Joint hypermobility

Terms Related to Joint Hypermobility

• Hypermobility: increased joint play
• Ligamentous hyperlaxity: increased flexibility of the bands of tissue that connect bones
• Hyperflexibility: extremely high flexibility
• "Double-jointed": an English expression used to describe a person who is very flexible, without any extra joints

What is joint hypermobility?

Joint hypermobility refers to a joint that moves beyond the range of motion typical for a person’s age. It can affect a single joint or multiple joints. It is important to distinguish between hypermobility in a single joint and generalized hypermobility. Our physical therapy guide on joint hypermobility explains how to manage the condition.

This condition is common; its prevalence varies widely depending on age, sex, ethnicity, and the criteria used to define it, and it is more commonly observed in women and children. ¹

Generalized hypermobility affects multiple joints in different parts of the body. The Beighton score assesses certain movements of the fingers, elbows, knees, and trunk on a scale of up to nine points. It helps identify generalized joint hypermobility, but it is not sufficient on its own to confirm or rule out the diagnosis. The evaluation must also take into account joints not included in the score, as well as symptoms, past injuries, and other signs of health ². Flexibility can be partly hereditary and may vary with age and training. High flexibility is sometimes associated with an inherited condition—that is, one passed down through families—such as certain Ehlers-Danlos syndromes. These conditions affect the tissues that support and connect the various parts of the body. Generalized joint hypermobility is frequently present in this type of connective tissue disorder ³. When pain-free, generalized hypermobility—greater flexibility in multiple joints—is not a disease in itself. In some people, it may be accompanied by sprains (ligament injuries), injuries related to repetitive strain, or pain that develops later. ⁴

Hypermobility covers a wide range. It ranges from flexibility that causes no problems to extreme flexibility associated with pain or a connective tissue disorder—that is, a disorder affecting the tissue that supports and connects the body’s parts. Being flexible is therefore not automatically a health problem.

The following section focuses primarily on hypermobility in a single joint. Research on generalized conditions is identified as such. A very flexible joint does not automatically cause pain; the evaluation also looks for other possible causes.

What are the causes of joint hypermobility?

Joint hypermobility may be related to the characteristics of the tissues that support the joint, to exercise, or to an injury. A distinction is made between flexibility present from birth and flexibility that develops later:

• Congenital (meaning you are born with it)
• Acquired (meaning you develop it at some point)

Two situations can help us understand flexibility that has emerged or been recognized later on:

• Les gens très souples sont nombreux dans les activités qui demandent beaucoup de souplesse. Chez des athlètes adolescents d'élite, l'hypermobilité était plus fréquente en danse et en gymnastique qu'au handball⁵. Le plongeon demande aussi une grande souplesse, mais les études présentées ici concernent la danse, la gymnastique et le handball. La comparaison de ces athlètes ne permet pas de séparer l’effet de l’entraînement de la sélection de personnes déjà souples. Des élèves de première année en ballet, qui avaient peu ou pas d'entraînement préalable, étaient déjà plus hypermobiles que les enfants du même âge qui ne faisaient pas de ballet, ce qui appuie l’hypothèse d’une sélection sans la prouver à elle seule⁶.
• Après une blessure importante, une articulation peut bouger davantage et donner une sensation de déboîtement. Une chirurgie peut aussi modifier sa mobilité; ses effets dépendent de l’intervention. La grande souplesse et l’instabilité, c’est-à-dire la difficulté à garder l’articulation en place pendant les activités, ne sont pas synonymes. Après une première luxation de l’épaule liée à une blessure, où l’os sort de sa cavité, une instabilité peut revenir chez certains adultes. Un jeu plus grand dans l’articulation est associé à ce risque⁷. Chez les personnes ayant eu des luxations répétées, une plus grande souplesse de la capsule, l’enveloppe qui entoure l’articulation, a aussi été observée, sans preuve que les luxations l’avaient causée⁸. L’évaluation tient donc compte de la souplesse présente avant la blessure. Après une luxation de l’épaule, le traitement dépend aussi des tissus blessés, des épisodes précédents et de vos activités.

