The Double Jointed Page

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The Double Jointed Page


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The greatest single cause of disability, is joint stiffness

Amongst people who are not double jointed, only one in fifty will escape some form of rheumatic or arthritic complaint in their lifetime.

Being double jointed can be fun, it is not a disability and it does not inevitably lead to arthritis

Double jointed children are in danger from well meaning parents, teachers, and others who by discouraging the child from exercising its joints through their full natural range, cause the development of inadequate cartilage protection, and inevitable joint problems in later life. Some use the term hypermobility as a descriptive diagnosis. For years doctors have measured certain aspects of passive flexibility to indicate hypermobility , this is based on a concept of the average range of movement and, by examination, they can identify those who are more than usually supple, by convention most doctors use the diagnosis ‘hypermobility’ for those who fall within the most supple 5% of the population, that is a lot of people. But it is a useful diagnosis because it identifies the need for a particular exercise regime, which will be largely unknown by many physiotherapists and most exercise specialists.

Medical terminology is used by convention and is evolving. There is not universal agreement about hypermobility. Hypermobility is not a syndrome. Hypermobility is not considered normal, but neither is being tall and thin. Being tall and thin is not a symptom except when it is caused by a disorder.

Hypermobility is more complicated and it might not be a direct symptom of any syndrome. There are several disorders which cause joint instability, and it is easy to mistake joint instability for hypermobility (this depends on semantics and it may be that one should say that hypermobility is often observed when joint instability is present). Most hypermobile people do not have congenital joint instability nor is their hypermobility caused by any disorder. To consider hypermobility a defect is offensive.

Those whose ligaments allow extreme flexibility without joint instability have better crimp of the collagen allowing greater stretch in the crimp phase, but the ligament still locks in the linear phase as it should.
Those who have, or develop, unstable joints have ‘faulty’ weak collagen which over-stretches in the linear phase instead of firmly locking the joint, the ligament will be progressively damaged, destabilising the joint.



Some, of limited vocabulary, may say there is no such thing as double jointed.
The SOED (Shorter Oxford English Dictionary) gives 17 meanings of the verb "double", meaning 5 is:
5.a. v.t. Fold (a cloth, paper, etc.) so as to bring the two parts into contact, parallel; bend (the body) , esp. into a stooping or curled- up posture (also foll. by up); clench or close (the hand).
b. v.i. Become folded together or bent over; (of a person or limbs) bend double, stoop, curl up, (also foll. by up).
and gives examples:
5a. dryden The page is doubled down.
yeats He is all doubled up with age.
r. carver She doubled her legs under her.
j. g. cozzens A slow involuntary spasm doubled her.
b. oed The leaf has been folded, and tends to double over.

As an adjective:
adj. 1.b. Folded, doubled; bent, stooping forward, doubled up.
example: w. owen: Bent double, like old beggars under sacks.

One of the famous Cirque de Soleil contortionists, when challenged for a description, said; 'We are four little girls who fold'.

The SOED defines: double-jointed: a. having joints that allow an unusual bending and flexibility of fingers, limbs, etc.

The term 'hypermobility' is misleading because the prefix 'hyper' in medical terminology is used to mean 'too much', and should be reserved for ligament injuries and certain disabilities which cause weak joints or prevent proper control of the joint. If you have a disability or injury, medical advice is essential before commencing or continuing any exercise. Joint problems caused by not exercising joints properly are the scourge of the general population and much emphasis is placed on the therapeutic benefits of stretching exercises for everybody, those with unusually good flexibility will gain little from these routines because the exercises designed for the average person will not provide the range of movement to exercise their joints through their natural range. Whatever your natural range of joint flexibility, if you do not use it, the joint will degenerate.
As the Hypermobility Syndrome Association says: "Even if the person with hypermobile joints is pain free and leads a normal life, it is essential that full movement through their joint range is maintained." Link
(I suppose it's too late for them, but perhaps not for their children.)

