Joint Hypermobility – Beyond the Normal Range of Movement

Common conditions, Geeky stuff, Lifestyle

Hypermobility pictures

Our joints are responsible for movements and stability (e.g ability to maintain and control movements in your knees). Different joints have varying degrees of inherent stability considering its function, the way it articulates, anatomical position, load-bearing capacity, strength and flexibility of the soft tissue structures (muscles, ligaments, and fascia).  

Joint mobility, on the other hand, refers to the range of movement in a particular joint. Like stability, it is dependent on the strength and flexibility of the surrounding soft tissue structures. This means that any problems with the soft tissue structures would affect the stability and mobility, making the joint susceptible to injuries and dislocations.

Hypermobility

You are said to be ‘hypermobile’ when you have the ability to move your joints beyond the normal range of movement. Sometimes it’s also called ‘double-jointed’. This condition is fairly common in the general population and might sometimes become an advantage for athletes or dancers.

Having said that, there are different problems related to hypermobility. The most important being the lack of stability in the joints.  One may be predisposed to soft tissue structure injury and experience excessive muscular stiffness.

‘Hypermobility’ – How did I get so flexible?

  • Genetics – Connective Tissue Disorder

The exact cause is unknown. Due to genetic problems, it can be seen among infants at birth with sometimes a possible decline in hypermobility during childhood, teens and adulthood. An improper gene resulting in joint laxity is due to the lack of collagen, elastin and fibrin proteins which usually help with the stability of joints, tendons and ligaments.

  • Acquired hypermobility 

Without having inherited laxity in the joints, many ballet dancers and gymnasts get hypermobile as they push the joints to the hypermobile range while working to get the flexibility to perform. Intense and excessive stretching of the muscles and soft tissue structures can also lead to hypermobility.

When do we say you have a Hypermobility Syndrome?

Joint Hypermobility Syndrome (JHS)

Individuals who suffer from chronic joint pain and other symptoms related to their hypermobility have a condition called joint hypermobility syndrome (JHS). As the name suggests the most affected part is the musculoskeletal system.

Due to hypermobility, the risk of injury to the joint structures, ligaments, tendons and other ‘soft tissues’ around joints are increased. In addition, the structure of the collagen fibres and the shape of the bone (articulating surfaces) both play a major role. Even a lack of neuromuscular tone and proprioception could be the contributing factors to this condition.

Aggravating factors, Symptoms and Common conditions associated with JHS

There is no specific activity that can trigger pain. For some individuals, repetitive movements, overuse, excessive weight bearing or even simple activities of daily living can cause pain.

  • Incorrect posture and alignment of joints: During daily or sports activities incorrect movements due to faulty posture can affect the hips, shoulders, knees, and elbows joints. For example, hyper-extending the elbows can injure the tendons on the sides of the elbow causing conditions like “tennis elbow” and “golfer’s elbow.”
  • Laxity in the soft tissue structures: This leads to increased strain, tearing and spasm causing pain and stiffness around the joint. Due to over extending and twisting flexible joints, partial dislocations or complete dislocation can also occur.
  • Muscle imbalances: Pain due to injury causes adhesions withing the soft tissue structures (Muscles, ligaments and fascia) of one joint leading to imbalances in the mobility of other joints and surrounding structures. Pain and spasm of the hip muscles can pinch the sciatic nerve resulting in pain called as sciatica which can be felt radiating down the back to the leg. Sometimes it could also be because of the inter-vertebral discs (made of collagen) that has become too soft than normal and has impinged the nerve.
  • High-impact exercises: Sports that involve running, jumping or physical contact predisposes lax joints to dislocate.
  • Stretching: Incorrect technique or type of stretching that involve grabbing a joint and pulling or pushing on it to loosen it up.
  • Heavy lifting, pulling and pushing: Odd-shaped weights and unusual angles often lead to injury due to excessive load on the joints.
  • Recurrent Ankle sprains: Sprains may take very longer to heal because they tend to get injured repeatedly while trying to heal.
  • Knee pain: This is most common in hypermobile. People because the cartilage between the kneecap and the knee get lax. Due to excessive mobility, the cartilage underneath the kneecap starts to wear down (a condition referred to as chondromalacia), causing pain and sometimes a crunching or grinding noise – while kneeling, squatting or climbing the stairs.
  • Chest pain: A condition called costochondritis or inflammation of the rib cartilage causing pain and tightness.
  • The jaw, or temporomandibular joint (TMJ): This is often affected because of loose structures.

