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Hypermobility
Hypermobility Content Supplied by NHS Choices
Introduction

Joint hypermobility means some or all of a person's joints have an unusually large range of movement.

People with hypermobility are particularly supple and able to move their limbs into positions others find impossible.

Many people with hypermobile joints do not have any problems or need treatment. However, joint hypermobility can sometimes cause unpleasant symptoms, such as:

  • joint pain
  • back pain
  • dislocated joints - when the joint comes out if its correct position 
  • soft tissue injuries, such as tenosynovitis (inflammation of the protective sheath around a tendon)

If hypermobility causes these types of symptoms it is often called joint hypermobility syndrome. Read more about the symptoms of joint hypermobility.

Living with joint hypermobility syndrome

Joint hypermobility syndrome can be very difficult to live with because it can cause fatigue (extreme tiredness) and long-term pain. It may also take time to receive the correct diagnosis due to the wide range of symptoms that joint hypermobility syndrome can cause.

However, once diagnosed, joint hypermobility syndrome can be treated using a combination of exercise and physiotherapy (where physical methods are used to promote healing). An exercise programme to improve fitness and muscle strength may also be effective at reducing pain. Read more about treating joint hypermobility.

The nature of joint hypermobility syndrome means that you are at increased risk of injuries, such as dislocations and soft tissue injuries. Managing joint hypermobility syndrome may therefore involve treating short-term injuries as they arise, while following a long-term treatment plan to manage daily symptoms. 

Causes of joint hypermobility

Joint hypermobility is often hereditary (runs in families). One of the main causes of joint hypermobility is thought to be genetically-determined changes to a type of protein called collagen.

Collagen is found throughout the body - for example, in skin and ligaments (the tough bands that link two bones together at a joint).

If collagen is weaker than it should be, tissues in the body will be fragile. This can make ligaments and joints particularly loose and stretchy. As a result, the joints can extend further than usual.

Most cases of joint hypermobility are thought to be linked to Ehlers-Danlos syndrome hypermobility type, which is a group of inherited conditions that affect collagen proteins in the body.

Occasionally, joint hypermobility may be part of a rare and more serious condition such as:

  • osteogenesis imperfecta - a condition that affects the bones
  • Marfan syndrome - a condition that affects the blood vessels, eyes and skeleton
  • Ehlers-Danlos syndrome vascular type - a condition that can cause the arteries, bowel or womb (in pregnant women) to rupture (split)

Read more about the causes of joint hypermobility.

How common is joint hypermobility?

It is not clear how many people in the UK have joint hypermobility. There are estimates that up to 3 in 10 people may be affected to some degree. It affects women more than men, possibly because female hormones increase flexibility.

Joint hypermobility is common in children. Children with joint hypermobility can bend into unusual positions (often referred to as 'double-jointed').

In many children, the joints become stiffer by the time they reach adulthood, although in some people, joint hypermobility and its associated symptoms continue into adult life.

Marfan syndrome affects around 1 in 5,000 people.



Symptoms of joint hypermobility

Many people with hypermobile joints have few or no problems from their condition.

Being hypermobile does not necessarily mean you will have pain or difficulty. If you have symptoms, it is likely you have joint hypermobility syndrome.

Joint hypermobility syndrome can cause:

  • joint pains, particularly after physical work or exercise - due to overstretching of the joint capsule (the structure that surrounds the joint) and ligaments (tough bands that link two bones together at a joint)
  • muscle aches and pains because your muscles have to work harder with supple joints
  • back pain and neck pain 
  • a tendency to bruise easily
  • pain that gets worse through the day and better at night, after you have rested
  • fatigue (extreme tiredness)
  • night pains in children

Joint hypermobility syndrome can be caused by changes in your collagen (a protein in connective tissue). You may also have other related conditions or symptoms, as collagen is found throughout your body.

If you have joint hypermobility that is part of another condition, such as Ehlers-Danlos syndrome (stretchy skin and easy bruising), you may also have additional symptoms. Ehlers-Danlos syndrome type III, also called Ehlers-Danlos syndrome hypermobility type, is the same as joint hypermobility syndrome.

