Hypermobility: features and differential incidence between the sexes

Limited joint mobility of the ankle in diabetic patients with cutaneous sensory deficit

Limited joint mobility (LJM) of the ankle joint was measured in 48 diabetic patients classified into three groups: Insulin-dependent diabetes mellitus (IDDM = 15), non-insulin diabetes mellitus (NIDDM = 12) and patients with cutaneous sensory deficit in the foot (CD = 21). Specifically, plantar flexion, dorsiflexion and total range of motion was measured on both feet using goniometric techniques during active and passive movement conditions. No significant bilateral differences were established, therefore values for the right foot were used for statistical analyses. Diabetic patients were matched to 48 non-diabetic controls for age, weight and gender factors. A Semmes-Weinstein monofilament test was used on both feet to assess the integrity of cutaneous sensitivity in all patient and control subjects. Cutaneous sensory deficit patients (CD) had monofilament values greater than two standard deviations below control group mean values. There were no significant differences between the monofilament test values for the IDDM and NIDDM patients and control group data. LJM results indicated both plantar flexion and range of motion in CD patients under active and passive movement conditions were significantly reduced compared to control group data. No differences were observed for any pairwise comparisons between the IDDM and NIDDM groups compared to controls. The data is discussed in terms of the interaction between LJM in the foot and type of diabetic classification.

Hypermobility in two Dutch school populations

OBJECTIVE

To determine the presence of hypermobility and differences between females and males in a Dutch population.

STUDY DESIGN

Joint mobility was measured in a primary and a secondary school population. Beighton and Biro measurements were used. The data were evaluated statistically.

RESULTS

Using the Beighton score, 15.5% of group I (n = 252; 4-13 years) and 13.4% of group II (n = 658; 12-17 years) were hypermobile. Hypermobility was found more in females than in males, the difference being significant in the older group. Overall, hypermobility did not significantly diminish with ageing, although the individual joints did not show a significant decrease in mobility with ageing. Hypermobility was significantly more pronounced at the non-dominant body side in both groups. The Quetelet-index did not show a significant relation to hypermobility.

CONCLUSION

Hypermobility was found more in females than in males, with a trend of decrease of hypermobility with ageing. The non-dominant body side proved to be more hypermobile and the Quetelet-index did not show a relation to hypermobility. Beighton's measurements proved best, since Biro considers the two body sides being equal.

Postural stability of diabetic patients with and without cutaneous sensory deficit in the foot

Postural stability was measured in 50 patients classified into two diabetic groups: insulin-dependent diabetes mellitus (IDDM: n = 27), and diabetic patients with bilateral cutaneous sensory deficit in the foot (CD: n = 23). All patients were matched to 50 non-diabetic controls on age, weight and gender variables. The integrity of cutaneous sensory information at the foot was assessed using a monofilament test. Static and dynamic balance was evaluated using an objective balance test involving computer-controlled dual force platforms enclosed by a visual surround. The apparatus provided six test conditions designed to systematically manipulate or eliminate visual, vestibular or somatosensory information. Scores for the six tests, and a derived composite balance score together with movement strategy scores were used for data analysis. For all six tests and composite score CD patients revealed significant postural instability compared to controls. Additionally, the CD group recorded reduced strategy scores indicating an atypical shift from ankle to hip strategy movement as postural control was stressed. IDDM patient test scores were not significantly different from control data on any pairwise comparison. Results indicated significant balance loss associated with CD putting the individual at increased risk for falling and compromising foot mechanics.

Meniscal impingement syndrome

The meniscal impingement syndrome consists of three elements: impaction on the anterior medial femoral condyle by the leading edge of the medial meniscus, articular cartilage damage of at least Outerbridge grade 3, and knee hyperextension of at least 5 degrees. This report reviews this condition in a series of seven knees with an average follow-up of 39 months. The time from the onset of symptoms until surgery averaged 45 months. Treatment consisted of a thorough arthroscopic knee evaluation and debridement of the articular cartilage fragmentation and any impinging synovitis. Postoperative rehabilitation includes extension block bracing, hamstring strengthening, and closed-chain exercise. With this regimen, there was improvement in the Tegner scores and a reduction in postoperative knee hyperextension. Identification of this uncommon condition requires a complete evaluation of the medial femoral condyle in patients with knee hyperextension.

