Objective examination
The patient walked into the clinic independently mobile with no walking
aid but had a slight bilateral Trendelenberg walking pattern and stood
predominantly weight bearing through the left leg. Initial observations
were that the patient stood in a sway back posture (viewed from a
lateral aspect, the greater trochanter of her hips bilaterally was
positioned anterior to both the lateral aspect of the shoulder and
lateral malleolus), with hyperextended knees and bilaterally pronated
feet. On sitting she had her legs tightly crossed, with her feet tucked
around one of the chair legs. The Beighton’s hypermobility scale was 7/9
[3, 33, 34] with negative findings only for her thumb joints. The
scale was explained to the patient and she reported this had never been
performed on her before and she had never been told about hEDS in any of
her past healthcare experiences. A preliminary hypermobility discussion
ensued and it was explained that some patients experience a range of
common co-morbidities. This resulted in the patient disclosing that she
bruised easily, had unexplained stretch marks on the skin around her
trunk, widened atrophic scars from wounds from childhood injuries (from
falling over), suffered recurrent ankle sprains, previous left wrist
subluxations, allergies, and that she experienced dizziness and light
headedness upon standing (and on a few occasions had fainted and
fallen). She expressed how she often did not tell people about all of
her symptoms as she was afraid of not being believed and being labelled
as a hypochondriac.
Isometric muscle strength tests of the hips using a Hand-Held
Dynamometer (HHD) were carried out to record pre-operative benchmark
measurements. The testing protocol used was as per the Hip Arthroscopy
Pre-habilitation Intervention (HAPI) study [35] with the addition of
hip internal rotation in prone described by Thorborg et al [36].
Measurements are presented in Table II . Hip flexion and hip
extension strength tests were not recorded due to the patient’s high
pain level with these movements. Functional movements such as squatting,
bridges, one leg balance, single leg squat, step-ups, and gait were
observed, alongside assessment of proprioception and motor control. All
of these highlighted significant weakness, poor proprioception and poor
neuromuscular control. Due to her history of recurrent ankle sprains,
clinical observation of bilateral foot pronation and the understanding
of the importance of ankle push-off function in reducing pressures
through the anterior hip joint [37], the feet and ankles were
assessed in detail. Passive tests of the ankles and feet showed
excessive range of motion and ligament laxity [38]. Joint
hypermobility can be found in joints outside of the Beighton score so a
whole-body approach was adopted [20, 34]. Single leg calf raise
ability, in supported one leg stance, was a total of 5 repetitions on
each side before fatigue set in, which is a significantly lower value
than would be expected in an average healthy adult [39]. It is
normal following peri-acetabular osteotomy surgery for a patient to use
crutches and to have a weight restriction through the operated leg
[40]; thus, the non-operated leg must be of sufficient strength to
cope with this.