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Hi doctors! First, thanks for setting up this platform for us to ask our questions!
Quick intro, I’m 20 this year and am very active in sports. I’ve always had joint hypermobility (9/9 Beighton score), but in the past 3-4 years I’ve been battling chronic joint pain and instability, despite intense PT sessions and strengthening. Many PTs have also commented on my incredibly slow rate of healing, and I was wondering if there could be some underlying systemic issue causing all my symptoms.
I’ve seen multiple sports doctors for my injuries, but my injuries are typically treated in isolation. I was thinking of seeing a specialist to bring up my concerns, but wasn’t sure what specialty I should be turning towards. A pain specialist (most of them seem to be anaesthesiologists)? Rheumatologist? Sports doctor? Would love to hear your input and advice. Thank you!
Thanks for your email – sounds like you’re having a bit of a tough time! Both Dr Ethan and Dr Alan have provided excellent answers to your question so no point covering it all again. Nevertheless, just a couple of questions and considerations.
Firstly, are you male or female? You see, from clinical practice I note that younger female patients tend to be more flexible than men. While I know this is a very broad observation and does not provide much information or comfort, if you are male, then the hyper-mobility consideration of other conditions becomes more relevant.
Then there are the injuries and your comment about poor healing. This is very interesting – what are the nature of your injuries? Have they occurred from a trauma or were the spontaneous. Tissue healing can be affected by all the conditions that my colleagues have mentioned, but also your general health plays a big role; things like smoking, diabetes, general physical fitness – all are important.
I know there are more questions than answers but I think you do need to be followed up. Someone from Sports Med or Rheumatology might be a good start and as Dr Alan mentions, if there are concerns then perhaps genetic testing is important. Generally as we age. Things naturally get tighter and stiffer, but I realise that this may not give much comfort.
Thanks for a great question and good luck with looking into this further.
Dr Dinesh Sirisena
KTPH Sport Medicine Consultant
That’s actually a very good question.
Pain doctors are experts at managing chronic pain conditions, while rheumatologists treat systemic autoimmune conditions.
I think that in this instance, seeing either a sports doctor or a rheumatologist as a start would be reasonable.
If you are more concerned about ruling out a systemic autoimmune illness as a cause for your joint hypermobility, you should probably make a rheumatologist your first port of call.
On the other hand, a sports doctor will be able to better manage your joint pain and instability. Sports doctors are still fully trained medical doctors – they spend at least 3 years doing general medicine, and then another 3 years rotating through Sport Medicine-related specialities such as orthopaedics. So even if you started with a sports doctor, if he suspects that your joint hypermobility may be a manifestation of some systemic illness, he will still refer you to see a rheumatologist.
There are a few differential causes for hypermobile joints, which include hereditary connective tissue disorders and inflammatory joint conditions:
- Ehlers-Danlos syndrome
- Marfan’s syndrome
- Joint hypermobility syndrome
- Benign hypermobility joint syndrome
- Juvenile idiopathic arthritis
- Rheumatoid arthritis
- Ankylosing spondylitis
Hello, sorry to hear about your problems.
Hypermobile joints have a range of movement which exceeds the normal range, usually due to laxity of the surrounding ligaments. This determined by the content of various proteins such as collagen and elastin.
Rarely there may be an underlying genetic disorder such as Ehlers Danlos syndrome or Marfan’s syndrome. These conditions may be associated with blood vessel problems – if you have concerns it may be worth seeing a geneticist in Singapore for screening.
Hypermobility may be beneficial for certain sports e.g. gymnastics, dancing and swimming, but is associated with a higher rate of injury and potentially slower rate of recovery.
You should avoid stretching hyperflexible muscles further. Instead, concentrate on isometric or concentric strengthening exercises. In isometric exercise, the muscles are working, but the joints don’t change position. With concentric exercises, muscles shorten as they contract, for example like your biceps during a biceps curl.
Sustained muscle stretches are not recommended for hypermobility syndrome, because muscles and ligaments are already too lax.
Eccentric exercises should be avoided – these occur when a muscle contracts while lengthening. An example of an eccentric contraction is when you lower the weight back down to starting position after a biceps curl.
Keeping muscles strong throughout their entire range of motion is important. Muscles tend to be strongest in their mid-range and weakest at either extreme of motion. That means a joint will be most vulnerable, or least protected, when it is at the end of its range of motion.
Your condition is likely to be managed in a multidisciplinary setting (ie. seeing lots of specialists) due to its nature and the many effects it can have on your body.
I recommended initially working with a sports doctor and physiotherapist to strengthen the muscles surrounding the most vulnerable joints: your shoulders, elbows, knees and ankles, as well as your core musculature.
Here are various resources that will help you understand and manage your condition:
I hope you found this useful and Good Luck!
Dr Alan Cheung
Consultant Orthopaedic Surgeon