10/1/13 Articular hypermobility in Icelandic 12-year-olds

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Received March 31, 1998.; Revision received January 28, 1999.

Oxford Journals Medicine Rheumatology Volume 38, Issue 10 Pp. 1014-1016.

Rheumatologyrheumatology.oxfordjournals.org

Rheumatology (1999) 38 (10): 1014-1016. doi: 10.1093/rheumatology/38.10.1014

Articular hypermobility in Icelandic 12-year-olds

A. Qvindes land and H. Jónsson

Author Affiliations

H. Jónsson, Landspítalinn University Hospital, 101 Reykjavík, Iceland.

Abstract

Objective. To examine the prevalence of articular hypermobility and its

relationship to musculoskeletal pain in Icelandic 12-yr-olds, and to obtain

baseline data for a prospective study on the subject.

Methods. A total of 267 12-yr-olds were examined for articular

hypermobility by the Beighton criteria. The children also answered a

questionnaire concerning musculoskeletal pain and injuries, sports and

musical activity.

Results. The prevalence of hypermobility (defined as ≥4 Beighton criteria)

was 40.5% in girls and 12.9% in boys. Despite slight trends for

hypermobile subjects to be less active in sports and to report more joint

pain, no correlation could be found between hypermobility and

musculoskeletal symptoms.

Conclusions. An unusually marked sex difference in hypermobility exists

among Icelandic 12-yr-olds, but hypermobility does not seem to affect

joint symptoms or leisure activities at this age.

Key words Hypermobility Children Musculoskeletal pain Sports activity.

Articular hypermobility is a graded phenomenon which runs in families

and is affected by many factors, including age and sex [1]. The clinical

implications of this condition and its relationship to musculoskeletal

symptoms are a matter of considerable controversy. Several studies have

indicated an association with musculoskeletal pain [2, 3] and sports

injuries [4, 5]. Others, however, report no such association [6, 7].

The question of whether some hypermobile subjects are at risk of

developing musculoskeletal pain problems and injuries is highly relevant

with regard to screening and installation of preventive measures. We

present here the baseline results in a prospective study analysing this

relationship.

Methods

The participants were 267 schoolchildren, 143 girls and 124 boys, who

were due for their 12-yr-old health check-up, carried out at this point in

the Icelandic school and health system. A school nurse used a standard

questionnaire to record the children's participation in the school's physical

education, sports (type and frequency) and musical activity, along with

musculoskeletal pain, luxations and sprains.

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The medical examination was performed by a single observer (AQ) and

consisted of assessment of hypermobility according to the Beighton

criteria [8]. In addition, the presence or absence of the palmaris longus

muscle was examined clinically and the grip width (defined as the

maximum distance between the tips of the thumb and fifth finger on a

ruler) measured.

Statistics

The χ2 test was used for comparison between groups, and the Spearman

rank correlation test (Rs) for correlation.

The study has been approved by the Icelandic Data Protection

Commission.

Results

The prevalence of articular hypermobility (≥4 Beighton criteria) was 40.5%

among the girls and 12.9% among the boys. Corresponding figures for ≥6

criteria were 14 and 4.8%. The overall prevalence of each criterion varied

from 20 to 39% and all were more common in girls, with the exception of

90° extension in the fifth metacarpal joint, which was similar in the sexes

(Fig. 1⇔). Hypermobility was slightly more common on the left side

(331/1068 vs 279/1068 on the right; P=0.02), but this was mainly due to

the difference between the left and right fifth metacarpal extension

criteria (97/267 vs 61/267; P<0.001).

F IG. 1. 

Prevalence of each Beighton

criterion for both sexes.

There was a slight non-significant trend for hypermobile subjects to be

less active in sports (64% vs 69%; Table 1⇔) and to report more

musculoskeletal pain (55% vs 51%). A similar trend was seen for reported

pain frequency (Rs pain frequency vs Beighton score 0.11; P=0.06). The

`palms on the floor' criterion was more common in those reporting sports

activity (48/180 vs 8/87; P<0.01), but otherwise we did not find any

associations between particular joints and the clinical data. Thus,

hypermobility of hand or knee joints was not associated with pain in these

areas. No difference was found with regard to the school's physical

education programme, musical activity, type of sports, luxations or ankle

sprains.

