Multi-ligament Laxity

  • Kevin J. LittleEmail author
Reference work entry


Increased mobility of multiple joints is characterized as a hypermobility syndrome or generalized joint laxity. Joint hypermobility lies on a spectrum of disease from milder forms such as benign joint hypermobility syndrome or generalized joint laxity to more severe forms including Ehlers-Danlos syndrome and Marfan syndrome. While this increased joint mobility is not indicative of a pathologic state in the joint, it does confer an increased risk of injury or arthritis. In the upper extremity, joint laxity can increase the rate of shoulder multidirectional instability, increase the risk of supracondylar humerus fractures, and lead to early onset arthritis in the thumb carpometacarpal joint. Following injury, patients with hypermobility may require more extensive therapy and a longer duration of treatment to return to baseline function. Physiotherapy is the mainstay of treatment for joint hypermobility. This allows for increased dynamic stability for joints where ligamentous laxity does not impart adequate stability. Surgical treatment is recommended only after patients fail 3–6 months of extended physiotherapy or in cases where the injury sustained in addition to the baseline hyperlaxity has a better prognosis with surgical treatment than without, such as with a bony Bankart lesion in the shoulder. Prompt recognition of the hypermobility syndrome is critical towards patient education, beginning appropriate therapy, and returning the patient to baseline function.


Rotator Cuff Marfan Syndrome Joint Laxity Joint Hypermobility Ligamentous Laxity 
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  1. Acasuso-Díaz M, Collantes-Estévez E. Joint hypermobility in patients with fibromyalgia syndrome. Arthritis Care Res. 1998;11(1):39–42.PubMedCrossRefGoogle Scholar
  2. Aktas I, Ofluoglu D, Albay T. The relationship between benign joint hypermobility syndrome and carpal tunnel syndrome. Clin Rheumatol. 2008;27(10):1283–7.PubMedCrossRefGoogle Scholar
  3. Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51(3):444–53.PubMedGoogle Scholar
  4. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32(5): 413–8.PubMedCentralPubMedCrossRefGoogle Scholar
  5. Beighton P, De Paepe A, Danks D, Finidori G, Gedde-Dahl T, Goodman R, Hall JG, Hollister DW, Horton W, McKusick VA. International nosology of heritable disorders of connective tissue, Berlin, 1986. Am J Med Genet. 1988;29:581–94.PubMedCrossRefGoogle Scholar
  6. Beighton P, De Paepe A, Steinmann B, Tsipouras P, Wenstrup RJ. Ehlers-Danlos syndromes: revised nosology, Villefranche, 1997. Ehlers-Danlos National Foundation (USA) and Ehlers-Danlos Support Group (UK). Am J Med Genet. 1998;77:31–7.PubMedCrossRefGoogle Scholar
  7. Beynnon BD, Murphy DF, Alosa DM. Predictive factors for lateral ankle sprains: a literature review. J Athl Train. 2002;37(4):376–80.PubMedCentralPubMedGoogle Scholar
  8. Bravo JF, Wolff C. Clinical study of hereditary disorders of connective tissues in a Chilean population: joint hypermobility syndrome and vascular Ehlers-Danlos syndrome. Arthritis Rheum. 2006;54(2):515–23.PubMedCrossRefGoogle Scholar
  9. Burkhead Jr WZ, Rockwood Jr CA. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. 1992;74(6):890–6.PubMedGoogle Scholar
  10. Cameron KL, Duffey ML, DeBerardino TM, Stoneman PD, Jones CJ, Owens BD. Association of generalized joint hypermobility with a history of glenohumeral joint instability. J Athl Train. 2010;45(3):253–8.PubMedCentralPubMedCrossRefGoogle Scholar
  11. Carter C, Sweetnam R. Recurrent dislocation of the patella and of the shoulder: their association with familial joint laxity. J Bone Joint Surg Br. 1960;42:721–7.PubMedGoogle Scholar
