Demystifying Chiropractic Care with Dr. Carrie Skony

[01:05] Dr. Linda Bluestein: Welcome back to the Bendy Bodies Podcast, where we speak with experts bringing you state-of-the-art information to help you improve your well-being, enhance your performance, and optimize career longevity. This is co-host Jennifer Milner here with the Hypermobility MD, Linda Bluestein.
[01:22] We are so glad you are here to learn tips to help you self-manage your conditions and live your best bendy life. This information is for educational purposes only and is not a substitute for medical advice.
[01:49] I'm Dr. Linda Bluestein, and I started Bendy Bodies to educate the hypermobile community. Despite being a physician, I experienced decades of symptoms before being finally diagnosed with hypermobile EDS. I've combined my medical education and personal experience to treat and coach patients and clients to optimize their quality of life.

Jennifer Milner: I'm Jennifer Milner, a former professional ballet and Broadway dancer, and I struggled my whole career with hypermobility-related issues and injuries. Now I train dancers and want to make sure the next generation of hypermobile artists are better equipped to work to their fullest potential.
[02:08] Our guest today is Dr. Carrie Skony, certified chiropractic sports physician and owner of Perform Active Wellness Dance Medicine. Hello, Dr. Skony, and welcome to Bendy Bodies.

[02:19] Dr. Carrie Skony: Hi friends. Thanks so much for having me. I'm so glad to be on here.

[02:25] Jennifer Milner: We are so excited. This is a conversation we wanted to have for a while. But before we dig in, go ahead and just tell us a bit about yourself.

[02:33] Dr. Carrie Skony: Sure. Like you said, I'm a certified chiropractic sports physician, which means I got my doctorate in chiropractic, and then I did some postgraduate education in sports medicine and rehab. I have a private practice. I've been in private practice for 17 years in the Chicago suburbs, where I treat primarily dancers — youth, adolescent, pre-professional, and professional dancers. I do see other athletes, adolescent athletes and active adults, but primarily I treat dancers, which is my real passion.
[03:03] I danced recreationally growing up in a small town. I loved, loved, loved to dance. I also grew a really big fascination with movement and the human body. I loved the sciences. I got really interested in nutrition and fitness and exercise, and that was all so fascinating to me — I really thank dance for that.
[03:27] I had a number of common injuries when I danced. And at the time, this was in the '90s — I think like a lot of our stories — there just wasn't a lot of help out there. No one really knew what to offer or what advice to give, and maybe I should stop dancing. None of that seemed reasonable to me, of course. My parents had always seen a chiropractor, and they recommended, maybe you just see a chiropractor. And I got really good relief very quickly. The chiropractor I saw was more of what we would call a straight chiropractor, so she only did joint manipulation. She didn't have any other significant therapies that she did. But that was enough to give me some relief and keep me dancing. And so then I just got really interested — like, what if there's a way I could help dancers, and I could use a natural approach, and I could use my hands, and we could talk about fitness and exercise, and help other dancers?
So this was kind of like, I could do this. In the '90s, dance medicine wasn't really a thing yet, and so it was kind of a far-fetched idea, I thought. And then I went to school and lo and behold, I come out and I start working with dancers. It's just been so fun to watch this profession of dance medicine really grow. I love that I get to use my background in chiropractic specifically to help dancers.
[04:48] But my passion is really helping dancers prevent injury, prevent recurrence of injury, empowering dancers to understand their bodies, promote health and wellness, and how to care for their bodies, how to train smarter, not harder — those kinds of things. Adolescence is really where I love working with dancers because I feel like we can have the most impact on their lives and the trajectory of their dance career and just their health and wellness in general.

[05:15] Jennifer Milner: I would agree with that. And I think we all met — for everybody who cares, we all met in 2019, I think, in Montreal, right? And it's just been such a joy to be surrounded by medical professionals who have a like-minded approach that are thinking, what can we do to prevent? What can we do to encourage longevity? And I think that's why our group kind of hangs out with each other, even though it's on the internet.
[05:44] So you've been in our circle for a while, and we have been doing this podcast for — this is our third season, so 3 years now — and several listeners have requested that we do an episode on chiropractic care. As Dr. Bluestein and I started asking around trying to find somebody who specialized in chiropractic care for hypermobility, it just became very obvious to us that if such a unicorn does exist, we didn't know them. We do know you though, and we absolutely appreciate your approach to care. You do specialize in dancers, you do work with a lot of hypermobile people. So we thought we would dig into a topic today that clearly needs more discussion.
[06:31] There are a lot of misconceptions around chiropractic, a lot of things that people don't quite understand. So I thought we would kind of clear that up. Let's start with what defines chiropractic care. Lots of people think chiropractors are the poppers, but that's not the full story. So how would you define chiropractic care?