The accepted medical tests for joint hypermobility have been unhelpful. One test is to bend forward to place the hands on the floor with the legs straight. This does not test joint mobility, it tests muscle flexibility. Most people can pull their knee up until the thigh contacts the body with the leg bent, this is hip joint mobility. But with the leg straight the hamstring muscles often prevent the hip achieving it's natural range.

Is the girl on the left double jointed? Which joints are unusually flexible? The flexion of the hip joint (top of the femur) is no more than the average person would achieve when tying his shoelaces. The clever bit is allowing the hip joint to move freely with the legs straight. Her hamstring muscles are allowing the natural movement of the joints. There is no unusual flexibility of the joints here.

To answer "is she double jointed" we need to know if her flexibility is natural or has she worked long and hard to improve her flexibility. (If this is natural, what would she achieve if she worked long and hard to improve her flexibility!) People often have limited examples of unusual flexibility, such as a double jointed thumb, or double jointed elbows. To be a double jointed person suggests generalized excellent flexibility.


Articular fluid - which is found in the cavity of synovial joints - provides the articular cartilage with nourishment. The blood vessels which lie inside the bone tissue beneath the plates of articular cartilage also supply nourishment to the cartilage. The nutrients diffuse through the cartilage cells (being pressed or massaged through) and are not transported through small blood vessels (capillaries). If the joints are suitably exercised during childhood, they will be well supplied with nourishment. This in turn leads to a thickening and widening of the cartilage, thereby providing better protection against injury and degeneration. A joint which is not subjected to any kind of stress, or is not fully used in all possible directions, reacts in an opposite manner, the cartilage thins out and retreats from the extremities of the joint's natural range of motion.

It is important to distinguish between joint flexibility and muscle flexibility. Exercise programs for double jointed children must be designed to increase muscle flexibility not joint flexibility

Exercises and sports which stiffen joints reduce muscle flexibility, increase compression of the joint, and atrophy the outlying articulating surfaces. This is inappropriate for children, whose immature tendon to bone attachments are protected by highly sensitized tendon neuron spindles, which will directly communicate with the muscle during "rough and tumble" to protect the tendon attachment and prevent the muscle tension from restricting the joint range. Children cannot rely on muscle tension to restrict a joint and the joint will be progressively damaged by the unaccustomed movement beyond its artificially restricted range.

Some people are more naturally supple than others. Although inherited genes are the usual reason for our physical characteristics, in the interests of evolutionary improvement mother nature will occasionally produce a variation without a family history of a trait.

Joints are the junction between two bones the precise shape of the bones defines the natural flexibility of the joint. A shallow socket allows more movement than a deep one.

The protein collagen which provides strength and reinforcement in the joint capsule (or lining) varies considerably between individuals. If you have inherited supple collagen you will have supple joints. Cartilagenous bone linings in joints differ in width, thickness and shape changing the characteristics of the skeletal interfaces.
A child with a particularly supple spine will have naturally tall discs between the vertebrae, but because this flexibility is natural and a result of the particular development of the child’s spine, the facet joints will be lying in perfect alignment. Many doctors make two predictions to parents of such naturally flexible children; first that if they desist from ‘showing off’ (using) their flexibility they will ‘grow out of it’, and second that they will develop arthritic pains. As in the example of the spine this is a self fulfilling prophesy. Certainly the discs will recede if only used in the ‘normal’ range and the child’s flexibility will reduce to ‘normal’, but that is not normal for this child and the facet joints will now be subluxed. Walk around like that for a couple of years and the doctor’s prediction will certainly come true.

The movement of the joint is controlled by the muscle tension. This is controlled by the nervous system. Overactive autonomic neuron muscle spindles may restrict joint mobility. Many exercise programs and sports reduce muscle flexibility below the levels required to maintain healthy joints, a whole industry of Sports Injuries Clinics has grown up in response to these problems.

