[ research report ]

HEIDI SCHMIDT, PT, MHS1 • TRINE LYKKE PEDERSEN, MSS1 • TINA JUNGE, PT, PhD1,2
RAOUL ENGELBERT, PT, PhD3,4 • BIRGIT JUUL-KRISTENSEN, PT, PhD1,5

Hypermobility in Adolescent Athletes:

Pain, Functional Ability, Quality of Life,
and Musculoskeletal Injuries

G
eneralized joint hypermobility (GJH) has been suggested type of GJH is called hypermo-
Downloaded from www.jospt.org at on July 8, 2022. For personal use only. No other uses without permission.

to play a role in the incidence of musculoskeletal bility syndrome (HMS), and for
injuries in many sports activities.33 Individuals with GJH adults, HMS is diagnosed with
the Brighton criteria, which are
have excessive range of motion of joints.17 Generalized
based on a score of 4 or more on
joint hypermobility is typically classified using the Beighton the Beighton score and the pres-
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

9-point scoring system,35 with a score of 4 or greater as the criterion ence of joint pain in more than 4 joints for
for classification of GJH in adults.36 The most frequent symptomatic a period longer than 3 months.15 For chil-
dren, there is no consensus on a specific
UUSTUDY DESIGN: Cross-sectional. respectively, with a higher prevalence of GJH4 in cut point for GJH, and the criteria for
HMS have not yet been defined; there-
UUBACKGROUND: Generalized joint hypermobility
ballet dancers (68.2%) and TeamGym gymnasts
(GJH) may increase pain and likelihood of injuries
(24.6%) than in team handball players (13.2%). fore, cut points of 5/9, 6/9, and 7/9 on
There was no significant difference in lower the Beighton score have been suggested.18
and also decrease function and health-related qual-
extremity function, injury prevalence and related Previous studies have found the prev-
ity of life (HRQoL) in elite-level adolescent athletes.
factors (exacerbation, recurrence, and absence
UUOBJECTIVE: To assess the prevalence of GJH alence of GJH to range from 2% to 57%,
Journal of Orthopaedic & Sports Physical Therapy®

from training), HRQoL, or lengths of hop tests for

in elite-level adolescent athletes, and to study the those with and without GJH. However, the GJH depending on age, sex, ethnicity, and the
association of GJH with pain, function, HRQoL, and group had significantly larger center-of-pressure tests and criteria applied.36 Within the
musculoskeletal injuries. path length across sway tests. general population of schoolchildren
UUMETHODS: A total of 132 elite-level adolescent UUCONCLUSION: For ballet dancers and TeamGym aged 14 years, GJH (cut point, 4/9) prev-
athletes (36 adolescent boys, 96 adolescent girls; gymnasts, the prevalence of GJH4 was higher than alence of 11% to 28% has been reported.4
mean ± SD age, 14.0 ± 0.9 years), including ballet that of team handball players. For ballet dancers, Some studies have reported a high preva-
dancers (n = 22), TeamGym gymnasts (n = 57), the prevalence of GJH5 and GJH6 was higher than
lence of GJH for certain disciplines, such
and team handball players (n = 53), participated that of team handball players and the general
in the study. Generalized joint hypermobility was adolescent population. The GJH group demon-
as dancing and ballet,7,30 possibly due
classified by Beighton score as GJH4 (4/9 or strated larger sway in the balance tests, which, in to the great requirements of flexibility
greater), GJH5 (5/9 or greater), and GJH6 (6/9 or the current cross-sectional study, did not have an in these activities.30 However, no study
greater). Function of the lower extremity, muscu- association with injuries or HRQoL. However, the risk has reported the prevalence of GJH in
loskeletal injuries, and HRQoL were assessed with of having (ankle) injuries due to larger sway for the elite-level adolescent athletes for sports
self-reported questionnaires, and part of physical GJH group must be studied in future longitudinal
such as team handball, TeamGym gym-
performance was assessed by 4 postural-sway studies. J Orthop Sports Phys Ther 2017;47(10):792-
tests and 2 single-legged hop-for-distance tests. 800. doi:10.2519/jospt.2017.7682 nastics, as well as ballet.
UURESULTS: Overall prevalence rates for GJH4, UUKEY WORDS: ballet, Beighton, generalized joint
The consequences of GJH are suggest-
GJH5, and GJH6 were 27.3%, 15.9%, and 6.8%, hypermobility, gymnastic, handball, proprioception ed to include joint pain and musculoskel-
etal injuries, which can result in decreased

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. 2Health Sciences Research Center, University College Lillebaelt,
1

Odense, Denmark. 3ACHIEVE Center for Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands. 4Department of
Rehabilitation, Academic Medical Center, Amsterdam, the Netherlands. 5Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social
Sciences, Bergen University College, Bergen, Norway. The Scientific Ethics Committee of the region of Southern Denmark concluded that this project wasn’t under the obligation
of notification to the Scientific Ethics Committee (number S-20162000-35). The authors certify that they have no affiliations with or financial involvement in any organization
or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Heidi Schmidt, University of Southern Denmark,
Campusvej 55, Department of Sports Science and Clinical Biomechanics, DK-5230 Odense M, Denmark. E-mail: [email protected] t Copyright ©2017 Journal of
Orthopaedic & Sports Physical Therapy®

