The Aim Of This Report Is To Identify
The aim of this report is to identify a population that is at a higher risk of injury within a specific sport than the general population, and to discuss the available treatment and rehabilitation for injured athletes and how these methods may be improved. The chosen population is young athletes with hypermobile joints, within the sport of cycling.
“Joint Hypermobility Syndrome is a heritable disorder of connective tissue that comprises symptomatic hypermobility predisposing to arthralgia, soft tissue injury, and joint instability” (Skills for Action, 2017)
An estimated 10-15% of the general European (Javier Garcia-Campayo, 2011) population have hypermobile joints, which is a syndrome/condition that allows for their joints to a have a greater range of movement on all planes than most other people, leading to easy dislocations and sprains during exercise, as well as underlying and consistent joint pain. Also, within the younger population, the number of children with hypermobile joints is 15-25% (mYVmc, 12 Dec 2004, 14 Jun 2015), suggesting that hypermobility decreases with age both passively and with treatment over time. Joint Hypermobility Syndrome (JHS) has no cure and no known causes because it is a hereditary condition inherited as a mendelian dominant trait (mYVmc, 12 Dec 2004, 14 Jun 2015), the main treatment for which is simply building muscle strength and fitness in key areas such as the legs and arms to ensure joints like the elbow, ankle, and hips are well protected. JHS is also more common within females (Skills For Action, 2017), making young female children the most at risk section of the hypermobile population to injury.
The extent of advice given to sufferers of JHS who are looking to get involved in sports is to stay away from sports with frequent high impacts or collisions such as rugby, football, and hockey (Meakins, 2012); and to instead participate in swimming, jogging, or cycling as they do not feature collisions or impacts as a feature of the sport. As a result, many children with JHS take part in gymnastics, cycling and swimming but very few further steps are taken afterwards to increase the safety of these children, mostly because the chance of dislocation in children even with JHS is low (Skills for Action, 2017), but still possible. However, the injury they are most at risk to is lower back pain injuries, followed by knee, shoulder, hip and ankle injuries (Bojan BUKVA, 2018). Both cycling and gymnastics are the two sports where these injuries are most common in the entire population, and with cycling becoming increasingly popular due to televised cycling races and events as well as the competitiveness of cycling being revealed at the 2014 Olympic games, it was chosen as the sport of focus for discussion.
It is estimated that 31% of the people in the U.K own and use a bicycle; only 13% (or 6.5million) cycle regularly – once a week or more. The total number of recorded injuries each year in relation to the total number of cyclists is quite low overall in relation to the number of cyclists, with 20,000 cyclists injured each year and taken to hospitals, 3,000-4,000 of which are serious; and 100 of which are deaths (ROSPA, 2016). These statistics cover all forms of cycling injuries recorded within 2016, of which children attribute to 1,981 of the 20,000; however, there is no evidence available to quantify the percentage of these injuries that are common muscular injuries within cycling such as lower back pain, wrist sprains, or knee pains (SIC, 2018).
Children with JHS are at greater risk to injury in all sporting activities than the general population because they have several joints that are more flexible than the general population. This is due to the connective tissue which makes up the joint structures is more compliant and subjective to stretching when experiencing loading during exercise (Skills For Action, 2017). Connective tissue is a stiff but pliable material that has just enough give to allow the joint capsule and ligaments to stretch whilst the joint is in motion while at the same time holding the joint surfaces together quite firmly. In JHS sufferers, the connective tissue has more give than usual and as a result the joint surfaces are less firmly held together, are less stable and the joint is able to move further than normal.
By having connective tissue that is generally weaker than athletes without JHS, those with hypermobility are more likely to suffer minor tears and overstretched muscles especially in the knee, hip, back, neck, arms and hands. Additionally, since the muscle tissue is weak and therefore being put through a large range of motion on multiple planes consistently (Grahame, 2001), there is a higher tendency for sufferers of JHS to experience joint sprains and strains due to joint instability. Some physiotherapists will recommend that all people with JHS should avoid exercise, however there are many (Meakins, 2012) that argue that regular exercise that is free from impacts or quick changes in direction are crucial to staying strong and avoiding these common injuries by developing the weak muscles and providing more resistance in the form of muscle mass when they try to stretch or move out with the range of motion that is considered normal.
Therefore, when participating in cycling, those with JHS are even more likely than a similar cyclist in build and skill to experience one of the many common muscular injuries in cycling including lower back pain, knee sprains and wrist strains. Lower back pain in cycling is most often cause by poor posture and riding position when cycling leading to the stretching and use of muscles that aren’t used to being subjected to loading, meaning that for cyclists with hypermobility this injury is even more likely to occur to them as a result of the weak muscle tissue around the Coccygeal area surrounding the hips, and the Lumbosacral region of the spine in the lower back area (Wheeler, 2017) .