See joint hypermobility - causes for more information about the role of collagen and other conditions that can cause hypermobility.

Digestive system symptoms

Joint hypermobility syndrome can cause symptoms that affect your digestive system. A series of muscles squeeze food through your digestive system.

In joint hypermobility syndrome, these muscles may be weaker than they should be and this leads to food progressing more slowly though your digestive system. This can cause a range of symptoms including:

  • stomach acid leaking from your stomach to your gullet, causing symptoms such as heartburn (a burning sensation or discomfort in the chest)
  • your stomach having difficulty emptying its contents into the small bowel, which can cause bloating and nausea (gastroparesis)
  • an overgrowth of bacteria in your bowels - this may cause symptoms such as diarrhoea, bloating and cramps
  • not being able to pass stools (faeces) as often as you usually do, or having to strain more than usual (constipation)
  • irritable bowel syndrome (IBS) - a disorder that affects the digestive system, causing tummy pain, diarrhoea and constipation

Postural orthostatic tachycardia syndrome (POTS) 

Joint hypermobility syndrome can cause abnormalities in part of your nervous system that controls the bodily functions you do not actively think about, such as the beating of your heart. This is called your autonomic nervous system.

These abnormalities can cause problems when you stand up or sit in the same position for a while. Your blood pressure can drop to low levels, making you feel sick, dizzy and sweaty. You may also faint.

In some people, these abnormalities can lead to postural orthostatic tachycardia syndrome (POTS). POTS causes your pulse rate to increase rapidly within 10 minutes of standing up. You may also experience:

  • dizziness or fainting
  • headaches
  • tummy upsets
  • sweating
  • a sensation of anxiety
  • purple puffy fingers and feet
  • a pounding or fluttering heart beat (heart palpitations)

Further symptoms

People with joint hypermobility syndrome may have other related conditions and further symptoms including:

  • stress incontinence - a type of urinary incontinence that occurs because the pelvic floor muscles are too weak to prevent accidental urination
  • hernias - an internal part of the body, such as an organ, pushes through a weakness in the muscle or surrounding tissue wall
  • varicose veins - swollen and enlarged veins, usually blue or dark purple
  • flat feet - where the inner part of your feet (the arch) is not raised off the ground when you stand
  • drooping eyelids
  • thin or stretchy skin
  • bluish tinge to the white part of the eyes (sclerae)
  • a sense of anxiety - feelings of unease or worry  

Injuries

If you have joint hypermobility syndrome, you may be at increased risk of injuring your joints - for example, by partially or completely dislocating them (when the joint comes out of its correct position). Joints, particularly the shoulder or knee-cap, can dislocate if overstretched.

A dislocated joint will need to be moved back into place, usually in hospital, in a procedure called a reduction. Some people with joint hypermobility syndrome may be able to put their joints back into place themselves. However, you should still seek medical attention if you have dislocated a joint.

You may also be at increased risk of soft tissue injuries such as:

  • tenosynovitis - inflammation (swelling) of the protective sheath around a tendon (the tough, rubbery cords that link muscles to bones)
  • bursitis - inflammation of a bursa (a small, fluid-filled sac found over the joints and between tendons and bones)
  • epicondylitis (tennis elbow) - a condition that affects the outside of the elbow, causing swelling and pain


Causes of joint hypermobility

There are four factors that may contribute to joint hypermobility.

These are:

  • the shape of the ends of your bones
  • the structure of your collagen (a type of protein found in some types of tissue)
  • muscle tone
  • proprioception - sensing your body's position and movements

These are explained in more detail below.

Shape of the bone ends

A joint is the junction between two bones. The shape of the bones determines how far you can move your limbs. For example, your limbs will be more flexible if the socket that the bone moves around in, such as the shoulder or hip socket, is shallow. A shallow socket will allow more movement in a joint.

Collagen structure

Collagen is a type of protein found throughout your body - for example, in skin and ligaments. Ligaments are tough bands of connective tissue (fibres that support other tissues and organs in your body) that link two bones together at a joint. They strengthen the joint and limit its movement in certain directions.

