Touching the inside of the forearm with the tip of the thumb. Check. Elbows and knees that bend 10 degrees or more in the wrong direction. Double check. Pinkie fingers that flex 90 degrees backwards or more. Almost. Placing hands flat on the floor with straight legs and feet together. Easy peasy.
If, like me, you can do most of these things, and other joint-defying feats that make non-bendy people feel a bit queasy, the chances are that you’re hypermobile. For most of my life, I have believed this to be a good thing: I often feel smug in yoga classes, and am not someone you should challenge to the cereal box game, which involves picking up a cardboard box off the floor with your teeth. Many world-class athletes, from the swimmer and most decorated Olympian Michael Phelps, to the multi-medal-winning gymnast Simone Biles, also have hypermobility. So I’m in good company.
But I’ve started to worry that there might be a downside to excessively flexible joints, such as an increased risk of falls and frailty in old age. Recent research has suggested that hypermobile teens may be at an increased risk of joint pain as they get older. So is hypermobility a blessing or a curse, and is there anything that bendy people can do to guard against injury?
Hypermobile joints are ones that bend beyond the typical range of human movement, due to variation in the shape of people’s bony sockets and hinges, or the stiffness of the connective tissues holding these structures in place. “We think that in hypermobility the ligaments are a bit laxer, which allows the joints to bend back more,” says Emma Clark, a consultant rheumatologist and professor of clinical musculoskeletal epidemiology at the University of Bristol.
Some people only have one such joint, while others may have many excessively mobile joints, known as generalised joint hypermobility (GJH). One way of diagnosing this is by using the Beighton test, which assigns a score from zero to nine based on the flexibility of an individual’s thumbs, little fingers, elbows, knees and spine. For children and adolescents, a score of six or more is indicative of GJH; for men and women under 50, it’s five or more, while for the over 50s, a score over four would suffice.
While this tool does not assess all the joints, and these cutoffs have been internationally debated, “it does give an indication of this generalised hypermobility or laxity in the joints,” says Jane Simmonds, professor of physiotherapy and health education at University College London, who works with children and adolescents with hypermobility-related problems, such as joint subluxations and dislocations.
Scientists have also used the Beighton score to assess the prevalence of joint hypermobility in populations. When Clark and her colleagues assessed 6,022 British 14-year-olds, they found that 45% of girls and 29% of boys had hypermobile fingers; while 27.5% of girls and 10.6% boys had a Beighton score of four or higher.
Among adults, up to 20% of the population has generalised hypermobility, with women and people of African-Caribbean and Asian descent tending to be more affected. Many such individuals are completely healthy, or have only mildly impairing symptoms. I am prone to twisting my ankles on rough ground and I suspect I may be clumsier than average, because I’m frequently stubbing toes or bashing into the same old pieces of furniture; some studies have suggested that proprioception – the sense of where your body is in relation to the things around it – may be slightly impaired in people with hypermobility.
However, hypermobility can also be advantageous. “Some of the greatest athletes in the world are hypermobile,” says Simmonds. A study of student and professional dancers at the Royal Ballet School in London found that hypermobility was 11 times more common among dancers compared to the general population. Hypermobility is also more common among elite swimmers, including Phelps, who many experts believe may have hypermobile shoulders, knees and ankle joints. “Swimming does lend itself to hypermobility. If you’ve got more range, then you’re able to push more water and propel yourself forwards,” Simmonds says.
So is hypermobility anything to worry about, or should we be celebrating our bendiness? “I think it is probably important to realise that joint mobility is on a spectrum – with people like me who are really stiff at one end, through to people who have lots of joint hypermobility but don’t have any problems, such as sports people and musicians, all the way through to people who have a recognised clinical syndrome,” says Shea Palmer, professor of physiotherapy at Cardiff University.
Somewhere in between the latter two categories are people with so-called joint hypermobility syndrome, who don’t quite meet the diagnostic criteria for a connective tissue disorder, but whose hypermobility is causing them pain or other problems. Research by Profs Palmer and Clark found that joint hypermobility in early adolescence was associated with a doubling of the risk of moderately troublesome shoulder, knee, or ankle pain when those teenagers turned 18.
“When you superimpose obesity on top of that, they were 11 times more likely to have at least moderate knee pain when they were 18,” says Palmer. “What we think is happening is that, if you’ve got a floppy joint then [its components] will be moving around a lot more, and the joint surfaces will be getting rubbed against each other more than in a healthy person, which might be causing some of the pain.”
People with joint hypermobility syndrome or connective-tissue disorders are also more prone to fatigue – possibly because of the effort associated with constantly trying to keep their joints stable – as well as more frequent joint injuries, easy bruising, stretchy or soft skin, and stomach and digestive problems, because connective tissues are important in the composition of the gut, skin, and blood vessels as well as the joints.
Of course, ordinary people can also experience joint injuries. What a clinician would be looking for is whether there is any pattern to these injuries, says Palmer. “If you are having recurrent problems in multiple joints, it is very clear that you are hypermobile and are having difficulty controlling movements in these joints, and you’ve potentially got other signs related to connective tissue disorders, then this package would be suggestive that your hypermobility could be a factor.”
In such cases, the remedy is likely to focus on strengthening the muscles around the joints, as well as exercises to improve posture and everyday movements – such as standing balance exercises on a wobble-board to improve balance, or basic mat-based pilates moves and resistance band exercises to build strength, as well as aerobic exercises that get the heart pumping, like walking or swimming.
“By strengthening the muscles and re-educating how they control the movement within joints,” says Palmer, “we’re hoping to reduce the amount of irritation that’s happening within the joint and reduce the pain – or certainly prevent it from getting worse in the long term.”
Researchers led by Muhammad Maarj at the University of Newcastle in Ourimbah, Australia, are also investigating whether customised shoe or heel inserts, known as orthotics, could help to improve gait and balance in children with generalised joint hypermobility. In a small study published last year, they found that children reported reduced lower limb pain and improved quality of life, after wearing custom-made orthotics over three months.
As for hypermobile but largely healthy individuals like me, the advice is simply to stay active. “As we get older, we need to do more activity, not less,” says Clark. “I see people who have done a lot of sport as a teenager, then life becomes busy, their exercise levels go down, and I see them developing pain in their hypermobile joints.”
Her hypothesis is that joints that were previously supported by strong muscles become less well supported, and this may be the source of their pain. Exercise may also help people to maintain their flexibility, says Clark, showing me her own hypermobile fingers and thumbs. A viola player, she believes this trait may have aided her ability to comfortably reach the notes on the instrument’s neck. Now she’s in her 50s, it is only the fingers on her left hand – the one that plays these notes – that remain hypermobile. The other hand has stiffened somewhat. “That’s not very scientific evidence, but it does make me think that this theory that the exercise maintains the hypermobility is probably correct,” she says.
So if you are hypermobile, you can carry on contorting yourself into joint-defying shapes, provided it’s not causing you pain or other problems. And if your loose joints are becoming problematic, staying active is probably the best medicine there is – though you should consult a health professional for further advice. As for me, I’ve resolved to do more of the yoga, pilates and swimming that I love – particularly as such exercises are likely to facilitate balance and joint control. And if you fancy challenging me to a round of the cereal box game sometime, you’re on.