Knee sprains tend to occur when the patella rubs on the femur bone underneath and results in damage or irritation of the articular cartilage underneath the patella, and for a normal cyclist this happens from overuse either intensively in a short period of time defined as <2months, or regularly for a long period of time, generally considered >3years (Arthurs-Brennan, 2017). JHS sufferers are more likely to experience this injury when cycling due to their weaker muscle tissue, as cyclists with hypermobility experience the pain and injury as a strain rather than a sprain, due to the stretching of and resulting damage to the muscle around the patella (Bojan BUKVA, 2018), which will happen sooner than any damage to articular cartilage. Finally, wrist strains within cycling are either caused by a sudden acute force from a crash, or from overuse leading to a repetitive strain injury (Sports Injury Clinic, 2017). Cyclists with hypermobile joints are more likely overall to incur a RSI than someone without hypermobility, but within the sport of cycling it does not appear to be more likely for someone with JHS to experience it due to the lack of strain on the wrists and lack of movement needed (Skills For Action, 2017); However in the event of a crash, a JHS sufferer will most definitely be subjected to a more severe strain of the wrist due to the more extensive range of motion they have due to the weak connective tissue, meaning the hand/wrist will bend backwards further then another cyclist without JHS, leading to either soft tissue or closed tendon injuries.
Currently the primary strategy to moderate the risk of injury within all sports for those with hypermobility is to exercise and stretch regularly (Meakins, 2012), as well as frequent physiotherapy sessions; these coupled with regular psychological pain management methods like pain medication or techniques such as imagery and meditation (Hakim, 2013) are recommended in order for both children and adults who suffer from JHS to be able to enjoy sport without the worry of serious injury. For cycling specifically there is no recommendation of strategy available for hypermobile athletes outside of those presented for cyclists without hypermobility. Most muscular injuries in cycling can be fixed by ensuring the bike and equipment is properly set-up, with the cleats positioned correctly to stop knee pain, a proper posture to address lower back pain, cushioned handlebar tape for hand and wrist pain (McOmarin, 2017).
For cyclists with JHS it could be worthwhile going a step further and trying to tackle the route of these soft tissue injuries through professional assistance; Going to a bike shop every month to have the bike serviced and properly set-up; visiting a sport specialist who can use video technology and infrared cameras to analyse your posture using stick on beacons allowing the cyclist to understand how to adjust their body positioning appropriately; Wearing a small brace or splint to protect the proximal bones of the wrist.
The reason these strategies should be carried out under professional supervision is because misuse or misplacement of beacons on the body or a splint/brace can lead to worse injuries than already being experienced – misuse of splints/braces can cause damage to the body in the form of muscle atrophy, increased cardiovascular stress, and also increased blood pressure which all come with their own additional injuries/issues (Dave Bucy, 2017).
The rehabilitation process for joint sprains and subluxations for JHS sufferers is the RICE method (Skills for Action, 2017). RICE stands for Rest, Ice, Compression and Elevation: This method helps minimise inflammation and swelling following these injuries, through the Rest and Ice steps, followed by a program of exercises as the Compression and Elevation steps to help restore a full range of movement, along with the strength of the tissue and the athlete’s coordination. This is very important not only to ensure full recovery of function and movement but also to help prevent the same injury from occurring in the future.
This method could be applied directly to the cycling injuries that have been previously mentioned, as they are all forms of sprains or subluxations, and RICE is even used by the general cycling population with an additional step called Protection (SIC, 2018), which is where a splint is used to keep the affected area still. However, for hypermobile cyclists it is essential to maintain some movement of the muscles even when injured, through gentle motions as this not only helps to reduce the swelling but also restores normal movement and importantly helps to overcome the fear of movement that can develop after an injury (Collinge R, 2009), and therefore this Protection step is disregarded. For a longer time-frame of rehabilitation for an injured JHS sufferer, active and methodical stretching is advised by all physiotherapists and papers online (A J Bridges, 1992), but additional methods such as electro-stimulation or massage therapy have no literature detailing whether they would be appropriate methods of rehabilitation for athletes with hypermobility, despite these methods having been proven to be effective for muscle damage in the general population, leaving room for further research into these options.
The objective of this report was to outline and discuss the ways of risk reduction and rehabilitation for young cyclists with hypermobility. Hypermobile joints are caused by weak connective tissue and is the reason why people with this condition experience injuries that the general population also receive, only they are amplified and more frequent. Standard ways of preventing injuries within cycling are not effective for JHS sufferers, as they require more protection and preparation to avoid serious injuries on a regular basis. Furthermore, the typical PRICE rehabilitation for cycling strain injuries is changed to RICE for JHS sufferers, so they can recover in a way that allows for their connective tissue to repair with consistency. Finally, for long term rehabilitation there is very little literature or online resources surrounding this topic for those with hypermobility, with the overall advice being to visit a chiropractor or physiotherapist, meaning there is room for further research and resulting evidence to be found for this at-risk population in order to increase their safety within cycling, and sport in general.