Hypermobility

Page last reviewed: 13/07/2011

Joint hypermobility means that some or all of the joints have an unusually large range of movement. People with hypermobility are particularly supple and able to move their limbs into positions that other people find impossible.

Many people with hypermobile joints do not have any problems and do not 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.

What causes joint hypermobility?

Joint hypermobility is often hereditary (runs in families).

One of the main causes of joint hypermobility is thought to be changes to a type of protein called collagen.

Collagen is found throughout the body - for example, in the skin and in ligaments (the tough bands that link two bones together at a joint). If the collagen is weaker than it should be, the tissues in the body will be fragile. This can make the ligaments and joints particularly loose and stretchy. As a result, the joints can extend further than usual.

Occasionally, joint hypermobility is 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 - a condition that causes stretchy skin and the skin to bruise easily

How common is joint hypermobility?

It is thought that the condition may affect up to 3 in 10 people to some degree. It affects women more than men because female hormones increase flexibility.    

Joint hypermobility is quite 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 puberty, but in some people, joint hypermobility and associated symptoms continue into adult life.

Marfan syndrome affects around 1 in 5,000 people.

Outlook

Joint hypermobility syndrome can be very difficult to live with because it can cause fatigue (extreme tiredness) and long-term pain. People may also find that it takes 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 with a mixture 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.

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 may therefore involve treating short-term injuries as they arise, while following a long-term treatment plan to manage your daily symptoms. 

Collagen
Collagen is a type of protein that is found throughout your body - for example, in your skin and in ligaments.
Hormones
Hormones are groups of powerful chemicals that are produced by the body and have a wide range of effects.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Ligaments
Ligaments are made of fibrous tissue. They connect bone to bone, providing support while allowing flexibility and movement.
Tendon
A tendon is a fibrous cord that joins bones to muscle. It allows the bone to move when the muscle contracts.

People with joint hypermobility have an unusually large range of movement in some or all of their joints. 

Page last reviewed: 13/07/2011

Many people with hypermobile joints have few problems or none at all. Being hypermobile does not necessarily mean you will have any pain or difficulty. If you have symptoms, it is likely that you have joint hypermobility syndrome.

Joint hypermobility syndrome

Joint hypermobility syndrome can cause:

  • joint pains, particularly after physical work or exercise - this is due to overstretching of the joint capsule (the structure that surrounds the joint) and ligaments (the 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
  • a tendency to bruise easily
  • pain that gets worse throughout 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). In this case, you may 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.

Further symptoms 

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

  • irritable bowel syndrome (IBS) - a disorder that affects the digestive system, causing tummy pain, diarrhoea and constipation
  • stress incontinence - a type of urinary incontinence that occurs because the pelvic floor muscles are too weak to prevent urination
  • low blood pressure (hypotension), which may lead to fainting 
  • 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 that are usually blue or dark purple
  • flat feet - 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) 
  • anxiety - feelings of unease or worry  

Injuries

If you have hypermobile joints, 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, can dislocate if they are overstretched. A dislocated joint will need to be moved back into place, usually in hospital, in a procedure called a reduction.

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

  • tenosynovitis - inflammation (swelling) of the protective sheath around a tendon; tendons are the tough, rubbery cords that link muscles to bones
  • bursitis - inflammation of a bursa, which is a small fluid-filled sac that is found over the joints and between tendons and bones
  • tennis elbow (epicondylitis) - a condition that affects the outside of the elbow, causing swelling and pain
Collagen
Collagen is a type of protein that is found throughout your body - for example, in your skin and in ligaments.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Ligaments
Ligaments are made of fibrous tissue. They connect bone to bone, providing support while allowing flexibility and movement.
Pelvic floor muscles
The pelvic floor muscles support and hold in place your bladder and urethra. They give you control over your bladder and are used to urinate.
Tendon
A tendon is a fibrous cord that joins bones to muscle. It allows the bone to move when the muscle contracts.

Page last reviewed: 13/07/2011

There are four factors that may contribute to joint hypermobility:

  • the shape of the ends of your bones
  • the structure of your collagen (a type of protein that is 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 that is found throughout your body - for example, in your skin and in 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. Changes to these genes may cause joint hypermobility.

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 periods stop). This is why women are more flexible than men.

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 on to their children.

Osteogenesis imperfecta

Osteogenesis imperfecta is a rare condition that is sometimes known as brittle bone disease because it causes fragile bones. The condition can also affect the teeth, cause hearing loss and may cause blue sclerae (the white part of the eye). 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 and 2 in every 10,000 people.

