What is…..Hypermobility?

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Joint hypermobility means some or all of a person's joints have an unusually large range of movement.

We've all at some point come across someone who can hyper-extend their elbows, or push their thumbs to touch their forearms. You may well be one of these people, having hypermobile joints is fairly common.

There are many reasons why joints may have an unusually large range of movement

  • Abnormalities in bone shape at the joints affecting the congruency of the bones
  • Collagen or connective tissue defects affecting ligament, tendon and muscle strength and laxity
  • Muscle tone around the joint
  • Impaired proprioception affecting the brain's ability to determine the joint position

So how can I tell if I am hypermobile?

There are a number of factors that can influence your risk of joint hypermobility:

  1. Genetics - there is fairly strong evidence for a genetic component in joint hypermobility. The main reasons for inherited joint hypermobility are collagen abnormalities or joint shape, such as shallow sockets in the hip and/or shoulder.
  2. Age - Collagen elasticity decreases and adhesions increase with age causing joint laxity to reduce. The younger you are the more likely to you are to have some hypermobile joints.
  3. Gender - Women are generally more flexible than men primarily due to hormone differences. Monthly fluctuations in hormone levels means that in women flexibility (and therefore any joint hypermobility) is highest just before menstruation.
  4. Ethnic background - there are differences in the collagen structure between different ethnic groups which can affect the likelihood of joint hypermobility.
  5. Activity & lifestyle - active stretching of the joint capsule through activities like ballet, gymnastics and yoga can cause long term changes in ligament length and make someone more susceptible to joint hypermobility. Trauma to the ligaments will also result in joint laxity and increased movement.

The Beighton score is used to indicate if someone has widespread joint hypermobility. These are a simple set of movements each awarded one point if you complete the movement. A score of more than 4 indicates probable generalised joint hypermobility.

Beighton score
Placing flat hands on the floor with straight legs 1
Left knee bending backward 1
Right knee bending backward 1
Left elbow bending backward 1
Right elbow bending backward 1
Left thumb touching the forearm 1
Right thumb touching the forearm 1
Left little finger bending backward past 90 degrees 1
Right little finger bending backward past 90 degrees 1
Total

I'm hypermobile, help!!

Don't panic! A recent study showed that 18% of the population are classified as hypermobile (Mulvey et al 2013) and the majority of people with hypermobility have no symptoms at all. In some sports being flexible is actually an advantage, like rowing, gymnastics or yoga.

If you are hypermobile it does mean you may be more vulnerable to certain injuries:

  • Joint sublaxation (incomplete dislocation) or complete dislocation of joints - these can be traumatic, such as impact sports injuries, or non-traumatic, such as someone who can 'pop' their shoulder in and out of its socket
  • Poor balance/clumsiness - because the joints have a larger than normal range of motion and are unstable your brain may struggle to work out your joint position (proprioception) resulting in 'unnecessary' trips and falls etc.
  • Repeated strains and sprains - as a result of the above two factors.
  • Muscle fatigue - because the muscles are having to work for longer and in ways the muscles aren't designed to be strong (against the grain of the muscle fibres)

Training to increase muscle strength, regulate muscle compliance (stiffness) and increase proprioception will all help to moderate any minor symptoms and injury risk you may have.

But when does hypermobility become a problem? Hypermobility can cause some people significant pain and other symptoms; this is called joint hypermobility syndrome.

What is the difference between generalised joint hypermobility and joint hypermobility syndrome (JHS)?

Someone is diagnosed with JHS when they meet the Beighton criteria which includes being generally hypermobile but also having associated pain and symptoms. These can range from the more obvious symptoms of joint pain through to gastrointestinal problems. One of the reasons the symptoms can be so widespread is due to defects in the collagen protein throughout the body. The collagen laxity impairs the fibrous/elastic properties of the tissue causing it to perform poorly. Collagen, apart from being present in ligaments, is also found in other sites of the body including skin, blood vessels, eyes, gut and cartilage; all of which can be affected in someone with JHS.

Brighton criteria

Major criteria

  • Beighton score of >4
  • Arthralgia for longer than 3 months in four or more joints

Minor criteria

  • Beighton score of 1, 2, or 3
  • Arthralgia (>3 month duration) in one to three joints or back pain (>3 month duration) or spondylosis, spondyloysis/spondylolisthesis
  • Dislocation or subluxation in more than one joint, or in one joint on more than one occasion
  • Three or more soft tissue lesions (eg, epicondylitis, tenosynovitis, bursitis)
  • Marfanoid habitus (tall, slim, span greater than height (>1.03 ratio), upper segment less than lower segment (<0.89 ratio), arachnodactyly)
  • Skin striae, hyperextensibility, thin skin, or abnormal scarring
  • Ocular signs: drooping eyelids, myopia, antimongoloid slant
  • Varicose veins, hernia, or uterine or rectal prolapse
  • Mitral valve prolapse

Requirement for diagnosis

Any one of the following:

  • Two major criteria
  • One major plus two minor criteria
  • Four minor criteria
  • Two minor criteria and an unequivocally affected first degree relative in family history

Treatment for JHS

The primary treatment for JHS is physiotherapy. Physiotherapy can be used in a number of ways including pain management, improving proprioception, increasing muscle tone, improve overall posture and re-education of movement patterns. You can approach a GP for diagnosis and referral to a physiotherapist.

Pain management is a major factor for JHS sufferers. Input from a specialist rheumatologist is often required to help manage and monitor the condition. Associated problems, such as osteoarthritis, can develop later in life and require additional management.

Occupational therapists work to help manage the condition by adapting the home to make life more managable. This could include the installation of rails around the home, specialist equipment to help with washing and dressing, or just any activity of daily living (ADL) that is affected by the condition.

Other treatments such as cognitive behavioural therapy, podiatry and alternative therapies such as manual therapy and massage can be used to complement the traditional treatment methods for JHS.

Click here for more information how our Chronic Pain Clinic can help with the symptoms of JHS.

Further resources:

 

References:

1. Mulvey et al 2013 Arthritis Care Res

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Headstart Sports Injury and Performance Clinic is owned and run by experienced sports massage therapist Vicki Marsh. We are based in Cambridge, UK, and specialise in resolving complex injuries that are causing acute or chronic pain,affecting quality of life and sporting performance. Vicki has over 12 years experience delivering sports massage to rowers, runners, international athletes and Olympic medallists.

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