Growth rates

In early childhood both girls and boys grow at a similar rate in height and weight. The most rapid rate of growth occurs just before birth and it then remains relatively steady until adolescence. The rate of growth is disproportionate throughout the body: until the teenage years the rate of growth is greater in the limbs than the spine, but during adolescence the rate of growth is greater in the trunk. The peak height velocity (adolescent growth spurt) occurs approximately two years after the onset of puberty (Porter 1989). The onset of puberty is approximately 10.5 years of age in girls and 12.5 years in boys. There is a change of body shape and proportion in various body parts during this growth period. On average girls add between 6–11 cm and boys 7–12 cm to their height during this period. Most girls have reached 99% of their adult height by the time they are 15 whereas boys reach adult stature between 18 and 21 years old. Although peak height velocity occurs earlier in girls, boys eventually surpass girls to attain a larger adult stature. By the age of 18, the average boy is 12 cm taller and 10 kg heavier than the average 18-year-old girl (Riddoch 1991).

When treating an adolescent it is useful to monitor whether the individual is going through a rapid growth phase. Some adolescents will grow steadily throughout their teenage years whereas others will have periods of rapid growth spurts. It is essential to measure standing height and sitting height separately to give an indication of the relative rate of growth of the limbs and spine. Measurement of sitting height (stem height) is considered to be a measurement of spinal height.

Co-ordination

There is a perceived ‘adolescent awkwardness’ that accompanies the growth spurt and manifests in poor co-ordination and balance. There is some evidence (Beunen & Malina 1988) that this clumsiness affects one-third of teenage boys, lasts up to 6 months and is probably a result of the disproportionate rate of growth between the trunk and legs.

Flexibility

In adolescence there is often a reduction in flexibility in both those with JHM and those with normal tissues. It has been thought that during the growth spurt, the growth of the bony elements often outstrips that of the soft tissue elements (Thein 1996) and there is a subsequent decrease in strength and flexibility. It is this stage in development that tissues can become overstressed in a cumulative overload, and many adolescents find that their joints are less lax and movements are stiffer. Until the muscles catch up with the increase in bone length they are under a degree of tension that is felt as increased muscle tightness and this may be one of the causes of growing pains in adolescents. In addition, the lumbar fascia may not be able to keep pace with the bony growth spurt during adolescence which can result in increased tension and tethering in the thoracolumbar fascia giving rise to an increased lumbar lordosis. Typical postural changes at this time include:

Some adolescents with JHM will not notice any increase in stiffness, but others will notice a reduction in joint laxity in a range that nevertheless remains hypermobile. As changes occur in the muscles and more sarcomeres (the contractile unit of muscle) are laid down, flexibility may improve again. However, a study of 600 high-school children did not find any correlation between growth and decreased flexibility during the peripubescent period (Feldman et al 1999).

Weight

Weight increases steadily throughout childhood and adolescence. Peak weight velocity follows peak height velocity and is closer to age in boys than girls. In boys the difference between peak height velocity and peak weight velocity ranges from 0.2 to 0.4 years whereas the ratio for girls is 0.3 to 0.9 years (Malina et al 2004). A study measuring pre- and post-puberty weight change showed that boys increase in weight by an average of 113% and girls by an average of 67% (Buckler 1990). This increase in mass (body weight) substantially increases the ground reaction forces to which the joints are subjected, and the more fragile tissues of a child with JHS become vulnerable if joint stability is further compromised by poor muscle control.

Increase in muscle mass and strength are proportional to weight gain during adolescence (Thein 1996). A boy’s muscle mass will double between the ages of 11 and 17 years, and peak height and muscle growth occur simultaneously. A girl’s muscle mass doubles between 9–15 years of age, and the fastest growth is approximately 6 months after peak height velocity. In both sexes increases in muscle strength closely follow increases in muscle mass, which occur approximately 9–12 months after peak height and weight gain (Porter 1989).

Bone

Bone maturation is the process whereby the tissue undergoes changes from the embryonic rudiment of bone to the adult form (Roche 1986). Before puberty chronological age correlates well with bone age but during adolescence bone age is more closely related to adult maturity levels, so that bone age is related to the timing of puberty and growth in height in an individual (Roche 1986). Hence, two adolescents of the same chronological age can have different levels of bone maturation owing to differences in timing of onset of puberty. This can be particularly relevant in teenagers who are playing contact sports (Chapter 13) in teams where the selection criterion is based on age rather than skeletal maturity.

