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.  

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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?

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Comments

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?

Poor bladder control and joint hypermonility

Thank you for your question.

Children with joint  hypermobility do often have bladder control issues. There are two reasons for this. Both the wall of the bladder and the external sphincter are made of connective tissue and so like the joints are more lax than usual and affects control.

The other condition that does occur is vesicoureteral reflux where the urine flows backwards from the bladder to the kidneys. When leads to kidney infections. If your child is experiencing pain in the back, especially after exercise this may by the reason.

In either case the incontinence specialist will provide you with the help that you need. 

Best wishes 

Pam

Hi again, We are now waiting

Hi again,

We are now waiting to be referred to someone about incontinence. Prior to my daughter being diagnosed, our School Nurse had told us to stop telling her when to go to the toilet as we were pre-empting her need to go and preventing her from getting used to the sensation that she may not have been receiving. However, knowing what we do now, that it appears that she has a physcial problem and is currently unable to control the need to go to the toilet, when it comes.

Therefore we have started to tell her to go to the toilet at regular intervals to try & prevent her from having as many accidents. We are particularly worried that her class mates will start to notice as she doesn't always tell when she has had an accident......

In your experience, do you think this is the right appraoch to take? And is there anything else we can be doing help her while waiting to see someone (bearing in mind that our last referral to Occupational & Physiotherapy took 7 months!)?

Poor bladder control

Hello 

I do not have any experience with poor bladder control in children so cannot make an informed comment. This being said, I think it is probably a good thing to avoid as many accidents as possible by having some sort of routine. It is a very unpleasant experience for your daughter and you want to spare her embarrassment where possible while you wait for an appointment. 

It is very frustrating having to wait to long for appointments. Some adult physiotherapy services do have an incontinence clinic - see if this could be a way in.  Physiotherapy can be very effective for incontinence in same cases. 

Pam 

 

Hi Pam, Thanks for your

Hi Pam,

Thanks for your reply. We think by getting her to go to the toilet more regularly, she is getting into some sort of a routine, certainly at school and as as a result we are preventing some accidents. But she still has quite a few! More soiling than wetting. And we have just discovered that a niece on my husband's side has joint hypermobility syndrome but she has severe pains in her knees so we are thankful my daughter appears to have a more mild version.

We have just had a referral come through for the beginning of June for a paediatrician specialising in toilet problems so fingers crossed they will be able to help!

Kind regards

8 year old daughter, confirmation diagnosis needed

My eight year old daughter has just been told she has hyper mobility by a podiatrist. Eight years of symptoms have just been answered by this site!!! Luckily she is not as severly affected as some but she has been swimming and had ballet lessons from a very early age so perhaps this has helped? We have an appointment with a paediatrician soon, originally to investigate nocturnal enuresis but I think I will be asking a lot more questions about hyper mobility than originally planned, thank you.
We've asked relatives and no one else seems to have any similar symptoms apart from flat feet on the maternal side andeasy bruising on her paternal side. Is it always Inherited?

Checking for hypermobility

Hello and thank you for your question.

Genes are funny things - they find expression in different ways, But in my experience there is usually at least one parent with hypermobile joints.And flat feet in the family is a an indication of a family connection. But then not all people with joint hypermobility have flat feet either!.

The other point is that many symptoms associated with joint hypermobility are exacerbated by having a very cautious nature. And this too has a family connection. Look around for the perfectionist parent.

However, it is important to remember that not all people with hypermobility have symptoms other than having increased joint flexibility. Also with age some joints stiffen up so it is not so obvious. The best joints to check are elbows and the middle thumb joints They tend to bend backwards and this does not change with age. 

And you are right bout the ballet and swimming helping your daughter.

I hope that your visit to the paediatrician answers all your question - but in the meantime become an expert parent and find out as much as you can about joint hypermobility syndrome. Hypermobility.org is a good place to start.

Paml

 

2 year old- 'cautious'?

Your site has been so helpful, thank you! I have a 26 m old who is hypermobile and low muscle tone, and I am wondering if she is cautious (as described in your other article). She was late in large motor skills (now that I have a normally developing 11 m old I see a huge diference!) She seemed a fairly normal baby but now she is very nervous whenever we go out. She basically has a melt down and has to be held by someone (usually me). It can take her 20 min or more to just venture out. Even in the library program, which she loves and we have been going to for a year, I have to hold her for a while before she will interact.

She seems to be getting worse- will she outgrow it around age 3? I hope so, we have another baby due and it is difficult for me to go out alone with her and my son, when she is so clingy. I always have to take the double stroller bc I never know when she will freak out and crumple into jello on the floor.

Also, she is a bit speech delayed (at 18 m level) and the therapist said it is likely due to her low mucle tone. Do you know anything about that? She is bright in other respects and right on par for comprehension, was potty trained to 19 m.

And finally I know I am hypermobile too! such a relief to know I have a real condition and am not 'weird' or 'weak'. The handwriting info is great, I love to write but always get sore and tired and my mum hated my 'chicken scratch'.

Cautious nature and anxiety

Hello 

Thank you for telling us about your cautious daughter. It is very important to help cautious toddlers to overcome their fear of novelty and in most instances this involves helping the child to calm down and then supporting them to stay with the situation. Your daughter may be particularly sensitive to certain types of situations - and it is useful to understand what these are and to help her deal with them. 

If your daughter's anxiety does not improve as she matures it might be useful to get some parenting advice from a child psychologist, especially with a new bay on the way which is going to provide another challenge for your daughter.

Generally speaking "low muscle tone" and joint hypermobility are not associated with speech delay. Perhaps you can discuss with the speech therapist other possible reasons for your daughter's delayed speech.  I am wondering if there is not a connection between the anxious  and the speech delay. 

Pam

 

HMS

My sister, my son, and myself have HMS. I had terrible anxiety until I went full on vegan and also cut out wheat. I was also diagnosed with IBS but because of my diet, my son and I are very regular. I do suffer from joint pain but only when I eat inflammatory foods. Tomatoes are the worst for me as well as my dependency on Splenda. Another symptom of HMS is Chronic Fatigue Syndrome so I drink lots of tea but using sugar diminishes the caffeine rush which is why I use the Splenda that causes pain in my hips. Oh, and my son is extremely cautious which may be the reason he was speech delayed.

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