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.  

finger extension_0.jpg wrist flexion_1.jpg

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. 

Muscles laxity 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 SfA Webmanual page on JHS)

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.

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?

DG Webspace Children_0.jpgDG webspace.jpg

 

Comments

almost 18 months possibly hypermobile?

My son is almost 18 months old and does not walk. He stands up and cruises around furnitre and crawls fast everywhere. I have noticed that his feet cave inwards I expressed my concern for this with a pediatrician who said his ankles were extra flexabile and said it should correct itself once he is walking and didn't seem concerned that has wasn't yet as he has done everything late. Didn't sit until 7 months hated tummy time so spent most time sitting and began crawling at 12 months pulling upto stand at 14 months and has been cruising since then. He will oftern let go and stand alone then fall back on his bottom. I have been doing my own research and came across the term hypermobile and it describes my son exactally especially his caved in ankles. Do u have any advise for me? Im a very big worrier.

Hello My son was the same as

Hello
My son was the same as yours.He is extremely flexible in his ankles and his feet caved outwards.Pl dont worry because they will eventually walk and are completely normal kids.Our pediatrician advised us to put him in high rise ankle boots (Ecco brand has such shoes).It keeps the ankle firm.Also physiotherapy or physical activity was very helpful.I used to take my kid to park every day make him climb a lot to improve muscle strength.

My daughter - possible GJH

Hello,

My daughter is 4 years old and has been diagnosed with extremely low muscle tone in her legs. She does not walk unassisted, uses a walker and is just starting to use longstrand crutches with assistance. She has very flat feet (hereditary from me), her left foot turns inward when she walks and appears to have many of the symptoms of GJH listed above. She prefers to sit "W" style instead of criss-cross, and also prefers to bunny-hop around as her main mode of transportation when not using the walker. She also wears AFO ankle braces and uses a derotation strap to turn her left foot back outward. We have had every test under the moon and nothing has come back positive. My question is there a test that can confirm GJH? Also, we have her in PT once a week but the improvements have been marginal. Is there any advice you would have as far as what we could/should do to get our daughter walking?

Thank you,
Larry

Diagnosing GJH

Hello

It is indeed very distressing when the cause of a child's disability cannot be found. There is not specific test that can be done for GJH other than the presence of hypermobility in the joints. Ask your child's physiotherapist to check this and score your daughter on the Beighton scale. (http://webmanual.skillsforaction.com/node/13).

That having been said, children with GJH and even those with Ehlers Danlos (hypermobility subtype) usually learn to walk independently by the age of two years. 

Unless there is a particular reason why a child should engage in strenuous muscle activity, then generally speaking all children will benefit from a program of exercises to strengthen the muscles. Has your physiotherapist provided you with a daily exercise program to strengthen the trunk and leg muscles?  If not, ask her if she can help you to set up a daily functional strengthening program. 

Healthy children are very active by nature and the engage in activities that challenge their muscles to work harder many times each day. Just think of the many times a 4-year-old child runs, jumps, gets up from sitting on the floor, goes up and down steps, climbs onto the furniture, jumps down again, climbs the jungle gym, the stairs to the top of the slide, etc etc.

Children with a disability do not engage in this kind of activity and so need to have dedicated time spent on encouraging them to work their muscles to get them stronger.  The trick is to adapt an activity so that the child can do it, and then slowly but surely change the demands so that the child needs to work hard to achieve the goal but can still do the task. Take standing up from sitting on a chair. One starts with standing up from a raised chair and then once the child can stand up and sit down with good control at least ten times from this height, you lower the height of the chair a little, and work at getting up from this new height.

Best wishes 

Pam 

 

Im a child care provider and concerned for one of 'my' kids

This post was from a child care provider who has concerns about one of the infants in her care who is not developing well but whose parents do not seem to be concerned about it. 

She has asked for advice about what to do - and I have made some suggestions in my replay. 

I have not left the full post on the site for ethical reasons:  we need to be mindful at all times regarding confidentiality. 

Pam

Finding help

Hello 

You have concerns about this infant and it seems need some advice about what to do in the child's best interest.

You can check with the parents about whether the infant has had a 12 month developmental check up - this often happens when the child attends the clinic for vaccinations at a year.  At least that is the case in my country. 

Another  option is discuss your concerns  with someone from the early years health and welfare services that operate in your country. 

Remember that from an ethical perspective you may not discuss the particular child with anyone without the parents permission - but you can ask for guidance in a general way. 

Pam

 

Toddler Hypermobility and walking

Hello Pam,

My 23month old son has been diagnosed with Hypermobility. He sat at around 7 months unsupported and did a bunny hop kind of crawl using his hands and not moving his legs actively,but at 13 months he mastered the art of crawling and since then has been very good at it. He started cruising around 16months and now he seems to be cruising everywhere,but still cannot stand or walk unaided. He walks holding our finger but his walk is slow,wide-gaited and feet turned outward. We have noticed the wide-gait is improving over time. Earlier he stood aided with wide-gait,now there is no wide-gait while standing, only while walking. He does not bend his knees , kind of keeps his leg straight and walks(bendy ankles and knees). We try to encourage him to walk independently but he seems very scared and wants to hold our fingers all the time.We twice tricked him to take 2-3 steps unaided,he also once stood on his own unaided . And,what surprises me is that he has been crawling for so long and has not developed much strength in his leg. He does climb on chairs and sofas and we have seen progress but it seems slow. Are there any suggestions how I can encourage my son to walk independently and how I could strengthen his legs? We are working with the NHS Physio and Pediatrician,but additional advice from you will be helpful . Do you also have any recommendation on any indoor gym toy that we could purchase for our son to strengthen his leg?

Thanks
JSR

walking

My son is nearly 2years old, He has hypermobilty. He walked at 21months unaided. He had a long period of time where he appeared to make no progression but then suddenly let go and walked. He was very similar to your child, wide gate etc. He now has inserts in his supportive boots and walks much better with these. We take him to an osteopath regularly which really seems to have helped. Its a long road and we are still learning! Hope it puts your mind at rest a bit.

Reply to your note

Hello,

Thank you for the response. Just a day before his 2nd Bday my son took steps unaided and he could walk from one room to the other with no support. He needs a lot of encouragement (clapping and cheering) and right now its more of task-based walking like keeping a pen on the table, only when we tell him to walk .He prefers to crawl more than walk. I m just waiting for the day when he would know that walking is the normal mode of moving around and not crawling. Did you have a similar experience. I have noticed his wide-gait has lessened over course of time.

Thanks
JSR

Babies walk and fall

Hi and thank you for telling us about your  son's progress.

All babies fall a lot when they start to walk, especially the very active ones who run rather than walk. . They are still working out how to coordinate their legs and keep their balance. 

Cautious toddlers often do not  like falling - so they either go slowly and carefully or will only walk when highly motivated. 

I suggest you spend some time several times a day playing walking games with your son. Typically new walker love to fetch and carry things - walking frees the hands to do this.  Good props for fetching and carrying are empty or partly filled large plastic bottles. Have 5-6 or more bottles and put them in a cardboard box. Encourage your child to pick up the bottles one at a time and carry them across the room to another box or a low table. 

You will find more suggestions for increasing walking control and steadiness in the Developmental Gym for Infants Webspace  of the website. As a SfA member you have access the Sturdy on the Feet page

Pam

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