792 | october 2017 | volume 47 | number 10 | journal of orthopaedic & sports physical therapy
 health-related quality of life (HRQoL)13 athlete,3 but not in studies of children with Study Population
and decreased physical activity in both nonsymptomatic GJH.22 However, motor Participants were elite-level adolescent
children and adolescents.11 Despite no performance has never been studied in athletes, aged 13 to 16 years, who par-
increased musculoskeletal pain or de- elite-level adolescent athletes with GJH. ticipated in ballet, TeamGym gymnastics
creased perceived physical activity in the The current study aimed to determine (noncontact sports), or team handball
general population of schoolchildren aged the prevalence of GJH in elite-level adoles- (contact sport). A total of 132 (36 adoles-
8 and 10 years old,24 GJH was associat- cent ballet dancers, TeamGym gymnasts, cent boys, 96 adolescent girls) adolescents
ed with pain development in adolescents and team handball players. A second aim participated, representing a random se-
aged 14 years.41 This may be due to imbal- was to investigate whether GJH is asso- lection of 22 of 28 ballet dancers (79%),
ance in growth of bone and soft tissues, ciated with self-reported pain, functional 57 of 184 TeamGym gymnasts (31%), and
as well as hormonal changes, resulting ability, HRQoL, injury frequency, postural 53 of 91 team handball players (58%).
in musculoskeletal pain as children with sway, and motor performance. The teams were chosen by the researcher
GJH enter puberty.12 Furthermore, a re- and offered participation; both the entire
cent study reported that elite-level ado- METHODS team and the individual athlete within a
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lescent and adult dancers with GJH aged team could decline to participate. It was,
17 to 27 years have more musculoskeletal Design however, not possible to perform analysis

T
complaints, more fatigue, and reduced his is a cross-sectional study of of the nonparticipants. Primarily, whole
physical fitness level compared to dancers elite-level adolescent athletes with teams participated, with only a few cases
and nondancers without GJH.39 and without GJH, which included of individual nonparticipants. Reasons
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Adult elite-level athletes perceive in- ballet dancers, TeamGym gymnasts, and for not participating were illness, declin-
juries more often than nonelite athletes, team handball players. ing to spend the time or not wanting to
and GJH is suggested to lead to an in- be absent from training, participation in
creased injury frequency.33 Reasons for Procedures other studies, or parents declining with-
an increase in injury frequency in those On the day of examination, all adoles- out reason. The included ballet dancers
with GJH may include ligamentous laxi- cents were tested for the presence of GJH represented the absolute elite of ballet
ty and reduced knee joint proprioception, by the same physical therapist (H.S.) dancers in Denmark, while TeamGym
as found previously in a study of children before completing the motor perfor- gymnasts and team handball players rep-
aged 8 to 15 years with HMS.14 Proprio- mance tests. The participants complet- resented elite-level teams from two thirds
Journal of Orthopaedic & Sports Physical Therapy®

ception is known as an important part of ed 2 electronic questionnaires (HRQoL of the country at a minimum level of sec-
the somatosensory system for controlling and injury occurrence) and performed ond division, ranging up to Liga (highest
balance, with poor balance potentially as- 4 sway tests and 2 motor performance division). When performing sport at this
sociated with poor proprioception.28 Poor tests. Three physical therapists, 3 MSc level, a high level of training exposure per
balance, measured as increased sway, has students, and 1 TeamGym coach admin- week (6.5-10.5 hours) was expected and
been identified in adults with GJH,31 and istered the 2 motor performance tests. confirmed in all 3 groups.
a recent study found increased sway to be One associate professor, 1 PhD student, Parents of the participating adolescent
a predictor of injuries in a general pop- 5 MSc students, 2 physical therapists, gave their written informed consent, and,
ulation of children aged 9 to 15 years.27 and 1 TeamGym coach administered before testing, each adolescent gave ver-
However, adult elite-level dancers have the 2 questionnaires. All examiners bal consent to participate, following the
shown superior balance ability com- and testers were instructed and trained Declaration of Helsinki. The Scientific
pared to the general population, possibly thoroughly in the standardized test pro- Ethics Committee of the region of South-
because the elite-level training leads to cedures prior to the investigation, and ern Denmark concluded that this project
a protective effect against falling, even examiners, testers, and adolescents were was not under the obligation of notifica-
in dancers with GJH.5 Whether or not blinded to their mutual test results and tion to the Scientific Ethics Committee
elite-level adolescent athletes with GJH GJH status. Groups of 4 to 8 adolescents (number S-20162000-35).
have reduced balance compared to those were tested together, with test durations
without GJH is unknown. of 45 to 90 minutes per group. The par- Clinical Examination
Additional reasons for sustaining an ticipants moved through the various test- The participants were tested to deter-
injury may be decreased muscle strength ing locations in a semi-random order to mine their Beighton score, and criteria
and consequent decreased muscular sta- maximize time efficiency for testing. The were applied to determine their status
bility, as confirmed in some studies of study took place from December 2013 on the Brighton test.25 A goniometer
8-to-10-year-old children with sympto- to March 2014 at the participant’s usual was used to measure elbow and knee hy-
matic GJH10 and in the general adolescent training facilities. perextension above 10°, for a potential