If the structure of your collagen is altered, it may not be as strong, and the tissues that contain collagen will be fragile. This can lead to weakened or easily stretched ligaments. All joints can be affected, particularly your knees and thumbs.

Changes in the structure of your collagen are likely to be caused by changes to your genes. Genes are single units of genetic material that you inherit from your parents. They contain genetic instructions that tell your body how to work. If the genetic instructions within the genes change, it can alter your collagen.

There may be several genes that affect the structure of collagen. Read more about how genes change and are inherited.

Hormones also appear to play a role in joint hypermobility because the female hormone, oestrogen, increases flexibility, probably by affecting collagen. Women may find that they are more supple before a period and less supple after the menopause (when a woman's monthly periods stop).

Muscle tone

Children with joint hypermobility may have a degree of hypotonia (low muscle tone). This is more commonly seen in children with autistic spectrum disorders (developmental disorders) and chromosomal abnormalities, such as Down's syndrome. Down's syndrome affects physical development and causes learning difficulties.

Sense of joint movement

You should be able to sense the position and movement of your joints. For example, even with your eyes shut you should know whether your arm is bent or straight. The medical term for this sense is proprioception.

However, if you have an abnormal sense of joint movement, you may not be able to sense when a joint is overstretched, so you will have a wider range of movement.

Other conditions

Joint hypermobility can be part of a more serious underlying condition. These are often hereditary (inherited) conditions which parents pass to their children. Some conditions that can cause symptoms of joint hypermobility are discussed below.

Osteogenesis imperfecta

Osteogenesis imperfecta is a rare condition sometimes known as brittle bone disease because it causes fragile bones. The condition can also affect teeth and cause hearing loss. The most severe forms of osteogenesis imperfecta may affect 1 in 25,000 people.

Marfan syndrome

Marfan syndrome is a condition that affects the body's connective tissues. These provide support and structure to other tissue and organs. It can affect the:

  • blood vessels, causing damage to the heart 
  • skeleton, causing long, thin limbs 
  • eyes, causing the transparent lens at the front of the eye to fall into an abnormal position (lens dislocation)

Approximately 1 in 5,000 people have Marfan syndrome.

Ehlers-Danlos syndrome

It is estimated that Ehlers-Danlos syndrome affects between 1 or 2 people in every 10,000.

Like Marfan syndrome, Ehlers-Danlos syndrome also affects connective tissues, although different types of the syndrome cause slightly different symptoms. Ehlers-Danlos syndrome can cause:

  • easy bruising
  • stretchy skin 
  • poor wound healing - leading to scars 
  • blue sclerae (white part of the eyes)

There are several different types of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome type III, also called Ehlers-Danlos syndrome hypermobility type, is the same as joint hypermobility syndrome. 

It is important to identify the correct type of Ehlers-Danlos syndrome because some types (particularly type IV) carry an increased risk of burst blood vessels or other organs.

If you have Ehlers-Danlos syndrome type IV, you may be at increased risk of conditions such as strokes, or of developing a problem with your womb (uterus) if you are pregnant.



Diagnosing joint hypermobility

Joint hypermobility can be difficult to measure because the extent of the condition varies from person to person.

However, you can use a system called the Beighton score to determine whether you have joint hypermobility.

The Beighton score

The Beighton score consists of a series of nine tests listed below. Each test carries a score of one point.

  • Can you put your hands flat on the floor with your knees straight? 
  • Can you bend your left elbow backwards? 
  • Can you bend your right elbow backwards? 
  • Can you bend your left knee backwards? 
  • Can you bend your right knee backwards? 
  • Can you bend your left thumb back on to the front of your forearm? 
  • Can you bend your right thumb back on to the front of your forearm? 
  • Can you bend your left little finger at 90 degrees, towards the back of the hand? 
  • Can you bend your right little finger at 90 degrees, towards the back of the hand?

The Hypermobility Syndrome Association has images of the Beighton score tests if you would like more information.

Most people score less than two, but if you score four or more you probably have joint hypermobility. See your GP to confirm your diagnosis and check your symptoms are not caused by another condition.