[06:45] Dr. Carrie Skony: Yes, right. Thanks. I just want to say thank you for having this topic on because I get a lot of questions also about chiropractic, and I love your podcast and I think you just cover so many great topics. So I'm honored that you would cover this topic and have me on. Thank you both.
[06:59] Okay, so chiropractic — if we have this broad picture of chiropractic — is basically a conservative, natural, drug-free, holistic-minded approach to treating pain and dysfunction of the body. That's kind of this all-encompassing picture of like, let's help people restore their health and maintain wellness. Most people think of chiropractic by the one technique that we're most known for, and that's joint manipulation or chiropractic manipulation. Chiropractic was historically founded on that principle of manipulating joints, and so we're still really strongly known for that. In reality, it's just one technique that we use in a whole wide range of conservative approaches.
[07:50] Going back historically, chiropractic in the late 1800s was founded on basically a philosophy that all the nerves that come out of the spine control all the body functions. And if there's disease or dysfunction in the body, it must be because those nerves are not working correctly. The philosophy was that perhaps there were bones out of place that were interfering with nerve function, and if we restored proper alignment — quote unquote — in the spine, nerves would work better and disease and dysfunction would go away. So that's where chiropractic started. There are still chiropractors who practice in that philosophy-based way, although a lot has changed in medicine since the late 1800s, and chiropractic has evolved quite a bit since then.
[08:37] While there is still a lot of benefit to joint manipulation — and it is a really powerful, meaningful conservative way to treat the body — it's modernized quite a bit. I'll speak for myself: I don't use the bone-out-of-place theory. I don't say bones are misaligned. It's really just not an accurate description of what happens in the body. We do get joint restrictions, we lose motion, we do have dysfunction in how muscles and ligaments and tendons work, and that can all be addressed with hands-on care and joint manipulation. But this idea that maybe a bone is out of place and if we treat the nerves we can cure cancer — that's all kind of in the past. So chiropractic has modernized quite a bit and now includes exercise and rehab and therapeutic modalities and a wide range of conservative drug-free options to help people live better, move better, feel better.
[09:42] Joint manipulation is one part of chiropractic, but a lot of times people think, I'm going to the chiropractor, I'm just going to get my joints manipulated. My practice is a sports medicine and rehab-based practice, so the way I practice looks a lot like how a physical therapist practices. I use joint manipulation, but I also do really comprehensive orthopedic neurologic testing. We do a lot of exercise in my office, functional rehab. And chiropractic also exists on this big spectrum where I have chiropractic colleagues who go on to specialize in other fields of medicine — chiropractic neurology, functional neurology, functional medicine, chiropractic nutritionist, chiropractic radiologist, chiropractic internist, acupuncture. So chiropractic is this base principle of conservative treatment, and then you can specialize in a lot of areas from there.

[10:38] Jennifer Milner: Thank you for that. It's helpful to sort of understand that chiropractic is kind of a big broad umbrella term. So thinking about that, and that it's a conservative approach to care, what sort of people tend to seek out chiropractic care?

[10:51] Dr. Carrie Skony: In a broad sense, I think anyone who's looking for maybe a more natural approach to health and wellness. These are people who don't want to jump into surgery, they would prefer not to take drugs if they can, they're more interested in nutrition or supplementation, and they generally have an interest in health and wellness. So in a broad sense, I think that draws people to chiropractic.
[11:15] In a really specific sense, of course, we have people who come to chiropractic because they have neck and back pain. So that's like, I have neck pain and back pain — who would I see? I see a chiropractor. And headaches, too. Those are probably the 3 most common reasons people would be drawn to chiropractic.
[11:36] Chiropractors treat musculoskeletal injuries across the whole body. Anywhere there's a joint, a muscle, a tendon, a ligament — which is everywhere in the body — we treat that. For instance, I have people who come to me because they don't want to have labral repair surgery on their hip yet or at all. We treat hip impingement and hip labral tears. The outcomes on meniscus surgery and rehab are very similar, and so people choose, I don't really want to have surgery. I'd rather have rehab. Ankle impingement, rotator cuff syndrome. So anywhere there's a joint and there are muscles and ligaments and tendons, we can treat that. Generally we get people who are like, hey, I'm willing to put in the work to do this conservatively to avoid the risks of medication or surgery.

[12:23] Dr. Linda Bluestein: Obviously, people with joint hypermobility get subluxations and dislocations, but sometimes the way it's presented makes it more scary and makes people think that there's so much that's wrong in their body. I think we can be really thoughtful about how we say things that give people more confidence in their body and more confidence in their ability to get better. So you probably see lots of hypermobile people — some of them struggle with chronic dislocations and subluxations. Would they benefit from chiropractic care even if their joints are already, quote unquote, too loose? Which of those patients would likely benefit? And obviously knowing that this is general information, not a one-on-one consult.

