Hypermobility in Adolescent Athletes: Pain, Functional Ability, Quality of Life, and Musculoskeletal Injuries

Falls and balance impairment; what and how has this been measured in adults with joint hypermobility? A scoping review

BACKGROUND

People with joint hypermobility have excessive joint flexibility, which is more common in young women. The people with symptomatic hypermobility report poor balance and even falls. This scoping review aims to identify and map the available evidence related to balance and falling in adults with joint hypermobility to support research planning and ideas for treatment direction.

METHODS

A framework for the search was constructed using the Joanna Briggs Institute (JBI) approach. Electronic searches of primary evidence were performed using the following databases: Medline, Web of Science, CINAHL, Scopus and EMBASE. Papers written in English and published between 1946 and November 2023 were included. Titles, abstracts, and full papers were independently screened by two reviewers. Data extracted related to the population, the concept under investigation, the method of measurement, the level of evidence and the result.

RESULTS

Nineteen of 1,950 screened articles were included. In terms of the population, details related to ethnicity of the research participants was missing. The hypermobility classification criteria varied; it was not always clear if people who were hypermobile had symptoms. Concepts related to fear of falling, balance and adaptive strategies prompted by different postural tasks with and without vision were explored. Centre of pressure, muscle activity, kinematics and psychological factors were measured using force plates, electromyography (EMG), motion capture, patient and clinician reported outcome measures, focus groups and interviews. Most papers were low on the hierarchy of evidence (i.e. equal or lower than a case control study). The participants with joint hypermobility had increased sway, different muscle activity, and different kinematics compared to people without hypermobility. When surveyed, they commonly fell and had a fear of falling.

CONCLUSIONS

It is unclear whether the participants represent the population of people with hypermobility. Different classification systems were used making it difficult to generalise the results. Although the methods used suggest a low level of evidence, it seems clear that people who are hypermobile have poor balance. The underlying mechanisms driving poor balance have not been explored in depth.

The strength of balance: Strength and dynamic balance in children with and without hypermobility

BACKGROUND

Generalized Joint hypermobility (GJH) is predominantly non-symptomatic. In fact, individuals with joint flexibility usually perform better than their non-hypermobile counterparts during physical activities. Notwithstanding, strength and balance are essential to maintain the control of the extra range of motion during activities and to prevent musculoskeletal complications. There are limited and conflicting pieces of evidence in literature regarding the association between strength and balance in children with GJH.

OBJECTIVES

The purpose of this study was to examine differences in functional strength, dynamic balance, proprioception, and isometric strength in children with and without joint hypermobility and determine the association between strength outcomes and dynamic balance.

METHOD

A cross-sectional study was conducted among children aged 6 to 11. Hypermobility was determined using the Beighton Score, with scores ≥6 representing hypermobility. Functional strength was assessed with the Functional Strength Measure (FSM), isometric strength was determined with a handheld dynamometer (HHD), the Y-Balance Test (YBT) was used to assess dynamic balance and the Wedges test to measure proprioception.

RESULTS

This study included 588 participants (age: 7.97 ± 1.3 years; height: 128±10.1 cm; mass: 27.18 ± 7.98 kg). 402 children were classified as having normal mobility and 186 as being hypermobile. Hypermobile children had better functional strength in the lower extremities than children with normal range mobility but lower reach distance in the YBT. No differences in proprioception, functional strength of the upper extremity or isometric strength in the hands were found. However, isometric lower extremity force was less in hypermobile children than children with normal range mobility. Irrespective of their joint mobility, a fair significant correlation existed between total Y-balance distance and FSM items r = 0.16-0.37, p = 0.01. Correlations between total Y-balance distance and isometric strength of knee and ankle muscles ranged between r = 0.26-0.42, p = 0.001.

CONCLUSION

Hypermobile joints seem to co-occur with lower extremity isometric strength, more functional strength in the lower extremities and less reaching distance in dynamic balance. The opposing direction of the results on functional and isometric strength tests highlights the importance of the type of outcome measures used to describe the association of strength and the range of motion.

Predisposing Anatomy for Thoracic Outlet Syndrome and Functional Outcomes after Supraclavicular Thoracic Outlet Decompression in Athletes

Purpose

This study aims to examine predisposing anatomic factors and subsequent post-decompression functional outcomes among high-intensity athletes with thoracic outlet syndrome (TOS).