The increase in height and decrease in muscle strength and coordination that occurs during adolescence is compounded further by dramatically changing hormone levels. Furthermore, changes in body shape and size also challenge the self-image of the teenager and this must be considered when treating an adolescent with JHS.

Pain

Although pain is usually the predominant symptom, the adolescent may present with a variety of different problems. Pain may be widespread, or confined to just one joint. Common symptoms described by hypermobile adolescents include joint and muscle aches which are often worse at night, frequent and excessive joint noises (clicking, popping, clunks), a history of subluxation or dislocation (particularly of the patella, shoulder or temporomandibular joint), non-specific low back pain, joint effusions and repetitive strain injury (RSI). They may also complain of a feeling of weakness or vulnerability as if a joint is going to lock or ‘go out of place’. Other symptoms include paraesthesia, chest pain, fainting and light-headedness. Headaches are also a familiar feature of JHS in adolescents. Symptoms may be worse after periods of prolonged inactivity, such as a long journey, or following vigorous or unusual activity. At a time when the adolescent body is going through rapid physiological and psychological change the onset of symptoms can be particularly worrying to the teenager.

Function and posture

There are a number of functional activities that adolescents with JHS may find problematic. They often have difficulty sitting still for any length of time, probably owing to their inability to find a comfortable, stable position, and have a tendency to fidget. In the classroom this may result in the child being labelled as inattentive or hyperactive. Adolescents have particular difficulty sitting on high stools in science laboratories because they are unsupported without an adequate back support. The problem can be compounded further if the stool does not have a foot rest that would allow transference of body weight through the legs. The inability to place the feet on a foot rest or the ground also compromises the stability of the trunk.

In common with adults, some adolescents with JHS report that prolonged standing brings on symptoms of low back, knee and foot pain. Standing in queues and school assemblies can be a particular problem. An upright relaxed balanced posture requires good muscle tone and conditioning. Adolescents with JHS tend to shift their weight frequently from foot to foot, often locking one knee into hyperextension and pushing the hip into extension. In this position, the individual hangs on the hip ligaments rather than using the pelvic postural muscles for support. This creates an accumulative overload of the joints and soft tissues, often giving rise to symptoms.

Another common problem is pain in the forearm, wrist and fingers when writing or using the computer for a sustained period. This can lead to symptoms of repetitive strain injury and can be particularly difficult when writing at speed and under stress in exam conditions.

Co-ordination

Adolescents with JHS may also report that they are clumsy, have poor co-ordination, bruise easily and may fall more frequently than children with ‘normal tissues’.

Fatigue

Adolescents with JHS may complain of an overwhelming fatigue. In a matched case-control study comparing Beighton joint hypermobility scores (Chapter 1) in 58 consecutive children with chronic fatigue syndrome (CFS) with 58 healthy controls (Barron et al 2002), it was found that there was a higher incidence of JHM in those with CFS than in the control group. Nijs et al (2006) also found that generalized JHM is more common in patients with CFS than in healthy controls (Chapter 6.1).

A study has shown an association between JHM and malnutrition. A cross-sectional field study of 829 children of the lower urban socio-economic strata in Mumbai, aged 3–11 years, found that moderate and severe malnutrition were associated with JHM and that moderately and severely malnourished hypermobile children were more likely to have musculoskeletal symptoms as compared to their non-hypermobile counterparts (Hasija et al 2008).

Lumbar spine

Hypermobile subjects are particularly susceptible to low back pain, and the incidence of lumbar disc prolapse, pars interarticularis defects and even spondylolisthesis occurs with increased frequency in hypermobile individuals (Chapter 12.8).

Non-specific low back pain is a common problem in hypermobile adolescents and occurs in the absence of demonstrable radiological change, neurological signs or identifiable back pathology. Studies have shown that there is a relationship between joint laxity and low back pain (Chabot 1962, Hirsch et al 1969, Howes & Isdale 1971, Gedalia et al 1985).

