Masterclass: Hypermobility and hypermobility related disorders

by ptfadmin | Feb 15, 2022 | Health Tips

Reviewed by Evan Peterson PT, DPT

Introduction

Mobility over the last several years has been a source of topic when discussing general health and wellness. Many people believe the more mobile a joint is the better off it will be. There are varying degrees to which a joint may be mobile. A hypomobile joint is one in which the bones do not glide or roll as well as one would expect. The opposite is for a joint to be hypermobile. Joint hypermobility is the excess to which a joint has the ability to go through its range. Increased joint play is not always bad, at times it can be advantageous. However, increased mobility may lead to increased risk for injury or be a sign of systemic disease. These diseases are known as Heritable Disorders of Connective Tissue (HDCT). The 2 most common of them is Ehler’s Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorder (HSD).

Where do we see hypermobility?

A variety of factors can influence who gets hypermobility, including age, gender, muscle tone, joint shape, injury, and systemic disease. More often than not, children are more mobile and as they age they become less mobile. Due to the aging affects on joint mobility, scoring tools must be adjusted to determine the severity. Factors such as injury or training can play a factor in the development in mono-articular joint hypermobility. For example, the article notes swimmers tend to have knee extension hypermobility and gymnasts seem to have greater hip hypermobility.

Identifying Hypermobility

To identify hypermobility, it is important to examine both active a passive range of motion (ROM) in joints. Several screening tools have also been developed to look for generalized hypermobility. The most commonly utilized is the Beighton scale which is a 9-item list. Scores of 6 or more in 5-year olds to skeletal maturity, 5 or more in adults to 50 years of age, and 4 or more when older than 50, is positive. Along with the screening tool, a 5-part questionnaire is typically attached. This is the 5-part hypermobility questionnaire which asks questions such as “Do you consider yourself double jointed” and “Can you now (or could you ever) bend your thumb to touch your forearms?”. Despite this screening tool, it does not completely rule out generalized or other forms of hypermobility. Specifically, the temporomandibular, shoulder, hip, cervical, and ankle, joints should be paid close attention. Other recommended screening tools are the Upper Limb Hypermobility Assessment Tool (ULHAT) and the Lower Limb Assessment Score (LLAS). The LLAS is the only one of the two which has been validated for the pediatric and adult; whereas, the ULHAT has been validated for adults.

Diagnosing Hypermobility Disorders

The most common diagnosis of hypermobility in the past was Joint Hypermobility Disorder; however, most recently hypermobile Ehler’s Danlos Syndrome (hEDS) and Joint hypermobility (JH) are thought of as a spectrum ranging from asymptomatic JH to hEDS. Filling the middle of this spectrum is HSD. The importance of recognizing HSD is to understand that it may appear in a variety of different ways: localized, peripheralized, generalized, or historic. Historic refers to someone who had joint hypermobility in the past but due to an injury lost their ability to demonstrate increased mobility.

Presentation

The severity of both HSD and hEDS present across a spectrum and can be complex or present with minimal symptoms. Symptoms typically are musculoskeletal pain, fatigue, dysautonomia, gastrointestinal, urogenital, and cognitive symptoms. Central sensitization has also been found to be a common symptom. Other common findings alongside hEDS and HSD are postural tachycardic syndrome (POTS) and Mast Cell Activation Syndrome. The link between hypermobility and these disorders are not fully understand at this time.

Assessment

Dysfunction in hEDS or HSD typically are related to pain, fatigue, or psychosocial stress. In children it is common to also have developmental coordination disorder which can persist into adulthood. A key aspect of hEDS is that it is a first-degree family diagnosis which can be picked up in the subjective. Due to systemic symptoms, therapist may need to refer out to other specialists for more well-rounded care. When performing physical aspect of assessment pay close attention to end ranges of motion due to increased risk of aggravating pain. It is also recommended to perform tests such as the LLAS or ULHAT. The author suggests tests, such as the navicular drop test, are indicated to further assess mobility of foot and ankle joints. Therapist should pay close attention to neuromuscular control, balance, and proprioception as these have all been shown to be associated with hypermobility disorders. If finding symptoms of dizziness, chest pain or syncope, therapist should take blood pressure and heart rate. Greater than a 30-beat increase in heart rate upon standing in adults is suggestive of POTS; greater than 40 beats in children. When examining children, it is important to address quality of movements as well which may not be observed when utilizing the BOT-2 or Movement ABC.

