An intro to Hypermobility

Joint Hypermobility facilitates movement and therefore favours selection into dance. Great right? But what are the pitfalls?

In 2015 we had a young professional performer come into the clinic. She had recurrent injuries, mainly affecting her knees and ankles, and had seen numerous physios and trainers – been issued training plan upon training plan, where injury continued to outweigh progression. How did she feel? Anxious, tentative during training and powerless against another inevitable injury – WHY did this keep happening? We started by talking through her complex history, including not only joint pain but chronic fatigue, gastrointestinal issues and cardiovascular symptoms, it was clear that there was something else going on. After a biomechanical assessment, identifying hypermobile joints was no surprise. To investigate the other symptoms outside of our remit to diagnose as a Physiotherapist we referred her to a trusted colleague, an orthopaedic consultant with a keen interest in hypermobility and a cardiologist. A few tests and consultations later, our client was given the diagnosis of Hypermobility Syndrome, which is different to the more commonly known joint hypermobility

Hypermobility Syndrome includes symptoms including chronic fatigue, gastrointestinal issues and cardiovascular symptoms to name a few. With this diagnosis, we were able to create a management plan that allowed her to continue to train and more importantly progress. The client went from feeling lost, frustrated and somewhat unmotivated to now having an in-depth understanding of what is going on within her body, why the symptoms present as they do, and how they can be managed to make way for optimal performance

Joint hypermobility (JH) is a common connective tissue condition and is marked as exceptional joint mobility. Individuals often present with recurrent dislocations, traumatic or overuse soft tissue injuries or low-grade inflammation. Although hypermobility in dancers is considered one of the factors associated with talent and highly desirable, it also increases the risk of injury and also lengthens the time it takes to recover from injury. Symptoms include decreased physical fitness and muscle strength and global fatigue. The injury risk is related to the structural reality that greater connective tissue (ligament, tendon and fascia) structural laxity increases the demand on muscles to provide joint stability and absorb force, this is often extremely challenging for the individuals’ system to meet.

Within the hypermobility spectrum, there is Joint Hypermobility Syndrome (JHS) which is a benign multi-system genetic condition that also affects the connective tissue. However, it has widespread features such as fatigue, uterine or rectal prolapse, chronic pain and GI dysmotility to name a few. As you can imagine this can often present as a complex clinical picture, and one which is commonly overlooked.

There is a hormonal aspect in both JH and JHS, and this is because hyper lax joints are more symptomatic by progestogens; therefore symptoms can be exacerbated at the time of menstruation and times of chronic hormonal imbalances (for example, stress). Often it can be seen that polycystic ovaries and endometriosis can be diagnosed from symptomatic joints before a diagnosis is made by a gynaecologist.

Rehabilitation should include strength, cardiovascular, and trunk stability (commonly referred to as core stability) training. Although these areas of rehab are paramount for all performers, there is a greater need to include them for the hypermobile performer along with more specific considerations within their programming. Other areas that need addressing are pacing, coping and behavioural strategies, avoiding resting in end-range positions and improving joint proprioception.

Some common pitfalls which we are faced with hypermobility are that it is often overlooked (more notably the hypermobility syndrome patients). They can be misdiagnosed and therefore, inappropriately treated with modalities such as drug therapy, surgery and overenthusiastic manipulation and manual therapy. However, slowly, awareness in this vast area is increasing.

Testing for Hypermobility

Beighton Score

This is a scoring system which has been used for years as an indicator of widespread hypermobility. It can be seen more as a research tool and a quick indicator of generalised hypermobility. As a clinical tool, it’s quick and straightforward but should not be relied upon as the gospel in terms of diagnosis of general hypermobility. Here are two important things to consider when using this scoring system.

  1. A high Beighton score does not mean that the individual has hypermobility syndrome. Other symptoms also need to be present, which we will go into next time.
  2. The joints that are assessed are set to 5 specific movements/tests, a low score should also be considered when assessing someone with widespread pain. This is because hypermobility can be present in some joints that are not on the Beighton testing list, including the jaw (TMJ), shoulders, hips, and ankles.
Figure 1 : how the Beighton scoring system is implemented. Each test corresponds to one of the pictures in Figure 1
Table 1 : how the Beighton scoring system is implemented. Each test corresponds to one of the pictures in Figure 1

So, what is tested?

Some issues with the Beighton scoring system are that the joints were not specifically selected to accurately reflect generalised hypermobility and therefore need to take into consideration hypermobility in other joints. It was chosen on a functional basis, for ease and efficiency without the need for equipment, to give an indication of a widespread level of mobility that require further investigation. However, this resulted in two-thirds of the joints being upper limb and many of the major joints disregarded, with only a single plane of joint movement being measured. The measuring system is ‘all or nothing’, which determines the presence of hypermobility and gives no indication of its severity or direction.

Validity when using the Beighton scale is questionable, and it’s important to be aware of this when using it. As always, a clinical assessment and history taking are crucial to gain the full picture. Alternative tools to measure hypermobility do exist, which we will delve into another time. However, with over 300 joints in the body, it is unlikely that any single assessment method will ever truly capture all variable presentations of generalised joint hypermobility.

If we now venture into the realms of hypermobility syndrome – with the Beighton score being the initial assessment for joint hypermobility. Historically, a score of 4/9 or higher is generally considered to be a good indication of hypermobility syndrome. However as previously mentioned the Beighton score is a quick assessment of joint hypermobility and is not the sole criteria for a cast-iron diagnosis. The next clinical step is utilising the Brighton criteria, which includes other major and minor indicators for a more comprehensive diagnosis of hypermobility syndrome.

