Joint hypermobility

About 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 easy 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? 

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 material that has a little give and as the joint move the capsule and ligaments stretch a little bit, but still hold the joint surfaces together quite firmly and limit the amount of movement at the joint.

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.

In typical joints with typically stiff connective tissue, the finger, knee and elbow joints can straighten to 180 degrees.In these joints are hypermobile, they can be straightened further than 180 degrees creating a backwards bend

When a child with hypermobile knees stand, the knees bend backwards in such a way 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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The fingers can be bent back to 90 degrees.

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

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.

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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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Ehlers Danlos and other connective tissue disorders also cause joint instability 

There are several genetic disorders that affect connective tissue such as Ehlers Danlos, osteogenesis imperfecta and Marfan Syndrome. 

The joint hypermobility associated Ehlers Danlos is such that the joints are unstable and children often experience  subluxation of the joints which leads to severe pain and loss of function. 

Please see the article by Tofts et al  (200)   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. 

The information on this page does not appply to children with Ehlers Danlos Syndrome
- or any of the other genetic disorders of connective tissue. 

 

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

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 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.  However some experts argue that all joint hypermobility is due to an abnormality in the connective tissue. 

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 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 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

Daughter with Autism Poor Muscles?

Hello...
My daughter is now 4 years old, and diagnosed with Austism since she was 3. I always felt she has poor or less than normal muscle coordination, etc. since she has been an infant. She currently is having much trouble walking by herself this past week. She can stand, but cannot make steps at all.. I can tell she is in pain to utilize her right leg at all. When she does walk, but her hips look like they are stiff somewhat and she says she has to keep her right leg completely straight, she cannot bend it. We thought she fell somewhere playing around the house and hurt her knee/leg. She complains of knee pain and the top part of her leg. I took her to her Pediatrician, who said it didn't look broken, and said it probably was just a sprain. Two days later with no healing at all, I took her for an x-ray to rule out a fracture or something broken, x-ray came back fine, nothing found. Five days have now passed, and she is still not any better. I think she may even be worse. Does it sound like Hyper-mobile or something more with the muscles and Autism? I am not sure what to do next? She is still in a lot of pain, and I am concerned. Should I have her see a Children's Orthoepedic specialist?

Give it a few days

Thank you for your question.

I would like to suggest that since your child has been examined by her pediatrician, you might want to give it a few more days and see what happens. If your daughter suddenly stops walking and complains of pain she has probably hurt herself while playing.  If there is no obvious swelling of the knee she has not done any major damage. 

Some children, especially those on the autistic spectrum react very strongly when they hurt themselves and will refuse to walk because they fear that something is broken. Will she bend her legs when she is lying down or in the bath? Does this also cause pain? Try playing a game suck as kicking a ball when she is sitting on the floor to coax her to use her leg. 

If the pain continues, you need to take her back to her doctor. Pain in the thigh radiating into the knee may be coming from her hip. This is often missed by doctors who look only at the knee. So make sure that the hip is checked this time. 

Pam

About JHS, EDS hypermobile being one and the same

Hello!
I'm a mum from Finland. We have a 7- year old son diagnosed with Ehlers danlos hypermobilitytype. He has never suffered from any injuries, no dislocations or subluxations. He has allergies and has had difficulties with eating. He can't keep up with his peers running, he has poor strength in his hands, but he doesn't tire easily. He has flat feet and sometimes he has pain on the upper side of his feet at night, but normal, mild pain medicine for children helps. He had some sudden, short nackpains under the age of 5. He scores 6 on the Beightonscale, his hands and elboes are very hypermobile. Neither me or my husband are hypermobile.