  12. Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Joint Surg Br. 1964;46:40–5.PubMedGoogle Scholar
  13. Collinge R, Simmonds JV. Hypermobility, injury rate and rehabilitation in a professional football squad: a preliminary study. Phys Ther Sport. 2009;10(3):91–6.PubMedCrossRefGoogle Scholar
  14. Cooley HM, Stankovich J, Jones G. The association between hormonal and reproductive factors and hand osteoarthritis. Maturitas. 2003;45:257–65.PubMedCrossRefGoogle Scholar
  15. Cooper RA, Brems JJ. The inferior capsular-shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am. 1992;74(10):1516–21.PubMedGoogle Scholar
  16. Crisco JJ, Chelikani S, Brown RK, Wolfe SW. The effects of exercise on ligamentous stiffness in the wrist. J Hand Surg Am. 1997;22(1):44–8.PubMedCrossRefGoogle Scholar
  17. Decoster LC, Vailas JC, Lindsay RH, Williams GR. Prevalence and features of joint hypermobility among adolescent athletes. Arch Pediatr Adolesc Med. 1997;151(10):989–92.PubMedCrossRefGoogle Scholar
  18. Decoster LC, Bernier JN, Lindsay RH, Vailas JC. Generalized joint hypermobility and its relationship to injury patterns among NCAA lacrosse players. J Athl Train. 1999;34(2):99–105.PubMedCentralPubMedGoogle Scholar
  19. Earp BE, Waters PM, Wyzykowski RJ. Arthroscopic treatment of partial scapholunate ligament tears in children with chronic wrist pain. J Bone Joint Surg Am. 2006;88(11):2448–55.PubMedCrossRefGoogle Scholar
  20. Farr S, Grill F, Ganger R, Graf A, Girsch W. Pathomorphologic findings of wrist arthroscopy in children and adolescents with chronic wrist pain. Arthroscopy. 2012;28(11):1634–43.PubMedCrossRefGoogle Scholar
  21. Ferrell WR, Tennant N, Sturrock RD, et al. Amelioration of symptoms by enhancement of proprioception in patients with joint hypermobility syndrome. Arthritis Rheum. 2004;50(10):3323–8.PubMedCrossRefGoogle Scholar
  22. Freedman DM, Eaton RG, Glickel SZ. Long-term results of volar ligament reconstruction for symptomatic basal joint laxity. J Hand Surg Am. 2000;25(2): 297–304.PubMedCrossRefGoogle Scholar
  23. Garcia-Elias M, Pitágoras T, Gilabert-Senar A. Relationship between joint laxity and radio-ulno-carpal joint morphology. J Hand Surg Br. 2003;28(2): 158–62.PubMedCrossRefGoogle Scholar
  24. Goldman JA. Hypermobility and deconditioning: important links to fibromyalgia/fibrositis. South Med J. 1991;84(10):1192–6.PubMedCrossRefGoogle Scholar
  25. Grahame R, Hakim AJ. Hypermobility. Curr Opin Rheumatol. 2008;20(1):106–10.PubMedCrossRefGoogle Scholar
  26. Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol. 2000;27:1777–9.PubMedGoogle Scholar
  27. Gulbahar S, Sahin E, Baydar M, et al. Hypermobility syndrome increases the risk for low bone mass. Clin Rheumatol. 2006;25(4):511–4.PubMedCrossRefGoogle Scholar
  28. Ho AM, Goitz HT, Goitz RJ. Examination of the shoulder. In: Trumble TE, Budoff JE, editors. Hand surgery update 4. Rosemont: American Society for Surgery of the Hand; 2007. p. 903–16.Google Scholar
  29. Holbrook KA, Byers PH. Structural abnormalities in the dermal collagen and elastic matrix from the skin of patients with inherited connective tissue disorders. J Invest Dermatol. 1982;79 Suppl 1:7S–16S.PubMedCrossRefGoogle Scholar
  30. Jansson A, Saartok T, Werner S, Renström P. Evaluation of general joint laxity, shoulder laxity and mobility in competitive swimmers during growth and in normal controls. Scand J Med Sci Sports. 2005;15(3):169–76.PubMedCrossRefGoogle Scholar
  31. Jónsson H, Valtýsdóttir ST. Hypermobility features in patients with hand osteoarthritis. Osteoarthritis Cartilage. 1995;3(1):1–5.PubMedCrossRefGoogle Scholar
  32. Juul-Kristensen B, Røgind H, Jensen DV, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology (Oxford). 2007;46(12):1835–41.CrossRefGoogle Scholar