Neuromuscular performance characteristics in elite female athletes

The purpose of this research was to identify possible predisposing neuromuscular factors for knee injuries, particularly anterior cruciate ligament tears in female athletes by investigating anterior knee laxity, lower extremity muscle strength, endurance, muscle reaction time, and muscle recruitment order in response to anterior tibial translation. We recruited four subject groups: elite female (N = 40) and male (N = 60) athletes and sex-matched nonathletic controls (N = 40). All participants underwent a subjective evaluation of knee function, arthrometer measurement of anterior tibial translation, isokinetic dynamometer strength and endurance tests at 60 and 240 deg/sec, and anterior tibial translation stress tests. Dynamic stress testing of muscles demonstrated less anterior tibial translation in the knees of the athletes (both men and women) compared with the nonathletic controls. Female athletes and controls demonstrated more anterior tibial laxity than their male counterparts and significantly less muscle strength and endurance. Compared with the male athletes, the female athletes took significantly longer to generate maximum hamstring muscle torque during isokinetic testing. Although no significant differences were found in either spinal or cortical muscle reaction times, the muscle recruitment order in some female athletes was markedly different. The female athletes appeared to rely more on their quadriceps muscles in response to anterior tibial translation; the three other test groups relied more on their hamstring muscles for initial knee stabilization.

Benefits and liabilities of hypermobility in the back pain disorders of industrial workers

OBJECTIVES

Back pain disorders, sometimes called 'the nemesis of medicine and the albatross of industry', are ubiquitous, but have stubbornly defied diagnosis and treatment. Hypermobility syndrome, which is also very common, has been called 'an enigma of human physiology'. Both conditions have attracted wide attention and interest only recently. In an earlier study, we considered the benefits and liabilities of joint hypermobility by studying 660 musicians in the USA. In a parallel manner, the present study analysed the back pain disorders of 606 workers in a Swedish high-technology industrial plant in the context of spinal hypermobility.

SUBJECTS AND METHODS

The 606 industrial workers were examined for spinal hypermobility using a standard protocol, and interviewed for work-related body-posture requirements and the low back, shoulder and neck pain disorders experienced by them. The data were analysed for associations between hypermobility and physical complaints as a whole, and by taking into account gender and body-postures at work.

RESULTS

Twenty-six per cent (37) of 144 workers with hypermobility but only 14% (64) of 453 without hypermobility experienced back pain (P < 0.002). Among the 326 workers with sitting or standing jobs, 40% (29) of 71 with hypermobility had back pain, whereas only 12% (30) of the 255 without hypermobility experienced back pain (P < 0.001). The corresponding numbers with back pain for 235 in jobs with changing body-postures were 4.5% (3) of 66 with hypermobility and 14% (14) of 169 without hypermobility (P = 0.04).

CONCLUSIONS

Hypermobility of the spine is an asset if the work requires change of body-posture, but a liability for those in a standing or sitting assignment. It reinforces a similar hypothesis proposed by Larsson et al.

Occlusal interferences in retruded contact position and temporomandibular joint sounds

In 193 non-patient adolescents, unilateral contacts in retruded contact position (RCP) were seen more often in girls than in boys (P < 0.001) and were more frequent in subjects with than without general joint instability (P < 0.05). A negative correlation (r = -0.70***) was found between the side of the temporomandibular joint sound and the side of unilateral contact in RCP. Boys with unilateral contacts in RCP had more non-reciprocal clicking than girls. No signs were found indicating that a unilateral contact in RCP is an aetiological factor for development of temporomandibular disorders. Unilateral contacts in RCP may in adolescents be considered a predictive factor for temporomandibular joint disturbance. Contradictory causes may determine the sagittal distance between RCP and ICP.