[13:07] Dr. Carrie Skony: Right, right. Great question. If I can go back — in hypermobile patients, subluxation is a real medical term. It's a partial dislocation. The problem is chiropractors have adopted the term subluxation in a non-dislocation way. So subluxation is a common term in chiropractic — some chiropractors are subluxation-based, meaning they believe that there is a bone out of place or there's misalignment and they want to correct the subluxation. That's not exactly how that happens. In hypermobile patients, we use the term subluxation accurately — there are actual partial dislocations of the joints because of the hypermobility. So we need to be careful about hypermobile patients who are experiencing true subluxations and protecting those joints well.
[14:01] I see a lot of hypermobile patients, and they can benefit a lot from chiropractic. Joint manipulation is a powerful tool. It can reduce acute pain pretty quickly, even if it's for a short period of time. Sometimes we use joint manipulation to reduce pain in a painful area so that we can then work on stabilization and strengthening in that area. If I have someone who has a disc herniation and they can tolerate a joint manipulation, it will reduce their pain enough that we can do the next step. I like to use joint manipulation as one step in the process to get to other steps. We're trying to improve overall function of the body, and sometimes manipulation is one way that we can do that.
[14:46] In hypermobile bodies, they don't always need joint manipulation or mobilization. Obviously, there's a lot of mobility in the joint already. And with great mobility comes a great responsibility to try to stabilize those joints and be strong through there. So a lot of the work I do with hypermobile patients is reframing their thinking about their joints and what they're feeling — teaching them when it would be appropriate to move a joint into other ranges of motion and when we should not.
[15:16] I use joint manipulation very sparingly with my hypermobile patients. When it's appropriate, I'll offer more low-grade mobilization techniques. Some chiropractors use instrument-assisted joint manipulation, like an activator technique — a lower-force technique for moving joints — that can be appropriate in hypermobile patients. Otherwise, I prefer, with dancers especially, to work on joint stabilization, retraining the proprioception around the joint, having them not rely on that feeling of immediate relief that they get from joint manipulation.
[15:58] If we can pull them back from that and get them to realize, okay, what my body really is craving is stability and strength — for a lot of my dancers that come in, often I am the first time they're ever even learning that they're hypermobile. I think you guys have talked a lot about this too: these dancers just don't know. They think, I'm a good dancer, I'm really flexible, my teachers give me a lot of roles because I'm so good at them. And it's like, oh yeah, you have generalized joint hypermobility, or very specific joint hypermobility, and they don't know what that means. There's a lot of education that happens there.
So to answer your question: yes, hypermobile patients can have joint manipulation in certain circumstances when you're using it responsibly and appropriately. I use it sparingly, if at all. I think it can help with acute pain — when our dancers feel like, okay, this actually does feel like I subluxed this today, or I'm getting a lot of rib pain or low back pain — and we can get them some immediate relief to move on to the next step.
[17:10] And here's the other thing: a lot of hypermobile dancers are cracking their joints on their own. There's a lot of self-manipulation happening in the dancer population, especially when they're hypermobile. And it's understandable. It's very relieving. It gives them a lot of proprioceptive feedback, which they're lacking in their joints. It gives them an immediate sense of relief. There's a neurochemical response where they're feeling an endorphin-like response — oh, I'm getting pain relief from this. That stretch reflex on the muscle or around the tendons feels good to them. And it happens easily for them. It's really easy for them to click and pop everywhere.
[17:54] So a lot of them are self-manipulating anyway. I educate them not to do that generally, but the chiropractor is a great place to do that safely. I'd rather have you stop doing that on your own and see a chiropractor who can tell you, okay, this is where you need motion — you definitely don't need motion in this joint. We're not putting more motion in this joint. You need stability and strength here. Regardless, a chiropractor is trained to move those joints safely, as opposed to when a dancer is doing it by themselves and they're perpetuating this cyclic pattern of stretch a joint, feels better, stretch it again, feels better. You just keep stretching these ligaments and creating more and more instability or promoting the laxity in the joint. And that almost always leads to problems.

[18:50] Jennifer Milner: Can I just clarify something in there really quick?

[18:54] Dr. Carrie Skony: Yeah.

[18:55] Jennifer Milner: You said a lot of dancers want to self-manipulate anyway, and so if they're going to do that, they might as well go see a chiropractor and have them do it. I know you, so I'm pretty sure what you're saying is not, if you like to twist and pop your lower back, have a professional do it for you instead. You're not saying seek out a professional to do that joint popping that you already like to do. You're saying we acknowledge that dancers do enjoy that popping feeling, so let's go talk to a professional about why they enjoy that popping feeling, where they might need some relief, and what they should be doing instead. I just didn't want people to hear that and be like, oh, I'll go to a chiropractor, and I can pull up my menu and tell them do this, this, and this for me.

[19:38] Dr. Carrie Skony: Yeah, thanks for clarifying. It made more sense in my head when I said it. But you said that lovely.
[19:40] I do get dancers who come to me who have been referred to chiropractors already for neck pain and back pain, because we know our hypermobile dancers do have quite a bit of neck and back pain at times. And so their first choice is chiropractic. There are chiropractors who are maybe not as selective in what they do, or maybe joint manipulation is the only thing they offer, and everyone who walks into the office gets the same treatment. I highly discourage hypermobile dancers from seeking out that type of care. I've had patients who, as young as 10 or 11 years old, go to the chiropractor twice a week for the last 5 years. And when I ask, why are you here? they say, well, I'm in a lot of pain. And I ask, is that working for you?
[20:45] Joint manipulation can be a tool that we use. But in the hypermobile dancer, I just think we have to be really, really cautious. I err on the side of not moving hypermobile joints whenever possible. It's uncommon for me to manipulate my hypermobile dancers. I do spend a lot of time educating them about why that is. I want them to know. And a lot of them, once they understand what self-manipulation or seeing a chiropractor twice a week is doing to their joints and why that might be difficult for a hypermobile joint long-term, most of them are on board right away. Like, absolutely — now I get it. I'm on board. I want to preserve my joints. I want to protect my dancing.

[21:32] Dr. Linda Bluestein: I'm so glad that you brought up self-manipulation, because whether I am seeing someone one-on-one or giving a talk, you see people doing those things constantly. And I have some self-manipulation that has become habitual for me. If you just Google it or ask a lot of people, they'll say, oh no, that's fine to do. But I have the same philosophy that you do — that especially if you're doing it repetitively, that's really problematic. And trying to understand why you feel the need to do it is so important. And that's different, right, from spontaneous — like you just moved and something made a sound.

[22:11] Dr. Carrie Skony: Yes, absolutely. It's okay for joints to move and it's okay for them to make noise, especially in our hypermobile dancers. And that's not scary or alarming. It's when we do it forcefully, repetitively, habitually for an effect that is not serving you a purpose long-term. It's a short-term relief that's probably causing more harm than good in the long run. So a lot of room for education there in teaching our dancers about the safety of joint motion and stabilizing their joints.

