Hypermobility Syndrome

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Search Strategy

Search on Pubmed and Pedro with keywords: “hypermobility”, “hypermobility syndrome” , “hypermobility ”and “therapy”. Search in libraries books about sport injuries, sports medicine, sport anatomy.

Definition/Description

Hypermobility syndrome (HMS) is defined as the presence of musculoskeletal symptoms in subjects with Hypermobility in the absence of demonstrable systemic rheumatic disease. [1]
Excessive laxity in multiple joints is necessary to have HMS.

Most common symptoms:

• pain in multiple joints
•  back pain
•  overuse syndromes with normal levels of activity
• always being tired

Less common symptoms:

• joint stiffness
• myalgia
• muscle cramps

[1][2][3]
Although women are more likely than men to have HMS and Asians and Africans are more likely to have HMS than white people, joint laxity is a consequence of a connective tissue disorder with a chance on heredity of 50%.

Epidemiology /Etiology

Generalized hypermobility is both sex- and age-related. Racial differences are also identifiable. The existence of BJHS can be accepted using present criteria. (2) (6)

Characteristics/Clinical Presentation

_ Acute or Traumatic'
▫ Sprains
— recurrent ankle sprains
▫Meniscus tears
▫ Acute or recurrent dislocations or subluxations of the:
— shoulder
— patella
— metacarpophalangeal joint
— temporomandibular joint
▫ Traumatic arthritis
▫Bruising
▫ Fractures
_ Chronic or Nontraumatic
▫ S'oft tissue rheumatism
— tendinitis
— epicondylitis
— rotator cuff syndrome
— synovitis
— juvenile episodic synovitis
— bursitis
▫ Chondromalacia
▫ Back pain
▫ Scoliosis
▫ Fibromyalgia
▫ Temporomandibular joint dysfunction
▫ Nerve compression disorders
— carpal tunnel syndrome
— Tarsal_Tunnel_Syndrome
— acroparesthesia
— thoracic outlet syndrome
▫ Raynaud syndrome
▫ Flat feet and sequelae
▫Unspecified arthralgia or effusion of affected joint(s)
(foot, ankle, knee, hip, back, neck, shoulder, elbow,
wrist, finger)
▫ Osteoarthritis
▫ Delayed motor development
▫ Congenital hip dislocation

Differential Diagnosis

Questions to Ask
_ Can you now (or could you ever) place your hands flat on the floor without bending your knees?
_ Can you now (or could you ever) bend your thumb to touch your forearm?
_ As a child, did you amuse your friends by contorting your body into strange shapes or could you do the splits?
_ As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?
_ Do you consider yourself double-jointed?

The signs and symptoms of hypermobility syndrome are variable. Most commonly, the initial complaint in a hypermobile patient is joint pain, which may affect one or multiple joints and may be generalized or symmetric. Primary care physicians can use the five simple questions (Figure 1) to aid in recognizing hypermobility. (5)

Diagnostic Procedures

The Beighton score measures the degree of hypermobility, the Brighton criteria is to determine the syndrome.

- Beighton score:

File:Beighton score.jpg

Beighton score.jpg

1. Hands flat on the floor with knees extended (1 point if positive)
2. Hyperextension of the elbow (1 point for each positive side)
3. Hyperextension of the knee (1 point for each positive side)
4. Thumb touching the forearm (1 point for each positive side)
5. Hyperextension of the 5th MCP (1 point for each positive side)

Maximum possible score: 9

Hypermobility present if total score ≥ 4

- Brighton criteria:

• Major criteria:

           • Beighton score of ≥4
           • Arthralgia for longer than 3 months in 4 or more joints

• Minor criteria:

           • Beighton score of 1, 2 or 3
           • Arthralgia (>3 months) in 1 to 3 joints or back pain (>3 months) or spondylosis/spondylolysis/spondylolisthesis
           • Dislocation or subluxation in more than 1 joint, or in 1 joint one more than 1 occasion
           • 3 or more soft tissue lesions (epicondylitis, tenosynovitis, bursitis)
           • Marfanoid habitus (span: height ration >1.03 or upper segment lower segment ratio < 0.89)
           • Abnormal skin: striae, hyperextensibility, papyraceous scars, thin skin
           • Eye signs: drooping eye lids, myopia, or antimongoloid slant
           • Varicose veins, hernia, uterine/rectal prolapse

• Requirement for diagnosis of hypermobility syndrome:

           • 2 major criteria
           • 1 major criteria + 2 minor criteria
           • 4 minor criteria
           • 2 minor criteria and unequivocally affected first-degree relative in family history

Another tests that the physiotherapist can do is:
1. A passive dorsiflexion of the fingers above 90degrees (1 point for each hand).
2. Bringing the thumb passive against the ventral side of the forearm (1 point for each thumb).
3. Hyperextension of the elbow above 10 degrees ( 1 point for each elbow)
4. Hyperextension of the knee above 10 degrees (1 point for each knee)
5. Flexion of the trunk, whit knees straight and the palms flat on the ground ( 1 point)

So the total score of the patient can be between 0 and 9 points. Depending on the hypermobiliteit of the patient. (Mink et al, 1990, Van der El, 1996)

Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

The Hypermobility Syndrome can’t be healed and there is not much known about an effective treatment yet.
Important is that HMS-patients have a good body conscience, to lower the risk of injuries, a good muscle balance, to support the joints, and they have to avoid excessive laxity movements.
They have to know their own body and their own limits.
Relieving joint pain and preventing its recurrence are primary aims of treatment and exercise to improve joint stability and control is a major component of physical rehabilitation. Research has identified that posture, proprioception, strength and motor control are important components in achieving this aim along with education, physical activity and fitness. (4)

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

1. 1.0 1.1 1.2 1.3 LAWRENCE A. Benign hypermobility syndrome. Indian Journal of Rheumatology 2005; 13:150-155 (2B)
2. 2.0 2.1 SIMPSON MR. Benign Joint Hypermobility Syndrome: Evaluation, Diagnosis, and Management. JAOA 2006;106(9):531-536 (1B)
3. RUSSEK LN. Examination and Treatment of a Patient With Hypermobility Syndrome. Physical Therapy 2000; 80(4):386-398 (C)
4. KEER R., SIMMONDS J., Joint protection and physical rehabilitation of the adult with hypermobility syndrome, Central London Physiotherapy Clinic, UK. (1B)
5. Michael MAJ. Simpson R. , Benign Joint Hypermobility Syndrome: Evaluation, Diagnosis, and Management, JAOA VOL 106, 2006 : 531-536 (1B)
6. Remvig L. Jensen DV. Ward RC., Epidemiology of general joint hypermobility and basis for the proposed criteria for benign joint hypermobility syndrome: review of the literature. J Rheumatol April 2007 34(4):804-809 (1A)