Hypermobility: Understanding Joint Laxity, Symptoms, Causes, and Management

What is True About Hypermobility?

Hypermobility refers to joints that can move beyond their typical anatomical range, often termed "double-jointedness." While it can be a benign characteristic, for some individuals, it leads to symptoms and requires specific management strategies focused on stability and strength.

Understanding Joint Hypermobility

Joint hypermobility, also known as joint laxity or "double-jointedness," describes the ability of a joint to move beyond its normal anatomical limits. It is a common characteristic, affecting a significant portion of the population, particularly children and women. While often perceived as a unique flexibility, it exists on a spectrum, ranging from localized hypermobility (affecting one or a few joints) to generalized joint hypermobility (affecting multiple joints throughout the body).

It's crucial to understand that hypermobility itself is not inherently a disorder. Many individuals with hypermobile joints experience no pain or problems and may even find it advantageous in certain activities like gymnastics or dance. However, when hypermobility leads to symptoms such as pain, instability, frequent sprains, or dislocations, it then becomes clinically significant and may be diagnosed as Hypermobility Spectrum Disorder (HSD) or, in rarer cases, Hypermobile Ehlers-Danlos Syndrome (hEDS).

Causes of Hypermobility

The underlying causes of joint hypermobility are primarily genetic and relate to the structure of connective tissues, particularly collagen. Collagen is a fundamental protein that provides strength and elasticity to ligaments, tendons, skin, and blood vessels.

Key contributing factors include:

• Genetic Predisposition: A family history of hypermobility is common, indicating an inherited genetic component that affects collagen synthesis or structure, leading to more elastic and less rigid connective tissues.
• Ligament Laxity: Ligaments, which connect bones to other bones and stabilize joints, may be inherently more elastic or "stretchy" in hypermobile individuals.
• Bone Shape: The shape of the bone ends forming a joint can sometimes contribute to increased range of motion.
• Muscle Tone and Strength: While not a primary cause, lower muscle tone or insufficient muscle strength around a joint can contribute to instability in an already lax joint.
• Proprioception: Some research suggests that altered proprioception (the body's awareness of its position in space) may play a role, as individuals might not accurately sense their joint's position, leading to overextension.

Recognizing Hypermobility: Signs and Symptoms

Recognizing hypermobility involves observing specific physical signs and understanding potential associated symptoms.

Common Physical Signs:

• Excessive Joint Range of Motion: The most obvious sign is the ability to move joints further than typically expected (e.g., hyperextending elbows or knees, touching thumbs to forearms).
• "Double-Jointed" Appearance: Often used colloquially to describe individuals with noticeable hypermobility.
• Clicking or Popping Joints: While common in non-hypermobile individuals, it can be more frequent in hypermobile joints due to increased laxity.

Potential Associated Symptoms (when symptomatic):

• Joint Pain: Often chronic and widespread, varying in intensity. It can be due to increased stress on joint structures, muscle fatigue from overcompensation, or microtrauma.
• Joint Instability: A feeling that joints might "give way" or are not securely held.
• Frequent Sprains and Subluxations/Dislocations: Due to lax ligaments, joints are more prone to injury from minor trauma or even everyday movements.
• Fatigue: Generalized fatigue is common, potentially due to the increased muscular effort required to stabilize joints.
• Proprioceptive Deficits: Difficulty with balance and coordination due to reduced feedback from lax joints.
• Muscle Weakness: Paradoxically, despite increased flexibility, surrounding muscles may be weak or easily fatigued trying to stabilize lax joints.
• Bruising Easily: Can be a systemic symptom related to fragile connective tissue, more common in HSD/hEDS.
• Autonomic Dysfunction: Conditions like Postural Orthostatic Tachycardia Syndrome (POTS) can be co-occurring in more severe hypermobility disorders.

Assessing Hypermobility: The Beighton Score

The Beighton Score is a widely used, simple, 9-point scale to assess generalized joint hypermobility. It evaluates the range of motion in specific joints, with each positive test contributing one point.

The assessment includes:

1. Passive Dorsiflexion of the 5th Metacarpophalangeal Joint: Extend the little finger back to 90 degrees or beyond (1 point for each hand).
2. Passive Apposition of the Thumb to the Forearm: Touch the thumb to the forearm (1 point for each hand).
3. Hyperextension of the Elbow: Elbow extends beyond 10 degrees (1 point for each arm).
4. Hyperextension of the Knee: Knee extends beyond 10 degrees (1 point for each leg).
5. Forward Trunk Flexion with Knees Extended: Place palms flat on the floor with knees straight (1 point).

A score of 4 or higher (in adults) typically indicates generalized joint hypermobility, though thresholds can vary by age and ethnicity. It's important to note that the Beighton Score assesses generalized hypermobility and does not diagnose a specific hypermobility disorder on its own.

Hypermobility Spectrum Disorder (HSD) vs. Hypermobile Ehlers-Danlos Syndrome (hEDS)

For individuals experiencing symptoms related to their hypermobility, a diagnosis is often sought. The distinction between Hypermobility Spectrum Disorder (HSD) and Hypermobile Ehlers-Danlos Syndrome (hEDS) is critical.