  33. Kim SJ, Chang JH, Oh KS. Posterior cruciate ligament reconstruction in patients with generalized joint laxity. Clin Orthop Relat Res. 2009;467(1):260–6.PubMedCentralPubMedCrossRefGoogle Scholar
  34. Kirk JA, Ansell BM, Bywaters EG. The hypermobility syndrome. Musculoskeletal complaints associated with generalized joint hypermobility. Ann Rheum Dis. 1967;26:419–25.PubMedCentralPubMedCrossRefGoogle Scholar
  35. Kobayasi T. Abnormality of dermal collagen fibrils in Ehlers Danlos syndrome: anticipation of the abnormality for the inherited hypermobile disorders. Eur J Dermatol. 2004;14(4):221–9.PubMedGoogle Scholar
  36. Kobayasi T. Dermal elastic fibres in the inherited hypermobile disorders. J Dermatol Sci. 2006;41(3): 175–85.PubMedCrossRefGoogle Scholar
  37. Larsson LG, Baum J, Mudholkar GS. Hypermobility: features and differential incidence between the sexes. Arthritis Rheum. 1987;30(12):1426–30.PubMedCrossRefGoogle Scholar
  38. Lemaire R, Farina G, Kissin E, Shipley JM, Bona C, Korn JH, Lafyatis R. Mutant fibrillin 1 from tight skin mice increases extracellular matrix incorporation of microfibril-associated glycoprotein 2 and type I collagen. Arthritis Rheum. 2004;50(3):915–26.PubMedCrossRefGoogle Scholar
  39. Lenters TR, Franta AK, Wolf FM, Leopold SS, Matsen 3rd FA. Arthroscopic compared with open repairs for recurrent anterior shoulder instability: a systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2007;89(2):244–54.PubMedCrossRefGoogle Scholar
  40. Lomasney LM, Choi H, Jayanthi N. Magnetic resonance arthrography of the upper extremity. Radiol Clin North Am. 2013;51(2):227–37.PubMedCrossRefGoogle Scholar
  41. Magnusson SP, Hansen M, Langberg H, Miller B, Haraldsson B, Westh EK, et al. The adaptability of tendon to loading differs in men and women. Int J Exp Pathol. 2007;88:237–40.PubMedCrossRefGoogle Scholar
  42. March LM, Francis H, Webb J. Benign joint hypermobility with neuropathies: documentation and mechanism of median, sciatic, and common peroneal nerve compression. Clin Rheumatol. 1988;7(1):35–40.PubMedCrossRefGoogle Scholar
  43. Marquass B, Josten C. Acute and chronic instability of the elbow joint. Z Orthop Unfall. 2010;148(6):725–38.PubMedGoogle Scholar
  44. Messmer C, Ruch DS. Elbow and forearm: instability and arthroscopy. In: Trumble TE, Budoff JE, editors. Hand surgery update 4. Rosemont: American Society for Surgery of the Hand; 2007. p. 859–70.Google Scholar
  45. Meyer C, Cammarata E, Haumont T, Deviterne D, Gauchard GC, Leheup B, Lascombes P, Perrin PP. Why do idiopathic scoliosis patients participate more in gymnastics? Scand J Med Sci Sports. 2006;16(4):231–6.PubMedCrossRefGoogle Scholar
  46. Mikkelsson M, Salminen JJ, Kautiainen H. Joint hypermobility is not a contributing factor to musculoskeletal pain in pre-adolescents. J Rheumatol. 1996;23:1963–7.PubMedGoogle Scholar
  47. Mishra MB, Ryan P, Atkinson P, et al. Extra-articular features of benign joint hypermobility syndrome. Br J Rheumatol. 1996;35(9):861–6.PubMedCrossRefGoogle Scholar
  48. Neer II CS, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: a preliminary report. J Bone Joint Surg Am. 1980;62(6):897–908.PubMedGoogle Scholar
  49. Nijs J, Van Essche E, De Munck M, Dequeker J. Ultrasonographic, axial, and peripheral measurements in female patients with benign hypermobility syndrome. Calcif Tissue Int. 2000;67(1):37–40.PubMedCrossRefGoogle Scholar
  50. Nilsson C, Wykman A, Leanderson J. Spinal sagittal mobility and joint laxity in young ballet dancers: a comparative study between first-year students at the Swedish Ballet School and a control group. Knee Surg Sports Traumatol Arthrosc. 1993;1(3–4):206–8.PubMedCrossRefGoogle Scholar
