'Double jointed'? 'Bendy'? An osteopath's guide to joint hypermobilty

It can often be under diagnosed and many health professionals overlook it, but hypermobility can cause joint pains and muscles aches, so often people can experience problems for a long time before getting the help they need. When we’re younger, we’re generally more flexible, but sometimes this flexibility is more than we should have. It’s often called being “double jointed”, but the technical name is hypermobility. In many people, hypermobile joints don’t cause any problems, but in some it can be the reason for many symptoms that no one has pieced together before.

When a patient first visits me, my first role is to find out exactly what is causing the problem the patient is presenting with. This is why I ask a lot of questions during the first session! Particularly if a problem has been there for a long time, it can be tricky to locate the cause and more often than not, there is a combination of factors that have built up and started causing symptoms. This process of detective work is essential, because only through identifying the underlying causes, can I confidently treat the problem and stop it from returning in the future. Hypermobility is often just one factor contributing to someone’s pain, but it can be a factor delaying recovery if it’s not addressed properly.

Some specifics about the types of hypermobility…

There are different types of hypermobility. If someone is only hypermobile in a couple of joints, it’s most likely that these joints are a slightly different shape to usual, making them move differently. This means the problem is local to those joints. If many joints move excessively, it’s most likely due to increased flexibility of the ligaments that hold joints together and the person may have Hypermobility Spectrum Disorder (HSD) or some form of Mixed Connective Tissue Disease (MCTD). This means treatment and management needs to look at the body as a whole.

Image

In simple terms, the ligaments hold bones together and limit the movements they make to a safe and comfortable range. The muscles are the things that make the joints move. So when your muscles relax, such as when you’re stood and your knees are locked to keep your legs straight, your ligaments hold the joint in the right position. In someone who is hypermobile, the ligaments will hold the joint in a different position and this can sometimes cause symptoms, such as knee, hip or low back pain.

Although it can seem like a major diagnosis, there is a lot that you can do to manage hypermobility and prevent problems in the future. The key is to receive the correct diagnosis so that you receive the right advice and can access any care you need.

Spectrum of hypermobility...

The term 'Hypermobility Spectrum Disorder' is relatively new and it's to reflect that someone with joint hypermobility can be anywhere along a scale from mild hypermobility with no symptoms, right up to the connective tissue disorders I mentioned earlier. The more severe forms can affect any structure in the body that contains collagen, including organs, and therefore can have lots of serious effects. When I suspect someone is hypermobile, I always assess whether they could potentially have a more severe form, as often they should be referred to a rheumatologist or geneticist to confirm the diagnosis and have a clear management plan with a healthcare team. It’s safe for someone with MCTD to have osteopathic treatment, but it’s part of a broader management with other medical professionals. I’m therefore only going to talk about HSD in this post.

So who has hypermobile joints?

It's difficult to know how many people have HSD, because it's under diagnosed. It’s more common in children and young people because joints tend to stiffen as we age. It’s also more common in women than men.

The symptoms…

Not everyone with JHS experiences symptoms and those symptoms can vary over time. For people who do experience symptoms, they can include:

• Joint pain
• Muscle aches and stiffness
• Recurrent injuries e.g. joint sprains, muscle strains
• Chronic fatigue
• IBS-like symptoms

In more severe cases, someone can potentially have one or more of these symptoms:

• Poor awareness of the body (proprioception) can lead to increased risk of injury
• Partial or complete dislocation of joints
• Changes to joints, usually when joints are overused for a long period of time e.g. dancers, gymnasts…
• Fragile skin with increased bruising, easier marking, scarring and stretch marks
• In severe cases, it can cause problems such as low blood pressure, heart problems, varicose veins

Diagnosis is essential…

HSD is diagnosed through testing general movement of joints (Beighton Score) and then assessing for other symptoms, such as stretch marks or joint pain, to form the Brighton Score. Other connective tissue disorders are ruled out based on symptoms and/or tests.

Once HSD has been diagnosed, a plan to manage the condition and limit the risk of complications such as muscle strains and joint sprains can be formed. I always take the time in my appointments to get to know the patient and learn what activities they need to do in their daily life, for example with their job, as well as activities they enjoy and want to continue enjoying. These give direction to my plan and help me work out what treatments are best for that person.

Important note for women about hormonal effects...