• Hypermobility Spectrum Disorder (HSD): This diagnosis is given to individuals with symptomatic joint hypermobility who do not meet the stricter diagnostic criteria for hEDS or any other specific connective tissue disorder. HSD is a broad term, encompassing a range of presentations from localized joint pain to widespread symptoms, all rooted in joint hypermobility. The severity and impact on daily life can vary significantly among individuals with HSD.
• Hypermobile Ehlers-Danlos Syndrome (hEDS): This is a specific, heritable connective tissue disorder characterized by generalized joint hypermobility, skin hyperextensibility, and tissue fragility, along with a range of other systemic manifestations. The diagnostic criteria for hEDS are more stringent and require the presence of specific additional systemic features beyond just joint hypermobility. hEDS is considered a more severe and complex condition than HSD, often involving multi-systemic issues.

Both conditions are managed similarly in terms of physical therapy and symptom management, but the diagnostic distinction is important for understanding potential co-occurring conditions and long-term implications.

The Benefits of Hypermobility

While often discussed in the context of challenges, hypermobility can offer distinct advantages in certain fields:

• Athletic Performance: Athletes in sports requiring extreme flexibility, such as gymnastics, dance, figure skating, martial arts, and certain yoga disciplines, can benefit significantly from an increased range of motion. This allows for aesthetically pleasing movements and complex maneuvers.
• Reduced Risk in Certain Injuries: In some contexts, increased joint flexibility may paradoxically reduce the risk of certain acute injuries by allowing joints to absorb greater forces before reaching their anatomical limits. However, this is balanced against the increased risk of instability and chronic issues.

Potential Challenges and Risks Associated with Hypermobility

Despite potential benefits, symptomatic hypermobility can lead to several challenges and increased risks:

• Chronic Pain: Persistent joint and muscle pain is a common complaint, often due to the increased strain on supporting structures.
• Joint Instability and Injury:
  • Sprains: Ligaments are stretched or torn more easily.
  • Subluxations and Dislocations: Joints can partially or fully come out of alignment with minimal trauma.
• Early Onset Osteoarthritis: Chronic instability and repetitive microtrauma to joints may accelerate cartilage degeneration, leading to earlier development of osteoarthritis.
• Proprioceptive Impairment: Reduced joint position sense can lead to clumsiness, poor balance, and an increased risk of falls.
• Muscle Fatigue and Weakness: Muscles must work harder to stabilize lax joints, leading to quicker fatigue and, paradoxically, perceived weakness.
• Soft Tissue Injuries: Tendinopathy and muscle strains can be more common due to altered biomechanics and compensatory movements.
• Systemic Manifestations: In HSD and especially hEDS, non-musculoskeletal issues can arise, including fatigue, autonomic dysfunction (e.g., POTS), gastrointestinal problems, anxiety, and skin fragility.

Managing Hypermobility: Exercise and Lifestyle Strategies

Effective management of symptomatic hypermobility focuses on enhancing joint stability, improving proprioception, and strengthening the surrounding musculature, rather than increasing flexibility.

• Prioritize Strength Training:
  • Focus on Stability: Emphasize exercises that build strength around the joints, particularly isometric holds and controlled eccentric movements.
  • Compound Movements: Incorporate exercises like squats, deadlifts, and presses with proper form to build global strength.
  • Low Reps, Moderate Weight: Focus on quality of movement and muscle engagement over heavy lifting.
  • Core Strength: A strong core is fundamental for spinal stability and overall body control.
• Enhance Proprioception and Balance:
  • Balance Exercises: Single-leg stands, unstable surface training (e.g., wobble boards, foam pads).
  • Mindful Movement: Consciously engaging muscles to stabilize joints during daily activities.
• Avoid Overstretching and Hyperextension:
  • Limit Passive Stretching: Focus on active range of motion within stable limits.
  • Awareness: Learn to recognize and avoid "locking out" or hyperextending joints during exercise and daily tasks.
• Low-Impact Activities:
  • Swimming, Cycling, Elliptical Training: These activities provide cardiovascular benefits with less joint impact.
• Pain Management:
  • Heat or Cold Therapy: For localized pain relief.
  • Anti-inflammatory Medications: Over-the-counter options, or prescription under medical guidance.
  • Manual Therapy: Physiotherapists or osteopaths can help address muscle imbalances and joint restrictions.
• Pacing and Energy Conservation: For individuals with significant fatigue, learning to pace activities and conserve energy is crucial.
• Proper Footwear and Support: Supportive shoes and, if necessary, orthotics can help stabilize the feet and ankles. Bracing may be used for specific unstable joints under professional guidance.

When to Seek Professional Guidance

While benign hypermobility often requires no medical intervention, it is important to seek professional guidance if:

• You experience persistent or worsening joint pain.
• You have frequent joint sprains, subluxations, or dislocations.
• Your hypermobility interferes with daily activities or exercise.
• You experience significant fatigue, bruising, or other systemic symptoms.
• You suspect you might have Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS).

A doctor, physical therapist, or kinesiologist experienced in hypermobility can provide an accurate diagnosis, develop a personalized exercise program, and recommend appropriate management strategies.

Conclusion

Hypermobility is a spectrum of joint laxity, ranging from a harmless characteristic to a complex condition that can significantly impact quality of life. Understanding what is true about hypermobility involves recognizing its genetic basis, the potential benefits in certain activities, and the challenges it can pose when symptomatic. Effective management hinges on a proactive approach that prioritizes joint stability through targeted strength training, proprioceptive exercises, and mindful movement patterns, empowering individuals to manage their condition and live active, fulfilling lives.