Joint hypermobility

Terms Related to Joint Hypermobility

• Hypermobility: increased joint play
• Ligamentous hyperlaxity: increased flexibility of the bands of tissue that connect bones
• Hyperflexibility: extremely high flexibility
• "Double-jointed": an English expression used to describe a person who is very flexible, without any extra joints

What is joint hypermobility?

Joint hypermobility refers to a joint that moves beyond the range of motion typical for a person’s age. It can affect a single joint or multiple joints. It is important to distinguish between hypermobility in a single joint and generalized hypermobility.

Generalized hypermobility affects multiple joints in different parts of the body. The Beighton score assesses certain movements of the fingers, elbows, knees, and trunk on a scale of up to nine points. It helps identify generalized joint hypermobility, but it is not sufficient on its own to confirm or rule out the diagnosis. The evaluation must also take into account joints not included in the score, as well as symptoms, past injuries, and other signs of health¹. Flexibility may be partly hereditary and can vary with age and training. High flexibility is sometimes associated with an inherited condition—that is, one passed down through families—such as certain Ehlers-Danlos syndromes. These conditions affect the tissues that support and connect the various parts of the body. Generalized joint hypermobility is frequently present in this type of connective tissue disorder². When pain-free, generalized hypermobility—greater flexibility in multiple joints—is not a disease in itself. In some people, it may be accompanied by sprains (ligament injuries), repetitive-stress injuries, or pain that develops later.³

Hypermobility covers a wide range. It ranges from flexibility that causes no problems to extreme flexibility associated with pain or a connective tissue disorder—that is, a disorder affecting the tissue that supports and connects the body’s parts. Being flexible is therefore not automatically a health problem.

The following section focuses primarily onhypermobility in a single joint. Research on generalized conditions is identified as such. A very flexible joint does not automatically cause pain; the evaluation also looks for other possible causes.

What are the causes of joint hypermobility?

Joint hypermobility may be related to the characteristics of the tissues that support the joint, to exercise, or to an injury. A distinction is made between flexibility present from birth and flexibility that develops later:

• Congenital (meaning you are born with it)
• Acquired (meaning you develop it at some point)

Two situations can help us understand flexibility that has emerged or been recognized later on:

• There are many highly flexible people in activities that require a great deal of flexibility. In a study of 132 elite adolescent athletes, hypermobility was more common in dance and gymnastics than in handball⁴. Diving also requires a high degree of flexibility, but the studies presented here focus on dance, gymnastics, and handball. Comparing these athletes does not allow us to distinguish the effect of training from the selection of individuals who are already flexible. A small study of 23 first-year ballet students, who had little or no prior training, found that they were already more hypermobile than children of the same age who did not take ballet, which supports the selection hypothesis but does not prove it on its own⁵.
• After a serious injury, a joint may become more mobile and feel as if it is dislocated. Surgery can also alter a joint’s mobility; the effects depend on the specific procedure. Excessive flexibility and instability—that is, difficulty keeping the joint in place during activities—are not the same thing. After an initial injury-related shoulder dislocation, in which the bone slips out of its socket, instability may recur in some adults. Increased joint play is associated with this risk⁶. In people who have had repeated dislocations, a study also observed greater laxity of the capsule—the membrane surrounding the joint—though it could not prove that the dislocations had caused it⁷. The evaluation therefore takes into account the flexibility present before the injury. After a shoulder dislocation, treatment also depends on the injured tissues, previous episodes, and your activities.

What are the symptoms of joint hypermobility?

Joint hypermobility may be accompanied by pain, a feeling of looseness, or a locking sensation, but it can also be asymptomatic. Pain may sometimes develop over time. It is important to understand that just because you have hypermobility does not mean you will experience symptoms. Many hypermobile people have no pain at all, although symptoms may develop later in some³. Among college students aged 18 to 25, hypermobile individuals did not report more chronic pain—defined as pain lasting longer than three months—than others⁸, but this single-point-in-time observation does not allow us to predict their lifelong course.

When a very flexible joint becomes painful, the pain can become chronic. In a study of 654 college students aged 18 to 25, the proportion of people reporting an injury did not differ based on their flexibility score⁸. (Reuter and Fichthorn, 2019)

A painful hypermobile joint is characterized by the following:

• Very high flexibility of the painful joint

People may also report the following:

• Feeling that your joint has some play in it or is dislocating
• To have had several in the past joint dislocations, in which the bone slips out of its socket
  
  • This is relative to the shoulder, for example.
• Sometimes feeling as if the joint is locking up

How is joint hypermobility diagnosed?

The physical therapist identifies joint hypermobility by measuring range of motion and reviewing your symptoms and past injuries. This evaluation includes observing movement and performing tests specific to the joint. The physical therapist also checks whether certain areas are particularly flexible and whether other signs warrant a medical evaluation. The Beighton score can contribute to this evaluation, but it is not a substitute for it.

When should you see a physiotherapist for joint hypermobility?

A physical therapy appointment is recommended when pain, a feeling of instability, or difficulty moving limits your activities. Good flexibility without pain or difficulty does not automatically require treatment.