Materials and Methods

A single-institution retrospective review was performed on a prospective database of patients with TOS from 2018 to 2023 who had undergone operative decompression for TOS. Demographics, TOS characteristics, predisposing anatomy, operative details, and postoperative outcomes were examined. The primary outcome was postoperative return to sport. Secondary outcomes included vascular patency.

Results

A total of 13 patients who were engaged in high-demand athletic activity at the time of their diagnosis were included. Diagnoses included 8 (62%) patients with venous TOS, 4 (31%) patients with neurogenic TOS, and 1 (8%) patient with arterial TOS. Mixed vascular and neurogenic TOS was observed in 3 (23%) patients. The mean age of the cohort was 30 years. Abnormal scalene structure was observed in 12 (92%) patients, and abnormal bone structures were noted in 4 (27%) patients; 2 (15%) with cervical ribs and 3 (23%) patients with clavicular abnormalities. Prior ipsilateral upper extremity trauma was reported in 4 (27%) patients. Significant joint hypermobility was observed in 8 (62%) patients with a median Beighton score of 6. Supraclavicular cervical and/or first rib resection with scalenectomy was performed in all patients. One case of postoperative pneumothorax was treated non-operatively. Ten (77%) patients returned to sport. Duplex ultrasonography showed subclavian vein patency in all 8 patients with venous TOS and wide patency with no drop in perfusion indices in the patient with arterial TOS.

Conclusion

Athletes with TOS who required operative intervention had a high incidence of musculoskeletal aberrations and joint hypermobility. Supraclavicular decompression was associated with a high success rate, with overall good functional outcomes and good likelihood of patients returning to preoperative high-intensity athletics.

The effects of joint hypermobility on pain and functional biomechanics in adolescents with juvenile fibromyalgia: secondary baseline analysis from a pilot randomized controlled trial

BACKGROUND

Joint hypermobility is a common clinical finding amongst hereditary connective tissue disorders that is observed in pediatric rheumatological settings, and often associated with chronic pain. Joint hypermobility may also contribute to deficits in physical functioning and physical activity, but previous findings have been inconsistent. It is possible that physical activity impairment in joint hypermobility may be due to chronic aberrant movement patterns subsequent to increased joint laxity.

METHOD

As part of a larger randomized pilot trial of juvenile onset fibromyalgia (JFM), a secondary analysis was conducted to explore whether adolescents with JFM and joint hypermobility differed from non-joint hypermobility peers in terms of pain, daily functioning, and biomechanics (i.e., kinetics and kinematics) during a moderately vigorous functional task.

RESULTS

From the larger sample of adolescents with JFM (N = 36), 13 adolescents (36.1%) met criteria for joint hypermobility and 23 did not have joint hypermobility. Those with joint hypermobility exhibited poorer overall functioning (Md = 20, Q1,Q3 [5.8, 7.6] vs. Md = 29, Q1,Q3 [5.1, 7.6]) but there were no differences in pain (Md = 6.9, Q1,Q3 [22, 33], vs. Md = 6.45, Q1,Q3 [15, 29.5]). Inspection of time-series plots suggests those with joint hypermobility exhibited decreased hip flexion and frontal plane hip moment (e.g., resistance to dynamic valgus) during the landing phase (early stance) and greater hip and knee transverse plane moments during the propulsion phase (late stance) of the drop vertical jump task (DVJ). No other differences in lower extremity biomechanics were observed between study groups.

CONCLUSIONS

In this exploratory study, there were small but notable differences in biomechanics between patients with JFM who also had joint hypermobility versus those without joint hypermobility during a landing and jumping task (e.g., DVJ). These differences may indicate decreased joint stiffness during landing, associated with increased joint laxity and decreased joint stability, which may put them at greater risk for injury. Further study with a larger sample size is warranted to examine whether these biomechanical differences in patients with JFM and joint hypermobility affect their response to typical physical therapy or exercise recommendations.

Injury Risk in Collegiate Football Players With Generalized Joint Hypermobility: A Prospective Cohort Study Over 2 Years

Background

Generalized joint hypermobility (GJH) has been identified as a risk factor for injury in various athletic patient populations.

