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Is "hypermobile" acceptable terminology?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Jul 7, 2011.


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    Kevin Said:-

  2. Admin2

    Admin2 Administrator Staff Member

  3. Ah, I'd forgotten Dave's rather beautiful version of Romeo and Julliet


    However. In defence of Hypermobile, and because I hang around with too many physio's.

    Global hypermobility is a defined and recognised term in paediatrics, defined by the score on the Beighton scale.

    The LLAS is rather more specific to podiatry and again refers to a score on a series of tests.

    For starters, is it acceptable in thine eyes to refer to hypermobile in context of these criteria?

    Your 4 criteria are definable, precise, quantifiable and unambiguous. I'd say that the LLAS meets all 4.
  4. I agree. However, if we are to talk in terms of load/ deformation we need methods and instruments to reliably quantify these. How might the quantification of load/deformation characteristics of the foot and lower extremity impact on treatment strategies?

    While the Beighton scale may define global "hypermobility", Kevin was talking about the use of the term hypermobility in association with the first ray of the foot. As far as I can recall, the Beighton scale does not use the 1st ray within it's criteria. Moreover, as far as I can recall, the Beighton scale uses among other factors the extended position of the knees and elbows. As such it doesn't really test the mobility of these joints at all, the knees might be "hyper-extended" yet have zero degrees of mobility from this position under physiologic loading; what about the flexion at these joints? What if these joints extend many degrees beyond zero, but only flex by 1 degree?

    What does LLAS mean?
  5. Lower limb assessment score. The Ferrari one.

    Sorry Acronym alert.
  6. And does this measure the range of motion of the first ray? Moreover, does it standardise the loading applied to the joints to determine their deformation under this load?

    To paraphrase what you said that I said in another thread: if I use a high velocity ram to extend your knee, I bet I could get 180 degrees of extension. It might smart a little.
  7. timharmey

    timharmey Active Member

    Can one compare a human to a bike (no rude jokes)
  8. If your discussing stiffness you can compare anything
  9. RobinP

    RobinP Well-Known Member

    Like you Robert, I too have spent a lot of time around physios who have a real fondness for "hypermobility", the word and the diagnosis. I must confess that I find it's usage as a diagnosis, as in "Benign Joint Hypermobility Syndrome" is every bit as irritating as pes planus. However, as inaccurate as it is, it undeniably serves a purpose in conveying an impression of a certain presentation between health professionals, as does pes planus.

    If I am writing a letter of referral to a foot ankle consultant I always want to describe specific biomechanical issues as I see them. However, as they are quite good friends of mine, they have no problem telling me that they are not interested in my mumbo jumbo - "just give it to me in terms I can understand"

    Terms like pes planus and hypermobile.

    Does that mean that we should stop being accurate? No, we should always endeavour to move the profession forward. But should we do it at the risk of alienating ourselves from our fellow professionals who are comfortable with less accurate terminology?

    Lets just say that I still give them the long winded, detailed, biomechanically more accurate version. Otherwise known as "******* in the wind"
  10. timharmey

    timharmey Active Member

    So,and I am only seeking knowledge , I can tell when a foot moves so easily as to be Hypermobile in the same way as I can feel if a foot is weak in say resisted dorsiflexion , how should i describe this ?
  11. i would say in terms of stiffness in a direction.

    Ie jacks test - dorsiflexion stiffness at the 1st MTPJ. Ideally in newtons but a sliding scale from more stiff to less stiff will work.

    The other thing to consider is a mobile foot/joint non-weightbearing maybe unmobile or have increased stiffness weightbearing and of course have various degrees of stiffness during different stages of gait.
  12. No. But to be fair Kevin did not mention the first ray in the op...

