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.

hypermobile standing with elbows_0.jpg

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.

Sitting on floor.jpg

 

 

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. 

T sitting slumped_0.jpgxleg slumped.jpg

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

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

Toddler with wide gait

Hello and thank you for your question.

In my experience a toddler who stands and walks with the feet wide apart usually has tightness in the muscles that cross over the sides of the hips.These muscles are tight because they lie and sit with the legs apart. This makes it difficult to bring the feet together when they stand, Along with the hip tightness they also have weakness in the leg muscles and this weakness and tightness makes it difficult to stand up without holding on for support.

The Infant Developmental Gym webspace has ideas for exercises and activities for stretching these muscles, as well as for strengthening the leg muscles and training the standing up action. You might want to incorporate standing up and bending down exercises in your daily exercise programme.

      

Take a look at the exercises and discuss how you can incorporate them into your home physio programme on a daily basis. 

The DG-I Webspace also has ideas for activities for improving walking fitness and coordination once your son is walking independently.

Your physio might also like to take a look at the information on active mobilisation on the developmental Gym Webmanual site http://webmanual.skillsforaction.com/node/196.

Let us know how you get on.

Pam

follow up query

Thank you Pam for your response. I will follow your suggestion.Just 2 follow up queries, 1)whether you see the wide stance walking in hypermobile children as common occurrence.2) hv u seen kids who crawl early say 13months walk that late around 24 months.

This is a good question.

Hi

This is a good question.  Typically developing infants learn to crawl on average between 8-10 months. So crawling at 13 months is quite late, but not unexpected if an infant is hypermobile.

There is no published research about the link between joint hypermobility and a wide stance or gait.  So I can only comment based on my experience of the children who are referred for physiotherapy.  These children commonly have a wide base - but this improves as they get more flexible and stronger. and walking follows soon after the start of physiotherapy.    These children's hip joints  have also been checked for problems such as hip dysplasia.  

Walking later than 18-20 months is generally regarded as a cause for concern and I would refer the child to a paediatrician to check that there are no other  factors affecting development. 

You will find more on the development of children with hypermobility here How joint hypermobility affects a baby's development

Pam 

 

 

Toiletting Issues

Hi Pam - my nearly 7-year old daughter has just been disgnosed by an Occupational Therapist & a Physiotherapist as having muscle laxity. She is also a terrible fidget and has concentration problems as well as being what is termed on this site highly cautious. Although she can also be very loving, I am very relieved that there is a reason behind her behaviour as my greatest fear was that she was just an incredibly difficult child!

She has always been slow to reach the usual developmental milestones but apparently is over-compensating nicely for her poor muscle tone. Luckily she does ballet lessons which is helping her posture and I have recently moved her to private swimming lessons as her group one was a nightmare. Her handwriting still isn't where it should be but my main concern is her daytime toiletting issues. I have read somewhere that this can be linked to muscle laxity but there really isn't much information about this, even on your wonderful site.

She is getting better but still has accidents practically every day (on some days several times) as well as soiling herself at least once a week although this too can be far more frequent. At her assessment I was told to go & see an incontinence specialist so I have an appointment booked with my GP for March 5th to hopefully get the ball rolling.

Can you help me on this at all please?

Post new comment

By submitting this form, you accept the Mollom privacy policy.