Differences in joint mobility and foot pressures between black and white diabetic patients

Limited joint mobility is common in diabetes and is related to high foot pressures and foot ulceration. We have examined the differences in joint mobility and foot pressures in four groups matched for age, sex, and duration of diabetes: 31 white diabetic, 33 white non-diabetic, 24 black diabetic, and 22 non-diabetic black subjects. Joint mobility was assessed using a goniometer at the fifth metacarpal, first metatarsal, and subtalar joints. In-shoe and without shoes foot pressures were measured using an F-Scan system. Neuropathy was evaluated using clinical symptoms (Neuropathy Symptom Score), signs (Neuropathy Disability Score), and Vibration Perception Threshold. There was no difference between white and black diabetic patients in Neuropathy Symptom Score, Neuropathy Disability Score, and Vibration Perception Threshold. Subtalar joint mobility was significantly reduced in white diabetic patients (22 +/- 7 degrees) compared to white controls (26 +/- 4 degrees, black diabetic patients (25 +/- 5 degrees), and black controls (29 +/- 7 degrees), and increased in black controls compared to white controls and black diabetic patients (level of statistical significance p < 0.05). Without shoes foot pressures were higher in white diabetic patients (8.31 +/- 400 kg cm-2) compared to white controls (6.81 +/- 2.31 kg cma2), black diabetic patients (6.2 +/- 2.53 kg cm-2) and black controls (5.00 +/- 1.24 kg cm-2) and lower in black controls compared to white and black diabetic patients (p < 0.05 in all cases). We conclude that racial differences exist in joint mobility and foot pressures between black and white subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of joint laxity on scaphoid kinematics

Excessively lax wrists more frequently become symptomatic if overloaded or injured than normal joints. Whether this is the consequence of biological or mechanical factors or both remains unknown. This study evaluates the relationship between the degree of joint laxity and scaphoid kinematic behaviour during radio-ulnar deviation of the wrist in 60 normal volunteers. There is a significant linear relationship between the direction of scaphoid rotation and the amount of wrist joint laxity. During lateral deviation of the wrist, joints that are more lax have a scaphoid rotating mainly along the sagittal plane of flexion and extension, with little lateral deviation. In contrast, the scaphoid of volunteers with decreased laxity rotate mostly along the frontal plane of radioulnar deviation with minimal flexion extension. These results support the concept of increased out-of-plane scaphoid rotation as a factor of increased vulnerability during over-work or injury.

The relationship between temporomandibular joint mobility and peripheral joint mobility reconsidered

The purpose of this paper was to study the relationship between temporomandibular joint (TMJ) mobility and mobility of joints and to study the general character of joint mobility in 83 subjects, 55 females and 28 males (mean age 26.7, range 13-46 years). The subjects were recruited from the Department of Oral and Maxillofacial Surgery of the University Hospital of Groningen. All participants had a good general health and did not present anamnestically, clinically or radiographically TMJ disorders. Of these subjects, angular displacement of the mandible relative to the cranium during maximal mouth opening (AMO) was measured. Furthermore, the maximal range of motion of passive digit five hyperextension, passive thumb apposition to the wrist, active elbow and knee hyperextension, active ankle dorsal flexion and trunk flexion were measured. All measurements were performed bilaterally, except trunk flexion. Calculation of product moment correlations (Pearson) revealed a weak relationship between AMO and mobility of right digit five and elbows for the total group and between AMO and mobility of both digits five and elbows for women. The correlations were never stronger than 0.4. Multiple regression revealed that only 25.9% of the total variance of AMO could be explained by mobility of peripheral joints, age and sex. Calculation of product moment correlations between mobility of peripheral joints, trunk flexion and age revealed weak correlations between the different joints, with the exception of paired joints. Principal component analysis revealed a weak general character of joint mobility.(ABSTRACT TRUNCATED AT 250 WORDS)

