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Hypermobility-- Asset or Liability?

Updated: May 27

By Eleanor Au


Introduction


Have you ever wondered why someone could hit the splits so effortlessly when it takes some of us months of practice? Although flexibility can be improved later in life, some of us are born with bendy joints (hypermobility) which might be advantageous to certain sports like cheer and dance, but is hypermobility truly a gift?


Definition


Before going into details, let's go through some confusing concepts together.

Flexibility refers to the ability of muscles at a joint to move through an unrestricted, normal range of movement.


Hypermobility refers to a range of movement that exceeds what is considered to be 'normal', taking into account the person's age, gender, and ethnicity.

A 4/9 Beighton score (see below) for adults and 6/9 in children is considered to be positive for hypermobility.


Flexibility =/= hypermobility. You can be very flexible to move within a 'normal' joint range of movement but not hypermobile, and vice versa.


Causes


Collagen imbalance is the major cause of hypermobility. Type I collagen has a high tensile strength and normally makes up most of the joint capsules, tendons, and skin. Type III collagen is stretchy and mostly abundant in the gut and blood vessels. The composition of collagen is dependent on genetics. If a person is born with more type III collagen in connective tissues, he/she is more likely to be hypermobile.


Adolescence

  • Hormonal Changes. The increase in progesterone (a hormone that regulates menstruation) during adolescence can increase the laxity of connective tissues, especially in females.

  • Growth spurt. During adolescence, bones grow faster than muscles, leading to a temporary muscle imbalance in joints, which can cause instability. Repetitive movements into extreme joint ranges in sports like cheerleading, dance, or gymnastics can further increase muscle imbalance without proper strength training.


Complications


Even though hypermobility might seem to be a superpower, it comes with a price...

About 20% of our population has hypermobility and of which, 10% have physical or psychological symptoms with it.

2017 Castori et al. defined hypermobility as a spectrum (see below). It ranges from being asymptomatic to having Ehlers-Danlos Syndrome (EDS).

Ehlers-Danlos Syndrome (EDS) is a heritable connective tissue disorder. Depending on the type of EDS, symptoms include joint laxity, hernias, fatigue, anxiety, bladder prolapse, gastrointestinal dysmotility, abnormal skin scarring, and more. These symptoms can be very debilitating and greatly impact a person's quality of life and psychological health.


However, being asymptomatic doesn't mean problem-free. Hypermobility increases the likelihood of sustaining an injury in sports due to reduced stability and proprioception. Common injuries include sprains, subluxations, dislocations, and chronic joint pain. Liaghat et al., in 2021, suggested that the hypermobile population is three times more likely to sustain a shoulder injury compared to those without.


Conservative Management


  • Exercises to improve strength, stability, and proprioception.

    • Start with mid-range to avoid pain in extreme ranges and progress through the range (yes! Into hyperextension!). Pacey et al. (2013) suggested that strengthening exercises at the end range can improve psychosocial health in the hypermobility population.

    • Use of mirrors and resistance bands to increase proprioceptive feedback.

    • Exercises that strengthen the whole kinetic chain to improve motor control.

    • Here are some examples:

Early stage rehab:


  1. Holding a plank



2. Wall sits



Later stage rehab:


  1. Resisted Bird Dog


2. Step Ups with Banded Arm Elevation




  • Pacing means breaking down activities into smaller and more manageable tasks and adding rest time between tasks. This can help manage fatigue and flare-ups.


Other management includes braces, NSAIDs for pain, and supplements like vitamin D and iron tablets. Please consult your GP for more information. For EDS patients, you should consult a rheumatologist for appropriate medical management.


Take Home Messages:


  1. Flexibility is not hypermobility. You can be very flexible and move within a 'normal' joint range of movement but not hypermobile.

  2. Growth spurt and hormonal changes in adolescence can impact the mobility and stability of joints.

  3. Hypermobility comes in a spectrum of symptoms, from asymptomatic to having EDS.

  4. Exercises, taping, and pacing are some strategies to manage hypermobility conservatively.


References


Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F., & Hakim, A. (2017, March). A framework for the classification of joint hypermobility and related conditions. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics (Vol. 175, No. 1, pp. 148-157).


Engelbert, R. H., Juul‐Kristensen, B., Pacey, V., De Wandele, I., Smeenk, S., Woinarosky, N., ... & Simmonds, J. V. (2017, March). The evidence‐based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers-Danlos syndrome. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics (Vol. 175, No. 1, pp. 158-167).


Liaghat, B., Pedersen, J. R., Young, J. J., Thorlund, J. B., Juul-Kristensen, B., & Juhl, C. B. (2021). Joint hypermobility in athletes is associated with shoulder injuries: a systematic review and meta-analysis. BMC musculoskeletal disorders, 22, 1-9.


Malfait, F., Francomano, C., Byers, P., Belmont, J., Berglund, B., Black, J., ... & Tinkle, B. (2017, March). The 2017 international classification of the Ehlers–Danlos syndrome. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics (Vol. 175, No. 1, pp. 8-26).


Malek, S., Reinhold, E. J., & Pearce, G. S. (2021). The Beighton Score is a measure of generalized joint hypermobility. Rheumatology International, 41(10), 1707-1716.


Pacey, V., Tofts, L., Adams, R. D., Munns, C. F., & Nicholson, L. L. (2013). Exercise in children with joint hypermobility syndrome and knee pain: a randomised controlled trial comparing exercise


Accessed 11/5/2024


Pate, R., Oria, M., & Pillsbury, L. (2012). Health-related fitness measures for youth: flexibility. In Fitness Measures and Health Outcomes in Youth. National Academies Press (US).


Simmonds, J. V., & Keer, R. J. (2007). Hypermobility and the hypermobility syndrome. Manual therapy, 12(4), 298-309.



 

Our blogs and articles are not designed to replace medical advice. If you have an injury, we recommend seeing a qualified health professional. We offer both in-person assessments and online consultations!


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