Hypermobility syndromes are disorders of unknown etiology that cause musculoskeletal pain secondary to excessive mobility of joints. These disorders most commonly present in children 3 to 10 years of age. Girls are more commonly affected than boys. There is a familial predisposition to hypermobility syndromes.
Hypermobility can be isolated to a specific joint group or can present as a generalized disorder. Symptoms vary depending on the joints involved. The most consistent symptom is pain, which may occur during the day or night. The discomfort may increase after exertion but rarely interferes with regular physical activity. Children with hypermobility of the ankles or feet may complain of chronic leg or back pain.
Joint hypermobility may be quite marked. Range of motion may be exaggerated with excessive flexion or extension at the metacarpophalangeal joints, wrists, elbows, or knees (genu recurvatum) (Fig. 92-1). There may be excessive pronation of the ankles. Hypermobility of the foot (flat foot; pes planus) is shown by the presence of a longitudinal arch of the foot that disappears with weight bearing and may be associated with a shortened Achilles tendon (see Chapter 200). These findings
Touch thumb to flexor aspect of the 1 point each for right and forearm
Extend fifth metacarpophalangeal 1 point each for right and joint to 90 degrees left >10 degrees hyperextension of 1 point each for right and elbow left >10 degrees hyperextension of knee 1 point each for right and left
Touch palms to floor with knees 1 point straight *>6 points defines hypermobility.
are rarely associated with tenderness on examination. No laboratory test abnormalities are apparent, and radiographs of affected joints are normal.
The diagnosis of isolated hypermobility is made on the basis of physical examination with demonstration of exaggerated mobility of a joint. Generalized hypermobility is diagnosed by the presence of sufficient criteria (Table 92-1) and the absence of evidence of other underlying disorders. Excessive skin elasticity, easy bruisability, or mitral valve prolapse suggests Ehlers-Danlos syndrome or Marfan syndrome rather than benign hypermobility.
The treatment of hypermobility consists of reassurance and regular stretching, similar to treatment for other benign musculoskeletal disorders. NSAIDs can be administered as needed but do not need to be prescribed on a regular basis. Arch supports can be helpful in children with symptomatic pes planus but are not indicated in the absence of symptoms. Benign hypermobility tends to improve with increasing age and is not associated with long-term complications.
The myofascial pain syndromes are a group of noninflammatory disorders characterized by diffuse musculoskeletal pain, the presence of multiple tender points, fatigue, malaise, and poor sleep patterns. The etiology of these disorders is unknown, although there seems to be a familial predisposition. Although these disorders sometimes follow viral infection or trauma, no causal relationship has been shown. The myofascial pain syndromes are most common in adults but can occur in children (particularly >12 years of age). The syndromes are more common in girls than in boys. The prevalence of fibromyalgia in children has been reported to be 6%.
Patients with myofascial pain syndromes complain of long-standing diffuse pain in muscles and in the soft tissues around joints that can occur at any time of day, awaken the patient from sleep, and interfere with regular activities. There is frequently a high degree of school absenteeism, despite maintaining adequate school performance. A significant percentage of patients with myofascial pain syndromes exhibit symptoms consistent with depression. An increased incidence of sexual abuse has been reported in children presenting with fibromyalgia.
Physical examination is typically unremarkable with the exception of the presence of specific points that are painful—not just tender—to digital palpation. These points often are located on the neck, back, lateral epicondyles, greater trochanter, and knees. There is no evidence of arthritis or muscular weakness.