One of the complaints I see very often in my clinic is patient saying they feel stiff or they can’t move as much in a certain direction. However for every patient I see that complains of feeling restricted there is almost an equal number that have too much movement. Often you can be very stiff in one joint but then the other surrounding joints move too much as they are working harder to do the movement the other joint isn’t able to achieve.
Hypermobility is a condition where you can move beyond the normal range for your age, gender and ethnicity in your synovial joints. Grahame 2003. You can naturally be hypermobile simply from your genetics, one of these conditions is Elhos Danlos but you can also develop hypermobility through training for sports like gymnastics, yoga or dancing. It not necessarily a bad thing but in some people it can cause more harm than good and you will need to work towards strengthening your muscles to help stabilise your joints that have increased movement.
Who does it affect?
Hypermobility is more common in:
- African or Asian descendent.
- Children most apparently 13-19 years
- Temporarily in pregnancy
- Sports where you want increased movement 9dancing, gymnastics, cheerleading, yoga)
- Family history of more flexibility
People that have hypermobility syndrome often have a problem with the cells that make up their connect tissues for example their tendons and ligaments, which are more disorganised and lax compared to the general population. In severe cases this doesn’t just affect the joints but every part of the body including the gut, skin and blood vessels. (Beighton et al., 1989d
What are the symptoms?
Just because you maybe more flexible than most people doesn’t mean you will have any problems of pain. The symptoms are very vast with some being asymptomatic to others have severely debilitating problems. You will normally notice it in childhood and your early adult life you’re more likely to sprain your ankle more than most people for example. You will normally notice the symptoms or get injuried after a trauma such as a sprain ankle or during pregnancy/child birth.
Here is a list of some of the symptoms:
- Feeling stiff (even if you can still move more than most)
- Deceased joint awareness (clumsiness)
- Clicking/clunking/ popping
- Subluxations/ dislocations
- Dizziness, low blood pressure
- Increase bruising
- Carpel tunnel
- You are more likely to have flat feet, a bigger lower back curve, or a uneven pelvis as well as one leg longer than the other (theses all can be very minor observations)
How can I tell if I am just flexible or if I actually have hypermobility?
There are several ways you can tell if you are actually clinically hypermobile rather than just flexible these include a simple examination and a questionnaire.
(Hakim and Grahame 2003) Questionnaire:
- Can you now or previously been able to place your hands flat on the floor without bending your knees?
- Can you now or even been able bend your thumb to touch your forearm?
- As a child, did you amuse your friends by contorting your body into strange shapes or could you do the splits?
- As a child or teenager, did your kneecap or shoulder dislocate on more than one occasion?
- Do you consider yourself ‘‘double-jointed’’?
If you said yes to 2 or more of the questions then you may be hypermobile the questionnaire is 85% sensitive and 90% specific.
The beighton scale is the best way to test if you are actually hypermobile and it will also show how much you are hypermobile. It is a 9-point scale and you get a point for each joint that is very mobile.
Beighton criteria and beigton score: (Grahame et al., 2000)
To be hypermobile you need to have a score of higher than 4. However if you are older than 50 then you can be hypermobile with a lower score of 2 or 3.
|Little finger (left)||Bend it back to 90 degrees +||1|
|Little finger (right)||Bend it back to 90 degrees +||1|
|Thumb (left)||Bend it forwards to touch your forearm||1|
|Thumb (right)||Bend it forwards to touch your forearm||1|
|Elbow (left)||Bend it back 10 degrees or more past being straight||1|
|Elbow (right)||Bend it back 10 degrees or more past being straight||1|
|Knee (left)||Bend it back 10 degrees or more past being straight||1|
|Knee (right)||Bend it back 10 degrees or more past being straight||1|
|Spine||Can touch your toes and put your hands on the floor||1|
The diagnostic criteria is the following:
To be hyper-mobile you need to have either both the main points or 1 main point and 2 minor points. However if you have a diagnosis of Ehlers-Danlos or Marfans then you don’t wont simply have hypermobility syndrome as you will have a specific hypermobility condition.
- A Beighton score of 4/9 or greater (either currently or historically)
- Joint pain for at least 3 months in four or more joints.
- A Beighton score of 4 + (2/3 if aged 50+).
- Joint pain (for 3 months or longer) in one to 3 joints or back pain including a diagnosis of Arthritis of the lower back or discal problems
- Dislocation/subluxation: 1 + joints, or repetitive dislocations in one joint.
- Inflammation of your Soft tissues conditions in more than 3 joints such as: tendonitis, synovitis and bursitis.
- Diagnosis of Marfans
- Abnormal skin problems: stretch marks, stretchy skin, thin skin, papyraceous scarring.
- Eye problems including: drooping eyelids, short sighted or downwards slant of the eye
- Varicose veins, hernias or prolapse including uterine or rectal.