Evaluation, Diagnosis, Management

For hEDS to be diagnosed 3 criteria must be met. They must have generalized joint hypermobility, systemic manifestations of a connective tissue disorder, and the exclusion of other reasons for the current symptoms. After diagnosis is made, the therapist must address the severity of the disorder in order to establish if a multi-disciplinary approach is required. One of the most important interventions is education. Patients who understand their triggers for exacerbation can more effectively reduce symptoms when flare ups occur. It is also important to understand various strategies to protect joints as well as manage subluxations/dislocations. Other suggestions are adding compression clothing in order to enhance proprioception. Exercise is the mainstay in management as it has been shown to decrease spinal pain, joint pain, and improved neuromuscular control of movements. Often patients with hEDS respond well to strengthening programs but require gradual progressions in order not to aggravate muscle and tendon. In patients with POTS, it is also important to understand their decreased tolerance for exercise and increased fatigue following exercise. Patient’s should be educated on ways to mitigate symptoms such as fist clenching. It is recommended to begin with recumbent exercises and lower extremity tasks to promote venous return.

In Summary

As is evident by the above presented information patient with hypermobility disorders would benefit greatly from skilled intervention focusing on a variety of factors. It is important to address each of the impairments through exercise and education. It is also important to recognize when a person requires a multi-disciplinary approach for overall improvement in symptom management.

Physical Therapy First

We here at Physical Therapy First are trained to examine a variety of patients who presents with symptoms related to hypermobility. At PTF, therapists are experienced utilizing scales, such as the Beighton scale, and work with patients to create exercise routines appropriate for the individual. We understand the many factors that may present themselves in a person with hEDS and can tailor strategies to decrease pain and improve functionality. If you are someone who was diagnosed with hEDS or feel that you are hypermobile and have increased pain, please do not hesitate to reach out to the therapists at Physical Therapy First.

References

Simmonds, J. V. (2022). Masterclass: Hypermobility and hypermobility related disorders. Musculoskeletal Science and Practice, 57, 102465. https://doi.org/10.1016/j.msksp.2021.102465

Examination and Treatment of Cuboid Syndrome: A Literature Review

by ptfadmin | Feb 8, 2022 | Health Tips

Article reviewed by Evan Peterson PT, DPT

Background

Foot pain is a common injury experienced across the population in both the athletic and non-athletic population alike. There are many different causes for foot pain, but one in particular is often misdiagnosed or missed. Cuboid syndrome is one cause of lateral foot pain which is thought to arise from a change in the arthrokinematics of the calcaneocuboid joint. The author of this article states this condition may be brought on insidiously or after a traumatic event.

The Cuboid and It’s Mechanics

The cuboid is surrounded by a variety of other foot bones on the lateral side of the foot. Its borders are the navicular, the calcaneus, the 4^th and 5^th metatarsals, and the lateral cuneiform. The cuboid is part of the midtarsal portion of the foot and moves in tandem with the navicular. Though it has a variety of motions, the calcaneocuboid joint typically rotates medially or laterally (inversion or eversion). Due to the congruence of articular surfaces, the cuboid is relatively stable but it also has the support of ligaments as well as a fibroadipose labra between the calcaneocuboid joint and cuboid-metatarsal joints. Another stabilizing feature is the peroneus longus tendon wrapping underneath the cuboid. The cuboid acts as a pulley system for the peroneal tendon to allow for efficient eversion during the late stance phase of gait to propel the body forward. The mid tarsal joint plays a large role in allowing the foot to be both a mobile adaptor and a rigid lever for push off. When the foot transitions its weight from lateral to medial, it creates the windlass effect giving the foot enough energy to push off effectively.

