What is Hypermobility?
On a fundamental level, joint hypermobility (JH) is the concept that “a joint has the capacity to move, actively or passively, beyond normal limits along physiological axes” 1. Every joint in the body has a certain amount of movement capacity, which varies depending on the body part, the type of joint, and the direction (or plane) of movement. Some common terms you may have heard in reference to joint hypermobility include “double jointed” or “joint laxity.”However, joint hypermobility is a descriptor term rather than a diagnosis and can exist on a spectrum as it can present as a single finding, or be included as a characteristic of a larger diagnosis 1.
Let’s take a look at some main distinctions:
Localized Joint Hypermobility (LJH) exists when hypermobility occurs at multiple joints, but fewer than five. Typically LJH affects a single small or large joint but may affect both sides (e.g., bilateral genu recurvatum which is the ability to hyperextend the knees). Although LJH can have a genetic component, it can also simply be the result of a learned movement pattern as a result of a trauma, history of surgery, or movement training (eg., athletes, dancers, etc) 1.
In contrast, Ehlers Danlos Syndrome (EDS) is a heritable condition characterized by hypermobility of connective tissue in the body. Connective tissue generally serves the purpose of supporting body structures (organs and cells), transporting nutrients, defending against pathogens, storing fat, and repairing damaged tissue 4. There are 13 subtypes of EDS, the most widespread type of EDS is the hypermobile (hEDS), and symptoms of hEDS include joint hypermobility (affecting multiple areas of both large and small joints), soft and smooth skin that might bruise easily and present as slightly elastic, and chronic reports of musculoskeletal pain and symptoms 5. It’s noteworthy that unlike LJH, hEDS affects various aspects of the entire system, and is not just categorized by musculoskeletal symptoms. The below figure indicates the overlap of both musculoskeletal and systemic manifestations that can present with hEDS 1.
Given that there are many subtle differences between the classifications of various hypermobility syndromes, diagnosis can be challenging, and is a largely clinical process, relying heavily on the patient’s medical history, clinical presentation, and a commonly used diagnostic tool known as the Beighton Score (BS). According to Child (1986), a score of 4 or more out of 9 indicates generalized hypermobility of the joints 6. Although it’s helpful to have a diagnosis, diagnosis of either LJH or hEDS is not necessary in order to receive physical therapy treatment for musculoskeletal symptoms of hypermobility leading to pain or dysfunction.
Can PT help?
In short, yes! Although there are a few different classification of hypermobility with different etiology, physical therapy can be a helpful resource for all cases.
Physical Therapy for Hypermobility
It is important for physical therapists to understand an individual’s medical history, surgical history and activity history to get a baseline for previous movement experience and capacity. Additionally, we will discuss goals and what each patient is hoping to accomplish during the course of treatment. In some cases, it will be pain relief and improving capacity for functional movement throughout the day. In other cases, it may include fitness goals for return to running, weight lifting, or other sport-related activities.
Whether in the context of LJH or hEDS, it is important for a physical therapist to get a baseline for movement capacity, so whether a history of diagnosis is confirmed, or simply reported using subjective history of double jointedness and flexibility, the physical therapist will take joint measurements to compare range of motion (ROM) to normal parameters. Based on objective (ROM measurements) and subjective information (reported history/symptoms), as well as diagnosis from a physician if available, a physical therapist will create a plan of care in order to target specific musculoskeletal symptoms and structures 2.
Each plan of care will individually adapt exercise principles to the needs of patients in accordance with their given principles. This includes: general fitness principles, core strengthening and joint stabilization stabilization exercises, proprioception, as well as targeting any underlying nervous system response to pain and exercise 2. Research has shown that strengthening of muscles around the joint as well as improving joint proprioception aids in the dynamic stability of joints 3. A graded increase in activity has been proven as beneficial and appropriate for both deconditioned and active individuals in clinical management of musculoskeletal presenting hypermobility. awareness, proprioception and balance strategies, while in the more advanced treatment stage the emphasis has to be placed on eccentric and concentric muscle reinforcement 5.
A physical therapy program for an individual with joint hypermobility may involve the following:
Calm symptoms down with soft tissue mobilization and/or manual techniques. Research has shown that manual therapy techniques can facilitate tissue repair and modeling. Manual therapy can reduce pain signaling from the brain, inhibit muscle tension, reduce activity of pain receptors, and decrease pressure within or around the joint structures 6. This can be very beneficial for patients experiencing musculoskeletal pain as a result of hypermobility.
Additionally, in hypermobile individuals it is important to have neuromuscular control over the available range of motion. Although there are currently no exercise guidelines or protocol for therapeutic exercise for LJH or hEDS, according to a cohort study by Bathen et al reported participants who performed strength, proprioceptive, and core stability exercises 3x/week for 3 months supervised by a physical therapist and in conjunction with cognitive behavioral therapy demonstrated improvements in activities of daily living, motor tests (up/down stairs), and pain5.
Strength training includes targeting stabilizing muscles of various major joints throughout the body.
Important Areas for Strength Training:
Pelvic Girdle Stability: it is important to stabilize through musculature surrounding the hips and pelvis in order to properly support above structures, as well as improve force distribution and tolerance to load during activities such as sitting/standing, walking, running, jumping and other activities that include increased load through the lower body.
Shoulder Girdle Stability: similarly to pelvic stability, it is important to stabilize through the shoulder girdle in order to best be able to transfer forces through the upper body throughout the day, such as pulling open doors, lifting/putting down bags, holding groceries, etc.
Spinal Stability: additionally it’s important to ensure that the core muscles, and small muscles surrounding the spine are properly able to contract and have the endurance to support the spine and help to distribute load during sitting and standing activities throughout the day.
For examples of stability and strength exercises, check out our Instagram @perfectstridept for a sneak peak for some of our favorite exercises to address hypermobility for various joints.
Come see us at Perfect Stride if you need guidance in addressing hypermobility, improving strength, or getting back to your favorite activity. Please contact email@example.com or visit us in Union Square to learn more.
Castori M, Tinkle B, Levy H, Grahame R, Malfait F, Hakim A. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet C Semin Med Genet. 2017;175(1):148-157. doi:10.1002/ajmg.c.31539
Ross J, Grahame R. Joint hypermobility syndrome. BMJ. 2011;342(jan20 1):c7167. doi:10.1136/bmj.c7167
Boudreau PA, Steiman I, Mior S. Clinical management of benign joint hypermobility syndrome: a case series. J Can Chiropr Assoc. 2020;64(1):43-54.
Connective tissue. Cancer.gov. Accessed August 2, 2023. https://training.seer.cancer.gov/anatomy/cells_tissues_membranes/tissues/connective.html
Corrado B, Ciardi G. Hypermobile Ehlers-Danlos syndrome and rehabilitation: taking stock of evidence based medicine: a systematic review of the literature. J Phys Ther Sci. 2018;30(6):843-847. doi:10.1589/jpts.30.847
Manual therapy. Physiopedia. Accessed August 2, 2023. https://www.physio-pedia.com/Manual_Therapy