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2000, Vougiouka et a1. 2000). It has been recognized that hypermobility may be a contributing factor in the pathogenesis of chondromalacia patellae, and that this may be associated with pain in the ankles, hips and back (Al-Rawi and Nessan 1997). A number of children with a history of 'growing pains' or 'benign paroxysmal nocturnal leg pain' have been documented as having generalized hypermobility. Others who are diagnosed with a hypermobility problem or JHS in later life often recall a history of 'growing pains'.

The child occasionally complains of stiffness in the mornings, but this rarely lasts for long. In JHS there is also the issue of developing a downward spiral of recurring acute and chronic pain symptoms, which needs to be broken to avoid a continuation of symptoms (Fig. 1). This notion should be explained to the family, and from the assessment the relative proportion and timing of the rest periods and active periods should be defined. It is also important to ascertain when the pain-free times occur: for example always at weekends, requiring the child to recover during the week instead of attending school because of the pain.

To discuss the multidisciplinary management of JHS Joint hypermobility is understood to result from either genetic defects or variations in connective tissue matrix proteins, which results in more extensible tissues. Some authors describe this heterogeneous group as the heritable disorders of connective tissue (HDCT) (Grahame 1999). Within this group are disorders such as EhlersDanlos syndrome, Marfan syndrome and osteogenesis imperfecta. All these genetic connective tissue disorders have hypermobility as a feature, but hypermobility is also relatively common within the general population and may be a result of more common genetic variations rather than mutations as such (Grahame 2000).

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