Too Much Flexibility - Not Such a Good Thing!

Hypermobility Syndrome and Its Effects on the Joints, Ligaments and Tendons of the Foot and Ankle.

What is Hypermobility?

Hypermobility, (commonly referred to as being “double jointed”), is characterized by an increased range of motion in the joints. It can significantly impact the foot and ankle's biomechanical and structural integrity. Hypermobility is frequently associated with alterations in collagen composition, leading to increased elasticity and decreased tensile strength of ligaments and tendons. Unfortunately, this alteration predisposes joints to excessive motion, potentially leading to instability. Understanding the implications of hypermobility in the foot and ankle region is crucial for effective management and prevention of potential complications.

Hypermobility in the foot and ankle can lead to various clinical issues: The foot and ankle complex, a critical component in weight-bearing and locomotion, experiences altered biomechanical forces with hypermobility. These changes can lead to abnormal gait patterns and uneven distribution of pressure, predisposing to overuse injuries and degenerative changes.

Because hypermobility can manifest as a tendency for overextension or over-flexion in the ankle joint, it often leads to recurrent sprains and strains. Instability of the subtalar joint is a common finding which contributes to altered foot mechanics. Ultimately, this causes excessive pronation of the foot. Chronic pain, often diffuse, can be a significant issue resulting from joint instability and recurrent microtrauma.

Hypermobility increases stress on tendons and ligaments, leading to a higher risk of Plantar Fasciitis, Achilles Tendonitis and other Tendinopathies. Arthralgia (joint pain and stiffness) is commonly experienced in the foot and ankle due to repetitive stress and strain. Decreased proprioceptive sense, or body awareness sense, can contribute to a higher risk of injury due to impaired neuromuscular control.

Good Management strategies:

- Physiotherapy focusing on strengthening periarticular muscles to improve joint stability. - Proprioceptive training to enhance neuromuscular control.

- Orthotic interventions to correct abnormal foot mechanics and distribute the load evenly.

Hypermobility and its effects on bunions and Predislocation Syndrome:

In addition to the previously discussed effects of hypermobility on the foot and ankle, it is essential to address its specific implications for the development for bunions (Hallux Valgus)

and Predislocation Syndrome at the 2nd metatarsophalangeal (MTP) joint (big toe joint) and tibialis posterior tendonitis (tendonitis on the inside of the foot).

With hypermobility, the increased laxity of the ligaments around the first MTP joint can lead to an imbalance in muscular forces acting on the joint. This imbalance predisposes to the valgus deviation of the great toe and subsequent bunion formation. The hypermobility of the 1st MTP can exacerbate the valgus stress on the hallux, further contributing to the development and progression of a bunion.

Bunions manifest as progressive lateral deviation of the big toe and medical prominence at the first big toe joint often accompanied by pain and inflammation. Callus formation and pain under the 2nd metatarsal head can occur as a result of altered weight distribution.

Good Management strategies:

-Orthotic devices to stabilize the first MTP joint and correct abnormal foot mechanics

-Physiotherapy focusing on strengthening the muscles inside the foot.

Hypermobility can lead to an overload and subsequent instability of the 2nd MTP joint. This instability may progress to Predislocation Syndrome, characterized by the toe becoming crooked. The laxity of the ligaments and capsular redundancy associated with hypermobility contribute to the displacement of the plantar plate, an essential stabilizing structure of the MTP joints. Symptoms of this syndrome can be pain and swelling around the 2nd MTP joint. Also, a progressive drift of the 2nd toe often with callus formation under the 2nd metatarsal head as well as difficulty with toe-off phase during gait and potential cross over toe deformity.

Good management strategies:

- Early intervention with orthotics to redistribute pressure away from the affected joint.

- Taping or splinting the toe to help support the ligaments.

- Strengthening exercises targeting the intrinsic and extrinsic muscles of the foot.

Hypermobility and Tibialis Posterior Tendonitis:

The tibialis posterior tendon is the “main” tendon that supports the arch of the foot. When there is too much flexibility in the tendon and nearby ligaments in the middle of the foot, the arch will start to collapse and this will cause arthritis and pain.

Good Management Strategies:

-Wearing good fitting shoes with arch supports.

Hypermobility significantly influences the development and progression of bunions, Predislocation Syndrome at the 2nd MTP joint and Tibialis Posterior Tendonitis. Although understanding of these specific conditions is crucial to providing comprehensive care, Management should be tailored to individual needs, focusing on symptomatic relief and addressing the underlying biomechanical abnormalities.

In the case of hypermobility, education and prevention is of the utmost importance. Regular exercise, proper foot care, supportive footwear and activities that enhance proprioception and joint stability are excellent care and prevention methods.

In severe cases, surgical intervention is usually required. However, at our Institute, we constantly stay up to date with the latest advances in Regenerative Medicine. In many cases, regenerative medicine can be used to help with hypermobility and its complications, without surgical intervention.