Joint Hypermoblity Syndrome
IS FLEXIBILITY ALWAYS A GOOD THING?
As someone with hypermobilty himself, Luke (physio) discusses the spectrum of mobility and what the implications of being too stretchy can mean.
If you’ve always thought of yourself as double jointed or have always strived to achieve the level of mobility that a contortionist posses, this might the article for you!
Formally known as Benign Joint Hypermobility Syndrome (BJHS), Joint Hypermobility Syndrome (JHS) is a heritable disorder of the connective tissues. People typically present with very elastic skin, a large amount of flexibility and often with a history of joint injuries.
“I’ve always found stretching to be quite easy and I’ve always been surprised when my friends couldn’t touch their toes. Yoga has always been easy for me, but little did I know that it was because I was hypermobile rather than a Yogic Legend.
It wasn’t until I had some joint dislocations & other weird musculoskeletal conditions that I was screened for hypermobility. Thankfully my GP referred me to a rheumatologist & to have my heart checked as hypermobility can affect a lot of different structures throughout the body!”
What Is The Prevalence Of Hypermobility
Affects 10-20% of the population in Western countries and higher still in Indian, Chinese, & Middle Eastern populations
More common in children and decreases with age
Hypermobility is more common in women than men
There are wide variations between ethnic groups
What Are The Causes Of Hypermobility?
JHS is commonly found to have a hereditary factor, in particular a genetic variation in collagen. Collagen is found throughout the body in structures such as the skin, ligaments, and the heart valves. If collagen is weaker than it should be, there can be increased laxity in these structures which can lead to issues.
Does It Really Matter If I’m Stretchy?
We believe it is important to screen patients for hypermobility that could be contributing to their symptoms. Ross and Grahame (2011) describe the following factors that highlight this importance:
Inappropriate and potentially harmful labelling of treatments may be applied on the basis of an erroneous diagnosis such as rheumatoid arthritis, hypochondriasis, or somatisation.
Over zealous physical manipulation causing avoidable damage, such as dislocations, connective tissue ruptures, or fracture of fragile bone.
Exercise therapy may be excessively forceful or ineffectual.
Anecdotal evidence exists that orthopaedic operations on patients with connective tissue disorders, leading to poorer outcomes.
Chronic pain may sometimes lead to a potentially reversible downward spiral or immobility, reconditioning, dependency, and despair.
What Are Some Of The Clues Suggesting Joint Hypermobility?
Hypermobility In Children & Adolescents
Coincidental congenital dislocation of the hip
Late walking, with bottom shuffling instead of crawling
Recurrent ankle sprains
Poor ball catching and handwriting skills
Tiring easily compared with peers
So called growing pains of chronic widespread pain
Joint dislocations
Hypermobility In Adults
Non-inflammatory joint or spinal pain
Joint dislocations
Multiple soft tissue injuries
Increase in pain or progressive intensification of pain that is largely unresponsive to pain medications
Progressive loss of mobility owing to pain or kinesiophobia (pain avoidance through movement avoidance)
Premature osteoarthritis
Autonomic dysfunction such as dizziness or faintness
Functional gastrointestinal disorders (sluggish bowel, bloating, rectal evacuator dysfunction)
Laxity in other supporting tissues such as hernias, varicose veins, or uterine or rectal prolapse
How is Hypermobility Diagnosed In Physiotherapy?
A huge part of a physiotherapy assessment is the subjective assessment, the interview your physio does with you at the start of a session. It helps us to learn about your injury, family history, previous problems etc… If we consider some of the clues from the previous section, a thorough subjective assessment can help build a Physio’s suspicion that hyper mobility may be a factor in your complaint.
When looking at things that can be tested to confirm a suspicion of hypermobilty, a physiotherapist will typically use a screening test called the Beightons Score. This test assesses the amount of movement in your elbows, knees, hands & trunk. Scored out of 9, with a score of > 4 typically considered to be a positive finding for hypermobility (Clinch et al. 2011). Though the Beightons Score is a great tool to quickly give an impression of a patients mobility, it does have limitations as it doesn’t look at the wider system such as the shoulder, hip or ankle.
Beightons Score
If your physiotherapist holds concerns about your level of hypermobility, they may refer you back to your GP who may request blood tests and / or refer you to a Rheumatologist for a more thorough investigation.
How Can Physiotherapy Help?
The role of a physiotherapy can vary greatly depending on the presentation of a patient. The team at Richmond Rehab are passionate about having a positive influence in the areas we can help with, and directing patients to a more appropriate service when required. We believe that simply identifying patients with JHS and educating them about how it can influence their symptoms is an essential step in helping a patient manage their symptoms. When a patient has a good understanding, they then have the power to modify their behaviours and rely on passive treatment less.