We are not certain that he really suffers from EDS or if he has been wrongly diagnosed. But when searching for information about EDS hypermobilitytype and JHS I have many times run over the fact that during the recent years meny experts have started to see JHS and EDS as conditions that probably have the same medical background. People with EDS hypermobililytype and JHS both have less collagen or wrongly built up collagen in their bodies then people that are not hypermobile. Many experts say there is no use differenting the conditions, because the causes are the same and treatment very often too. (Strengtening muscles, eating right) People who have had JHS at an early age might get the diagnosis EDS hypermobilitytype later in life.
That's why I get a little worried hearing for instance that ballet is good for hypermobile children. With kids you might not know how badly affected they are. The condition might be benign, but difficult symtons in EDS hypermobilitytype often show later in life, at least based on what I have read and heard when speaking to finnish and swedish doctors. Building up muscle strength and letting children enjoy sports and movement is important, but if the child is very hypermobile fysiotherapists in the Nordic countries usually recommend low- impactsports without stretching. And yes- we let our son jump on the trampoline with his friends. I let him jump from high places if he wants to, but I tell him to land softly. When he learned to walk at 18 month we more or less took away his stroller to sthrengthen his legs. We let him do sports, but we would not encourage him to do soccer or other high- impact sports or ballet or yoga, that stretches muscles. He dreams about kungfu or karate, but we try to lead him towards non- contact, more low- impact martial arts...

We hope for the best future for our happy, bright son, and for everybody else who visit this website, and/or for their hypermobile children!

My 13 years old son - possible Hypermobility

hi
My son is 13. He has never liked running, he is quite awkward when he runs and can't keep up with the others. He has never been very good and catching or throwing/kicking a ball although is better now he is older. I noticed when he was about 6 that his posture was really bad and that he had flat feet, making his knees knock together at the side, he also complained of knee pain. I got an appointment at the orthotics department at the hospital and he now wears insoles in his shoes which I think have helped a lot. However, his posture is still dreadful and getting worse - even the way he walks and just holds himself is very awkward, he also seems to stand or sit with his head very forward from the rest of his body. He also finds it very difficult with handwriting and has been diagnosed with dysgraphia by an educational psychologist. I am becoming very concerned about his posture and gait and would like him to see someone about it but not sure where to go or what kind of doctor to ask for. He is also qutie clumsy, walking into things or tripping over his own feet. Aside from his posture issues, he is a happy bright child who is fine with making friends. I would really appreciate any advice, I feel terrible nagging him all the time about his posture but I am also worried that if I don't he will end up with an arc or humped back.

Could GJH affect a child's speech?

Could GJH affect a child's speech? My child does seem to have some of the characteristics but also seems to find it difficult to pronounce words properly. She talks a lot and knows exactly what she is saying. But will say things like foo instead of fish and sometimes I can only identify one word in the sentence she says eg. she will mumble most of the sentence then say Mummy clearly.

Just wondering if there could be a link or if there is something I can do to help her improve, she is 2 1/2yrs old.

Thank you for your time

Clear speech at 2 1/2

Hello

I do not know of any connection between articulation and hypermobility. 

You would have to ask a speech therapist about about your daughters articulation.  What I can say is that my own who is also 2 1/2  sometimes says words clearly and sometimes makes long speeches with great conviction but which to me sounds like gobbledy gook. 

Pam 

3 Year Old

Hi,

I am very grateful to have found this site as it has really helped explain my son's issues! He is 3 years and 4 months old. We think he has JHS and also hypotonia. When he's tired (which is right before and right after naptime and bedtime) his legs just won't support his weight anymore and he will wobble until he gives up and sits down. If he's sitting on his bottom with his legs straight out in front of him, sometimes he will keel over before he can catch himself. If he sits in the w form or he sits on one knew with the other knee bent, he's solid no matter how tired he is.

His first therapy appointment isn't until November. I'm wondering what we can do for him in the meantime to help prevent the falling when he's fatigued?

Thank you!
Tiffany

Need a full assessment first

Hello and thank you for your question

Your son presents with an interesting set of difficulties that do not fit into a generally seen pattern, so without doing a full assessment it is not possible to give any general advise for helping your son.

Hopefully your  visit to the physical therapist will provide the help you need.

Pam

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hand bending backwards

my daughter is 5 years old and she always turn her hands backwards completely and cannot walk like a normal person i consults with many doctors but in vain can someone give me better suggestions consultstation advise because of this problem i am too worried

Home exercises

First of all I want to apologize because i'm not good in english but i will try my best.
My 3 months son has been diagnosed with joint Hypermobility,and he has larger than normal head.
is there any home exercises that I can start with to strengthen his muscles specially for the neck.

thanks for your help
Yasser

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