Annals ofthe Rheumatic Diseases 1992; 51: 793-796 793 Joint hypermobility in adults referred to Ann Rheum Dis: first published as 10.1136/ard.51.6.793 on 1 June 1992. Downloaded from rheumatology clinics Alan J Bridges, Elaine Smith, John Reid Abstract rheumatologist for musculoskeletal problems, Joint hypermobility is a rarely recognised we evaluated 130 consecutive new patients for aetiology for focal or diffuse musculoskeletal joint hypermobility and associated clinical symptoms. To assess the occurrence and features. importance of joint hypermobility in adult patients referred to a rheumatologist, we prospectively evaluated 130 consecutive Patients and methods new patients for joint hypermobility. Twenty PATIENTS women (15%) had joint hypermobility at One hundred and thirty consecutive adult three or more locations (¢5 points on a patients (age >18 years) referred to the out- 9 point scale). Most patients with joint patient rheumatology clinic at the University hypermobility had common musculoskeletal of Missouri-Columbia for musculoskeletal problems as the reason for referral. Two problems or connective tissue disease were patients referredwith adiagnosis ofrheumatoid evaluated by ES and AJB. There were 97 arthritis were correctly reassigned a diagnosis women and 33 men with an average age of 51 of hypermobility syndrome. Three patients years (range 18-83). with systemic lupus erythematosus had diffuse joint hypermobility. There was a statistically significant association between METHODS diffuse joint hypermobility and osteoarthritis. A complete history and physical examination Most patients (65%) had first degree family was performed including an examination for members with a history of joint hypermobility. joint laxity. The criteria devised by Carter and These results show that joint hypermobility is Wilkinson'5 with a modification by Beighton common, familial, found in association with et al 8 were used to assess hypermobility (table common rheumatic disorders, and statistically 1). A mobility score was calculated by allocating associated with osteoarthritis. The findings one pointfor the ability to perform the manoeuvre http://ard.bmj.com/ support the hypothesis that joint hypermobility at each joint. Two points were allocated if predisposes to musculoskeletal disorders, hypermobility was detectable at bilateral joints. especially osteoarthritis. Truncal hypermobility received a score of 1. A mobility score greater than or equal to 5 was considered consistent with joint hypermobility. A commonly unrecognised aetiology for focal The following features were also assessed: (a) or diffuse musculoskeletal problems is the easy bruising; (b) history of joint dislocations; on September 25, 2021 by guest. Protected copyright. hypermobility syndrome. ' 2 The hypermobility (c) history of recurrent joint sprains; (d) history syndrome refers to a constellation of musculo- or physical finding of joint swelling (effusion); skeletal symptoms and clinical findings of (e) loose skin or hernias; (f) temporomandibular Department of diffuse joint laxity in an otherwise normal crepitus and pain; (g) scoliosis; (h) mitral valve Medicine, subject.' 2 When not associated with musculo- prolapse by auscultation (click-murmur with Division of skeletal problems the clinical findings are best characteristic changes on Valsalva manoeuvre) Immunology and Rheumatology, termed diffuse joint hypermobility. Although or echocardiography; (i) passive hyperextension University of the clinical features may mimic inflammatory of one or more proximal interphalangeal joints Missouri School arthritis with joint swelling and pain, the course to greater than 900; (j) passive internal rotation of Medicine, Columbia, MO, USA of joint hypermobility is not progressive, of the hips greater than 450; (k) passive dorsi- A J Bridges destructive, nor disabling.27 flexion of the ankle beyond 150; (I) flat medial E Smith In population studies joint hypermobility has arch of the foot on standing. Department of been found more often in children, with The criteria used to make the diagnoses were Biostatistics, University of diminishing occurrence as age increases.89 Missouri School Joint hypermobility was commonly noted in of Medicine, paediatric patients referred to a rheumatologist Columbia, MO, USA and in normal schoolchildren.' Investigations J Reid in adults have suggested that joint hypermobility Table I Criteria used to evaluate joint hypermobility. Correspondence to: Based on Carter and Wilkinson'" modified by Beighton et Dr Alan Bridges, is associated with osteoarthritis, mitral valve al 8 MA-427 Health prolapse, and chondrocalcinosis.' '3 Only one Sciences Center, Passive dorsiflexion of fifth finger beyond 90° at One Hospital Drive, report has focused