Hypermobility Disorders
Hypermobility is often described simply as being "double-jointed" or unusually flexible. However, for some individuals, increased joint mobility is part of a broader condition that can affect the joints, muscles, connective tissues, and overall function.
Hypermobility Spectrum Disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) are conditions associated with symptomatic joint hypermobility. People with these conditions may experience joint pain, instability, recurrent injuries, fatigue, muscle discomfort, balance difficulties, and challenges with everyday activities.
Hypermobility disorders can look very different from one person to another. Some individuals may have relatively mild symptoms, while others experience widespread and persistent difficulties that significantly affect their quality of life.
Understanding the difference between normal joint flexibility and a symptomatic hypermobility disorder is an important first step toward appropriate assessment and management.
What Is Hypermobility?
Joint hypermobility means that a joint can move through a greater range of motion than is typical.
Hypermobility can occur in:
One or a few joints
Several joints
Most of the major joints throughout the body
Having flexible joints by itself is not necessarily a medical problem. Many people have generalized joint hypermobility without pain, instability, or functional limitations.
However, when joint hypermobility is associated with significant symptoms or functional difficulties, it may fall within the spectrum of hypermobility disorders.
This distinction is important because being flexible does not automatically mean that someone has HSD or hEDS.
What Are Hypermobility Spectrum Disorders?
Hypermobility Spectrum Disorders (HSD) are a group of conditions involving symptomatic joint hypermobility.
People with HSD have symptoms that are associated with their joint hypermobility but do not meet the established diagnostic criteria for another specific disorder, including hEDS.
HSD can present in different ways. Some individuals may have symptoms primarily affecting one or two areas, while others may experience more widespread musculoskeletal problems.
Symptoms may include:
Joint pain
Joint instability
Recurrent sprains
Soft-tissue injuries
Muscle fatigue
Reduced proprioception
Balance difficulties
Reduced exercise tolerance
Functional limitations
HSD is therefore more than simply having flexible joints. It involves hypermobility that is associated with symptoms or difficulties with physical function.
What Is Hypermobile Ehlers-Danlos Syndrome?
Hypermobile Ehlers-Danlos syndrome (hEDS) is one of the recognized types of Ehlers-Danlos syndrome, a group of heritable connective tissue disorders.
Connective tissue provides structure and support throughout the body and is found in structures such as skin, ligaments, tendons, blood vessels, and other tissues.
hEDS is characterized by generalized joint hypermobility along with additional clinical features.
People with hEDS may experience:
Generalized joint hypermobility
Joint instability
Recurrent subluxations or dislocations
Chronic musculoskeletal pain
Recurrent soft-tissue injuries
Easy bruising
Skin-related features
Muscle fatigue
Headaches
Gastrointestinal symptoms
Pelvic floor symptoms
Autonomic symptoms
Not every person with hEDS experiences all of these symptoms.
The presentation can vary considerably between individuals, which can sometimes make the condition difficult to recognize.
HSD vs. hEDS: What Is the Difference?
HSD and hEDS can have many overlapping symptoms, and distinguishing between them requires a clinical assessment.
One important difference is that hEDS has specific diagnostic criteria that include generalized joint hypermobility and additional systemic and musculoskeletal features.
HSD is used when an individual has symptomatic hypermobility but does not meet the criteria for hEDS or another specific connective tissue disorder.
Importantly, this does not mean that HSD is simply a "milder" version of hEDS.
People with HSD can experience substantial pain, fatigue, instability, and functional limitations.
The severity of symptoms cannot be determined simply by whether someone has an HSD or hEDS diagnosis.
What Causes Hypermobility Disorders?
The underlying causes of hypermobility disorders are complex.
In hEDS, there is evidence of a hereditary component. However, unlike several other Ehlers-Danlos syndromes, the specific genetic cause of hEDS has not yet been identified.
HSD is also not explained simply by having "loose joints." A combination of joint mobility, connective tissue characteristics, musculoskeletal factors, and other individual factors may contribute to symptoms.
Researchers continue to investigate the biological mechanisms involved in hypermobility disorders.
