Lumbosacral Instability in Hypermobile Patients
If you are naturally very flexible or have been told that you are hypermobile, you may also be familiar with recurring low back or pelvic pain.
Some people with joint hypermobility describe feeling as though their low back or pelvis is:
“Unstable”
“Loose”
Easily irritated
Tired after standing
Painful after repetitive bending or lifting
Better with support or compression
These symptoms may be related to lumbosacral instability or reduced movement control.
The lumbosacral region includes the lower lumbar spine, the sacrum, and the surrounding pelvis. In people with hypermobility, these areas may sometimes move more than the muscles and nervous system are able to comfortably control.
The good news is that physiotherapy can often help improve strength, coordination, confidence, and tolerance to daily activities.
What Is Joint Hypermobility?
Joint hypermobility means that one or more joints move beyond the range considered typical for most people.
For some people, being flexible causes no problems at all.
For others, hypermobility can be associated with:
Joint pain
Recurrent strains
Joint fatigue
Poor balance
Muscle tightness
A feeling of instability
Difficulty tolerating prolonged positions
Repeated flare-ups after activity
Hypermobility may occur on its own or as part of a hypermobility spectrum disorder or a connective tissue condition such as hypermobile Ehlers-Danlos syndrome.
Not everyone who is flexible has a medical condition, and not everyone with hypermobility develops pain.
What Causes Lumbosacral Instability in Hypermobile Patients?
The spine and pelvis rely on several systems working together.
These include:
Ligaments and connective tissues
Joints
Deep spinal muscles
Abdominal muscles
Pelvic floor
Hip and gluteal muscles
The nervous system's ability to sense and control movement
In hypermobile individuals, passive structures such as ligaments may provide less resistance at the end of a joint's range.
This means the muscles around the trunk and pelvis may need to work harder to provide control.
Over time, some people develop pain because their body is repeatedly moving into ranges that are difficult to control.
Common contributing factors may include:
Generalized joint hypermobility
Previous low back or pelvic injuries
Pregnancy and childbirth
Reduced core and hip strength
Repetitive bending or twisting
Prolonged standing
Heavy lifting
Poor endurance of trunk muscles
Sudden increases in exercise
Habitually standing or sitting at the very end of joint range
Reduced body awareness or proprioception
It is important to understand that pain does not necessarily mean that the spine is damaged or slipping out of place.
Often, the issue is more about how the area is being controlled and loaded.
What Are the Symptoms?
Symptoms can vary significantly from person to person.
Common complaints may include:
Aching across the lower back
Pain around the sacrum or sacroiliac joints
Pain after prolonged standing or sitting
Discomfort with repeated bending
Pain with lifting
Increased symptoms after exercise
A feeling that the back is “giving way”
A feeling of looseness or poor support
Muscle spasms
Tightness around the back, hips, or gluteal muscles
Difficulty maintaining one position
Temporary relief from belts, braces, or external support
Some people feel better when they constantly stretch.
However, in hypermobile patients, repeated stretching into already excessive ranges may sometimes worsen symptoms rather than improve them.
How Is It Diagnosed?
There is no single test that diagnoses lumbosacral instability in every patient.
A physiotherapy assessment usually considers the whole picture.
Your physiotherapist may assess:
Your history of hypermobility
Previous injuries
Pain patterns
Lumbar and pelvic movement
Hip movement
Core strength
Gluteal strength
Balance
Movement control
Proprioception
Posture
Breathing
Functional activities such as squatting, lifting, walking, or standing
Physiotherapists can assess hypermobility, movement control, strength, joint function, and the effect these factors have on pain and daily activity. However, physiotherapists do not diagnose hEDS based on a physiotherapy assessment alone.
If your history and examination raise concerns about a connective tissue disorder such as hEDS, your physiotherapist may recommend that you discuss this with your physician or another healthcare professional who is appropriately qualified to complete a broader medical assessment.
The physiotherapist can still identify and treat the physical problems contributing to your symptoms, such as reduced lumbopelvic control, muscle weakness, poor endurance, or difficulty managing load.
When Should You Seek Medical Attention?
Most mechanical low back pain is not dangerous.
However, seek medical assessment if back pain is accompanied by:
New bowel or bladder control changes
Numbness around the groin or saddle area
Progressive leg weakness
Severe unexplained pain
Significant trauma
Fever or feeling systemically unwell
Unexplained weight loss
A history of cancer with new persistent back pain
These symptoms require further medical assessment.
You Do Not Have to Avoid Exercise Because You Are Hypermobile
Hypermobility does not mean that your body is fragile. It does mean that your joints may rely more heavily on muscular control, strength, and coordination. For many people, the most effective strategy is not avoiding movement or repeatedly stretching. It is gradually building the strength and confidence to control movement well.
Physiotherapy can help identify which areas need more support, which movements are contributing to symptoms, and how to safely progress your activity. If recurring low back or pelvic pain is limiting your ability to exercise, work, stand, lift, or participate in daily activities, consider booking a physiotherapy assessment at Integrative Physiotherapy & Wellness.
An individualized program can help you improve strength, stability, and confidence while continuing to move in a way that works for your body.
References
The Ehlers-Danlos Society. Clinical resources related to hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome.
Castori M, Tinkle B, Levy H, et al. A Framework for the Classification of Joint Hypermobility and Related Conditions. American Journal of Medical Genetics Part C. 2017.
Russek LN, Stott P, Simmonds J. Recognition and rehabilitation of individuals with hypermobility-related conditions.
World Health Organization and international low back pain clinical guidance regarding exercise, activity, and conservative management of mechanical low back pain.