Although pain and fatigue are the common complaints, the range of symptoms could be wider considering that cardiovascular and endocrine system could also be affected.

Are my symptoms related to Pain and Fatigue syndromes or is it because of Joint Hypermobility Syndrome?

Hypermobility predisposes people to developing Chronic fatigue syndrome (CFS), Fibromyalgia (FM), Chronic Regional Pain Syndromes (CRPS), Chronic Widespread Pain (CWP). In simple words, someone with hypermobility may have other pain and fatigue syndrome. However, people with pain and fatigue related syndromes may not be hypermobile. Thus, a careful diagnosis is necessary.

Hereditary Syndromes associated with JHS

  • Marfan’s syndrome or Ehlers-Danlos syndrome, Osteogenesis Imperfecta: These are usually inherited disorders that are passed on to children by their parents. Often, children with Down syndrome will also be hypermobile.

Diagnosis of Joint Hypermobility Syndrome and Management

In some cases, people may have inflammation in their joints but no presence of abnormalities of their blood tests (so called seronegative inflammatory arthritis). Similarly, confusion is very common among clinicians to come to a particular diagnosis with the number of pain and fatigue syndromes associated with the joint hypermobility syndrome.

Most clinicians use the Beighton score which is a nine-point scoring system that looks for hypermobility. In the thumb, elbow and knee on both sides of the body and the ability to bend forward and place the palms of the hands flat on the floor without bending the knees. Hypermobility is often found at the jaw, neck, shoulders, other small joints of the hands and feet, hips, ankles and mid-foot, sticking to the Beighton scoring method is not enough in clinical examination. A high degree of applied musculoskeletal expertise and knowledge of the condition will be required to address all the problems.

If someone has been diagnosed with hypermobility and symptoms of pain, it is advisable that particular care should be taken with physical treatments. Avoiding activities that would strain the hypermobile joints.

Treatments should focus on improving the functional stability and mobility of the soft tissue structures. Awareness such as perception of correct posture with neuro-muscular proprioceptive training. Maintaining an active lifestyle with lifestyle modification. Even simple things like nutrition and balanced diet to maintain optimal body weight will be beneficial.

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Avoiding the Glucose Rollercoaster

Food, Geeky stuff, Lifestyle

Several types of white sugar - refined sugar and granulated suga

We are all aware that Glucose is a primary source of energy for the body. it requires no further digestion and is available in your blood. Carbohydrates (carbs) is one such food group that breaks down into glucose during digestion.

The type of carbs that you consume will determine the amount of glucose present in your blood. The Glycemic Index (GI) is one such indicator which scales from 0 to 100, telling you the glucose level in your blood. The lower the GI, the better the food is for your body during the energy conversion process. Foods rich in protein and fats usually don’t have a GI value. While they do cause an eventual increase in blood sugar level, the process is slow unlike carbs/sugars which can cause an immediate spike.

Generally, when eating high GI foods together with proteins and fats, it slows down the body’s ability to convert the sugar as quickly. Slower sugar conversion results in a lower blood sugar spike. What this means is, if you ingest a fast-absorbing protein like casein which is found in milk, even though you will increase overall sugar levels, you decrease the effect of insulin and delay excessive absorption of the sugars in your blood. This in essence lowers the GI load on your body.

GI Standard Values (GI Low- less than 55, GI High- above 70)

Most fruits, vegetables and whole wheat foods  that we consume are on the lower side, with values in the 30s and 40s. On the other higher side of the scale, potatoes rank way up in the 80s, and white bread falls in the 70s.