Women often find that HSD symptoms vary depending on their menstrual cycle. This is because the hormones that control the cycle, oestrogen and progesterone, can increase and decrease how loose the ligaments in the joints are. For example, it’s common for joint pain to be worse five days before and a couple of days after menstruating due to higher levels of progesterone in the body. Something as simple as taking an oestrogen-only contraceptive pill can regulate the hormones and reduce fluctuating joint pains. This is something to talk to the GP about to see if it’s suitable and I would only recommend such measures if there’s a noticeable change in joint pains with the cycle. Tracking your menstrual cycle and joint pain can be a helpful way to notice any patterns. There are many apps available to do this, such as Clue.

So what treatment is there for HSD?

There is no particular treatment for HSD, but there are lots of things someone can do to manage and prevent problems occurring. Management of HSD has to be targeted at the body as a whole, not just trying to support particular joints. The symptoms can be varied, so the ‘action plan’ is different for every person. However, I always recommend:

• Strength and resistance exercises
• Balance exercises
• Cardiovascular exercise
• Lifestyle changes

Strengthening exercises

Doing gentle strengthening exercises for muscles in the whole body is essential. In HSD the ligaments are looser, which means that the muscles can play a bigger role in supporting joints and keeping them stable. The stronger the muscles, the stronger and happier the joints!

Ideal strengthening exercises include:

• Pilates
• Light free weights, with higher repetitions
• Gentle resistance machines in the gym (but be careful not to force the joints into a hypermobile position when exercising)
• Tai chi

Cardiovascular exercise

Cycling, swimming, walking, jogging, aqua aerobics, rowing machine and cross-trainer are all brilliant ways to raise your heart rate to get a good cardiovascular workout, but they’re not going to impact your joints

Balance exercises

In some people with HSD, they can have poor balance which is another risk for joint injury. Simple balance exercises such as standing on one leg, then as you improve, stand on one leg while doing activities such as the washing up or brushing your teeth. Another great exercise is walking in a straight line where you bring the heel of your foot to the front of your toe repeatedly as you step in a slow, controlled movement.

Lifestyle changes

Generally being more aware of your body is essential for someone with hypermobility. The key ways to reduce the risk of injury and to reduce the strain on your joints is to be more aware of your body to avoid over-stretching. For example, if your knees hyperextend when you relax and lock them out, you can teach yourself to hold them in a more neutral position. At first it can feel like they're slightly bent when you're stood straight, but you gradually learn how this new neutral feels and it can make standing more comfortable.

Changing position frequently when you're sitting or standing can be helpful to reduce muscle aches, so fidget lots!

Footwear is important, so ensure your shoes have a good arch support and comfortable sole.

Use mobility aids and tools if you need to help take pressure off joints. For example, using a wider pen or adding a pen grip can make writing far more comfortable for hypermobile fingers. Supports for joints can be great if there’s a problematic area and you’re doing a strenuous activity. Sports tape can be a great tool as well.

Perhaps most importantly, be kind to yourself! Pace yourself and listen to your body.

How osteopathy can help…

I find that as an osteopath, particularly my own personal experience, I can give people the right skills and knowledge to manage their HSD. I also have the ability to spend as much time as needed going through exercises, reassessing joint mobility and muscle strength and then treating any areas that need attention. My focus is always on giving someone the tools they need to manage their symptoms long-term. I don't recommend that people with HSD need osteopathic treatment frequently, unless they need help with exercises or an injury.

So that’s quite a detailed run through of hypermobility! Hopefully it will give you more information about a condition that isn’t very well known and for some people it may well shed light on a few symptoms! I’m passionate about raising awareness of HSD and MCTDs to help those who may have struggled along for years with many symptoms, but never had anyone ‘connect the dots’.

If you feel you may have hypermobility that's causing symptoms, don’t hesitate to get in contact. You can also see your GP or a local osteopath, particularly if they specialise in HSD. Even if you’re not local to me, I’m happy to answer any questions you have and will endeavor to find an osteopath in your area who can help if necessary.

Let me know in the comments below if this has helped you!

Zoë Clark is a registered osteopath trained at the British College of Osteopathic Medicine in London.

Practicing in Howe, near Norwich (01508 558373) and Burston, near Diss, Norfolk (07543 557746).