on the hypermobility syn- metacarpophalangeal joint University of Missouri drome as a diagnosis in adult patients referred 2 Passive apposition of thumb to flexor aspect of forearm Hospitals and Clinics, 3 Hyperextension of elbow beyond 10° Columbia, MO 65212, USA. to a rheumatologist.'4 To assess the occurrence, 4 Hyperextension of knee beyond 10° modes of and associations of joint 5 Forward flexion of the trunk with the knees fully extended so Accepted for publication presentation, that the palms of the hands rest flat on the floor 8 October 1991 hypermobility in adult patients referred to a 794 Bridges, Smith, Reid based on the accepted criteria of the American graphy in five patients. Easy bruising (three College of Rheumatology where applicable."6 patients), temporomandibular joint dysfunction Patients with findings including dislocation (two patients), history of joint effusions (five Ann Rheum Dis: first published as 10.1136/ard.51.6.793 on 1 June 1992. Downloaded from of the lens (or positive family history), aortic patients), and recurrent sprains (three patients), regurgitation or family history of aortic rupture, were rare. Joint dislocations, loose skin, and arachnodactyly, excessive arm span, marked hernias were not noted in any patient. skin hyperextensibility, or cigarette paper scars A primary diagnosis of hypermobility were suspected to have Marfan or Ehler-Danlos syndrome was made in two young women with syndrome and not considered to have benign joint mobility scores of 9, recurrent joint hypermobility syndrome. effusions, scoliosis, and mitral valve prolapse. The two patients were referred with a diagnosis of rheumatoid arthritis. One patient also had STATISTICS temporomandibular joint dysfunction and Categorical variables (two way tables) were chronic low back pain from sacroiliac hyper- tested using x2 analysis. Continuous variables mobility that became symptomatic during her were tested using the Wilcoxon signed rank or first pregnancy. Neither patient had eye, aortic, Mann-Whitney U tests. skin, or other skeletal abnormalities suggestive of Marfan or Ehlers-Danlos syndrome. Table 2 gives the primary diagnosis for the Results main symptom of each patient with joint hyper- Joint hypermobility was found in 20 (15%) mobility. Causes for the main symptom other patients. Table 2 summarises the findings. The than joint hypermobility were found in 18/20 average age of the patients with joint hyper- patients. Osteoarthritis and fibromyalgia were mobility was 50 years (range 23-80), whereas commonly noted in the patients with joint patients without joint hypermobility had an hypermobility. When all diagnoses were taken average age of 52 years (range 18-83); (p>0.4). into consideration, osteoarthritis was found in The patients with joint hypermobility had an 12/20 (60%) patients with joint hypermobility. average mobility score of 8 whereas patients In contrast, 33/110 (30%) patients without joint without joint hypermobility had mobility scores hypermobility had osteoarthritis (X2=6 73; of -2 (average 0-4; p<0 001). All patients with p<0-01). The age of the patients with osteo- joint hypermobility were women whereas only arthritis and joint hypermobility did not differ 75% of the total number of referred patients significantly from the age of the patients with were women. Most patients (65%) with joint osteoarthritis without joint hypermobility (60 hypermobility reported a family history of joint and 66 years respectively; p>005). Fibro- hypermobility in at least one first degree myalgia was common, but its occurrence did relative. Hypermobility of the trunk was found not differ significantly between the patients in the younger patients with joint hypermobility with (30%) and without joint hypermobility (average age 37 years) but was not found in (38%) (p>0.05). No other musculoskeletal http://ard.bmj.com/ older patients with joint hypermobility (average problem occurred more often in patients with age 62 years) (p<0 005). joint hypermobility compared with patients Table 2 shows that patients who met the without joint hypermobility. criteria for joint hypermobility had other Joint hypermobility was found in three features of joint laxity. Many patients had patients with systemic lupus erythematosus hypermobility of the fingers (50%), hips (35%), (SLE) and one patient with incomplete lupus rheumatoid and ankles (50%). Eighty five per cent of the erythematosus. A patient with on September 25, 2021 by guest. Protected copyright. patients had flat feet and 35% had scoliosis. arthritis had a joint mobility score of 5. This Mitral valve prolapse was found in nine (45%) patient had a history of hypermobility of the patients. This was documented by echocardio- hands and wrists before the onset of rheumatoid