If you also have symptoms, such as joint pain, you may have joint hypermobility syndrome. Your GP may be able to diagnose this using the Brighton criteria.

The Brighton criteria

The Brighton criteria take into account your Beighton score, but also consider other symptoms, such as joint pain and dislocated joints, and how long you have had them. There are major and minor Brighton criteria.

Major criteria

The major Brighton criteria are: 

  • having a Beighton score of four or more, either now or in the past
  • having joint pain for longer than three months in four or more joints

Minor criteria

The minor Brighton criteria are:

  • having a Beighton score of one to three, or having a Beighton score of zero to three if you are over 50 years of age
  • having joint pain for longer than three months in one to three joints, or back pain for longer than three months, or spondylosis (spinal arthritis) or spondylolisthesis (where one small bone in your spine slips forward over another bone)
  • dislocating, or partially dislocating, more than one joint or the same joint more than once
  • having three or more injuries to your soft tissues, such as tenosynovitis (inflammation of the protective sheath around a tendon) or bursitis (inflammation of a fluid-filled sac in a joint)
  • having particular physical characteristics called Marfanoid habitus - this includes being tall and slim and having long, slim fingers
  • having abnormal skin, such as thin and stretchy skin
  • having eye-related symptoms, such as droopy eyelids or short-sightedness, having swollen and enlarged veins (varicose veins), or a hernia (when an internal part of the body pushes through a weakness in the surrounding tissue wall) or a rectal or uterine prolapse (where an internal organ slips down from its usual position) 

Joint hypermobility syndrome may be diagnosed if you have:

  • two major criteria
  • one major criteria and two minor criteria
  • four minor criteria
  • two minor criteria and a close relative, such as a parent, who has been diagnosed with joint hypermobility syndrome

Your GP may also carry out blood tests and X-rays to rule out other conditions associated with joint pains, such as rheumatoid arthritis.

Assessing your condition

As well as diagnosing your joint hypermobility syndrome, it is also important that your GP fully assesses the effect the condition is having.

Joint hypermobility syndrome can cause a wide range of symptoms, including symptoms that affect your digestive system and blood pressure (read more about the symptoms of joint hypermobility).

It will be necessary to assess the effect of all your symptoms on your quality of life and ability to carry out every day tasks.



Treating joint hypermobility

Treatment is not necessary if you have joint hypermobility that does not cause any symptoms.

However, you may need treatment if you have joint hypermobility syndrome, which causes symptoms such as joint pain.

Depending on your symptoms of joint hypermobility, your condition may be treated by a number of healthcare professionals including:

  • your GP 
  • a rheumatologist - a specialist in conditions that affect muscles and joints
  • a physiotherapist - a healthcare professional using physical methods, such as massage and manipulation, to promote healing and wellbeing
  • an occupational therapist - a healthcare professional who can identify potential problem areas in everyday life, such as getting dressed, and work out practical solutions
  • a podiatrist - a footcare specialist

If you have any related conditions, such as flat feet or varicose veins, you can use the Heath A-Z index to find information about how they will be treated.

Physiotherapy and exercise

Physiotherapy, often referred to as physio, can help people with hypermobile joints in a number of ways. For example, physiotherapy may be used to:

  • reduce pain
  • improve muscle strength and fitness
  • improve posture
  • improve your sense of your body's position and movement (proprioception)
  • correct the movement of individual joints

A physiotherapist with knowledge about joint hypermobility syndrome can be very useful as some physiotherapy treatments can make symptoms worse.

There are a range of physiotherapy techniques that can be used. For example, you may be given an exercise programme that includes strength and balance training, special stretching techniques and advice about pacing.

Pacing involves balancing periods of activity with periods of rest. It means not overdoing it or pushing yourself beyond your limits because if you do, it could slow your long-term progress. Read more about physiotherapy and the different techniques used.

The Hypermobility Syndrome Association also provides useful advice about pain management through stretching, relaxing the muscles and doing gentle exercises.

One recent study of physiotherapy in children with joint hypermobility syndrome found that a general programme to improve muscle strength and fitness was just as effective as a programme aimed at specific joints. Both groups of children in the study experienced significantly reduced pain. 

