Joint hypermobility

About generalised joint hypermobility

The term generalised joint hypermobility (GJH) is used when a person has several joints that are more flexible than usual. This happens when the connective tissue which makes up the joint structures (capsule and ligaments) is more compliant (more easily stretched) than usual.  

Generalised joint hypermobility is quite a common occurrence - in fact it is just a normal variation in the way joints are put together. Most  ballet dancers and gymnasts have a degree of joint hypermobility - which means that you can be hypermobile, strong, active and fit.

Yet many children with hypermobile joints have movement difficulties. Why is this and what can be done to overcome these difficulties? 

A word about terminology

The term Joint Hypermobility Syndrome refers to a health condition which includes joint hypermobility along with pain and loss of function along with several related symptoms such as fibromyalgia, anxiety, low blood pressure and fatigue. 

Some people with very hypermobile joints which are unstable and may or may not partially dislocate also have a diagnosis of Ehlers Danlos Syyndrome (Hypermobility Subtype). People with a diagnosis of Ehlers Danlos have a genetic disorder which affects the structure of the connective tissue that holds the joint in place (joint capsule and ligaments) and connects the muscles to the bones via tendons and fascial sheaths. The poorly formed connective tissue also affects the skin which is velvety and very pliable (easily stretched). 

Please see the article by Tofts et al  (2009)   The differential diagnosis of children with joint hypermobility

A child with Erlos Danlos should be under the care of a paediatric rheumatologist and a physiotherapist with experience in this condition. 

Please note that this page provides information on children with generalised joint hypermobility. It does not apply directly to children who have Ehlers Danlos Syndrome (Hypermobility Subtype) or a diagnosis of joint hypermobility syndrome.


What is generalised joint hypermobility?

Joints are held together by a joint capsule and  ligaments which are made up of connective tissue. Connective tissue is a stiff but pliable material that has a just enough give give to allow joint capsule and ligaments to stretch a little bit,when the joint is moved  but still hold the joint surfaces together quite firmly. .

In generalised  joint hypermobility  the connective tissue has more give – it stretches more easily and  as a result  the joint is able to move further than normal and are less stable. 

Typical knee and elbow joints  can straighten to 1800. In children with joint hypermobility these joints can be straightened beyond 180to create a backwards bend. 

When a child with hypermobile knees stand, the knees bend backwards in such a way that the knees lock into position and the quadriceps muscles do not have to work to keep the joint steady.

This is fine as long as the knee is locked – but as soon as the knee is bent a little, the quadriceps muscles have to work to keep the knee straight and if they are not strong enough the knee is less stable.

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Hypermobile fingers can be bent back to 900 .

The wrist can be bent so the the thumb touches (or nearly touches) the forearm.

 

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The joints in the fingers and thumbs  also bend backwards. 

The increased flexibility in the fingers make the hands less stable and the muscles have to work a lot harder when using the hands to grip, lift and manipulate objects.  

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The hips, spine and ankles are also affected by increased laxity in the connective tissue.

The legs flop out sideways when sitting flat on the floor,  especially when the child is very young.  

The child may have flat feet., especially if the ankle muscles are weak. 

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Loose joints - some tight muscles 

Children with generalized joint hypermobility often have some tight muscles. This can be confusing.

The muscles tightness develops because of the postures the infant with hypermobile joints assume when sitting on the floor. They often sit with the legs wide apart , sometimes with a flexed spine. This leads to tightness in the muscles that cross over the back and sides of the hip and knee joints. 

As a result of the stiffness the child has difficulty sitting with the legs stretched forwards, may find sitting cross legged uncomfortable and has difficulty sitting erect on a chair. 

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Infants with joint hypermobility

Infants with joint hypermobility are often late learning to crawl and may not crawl at all, instead move around on their bottoms. They are slow to pull up into standing and often only learn to walk at 18 about months. 

An infant with joint hypermobility who sits with the legs wide apart will usually have some tightness in the hip muscles which affects their learning to crawl and walk. Gentle active stretching of the tight muscles is important in order to prevent later problems with  knee and back pain.

Muscles laxity (low muscle tone) and generalised joint hypermobility

Muscles are also held together by sheaths of connective tissue which provide them with a small amount of natural stiffness – sometimes referred to as muscle tone.  

