What is hypermobility?

• Hypermobility means your joints are more flexible than other people's (you may think of yourself as being double jointed). If there is some discomfort, it might be joint hypermobility syndrome.
• 27% of girls and 10% of boys at 13 years old have hypermobility (with no symptoms). It is considered a ‘normal variant’.  
• All children are ‘hypermobile’ when born. There is no ‘cut off’ point for childhood flexibility. Each person is different. 
• Many different types of athletes have hypermobility in some degree.

What is a normal variant?

• A normal variant means it is part of the normal development of the bones and joints.
• A good example is height. There are many variations of people’s height, but there is a wide range that is considered the norm.
• Flexibility is viewed the same as this!

What is flexibility?

• When someone is more flexible, the ligaments that hold the bones together are more stretchy, like a strong elastic band.
• The body is designed to allow some joints to be more flexible than others, e.g. your shoulders are more flexible to allow for more movement, and your hips are less flexible to allow for more stability.
• How flexible/hypermobile you are is a spectrum, everyone is different!
• Hypermobility does not refer to your muscles. Muscle length does impact how much movement you have, and this is why stretching can impact how much movement you have.
• However, hypermobility is more about the movement available in your joints from your ligaments.
• Lots of people who have flexible joints, also have long muscles, but not all!

Hypermobility assessment

• Having hypermobility is being able to achieve above and beyond normal movement.
• However, as there is not a standard average of joint range in children, based on their age or development, its very difficult to tell if you have more movement. But that is OK!
• As hypermobility is a normal variant, you do not need to see a health professional to find out if your child is hypermobile. 
• The only time you need an assessment is if your child is getting ongoing pain or a limit to function (struggling to be able to do things.)
• The Beighton score, can be used to look at how flexible someone is, however this only looks at 9 joints of the body and was designed to be used with adults.
• If you see a medical professional, they may use this assessment with your child, but it would not be used in isolation. 

Symptomatic hypermobility 

• Sometimes people can get joint pain or discomfort in their joints. This is often caused by not having enough muscle endurance to control the joints movement during an activity.  
• If your child is getting pain, their muscles may be over-worked, they are too tired! Or their joints are moving more than feels comfortable, but this pain does not mean they are injured. 

Possible Symptoms of Hypermobility include:

• Difficulty staying still
• Poor posture
• Clicking joints
• Joint/muscle pain
• Fatigue
• Reduced co-ordination/balance
• Stomach aches/constipation
• Headaches

Note — It is possible to have these symptoms if you have poor muscle power without increased flexibility.

• You may not realise your child needs to build strength because our bodies try to do things the most energy efficient way! 
• We often find positions or ways to do an activity where we do not need our muscles to work hard. Your child may be relying on their ligaments or the environment to help them. 

This can be during static postures as well as during activity! 

• If you think you know people that do this, or do this yourself, that is because it is very common and completely normal. 
• If your child’s joints have more flexibility, their muscles have to work harder to control that movement for the same activity that you or their peers may find easy to complete. 
• This can lead to pain and discomfort if your child is doing an activity they do not yet have the strength or endurance for. 

Try and sit upright in a chair, without support and see how long you last!

Strengthening 

Building the strength of muscles will help to control the extra flexibility during movement. 

Keeping up general activity is best!

Specific strengthening exercises or activities may be beneficial to target certain areas of the body E.g. the hands for handwriting or the ankles for running.

Consider activities that work on balance and controlled movements:

• Martial arts
• Dancing
• Gymnastics
• Swimming
• Using the equipment and balance beams at the park
• Walking over different surfaces, e.g. soft play, sand, slopes, grass, gravel, woodchips etc. 
• Activities weightbearing on your arms, e.g. crawling, climbing, wheelbarrow games etc. 

With general activity, your child may need more muscle endurance to do the same activity as their peers. They may need to pace themselves during activities with discomfort, if they struggle to walk long distances or when starting a new activity. 

Pacing

What is pacing?

• Often when children (or adults) are doing an activity, e.g. running round the playground with their friends, they keep going till they can not go any more! But then get pain or discomfort afterwards. They then stop doing as much activity while they recover.  
• And then it repeats!
• We call this the boom-bust cycle and over time we actually  lose muscle endurance. 
• Imagine when you first go to the gym or a run and then ache for days after and struggle to walk down the stairs!
• Often people prefer to avoid movement if they are in pain, or think they are going to get pain. 
• However, this often leads to people losing their muscle strength, making it more likely for them to get pain when they do the activity. 
• This then goes round in what is known as the chronic pain cycle. 

Pacing is all about taking planned breaks before you burn out.

• Start by timing how much of the activity they can do before they get symptoms. 
• Next time, take short breaks in their activity before the symptoms start. 
• Take as many breaks as needed to remain pain free during the activity. 
• Gradually increase how much they do. Either increase the time doing the activity, or reduce the length of the break. 
• Continue to build up until you can reach the goal. (the activity your child wants to do).

Note! This will take trial and error, especially if your pain comes after activity rather than during.

Struggling to know what is causing pain and what to pace? 

• If your child is getting pain at the end of the day, and are not sure what activity to pace, start a symptom and activity diary to help you find a starting point. 
• Note if your child is doing lots of activity on a single day, e.g. the daily mile, P.E. and an afterschool club on the same day. 
• Try spreading out activity through the week. This will pace over a longer period and not just the singular activity. 

Its all about finding the balance!

Finding the balance between getting enough activity to strengthen, and taking enough breaks to manage the symptoms can be difficult for some children. 

This take time, with trial and error, to find the best balance for your child. 

Static positions: Remember, sometimes sitting or standing positions can be even harder to maintain than activity. 

• Pace static positions by taking regular movement breaks. 
• Make sure you are supported when sitting, feet supported, sitting straight, hips and knees at 90 degrees. 
• Use equipment such as stools, cushions and writing slopes to help with positioning.

You can help the muscles to control and protect the joints with the following techniques.

• Avoid repetitive movements, allow for regular changes of position, e.g. writing/typing, sitting in class. 
• Avoid tight grips or gripping for long periods e.g. chunkier pens. 
• Use larger muscle groups for actions e.g.  Use palms of hands rather than fingers when carrying plates.
• Use supportive footwear with laces or Velcro which allow for conforming and supporting the shoe to the foot. 

What not to do

• Try not to do any ‘Party tricks’! E.g. knotting fingers, skipping through arms, clicking joints, etc. Repeatedly stretching your ligaments to their end range can cause problems for your ligaments later in life. 
• Don’t avoid activity.
• Pace yourself to avoid a Boom-Bust cycle.

Summary

• Hypermobility is not a bad thing!
• Pain does not equal damage.
• No party tricks!
• Keep strong and active.
• Pace static positions and activity.
• Protective joint positions for activity.