hour. The American Academy of Dermatology (AAD) also recommends that you look for a sunscreen that provides protection against both UV-A and UV-B rays. Even if the product says it is water proof, be sure to reapply the sunscreen every two hours during activity.

The AAD recommends that you do a yearly visual check of your skin in front of a mirror and make an appointment with a dermatologist if you notice any changes, growths, or bleeding on your skin.

Remember, the next time you are heading outside for practice, be sure that you protect yourself from the sun’s UV rays. “Be Sun Smart!”


American Academy of Dermatology (

American Cancer Society (

The Skin Cancer Foundation (

Shannon C. Harrison, FACD and Wilma F. Bergfeld, MD. (2009). Ultraviolet Light and Skin Cancer in Athletes. Sports Health, 1(4), 335-340.

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A Better Way To Stretch?

By: Kim Kranz, PT, DScPT, SCS

As PTs, we often preach the basic rule of stretching:  If you want to improve length in a muscle, you have to consistently perform static stretching, doing 3 sets of each stretch and holding each stretch for at least 30 seconds.  Not a bad place to start; but, maybe we have something to learn from the other disciplines that promote flexibility:  Yoga and Pilates.  After studying Anatomy Trains by Thomas Myers, it’s become clear that yoga practitioners really do have a leg up on us.  Anatomy Trains shows us that the fascial lines (connective tissue that is interwoven throughout our bodies) are more connected than we once thought and that to truly improve fascial mobility, and thereby muscle length, it’s important to stretch through the whole fascial line.  If we take the hamstrings, for example, we could stretch like this and target only the hamstring muscle:

Hamstring Stretch

The Hamstring Group








Or we could stretch like this and stretch the whole superficial back line of fascia:

Standing Forward Fold

Superficial Back Line

Superficial Back Line









If you doubt the role of fascia in “hamstring flexibility”, here’s a simple test.  Stand up and bend forward as far as you can.  Make a mental note of how far you can bend forward and then stand up.  Now, take a tennis ball (or other firm ball) and roll the ball on the bottom of your foot for one minute on each side.  Remove the ball and bend forward again.  Did you go farther?  Most likely, yes.  You released the fascia in part of the superficial back line (in this case, the fascia on the bottom of your foot) and as a result, you had better mobility throughout the fascial line, including the hamstrings.

Another thing that Yoga and Pilates have on us is the use of breath with stretching.  When you get stressed or frustrated and you take a few deep breaths, you feel a little more relaxed, right?  Well, the body uses deep breathing as a way to help your muscles relax, too.  By coordinating our breathing with our stretching, we can make stretching more effective.  Pilates is well-known for using rhythmic, controlled and low-intensity movements to gain flexibility.  In their book Stretch to Win, Ann and Chris Frederick (Chris Frederick is a Physical Therapist) postulate that a stretch should be undulating or wave-like, timing the stretch to your breath.  Inhale and then exhale as you move into the stretch, release the stretch as you inhale again.  Anyone who has ever taken a Pilates class will be familiar with those instructions.

The third thing to keep in mind is that the “no pain, no gain” mentality should never be used with stretching.  Our body has multiple protective mechanisms in place to try to keep us from hurting ourselves and the stretch reflex is one of those.  This reflex causes a muscle to tighten up or shorten in response to either a quick stretch or a prolonged, high-intensity stretch.  So, if your leg is “shaking” while you’re trying to stretch, that’s a sign that your stretch reflex is kicking in and you need to back off a little until that stops.

Lastly, we need to remember that most muscles work in many planes and across joints.  So, when you’re stretching, don’t just stretch in one plane of movement.  Thorough stretching of the hamstrings, for example, requires you to extend your knee and flex your hip (sagittal plane), rotate your leg in and out (transverse plane) and vary the position of the leg side to side (frontal plane) to stretch all of the fibers.  A good example is shown in this video:

If you have any pain with any activity, including stretching, consult your physician or a physical therapist for a personalized assessment and guidance in the best way to rehabilitate the injury.

CHKD’s Sports Medicine program is a comprehensive sports medicine program with services provided solely for athletes under the age of 21.  Call 757-668-PLAY (7529) or visit our website at

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Known dangers, hidden risks to teenagers using performance enhancing drugs

CHKD’s Dr. Joel Brenner recently contributed to this piece from our local ABC station.

Known dangers, hidden risks to teenagers using performance enhancing drugs.

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Pilates For Kids

By: Ashley deLalla, DPT, PMA®-CPT

“I’m a dancer and these exercises you are teaching me in therapy don’t really apply to me. Can I do some Pilates for my rehab?”

“How little is too little for Pilates training?”

“How is working on the reformer going to teach me to jump higher…I’m a basketball player?”

“What is Pilates anyway?”