You do not need to see a doctor before starting physical therapy. The physical therapist will refer you to a doctor if the evaluation warrants it, particularly if a condition affecting multiple tissues is suspected.

What physiotherapy treatments are available for joint hypermobility?

Physical therapy treats the symptoms of hypermobility through exercises, advice, and training for challenging activities. Treatment begins with an evaluation that guides the exercises and explanations⁹. For generalized disorders related to hypermobility and Ehlers-Danlos syndrome, hypermobile type, exercises and learning to control movements are the most well-supported interventions¹⁰. The program may also include guided manual movements for stiff adjacent joints and advice on activity levels. Research provides less robust support for these specific components; their inclusion depends on the assessment and your response.

Your physical therapist will conduct an evaluation to identify the factors contributing to your pain. Depending on your symptoms, this evaluation may include the following:

• The possible movements of your joint
• The sensitivity and response of nerves to movement
• Control and fluidity of your movements
• Your strength and your ability to control joint movement during activities

Based on the results of the evaluation, your physical therapist may:

• Use your hands to guide the movements of nearby joints that move less
• Suggest exercises to build strength and improve control of your joint
• Choose exercises to help you learn how to control your movements
• Work with you to adjust the duration, frequency, and intensity of your activities based on your symptoms and recovery
• Provide tips on how to vary your posture and adjust your movements.

The program is designed to improve joint control and make activities easier. The exercises work on both muscle strength and movement awareness³, and research on generalized disorders supports these exercises and the development of movement control¹⁰. The physical therapist selects the range and direction of movement based on the patient’s abilities, symptoms, and target activities.

What can you do at home for joint hypermobility?

Home care involves a combination of appropriate activities, rest periods, and a gradual resumption of movements you can tolerate. Temporarily limit movements that cause too much pain, then gradually resume them. Continue with activities that remain tolerable. A splint—a support that restricts certain movements—or taping (adhesive tape applied to the skin) can sometimes complement your care⁹. Kinesiology taping can provide temporary relief. In a study of people with hypermobile Ehlers-Danlos syndrome and shoulder pain, two taping techniques were associated with improvements in pain and functional ability at 48 hours. The absence of a control group without taping limits the extent to which the improvement can be attributed to the tape itself. Study by Tudini et al., 2023. Your healthcare provider will check with you to see if the chosen aid actually improves your comfort and ability to perform daily activities.

Avoid forcing a painful joint to make it crack or to show how far it can move.

If you don't see any improvement despite these adjustments, consult a physical therapist.

Signs That Require Urgent Medical Attention

A joint that appears to be dislocated after an injury should be evaluated in the emergency room. Do not attempt to put it back in place yourself. For a shoulder injury, seek immediate medical attention if you cannot move your arm. NHS advice on shoulder dislocation.

Sources

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2. Scheper MC, de Vries JE, Verbunt J, Engelbert RH. Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome (hypermobility type): a challenge. J Pain Res. 2015;8:591-601. (Back to section: 1)
3. Tinkle BT. Symptomatic joint hypermobility. Best Pract Res Clin Rheumatol. 2020;34(3):101508. (Back to sections: 1, 2, 3)
4. Schmidt H, Pedersen TL, Junge T, Engelbert R, Juul-Kristensen B. Hypermobility in Adolescent Athletes: Pain, Functional Ability, Quality of Life, and Musculoskeletal Injuries. J Orthop Sports Phys Ther. 2017;47(10):792-800. (Back to section: 1)
5. Nilsson C, Wykman A, Leanderson J. Spinal sagittal mobility and joint laxity in young ballet dancers. A comparative study between first-year students at the Swedish Ballet School and a control group. Knee Surg Sports Traumatol Arthrosc. 1993;1(3-4):206-8. (Back to section: 1)
6. Olds M, Ellis R, Donaldson K, Parmar P, Kersten P. Risk factors that predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med. 2015;49(14):913-22. (Back to section: 1)
7. Ng AW, Chu CM, Lo WN, Lai YM, Kam CK. Assessment of capsular laxity in patients with recurrent anterior shoulder dislocation using MRI. AJR Am J Roentgenol. 2009;192(6):1690-5. (Back to section: 1)
8. Reuter PR, Fichthorn KR. Prevalence of generalized joint hypermobility, musculoskeletal injuries, and chronic musculoskeletal pain among American college students. PeerJ. 2019;7:e7625. (Back to sections: 1, 2)
9. Simmonds JV, Keer RJ. Hypermobility and the hypermobility syndrome. Man Ther. 2007;12(4):298-309. (Back to sections: 1, 2)
10. Garreth Brittain M, Flanagan S, Foreman L, Teran-Wodzinski P. Physical therapy interventions in generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome: a scoping review. Disabil Rehabil. 2024;46(10):1936-1953. (Back to sections: 1, 2)
11. Eccles JA, Beacher FD, Gray MA, Jones CL, Minati L, Harrison NA, et al. Brain structure and joint hypermobility: relevance to the expression of psychiatric symptoms. Br J Psychiatry. 2012;200(6):508-9.
12. Boudreau PA, Steiman I, Mior S. Clinical management of benign joint hypermobility syndrome: a case series. J Can Chiropr Assoc. 2020;64(1):43-54.