White Pasta vs White Bread – Both made from Refined flour

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Non-whole grain bread and pasta noodles both contain similar amounts of starch. Their starches are similarly composed of long chains of the simple sugar, glucose. The structure of bread allows more of the starch to be exposed to enzymes in our saliva and in our digestive tract. This greater exposure to enzymes allows more of the starch to be broken down into sugars giving white bread a higher GI value than white pasta. Effectively, both are still high on the GI value scale so moderate consumption will be recommended.

Insulin Insensitivity

The problem with ingesting foods with a high GI load over a prolonged time  can cause your body to become insensitive to a hormone called insulin. In the early stages (pre-diabetic) this can be reversible by making dietary and lifestyle changes. If no changes are made, and the person continues to eat high quantities of GI rich foods, it can lead to type II diabetes.

Know the GI but also the nutrient profile of your foods 

While a very high intake of GI rich foods should be avoided, you must remember that GI load does not measure nutritional intake. The body needs more than sugar for health and some foods while high in GI values, may have benefits that outweigh the disadvantages. Like brown rice, bananas and oats are all foods high in GI values, but they are also high in important minerals, vitamins and proteins essential for a healthy body. Balancing the benefits of reducing GI load while also making sure you get your full nutritional requirements is much more important. Portion size also plays an important role when it comes to such foods.

Much research have shown the benefits of low GI diet in weight loss, lowering the risk of diabetes and eliminating the sudden sugar rush and crashes. However, some studies have also shown no difference in hunger, satiety, or energy level after eating high- or low-GI foods. With research, the results of studies can’t necessarily be replicated and generalized for everyone but yes, for people who eat only high GI foods knowing its bad effects is a must.

Eating sensibly is the key!

healthy snacks

Everybody is unique with different metabolisms. Having said that, people’s metabolism also have different effects on blood glucose levels.  And most often, we eat foods in combinations of all different nutritional values. All we have to understand is that even if research trials have shown the benefits of low GI diets, in reality, it is best to only incorporate the knowledge rather than eliminating all high GI foods. That would be impractical and impossible.

Here are some GI values of the most commonly eaten foods.

Enjoy eating healthy and making healthy choices because what makes you feel better on the inside will show on the outside.

High-carbohydrate foods   Breakfast cereals   Fruit and fruit products   Vegetables  
White wheat bread 75 Cornflakes 81 Apple, raw 36 Potato, boiled 78
Whole wheat/whole meal bread 74 Wheat flake biscuits 69 Orange, raw 43 Potato, instant mash 87
Specialty grain bread 53 Porridge, rolled oats 55 Banana, raw 51 Potato, french fries 63
Unleavened wheat bread 70 Instant oat porridge 79 Pineapple, raw 59 Carrots, boiled 39
Wheat roti 62 Rice porridge/congee 78 Mango, raw 51 Sweet potato, boiled 63
Chapatti 52 Millet porridge 67 Watermelon, raw 76 Pumpkin, boiled 64
Corn tortilla 46 Muesli 57 Dates, raw 42 Plantain/green banana 55
White rice, boiled 73     Peaches, canned 43 Taro, boiled 53
Brown rice, boiled 68     Strawberry jam/jelly 49 Vegetable soup 48
Barley 28     Apple juice 41    
Sweet corn 52     Orange juice 50    
Spaghetti, white 49            
Spaghetti, whole meal 48            
Rice noodles 53            
Udon noodles 55            
Couscous 65            
Dairy products and alternatives   Legumes   Snack products   Sugars  
Milk, full fat 39 Chickpeas 28 Chocolate 40 Fructose 15
Milk, skim 37 Kidney beans 24 Popcorn 65 Sucrose 65
Ice cream 51 Lentils 32 Potato crisps 56 Glucose 103
Yogurt, fruit 41 Soya beans 16 Soft drink/soda 59 Honey 61
Soy milk 34     Rice crackers/crisps 87    
Rice milk 86            

Mobility vs Flexibity

Exercise, Geeky stuff, Lifestyle

fexibility vs mobility

As professionals, we deal with a wide range of conditions for joints and soft tissue problems. We all work with different methods, approaches and principles. At the end of the day, the truth is, we are all solution driven and we all work to make lives better.