Dr. Linda Bluestein: And a quick follow-up to that. I feel like a lot of people think if there's a sound, if there's a cavitation or whatever, therefore the joint either was subluxed or it now is subluxed. So can you quickly explain the difference between those? Because I feel like that's an important thing.

[22:57] Dr. Carrie Skony: Yeah, the sound doesn't mean much. We start to connect: I heard a sound, it feels good, something positive really happened. We can manipulate joints and not get a sound. There's fluid in a joint. When you take a joint to its end physiological range of motion, there's basically a negative pressure effect in the joint. There are gas bubbles that can be released. It creates a cavitation — a popping sound. For some people, the feeling of getting to that end range of physiological motion feels good to them. It just so happens there's a pop too. But the pop doesn't really mean anything.
[23:36] I've seen dancers who crack their toes — they have really hypermobile toes and they're cracking them over and over again. They'll keep cracking to try to get a sound. In the meantime, they get capsulitis, they have completely stretched ligaments, toes that bend past 90 degrees, their big toe joint is swollen and painful. And it's like, stop. You don't need that. We don't need to crave this sound. The sound we don't correlate with much.

[24:04] Dr. Linda Bluestein: So we know that some people will have asymptomatic joint hypermobility, and other people have symptoms related — it could be that they have Ehlers-Danlos, it could be that they have hypermobility spectrum disorder, they could have a variety of different things. If someone comes to you and you're working with them and they have symptomatic joint hypermobility, does that change your approach in working with them?

[24:25] Dr. Carrie Skony: Yes, definitely. Everything then goes through the hypermobility lens too. Probably the first thing that comes to mind is that I try really hard not to chase the pain. My hypermobile dancers often — we'll set up a treatment plan, like I want to see you once a week for 6 weeks, and let's come up with a plan of what you can work on at home and at the studio. But every one of those times they come in, they're like, okay, today my shoulder, and low back, and today it's my ankle. I can totally sympathize with that. But I try not to chase the pain. We try to look at the big picture: okay, here's the deal. I'm going to try to give you some relief today. I'm going to teach you some self-care strategies of how you can handle this, because you may get these pains again. I'm not going to solve this problem today. Your shoulder may hurt from time to time. Here are some self-care strategies. Here are the exercises I want you to do instead. And then we really have to take this long-term focus.
[25:29] Sometimes people go to chiropractors wanting a quick fix — fix me, and I feel better. But then they feel like I have to go back 2 days from now because I don't feel good anymore. So in a hypermobility lens, it's like, yes, I want you to be out of pain today so that you can go back to class or rehearsals. But I'm also here to remind you — every time they're in — we are looking for long-term success with your body and wellness. Here's how we're going to work on stability of the joint. Here are the exercises you're going to do.
[26:01] The other thing is hypermobile bodies just can't always tolerate as much as other athletes. Hypermobile bodies have good days and bad days, as you guys know. And so we have to ask: is today a good day? Do you feel like you have a lot of fuel in your tank? Can you give us some effort today? Do you feel like doing some exercises? Should we review what we did last time? Sometimes they weren't able to this last week — hey, everything hurt, or I really struggled with this, I didn't get to my exercises. Okay. So a lot of times it's a much slower approach. I don't throw as much at them as I would some other athletes because I know there are a lot of variables.
[26:43] Of course, talking about self-manipulation with a hypermobile dancer, we always talk about breaking that habit. That's always one of my first conversations with a hypermobile dancer that comes in.
[27:01] I already mentioned using manipulation sparingly as my treatment technique with hypermobile dancers or bodies in general — focusing more on supportive care. Let's talk about what kind of pillow do you have, what kind of mattress are you on, how heavy is your backpack. Teaching them taping strategies they can use for support on their own. Joint braces if they need that. Educating a lot about what they're doing in the studio and rehearsals. There's such a big education component, especially if this is all new information and they don't know what hypermobility is, didn't know hypermobility had a spectrum. I try not to overwhelm them with a lot of information at once. I try to feed them little bits at a time — this joint is a little bit more lax, and this is what that means. And then we progress from there.
[28:15] Because I take a holistic approach, with hypermobile bodies especially I tend to start getting into more questions like, do you ever have GI dysfunction? How's your digestion? How's your nutrition? And then I can guide them to the appropriate resources. I have some training in all of those areas, but that's not my lane. So I refer out — I send them to Kristen Koskinen for nutrition, or let me send you to my functional medicine doctor for a GI workup, or you have stress and anxiety, let's get you in with a counselor, let's work through some of that.
[28:52] I do that with a lot of my patients, but especially for young bodies and hypermobile bodies, I feel a huge responsibility to be a resource for them and to advocate for them. We talk a lot about self-advocacy in classrooms, which is a huge issue. I try to be a resource for that and create communication with their instructors.
[29:23] So when a hypermobile patient comes in, it's just this all-encompassing — okay, let's pick this apart. We have a little anxiety: here's what I can teach you about that, and let me point you to resources. The GI issues, the chronic subluxations — I look at patients like they're a puzzle, and there are all these different pieces. My job is to try to help them put the pieces back together.

