Joint hypermobility

The most common problem with having hypermobile joints is pain, especially after hard physical work or exercise. The muscles have to work harder if the joint is very supple and this can lead to muscle strain. Sometimes the joint feels tense or stiff which may be caused by fluid collecting inside the joint.   

Sometimes hypermobility is caused by weakened collagen fibres (which normally give strength to our ligaments), and weakened collagen can cause other symptoms including hernias or varicose veins.

You may also have a flat arch to your foot, and this can lead to foot pain particularly after standing for a long period.

Backache can be a problem if the base of your spine is particularly supple, sometimes as a result of one of the bones in the back (vertebra) slipping on another. This is called a spondylolisthesis.

Hypermobile joints are more prone to injury than normal if they are over-stretched. Sometimes the joint can dislocate – this is most common in the shoulder. If you repeatedly dislocate a joint, particularly your shoulder or kneecap, without having had a serious injury, then you may well be hypermobile.

Occasionally, joint hypermobility is part of a more widespread problem. In these much rarer conditions, there is more serious damage to the tissue proteins, with the result that other parts of the body are involved:

• Osteogenesis imperfecta causes the bones to become fragile
• Marfan's syndrome involves the heart, the eyes and the blood vessels
• Ehlers–Danlos syndrome is the most difficult to diagnose because there are many different types. The most severe form causes weakness of the major blood vessels, which may swell (this is called an aneurysm).

Osteoarthritis

It is hard to predict whether hypermobility will lead to osteoarthritis in any particular case. If you have an inherited form of hypermobility and osteoarthritis is also common in your family then you probably will have a greater risk of developing osteoarthritis yourself. Joint injuries, whether or not they result from hypermobility, can also increase the risk of osteoarthritis later on.

However, there's no evidence that the symptoms of osteoarthritis are any worse in people who are hypermobile than in people who are not. If you are hypermobile we would recommend keeping to a healthy weight as it's known that obesity is often an important factor in the development of osteoarthritis.

Other conditions

Recent research suggests that hypermobile people may have more supple collagen in other parts of the body besides the joints.

This may be linked to a number of other symptoms including mild asthma, irritable bowel syndrome (IBS) and urinary stress incontinence. Blood pressure may also be lower than normal, so people who are hypermobile may be more prone to fainting. Very rarely, the heart valves may also be floppy.

• The shape of the bones – If the socket part of the hip or shoulder joint is particularly shallow the range of movement in the joint will be greater than usual and so will the risk of dislocation
• Weak or stretched ligaments – Small changes in the biochemical reactions that take place in the body can result in weakened collagen fibres which in turn cause weakness in the ligaments that help to hold our joints together. This is likely to cause hypermobility in many joints
• Muscle tone – The more relaxed your muscles are, the greater the range of movement you will have in your joints. This is likely to affect a smaller number of joints
• Sense of joint movement (proprioception) – Some people find it difficult to sense the position of a joint without being able to see it, and may develop joint hypermobility by over-stretching the joints without realising it.

Where joint hypermobility affects one or a small number of joints, particularly the hip and/or shoulder, suggesting shallow sockets in these joints, the condition is also likely to be inherited.

It's not yet known whether joint hypermobility resulting from abnormal proprioception is inherited (see What Causes Joint Hypermobility?). About a quarter of people affected by joint hypermobility have no previous family history of it.

Women tend to be more supple than men because of the effect of a hormone called relaxin (which allows the pelvis to expand during childbirth) and are therefore more likely than men to have hypermobile joints. Women or girls who are hypermobile may notice that their joints are more painful around the time of their period. The collagen fibres in your ligaments tend to bind together more as you get older, which is one reason why many of us become stiffer with age.

Different races have differences in their joint mobility, which may reflect differences in the structure of the collagen proteins. People from the Indian sub-continent, for example, often have much more supple hands than Europeans.

Joint hypermobility can sometimes be acquired, for example by gymnasts and athletes, through the training exercises they do. Yoga can also make the joints more supple by relaxing the muscles.

Many people with Down's syndrome will be hypermobile.