We often come across with words like mobility and flexibility throughout our education and training. Whether you are a physical therapist, an osteopath, fitness trainer or a massage therapist. From a professional perspective, when we look at problems with movements, we immediately think of all the tight structures that are causing any restriction in the range of motion (ROM).

Now, the big question is – is this lack of ROM a mobility problem or a flexibility problem?

Let’s make this clear so that we can consider what’s contemporary for best clinical practice.

Flexibility – “Oh this looks very tight, let me stretch this for you!” 

We often use the word “flexibility” too quickly because it is a very convenient and quick way to communicate with a novice. When you say that the lack of ROM is because of tightness in the muscles indicating a flexibility issue, it implies that stretching all the tight tissues can fix the problem. However, are we really dealing with the underlying issue here?  What we are doing is not addressing the real problem AND only treating the symptoms. What if there is a misalignment in the joints causing impingement or some sort of joint restriction?

What are we missing?

The term ‘flexibility problem’ for all joint restrictions would actually mean that we are looking at the problem from only one perspective. Thus using the word ‘flexibility’ shows a great lack of understanding of the injury itself.

When injured, why do we get tight muscles and soft tissue structures?

Post-injury your muscles involuntarily contract to safeguard the injured site. Contracted muscles get fatigued causing soreness and pain. They also pull on bones compressing joint structures. So over-tight muscles now cause over-tight joints. Tight joints lead to stiffness and can cause more pain. Long-term compression of these joints leads to cartilage damage and joint restriction in ROM. Therefore, if you are only looking at the flexibility problems of the muscles and have been stretching them, you might be favoring the injury and causing more damage. 

If you have a stone in your shoe and it hurts your feet to walk. No matter how much you stretch your foot, when you place your foot back in the shoe, your muscles will instantly tighten up in response to the pain.

Furthermore, when you have painfully contracted muscles protecting the injured area, you also adapt to different movement patterns. This adaptive pattern of incorrect movements only perpetuates the pain of injury through muscular over-contraction causing an increase in joint restriction.

ROM Restriction is a Stability and Motor Control Problem

Every movement of our body is a functionally skilled movement which is controlled by the neuro-muscular system that co-ordinates your joints and soft tissue structures. Simply put, your ability to actively move a joint through a range of motion is not only dictated by the flexibility of the muscles or the mobility at the joint but also by your central nervous system.

Mobility – “What is the restriction?”

Mobility is a correct and intelligent word used by clinicians. When we use the word ‘mobility’, we give a very holistic approach to the problem addressing the stability and mobility control of the body. We look at all the anatomical structures and physiological processes that are possibly affected in the injury process.

So when we say it’s a mobility problem, we address:

  • Flexibility problems of soft tissue structures.
  • Movement problems of the joint due to its structural changes.
  • Motor control problems of the joint due to behavior or protective responses.

Therefore, it is important to recognize that flexibility is crucial but is only one of the components of mobility. There are three solutions to ROM restriction but if we name it as a flexibility problem then there is by definition only one.

The Mobility Approach

Mobility is influenced by the structure of joint, ligaments, capsule, neurological control, behavior, fascia, pain and/or fluid dynamics. Whereas stretching generally focuses on muscles and to a lesser degree, ligaments and perhaps fascia.

Take your finger and pull it back as far as you can safely go, that is flexibility. Now hold your entire finger and the base near the knuckle and circle it in varying ways, the muscles are not stretched but the finger is still moving.

That is improving its mobility, which can influence synovial fluid and joint health.

In the Mobility approach, you look at,

1. Awareness of existing function or restrictions.

2. Releasing or promoting normal mobility through joint mobilization, education of correct movement patterns, correct stage of stretching depending on needs (dynamic, active, passive or active-assisted).

3. Functional stabilization training – prioritizing correct movements and motor-control.