    I think that there is some repeatabilty data for LLAS...
  13. David Smith

    David Smith Well-Known Member


    To the best of my knowledge, wasn't the Beighton scale first originally developed as an epidemiological measure and not really a clinical assessment tool. In this case there was a convenient assumption made about normal end range of joint mobility. (statisticians love convenience and simple assumptions as it makes the statistical analysis work so much better even though the results may not really reflect any useful truth in terms of clinical importance) Therefore any significant motion past that, pre assumed, end range was called hypermobility. The force applied was generally only that which the subject themselves would apply during the prescribed action, i.e. extending knees and elbows, extending the thumb to the radius with a flexed wrist - well this chart describes it best


    Therefore hypermobility was a convenient statistically efficient term never meant for clinical use (my reasoned conclusion :cool:)

    Dave Smith
  14. musmed

    musmed Active Member

  15. Tkemp

    Tkemp Active Member

    maybe instead of "hypermobility" we should discuss "ligamentous laxity"?
    And this can be measured by the levels and severity of its effect on the soft tissues/ connective tissues.
    Some types may be trauma induced and only affect specific areas. Others may be linked to diseases, for example, Ehlers- Danlos syndrome which affect the whole body.
  16. David Smith

    David Smith Well-Known Member

    Posted by Paul
    Last edited: Jul 12, 2011
  17. lusnanlaogh

    lusnanlaogh Active Member

    'Hypermobility' and 'ligamentous laxity' are well known and accepted terms that all medical/health disciplines understand ... why fix something that's not broken? :wacko:
  18. Lusnan:

    If the term "hypermobility" is so well known and accepted by all health professions, then it should also have a definition that has a precise mechanical meaning which is useful for the podiatrist and clinician. What, then is your best definition for "hypermobility"? Let's make it even more simple, please define "first ray hypermobility".
  19. Like pes planus?...:eek:

    Off the top of my head, I'd say decreased first ray dorsiflexion stiffness
  20. Decreased compared to what, or whom?
  21. lusnanlaogh

    lusnanlaogh Active Member


    This all comes down to what you want ...

    Do you want a terminology that most medical / health professionals can access?

    Or, do you want a terminology that only podiatrists (and similar disciplines) can access?

    Then again, do you want a terminology that is more physics/mechanics based?

    If you want a terminology that the majority of people understand, then hypermobility is a good term IMHO.

    Using terminology that a large section of medical/health professionals can not access is not the way forward.

    I personally see hypermobility as a general term and that it's a large/excessive ROM of a joint; outside the ROM normally expected for that joint.
  22. Don't know. I was Quoting Kevin.
  23. That's the point. In order to define something as decreased or increased then there needs to be a standard against which this is defined
  24. Lusnan:

    As far as what I want, I want podiatry to be on the cutting edge of biomechanics.... not stuck back behind everyone else. Using your logic, I suppose we should still be talking about the oblique and longitudinal axes of the midtarsal joint also and that all posterior tibial tendon swelling is "posterior tibial tenosynovitis" rather than "posterior tibial tendon dysfunction" since we don't want to confuse anybody.:craig:

    It seems to be your opinion, then, that we should we place a freeze on all new terminology since the majority of clinicians wouldn't understand a term if we made a change in terminology? I really could care less what other health practitioners think about the terminology...if the terminology does not the adequately describe the mechanical process occurring and can't be quantified, then, as far as I'm concerned, we should consider replacing it with terminology that can adequately describe the mechanical process and can be quantified. This is how progress is made in science and medicine.....by change!

    As far as standard terminology, since when have the engineers, biomechanists and bioengineers used the term "hypermobility" to describe the load-deformation characteristics of joints? Maybe 15 to 20 years ago?? Why don't you just look at what the standard biomechanics terminology used for load-deformation characteristics over the last decade in the Journal of Biomechanics, Clinical Biomechanics, etc to see if they use "hypermobility" or rather use the term "stiffness" to describe this mechanical characteristic of all joints.

    I like to be taking the lead down the best path, rather than waiting behind others content to follow the leader. Maybe your personality is different than mine.
  25. lusnanlaogh

    lusnanlaogh Active Member

    Ouch! If I was following the leader I wouldn't be challenging you, would I?