What are the symptoms of joint hypermobility?

L’Joint hypermobility peut s’accompagner de douleur, d’une sensation de jeu ou d’un blocage, mais elle peut aussi rester sans symptôme. Une douleur peut parfois s’installer dans la durée. Il est important de comprendre que ce n’est pas parce qu’on a une hypermobilité qu’on aura des symptômes. Plusieurs personnes hypermobiles n'ont aucune douleur, même si des symptômes peuvent apparaître plus tard chez certaines⁴. Chez des étudiants universitaires de 18 à 25 ans, les personnes hypermobiles ne rapportaient pas davantage de Chronic pain, c’est-à-dire qui dure depuis plus de trois mois, que les autres⁹, mais cela ne permet pas de prévoir leur évolution toute la vie.

Quand une articulation très souple devient douloureuse, la douleur peut s'installer dans la durée. Chez des étudiants universitaires de 18 à 25 ans, la proportion de personnes rapportant une blessure ne différait pas selon leur score de souplesse⁹.

A painful hypermobile joint is characterized by the following:

• Very high flexibility of the painful joint

People may also report the following:

• Feeling that your joint has some play in it or is dislocating
• Avoir eu dans le passé plusieurs luxations de l’articulation, où l’os sort de sa cavité
  
  • This is relative to the shoulder, for example.
• Sometimes feeling as if the joint is locking up

Joint pain may persist or worsen with certain activities. A subluxation is a partial displacement of the joint; a shoulder dislocation is a complete displacement. Sprains, including those of the lower back, can also recur. ^{10, 11} These symptoms warrant an evaluation, even if they occur after minimal exertion.

Conditions related to hypermobility may also be accompanied by fatigue, reduced stamina, dizziness upon standing, digestive problems, and sleep disturbances. ^{12, 11} Dizziness upon standing is not necessarily caused by inner-ear vertigo. Report these symptoms to your doctor so that the cause can be determined and treatment adjusted accordingly.

Pain intensity cannot be determined by flexibility alone. Some people who are very hypermobile have few symptoms, while others who are less hypermobile experience significant pain. The assessment also takes into account injuries, activities, fatigue, sleep, and other factors that influence how you feel.

Le risque de blessure au genou est accru chez les personnes hypermobiles qui pratiquent des sports de Contact. Aucune augmentation claire n’est trouvée pour les blessures à la cheville.¹³ Cela ne garantit pas l’absence de risque à la cheville. Les douleurs persistantes demandent aussi une prise en charge qui tient compte de leur diversité et de leur effet sur la vie quotidienne.³

How is joint hypermobility diagnosed?

The physical therapist identifies joint hypermobility by measuring range of motion and reviewing your symptoms and past injuries. This evaluation includes observing movement and performing tests specific to the joint. The physical therapist also checks whether certain areas are particularly flexible and whether other signs warrant a medical evaluation. The Beighton score can contribute to this evaluation, but it is not a substitute for it.

Le score de Beighton évalue cinq mouvements et donne un total de neuf points, car quatre mouvements sont testés des deux côtés.¹⁴ Les critères révisés de 2017 retiennent habituellement au moins 5 points sur 9 après la fin de la croissance et jusqu’à 50 ans inclusivement, puis au moins 4 points après 50 ans. L’examen tient aussi compte de votre ancienne souplesse, des symptômes et des autres diagnostics possibles¹⁵.

Les études plus anciennes utilisaient souvent le seuil de 4 sur 9.^{14, 1} Chez les enfants et les adolescents encore en croissance, un seuil de 6 sur 9 est utilisé pour la forme généralisée, avec une évaluation adaptée à l’âge¹⁶. Les tests comprennent les mouvements suivants; ne les forcez pas pour vous attribuer un score :

• Gently bring each thumb toward the inner side of the forearm, the section between the elbow and the wrist
• Raise each little finger to an angle of more than 90 degrees relative to the hand
• Exceed the upright position by more than 10 degrees at each elbow and each knee
• Touch the floor with your palms, legs straight

Asymptomatic hypermobility is a sign of flexibility. Hypermobility spectrum disorders, often abbreviated as HSD, refer to hypermobility that is accompanied by symptoms such as pain, instability, or injuries and that is not better explained by another condition. A medical evaluation helps make this distinction. ^{17, 11, 18}

Hypermobility and Ehlers-Danlos syndrome: What's the difference?

