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Paediatric Hypermobility & Joint Pain

  

Management of hypermobility should generally be in Primary Care


Hypermobility

Hypermobility can be:

  • Localised – single area affected and often acquired following trauma, joint disease or surgery
  • Generalised – affects more than 5 joints in more than one limb

Prevalence of hypermobility varies greatly depending on the literature.

Management of hypermobility should generally be in Primary Care

Hypermobility may be a red flag symptom of a more severe disease with underlying multi-organ involvement.

Symptoms of hypermobility
  • Chronic Pain
  • Impaired proprioception
  • Risk of trauma
  • Pain often worse at end of the day/ after activity
Clinical Assessment

Musculoskeletal: P GALS examination (paediatric Gait, Arms, Legs, Spine)

  • Flat feet and over pronation of ankles can contribute to pain.
  • Link to pGALS examination – click here
  • Beighton score is not validated for use in children, but forms part of diagnostic criteria for EDS 3 (Ehlers-Danlos Syndrome type 3).The Beighton score is a set of manoeuvres used to look for evidence of joint hypermobility. There are 9 points in total, and a score of 4 or more is considered a sign of there likely being generalised joint hypermobility.

Skin:  elasticity (ideal places abdominal wall, dorsum feet), atrophic scars, velvety skin, hernias

Mouth: high arched palate, dental crowding

General systemic examination: it is normal for children to be flexible and the degree of flexibility does not always correlate clinically.

  • With no other concerning clinical features or significant symptoms, consider psychosocial compounding factors.
  • Girls are more flexible than boys
  • Flexibility decreases with age.
  • It is normal for toddlers to be flexible and this should not be a reason for delayed motor milestones or pain.
Management
  • Encourage physical activity
  • Avoid over use of analgesia
  • Orthotics may offer some benefit if flat feet or over pronated ankles
  • Simple measures such as rucksacks to distribute weight in school bags
  • Physiotherapy
Red Flag symptoms
  • Morning stiffness easing through the day/ activity
  • Joint swelling, joint restriction
  • Recurrent dislocations
  • Cutaneous changes- atrophic scars, skin hyper extensibility, velvety skin, recurrent hernias, unexplained prolapse
  • Mouth- high arched palate, dental crowding
  • Constitutional symptoms which may suggest malignancy or systemic disease.
When to Refer To Paediatric Rheumatologist:
  1. Any red flag symptoms
  2. No improvement with physiotherapy and orthotics
  3. Evidence of joint restriction.

 

References:

Hypermobility in Children. W Coles et al. Paediatric and Child Health. 2017 28 (2)

Guidance for Management of Symptomatic Hypermobility in Children and Young People – A Guide for Professionals managing Children and Young People with this condition. British Society Rheumatology.

 

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