The Hypermobile Athlete Melody Hrubes MD Director NonOperative

The Hypermobile Athlete Melody Hrubes, MD Director, Non-Operative Sports Medicine, New York Region Rothman Orthopaedics New York

Presenter Disclosure Information Neither I, Melody Hrubes, or any immediate members of my family, have an financial relationships to disclose.

Hypermobility

Joint Hypermobility Syndrome • More prevalent in musicians than general population • Prevalence in classical ballet dancers 60 -90% Mc. Cormack M, Briggs J, Hakim A, et al. Joint laxity and the benign joint hypermobility syndrome in student and professional ballet dancers. J Rheumatol. 2004; 31(1): 173 -178.

Joint Hypermobility Syndrome • Declining prevalence of joint hypermobility from student to professional • Declining prevalence from corps de ballet to principal dancer (Mc. Cormack e al. , 2004)

Joint Hypermobility Syndrome • Joint laxity may lead to an increased injury risk (Hamilton et al. , 1992) • Or it may not (Klemp and Chalton, 1989) • Increases rehabilitation time (Coollinge et al, 2009)

Increased Stress on Secondary Stabilizers

Hypermobility History • Persistent pain/headache • Joint subluxations/dislocations • Fatigue/sleep disorder • GI complaints • Rectal or uterine prolapse

Hypermobility History • Mood disorders • Abnormal scarring/bruising • Slow healing • Abnormal reactions to local anesthetics

Hypermobility History

Hypermobility Physical Exam • Focused MSK • Genu valgus • Pes planus

Hypermobility Physical Exam • • Scoliosis Varicose veins Thin skin “Party tricks”

Beighton Scale

Revised Beighton Criteria Major Criteria 1. Beighton score ≥ 4/9 2. Arthralgia for > 3 months in ≥ 4 joints Minor Criteria 1. Beighton 1, 2, or 3/9 2. Arthralgia for > 3 months in ≥ 1 -3 joints, back pain for ≥ 3 months 3. Dislocation or subluxation in >1 joint, or in 1 joint >1 x 4. Soft tissue rheumatism ≥ 3 locations 5. Marfanoid habitus 6. Abnormal skin 7. Eye abnormalities 8. Varicose veins , hernia, or uterine/rectal prolapse

Revised Beighton Criteria • Two major criteria • One major and 2 minor criteria • Four minor criteria • Joint Hypermobility Syndrome (JHS) is excluded in those patients with MFS or EDS

Lower Limb Assessment Scale (LLAS) Ferrari J, Parslow C. , Lim E. , Hayward A. Joint hypermobility: The use of a new assessment tool to measure lower limb hypermobility Clin Exp Rheum 2005; 23: 413 -420 • Movement of joints in several planes of motion • 15 minutes • Scored out of 12

Lower Limb Assessment Scale (LLAS) • Compared it to Beighton scale • LLAS = 7 – Sensitivity 94% – False positive rate 7. 5% • LLAS = 8/12 – Sensitivity 70% – False positive rate 0. 4%

Upper Limb Hypermobility Assessment Tool (ULHAT) • Nicholson L, Chan C. The Upper Limb Hypermobility Assessment Tool: A novel validated measure of adult joint mobility. Muscul Sci Prac. 25(2019)38 -45. • Upper limb hypermobility did not vary with age or ethnicity • Greater in females (p<0. 001)

Upper Limb Hypermobility Assessment Tool (ULHAT) • Designed as analogue to • ULHAT = 7 12 point LLAS – Sensitivity 0. 84 – Specificity 0. 77 • Performed on both – False positive ratio 5. 4 upper limbs • Multiple directions

Hypermobility Further Testing • complete blood cell count • erythrocyte sedimentation rate • rheumatoid factor • antinuclear antibody test • serum complement (C 3, C 4, CH 50) levels • serum immunoglobulin (Ig. G, Ig. M, Ig. A) levels.

Treatment Strategies • Prioritize strength and control • straight instead of locked in hyperextension • approximate closed chain

Treatment Strategies Avoid static stretching and overstretching – dynamic vs static – release vs. lengthening

Treatment Strategies • Improve endurance – Mitigate risk of overuse injuries – Easily fatigued leads to easily injured

Treatment Strategies • Proprioception • Hypermobility leads to proprioceptive dysfunction

Treatment Strategies

Treatment Strategies • Modifications to playing biomechanics or choreography

Treatment Strategies • Brace when appropriate – wrist – finger – spine

Treatment Strategies

Mental Health Anxiety OCD Depression Selfcriticism/Perfectionism • Disordered eating patterns • •

Further Management • Is this more than hypermobility? Could it be Marfan syndrome? Ehlers-Danlos? • Scoliosis • Cardiac work-up • PHONE A FRIEND

Resources • Hypermobility Syndromes Association hypermobility. org • Linda Bluestien, MD hypermobilitymd. com • International Ehler’s Danlos Society. Ehlers. Danlos. com