Occupational therapy

Occupational therapy aims to promote people's health and wellbeing through their everyday activities. If you have joint hypermobility syndrome, an occupational therapist can help adapt your home and way of life around your condition.

Occupational therapy can be particularly useful in helping children with joint hypermobility syndrome who have problems with handwriting.

By using techniques to help improve your ability, or by changing the environment or equipment you are using, an occupational therapist can help you regain or improve your independence. For example:

  • bed rails can be fitted to help you get in and out of bed
  • toilet seats can be raised
  • small pieces of equipment can be used to help with dressing

Read more about the types of treatments available through occupational therapy.

Podiatry

Flat feet, where the inner part of the feet (the arches) are flattened, are frequently associated with hypermobility. This is because the foot arches collapse under your body weight due to the ligaments (bands of connective tissue) on the bottom of your feet being too loose.

Repositioning your foot arches by wearing insoles may help reduce knee and ankle pain. Read more about flat feet.

Painkillers

Medication can also be used to treat pain associated with joint hypermobility syndrome.

Painkillers, such as paracetamol, available over the counter from pharmacies, can be used. You may also be prescribed a medicine that contains both paracetamol and codeine, which is a stronger type of painkiller. Calpol is particularly helpful for children with joint hypermobility syndrome.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used to relieve any swelling of the joint.

Painkillers and NSAIDs are also available in the form of gels or sprays that can be applied directly onto painful joints.

Check the patient information leaflet that comes with your medication to make sure it is suitable for you. For example, ibuprofen should be used with caution in people with:

  • asthma - where the airways of the lungs become inflamed (swollen) 
  • kidney problems 
  • liver problems

Some people with joint hypermobility syndrome may find pain medication is not effective.

For example, there have been reports of local anaesthetic used during a surgical procedure not having an effect in people with joint hypermobility syndrome. If you are having a procedure that requires anaesthesia, such as dental treatment, you may want to discuss the issue with your dentist beforehand. 

Pain management

If painkillers are not effective in reducing your pain, you may benefit from being referred to a pain specialist at a pain clinic. Staff at the clinic will be able to provide further advice and treatment.

For example, a pain management programme that incorporates cognitive behavioural therapy (CBT) is one way that people with joint hypermobilty syndrome can learn to manage their pain when painkillers are not working.

Read more about NHS help for people with pain.

Surgery

Surgery is not recommended for joint hypermobility (where alternative non-surgical treatment is available) because joint tissue does not heal well and it can lead to osteoarthritis (arthritis that affects the cartilage within the joint).

The exception to this is in cases where there is a ruptured (split) tendon, which should be repaired surgically. Tendons are the tough, rubbery cords that link muscles to bones.



Complications of joint hypermobility

There are a number of complications associated with joint hypermobility syndrome.

These are discussed below.

Osteoarthritis

People with joint hypermobility may have a slightly increased risk of developing osteoarthritis. This is a condition that affects the joints and causes:

  • mild inflammation (swelling) of tissues in and around the joints 
  • cartilage damage - cartilage is the strong, smooth surface that lines the bones and allows joints to move easily and without friction 
  • bony growths that develop around the edge of the joints

Read more about osteoarthritis.

Sports injuries

One review of a number of studies found that people with joint hypermobility were at increased risk of sustaining injuries to their knee joints from contact sports. This includes sports such as football, rugby and hockey. However, the risk of injury to their ankle joints was not increased.

Read more about sports injuries.

Pelvic organ prolapse

Women with joint hypermobility syndrome, or conditions such as Marfan syndrome, or other types of Ehlers-Danlos syndrome, may be at increased risk of pelvic organ prolapse.

This is where the organs inside the pelvis slip down from their normal position. For example, the uterus (womb) may slip down into the vagina.

If you have joint hypermobility, or one of the conditions mentioned above, the connective tissues in your body that provide support and structure to other tissues and organs are weaker than normal. This means they are more likely to be unable to support your internal organs and you may have a prolapse.

Read more about prolapse of the uterus, including how it can be treated.



 
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