If you think you may have joint hypermobility, you can check your own Beighton score using the tests shown in Figure 1. Give yourself 1 point for each of the five simple tests you can do. The maximum score is nine, but most people score less than two, and only three or four people in a hundred score four or more points. If you score four or more points in the tests you are hypermobile. However, not everyone who is hypermobile has joint pains, so the Brighton criteria state that if you have four or more hypermobile joints and you have had joint pains in those joints for three months or more then it's likely that you have hypermobility syndrome, also known as benign joint hypermobility syndrome (BJHS).

Figure 1. Beighton's modification of the Carter and Wilkinson scoring system. Give yourself one point for each of the manoeuvres you can do, up to a maximum of nine points.

Table 1 shows the major and minor signs and symptoms (criteria) that your doctor will refer to. You should still consult your doctor to find out whether hypermobility is the cause of your symptoms, or whether something else is causing the pain.

Table 1. The 1998 Brighton Criteria

For a diagnosis of hypermobility to be confirmed your doctor would expect:

• 2 major criteria or
• 1 major + 2 minor criteria or
• 4 minor criteria or
• 2 minor criteria + a first-degree relative with confirmed hypermobility.

Drugs

Painkillers are the usual treatment for the symptoms of joint hypermobility.

Paracetamol is normally the first choice – you can take up to two 500 mg tablets up to four times a day. It's often better to take a dose before activity to keep the pain under control rather than waiting until it's very bad. Your doctor can prescribe a stronger, compound painkiller such as cocodamol or codydramol if necessary.

If the joint often swells up, especially after dislocation, a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen may be better. Your doctor may prescribe a higher dose if needed, or a different NSAID if the standard dose of ibuprofen is not strong enough.

You can also get either painkillers or NSAIDs as a spray or a cream, which allows them to be applied directly onto the troublesome joint. This method may not be quite so effective but may be an option if the tablets aren't suitable for you.

Long-term (chronic) pain can get you down, and you may need help to cope with this. Some centres offer pain management programmes – so ask your doctor about these.

Physical therapies

Research has shown the value of exercise. In most cases you can reduce your symptoms by doing gentle exercises to strengthen and condition the muscles around the joints that are particularly supple.

The important thing is to do these strengthening exercises frequently and regularly but not to overdo them. Use only small weights, if any. A physiotherapist will be able to advise on suitable exercises. For some people gentle stretching seems to be as effective as strengthening.

Splints or firm elasticated bandages can be used if necessary to protect against dislocation. An occupational therapist or physiotherapist can advise on these. It's also quite common for hypermobile people to manipulate and click their loose joints, which often makes the joints feel better.

Sometimes when a joint dislocates you may need professional help to manipulate the joint back into place.

Surgery

In general, surgery is not recommended for hypermobile joints. This is because tissue that is very supple doesn't usually heal as well as less supple tissue.

Operations such as removing a kneecap that dislocates frequently or stabilizing a very supple joint with a pin to fuse it, may increase the risk of osteoarthritis later in life so these are not usually recommended.

However, if you rupture a tendon (which is more likely than usual if you have hypermobile joints) this should usually be repaired surgically.

Exercise

Some sports can bring on joint hypermobility symptoms and cause pain. Non-contact sports are generally safer, but sports like squash, which involve twisting the joints under stress, are not recommended.

If any of your joints are prone to dislocation it may help to wear a splint or elastic bandage while exercising. Some people learn to manipulate their own joints back into place after such injuries.

Children with hypermobile joints do not have to avoid physical education – what is important is to avoid overstretching the joints. Swimming can help, where the weight of the body is supported by water, and so can cycling.

Read more general advice and specific exercises that will help you keep active.

Diet and nutrition

There is no specific diet to help joint hypermobility, but we would recommend a healthy, balanced diet to keep your weight under control.

Read more general advice on nutrition and nutritional supplements.

Complementary therapies

Glucosamine supplements may help to protect against osteoarthritis, especially of the knee.

Footwear

There's a wide variation in the shape of the foot in people who are hypermobile. Most tend to have flat feet but a few have a high-arched foot. Special insoles in the shoes (orthoses) often help to restore the arch of the foot. If your legs are different lengths this could cause a twist in the spine, but an orthosis can correct the difference.