Hypermobility Disorders

Hypermobility Disorders

Identifying and managing hypermobility disorders

 Hypermobility disorders are connective tissue disorders characterized by increase tissue and joint extensibility, ligamentous laxity, a propensity for bruising, poor scarring, muscle weakness.  Hypermobility is only of concern if it is causing adverse symptoms that are effecting quality of life.


The most common hypermobility syndromes are Benign Joint Hypermobility Disorder and Ehlers Danlos Syndrome. More recent terminology includes Hypermobility Spectrum Disorder. These can manifest in a number of ways. The child or young adult 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 or young adults are very coordinated but suffer from frequent sprains, strains/subluxations/dislocations and/or tendinopathies.


The aim of a treatment programme for hypermobility is to provide as much information for the parent/child to enable them to manage symptoms effectively at home. Often only 3 to 4 sessions are needed in early stages to get symptoms under control. Parents then continue with the principles of management at home. The family might only return to physiotherapy when new symptoms arise.


What the parent may 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 from relatively minor incidents
  • Coordination issues and awkward running style
  • 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 health professional may notice


  • Beighton hypermobility score of 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), increased or decreased 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 of 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 – Decreased length of hamstrings and gastrocnemius.
  • Tightness in gastroc-soleus can contribute to idiopathic toe-walking
  • Bruising – multiple in varying stages of healing
  • Poor scarring


Managing 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 or Flexible bracing
  • Heat
  • Massage


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 such as:

  • Wobble board, Balance discs, stepping stones
  • Flexible bracing or compression garments to provide proprioceptive input and biofeedback with movement


Stability exercises

  • Core stability exercises
  • Pelvic stability exercises
  • Postural muscle strengthening


Correction of gait abnormalities

Many children with hypermobility disorders have unusual or awkward looking gait patterns that contribute to trips/falls and not being able to keep up with peers in the playground. Pigeon toe, knock knees, inturned gaits are common place in children with hypermobility disorders. To a lesser degree the duck feet walker and tip toe walker are also reported in association with hypermobility conditions. Flexible bracing garments such as Spirak Thigh Brace or Spiral Power Shorts are an ideal adjunct to physiotherapy to  provide sustained biofeedback for motor learning and gait retraining, while limiting excessive internal rotation at the hip and thigh.


Postural Awareness

Many children with hypermobility suffer from postural muscle weakness. In sitting they may have a “c” shaped trunk posture. In standing the child may have slumped shoulders with an excessively sway back or an excessively flat lumbar region with hyperextension of the knees.  Children suffer considerable body fatigue and pain from postural weakness. In younger children with very poor postural awareness the flexible bracing garments, balance disc and wobble chairs are excellent short term tools to facilitate improved postural awareness and allow the child to experience a more normalised body positioning.


Strengthening exercises

Strengthen the weaker muscles and the muscles that stabilises body segments (usually the core and trunk).


Stretching

Stretching of compensatory tight muscle groups. The hamstrings and calves sometimes tighten up as a compensatory balance mechanism.

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.


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).


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- outer 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.


Ideal sports

  • Swimming
  • Non contact martial arts
  • Recreational gymnastics
  • Dance


Activities for younger children

Kindy gym/toddler gym, indoor climbing gyms in winter (beach house/fun station), local park, baby swim or aquatic leisure centres, balance circuit in own backyard and normal play and exploration for younger child.


Review by other allied health professionals sometimes includes:

Podiatry to assess need for foot support such as orthotics or  modified  footwear

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

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