How can you manage hypermobility?
It is possible to manage hypermobility through it will be a continual and long term as it will always be something that you will need to take into account. As I have said before there are massive variations to the severity of the condition. It may just mean that you need to do more strengthening in certain muscles in order to do certain sports or activities in order to prevent injury or do them to a higher or for longer distances/time. Similar to all long term health conditions or weaknesses it can be a slow process and there will always be periods of remission and flair ups. It is recommended to have a goal-orientated and indivual approach to rehab and management. What is the thing that you struggle with the most? Once you know what you want to work towards you can start to work out a management plan.
It is often a multi-faceted approach using many different approaches including, massage, articulation, splitting or taping, acupuncture, RICE, exercise and mobilisation in appropriate cases.
You can use different supports and taping in order to help stabilise the joint and re-educate and strengthen the muscles around it especially if they are postural muscles for example in your back. Often you can work with your manual therapist to addresses activities that you find challenging or you do a lot and simply adjust the way you do them in order to get achieve them in a pain free way. For example it may be painful to lift a bag but if you adapt the way you grip the bag to lift it, the task could be much more manageable as a result. It also might be helpful to simply change your work set up if you work at a desk based job or study a lot.
It is very important to focus on good core stability, repetitive movements and posture generally as these muscles are more likely to be overused as a result. A healthy lifestyle with regular exercise in some form is important in order to manage the condition in order to help your strengthen your muscle to support the joints.
Manual therapy including osteopathy and physiotherapy can be used to release muscular tension and increase mobility in restricted joints in order to restore normal biomechanics to the area. It is very common in people with hypermobility to have very tight muscles as the muscles will have to work much harder to increase the stability of the joint and often get overused as a result. It very common for the postural muscles in your spine to get very tight as you constantly relying on them for balance and support.
Depending on how severe the hypermobility is; it will depend on how long this stage lasts. It is vital that this groundwork is put into place to give you the basis to move into more strenuous exercises. It is recommended to start you should work towards improving your proprioception so where you think you joints are in space. If you are hypermobile it is more than likely you will dislocate or get injuries from repetitive trauma so illuminate the amount of times you sprain you ankle for example is going to be vital to managing your symptoms.
You also want to start to do low impact activities so exercises with Swiss balls to help with your balance and core strength are recommended as well as hydrotherapy or swimming. All these exercises should be pain free and a way to slowly build up some strength in a safe and encouraging way.
Hydrotherapy or swimming is a great way to build up your strengthen and fitness in a safe way. Again it is vital to tailor it to what you struggle with and do though exercises off weight bearing and supported in the water before building them up. So if you if you want increase your walking and eventually get back to running then it would be good to start walking or swimming in the pool. You can always add weights or carry something while walking in the pool. Then you could build it up to trending water or running on the spot or through the water, which is a bit more difficult before then processing to a treadmill or going for a walk. From there again build up slowly either walk for longer or try walking up hills or on an incline on a treadmill to make it a bit more difficult before starting to run. Start short and slow and slowly build up the distance and then the speed or do a combination, run a min walk 3 mins ect.
It is important to re-educate the muscles around the joints that are very mobile to try to increase the stability and overall co-ordination of the area. Core strength is very important, as it’s vital to completing all movements (you can read more on my previous blog article). You can use tools like a wobble board to help practice activities that you have poor balance and co-ordination in order to become better and more stable. You also want to start with small movements and then make them harder by trying to work out of their range of movement or on more unstable surfaces.
Middle and late rehab:
Once you have good stability in the joints then you can move on to more strength and endurance based exercises before getting back into exercise. The main research has shown that using resistance bands can be a great way to slowly increase the strength and endurance of the exercises to give you the most stability possible. The results show ad increase in balance, quality of life, strength and reduced pain. The best cardio activities include walking and deep-water walking/running and the use of cross trainers or exercise bikes where the impact is slightly less.
It is also import to tailor your rehab to what you enjoy doing but also want is relevant to the sport or activities that you want to get back to. Similar to any rehab programme you will need to break down the sport and practice exercises that will help strengthen the key areas.
If you want to get back into running then strengthening your ankles and calves would be important to minimise twisting or rolling your ankle when you run. So you would want to work on your balance like standing on one leg or on an uneven surface.
Then you can work towards building strength in the muscles that are essential for running:
You might also want to do lunges or step-ups exercises to practice the different motions you would need to do when running. Lunges would help as you increase your stride when you run and it is a very simple version of running, step ups would be good as you have to lift your knee as a part of the stride pattern.
To get back into sport again you want to focus on drills specifically for your sport, so drills in changing direction or catching or kicking a ball in a star shape. For racket sports you can do balance exercises on trampolines or uneven surface to get used to the sudden changes in direction. You want to do exercises that mimic your sport or activity as much as possible and build them up slowly till you are doing the sport fully.