    Correct me if I'm wrong (as I'm sure you will :rolleyes:), the title of this thread is 'Is 'hypermobile' an acceptable term?'

    I understand your line of argument ... and agree with it, to some extent. However, we don't live in an ideal world (e.g. not everyone understands 'biomech speak') and, as we have to communicate with other professionals (so we can collaboratively treat patients), I'm sure you'll agree that it's a good idea to 'speak the same language'?

    If this thread asked 'Is 'hypermobile' accurate terminology?' then I would agree with you wholeheartedly. It's all about semantics ... ;)
  26. I still use the term "hypermobile" when I speak to podiatrists about the way the foot works mechanically. However, I point out that the term "hypermobile" is vague and ambiguous and doesn't clearly describe the load vs deformation characteristics of any of the joints of the lower extremity.

    Therefore, I am trying to educate others as I gradually explain to them why they should ease themselves away from the the poor terminology to the more accurate and meaningful terminology using "stiffness". I believe this gradual replacement of "hypermobility" with "stiffness" will occur over time. In addition, I firmly believe that this terminology change will be for the overall good of the podiatry profession .....especially long after I am gone from this world.:drinks
  27. Tkemp

    Tkemp Active Member

    Is there then a quantified definition for "stiffness" as opposed to "hypermobility"?
    As we don't want Podiatry to stagnate, but do not want to see change merely for the sake of change.

    PS- Isaacs & Spooner.. "stiffness" as relating to the feet. Though I am sure you have a long list of alternative terminology and measurements :)
  28. Stiffness is defined as force /displacement http://en.wikipedia.org/wiki/Stiffness

    The point is, and this is the point I was making in my earlier posts here, we do not have base-line data for stiffness characteristics of the foot. So to talk about "reduced stiffness" or "increased stiffness" is a bit of a nonsense at the moment.
  29. Tkemp

    Tkemp Active Member

    Exactly!! So as we dont have a baseline, dispite a physic's definition and calculations, we cannot currently quantify the level of "stiffness" present. Just as we have no baseline for "hypermobility".

    The question is, will there ever be a study carried out on an adequate number of participants, using acceptable methods, to set such a baseline? :bash:
  30. As I recall, Craig studied dorsiflexion stiffness of the hallux. I'm currently engaged in a study which, among other things, measures medial longitudinal arch stiffness. So, we can currently quantify levels of stiffness and future studies will provide baseline characteristics.
  31. I would suggest you read this article to see the many reasons why "hypermobility" is poor terminology for describing the load vs deformation characteristics of the first ray.

    Attached Files:

  32. Tkemp

    Tkemp Active Member

    Thanks for the information.
    It seems that "stiffness" and "compliance" are terms that can be used to accurately describe the mobility of joints, in particular the 1st ray. In addition, knowing precisely the degree of "stiffness" present, will aid in the manufacture of orthoses.

    As the study did point out, clinicans and patients may be confused as to the use of the term "stiffness". Due to their assuming this means the joint in question has "less mobility than necessary for proper function". Therefore, clients will need clear explanations as to the use of such terminology (an important point as patient's compliance with orthotic treatment depends greatly on their knowledge and understanding of their condition and the reasons certain devices were chosen). So maybe a set of posters with the info for waiting rooms, etc? Accompanied by clinician education, of course.

    However, I feel that in the case of client who do have ligamentous laxity / due to anatomical factors have increased laxity of the plantar and dorsal ligaments in more than just the 1st ray/MTJ a term such as "hypermobility" be used to describe excessive ROM in the lower limb joints.

    Simon, I'd love to look at your research once completed, please.

  33. Perthpod

    Perthpod Active Member

    I hope the term doesn't end up being hyperdistorting 1st Ray, it will sound too much like a guitar pedal..Maybe were getting too close to physics and too far from medical terminology. I understand that it's not moving around of it's own accord excessively (hypermobile)', but has an excessive ROM compared to a 'norm'. Is it not mainly joint laxity (hyperlax) Gee that one might sound like a tablet one takes to aid gut motility...

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