In people with joint hypermobility, the muscle sheaths are also more pliable which means that the muscles have less inherent stiffness and give more easily.  The muscles have less muscle tone.  

The stiffness in the muscles also means that the forces generated by the muscles as they contract are easily transferred to the bones to produce movement and stability.   Because the muscles of children with hypermobility have more give,  they are less efficient at transferring force from the the muscle contraction to the bones. This means that the muscles have to work harder to produce movement and provide stability. 

The apparent low muscle tone can be improved by strengthening the muscles. Strong muscles always have good tone. 

Children with joint hypermobility, muscle weakness and possibly poor coordination are more likely to complain of  pain and tiredness and are more likely to suffer from joint sprains. Weak muscles are less able to able to protect the joints during during everyday activities that require a degree of fitness and agility.  

What causes joint hypermobility?

The degree of compliance (stretchiness) in connective tissue is genetically determined. Between 10 and 20% of people have connective tissue that is more pliable ( less stiff)  than usual.

So some degree of joint hypermobility can be viewed as part of the  normal variation of  in the degree of compliance in the connective tissue within the population.  

Children with generalised joint hypermobility will usually have a parent or other close relative with hypermobility.

Having hypermobile joints is often seen as a plus factor, particularly in gymnastics and ballet dancing.  To be a ballerina you have to be hypermobile.

Hypermobility is also not always associated with movement difficulties. In my experience as a children's physiotherapist,  it is the combination of hypermobility, some muscle tightness and a very cautious nature that leads to movement difficulties.

How is joint hypermobility diagnosed 

If a child has 5 or more joints that are more flexible than usual, he or she can be said to have generalised joint hypermobility.  The movements that are usually considered are finger extension, wrist flexion, elbow extension, hip rotation, knee extension and ankle flexion. (For more detail see the Generalised Joint HypermobIlity on the Developmental Gym website

Postural and movement difficulties children may have 

Sitting

Poor posture and discomfort , fidgets and tires quickly

Knees

 Night pain and pain walking or after exercise 

Back: and neck

Pain, stiffness and weakness 

Feet and ankles 

Flat feet and weak calf muscles 

Running

Awkward style, slow and poor endurance 

Shoulders and arms 

Poor flexibility, weakness and poor coordination 

Handwriting and drawing 

Poor graphic skills, hand tires, handwriting slow and untidy

Ball skills 

Poor catching and throwing skills 

Swimming 

Crawl stroke difficult, cannot keep legs up

Walking up and down stairs 

Cautious, holds on to banister,  goes one step at a time

Walking distances and uphill 

Tires quickly, complains of knee pain 

Monkey bars 

Cannot swing from bars at age 6. 


Generalised joint hypermobility is associated with a range of physical and psychological difficulties 

Joint hypermobility is caused by the increased compliance (stretchiness or give) in the connective tissue that makes up the structures that hold the joints together (joint capsule and ligaments). This increase compliance also affect connective tissue in other parts of the body, and this may cause a number of problems including:

  • Bladder problems and bed-wetting
    Low blood pressure
    Esophageal reflux

Hypermobility is also associated with a cautious natureCautious children tend to avoid physical effort - which means that they do not get the exercise needed to strengthen their muscles to support their hypermobile joints.

Children with joint hypermobility may be very anxious and respond to challenging situations with refusal, freezing or outbursts.  

Children with joint hypermobility often complain of leg and back pain

The combination of loose joint structures (ligaments and capsule)  along with muscle weakness and some tight muscles causes abnormal stresses on knee joints which in turn leads to knee pain after exercise or at night. More about leg pain

Children with joint hypermobility may also experience back pain due to poor posture and muscle weakness.

Different development - how joint hypermobility affects infants 

The amount of flexibility in the joints and muscles affects a baby's posture and movement from birth. babies naturally have a degree of stiffness in their hips and shoulders from lying in the curled up position in the womb. This stiffness supports the babies limbs in a degree of flexion which counteracts the ever present downward pull of gravity on the body. Children with joint hypermobility do not have this inherent springiness in their joints and muscles, and as a result gravity affects their posture and movement in different ways.   Read more

Joint hypermobility is associated with other developmental disorders 

Autism, joint hypermobility and poor movement skills

Highly sensitive / very cautious child and joint hypermobility

DCD and dyspraxia and joint hypermobility

How to help your child with joint hypermobility 

Children with joint hypermobility syndrome usually have muscle weakness, especially of the postural muscles, some tightness of muscles as a result of habitual poor posture, and poor endurance.