journal of orthopaedic & sports physical therapy | volume 47 | number 10 | october 2017 | 793
 [ research report ]
score of up to 4 points (1 for each joint). tionnaire with a 1-month recall. The mediolateral displacements of the COP.
Visual observation was used to evalu- questions included number and location The COP path length (COPL) was further
ate the participant’s ability to extend the of acute and overuse injuries, recurrence calculated as the total distance traveled
thumb to the volar aspect of the forearm, of an acute or overuse injury, exacerbation by the COP over 1 trial (30 seconds).
fifth finger dorsiflexion of greater than of an acute or overuse injury (yes/no), and Each trial was performed for 30 sec-
90°, and forward bending with touching the amount of absence from training and onds, with bare feet, and with the partic-
the palms of the hands to the floor. Par- competition due to injuries, rated as “not ipant looking at a fixed, eye-level target
ticipants were classified based on 3 cut absent,” “partly absent,” and “totally ab- placed approximately 2.5 m away, with
points: GJH4 for a Beighton score of 4 or sent.” The questionnaire was developed arms crossed at the chest, as described in
higher, GJH5 for a Beighton score of 5 or and modified from existing studies on in- previous studies.21 In the 2EO and 2EC
higher, and GJH6 for a Beighton score of juries among ballet, TeamGym, and team conditions, the participants stood with
6 or higher. Demographics (sex, age, body handball participants.2,29,33 The question- heels and toes together; in the 1EO and
mass, and height) were obtained. Finally, naire was pretested on a similar group of 1EC conditions, the contralateral leg’s big
the dominant leg was identified based on adolescents with respect to understanding toe was placed on the medial malleolus
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the question, “Which leg do you usually the definitions of injuries. After the pre- of the test leg. One trial of the 2EO con-
kick a ball with?” test, a few words were adjusted. The fol- dition was performed to familiarize the
lowing definitions were used: acute pain/ participant with the testing, while the
Questionnaires injury, “a pain/injury occurring suddenly remaining 3 balance conditions were
The Rheumatoid and Arthritis Outcome in the context of a known action/exercise”; measured for 3 successful trials, allowing
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Score for Children (RAOS-Child) Version overuse injury, “a pain in the muscles, ten- for a maximum of 3 failures (eg, exces-
LK1.0 was used for measuring perceived dons, or joints that develops over a period sive movements of the arms or legs from
leg function and HRQoL.34 The RAOS- without any known reason”; recurrence of the original posture, touch-down by the
Child was developed for children and is injury/pain, “pain/damage of the same foot on the floor or the measurement
presented in the same format as the Knee type and location as experienced previous- equipment, opening of the eyes during
injury and Osteoarthritis Outcome Score ly”; exacerbation of injury/pain, “a known 2EC or 1EC tests, or placing more than
for Children (KOOS-Child). The KOOS- injury/pain that is being exacerbated by the big toe on the test leg). If the par-
Child has been validated in children, known or unknown cause.” ticipant failed to complete the test more
but only covers questions regarding the than 3 times, the test was canceled and
Journal of Orthopaedic & Sports Physical Therapy®

knee.32 The RAOS-Child, modified from Static Motor Performance the examiner proceeded to the next test.
the KOOS-Child, covers questions re- The 4 postural-sway tests performed Between each trial, the participant rested
garding the hip, knee, and ankle. Simi- were the 2-legged stance with eyes open for approximately 30 seconds.
lar modifications have been performed (2EO), 2-legged stance with eyes closed
to the KOOS questionnaire for adults37 (2EC), 1-legged stance on the nondomi- Dynamic Motor Performance
to create the RAOS, a valid, reliable, nant leg with eyes open (1EO), and To assess dynamic motor performance,
and responsive outcome measurement.1 1-legged stance on the nondominant leg participants performed 2 hop tests: 1-leg
These properties have not been tested for with eyes closed (1EC). single hop for distance (OLHD) and 1-leg
the RAOS-Child, but it is assumed that Postural sway was assessed with a triple crossover hop for distance (COH).
the questionnaire has similar proper- portable Wii Board (Nintendo, Kyoto, Ja- Each test was performed 3 times in the
ties to those of the adult version. As in pan; area, 45.5 × 26.5 cm), at a sampling above order. Both tests have shown satis-
the RAOS, the RAOS-Child consists of frequency of 20 Hz. This device has been factory reliability.38
5 domains: pain, other symptoms, func- shown to have satisfactory reliability and For the OLHD, the participant stood
tion in daily living, function in sport and validity in children and adolescents.26 barefoot on the test leg, with his or her
recreation, and leg-specific quality of life The Wii Board measures center of pres- toe behind the start line. The participants
(www.koos.nu), with questions on com- sure (COP), a measure of ground reaction were instructed to hop forward as far as
plaints during the most recent week and force vector produced by movements of possible, allowing the use of their arms,
answers scored from 0 to 4. In total, 48 body segments. Postural sway is deter- land on the same leg, and keep their bal-
questions are answered, with the total mined by the excursion of the COP over a ance for at least 2 seconds after landing.
scores for each dimension ranging from fixed period of time.6 The Wii Board was The length of the OLHD was measured in
0 to 100 (0, extreme symptoms; 100, no connected to a laptop computer, with a centimeters from the big toe before take-
symptoms). custom-built program called Sway With off to the heel after landing.
In addition to the RAOS-Child, the Wii calculating the 95% confidence el- For the COH, the participant stood
participants completed an injury ques- lipse area and the anteroposterior and barefoot on the test leg along a 7-m line