Purpose

To evaluate GJH as a predisposing risk factor for injury in a population of National Collegiate Athletic Association (NCAA) Division I football players.

Study Design

Cohort study; Level of evidence, 2.

Methods

The Beighton score was collected for 73 athletes during their preseason physical examinations in 2019. GJH was defined as a Beighton score ≥4. Athlete descriptive characteristics, including age, height, weight, and playing position, were recorded. The cohort was evaluated prospectively for 2 years, and the number of musculoskeletal issues, injuries, treatment episodes, days unavailable, and surgical procedures for each athlete during this period were recorded. These measures were compared between the GJH and no-GJH groups.

Results

The mean Beighton score was 1.4 ± 1.5 for the 73 players; 7 players (9.6%) had a Beighton score indicating GJH. During the 2-year evaluation, there were 438 musculoskeletal issues, including 289 injuries. The mean number of treatment episodes per athlete was 77 ± 71 (range, 0-340), and the mean number of days unavailable was 67 ± 92 days (range, 0-432 days). There were 23 athletes who required 25 operations, the most common procedure being arthroscopic shoulder stabilization (n = 6). The number of injuries per athlete was not significantly different between the GJH and no-GJH groups (3.0 ± 2.1 vs 4.1 ± 3.0; P = .13), nor were there any between-group differences in the number of treatments received (74.6 ± 81.9 vs 77.2 ± 71.5; P = .47), days unavailable (79.6 ± 124.5 vs 65.3 ± 89.3; P = .61), or rates of surgery (43% vs 30%; P = .67).

Conclusion

A preseason diagnosis of GJH did not place NCAA football players at a greater risk for injury during the 2-year study period. Based on the findings of this study, no specific preparticipation risk counseling or intervention is warranted for football players who are diagnosed with GJH as defined by the Beighton score.

Hypermobility prevalence, measurements, and outcomes in childhood, adolescence, and emerging adulthood: a systematic review

General Joint Hypermobility (GJH) is a common condition found in 2-57% of the population. Of those with GJH, 10% suffer from accompanying physical and/or psychological symptoms. While the understanding of GJH in the general population is unfolding, its implication in a cohort of children, adolescents and young adults are not yet understood. This systematic review explored GJH's prevalence, tools to measure it, its physical and psychosocial symptoms, with a special interest in aesthetic sports. The CINHAL, MEDLINE, PsycINFO, SPORTDiscus and Scopus databases were searched for relevant studies. Inclusion criteria were (1) Age range of 5-24; (2) Participants had GJH; (3) A measurement for GJH; (4) Studies written in English language. Study screening for title, abstract and full text (when needed) and quality assessment were performed by two independent individuals. 107 studies were included in this review and were thematically grouped into six clusters expressing different foci: (1) GJH's Core Characteristics; (2) Orthopedic; (3) Physical Other; (4) Psychosocial; (5) Treatment and (6) Aesthetic Sports. The review revealed a growing interest in GJH in this cohort in the last decade, especially regarding non-musculoskeletal physical implications and psychosocial aspects. Prevalence varied between different ethnic groups and as a parameter of age, gender and measurement. The most widespread tool to measure GJH was the Beighton scale, with a cut-off varying between 4 and 7. Children show fewer, but similar GJH implication to those in the general population, however, more research on the topic is warranted, especially regarding psychosocial aspects and treatment.

Prevalence and Demographic Distribution of Hypermobility in a Random Group of School-Aged Children in Nigeria

BACKGROUND

The purpose of this study was to determine the prevalence of hypermobility in randomly selected healthy children, without previous trauma or disease process affecting the joints and whether other demographic variables (age, sex, BMI) had an impact on Beighton scores and range of motion (RoM) in children between 6 and 10 years of age.

RESULTS

286 children were included; 27.3% of them had a Beighton score ≥7/9 and 72% would be classified hypermobile if we had used a Beighton cut-off score ≥4/9. Prevalence declined with increasing age. Girls were more often hypermobile (34%) than boys (20%) and this was mainly caused by increased RoM in the knees. Positive scores of finger items of the Beighton were more common than on the other items, leading to a high prevalence of peripheral hypermobility. Localized hypermobility was only found in the fifth MCP joint. A total of 15% of the children with normal mobility reached 20 excess degrees RoM of the left and right fifth MCP. Pain was present in 12 of the 239 children but was not linked to the level of mobility.