Every day, hundreds of adults practice Pilates in gyms, on the mat, in the studio on equipment, in classes, and one-on-one. But, how young is too young? What are the benefits to the young population?  Recently, the Pilates Method Alliance (PMA) published a book called Pilates for Children and Adolescents: A manual of Guidelines and Curriculum. They also hosted a conference “PMA’s Pilates 4 Youth initiative” which is a grassroots program offering children the experience of Pilates. This program was taught at their educational level so they could understand the mental, physical, and emotional benefits of Pilates.  In learning about the program and developing an exercise regimen here at CHKD, I began to look at the differences in Pilates for adults and children as well as the things to keep in mind when working with young children and adolescents.

Male Pilates

As an adult who has been trained in the Pilates method, I have learned first-hand the benefits of Joseph Pilates “Contrology” method including an integrated body and mind.  His teachings sought to undo and “correct wrong postures, restore physical vitality, invigorate the mind and elevate the spirit”.  He did this through his 3 guiding Pilates principles: whole body health, whole body commitment, and breath.  Through practicing Pilates, one is able to override the body’s physiological response to stress, initiate relaxation response (through improved ability to concentrate and focus on proper breathing techniques), exercise multiple muscle groups to become energized (coordination), increase self-awareness and self-confidence, strengthen muscles (including the core or powerhouse),   improve posture, and enhance quality of life. The best news is that all of these benefits apply to Pilates training in young children and adolescents!1

In teaching Pilates to youth, the PMA breaks down the exercise programming to 3 different groups (with different goals and precautions based on the child’s development).  The three age groups are: 5-8 years old (the inquisitive learner), 9-13 years old (the “magic window” when a structured exercise program can be followed at this appropriate level of motor and cognitive development), and 12-18 years old (the adolescent).  The following are important areas to be aware of when teaching children and how Pilates is different in the younger population:

  1. Bone growth and open growth plates/flexibility: Since children’s bones are still growing, the teacher must be aware of muscle imbalances secondary to the bones growing faster than the muscle-tendon complex. The teacher must also be aware that young children’s bones are more flexible and may fracture easier than adults.
  2. Body Temperature and Regulation: A child’s body does not regulate temperature the same as adults secondary to smaller stature and less storage volume of fluids lost. Thus it is important to allow children water breaks and observe their reaction to exercise much more closely.
  3. Breathing: Since a child’s lungs are still developing up to adolescence it is important to recognize that children breathe differently than adults. Thus in teaching youth Pilates and focusing on Joseph Pilates’ principle of breath one must seek to educate the child on good breathing techniques and improved awareness of breath with movement.
  4. Posture: When teaching Pilates to youth, one must understand the development of children.  For example as children grow so do the arches of the feet.  A 12 year old may have a defined arch whereas a 5 year old may have a flat foot, so don’t expect them to have the same posture in standing.

The following are different injuries in children that you don’t see in adults that can have an effect on teaching Pilates to children:

  1. Growth Plate Injuries: Another important Growth Plate Cross Sectioncomponent in teaching Pilates to youth is the different injuries that are present in the growing population. One of these being growth plate injuries.  Occasionally inflammation can occur at the growth plate (especially the knees) resulting in point tenderness and pain.  It is important to be aware of this and to not “push the client through the pain” but address the issue and refer to the right professional for treatment.
  2. The Spine:
    1. Spondylolysis: This term refers to a defect in the spine which can range from a stress fracture to complete separation involving nervous system involvement. It is important to avoid all spine extension based exercises with this population.
    2. Scoliosis: This term refers to an abnormal curvature of the spine found in imaging the spine in the frontal plane. It is important to address the growing spine in this population to avoid further injury while improving muscle imbalances and improving posture.
    3. According to the PMA’s guidelines, the spinal growth plates are not completed until 20-25 years old. It is their recommendation that inversion exercises be avoided in the youth population.
  3. ACL Tears: These occur from a dynamic knee valgus and twisting position to the knee. The ACL is responsible for stability of the knee.  Following a tear, focus is on quad strengthening/stability with conservative treatment before repair. After surgical intervention, a protocol must be followed to allow for proper graft healing and save strengthening.

The following is an example of how the exercises can be modified for each age group to safely be successful with the movement:

The Hundred Table

Criss Cross TableSwimming TablePictures in table ©CHKD Sports Medicine Physical Therapy and may not be copied or used without permission.

I encourage children and adolescents interested in participating in Pilates to find a teacher who is knowledgeable about working with this population since children are not just little adults.  Keep checking back to the blog here at CHKD for information on weekly mat classes and private reformer classes coming soon to a clinic near you!


  1. Corey-Zopich C, Howard B, and Ickes D. (2014).  Pilates for Children and Adolescents: Manual of Guidelines and Curriculum.  United Kingdom: Handspring Publishing Limited.





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