HYPERMOBILITY

Identifying and Managing Hypermobility Disorders

Hypermobility means increased tissue or joint extensibility. The most common hypermobility syndromes are Benign Joint Hypermobility Disorder and Ehlers Danlos Syndrome. Hypermobility is only of concern if it is causing adverse symptoms that are effecting quality of life.

 

Hypermobility Disorders are connective tissue disorders which cause increase tissue extensibility. This causes ligamentous laxity, a propensity for bruising, poor scarring.

This can manifest in a number of ways. The child may have coordination issues, joint pain, greater incidence of growing pains and many small bruises in various stages of healing in “high contact” areas such as shins and forearms.

On the other hand some children are very coordinated but suffer from frequent sprains, strains and/or tendinopathies.

What a parent might notice

• A myriad of symptoms, of which the child may have some or all
• Tiredness, fatigue more than peers or other siblings at the same age
• Toddler – wants to be in the pram a lot
• School age – too tired to walk home or walk to car from classroom
• Exhausted more than peers/siblings at end of day
• Pain
• Night pain
• More frequent growing pains”
• Frequent strains, sprains
• Recurrent subluxations,  dislocations or fractures (commonly knee cap, elbow, shoulder)
• “Pulled elbows” in toddlers and babies
• Coordination issues
• Awkward running, difficulty putting clothes on in morning
• Difficulty keeping up with handwriting in early school years (either slow to finish or messy writing)
• Some are very coordinated and some poorly coordinated

What a professional might notice

• Beighton Hypermobility Score –(7-9/9 as a  determination of hypermobility)
• Body posture in standing- flat feet, femoral anteversion and tibial torsion ( ie. excessive internal rotation of the legs), incr or decr lordosis, winged scapula
• Muscle weakness
• Lack of muscle tone
• Classic ‘C’” trunk posture in sitting
• Balance/coordination issues
• Running style – often awkward gait,  trunk flexion, rigid trunk, excessive movement lower legs or side to side trunk movement
• Sometimes a toe-walker for extended period up to 8 years of age
• Core instability, pelvic instability
• Muscle strength – general lack of muscle tone and often more specific weakness in gluteals and trunk muscles
• Muscle length – frequently tightness in hamstrings and gastrocnemius.
• Tightness in gastroc-soleus can contribute to idiopathic toe-walking
• Bruising – multiple in varying stages of healing
• Poor scarring

Management of Hypermobility Disorders

The treatment for hypermobility is usually a combination of the several areas. Symptoms at the time of presentation will determine the focus of the program.

Pain Relief

• Hydrotherapy
• Taping
• Soft bracing
• Heat
• Massage
• Mobilisation

Proprioception

Proprioception is the body’s awareness of the position of a joint in space in relation to another joint. It facilitates body’s ability to synchronise limb and trunk movements. This reduces risk of dislocation, subluxation, tripping over injuries”.  There are several ways to improve this-

• Wobble board
• Theradisc
• Minitramp
• Multi-stones
• Progress difficulty by multi-tasking

 

Strengthening Exercises

Strengthen the chain. Strengthen the weak muscles and the muscles that stabilise body segments

Stretches – stretching of compensatory tight muscle groups. The hamstrings and calves sometimes tighten up as a compensatory mechanism to provide balance and stability.

Physiotherapists specialised in the management of Hypermobility Disorders can advise you of  exercises that you can incorporate into general family life that will strengthen the child’s core stability muscles and postural muscles , while appearing like  normal family fun activity. 

Stability exercises

• Core stability exercise (transversus abdominus and multifidis)
• pelvic stability exercises (gluteus medius and pelvic floor muscles)
• Postural strengthening

Relaxation exercises

Muscles are fatigued and often prone to spasm by end of day. The muscles are working hard to control movement . When it is time to sleep muscles are still in a state of semi tension. Relaxing before bed promotes muscle relaxation, better sleep pattern and reduces restless legs.

Pacing

Short frequent bursts of activity are always better than longer durations. The length of time dependent on child’s age. Avoid 2 sports on 1 afternoon (eg footy training followed by swimming squad).

Kids can enjoy sport if they "pace" their activity

General Sports Notes

• Avoid over-scheduling the child.
• Allow time for rest periods.
• Timing of activities –- younger children have more energy earlier in the day.
• Sport specific training – get advice re position on field, suitable sports
• Specific exercises for the area of body most at risk with particular sports eg. ankle- soccer, netball, knee- football, gymnastics- back
• Football- midfield is position where less body contact /impact occurs
• Netball- Goal shooter/Goal attack less running

Sports to Avoid

High impact sports such as rugby, touch rugby, ice hockey, football.

Ideal Sports

• Swimming
• Non contact martial arts
• Kindy gym/toddler gym

Activities for younger children

Recommendations – Kindy gym/toddler gym, indoor climbing gyms in winter (Beach House/Fun Station), local park, baby swim or Aquatic Leisure centres, circuit in own backyard and normal play and exploration for younger child.

Occupational therapy (OT) referral for hand management- hand exercises, pen grips, slope board, hand writing skills.

Successful results with new spiral thigh garment in children with hip, knee pain and pelvic stability (see Straps Bracing).

The aim of a treatment programme for hypermobility is to provide as much information for the parent/carer to enable them to manage symptoms effectively at home. Often five or six sessions are needed in early stages to get symptoms under control.

Parents then continue with the principles of management at home. The family might return to physiotherapy when new symptoms occurs, for example, tendinopathy, back pain, subluxations

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