CONCLUSION

Hypermobility is the rule in this pain-free population of children with GJH.

Balance training benefits chronic ankle instability with generalized joint hypermobility: a prospective cohort study

BACKGROUND

Balance training is the first choice of treatment for chronic ankle instability (CAI). However, there is a lack of research on the effects of balance training in CAI with generalized joint hypermobility (GJH). This study is to compare the outcomes of balance training in CAI patients with and without GJH.

METHODS

Forty CAI patients were assigned into the GJH group (Beighton ≥ 4, 20) and non-GJH group (Beighton < 4, 20) and they received same 3-month supervised balance training. Repeated measure ANOVA and independent t test were used to analyze self-reported questionnaires (Foot and ankle ability measure, FAAM), the number of patients experiencing ankle sprain, isokinetic muscle strength and postural control tests (Star excursion balance test, SEBT and Balance errors system, BES) before training, post-training immediately, and post-training 3 months, respectively.

RESULTS

At baseline, no differences were found between groups with except for GJH group having poorer SEBT in the posteromedial direction (83.6 ± 10.1 vs 92.8 ± 12.3, %) and in the posterolateral direction (84.7 ± 11.7 vs 95.7 ± 8.7, %). Following the balance training, GJH group demonstrated lower re-sprain ratio (immediately after training, 11.1% vs 23.5%, 3 month after training, 16.7% vs 29.4%) than non-GJH group, as well as greater FAAM-S score, plantarflexion strength and dorsiflexion strength at post-training immediately and 3 months, and both groups improved similarly in the FAAM-A score, muscle strength and balance control (SEBT in the posterior-lateral and posterior-medial directions, and BES scores) compared with baseline.

CONCLUSIONS

CAI patients with GJH gained equally even better postural stability and muscle strength after the balance training than the non-GJH patients. Balance training could still be an effective treatment for CAI patients with GJH before considering surgery.

TRIAL REGISTRATION

ChiCTR1900023999, June 21^st, 2019.

THE LEVEL OF DORSIFLEXION IN YOUNG GYMNASTS COMPARED TO YOUNG ATHLETES - PILOT STUDY

Gymnastic training develops strength, flexibility, concentration, balance, precision, and speed. The purpose of the study is to determine if gymnastic preparation leads to an increase in weight-bearing ankle dorsiflexion range of motion in a closed kinematic chain in young artistic gymnasts compared to a different type of sport. The weight-bearing lunge was chosen to measure the dorsiflexion range of motion in the ankle joint in the closed kinematic chain. The first group consists of members of the Slovak national youth team in artistic gymnastics (n-26). The second group consists of members of the Slovak national team in rhythmic gymnastics (n-13). The control group consists of young athletes (n-22). The mean dorsiflexion range of motion in artistic gymnasts was 47.32 ° in the right ankle joint and 44.75 ° in the left ankle joint. The mean dorsiflexion range of motion in rhythmic gymnasts was 44.32 ° in the right ankle joint and 43.41 ° in the left ankle joint. The mean dorsiflexion range of motion in young athletes was 44.27 ° in the right ankle joint and 42.32 ° in the left ankle joint. Results indicate a statistically significant difference in favor of artistic gymnasts compared to rhythmic gymnasts at the right ankle joint (p-0.04). In the left ankle, the two groups did not differ significantly from each other (p-0.38). There was no significant difference between artistic gymnasts and athletes in the right ankle joint (p-0.09) and the left ankle joint (p-0.19). There was no significant difference between rhythmic gymnasts and athletes at the right ankle joint (p-0.38) and the left ankle joint (p-0.24). A greater dorsiflexion range of motion in a closed kinematic chain in the ankle joint was detected in young gymnasts compared to rhythmic gymnasts. There was no significant difference between artistic gymnasts and athletes.