The child may also avoid strenuous physical activity - and may need extra help to take on physical activities that require effort.

Children with difficulties associated with joint hypermobility respond well to a program of exercises to increase muscle strength and endurance, stretch tight muscles, improve coordination and take on challenging tasks. 

How to help your child, starting today    

What exercises should we be doing - and how do I motivate my child to work hard at getting fitter?

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Comments

Thank you for your webpage!

I am a mother of two boys and also a doctor. I developed psoriatic arthritis in the last year and on seeing the rheumatologist she remarked on my joint hypermobility and linked it to my low blood pressure. There is a family history of hypermobility in my mother and brother. I have recently discovered that my nearly-four year old son has joint hypermobility that is causing some gross and fine motor delays. I took him to a physiotherapist about his flat feet and then it all fell into place when she thoroughly examined him - why he has long refused to walk distances that other children his age seem to relish, why he has demanded to go in the pram long after children his age seem to have moved out of theirs, and why he can't hold scissors properly, use a correct pencil grip or keep up with his friends when they are all running. Being a doctor I was reluctant to pathologise these things and was adamant that he will catch up in his own time, but it has been a relief to finally understand some of the things I've described. Now, reading your webpage I have had further lightbulb moments about my son and also about myself (including why I've always bruised easily despite having normal clotting times). Thank you. I just wanted to write to let you know the positive impact you've had on our little world from afar.
Nicole

hypermobile 9 year old who is very athletic

walked at 8 months, learnt to dribble a football at 12 months. KNees and elbows overbend, he can do the splits no problem, can touch his whole hand too his arm bending at the wrist.

He gets bad knee pains from sport, but really loves to play. He gets growing pains as well. Is tall, doctor reckons he will top out at 6ft4+

I want to find some way to minimise the issues with his knees?

Strengthening and stretching tight muscles

Hello and thank you for your question. 

Your best bet is to get an appointment with a physiotherapist who has a special interest in hypermobility and has some sports physiotherapy background for a full assessment and suggestions for exercises for your son. 

Pain in the knees is often associated with tightness in the iliotibial band .(ITB) and gentle active stretching can be useful in relieving pain. Specific strengthening of the quadriceps muscles has also been shown to be helpful in relieving knee pain in children with hypermobility. 

Before you start an exercise  program it is important to check with your GP that there is specific knee disorder causing the pain.  

Read more: Leg pain and gentle  stretches before going to sleep which can ne useful in the case of night pain. 

Pam

Get him into swimming

Hypermobility (especially in the ankles, knees, and shoulders) is a huge benefit to a swimmer. The sport is low impact and will build strength in surrounding muscles. I myself am very hypermobile and although i wasn't the strongest it helped me reach the Olympics.

hypermobility or cerebal palsy?

My 2.5 year old daughter has recently been diagnosed with cerebral palsy. This was picked up at her 2 year review as she was in toeing and presented with poor coordinaton and balance. She was referred to a paediatrician to made the diagnosis after observing her.

An MRI followed which came back clear however the diagnosis remained. We cannot understand as her birth and my pregnancy was fine. At an appointment with the OT and physiotherapist she was diagnosed with hypermobility which explained her w- sitting and poor posture and occasionally falling. My question is could this be in addition to the cerebral palsy or could this be the actual problem and not cp at all due to her textbook birth. My daughter also has a speech delay, can this be a speech delay in its own right with hypermobility or is it more likely to be cerebral palsy. This is all very new to me as she has only recently been diagnosed at 2.5 yrs and i have stumbled across this webpage and it seems so knowledge i would really appreciate your advice.
many thanks
julie

Intoeing gait

Hello and thank you for your question

An intoeing gait is usually associated with an excessive range of inward rotation coupled with limited external rotation of the hips when the hips are in extension.