[30:05] Jennifer Milner: That's great. I think there are a few different kinds of people that I've run into with regards to chiropractic. There are the people who are like, oh, those poppers — they just want to get you in there. And chiropractic is a huge field, right? You said it encompasses so many different things. There are some really bad chiropractors out there, just like there are really bad Pilates trainers out there as well. Some people may have had bad experiences, or they may think somebody just wants me to come in twice a week for the rest of my life so they can adjust me. And then there are people who are like, I love chiropractors, they're fantastic, they really help maintain me.
[30:49] This conversation hopefully is shedding some light on the possibilities of what you can get with chiropractic care. I have been through chiropractic care for most of my dance career and was fortunate enough to work with a really good person early on. She recognized my hypermobility. And one of the best things she did for me was to arm me with information for when I traveled. So when I was out on tour and having to look up other doctors, she literally wrote notes about how to put blocks under my hips or how to do this and that. I would hand the notes to them and they'd be like, this makes no sense. And I'm like, it doesn't have to. This is the recipe that works, so just read this.
[31:29] So I think the education that you're talking about is so key. The other piece that is really important for me as a hypermobile person who does go see a chiropractor is the concept of moving really slowly, as you said, because there can be great days and bad days. But also, as you said, we kind of crave that release. If a hypermobile person is tight, it's for a reason. There is tightness going on to help stabilize something that is unstable. What my current chiropractor has kind of learned with me — because she wasn't a specialist in hypermobile people, most people aren't — is that a little bit goes a long way. If she does some release work like soft tissue or anything, she might do just a tiny bit, but if you do too much, then all the joints are like, we're free, and they go running and something dislocates. So it's that constant: a little release, a little strengthen, a little release.
[32:23] And I think that's such a huge important component for working with hypermobile people — understanding you can't go, oh, that whole shoulder is so tight, let me just release all of it, because then the arm just falls out of the socket. So like you said, education is so important.

[32:46] Dr. Carrie Skony: Yeah. And if I could talk about that for just a second, because I think a conversation I have a lot with dancers is: there's a difference between feeling tight and being tight. It's a really common conversation. If a hypermobile dancer comes in and says, oh, my hamstrings are so tight — okay, let's check, let's see what's happening. Helping them to understand that if there's tightness in the muscle, it's there for a reason. You stretching the hamstring or the joint excessively into oversplits or hanging out in a straddle position is not serving you. It's not fixing the tightness.
[33:31] So if a dancer says my hamstring is really tight and I can take their leg to their nose, I want to say: the hamstring is not actually tight, but I understand that you feel tight. We need to understand why you feel tight. Is the joint craving stability? Have you been really overusing the hip joint? Maybe the core is lacking some strength and stability, the hamstrings are tightening up, you're feeling a tension because your body is trying to create stability in an effort to have a bigger role around the joints.
[34:10] I think that reframing is just so powerful for them. I often catch them, and they learn really quickly in my office — they walk in and say, oh, my neck is tight. And I'm like, mm-hmm. Let's just think for a second. Do we think the neck is tight, or does the neck feel tight today? And they say, you're right, the neck feels tight today. Okay, great. As long as we can reframe that. And then they understand: I don't need to sit in a stretch to fix this problem. That's not it. They know, okay, Dr. Carrie gave me all these tools to use. If I feel tight, what can I do? I can work on my proprioceptive exercises, I can work on joint stabilization exercises, I can work on my strengthening, I can use a taping technique — all of these other things that are actually going to have a positive effect on what their body is craving.

[35:06] Jennifer Milner: Well, and if I'm feeling tight — like my back starts to get crabby because I'm so loose, and my chest might start to get tight, right? So if my chest gets tight, I just want to stretch my chest, and my chiropractor's like, no, you have to strengthen your back. And I'm like, I don't want to work, I want you to just open it, you know? But I understand what she's saying, and I would love to just fall into the straddle and stretch, but instead we actually have to strengthen what it is that's making us feel like we need to fall into the straddle and stretch. So I really appreciate that.
[35:42] Are there issues that are common in people with hypermobility disorders? Because we know people with these disorders do have a lot of common comorbidities. Are there some issues that might give you pause in treating a certain issue, where you'd be like, let's wait until we know for sure?

[36:02] Dr. Carrie Skony: Yes. One that I see most often would be lumbar stress fractures. Because of hypermobility, there tends to be a lot of lumbosacral extension. Our dance teachers often exploit that hypermobility — lots of tricks — and dancers want to take their back this far, their leg this far, whatever. So there's a lot of extra impact forces there, in combination with not as much joint support. I do get lumbar stress fractures quite a bit in the office. I can still treat around there, so I wouldn't say that necessarily gives me pause in that area, but it's definitely high on my radar — okay, we need to get this evaluated for sure. We go for imaging sooner so we can get a proper diagnosis.
Less commonly, but I do see it, would be upper cervical instability. The ligaments, particularly in the upper part of the cervical spine near your head — anywhere ligaments can be lax, but especially there — we have some really sensitive structures through there at the brainstem, the base of the brain. We don't want to mess around too much if there's a lot of suspected laxity in the cervical ligaments; just a lot more susceptible tissues or potential injuries through there.
Some people with EDS and hypermobility are more susceptible to a Chiari malformation, which is basically a herniation of part of the brain into the spinal canal, so we need to be aware that those things exist. Hypermobile dancers often have dizziness or fainting — syncope — and so there are some vascular issues there that we need to be cautious of. I'm careful about what techniques I'm using, how aggressively we're working even on exercise, and certainly with cervical manipulation I'm much more cautious because of the laxity component through there.
If a dancer presents with, oh, I'm dizzy all the time and I faint sometimes and I have chronic daily headaches — okay, we need a referral. I'm not adjusting your neck today. We need a referral to evaluate further what's happening. And maybe that's just, you know, normal for them because of POTS or anything else, but we want to get that evaluated.
I'm also really careful around the shoulder because of shoulder dislocations. Just monitoring what techniques we do, even exercises — being cautious of that hypermobility and hyperextension in the knees and the elbows when we're doing exercises, or even in the wrists. If we're doing floor work, it's like, okay, we need to be careful because you may not be able to tolerate loading the wrist or the elbows during any of our exercises. So we have to get creative sometimes. I know you guys experience that as well, and Jen, especially you with your Pilates work.