794 | october 2017 | volume 47 | number 10 | journal of orthopaedic & sports physical therapy
 on the floor, with the toe behind the start dependent factors; GJH status (GJH4, participants with and without GJH were
line. When hopping on the right leg, the GJH5, GJH6, one at a time), type of comparable for all demographic vari-
initial start location was on the right side sport, and sex as fixed factors; and age ables, except for an increased prevalence
of the line, and vice versa for the left leg. and body mass index as covariates. The of girls in all GJH groups (TABLE 1). There
The participant was instructed to per- identification number was inserted as was a significant difference between
form 3 consecutive 1-legged maximal a random factor and the trial number sports, with a higher prevalence of GJH4
hops forward, each time crossing the as a repeated factor in the final GLM. in ballet (68.2%) and TeamGym (24.6%)
line on the floor and allowing use of the Only 1 trial was performed for the 2EO compared to team handball (13.2%). The
arms, and to keep his or her balance for condition, maximum OLHD, and max- prevalence of GJH5 and GJH6 was sig-
at least 2 seconds after landing the third imum COH; therefore, a GLM without nificantly higher for ballet than for team
hop. When completing the third consec- repeated factors was used for analyses handball (GJH5, P = .004; GJH6, P =
utive hop, the total length of the COH of these variables and the variables from .024), while sex distribution was similar.
was measured from the big toe before the questionnaires. For injury frequency There was no significant difference
take-off to the heel after landing. If the and location, logistic regression anal- in lower extremity HRQoL between
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participant did not keep his or her bal- yses (backward likelihood ratio) were those with and without GJH (TABLE 2),
ance at landing, or if there was a delay used, with sex and sport as categorical but significant effects of sports type were
between hops, the trial was disregarded. factors and age and body mass index as identified for the RAOS other symptoms
The participant was allowed to practice covariates. subscale and the RAOS leg-specific qual-
the test no more than twice with each leg, Based on the power calculations, at ity of life subscale, with lower scores for
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

and both mean and maximum distances least 26 adolescents with GJH and 79 ballet and TeamGym than for team hand-
were calculated. without GJH were required to show a ball. No significant difference between
difference of 29% in injury prevalence those with and without GJH was found in
Data Analysis between groups,2 with a power of 80% perceived injuries and related factors (ex-
Descriptive statistics were summarized and a significance level of .05. All anal- acerbation, recurrence, or absence from
using frequency tables and means. For yses were performed in SPSS Version 22 training) between groups, regardless of
demographic data, group differences by (IBM Corporation, Armonk, NY), and P the cut point (TABLE 3).
level of GJH status were tested using uni- values less than .05 (2 tailed) were con- In all balance tests, athletes with GJH
variate generalized linear model (GLM) sidered statistically significant. had significantly larger COPL than those
Journal of Orthopaedic & Sports Physical Therapy®

regression (continuous) and logistic re- without GJH (TABLE 4). For the 1EC test,
gression (nominal), with sport type as RESULTS fewer participants with GJH completed
the fixed factor. at least 1 of the trials (GJH4: 72% versus

P
The final GLM, a mixed model, in- revalence of GJH in elite-level 83%, P = .006; GJH5: 57% versus 84%,
cluded self-report variables (question- adolescent athletes was 27.3%, P<.001). Significant effects were seen for
naires) and measured variables (static 15.9%, and 6.8% for GJH4, GJH5, sex and sport for 1EO (TeamGym gym-
sway and hop lengths, one at a time) as and GJH6, respectively (TABLE 1). The nasts and boys having the greatest static

TABLE 1 Demographics of Elite-Level Adolescent Athletes Based on 3 GJH Cut Points*

