Subjective History Red Flags: What Physiotherapists Must Ask When Suspecting a Connective Tissue Disorder
The patient presenting with joint hypermobility often arrives in the clinic with a lengthy, frustrating history of chronic pain, recurrent injury, and failed rehabilitation efforts. While traditional physiotherapy focuses on the affected joint, a comprehensive subjective history for suspected Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (hEDS) requires the Joint hypermobility physiotherapist Gold Coast to look beyond the joint and inquire about the systemic effects of altered collagen.
The key to effective screening is to identify patterns of multi-system involvement that point toward a connective tissue disorder (CTD).
1. Musculoskeletal & Joint Instability History
The first set of questions confirms that the patient’s laxity is symptomatic and often traumatic, distinguishing it from simple flexibility.
| Red Flag Question | Clinical Significance |
|---|---|
| “How many times have you sprained/dislocated the same joint (e.g., ankle or shoulder)?” | Indicates chronic instability and poor ligamentous restraint, rather than acute injury. |
| “Do you experience pain after prolonged sitting, standing, or light activities like vacuuming?” | Suggests poor muscle endurance and inability to maintain postural stability, often leading to muscular fatigue and pain flares. |
| “Did you have unusual flexibility or clumsiness as a child, or were you slow to reach gross motor milestones?” | Points to congenital generalized joint hypermobility (GJH). |
| “Have you had chronic, widespread pain that cannot be localized to a specific injury for over three months?” | A primary criterion for symptomatic hypermobility. |
2. Skin and Soft Tissue Integrity
The quality of the connective tissue, particularly collagen, affects organs beyond the joints, including the skin. These signs are essential for fulfilling the systemic criteria for hEDS.
- Scars and Wounds: “How well do your wounds heal? Do your scars look thin, widened, or like ‘cigarette paper’?” (Papyraceous scarring is a hallmark sign.)
- Skin Quality: “Does your skin feel stretchy or soft, like velvet, or do you notice many unexplained stretch marks (striae) not associated with weight changes?”
- Bruising and Bleeding: “Do you bruise very easily and often, even from slight bumps?” (Though not specific to hEDS, easy bruising points toward vascular fragility.)
3. Systemic and Autonomic Red Flags (The Non-Joint Systems)
This category is often missed but is the most critical for differential diagnosis and patient validation. These symptoms relate to Dysautonomia (POTS), GI issues, and pelvic floor dysfunction—all linked to connective tissue laxity in blood vessels and internal organs.
Cardiovascular/Autonomic Dysfunction (POTS Screening)
- Orthostatic Intolerance: “Do you frequently feel lightheaded, dizzy, or faint when standing up quickly, or when standing still for a long time (like in a queue)?”
- Tachycardia: “Do you often feel your heart racing or pounding (palpitations) for no obvious reason, particularly after changing position?”
- Fatigue: “Is your fatigue debilitating, meaning you don’t feel rested even after a good night’s sleep?”
Gastrointestinal (GI) and Bladder Issues
- Motility: “Do you experience frequent, unexplained nausea, chronic constipation, or chronic diarrhea?” (Gastroparesis and functional GI disorders are common.)
- Reflux: “Do you suffer from persistent acid reflux (GERD)?” (Often due to a lax esophageal sphincter.)
- Pelvic/Bladder: “Have you had issues with bladder urgency, frequency, or incontinence, especially during exercise or coughing?” (Pelvic floor laxity is a common finding.)
Mental Health and Neurodiversity
- Anxiety/Trauma: “Do you struggle with anxiety or panic attacks? Have you found you are particularly sensitive to noise, light, or texture?” (There is a high correlation between HSD/hEDS and anxiety, often linked to nervous system dysregulation.)
Clinical Implications for the PT
A patient who answers positively to a cluster of questions across all three categories (joints, skin, and systemics) requires a nuanced approach:
- Stop Stretching: Immediately educate the patient on avoiding end-range stretching and yoga, which is often counter-productive and destabilizing.
- Referral: Clearly document the findings (e.g., Beighton Score, chronic pain, POTS-like symptoms, easy bruising) and communicate the strong suspicion of a CTD to the referring physician, rheumatologist, or geneticist.
- Treatment Prioritization: Adjust therapy to prioritize nervous system regulation, proprioception, and low-load stabilization before building muscle bulk, ensuring a safer and more successful rehabilitation journey.