Common Symptoms of Hypermobility Disorders
Symptoms can vary significantly between individuals.
Joint Pain
Joint pain is one of the most common concerns associated with symptomatic hypermobility.
Pain may occur after:
Physical activity
Repetitive movements
Prolonged standing
Walking
Exercise
Maintaining one position for a long time
Pain may affect one joint or multiple areas of the body.
Joint Instability
Some individuals describe their joints as feeling loose, unstable, or difficult to control.
A joint may feel as though it is going to "give way," particularly during activities that place greater demands on stability.
Some people experience subluxations, where a joint partially moves out of its normal position, or dislocations, where the joint surfaces become completely displaced.
Recurrent Injuries
Repeated sprains and soft-tissue injuries can occur in people with symptomatic hypermobility.
This may include recurring:
Ankle sprains
Muscle strains
Tendon problems
Shoulder instability
Knee problems
Wrist or hand injuries
Repeated injuries can affect activity levels and confidence in movement.
Fatigue
Fatigue can be a significant symptom for some individuals with HSD or hEDS.
People may describe feeling unusually tired after activities that others seem to tolerate easily.
Fatigue can be influenced by many factors, including pain, physical effort, sleep, activity levels, and other symptoms associated with the condition.
Proprioception and Balance Difficulties
Proprioception is the body's ability to sense where a joint is positioned and how it is moving.
Some people with hypermobility disorders report difficulty with body awareness, coordination, or balance.
This can contribute to feelings of instability or uncertainty during movement.
Muscle Pain and Tension
Muscles may work harder to help control and stabilize hypermobile joints.
Some individuals experience persistent muscle tightness, aching, or fatigue as a result.
Interestingly, a person can have hypermobile joints while simultaneously feeling that certain muscles are very tight.
Headaches and Other Symptoms
Some individuals with hEDS or HSD report headaches, migraines, gastrointestinal symptoms, pelvic floor problems, sleep difficulties, or autonomic symptoms.
These symptoms are not present in everyone with a hypermobility disorder and can have many possible causes.
When symptoms occur across multiple body systems, a comprehensive medical assessment may be appropriate.
How Are Hypermobility Disorders Diagnosed?
There is no single test that diagnoses all hypermobility disorders.
Assessment generally involves a detailed medical history and physical examination.
A healthcare professional may consider:
Joint mobility
History of joint instability
Previous dislocations or subluxations
Recurrent injuries
Chronic pain
Family history
Skin and connective tissue features
Musculoskeletal findings
Other systemic symptoms
Alternative medical diagnoses
The Beighton Score
The Beighton score is commonly used to assess generalized joint hypermobility.
It evaluates flexibility at several joints, including:
Little fingers
Thumbs
Elbows
Knees
Spine
The score can help identify generalized joint hypermobility, but it does not diagnose HSD or hEDS by itself.
A person can have significant symptoms associated with hypermobility even if they do not demonstrate generalized hypermobility on a Beighton assessment.
Can You Develop Symptoms Later in Life?
Yes.
Some people may have been flexible throughout childhood without experiencing significant problems.
Symptoms may become more noticeable later due to factors such as:
Repeated injuries
Changes in physical activity
Deconditioning
Occupational demands
Hormonal changes
Aging
Increased physical demands
Changes in recovery or activity tolerance
Someone may therefore recognize symptoms of a hypermobility disorder in adolescence or adulthood even though they have always been naturally flexible.
Does Hypermobility Get Worse With Age?
Hypermobility itself does not necessarily mean that the joints will continually become more mobile.
In fact, some people become less flexible with age.
However, symptoms associated with hypermobility can change over time.
Previous injuries, reduced strength, changes in activity levels, altered movement patterns, and the cumulative effects of repeated joint instability may contribute to increasing symptoms for some individuals.
This is one reason why understanding and managing symptoms early can be helpful.
Hypermobility and Exercise
Having a hypermobility disorder does not mean that a person should avoid exercise.
However, individuals may have different tolerances for different activities.
Some people participate successfully in running, strength training, swimming, cycling, yoga, Pilates, dancing, and sports.