[39:17] Dr. Linda Bluestein: What kind of things make you think specifically, oh, we need to do imaging for this dancer?

[39:23] Dr. Carrie Skony: That's kind of hard to explain. There's a pretty common clinical presentation. If someone comes in and we can point to the pain — it's there, it's at L5-S1, they can point to it, it's sharp, it hurts during these orthopedic tests, it hurts every time they arch their back, it hurts with jumping — we kind of go through this orthopedic eval where it starts to check all the boxes.
[39:47] Sometimes we'll do a trial of conservative care: okay, let's work on this 2 or 3 visits. But if I still have a really high clinical suspicion and you're getting no relief from the things I can provide — stabilization or manipulation if it's appropriate, or any other technique we're using for pain management — if they're like, no, it's still an 8 out of 10 pain, that's a really high clinical suspicion for me.
[40:10] And in reality, in dancers, it's not even just the dancers who are doing hyperextension movements. Dancers who have a lot of mobility but have a hard time controlling what their core is doing functionally — a hard time stacking the rib cage, they're in an anterior pelvic tilt, they're doing a lot of jumping — that can cause a lot of compression and extension in the lumbar spine, even if you're not in extreme ranges of motion.
A stress fracture in any case is where the load is greater than the capacity. There's some mechanical dysfunction, whether it's anatomical-structural or functional because of weakness someplace. The capacity of the body is lower than its ability to handle the load being given to it. So yes, it becomes very apparent when we have dancers who are doing lots of tricks and overarching their back. But it doesn't have to be that — I see dancers who are just training hard and not doing anything too abnormal, but maybe have these other functional weaknesses that lower their capacity to tolerate the load. Not to mention growth spurts and a lot of other contributing factors to stress fractures. I see that in some gymnasts too, of course. But I see that in some of my patients who are not dancers or gymnasts.

[41:35] Jennifer Milner: It seems like those fractures are not that uncommon, at least in this population of people.

Dr. Carrie Skony: Right.

[41:37] Jennifer Milner: That makes sense. I mean, I can obviously see how exploiting the super flexibility can cause them, but also the impact of it. People don't think about that, but I've seen more impact-originated stress fractures in the low back from gymnasts than in dancers, from all of the hard landing they do and the way they absorb it in their lower back. But I could see why that would be an issue in hypermobile dancers, just with the inability to control their spine and absorb the load from jumping efficiently. So I can definitely see that.

[42:17] Dr. Carrie Skony: You know, also, I think it's something we need to continue to make sure all of our providers are really well-educated, which is why what you guys do is so powerful. When we think about a dance instructor saying, oh, your low back still hurts? Okay, go see the chiropractor. It still hurts? Okay, keep going to the chiropractor. And if we're seeing someone who is not really attuned to the risks or looking for those risk factors, or maybe is not doing a full orthopedic neurologic exam, then as dancers, we think, oh, it's normal to be in pain. My back still hurts. My back still hurts. Oh, I had a busy week, my back still hurts.
[42:59] So I think educating our instructors and educating medical providers more about hypermobility and what to look for — of course, I want everyone to understand the stress that dancers go through. But I think sometimes there are chiropractic facilities that don't do full examinations, and you're in and out in 5 minutes. I don't want to be disrespectful to my colleagues, but I think it waters down what we can offer in the profession. And I think there's some risk there if we're not really understanding what's walking in the door. We can't just manipulate away pain all the time. At some point you need to ask, okay, what's actually happening here? What is going on?
[43:50] So yes, you can go to a facility down the street and walk in and get adjusted, take walk-ins, feel better and walk out. But it's such a disservice to what chiropractic is and can offer on a whole, and also just a disservice to patients. Everyone deserves a full workup. But it's common now to see, I just want to pop in to my chiropractor and pop out. And that makes me nervous for dancers especially.

[44:21] Jennifer Milner: So as you have just explained, there can be a really wide variety of chiropractic care out there — it can be the really great, full-on, full exam every time you walk in, very comprehensive, including physical therapy exercises, all of that. And it can be what feels more like a drive-through, order off the dollar menu and you're on your way again.
[44:42] So for everybody who is not in the Chicago area, which is where you live, and would be great to be able to see you — what should someone be looking for when they are searching for a chiropractor? How do they know?