Table 2 : Brighton Scoring system

The Brighton criteria

Benign hypermobility syndrome is a relatively prevalent condition of the spectrum of heritable connective tissue disorders, with musculoskeletal, visceral and psychological manifestations.

The diagnostic Brighton criteria characterises hypermobility findings into ‘major’ and minor’ categories (table 2). Benign joint hypermobility syndrome is diagnosed in a few ways. Firstly, the presence of 2 major criteria, or secondly 1 major and 2 minor criteria, or finally 4 minor criteria. Within some of these criteria is the Beighton score which we discussed in the previous hypermobility post, mentioned earlier.

Although there has been a lot of research into joint hypermobility syndrome it still remains insufficiently identified, inadequately understood and very commonly, poorly managed by practitioners. It is very common for patients often get pin-balled around from doctor to physiotherapist to chiropractor etc without an appropriate diagnosis or management plan. This is something we feel strongly about, and this needs to improve for the long-term health of performers.

Table 3 : Adapted from: Malfait F, Francomano C, Byers P, Belmont J, et al. The 2017 International Classification of the Ehlers-Danlos syndromes. Amer J Med Genetics 2017; 175c (1): 8–26.

If Hypermobility Syndrome is suspected then alternative causes of generalised joint laxity need to be ruled out, these include heritable connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, Larsen syndrome and osteogenesis imperfecta (some are listed in table 3). Often patients with one of these conditions are initially labelled hypermobile due to their generalised joint laxity; however, the underlying cause is often left undiagnosed.

These patients can also present with significant cardiovascular, skin, bone and eye abnormalities. If one or more of these are identified then onward referral is required, and working with a wider multidisciplinary team (MDT) is essential, such as a doctor, geneticist, and/or nutritionist etc. This enhances care due to the overlap in the common area of hypermobility but different approaches due to the specialisms in their different fields. The common features of these syndromes can be seen in Table 3.

The lack of awareness of joint hypermobility syndrome may delay the diagnosis and effective care of the condition, in turn exacerbating symptoms and making the journey to accurate diagnosis longer and more uncomfortable. There is no cure, so management is the route of care and this can be very successfully achieved when the condition and the individual’s drivers are identified.

How hypermobility affects performers

The number of times we have spoken with hypermobile performers who call themselves clumsy is numerous, the interesting thing is that there is a physiological mechanism behind this. Hypermobiles have a reduced proprioceptive ability which means that their awareness of their joints position in space is significantly reduced compared to non-hypermobiles, as well as the defensive mechanisms around bracing the joints of the peripheries is reduced and slower than non-hypermobiles. This reduces their automatic muscular bracing and adjustments around a joint to accommodate uneven surfaces or obstacles that may be tripped over or avoided late. Further increasing the risk of things like ankle sprains.

Although the underlying increase in tissue compliance and mobility is incredibly desirable in performers, it can be a bit of an issue when it comes to quickly stiffening tissue to absorb force effectively. The lack of innate tissue stiffness causes the connective tissue to lengthen under force which can be difficult to control once the momentum is gathered, this makes the bracing effect around joints a key component of a hypermobile performance conditioning.

Again, the increased range of motion that hypermobiles have needs to be controlled. Control in these longer lengthened ranges is more difficult as the muscles are naturally weaker in these longer positions. This makes strength training a vital component in helping hypermobiles’ control this larger range of motion, and strengthening within these longer ranges is incredibly advantageous.

Another interesting but uncommonly known effect of being hypermobile is the fact that tissue healing times take longer for hypermobiles and often the quality of the scars are lower due to its increased mobility. This highlights a greater need for strengthening work in any rehabilitation process for hypermobiles sustaining strain or sprain injuries.

General management guidelines

To briefly summarise the hypermobiles management plan, it should include:

  1. Exercise: absolutely essential, including appropriate strength training and proprioception training
  2. Rehab and training plans need to be closely managed as progressed/regressed in order to avoid tissue/joint overload, which in turn leads to pain and/or injury
  3. Pacing and managing symptoms
  4. Manual therapy must be used cautiously
  5. Knowing when referral is needed (cardiologist, orthopod etc) and then working closely with them is essential.

Do any of these tables of symptoms seem familiar, if you’re a clinician have you worked with any patients with hypermobility syndrome? How have you managed it? And if any of the above sounds like you, as a performer, rest assured there are strategies available to maximise your performance and control any pains you may suffer.

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"Barry and Sophie have always been brilliant and crucial physiotherapists for me during my career. Taking the time to really listen and understand everything regarding my injuries from years of being a professional dancer and performer on stage and on screen. From physical treatment to equipping me with the necessary knowledge and exercises for rehabilitating myself in between in-person sessions to speed up recovery. I will always highly recommend Production Physiotherapy to anyone seeking physical help as they have saved me on uncountable occasions!"

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“When I arrived in January 2013 I was in such pain and discomfort from a long year of training and racing triathlons. Ending with an Ironman in Late November. I was suffering with what I thought was a hip problem. I was REALLY struggling. Through our sessions together not only did Barry help relieve the discomfort , he educated me with body mechanics and exercises to help heal and prevent future problems. I came to the UK barely able to run 100m , and last weekend completed half marathon with a personal best. You saved my Life Mate!”

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