Variables GJH4 No GJH4 P Value GJH5 No GJH5 P Value GJH6 No GJH6 P Value
GJH status, n (%) 36 (27.3) 96 (72.7) 21 (15.9) 111 (84.1) 9 (6.8) 123 (93.2)
Girls, n (%) 33 (91.7) 63 (65.6) .001†‡ 20 (95.2) 76 (68.5) .01†‡ 9 (100) 87 (70.7) .03†‡
Age, y 13.9 ± 0.9 14.1 ± 0.9 .45 13.9 ± 0.94 14.0 ± 0.9 .62 14.2 ± 1.9 13.9 ± 0.9 .39
Height, cm 166.3 ± 7.2 171.3 ± 9.3 .16‡ 166.8 ± 8.1 170.5 ± 9.1 .57‡ 165.4 ± 8.4 170.3 ± 8.9 .57‡
Weight, kg 51.1 ± 8.5 59.4 ± 11.0 .06‡ 51.8 ± 9.9 58.2 ± 10.9 .34‡ 49.3 ± 8.0 57.7 ± 11.0 .31‡
Body mass index, kg/m2 18.4 ± 1.9 20.1 ± 2.3 .11‡ 18.5 ± 2.2 19.9 ± 2.2 .31‡ 17.9 ± 1.8 19.8 ± 2.3 .26‡
Training, h/wk 11.6 ± 4.8 8.7 ± 3.4 .58‡ 10.9 ± 5.3 9.2 ± 3.7 .84‡ 10.5 ± 6.3 9.5 ± 3.9 .79‡
Abbreviations: GJH, generalized joint hypermobility; GJH4, generalized joint hypermobility with a Beighton score of 4 or higher; GJH5, generalized joint
hypermobility with a Beighton score of 5 or higher; GJH6, generalized joint hypermobility with a Beighton score of 6 or higher.
*Values are mean ± SD unless otherwise indicated.
†
Significant difference (P<.05) between those with and without GJH.
‡
Significant effect for sports type (P<.05).

journal of orthopaedic & sports physical therapy | volume 47 | number 10 | october 2017 | 795
 [ research report ]

TABLE 2 Perceived Lower Extremity Function Based on the RAOS*

GJH4 No GJH4 GJH5 No GJH5 GJH6 No GJH6

RAOS Domain† (n = 36) (n = 95) P Value (n = 21) (n = 110) P Value (n = 9) (n = 122) P Value
Other symptoms 86.9 ± 8.8 90.1 ± 8.6 .66 85.2 ± 9.3 89.1 ± 12.0 .15 84.9 ± 10.1 88.77 ± 11.8 .49
Pain 89.1 ± 8.9 90.1 ± 9.5 .95 87.5 ± 10.9 89.4 ± 12.4 .37 86.1 ± 15.3 89.33 ± 11.9 .43
Function in daily living 97.4 ± 3.6 96.4 ± 6.9 .71 96.8 ± 4.3 95.8 ± 11.3 .82 97.9 ± 3.8 95.81 ± 10.8 .64
Function in sport and recreation 88.6 ± 11.3 87.2 ± 13.9 .36 87.4 ± 12.4 86.8 ± 15.7 .84 88.1 ± 14.8 86.79 ± 15.3 .60
Leg-specific quality of life 77.2 ± 13.9 81.0 ± 14.5 .92 74.9 ± 15.9 80.2 ± 15.9 .40 78.3 ± 15.7 79.45 ± 16.0 .63
Abbreviations: GJH, generalized joint hypermobility; GJH4, generalized joint hypermobility with a Beighton score of 4 or higher; GJH5, generalized joint hyper­
mobility with a Beighton score of 5 or higher; GJH6, generalized joint hypermobility with a Beighton score of 6 or higher; RAOS, Rheumatoid and Arthritis
Outcome Score.
*Values are mean ± SD unless otherwise indicated.
†
Score ranges from 0 to 100, where 0 is worst function and 100 is best function.
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Acute and Overuse Injuries for Elite-Level Adolescent Athletes,

TABLE 3
Based on 3 GJH Cut Points*
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

GJH4 No GJH4 GJH5 No GJH5 GJH6 No GJH6

(n = 35) (n = 92) P Value (n = 20) (n = 107) P Value (n = 8) (n = 119) P Value
Pain in last year 5 (14.3) 11 (12) .99 2 (10) 14 (13.1) .45 0 (0) 16 (13.4) .11
Acute/overuse injury 20 (57.1) 56 (60.9) .15 11 (55) 65 (60.7) .23 4 (50) 72 (60.5) .27
Any injury 22 (62.9) 59 (64.1) .27 12 (60) 69 (64.5) .28 4 (50) 77 (64.7) .18
Acute injuries 6 (17.1) 18 (19.6) .65 4 (20) 20 (18.7) .98 2 (25) 22 (18.5) .56
Exacerbation (yes) 2 (5.7) 3 (3.3) .99 2 (10) 3 (2.8) .35 1 (12.5) 4 (3.4) .63
Recurrence (yes) 2 (5.7) 9 (9.8) .22 2 (10) 9 (8.4) .96 1 (12.5) 10 (8.4) .66
Journal of Orthopaedic & Sports Physical Therapy®