Depending on the severity of presentation, your physiotherapist may opt for some supportive taping in the short term and possibly bracing for long-term management if required.
The one thing that all Physio’s should do however, is to develop an exercise program suitable for your specific presentation. Palmer et al. (2013) reports that exercise interventions can create improvements with JHS over time without any adverse effects. The mode of exercise was inconclusive however, with generalised exercise performing better than joint-specific exercise and that further studies in the area are indicated.
Is Massage Or Manipulation Helpful?
The difficulty for patients in pain with undiagnosed JHS is that they are not best placed to decide which treatments are best suited for them. Typically looking for a relief in pain, they often bounce from therapist to therapist seeking short-term relief from passive treatments.
In relation to helping to ease the pain, manual therapies can have their place, however they do little to create any longterm changes. Instead they can create a reliance on practitioners to help ease a patients pain and potentially lead to a lot of costly appointments over time.
We believe it is imperative to identify hypermobile patients as early as possible to allow us to develop an appropriate management plan that is guided by evidence. We may refer JHS patient for manual therapy if they require temporary relief, however our focus is always on education and self-management in the longterm.
So What Are We Saying?
The purpose of this article is to illustrate to you that more mobility isn’t necessarily a good thing. Sure it’s great to have a good level of mobility to move well, but there are limits. If you’ve always thought of yourself as being quite bendy and have been struggling with ongoing musculoskeletal pain, it might be time you had a chat with your physio or GP.
We’d be thrilled to see more patients educated about their bodies and taking a proactive approach to managing their health. When you’re informed you can make better decisions about which treatments are best for you and how you’d like to spend your hard earned money.
Prevention Is The Best Medicine
Injury prevention is one of the most important steps an athlete can take. Jesse Dean (physio) works with Scott who is one of Richmond Rehab’s sponsored athletes.
This blog follows the initial screening of a running athlete in their lead up to a big event.
Training for a Marathon
Continuous and long distance events can take a toll on your body and can ultimately interrupt training periods.
The best way to get out in front of this is through preventative injury screening with a physiotherapist or prophylactic soft tissue massage for those high load areas with a Myotherapist or Remedial Massage Therapist.
What is a “Screening”? - Musculoskeletal screening of athletes is an assessment designed to detect internal abnormalities that may increase the risk of injury for an individual. (Harvey, 1998)
This is something that we deal with regularly and something that our Richmond Rehab sponsored athlete Scott knows all about.
Scott has a history of track and long distance running as well as completing the Melbourne Ironman, with his current target the Melbourne Marathon in October.
His injury history includes stress fractures of the lower leg, so preventative assessment and management was high on his list of considerations heading into the final 3 months of training.
Through this series we will outline the structure of Scott’s sessions and outcomes on his training plan through until October, including his assessment and treatment modalities provided.
Session 1: Initial Assessment
Physiotherapy: Injury screen and Endurance testing
After Scott had provided me with all the necessary information on his running distances, symptoms and running plan for the upcoming period it was onto objective testing to apply any specific treatment modalities to address issues that Scott himself may not be aware is going on while running.
Primary symptoms included bilateral lower calf and bilateral lateral hip tightness, both of which are common sites for long distance runners.
From this we started with the following.
Figure 1. Muscle Length Testing
Thomas Test: Designed to examine flexibility of the anterior hip (Illiopsoas), Lateral Hip (Tensor Fascia Latte / Illiotbial Band) and the anterior thigh (Quadriceps Group)
Lumbar Spine Active Range of Motion: How far can the patient move and how do they move through the muscles and joints of the lower back.
Muscle Length Testing of the Lower Leg: Both the flexibility of the Gastrocnemius, Soleus and Achilles Tendon through the knee to wall test. Fig 1.
Calf Raise Endurance Test: A metronome based test to examine how many single leg calf raises you can complete prior to failure. Fig 2.
Figure 2. Calf Endurance Test
Figure 3. 3 Hop Test
3 Hop Test: Power test of the lower leg where the patient hops forward 3 times and holds the landing on the last hop. The distance is measured and compared to the opposing leg. Fig 3.
This concluded the testing portion of Scott’s initial assessment, which will mould the basis of his ongoing treatment.
Treatment provided on the initial assessment was soft tissue massage through the Soleus/Gastrocnemius as well as the TFL/Glute Medius/ITB. For the endurance portion of Scott’s strength and conditioning, single leg calf raises were prescribed to improve his endurance.