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.