Others may need to modify the type, intensity, or duration of activities to manage symptoms.
The goal is generally to find physical activities that can be performed safely and sustainably rather than avoiding movement altogether.
Hypermobility and Mental and Emotional Well-Being
Living with chronic pain, unpredictable symptoms, recurrent injuries, or fatigue can be frustrating.
Some individuals may experience uncertainty about their bodies or become hesitant to participate in activities because they are worried about pain or injury.
People with hypermobility disorders may also experience a long journey toward diagnosis, particularly when symptoms involve multiple body systems or do not fit a straightforward pattern.
It is important that symptoms are taken seriously and evaluated within the individual's overall health history.
When Should You Seek Assessment?
Consider speaking with a healthcare professional if you experience persistent or recurring:
Joint pain
Joint instability
Sprains or soft-tissue injuries
Subluxations or dislocations
Unexplained muscle pain
Significant fatigue
Balance difficulties
Exercise intolerance
Widespread musculoskeletal symptoms
You may also want to discuss hypermobility with your healthcare provider if you have a family history of a connective tissue disorder or notice symptoms affecting multiple body systems.
A physiotherapist can assess musculoskeletal symptoms and functional limitations and may recommend further medical assessment when appropriate.
Patient Education and Self-Management
Understanding your condition can be an important part of managing a hypermobility disorder.
Rather than focusing solely on flexibility, it can be helpful to pay attention to:
Joint stability
Strength
Movement control
Activity tolerance
Recovery
Sleep
Pain patterns
Energy levels
Injury prevention
Keeping track of activities that consistently increase symptoms can also help identify patterns and guide discussions with your healthcare providers.
Importantly, there is no single strategy that works for everyone with HSD or hEDS. Management should be individualized according to symptoms, goals, and overall health.
Conclusion
Hypermobility disorders are much more complex than simply being flexible or "double-jointed." Hypermobility Spectrum Disorders and hypermobile Ehlers-Danlos syndrome can involve joint instability, chronic pain, recurrent injuries, fatigue, proprioceptive difficulties, and a range of other symptoms.
Because these conditions can present differently from one person to another, recognizing the broader pattern of symptoms is important.
A diagnosis of HSD or hEDS should be made using appropriate clinical criteria and consideration of other possible explanations for symptoms. Importantly, not everyone with joint hypermobility has a hypermobility disorder, and not everyone with a hypermobility disorder will experience the same symptoms.
If you are experiencing ongoing joint pain, instability, recurrent injuries, or other symptoms associated with hypermobility, speaking with a healthcare professional can be an important first step toward understanding your symptoms and developing an individualized plan for managing them.
At Integrative Physiotherapy & Wellness in Barrie, physiotherapy assessment can help identify musculoskeletal concerns associated with hypermobility and provide individualized support based on your symptoms and functional goals.
Contact Integrative Physiotherapy & Wellness today to book an assessment and learn more about managing the symptoms associated with hypermobility disorders.
References
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Hakim, A. (2024). Hypermobile Ehlers-Danlos syndrome. In GeneReviews®. University of Washington, Seattle.
Malfait, F., Francomano, C., Byers, P., Belmont, J., Berglund, B., Black, J., Bloom, L., Bowen, J. M., Brady, A. F., Burrows, N. P., Castori, M., Cohen, H., Colombi, M., Demirdas, S., De Backer, J., De Paepe, A., Fournel-Gigleux, S., Frank, M., Ghali, N., ... Zschocke, J. (2017). The 2017 international classification of the Ehlers-Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), 8–26.
Malfait, F., et al. (2020). The Ehlers-Danlos syndromes: Classification, diagnosis, and management. Journal of Medical Genetics, 57(4), 1–10.
Tinkle, B., Castori, M., Berglund, B., Cohen, H., Grahame, R., Kazkaz, H., & Scurlock, B. (2017). Hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders: An updated review. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), 48–69.
Hakim, A. J., & Grahame, R. (2003). A simple questionnaire to detect hypermobility: An adjunct to the assessment of patients with diffuse musculoskeletal pain. International Journal of Clinical Practice, 57(3), 163–166.