Absence (yes) 4 (11.4) 13 (14.1) .23 2 (10) 15 (14) .55 1 (12.5) 16 (13.4) .64
Lower extremity (yes) 3 (8.6) 7 (7.6) .83 3 (15) 7 (6.5) .24 2 (25) 8 (6.7) .12
Upper extremity (yes) 2 (5.7) 7 (7.6) .99 2 (10) 7 (6.5) .33 1 (12.5) 8 (6.7) .19
Back (yes) 2 (5.7) 0 (0) .02 1 (5) 1 (0.9) .64 0 (0) 2 (1.7) .34
Neck (yes) 1 (2.9) 1 (1.1) .41 0 (0) 2 (1.9) .40 0 (0) 2 (1.7) .75
Overuse injuries 17 (48.6) 45 (48.9) .19 10 (50) 52 (48.6) .44 4 (50) 58 (48.7) .44
Exacerbation (yes) 3 (8.6) 11 (12) .49 3 (15) 11 (10.3) .59 1 (12.5) 13 (10.9) .76
Recurrence (yes) 10 (28.6) 25 (27.2) .54 7 (35) 28 (26.2) .53 3 (37.5) 32 (26.9) .70
Absence (yes) 3 (8.6) 19 (20.7) .58 1 (5) 21 (19.6) .35 1 (12.5) 21 (17.6) .98
Lower extremity (yes) 17 (48.6) 30 (32.6) .81 10 (50) 37 (34.6) .97 4 (50) 43 (36.1) .84
Upper extremity (yes) 3 (8.6) 9 (9.8) .36 2 (10) 10 (9.3) .56 1 (12.5) 11 (9.2) .68
Back (yes) 1 (2.9) 7 (7.6) .49 1 (5) 7 (6.5) .99 0 (0) 8 (6.7) .39
Neck (yes) 1 (2.9) 0 (0) 1.00 0 (0) 1 (0.9) .02 0 (0) 1 (0.8) .34
Abbreviations: GJH, generalized joint hypermobility; GJH4, generalized joint hypermobility with a Beighton score of 4 or higher; GJH5, generalized joint
hypermobility with a Beighton score of 5 or higher; GJH6, generalized joint hypermobility with a Beighton score of 6 or higher.
*Values are n (%) unless otherwise indicated.

sway) and 1EC (team handball players DISCUSSION GJH6 was higher than for team handball
and boys having the greatest static sway) players and the general adolescent popu-

F
conditions. or ballet dancers and TeamGym lation. The injury frequency, HRQoL,
Overall, there was no significant dif- gymnasts, the current prevalence and functional muscle performance were
ference between those with and without of GJH4 was higher than for team similar between those with and without
GJH for the 2 hop tests (OLHD and handball players. Furthermore, for bal- GJH, but those with GJH demonstrated
COH) (TABLE 4). let dancers, the prevalence of GJH5 and larger sway in the balance tests.

796 | october 2017 | volume 47 | number 10 | journal of orthopaedic & sports physical therapy
 Postural Sway and Hop Length for Elite-Level Adolescent Athletes,
TABLE 4
Based on 3 GJH Cut Points*

GJH4 No GJH4 GJH5 No GJH5 GJH6 No GJH6

(n = 36) (n = 95) P Value (n = 21) (n = 110) P Value (n = 9) (n = 122) P Value
Sway, mm
2EO
COPL 66.6 ± 10.6 57.2 ± 11.6 .001 68.8 ± 11.7 58.1 ± 11.4 .001 70.5 ± 12.9 59.0 ± 11.6 .005
AP displacement 3.2 ± 1.0 2.6 ± 0.7 .03 3.2 ± 1.2 2.7 ± 0.8 .13 3.7 ± 1.4 2.7 ± 0.8 .03
ML displacement 2.9 ± 0.7 2.7 ± 0.7 .06 3.0 ± 0.7 2.7 ± 0.7 .043 3.1 ± 0.5 2.7 ± 0.7 .34
2EC
COPL 98.1 ± 19.1 83.0 ± 18.9 <.001 104.3 ± 17.4 83.9 ± 18.8 <.001 103.8 ± 17.9 85.9 ± 19.7 <.001
AP displacement 4.0 ± 0.7 3.5 ± 0.9 <.001 4.0 ± 0.6 3.6 ± 1.0 .001 4.1 ± 0.7 3.6 ± 1.0 .05
ML displacement 3.9 ± 0.8 3.6 ± 0.8 .001 4.0 ± 0.7 3.67 ± 0.8 .01 4.0 ± 0.7 3.7 ± 0.8 .30
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1EO
COPL 154.7 ± 25.6 142.1 ± 29.8 <.001 155.4 ± 27.8 143.7 ± 29.1 <.001 147.97 ± 16.1 145.4 ± 30 .22
AP displacement 4.79 ± 1.0 4.8 ± 1.1 .17 4.8 ± 0.7 4.8 ± 1.1 .24 5.0 ± 0.6 4.8 ± 1.0 .13
ML displacement 3.38 ± 0.4 3.4 ± 0.5 .002 3.3 ± 0.3 3.4 ± 0.5 .24 3.2 ± 0.2 3.4 ± 0.5 .80
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

1EC
COPL 288.3 ± 49.9 266.8 ± 60.7 <.001 281.9 ± 34.1 270.9 ± 61.3 .04 294.5 ± 29 270.8 ± 59.9 .02
AP displacement 7.9 ± 1.5 7.7 ± 2.0 .20 8.2 ± 1.4 7.7 ± 2.0 .047 8.3 ± 1.0 7.7 ± 2.0 .09
ML displacement 5.1 ± 0.6 5.1 ± 0.9 .02 5.2 ± 0.4 5.1 ± 0.9 .02 5.2 ± 0.4 5.1 ± 0.8 .14
Hop, cm
OLHD
R leg maximum length 126.9 ± 19 134.8 ± 24 .08 124.2 ± 18 134.2 ± 24 .07 122.1 ± 9 133.4 ± 23 .16
R leg mean length 120.3 ± 19 128.1 ± 23 .08 117.5 ± 18 127.6 ± 23 .06 115.7 ± 12 126.7 ± 23 .16
L leg maximum length 126.6 ± 21 135.7 ± 25 .05 126.0 ± 17 134.5 ± 25 .14 121.7 ± 11 134.0 ± 25 .14
Journal of Orthopaedic & Sports Physical Therapy®