Like Marfan syndrome, Ehlers-Danlos syndrome also affects the 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)
Collagen
Collagen is a type of protein that is found throughout your body - for example, in your skin and in ligaments.
Hormones
Hormones are groups of powerful chemicals that are produced by the body and have a wide range of effects.

Page last reviewed: 13/07/2011

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 that are described 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?

If you score four or more, you probably have joint hypermobility. Most people score less than two. See your GP to confirm your diagnosis and to check that 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 should 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 and how long you have had them, such as joint pain and dislocated joints. The Brighton criteria includes:

  • joint pain and whether you have had it for longer than three months
  • back pain and whether you have had it for longer than three months
  • spondylosis (spinal arthritis) 
  • spondylolisthesis - when one vertebra (small bone in your spine) slips forward over another vertebra
  • dislocation or partial dislocation in more than one joint, or in the same joint more than once 
  • 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)

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

Arthritis
A common condition that causes inflammation in the joints and bones.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Tendon
A tendon is a fibrous cord that joins bones to muscle. It allows the bone to move when the muscle contracts.

Page last reviewed: 13/07/2011

If you have joint hypermobility that does not cause any symptoms, treatment is not necessary. However, you may need treatment if your joint hypermobility syndrome causes symptoms such as joint pain.

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

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

Physiotherapy and exercise

Physiotherapy, often referred to as physio, can be used by people with hypermobile joints for a number of reasons. 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

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.

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 had significantly reduced pain. 

Occupational therapy

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

You can learn ways of carrying out tasks at home or at work that reduce the strain on your joints

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

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 (tough bands of connective tissue) on the bottom of your feet being too loose.

Repositioning your foot arches by wearing insoles may reduce knee and ankle pain.

Painkillers

Another aspect of treatment for joint hypermobility syndrome is using medication to treat pain.

Over-the-counter painkillers, such as paracetamol, can be used. You may also be prescribed a medicine that contains both paracetamol and codeine, which is a stronger type of painkiller.

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 that it is suitable for you. For example, ibuprofen should be used with caution in people with:

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

Some people with joint hypermobility may benefit from referral to a pain specialist - for example, at a pain clinic.

Surgery

Surgery is not recommended for joint hypermobility 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.

Arthritis
A common condition that causes inflammation (swelling) in the joints and bones.
Cartilage
Cartilage is a tough, flexible tissue that is found throughout the body. It covers the surface of joints, enabling bones to slide over one another while reducing friction and preventing any damage.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area. 
Ligaments
Ligaments are made of fibrous tissue. They connect bone to bone, providing support while allowing flexibility and movement.
Tendon
A tendon is a fibrous cord that joins bones to muscle. It allows the bone to move when the muscle contracts.

Self-help measures

  • If you have an injury from over-stretching, rest the joint and elevate it – for example, by propping it up on some pillows. You can also apply ice wrapped in a damp towel to the injured area.
  • Applying heat, such as a hot water bottle or heat-rub cream, may soothe a sore joint. 
  • A splint, which is a support that keeps part of the body stable and motionless, can provide relief for injured elbows and knees. 
  • Avoid aerobics and sports such as squash, where you have to twist your joints in a small space. Try swimming or cycling instead. 
  • Join a support group.

Page last reviewed: 13/07/2011

People may have a number of complications with hypermobile joints. These are briefly 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 the tissues in and around the joints 
  • damage to cartilage, 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

Sports injuries

One review of a number of studies found that people with joint hypermobility were at increased risk of 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.

Pelvic organ prolapse

Women with joint hypermobility, or conditions such as Marfan syndrome or 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 these conditions, the connective tissues in your body, which provide support and structure to other tissues and organs, are weaker than normal. They are more likely to be unable to support your internal organs and you may have a prolapse.

 

Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Cartilage
Cartilage is a tough, flexible tissue that is found throughout the body. It covers the surface of joints, enabling bones to slide over one another while reducing friction and preventing any damage.
Uterus
The uterus (or womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.
Vagina
The vagina is a tube of muscle that runs from the cervix (the opening of the womb) to the vulva (the external sexual organs).

Page last reviewed: 13/07/2011

Gymnasts, ballet dancers, acrobats, divers, hurdlers and musicians can all benefit from hypermobile joints.

Glossary

Joints
Joints are the connection point between two bones that allow movement.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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