Hip Instability in Ballet Dancers: A Narrative Review

BACKGROUND

Dancers possess a large degree of hip range of motion that results from a combination of innate and acquired osseous morphology and permissive soft tissues. Generalized hypermobility in dancers may predispose them to a spectrum of hip instability. The objective of this narrative review is to discuss the anatomical characteristics, pathogenesis, risk factors, clinical signs and symptoms, management, and outcomes of hip instability treatments in dancers.

METHODS

A retrospective search was performed beginning November 1, 2017, for English language articles regarding hip stability in the dancer. Key words used included but were not limited to: dance(r), ballet, hip, hypermobility, range of motion, instability, microinstability, and laxity. PubMed, Scopus, and MEDLINE databases were used.

RESULTS

Forty-three studies were analyzed. Groin pain was found to be the most common presenting symptom of hip instability. A variety of impingement and instability signs may be elicited during physical examination. Hypermobility is frequently observed and is thought to be a necessity for participation in elite levels of ballet. Radiographs and advanced planar imaging (magnetic resonance imaging and computed tomography) should be scrutinized to evaluate for dysplasia, cam, pincer, subspine, and rotational morphologies. Dysplasia (low volume acetabulum), cam morphology, femoral retroversion, and coxa valga are common findings in the ballet dancers' hip. Labral injuries and ligamentum teres tears are common and may potentiate instability in the hip. Management options include education, oral non-opioid medications, activity modification, exercise prescription, and surgery. Reported outcomes of these treatments in ballet are limited.

CONCLUSION

Hip hypermobility is prevalent in the ballet population and is a clear advantage. However, it may increase the risk of instability. It is important to identify the multifactorial osseous and soft tissue etiology of hip or groin pain in dancers. Practitioners should have a high level of suspicion for hip instability in the dancer presenting with hip pain and treat accordingly. There is a significant need for increased quantity and quality of investigation into the outcomes of treatment for hip instability in the dancer.

Generalized joint hypermobility and perceived harmfulness in healthy adolescents; impact on muscle strength, motor performance and physical activity level

Objective: The first aim of this study was to determine whether adolescents with asymptomatic Generalized Joint Hypermobility (GJH) have a lower level of physical functioning (physical activity level, muscle strength and performance) compared to non-hypermobile controls. Secondly, to evaluate whether the negative impact of perceived harmfulness on physical functioning was more pronounced in adolescents with asymptomatic GJH.Methods: Cross-sectional study. Sixty-two healthy adolescents (mean age 16.8, range 12-21) participated. Hypermobility (Beighton score), perceived harmfulness (PHODA-youth) and muscle strength (dynamometry), motor performance (Single-Leg-Hop-for-Distance) and physical activity level (PAL) (accelerometry) were measured. Hierarchical regression analyses were used to study differences in physical functioning and perceived harmfulness between asymptomatic GJH and non-hypermobile controls.Results: Asymptomatic GJH was associated with increased knee extensor muscle strength (peak torque/body weight; PT/BW), controlled for age and gender (dominant leg; ß = 0.29; p = .02). No other associations between asymptomatic GJH and muscle strength, motor performance and PAL were found. Perceived harmfulness was not more pronounced in adolescents with asymptomatic GJH.Conclusions: Adolescents with asymptomatic GJH had increased knee extensor muscle strength compared to non-hypermobile controls. No other differences in the level of physical functioning was found and the negative impact of perceived harmfulness was not more pronounced in adolescents with asymptomatic GJH.

Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome after ACL reconstruction: a systematic review

Objectives

To investigate the association between generalised joint hypermobility (GJH) and ACL injury risk. Secondary aims involved evaluating associations between GJH and postoperative outcome (including graft-failure risk, knee laxity and patient-reported outcome). Furthermore, we aimed to compare the performance of different grafts in patients with GJH.

Methods

Databases MEDLINE/PubMed, EMBASE and the Cochrane Library were searched, including 2760 studies. Two reviewers independently screened studies for eligibility. A modified version of the MINORS score was applied for quality appraisal. Studies assessing GJH while reporting the risk of ACL injury and/or postoperative outcome were included.