Adolescents with non-specific low back pain and JHS frequently have poor static and dynamic control of the deep trunk and pelvic stabilizing muscles thus compromising their ability to perform normal functional activities. This control is frequently inadequate in static postures and is compromised further during daily functional activities, particularly those that are performed at speed or include a change in direction of motion.

Scoliosis

It is reported that there is a link between adolescent idiopathic scoliosis (AIS) and JHM. A study of a group of 109 Chinese girls with AIS found them to have more joint flexibility than a control group (Binns 1988). Another study set out to compare the influence of physical and sporting activities on AIS (Perrin 2006). It was found that girls with AIS had a higher level of joint laxity than a control group, regardless of whether they were practising gymnasts. The researchers concluded that girls with high joint laxity may be more prone to developing AIS.

Cervical spine

A history of recurrent episodes of acute torticollis is a common finding in adolescent JHS (Chapter 12.7a). This is a painful unilateral condition that develops after minor trauma or an acute respiratory infection (Staheli 2007). It can also manifest on rising in the morning, particularly in teenagers who sleep prone with their head rotated and extended. A sudden uncontrolled movement of the head can cause the neck to become ‘locked or stuck’. Poor control of the deep neck and shoulder girdle stabilizing muscles is a contributing factor, and it has been proposed that overstretching of the neck may cause partial subluxation of the facets, or straining of the muscles and ligaments. A case report in which magnetic resonance imaging (MRI) was performed on a 15-year-old male adolescent within a few hours of onset of an acute torticollis showed there was a signal intensity compatible with a fluid collection at C2–3, and that the lesion was probably linked to a sudden disruption of the disc collagen fibres, thereby causing excessive lateral pressure, pushing C2 to the left; MRI 3 weeks later was unremarkable (Maigne et al 2003).

A study of 564 pre-adolescent children with musculoskeletal pain showed that at 4-year follow-up, neck pain was the most persistent/recurrent musculoskeletal pain and that age, headache, JHM and having combined musculoskeletal pain were found to be independent predictors of pain in adolescence (El-Metwally et al 2004).

Persistent headaches are a feature of JHS in adolescence. Cervical spine JHM has been found to be a possible predisposing factor for new daily persistent headache (Rozen et al 2006).

The shoulder

Instability of the shoulder can vary from a vague sense of loss of shoulder function and control to a frank instability due to a traumatic dislocation. Atraumatic instability is a common finding in adolescents with JHS that can become symptomatic during the teenage years; it is seen more frequently in young women than young men. The individual may have had repeated episodes of recurrent transient subtle subluxations which eventually progress to atraumatic dislocations. Some hypermobile adolescents are able to dislocate or sublux their shoulders voluntarily and may do this as a ‘party trick’ and may present as a unilateral or bilateral problem.

The extensible shoulder joint capsule of an adolescent with JHS may allow humeroscapular positions outside the range of balanced stability, and poor neuromuscular control may fail to position the scapula to balance the net humeral joint reaction force. An excessively compliant capsule with relatively weak rotator cuff muscles and poor proprioception will also reduce the stability of the joint. This type of instability is often most prevalent in mid-range positions and simple activities of daily living such as putting on a coat or reaching for an object can cause the shoulder to sublux. See Chapter 12.1 for more detail on shoulder pathology in JHS.

The hip

In hypermobile adolescents a snapping or clicking hip is a common phenomenon. The click may or may not be associated with pain and symptoms (Sanders & Nemeth 1996). The adolescent may complain that it feels as though their hip ‘goes out of joint’ and they may have intermittent difficulty in fully weight-bearing through the hip. Clicking of the hip has also been associated with excessive femoral head translation (in an anterior or posterior direction) that results from poor control of the muscles that stabilize the hip and pelvis (Sahrmann 2002). In particular, these individuals tend to have particularly weak gluteal muscles and iliopsoas. Hip problems associated with JHM are discussed in further detail in Chapter 12.3.

Knee joint

Related posts:

Anxiety disorders, their relationship to hypermobility and their management Fibromyalgia and hypermobility The physiology of pain Principles of rehabilitation and considerations for sport, performance and fitness Regional complications in joint hypermobility syndrome Neuromuscular physiology in joint hypermobility

Stay updated, free articles. Join our Telegram channel

Join