This abnormal range of movement at the hips is commonly associated with joint hypermobility along with an imbalance in the strength and flexibility of the hip muscles. This combination of abnormal joint range and muscle imbalance also goes with idiopathic toe walking. What is important is that   the muscle tone and reflexes are normal.

Cerebral palsy is a less common cause of abnormal hip rotation and tight muscles. A child with mild cerebral palsy will usually also have increased muscle tone especially in the calf muscles along with changes in the tendon reflexes and also has a tendency to walk on the toes. 

Poor coordination and balance can be due to developmental coordination disorder (DCD). It is interesting to note that DCD is often associated with language disorders and hypermobility. 

I am sure that your child's paediatrician based the diagnosis of cerebral palsy on a full consideration of a full neurological examination, including abnormal reflexes and the presence of abnormal movement patterns and muscle tone.  

Whatever the underlying reason for your child's intoeing gait and tendency to fall it is very important to work with the physiotherapist to improve and maintain your child's flexibility, improve muscle strength, balance and coordination. This can be quite tricky in a 2 1/2 year old who have ideas of their own and do not like to follow instructions. 

Pam

 

intoeing

Wow Pam thank you so much for your thorough and knowledgeable advice. I am both relieved and happy to have found this webpage.

Everything you say makes sense which is why i find it hard to accept the CP diagnosis when her muscle tone and reflexes are absolutely fine it is just the stifness around the hips, immature gate and intoeing she suffers with. Her fine motor skills and hand eye corodination is also fine.

It is also interesting you say this can be linked.to language disorder as when i broached the subject of it being hypermobility and not CP I was asked.how do you explain the speech delay?! In your experience Pam have hypermobile children successfully gone on to talk?

Pam, your words have helped me at a time when we have felt nothing but confusion and disbelief.

Thanks

Julie

Language delay

Hi Judy

I just need to clarify something - joint hypermobility in itself is not associated with language delay. However children with DCD (developmental coordination disorder) may have a co-occurring language disorder. This may be a specific language disorder or something called developmental apraxia of speech (DAS).  This seems to be good article on DAS.   http://www.tayloredmktg.com/dyspraxia/das.shtml

I do hope that you have had a referral to a speech and language therapist. The SLT will fuly assess your chil's  speech and language abilities and provide an informed and specific diagnosis along with a plan of action for working on speech and language and support going forwards regarding schooling etc.

It is very important to start working on communication and if your daughter is not using words to communicate, you need to get going with non-verbal communication and using some form of hand signing. If you are still waiting to see the SLT you can get going using  baby signing or Makaton.  Signing and other non-verbal language are often is a powerful  trigger for using words. 

You may also find some of the information on the Developmental Gym for Infants website useful. Look out for the information on stretching tight hip muscles. 

Good luck in finding the help and support you and your infant need. 

Pam

 

 

3 year old with hypermobility

I had an appointment with our community peads today who has said my 3 year old is hypermobile. His bottom half is worse than his top half and his co-ordination is poor. He falls over nothing and with dyspraxia in the immediate family I thought it might have been that. The doctor has said he will grow out of it and nothing can be done as it affects the joints. My boy rarely tells me he has hurt himself (doesn't seem to feel pain) and is still showing no signs of potty training (although I know this is not abnormal in boys). Can something be done to help him? Should I be asking to see a physio? Any advice gratefully received.
Thanks cat.

Your paediatrician is misinformed

Hello and thank you for your question. 

It is a real shame that many pediatricians remain misinformed about the importance of early intervention and so easily dismiss parents' concerns. Children do not grow out of having poor coordination - falling a lot is an issue and needs attention. 

Young children may fall  for one or more of the following reasons: their legs give way because the leg muscles are not strong enough  when they encounter a sudden stop or turn, because their coordination is poor, or because they simply have not learned to look where they are going and to anticipate obstacles.  Read more: Erin has wobbly knees

Your child needs a full assessment by a pediatric physiotherapist of his strength, flexibiity and coordination and a plan of action to improve his tendency to fall. 

Children with generalised joint hypermobility are often late with potty training - in part because the walls of the bowel and bladder are also more pliable than usual and the messages about when it is time to void are less reliable. Perhaps you can find out if there is an incontinence service for children where you are and get some advise. 

Best of luck finding the help that your boy needs. 

Pam 

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