What Causes Cuboid Syndrome?

Although a distinct reason for the cause of cuboid syndrome is uncertain at this time, several pathologies have been suggested as culprits. Causes proposed are excessive pronation, overuse, and inversion ankle sprains. The actual mechanical movement of the cuboid is isolated eversion while the calcaneus is in an inverted state. The unwanted cuboid eversion may be caused by improper peroneus longus muscle firing causing an eversion moment on the cuboid. In turn, causing incongruence between the calcaneus and the cuboid resulting in pain.

There are a multitude of factors that could predispose someone to cuboid syndrome such as ill-fitting shoes, midtarsal instability, and being overweight. A study showed 80% of patients with excess pronation had cuboid syndrome due to the increased moment arm of the peroneus longus. Because the calcaneocuboid joint has a labrum, it may become impinged and restrict motion.

The prevalence of cuboid syndrome is not fully understood but it appears to be most common in ballet dancers with foot/ankle injuries or those with plantarflexion/inversion sprains.

What to Look For

Pain is often broadly felt along the lateral aspect of the foot. There may also be bruising, redness, and in some cases a prominence may be felt along the plantar surface of the foot. Patient may be tender to palpate along the peroneals, the cuboid groove, or the extensor digitorum brevis muscle. The patient may also have pain with resisted eversion as well as painful or decreased push off during gait. Although there is no gold standard for cuboid syndrome testing, the author suggests two procedures to rule in the possibility of cuboid syndrome. Either the midtarsal adduction test or the midtarsal supination test. The adduction test stabilizes the calcaneus while the mid tarsal joint is distracted medially and compressed laterally. The supination test adds compression into inversion and plantarflexion. Pain may also be elicited with dorsal or plantar cuboid movement with surrounding joints stable. The therapist must rule out fracture or dislocation of the cuboid, calcaneus, 4^th and 5^th metatarsals, plantar fasciitis, sinus tarsi syndrome, and several others.

Treatment of Cuboid Syndrome

It is recommended to perform manipulations upon initial presentation of cuboid syndrome. The two techniques most commonly used are the cuboid whip and the cuboid squeeze. The cuboid whip is performed with the patient in prone and the patient’s foot resting in neutral. The therapist then will “whip” the foot into plantarflexion and inversion while thrusting thumbs into cuboid. The cuboid squeeze is performed when the therapist stretches foot into maximal plantarflexion and maximal toe flexion. The therapist will then push the cuboid dorsal. Manipulation should only be performed when bruising subsides or the patient has no other contraindications for manipulation. Following manipulation, if successful, the therapist can implement taping techniques, lateral wedge, and foot intrinsic strengthening.

Physical Therapy First

If you are someone who recently had an ankle sprain or have been experiencing lateral foot pain, reach out to Physical Therapy First where you will be examined by a physical therapist trained in the techniques to pick up on and address cuboid syndrome.

Reference:

Durall, C. J. (2011). Examination and treatment of Cuboid syndrome. Sports Health: A Multidisciplinary Approach, 3(6), 514–519. https://doi.org/10.1177/1941738111405965

When Treating Coexisting Low Back Pain and Hip Impairments, Focus on the Back: Adding Specific Hip Treatment Does Not Yield Additional Benefits

by ptfadmin | Jan 18, 2022 | Health Tips

ARTICLE REVIEW by Tyler Tice PT, DPT, ATC

It is common for individuals with low back pain to also have associated hip pain and is often times challenging to determine the primary source of the pain. This article, which was recently published in the Journal of Orthopaedic and Sports Physical Therapy in December 2021, suggests the focus of rehab for concomitant hip and low back pain should be to the low back. Below is a review of the article.

Introduction: The cause of low back pain is not always clear and for individuals with hip AND low back pain makes the cause even harder to find. Clinicians will often perform interventions to both hip and back without knowing which treatment interventions are truly helping. This has potential to prolong symptoms and increase health care costs. The goal of this study was to determine the short term and long term effects of low back only treatments compared to low back and hip specific treatments.