Musculoskeletal problems of performing artists

We have reviewed the frequency and variety of rheumatic problems among performing artists. For instrumentalists, injuries are related to the type of instrument played, the technique used and the effort expended in the quest for excellence. For dancers, musculoskeletal problems too reflect technique and effort. We should not be surprised at the frequency of these problems. Rheumatologists, as well as orthopaedic surgeons, physiotherapists, neurologists and other physicians, encounter performing artists as patients. We should be familiar with their problems and be able to knowledgeably diagnose and manage them. This may include observing the artist during actual performances. How is the instrument being held? What is the posture of the artist? What are the comments of the coach or teacher. What type of shoes does the ballerina wear? What movements in particular cause discomfort? These and similar observations will have direct bearing on the musculoskeletal problems of these artists. Published studies have related the variety, frequency and disabling nature of performance-related musculoskeletal problems. Unfortunately few if any of these are controlled, blinded or prospective. We need more and better information. We will want clear information about prevalence of problems, better definition of the musculoskeletal ailments, classification of the relationship of problems with performance and individual biomechanical features, information about response of specific problems to interventions, and data about the long-term consequences, if any, of these rheumatic problems to the musculoskeletal system. Artists as patients are unique. Minor problems can become potentially career-ending disabilities. Making music or performing dance may provide us with delightful entertainment but represents a source of livelihood to artists. Understanding their medical needs and enabling them to continue to perform is the challenge before us.

Joint mobility measurements: reliability of a standardized method

Assessment of hypermobility and hypomobility is frequently performed visually with all its limitations. In this study, a standardized joint mobility measurement method is suggested, and its reliability is tested. The maximal range of motion of passive digit five hyperextension, passive thumb apposition to the wrist, active elbow and knee hyperextension, active ankle dorsal flexion and trunk flexion was measured in 30 healthy subjects. All measurements were performed bilaterally, except for trunk flexion. Three experienced observers performed the measurements according to a rigidly standardized protocol, using appropriate goniometers and rules. During one measurement session each observer measured each subject. Two consecutive measurement sessions were organized. Analysis of variance, with subject and time as explaining variables, was performed on the data obtained. The inter-observer variability ranged from 1.42 degrees (left knee hyperextension) to 4.05 mm (right thumb apposition) in the first measurement session and from 1.35 degrees (left knee hyperextension) to 4.58 degrees (right digit five hyperextension) in the second measurement session. The intra-observer variability ranged for observer A from 0.75 degree (left knee hyperextension) to 3.67 mm (left thumb apposition), and from 0.93 degree (left knee hyperextension) to 3.88 degrees (left digit five hyperextension) for observer B. Observer C ranged from 0.71 degree (left knee hyperextension) to 4.01 mm (right thumb apposition). Based on the results of this study, the authors conclude that joint mobility can be measured reliably and accurately with the presented simple tools.(ABSTRACT TRUNCATED AT 250 WORDS)

Benefits and disadvantages of joint hypermobility among musicians

BACKGROUND

Joint hypermobility is considered to be both an advantage and a disadvantage. However, the degree of hypermobility in members of particular occupations requiring intense physical activity and the nature of the association between symptoms referable to specific joints and their hypermobility are unknown.

METHODS

We interviewed 660 musicians (300 women and 360 men) about work-related symptoms such as joint pain and swelling and examined them for joint hypermobility according to a standard protocol. We then determined the relation between the mobility of their fingers, thumbs, elbows, knees, and spine and any symptoms referable to these regions.

RESULTS

Five of the 96 musicians (5 percent) with hypermobility of the wrists, mostly instrumentalists who played the flute, violin, or piano, had pain and stiffness in this region, whereas 100 of the 564 musicians (18 percent) without such hypermobility had symptoms (P = 0.001). Hypermobility of the elbow was associated with symptoms in only 1 of 208 musicians (< 1 percent), whereas 7 of 452 (2 percent) without this hypermobility had symptoms (P = 0.45). Among the 132 musicians who had hypermobile knees, 6 (5 percent) had symptoms, whereas only 1 of 528 (< 1 percent) with normal knees had symptoms (P < 0.001). Of the 462 musicians who had normal mobility of the spine, 50 (11 percent) had symptoms involving the back, as compared with 46 of the 198 musicians (23 percent) who had hypermobility of the spine (P < 0.001).