Having hypermobile joints does not mean you have arthritis. Nevertheless, you may still experience pain around the joints. Children get 'growing pains', particularly after exercise, and fluid may collect in the joints. Individuals often have flat feet. The knee cap, shoulder or even the hip may dislocate, although they can usually be returned to the correct position with relative ease. The symptoms may mimic other more serious arthritic conditions or may be dismissed as neurotic. When symptoms are bad individuals will feel a pronounced stiffness and there may even be a flu-like feeling.

The thickness of the cartilage of a joint depends on the stress to which it is normally subjected. The cartilage is able to absorb certain substances from the synovial fluid and swell temporarily. If we measure the size of the articular cartilage after a period of warming up, we would find that it had thickened. The thickening is only temporary, lasting for 10 - 30 minutes after the activity has ceased. Prolonged training causes the cartilage to thicken by the formation of additional cartilage cells.

Pain often occurs in hypermobile joints and the adjacent muscles after exercise. Paracetamol (an analgesic) and ibuprofen (a non-steroidal anti-inflammatory drug or NSAID) can be purchased without prescription. Try each in turn to see which helps more. remember that one or two tablets should be taken half an hour before the activity which brings on the pain. The peak benefit will be experienced after one or two hours and the effect will have worn off within four hours. If these are not strong enough, your doctor can prescribe more effective analgesics or NSAIDS according to which suits you best. If the discomfort predictably persists for longer periods, you should ask your doctor for a different tablet with a longer action.

Hormones affect flexibility, male hormones reduce flexibility, female hormones increase flexibility.

Certain commonly available medicines used for the treatment of aches and pains contain substances which are banned in competitive sport, for example Ephedrine, Pseudoephedrine, Phenylpropanolamine, Phenylephrine and Caffeine (above 12 micrograms per milliliter).

Check with your sports governing body about the doping regulations which apply to your sport and tell your Doctor or Chemist that you participate in competitive sport and may be subject to drug testing.

Allowed medications include; Aspirin, Paracetamol, Ibuprofen, Codeine and Dihydrocodeine, all Antibiotics, Antihistamine Creams, Non Steroidal Anti-inflammatories. But only your Doctor can tell you if it is safe for you to use any of these.

Your doctor may refer you for specialist physiotherapy advice. At present the best method of physiotherapy treatment has still to be decided but you can tell your doctor that the two front runners appear to be:

1. Slow static contractions throughout the full range of movement. These should be supplemented with active movement throughout the range, holding the position at each extreme to develop the muscle tone there. The use of weight resisted exercise is not recommended.

2. Stretching, which exercises the muscles and ligaments around the joints, also offers relief. The aim is to restore a range of movement that is normal for each individual.

Others have found benefit from gentle mobilization, ultrasound, behavioral techniques such as biofeedback, hydrotherapy or acupuncture. If pain is more severe, both interferential and transcutaneous electrical nerve stimulation (TENS) have proved effective. Unfortunately many doctors and physiotherapists are unfamiliar with the treatment of hypermobile patients, and there is no single treatment which suits all individuals at all times.

If swelling is more pronounced than pain there are simple physiotherapy techniques to relieve this. Your doctor may also prescribe stronger NSAIDS or consider injection therapy with steroids. A variety of steroid preparations of varying strengths is available.

A small minority of patients may need surgery, though these older procedures are being used much less often. All surgery carries some risk, and with hypermobile patients, particularly if there is a problem with the collagen, there is an increased risk of bruising, bleeding (and therefore infection) and poor wound healing. Earlier operations such as removing the patella (knee cap) carry an increased risk of later osteoarthritis. Surgery to the spine, although it relieves local symptoms, may cause strain elsewhere and make the problem worse. For those reasons, surgery is now only considered as a last resort

The days of the physio's philosophy; "If it's stiff, loosen it. If it's loose, stiffen it." should be long gone. We particularly owe our children a more individualized approach which recognizes and develops their natural flexibility.