[44:55] Dr. Carrie Skony: Referrals are a good option. If you know someone who's been somewhere and they can attest to their experience, that's a good option. I think looking for chiropractors who are certified in additional methods — sports medicine or rehab. Generally, if a chiropractor has additional training and certification for sports medicine rehab, they are taking an active approach to care. It's not subluxation-based, philosophy-based care. It's like, okay, we're here to make you work. We're going to work together, we're going to be a team. So that's a good starting place: someone who has some certification with sports medicine.
[45:31] I do see chiropractors who have that and advertise it and still have really quick, non-thorough visits. So that's probably not a be-all end-all, but it's a good starting place. Anyone who's rehab-based, of course. I think a doctor who takes a detailed history — my first visits are 60 minutes or longer. Someone who's really trying to understand you as a person, who wants to know your full medical background, who's looking at how you move and function. That's a good option.
[45:58] You can ask, how long do you spend with a patient? You know, if you're interviewing for a chiropractor: how long are you spending with the patient? Generally, a subsequent visit should be at least 20 minutes, if not 30 to 60 minutes of care, so that you're not just walking in and getting adjusted and leaving. You can ask, are there exercises that are going to be prescribed? Does someone watch me do those exercises, or are you just going to hand me a sheet and send me home? You want those exercises supervised. You want someone who understands how to squat and how to lift and how to bend. You don't want someone to just hand you an exercise sheet and send you home.
[46:43] I think looking for someone who's willing to create a personalized plan for you that is unique to your goals. Some of this stuff you just have to interview — you go to an appointment and interview them. It's hard to gain some of this information from a website or from what people say online.
[47:03] I think staying away from cookie-cutter type treatments where maybe there's a scare tactic. I think staying away from chiropractors who do full spine X-rays on every patient — it's not clinically indicated to do that. It's unnecessary, it's overutilization. That's always a flag for me: do we need that? Is that clinically indicated? Or someone who uses X-rays as a scare tactic — oh, see how this is what a normal neck looks like and this is what a bad one looks like, ooh, I can fix that, you just need to come to me 3 times a week for the next 6 months. I would not sign up for that kind of care. You may get some temporary relief from joint manipulation, but that's not an ideal place, especially for dancers and hypermobile dancers. You want a doctor who's going to give you some lasting relief.
[48:05] If I have a 12-year-old who's been seeing a chiropractor twice a week and not feeling any improvement after years, something's not working. That's a bit of a red flag. I generally am seeing my patients 6 to 10 visits max. And then if they want to stay on for long-term performance-based care — how are we going to continue to help you manage chronic pain or dysfunction — we can do that. But don't be signing up for those long-term care plans.
[48:57] It's really hard to tell from someone's website or from what someone says, because everyone says the right things. But a referral from someone who's experienced what a chiropractor offers and can speak directly to it — oh no, my chiropractor taught me a lot, I did exercises — or if you go in and interview someone or have a first visit, those are some things I would look for.

[49:15] Jennifer Milner: Well, and I think there is something too — you said you don't want to go to someone who's going to keep you coming back twice a week for 5 years. There is something to maintenance care and preventative care and strengthening when we're working with elite athletes. I always encourage my dancers to start seeing a physical therapist before they have a serious issue, so that when they have a serious issue, the person already knows their body and is like, that's not what you normally look like. That's not how you normally are.
[49:44] I don't mind someone going in and seeing someone and getting help with some Achilles tendinopathy — which is not a small issue, but they think it is — and then being able to know that person. When we're working with elite athletes, there is going to be a degree of maintenance care. High-level dancers, especially people with hypermobility, high-level athletes will be going to a physical therapist once a month, once every 2 months for just what we call tune-ups, because they are doing extraordinary things with their body. So there is that component of it.
There was a chiropractor I didn't 100% agree with who tried to explain to me that it was like brushing your teeth — you do go to the dentist to get your teeth cleaned too, even though you're capable of brushing your teeth, but you have to go to the dentist regularly. And I was like, yeah, but if I have to get my teeth cleaned twice a week, I'm clearly not doing something right at home. I shouldn't have to depend on the dentist to do that maintenance for me.

[50:44] Dr. Carrie Skony: And here's the difference — and I think you brought that up really well — I want to be a guide for my patients. And once I have a patient, they generally are with me for a long time. It's just we need to be really clear about what my role is. My role is to help you as new injuries appear, to teach you, to educate you, to treat them as they pop up. I have people who have chronic Achilles tendonosis or ankle impingement. All right, we're going to treat that when that flares up. I'm here. I'm not kicking you out. It's not a bad thing that you need to come see me — certainly as an elite athlete, like you said, Jen, there are things we need to treat.
[51:19] The difference is: what is our overall goal, and are we working towards functional improvement and structural improvements that are long-lasting? When I talk about not signing up for those twice-a-week-for-the-rest-of-your-life care plans, I'm speaking specifically of offices that are just doing joint manipulation. From my perspective, we need active care. So if someone's coming to me and we're making objective progress, then yeah, absolutely stay. I've seen patients all the way through their youth, pre-professional, into their professional careers and into retirement. I've been in practice long enough that I've seen dancers on the whole spectrum, and they stay with me and they trust me, and I love that.
But we come in with clear goals of what we're trying to accomplish. We're going to be really intentional and personalized about how we're going to do that. This is not a cookie-cutter approach to just get you out of pain today and tomorrow. We have goals. Let's work on this. We generally reach those goals, and then something else happens, or they have a flare-up, and they come back and we work on it again. My job is to just be a guide and a resource for them. They're doing the work. I'm helping them along the way.
[52:28] I always say to my patients: you and me are in a rowboat, and we both have an oar, so we're both working. If I'm the only one doing the work, we're going in circles. My goal is to eventually hand you the oar. I'll jump back in the boat anytime you need me, but my job is to give you the oar so that you can go and take care of yourself. I don't want you to rely on me forever if you don't have to. I will be here if you need me. A lot of conditions need that. But my goal ultimately is to empower you to be able to self-care as best as possible and have the highest function and optimal health that we can.