TABLE 1. 

Sports, musical activity and

musculoskeletal symptoms

in relation to articular

hypermobility (percentages in parentheses)

Grip width correlated positively with the Beighton score (Rs 0.23,

P<0.001), but no association was found between hypermobility and either

unilateral (12.3%) or bilateral (11.6%) absence of the palmaris longus

muscle.

Discussion

10/1/13 Articular hypermobility in Icelandic 12-year-olds

rheumatology.oxfordjournals.org/content/38/10/1014.long 3/5

In this study of 267 Icelandic 12-yr-old schoolchildren, the prevalence of

articular hypermobility (≥4 Beighton criteria) was 40.5% among the girls

and 12.9% among the boys. Despite a slight tendency towards less sports

activity and more reported pain in hypermobile subjects, no evidence was

found to suggest that hypermobility affects joint symptoms or leisure

activities at this age.

There is an unusually marked sex difference in articular hypermobility in

Icelandic children, with the girls registering the highest prevalence in

Caucasian populations [6, 7, 9, 10]. This is particularly noteworthy

compared to the less pronounced sex difference found in Finnish

schoolchildren by Mikkelsson et al. [6], using similar methods. The

children in the present study were slightly older (average age 12.4 yr

compared with their two groups of 9.8 and 11.8 yr), and it is conceivable

that growth and hormonal effects at this age may have some bearing on

the sex-related differences, but otherwise the differences between the

populations remain unexplained. On the other hand, the two studies are

in total agreement with regard to the lack of association with

musculoskeletal symptoms, both regional and general, in this age group.

The studies of Larsson and co-workers [11, 12] indicate that

hypermobility of peripheral joints and spine could be favourable in

occupations requiring frequent movement of affected joints, but

unfavourable in less frequently used joint regions where stability may be

more important. However, the complex relationship between

hypermobility and the development of diverse musculoskeletal pain

problems and fibromyalgia [2, 3], sports injuries [4, 5] and the later

development of osteoarthritis [13] is insufficiently understood on the

basis of current data, which are mainly cross-sectional. Therefore, it

seems extremely relevant to follow this group prospectively. We have

recently described a subset of hand osteoarthritis with mainly thumb base

affection which is related to articular hypermobility in Icelandic females

[14]. This has not been described in other populations, although we have

found a similar trend in Swedish patients operated on for thumb base

osteoarthritis [15]. There is also evidence to suggest that musculoskeletal

pain and fibromyalgia have a high prevalence in Iceland [16].

Current evidence suggests that the `palms on the floor' criterion is

trainable [5]. It is possible, however, that inactivity may contribute to

increased laxity at the other sites, as suggested by increased left side

prevalence, a finding previously reported by Beighton and others [8, 17,

18]. This would be in concordance with studies reporting that post-

traumatic joint instability can be improved by training [19].

The palmaris longus muscle was tested as a possible marker of evolution;

the hypothesis being that humans are developing increased mobility at

the cost of stability. No such association was found, proving that Mother

Nature is still wonderfully unpredictable. The grip width measurement is

widely used in evaluation of hand surgery. The association found here is a

confirmation of recent findings by members of our group [15].

The association between articular hypermobility and subsequent

development of musculoskeletal problems appears to be of considerable

importance with regard to preventive measures. Should adolescents be

guided in their choice of sports or other activities? If we can identify those

who are particularly at risk, then screening procedures would be

indicated. These questions can only be answered through prospective

follow-up and the current study gives us a platform of baseline data for

these purposes.

Acknowledgments

We would like to thank our colleagues Atli Árnason, Halldór Jónsson and

10/1/13 Articular hypermobility in Icelandic 12-year-olds

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Jens Magnússon, along with their staff, for every assistance they have

given us in the course of this study.

© 1999 British Society for Rheumatology

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