L leg mean length 120.6 ± 21 130.5 ± 24 .03 119.6 ± 17 129.3 ± 25 .08 114.6 ± 11 128.7 ± 24 .09
COH
R leg maximum length 383.5 ± 52 385.6 ± 73 .87 377.0 ± 49 386.6 ± 71 .56 369.2 ± 37 386.2 ± 70 .47
R leg mean length 368.0 ± 54 368.8 ± 70 .95 357.4 ± 48 370.8 ± 68 .39 340.3 ± 31 370.7 ± 67 .18
L leg maximum length 381.4 ± 52 392.4 ± 77 .43 370.7 ± 44 392.9 ± 74 .19 363.2 ± 39 391.3 ± 73 .26
L leg mean length 379.2 ± 74 379.7 ± 76 .97 374.4 ± 85 380.6 ± 74 .73 391.4 ± 121 378.6 ± 72 .63
Abbreviations: 1EC, 1-legged with eyes closed; 1EO, 1-legged with eyes open; 2EC, 2-legged with eyes closed; 2EO, 2-legged with eyes open; AP, anteroposterior;
COH, 1-legged triple crossover hop; COPL, center-of-pressure path length; GJH, generalized joint hypermobility; GJH4, generalized joint hypermobility with a
Beighton score of 4 or higher; GJH5, generalized joint hypermobility with a Beighton score of 5 or higher; GJH6, generalized joint hypermobility with a Beigh­
ton score of 6 or higher; L, left; ML, mediolateral; OLHD, 1-legged hop for distance; R, right.
*Values are mean ± SD unless otherwise indicated.

As previously described, participants forward flexion in the Beighton score, GJH often choose to participate, and that
in specific elite sports like ballet have a which is known to correlate highly with GJH may help in becoming a successful
higher prevalence of GJH; however, there being a ballet dancer.36 Although warm- ballet dancer. TeamGym routines also
is a clear decline in prevalence from the up and training sessions differed between require flexibility, and the prevalence of
student to the professional level.30 and within sports groups at the time of GJH4 is remarkably higher in adolescent
The high prevalence of GJH4 found testing, this did not likely bias the data gymnasts than in the general adolescent
in ballet (68.2%) and TeamGym (24.6%) in relation to prevalence of GJH. Other population, but not as high as it is in ad-
athletes is consistent with previous stud- factors such as sex could not explain the olescent ballet dancers. An explanation
ies of elite-level adolescent ballet danc- different prevalence rates,36 because sex for that may be that GJH is only help-
ers30 and gymnasts, but higher than the distribution of participants was equal ful in the younger gymnasts, for whom
prevalence found in general adolescent across the 3 sports. The large prevalence the trampoline and tumbling are not
athletes.8 The high prevalence in ballet of GJH in ballet dancers suggests that so demanding. But, with increasing age
may partly be due to the inclusion of ballet may be a sport in which those with and the demands of muscular strength,

journal of orthopaedic & sports physical therapy | volume 47 | number 10 | october 2017 | 797
 [ research report ]
power, and stability, GJH may no longer case for the general child population and as the criterion, but not for GJH5 and
prove to be an advantage. for those who participated in our study. GJH6, potentially limiting the ability to
Between the groups with and without In this study, COPL was significantly identify differences between groups when
GJH, no difference was found with re- larger in those with GJH for all balance using these latter 2 criteria. Strengths of
spect to perceived leg function, including tests, consistent with recent findings the study include standardized testing
pain and HRQoL, which contrasts the in schoolchildren of the same age with procedures, blinding of testers and par-
findings of a recent study showing that GJH.23 The increased sway, especially ticipants, training of the testers, and the
GJH in the general population of school- with the eyes closed, may reflect altered use of reliable and valid objective tests.41
children aged 8 or 10 years may be a con- proprioception in those with GJH, con- Validity of the classification of GJH was
tributing and predictive factor in pain sistent with results from symptomatic optimized by using a single examiner.25
development between 13 and 15 years of individuals with GJH.14 Contrary to a The interpretation of the data is limited
age.41 In our participants, the high train- previous report that increased postural to elite-level adolescent athletes partici-
ing volume may be protective against sway is strongly associated with increased pating in sports such as ballet, TeamGym,
pain and injuries, consistent with a previ- risk of lower-limb injuries,27 participants and team handball.
Downloaded from www.jospt.org at on July 8, 2022. For personal use only. No other uses without permission.

ous study indicating that schoolchildren in the current study did not report higher
with GJH and high physical fitness gen- incidence of pain or injury. CONCLUSION
erally had fewer musculoskeletal com- The participants with and without