CONCLUSIONS

Among musicians who play instruments requiring repetitive motion, hypermobility of joints such as the wrists and elbows may be an asset, whereas hypermobility of less frequently moved joints such as the knees and spine may be a liability.

Joint hypermobility in adults referred to rheumatology clinics

Joint hypermobility is a rarely recognised aetiology for focal or diffuse musculoskeletal symptoms. To assess the occurrence and importance of joint hypermobility in adult patients referred to a rheumatologist, we prospectively evaluated 130 consecutive new patients for joint hypermobility. Twenty women (15%) had joint hypermobility at three or more locations (greater than or equal to 5 points on a 9 point scale). Most patients with joint hypermobility had common musculoskeletal problems as the reason for referral. Two patients referred with a diagnosis of rheumatoid arthritis were correctly reassigned a diagnosis of hypermobility syndrome. Three patients with systemic lupus erythematosus had diffuse joint hypermobility. There was a statistically significant association between diffuse joint hypermobility and osteoarthritis. Most patients (65%) had first degree family members with a history of joint hypermobility. These results show that joint hypermobility is common, familial, found in association with common rheumatic disorders, and statistically associated with osteoarthritis. The findings support the hypothesis that joint hypermobility predisposes to musculoskeletal disorders, especially osteoarthritis.

Temporomandibular joint dysfunction syndrome: a close association with systemic joint laxity (the hypermobile joint syndrome)

Sixty-two patients admitted for elective reconstructive surgery of the temporomandibular joint (TMJ) and eight seen as outpatients with a chief complaint of TMJ dysfunction during the same time interval were evaluated for possible etiologic factors contributing to the disease. All hospitalized patients had severe, end-stage degenerative changes within the TMJ, whereas outpatients had less severe disease and did not require surgery. TMJ dysfunction in some patients was said to be a result of established causes including bruxism, malocclusion, and trauma. No patient in this series had evidence of a systemic inflammatory polyarthritis. Of the 70 patients, 38 (54%) met criteria, based on those of Carter and Wilkinson, as modified by Beighton et al., sufficient to warrant a diagnosis of the hypermobile joint syndrome. Five patients had classic Ehlers-Danlos syndrome and therefore were not patients with "benign hypermobility," and an additional two cases were described as "marfanoid" and as possible Ehlers-Danlos syndrome, respectively. Radiographs showed TMJ hyperextensibility in four hypermobile patients. Long-term surgical outcome was identical in the hypermobile and nonhypermobile groups. The incidence of hypermobility in this series is strikingly higher than the expected incidence in an otherwise population. Magnetic resonance images of the TMJs on separate groups of asymptomatic normal and hypermobile women identified excessive anterior movement in the hypermobile group, together with abnormal anterior disk position in some. We hypothesize that hypermobility within the TMJ may cause accelerated disk destruction and degenerative disease.

A review of musculoskeletal problems in instrumental musicians

Musculoskeletal problems are common in instrumental musicians. Most of these problems can be classified as musculotendinous overuse, nerve entrapment/thoracic outlet syndrome, or motor dysfunction. Also seen in musicians are problems related to hypermobility and degenerative arthritis. Although these problems are seen in all instrumentalists, their prevalence is highest in professional musicians, with string players most commonly affected by musculotendinous overuse. Keyboard players are the performers most commonly affected by motor dysfunction. History and physical examination performed with an understanding of the problems of musicians are usually adequate to make the correct diagnosis. Electrophysiological studies are often helpful in confirming or excluding a diagnosis of nerve entrapment. With the exception of motor dysfunction, once these problems are recognized, they can be adequately treated. Treatment should begin conservatively with rest, evaluation of technique and practice habits, and possibly nonsteroidal antiinflammatory drugs. Depending on the type and severity of the problem, physical therapy, adaptive devices, steroid injection, or surgery may be indicated. A strong partnership with music educators is important in the management and prevention of these musculoskeletal problems.