  51. Nork SE, Hennrikus WL, Loncarich DP, Gillingham BL, Lapinsky AS. Relationship between ligamentous laxity and the site of upper extremity fractures in children: extension supracondylar fracture versus distal forearm fracture. J Pediatr Orthop B. 1999;8(2):90–2.PubMedGoogle Scholar
  52. Ramesh R, Von Arx O, Azzopardi T, Schranz PJ. The risk of anterior cruciate ligament rupture with generalized joint laxity. J Bone Joint Surg Br. 2005;87(6):800–3.PubMedCrossRefGoogle Scholar
  53. Rizzo M. Carpal instability. In: Trumble TE, Budoff JE, editors. Hand surgery update 4. Rosemont: American Society for Surgery of the Hand; 2007. p. 295–310.Google Scholar
  54. Rodeo SA, Suzuki K, Yamaguchi M, Bhargava M, Warren RF. Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability. Am J Sports Med. 1998;26(5):634–43.PubMedGoogle Scholar
  55. Rombaut L, Malfait F, Cools A, De Paepe A, Calders P. Musculoskeletal complaints, physical activity and health-related quality of life among patients with the Ehlers-Danlos syndrome hypermobility type. Disabil Rehabil. 2010;32(16):1339–45.PubMedCrossRefGoogle Scholar
  56. Russek LN. Hypermobility syndrome. Phys Ther. 1999;79(6): 591–9.PubMedGoogle Scholar
  57. Scher DL, Owens BD, Sturdivant RX, Wolf JM. Incidence of joint hypermobility syndrome in a military population: impact of gender and race. Clin Orthop Relat Res. 2010;468(7):1790–5.PubMedCentralPubMedCrossRefGoogle Scholar
  58. Simmonds JV, Keer RJ. Hypermobility and the hypermobility syndrome. Man Ther. 2007;12(4): 298–309.PubMedCrossRefGoogle Scholar
  59. Smith TO, Bacon H, Jerman E, Easton V, Armon K, Poland F, Macgregor AJ. Physiotherapy and occupational therapy interventions for people with benign joint hypermobility syndrome: a systematic review of clinical trials. Disabil Rehabil. 2014;36(10):797–803.Google Scholar
  60. Stanitski CL. Articular hypermobility and chondral injury in patients with acute patellar dislocation. Am J Sports Med. 1995;23(2):146–50.PubMedCrossRefGoogle Scholar
  61. Stewart DR, Burden SB. Does generalised ligamentous laxity increase seasonal incidence of injuries in male first division club rugby players? Br J Sports Med. 2004;38(4):457–60.PubMedCentralPubMedCrossRefGoogle Scholar
  62. Tan FK, Wang N, Kuwana M, Chakraborty R, Bona CA, Milewicz DM, et al. Association of fibrillin 1 single-nucleotide polymorphism haplotypes with systemic sclerosis in Choctaw and Japanese populations. Arthritis Rheum. 2001;44:893–901.PubMedCrossRefGoogle Scholar
  63. Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St. Pierre P, Taylor DC. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med. 2003;31(6):831–42.PubMedGoogle Scholar
  64. van Vugt RM, Bijlsma JW, van Vugt AC. Chronic wrist pain: diagnosis and management. Development and use of a new algorithm. Ann Rheum Dis. 1999;58(11): 665–74.PubMedCentralPubMedCrossRefGoogle Scholar
  65. Wolf JM, Cameron KL, Owens BD. Impact of joint laxity and hypermobility on the musculoskeletal system. J Am Acad Orthop Surg. 2011;19(8):463–71.PubMedGoogle Scholar
  66. Wynne-Davies R, Littlejohn A, Gormley J. Aetiology and interrelationship of some common skeletal deformities. (Talipes equinovarus and calcaneovalgus, metatarsus varus, congenital dislocation of the hip, and infantile idiopathic scoliosis). J Med Genet. 1982;19(5):321–8.PubMedCentralPubMedCrossRefGoogle Scholar
  67. Zaltz I, Waters PM, Kasser JR. Ulnar nerve instability in children. J Pediatr Orthop. 1996;16(5):567–9.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.University of Cincinnati Department of Orthopaedic Surgery; Hand and Upper Extremity SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiUSA

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