[53:07] Jennifer Milner: That's gorgeous. That was just pure gold right there. I think I'm going to put all of that on a pillow — empowering someone to have both of the oars.
[53:17] I know we've talked a lot about chiropractic care today, and I really appreciate your time. Was there anything that you wanted to cover that we didn't get to?

[53:27] Dr. Carrie Skony: Gosh, we covered a lot.

[53:27] Jennifer Milner: We did, right?

[53:29] Dr. Carrie Skony: All of that.

[53:30] Jennifer Milner: I feel pretty good about us.

[53:30] Dr. Carrie Skony: I would just say, one of my passions outside of chiropractic is really educating instructors. And I know you guys feel this to the depths of you also — there's such a lack of education in our dance instructors about hypermobility, and I really face this challenge on a daily basis. How can we get our instructors to help empower our students as well? How can we all get on the same page?
[53:58] I'm really fortunate. We have a huge competitive dance community in the Chicago area. I work with probably a couple dozen dance studios. I'm a consulting physician for health issues at many studios. I do have good relationships. But there's still a struggle sometimes, even with new teachers — the lack of certification or knowledge about how to work with hypermobile dancers.
[54:23] That would be my passion project: that we would continue to educate teachers about understanding hypermobile bodies. Teachers could, from a very young age, be able to acknowledge — yes, you're a bendy body. You don't have to diagnose that, but be able to say, we're not going to push you into your end range of motion because that's not necessary, especially at 10 or 11 years old. You can really empower kids at a young age instead of exploiting them. Instead of, you know, so-and-so can do all the tricks, so they're going to get all the tricks and all the dances, and we're going to use that to get points in all of our routines, and if you're hurting, I'm sorry, you still have to be a part of this. No one else can do this role.
[55:15] I think we set the stage for these young kids at this young age that they have committed their bodies to this practice, and I think it's really irresponsible of us. And I think it starts with the teachers unknowingly — I think it's all unknowingly. It's not on purpose. I just think education will go a long way.
[55:33] I have dancers who don't get enough time to eat between classes. And we know hypermobile dancers need more time to digest. They can't eat as much food. Maybe they have more sensitive stomachs. And to lump our hypermobile dancers all together with the other population is such a disservice and is harmful to hypermobile bodies.
[55:55] So when I see dancers come into my office, there are all these other factors contributing to their health and wellness, and I'm going to educate them on this, and I'm going to advocate for them, and I want them to advocate for themselves, and I want their parents to advocate for them, and I'm going to educate their instructors. But if we could just get all these pieces together from the get-go and have everyone understand — okay, a hypermobile body probably is going to complain of pain more, that's not uncommon. Let's not shame them or call them lazy if they ask to sit out because they're having a bad joint day. Let's not make them feel bad about that. We need to understand and say, okay, great — we want to preserve your body. We want you to function optimally. We want you as part of our team. We want you to be successful. If that's what your body needs — more time to eat, more sleep, less hyperextension in your tricks, fewer dances — we want to provide that for you because we care about you holistically as a person.
[56:57] And I just don't see that all the time. It's a lot of, you know, gosh, you have so much talent, let's put you front and center, let's make you do all the tricks, let's take your leg all the way over here.

[57:09] Jennifer Milner: And you're irreplaceable.

[57:11] Dr. Carrie Skony: Yes. And you're irreplaceable. And these kids are scared to bring it up. It's just — yeah, we are on that same soapbox.

[57:21] Jennifer Milner: I guarantee you we are on that same soapbox. We are working hard to change it.
[57:24] We so appreciate your input and everything that you have to offer the dance world, and your being willing to have this conversation with us. Because when we first approached you, you were like, I'm not an expert on hypermobility. But we need an expert on chiropractic who works with dancers in a way that aligns with what we think should be happening and who works with hypermobility. And you certainly have helped us understand all of that today. So if people want to learn more about you, where can they find you?

[57:54] Dr. Carrie Skony: I'm on social media, Instagram and Facebook at @DrCarrieSkony — D-R, Carrie, C-A-R-R-I-E, S-K-O-N-Y. And my website is performactivewellness.com. They can find me there and leave me messages.

[58:10] Jennifer Milner: Awesome. That's great. And we'll have the contact info in the show notes as well.
[58:14] Well, you have been listening to Bendy Bodies with The Hypermobility MD. Our guest today is Dr. Carrie Skony, certified chiropractic sports physician and owner of Perform Active Wellness Dance Medicine. Carrie, thank you so much for chatting with us today. It was a pleasure to have you here.

[58:32] Dr. Carrie Skony: Thank you guys. I love what you're doing. Keep up the hard work.

[58:35] Jennifer Milner: Thank you so much. We really appreciate you coming on today.

[58:38] Dr. Carrie Skony: Of course.

[58:40] Jennifer Milner: If you love what you learned, follow the Bendy Bodies Podcast to avoid missing future episodes. Screenshot this episode, tagging us in your story so we can connect. Our website is www.bendybodies.org and follow us on Instagram @bendy_bodies. We love seeing your posts and stories, so please tag us using #bendybody. Please leave a review and share the podcast to help us spread the word about hypermobility and associated conditions.
[59:08] This information is not intended to diagnose, treat, cure, or prevent any disease. The information shared is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for all medical concerns. We will catch you next time on the Bendy Bodies Podcast.