Hypermobility is common and a feature of normal development in healthy children i.e., the term reflects an increased range of movement compared to controls.
Hypermobility is more evident in young children, females and certain ethnic populations (e.g., Indian children are more flexible than age-matched white Caucasian children).
Hypermobility is more prevalent in competitive dancers, gymnasts and swimmers - and likely gives distinct advantage.
The photograph below shows hypermobility in a gymnast
However, hypermobility can be associated with pain although this is controversial. It is important not to ascribe pain to hypermobility without considering other causes. The pattern of joints involved must be symmetrical and can involve just peripheral joints or be widespread.
Hypermobility is also a feature of the inherited collagen disorders; these are rare but important, as individuals may be at risk of retinal and cardiac complications, as well as scoliosis. Such syndromes can be suspected by looking at the body habitus (look for tall stature, long fingers, wide arm span and high arched palate suggesting Marfan's syndrome), skin elasticity (easy bruising, thin skin, and paper thin scars suggesting Ehler's Danlos syndromes) and blue sclerae (suggesting osteogenesis imperfecta).
The photograph below shows blue sclerae
The photograph below shows a paper thin scar in Ehler's Danlos syndrome
The photograph below shows elastic skin in Ehler's Danlos syndrome
The presence of hypermobility may be suspected during history taking. Children and young people may complain of finger pain after handwriting or certain sporting activities or may describe 'clicky' joints. Recurrent dislocations may be reported. Pain may be predictable, occurring during or after specific activities and can be associated with morning stiffness the day following these activities. The child may stop doing the trigger sports, but then suffer increased pain when restarting. Anterior knee pain may occur in children who are hypermobile and often associates with flat feet. In some cases, hernias may be observed. There may be a history of other family members being diagnosed with hypermobility. A typical case is described.
Examination should include assessment of all joints (e.g., pGALS) and hypermobility may be obvious on inspection, e.g., hyperextension of fingers (pictures below), elbows or flat feet. Joints should be moved through their full range of movement, and hypermobility will be obvious to the examiner with knowledge of normal ranges of movement.
Photo: Hypermobility / Hyperextension of fingers.
Photo: Hypermobility / Hyperextension of thumb.
Photo: Hypermobility / Hyperextension at the elbows.
Photo: Hypermobility / Hyperextension of the knee.
Photo: Hypermobility at the spine
The manoeuvres within Beighton’s Criteria can be useful to guide the examiner. Children and young people may be hypermobile only in specific joints, but these should be symmetrical, and may or may not be associated with pain. The diagnosis of hypermobility can often be made with confidence when the history and examination findings are as expected. Often child and parent reassurance will suffice, with advice to maintain sporting activities and ensure good muscle strength with core stability optimised. Occasionally, advice from a paediatric physiotherapist can be useful, particularly in children struggling to return to normal activities, and especially if there is a history of recurrent dislocations. In some children with hypermobility there is an association with chronic pain and fatigue; the explanation is not clear and management is multidisciplinary.
Indications for referral include:
- Suspicion of inherited collagen syndromes (e.g., Marfans') - check body habitus, sclerae and skin.
- Pain and functional limitation.
- Asymmetrical joint involvement.
- Inflammatory joint or muscle disease is suspected (remember children with arthritis may also have hypermobility!)
- Recurrent dislocations.