Methods:

• Participants randomized to 1 of 2 groups: low back treatment only; low back and hip treatments
• Participants and therapists not blinded due to nature of the study
• Inclusion criteria: >/= 18 years old; low back pain 2/10 or more, self reported disability >20% on ODI, and concurrent hip impairment (groin pain, reproducible hip pain, limited hip ROM and/or strength, or positive special test for hip pathology)
• Exclusion criteria: contraindications to manual therapy, recent trauma to low back, positive neurological findings, recent spine surgery, hip replacement
• 76 total participants – 39 low back only, 37 low back and hip treatment
• 11 physical therapists provided treatments with each given a video training for this study
• Primary outcome measures: ODI (Oswestry Disability Index – a patient questionnaire that measures function), NPRS pain rating scale from 0-10.
• Secondary outcome measures: Fear Avoidance Beliefs Questionnaire, Global Rating of Change, Patient Acceptable Symptoms State
• Outcomes were assessed at baseline, 2 weeks, discharge, 6 months, and 12 months (please refer to article for more information on each measure)
• Treatments: all in person sessions, frequency/duration varied with recommendation of 2-3x/week for 45-60 minute sessions
• Low back only group received treatment based on therapist discretion
• Low back and hip treatment group received additional hip treatments including 2 manual therapy interventions and 2 exercise interventions based on a predetermined set of treatments

Results:

• 8 participants lost at discharge; additional 15 participants lost at 6 months; additional 5 lost at 12 months (Coronavirus played a role on this)
• Baseline characteristics and number of visits between the two groups were similar
• Disability and Pain: no significant difference on ODI and pain scores between groups at ANY time point. Both groups pain and disability improved at time of discharge and maintained at 6 and 12 month follow up
• Fear Avoidance Beliefs Questionnaire: For WORK subscale: better scores for low back group at discharge and long term follow up; For PHYSICAL ACTIVITY: no significant difference between groups
• Global Rating of Change: Slightly better for low back only group at 2 weeks and discharge; similar between groups at 6 months and 12 months; both groups improved
• Patient Acceptable Symptom Scale: no statistically significant differences between groups at ANY time; majority of patients reported an acceptable symptom state at discharge and 6 months, which reduced in both groups at 12 months

Discussion:

Based on these results, adding hip interventions for people with low back and hip pain did not improve functional disability or pain outcomes. There were some significant differences in the secondary outcome measures that favored low back only treatments. These findings suggest that adding hip treatments may not be necessary and to focus the interventions to the low back.

Limitations for this study include small sample size, missing data at long term follow ups, wide confidence intervals, and therapists and participants were not blinded. Therapists were also allowed to choose treatments per their discretion which is reflective of real world clinical practice, however can cause certain biases and non-compliance in eh research setting.

Conclusion:

“Adding treatment directed at the hips to usual low back pain care for individuals with low back pain and concurrent hip impairment did not improve disability and pain in the short or long term”

This is a well designed randomization control trial with its obvious limitations, however these limitations were hard to control for given the timing and nature of study. Based on these results, it is not necessarily a BAD thing or WRONG to perform hip interventions for these individuals with both low back and hip pain. If one of my patients have a clinical finding of a hip impairment, I think I will still address it using specific hip interventions. With saying that, we can not exclude interventions for the low back and by focusing on the low back in a rehab program may help the patient progress along more quickly. I also think this can have clinical significance when giving patients home exercise programs (HEP). Using these findings, it will be better to provide patients with 1-2 low back exercises to manage their back and hip pain instead of additional hip exercises. Patients typically have poor adherence to a HEP so it is better to consolidate their HEP to the most effective interventions using the best evidence.

If you’re one of these individuals having both low back pain with a hip impairment, give Physical Therapy First a call and we can help you out!

Reference:

Burns SA, Cleland JA, Rivett DA, et al. When treating coexisting low back pain and hip impairments, focus on the back: Adding specific hip treatment does not yield additional benefits—a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(12):581-601. doi:10.2519/jospt.2021.10593