Hypermobility is a characteristic of movement, whereas HSD and hypermobile Ehlers-Danlos syndrome are diagnoses that take into account symptoms and other signs. hEDS is a condition—often inherited—that affects the tissues that support and connect the body’s structures, known as connective tissues. The difference is not simply a matter of greater flexibility or more severe pain.

Asymptomatic hypermobility may not require any treatment. You can continue your usual activities while being mindful of your comfort. If you experience pain, instability, or repeated injuries, you should seek an evaluation.

HSD can be diagnosed when hypermobility is accompanied by muscle or joint problems, after ruling out other possible causes. It does not meet the criteria for hEDS, but its symptoms can be just as severe and may require treatment. ^{19, 18}

Hypermobile Ehlers-Danlos syndrome is diagnosed based on a set of clinical criteria revised in 2017, after growth has ceased. These criteria combine hypermobility, signs affecting other tissues, family history or certain complications, and the exclusion of other diseases. hEDS may be accompanied by more elastic skin, easy bruising, or digestive and circulatory problems. Its precise genetic cause has not been established; currently, no genetic test can confirm this diagnosis. However, a doctor may order tests to rule out other conditions. ¹⁷

hEDS can affect several bodily functions and may require consultations with various medical specialists. Other joint disorders may also coexist with it. ²⁰ The doctor therefore looks for the causes of new symptoms rather than attributing everything to hypermobility.

The diagnosis guides medical management and preventive measures. In physical therapy, patients with either condition can benefit from strength training, movement control exercises, and guidance. The program takes all symptoms into account, not just ligaments or flexibility.

What physiotherapy treatments are available for joint hypermobility?

Physical therapy treats the symptoms of hypermobility through exercises, advice, and training for challenging activities. Treatment begins with an evaluation that guides the exercises and explanations ²¹. For generalized disorders related to hypermobility and Ehlers-Danlos syndrome, hypermobile type, exercises and learning to control movements are the most well-supported interventions ²². The program may also include guided manual movements for stiff neighboring joints and advice on activity levels. Research provides less robust support for these specific components; their inclusion depends on the assessment and your response. Our guide on physical therapy for joint hypermobility describes the assessment, exercises, and home care.

When should you see a physiotherapist for joint hypermobility?

A physical therapy appointment is recommended when pain, a feeling of instability, or difficulty moving limits your activities. Good flexibility without pain or difficulty does not automatically require treatment.

You do not need to see a doctor before starting physical therapy. The physical therapist will refer you to a doctor if the evaluation warrants it, particularly if a condition affecting multiple tissues is suspected.

Signs That Require Urgent Medical Attention

Une articulation qui paraît déboîtée après une blessure doit être évaluée à l’urgence. Ne tentez pas de la remettre en place vous-même. Pour une blessure à l’épaule, consultez aussi immédiatement si vous ne pouvez pas bouger le bras²³.

Don't assume it's just your hypermobility.

• Go to the emergency room if a joint is dislocated or if you are unable to walk or put weight on your leg, even if you haven't recently been injured.
• After a fall or injury, severe pain, tingling, or a loss of sensation around the joint also warrant this evaluation.
• Seek urgent medical attention if a painful joint is swollen and warm, or if the pain is accompanied by general malaise, fever, or sensations of heat, cold, or chills.

Ces signes suivent les recommandations sur la Joint pain²⁴. Pour les symptômes sans urgence, consultez si la douleur ou l’enflure s’aggrave, revient souvent, gêne le sommeil ou les activités, ou si la raideur au réveil dure plus de 30 minutes. Les problèmes articulaires chez un enfant méritent aussi une évaluation.

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