F
plaints.16 Conversely, vigorous exercise GJH performed similarly on the 2 hop or ballet dancers and TeamGym
may lead to short-term lower-limb pain tests, which is in contrast with the results gymnasts, the prevalence of GJH4
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

in schoolchildren.9 The current findings of previous studies of a mixed group of was higher than for team handball
could also reflect an altered perception adolescents with GJH who had decreased players. Furthermore, in ballet dancers,
of pain and HRQoL in elite-level adoles- jumping and walking capacity.39,40 De- the prevalence of GJH5 and GJH6 was
cent athletes, because athletes generally spite similar performance, it is possible higher than that in team handball play-
seem to have higher HRQoL than non- that muscle activation strategies differed ers and the general adolescent popula-
athletes.34 It is noted that in the present between groups,20 a line of investigation tion. The injury frequency, HRQoL, and
study, ballet and TeamGym participants deserving additional attention. functional muscle performance were not
had lower HRQoL than team handball The participation rate was different different between those with and with-
players, as also previously reported.2,30,39 among sports, with a 79% participation out GJH. Those with GJH demonstrated
Journal of Orthopaedic & Sports Physical Therapy®

The current study did not find in- rate for ballet, 31% for TeamGym, and greater sway in the balance tests, which,
creased self-reported injury frequency in 58% for team handball. A sensitivity in the current cross-sectional study, was
elite-level adolescent athletes with GJH, analysis showed no difference in factors not associated with injury prevalence and
which is consistent with the results of a such as age, sex, and body mass index be- HRQoL. However, the possible risk of in-
recent study on children.19 However, this tween those who participated and those juries due to greater sway in this group
is in contrast to the results of a previous who did not. Different sports may reflect must be studied in future longitudinal
systematic review, in which GJH was as- different training cultures. studies. t
sociated with an increased risk of knee A potential limitation may be the use
injuries in athletes from a wide age range of the current self-reported injury ques- KEY POINTS
(9-39 years old) who participated in dif- tionnaire, which has not yet been tested FINDINGS: Elite-level adolescent athletes
ferent sports, especially contact sports.33 for psychometric properties. To minimize with and without generalized joint
Our results also contrast with those of a the risk of information/interpretation hypermobility participating in ballet,
5-year follow-up study, in which more bias, the testers read the injury question- TeamGym, and team handball had no
adult dancers with GJH had multiple naire to the participant and were there- significant difference in incidence of
joint pain and had to take time off from fore available to assist in interpretation, injury, pain, self-rated function, health-
dancing (greater than 6 weeks) due to in- if necessary. The short-term recall period related quality of life, and hop tests.
jury.2 The authors of that study hypoth- of 1 month was used to optimize recall of IMPLICATIONS: The current sports partici-
esized that injuries in individuals with injuries.1 Data collection occurred out- pants with generalized joint hypermo-
GJH may take more time to heal, and side the period of events/competitions, bility did not have higher prevalence of
that there may be greater tissue damage and therefore may not fully represent adverse health outcomes in this cross-
before an injury is reported.2 Overall, it the more intense period of activities for sectional study.
appears that participation in sports at a elite-level adolescent athletes. The re- CAUTION: The study was limited to a
high level leads to an increased risk of quired sample size of 26 participants 1-month recall period for injury and
injuries for adults, which may not be the with GJH was reached when using GJH4 included individuals participating in

798 | october 2017 | volume 47 | number 10 | journal of orthopaedic & sports physical therapy
 only 3 sports and who were of a homo- 4-year follow-up study. Pediatrics. 2005;116:673- chronic neck pain: a cross-sectional study.
geneous age group, limiting the external 681. https://doi.org/10.1542/peds.2004-1758 J Rehabil Med. 2013;45:376-384. https://doi.
validity of the results. Furthermore, the 10. Engelbert RH, Bank RA, Sakkers RJ, Helders org/10.2340/16501977-1120
PJ, Beemer FA, Uiterwaal CS. Pediatric 22. Juul-Kristensen B, Hansen H, Simonsen EB, et al.
current injury questionnaire has not yet
generalized joint hypermobility with and without Knee function in 10-year-old children and adults
been tested for psychometric properties. musculoskeletal complaints: a localized or with Generalised Joint Hypermobility. Knee.
systemic disorder? Pediatrics. 2003;111:e248-e254. 2012;19:773-778. https://doi.org/10.1016/j.knee.
ACKNOWLEDGMENTS: The authors thank the https://doi.org/10.1542/peds.111.3.e248 2012.02.002
11. E ngelbert RH, van Bergen M, Henneken T, Helders 23. Juul-Kristensen B, Johansen K, Hendriksen P,
participating ballet dancers, TeamGym
PJ, Takken T. Exercise tolerance in children and Melcher P, Sandfeld J, Jensen BR. Girls with
gymnasts, and team handball players; phys­ adolescents with musculoskeletal pain in joint generalized joint hypermobility display changed
ical therapist Charlotte Anker-Petersen from hypermobility and joint hypomobility syndrome. muscle activity and postural sway during static
the Royal Danish Ballet School in Copenha­ Pediatrics. 2006;118:e690-e696. https://doi. balance tasks. Scand J Rheumatol. 2016;45:57-
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12. F alciglia F, Guzzanti V, Di Ciommo V, Poggiaroni A. 1041154
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