Results

Twenty studies were included, using several different methods to determine GJH. There was consistent evidence showing that GJH is a risk factor for unilateral ACL injury in males, while in females, the results were conflicting. There was limited evidence associating GJH with increased knee laxity 5 years postoperatively. There was consistent evidence of inferior postoperative patient-reported outcome in patients with GJH. Moreover, there was limited yet consistent evidence indicating that patellar-tendon autografts are superior to hamstring-tendon autografts in patients with GJH in terms of knee laxity and patient-reported outcome. There was insufficient evidence to draw conclusions regarding the outcomes of bilateral ACL injury and graft failure.

Conclusions

In men, GJH was associated with an increased risk of unilateral ACL injury. Moreover, GJH was associated with greater postoperative knee laxity and inferior patient-reported outcome. Based on the available evidence, a patellar-tendon autograft appears to be superior to a hamstring-tendon autograft in patients with GJH. However, the included studies were heterogeneous and there is a need for consensus in the assessment of GJH within sports medicine.

The Risk Factors of Low Back Pain in Female High School Students

STUDY DESIGN

A prospective cross-sectional study.

OBJECTIVE

The aim of this study was to evaluate the prevalence and associated factors with low back pain (LBP) in female adolescents of high school age.

SUMMARY OF BACKGROUND DATA

The prevalence of LBP in Tehran is high, and the majority of previous studies on LBP in adolescent and its risk factors have been performed in the developed countries. Therefore, identification of risk factors and planning appropriate protocols for prevention of LBP in adolescents may substantially decrease the prevalence of LBP and its burden in developing countries in future.

METHODS

In a prospective cross-sectional study, demographic characteristics, including age, body mass index (BMI), weight and mode of using backpack, family history of LBP in first degree relatives, and passive smoking status of the participants along with a history of LBP were recorded. Joint hypermobility was assessed using Beighton scale. Also, anthropometric measurements, spinal flexion, and hip joint range of motion were measured for each participant.

RESULTS

In total, 372 students participated in the study. The mean (SD) age of the participants was 15.8 (0.9) years. The lifetime, more than 3 months, and last month history of LBP was 46.2%, 11.6%, and 31.2%, respectively. Positive history of LBP in the first-degree relatives was significantly associated with LBP in the participants (P < 0.01). The prevalence of passive smoking was significantly higher in the participants with last month history of LBP (P = 0.03). The prevalence of joint hypermobility was 15.9% and was significantly higher in those with the lifetime and last month history of LBP (P < 0.01).

CONCLUSION

LBP is a common complaint among adolescent and high school girl students. The results of this study identified the prevalence and associated factors with LBP in high school students and will help develop strategies for prevention and treatment of LBP in the adolescent population.

LEVEL OF EVIDENCE

3.

Disturbances of postural sway components in cannabis users

INTRODUCTION

A prominent effect of acute cannabis use is impaired motor coordination and driving performance. However, few studies have evaluated balance in chronic cannabis users, even though density of the CB1 receptor, which mediates the psychoactive effects of cannabis, is extremely high in brain regions critically involved in this fundamental behavior. The present study measured postural sway in regular cannabis users and used rambling and trembling analysis to quantify the integrity of central and peripheral nervous system contributions to the sway signal.

METHODS

Postural sway was measured in 42 regular cannabis users (CB group) and 36 non-cannabis users (N-CB group) by asking participants to stand as still as possible on a force platform in the presence and absence of motor and sensory challenges. Center of pressure (COP) path length was measured, and the COP signal was decomposed into rambling and trembling components. Exploratory correlational analyses were conducted between sway variables, cannabis use history, and neurocognitive function.

RESULTS

The CB group had significantly increased path length and increased trembling in the anterior-posterior (AP) direction. Exploratory correlational analyses suggested that AP rambling was significantly inversely associated with visuo-motor processing speed.

DISCUSSION

Regular cannabis use is associated with increased postural sway, and this appears to be predominantly due to the trembling component, which is believed to reflect the peripheral nervous system's contribution to the sway signal.

Musculoskeletal Pain in Children and Adolescents: A Way Forward

There are substantial gaps in our understanding of musculoskeletal pain in children and adolescents. While there are challenges to performing research in this space, the prevalence, burden, and lack of available evidence to inform clinical practice mean that overcoming these challenges is important. The editors see the collection of work in this special issue as a step in the right direction. J Orthop Sports Phys Ther 2017;47(10):702-704. doi:10.2519/jospt.2017.0109.