Physical Therapy for Joint Hypermobility

Physical Therapy for Joint Hypermobility

Physical therapy for joint hypermobility uses strength, balance, and movement control exercises to help reduce pain and provide better support for the joints. Hypermobility means that the joints move farther than usual. It does not automatically require treatment: some people experience neither pain nor difficulty.

Exercise can help improve symptoms and daily activities. Results vary from person to person, and studies do not allow for a one-size-fits-all program. The physical therapist will tailor the exercises to your needs and your progress.

What is joint hypermobility?

Joint hypermobility refers to joints that move beyond their normal range of motion¹. This condition is common; its prevalence varies greatly depending on age, sex, ethnicity, and the criteria used to define it, and it is more commonly observed in women and children.² Generalized hypermobility is the term used when multiple joints are affected.

The Beighton score evaluates five movements and yields a total of nine points, since four movements are tested on both sides.³ This score measures mobility; it is not sufficient to make a diagnosis. The revised 2017 criteria typically require a score of at least 5 out of 9 after growth is complete and up to age 50 inclusive, and at least 4 points after age 50. The evaluation also takes into account your previous flexibility, symptoms, and other possible diagnoses. These details are outlined in the clinical guidelines for hypermobile Ehlers-Danlos syndrome.

Older studies often used a threshold of 4 out of⁹.^{3, 2}. For children and adolescents who are still growing, the 2023 pediatric guidelines use a threshold of 6 out of 9 for the generalized form, with an age-appropriate assessment. The tests include the following movements; do not force them just to give yourself a score:

• Gently bring each thumb toward the inner side of the forearm, the section between the elbow and the wrist
• Raise each little finger to an angle of more than 90 degrees relative to the hand
• Exceed the upright position by more than 10 degrees at each elbow and each knee
• Touch the floor with your palms, legs straight

Asymptomatic hypermobility is a sign of flexibility. Hypermobility spectrum disorders, often abbreviated as HSD, refer to hypermobility that is accompanied by symptoms such as pain, instability, or injuries and that is not better explained by another condition.^{4, 5, 1} A medical evaluation helps make this distinction.

How does physical therapy help people with hypermobility?

Physical therapy helps people with hypermobility build strength, gain better control over their movements, and resume their activities.⁶Ligaments—bands of tissue that connect bones—contribute to stability. Muscles provide active support that can be trained. Treatment does not involve mechanically tightening all the ligaments.

The program focuses on strengthening the muscles around the joints, proprioception—that is, the perception of their position—and neuromuscular control, which is the coordination of muscles during movement. A review published in 2024 compiled 28 studies involving 630 participants, mostly women. It supports exercises and movement training for people with HSD, or hypermobile Ehlers-Danlos syndrome (hEDS).⁷ The studies vary widely and do not establish an ideal dosage for everyone.

Our physical therapists assess muscle and joint pain and then tailor exercises and advice to your specific challenges. The goal is to help you resume the activities that matter to you, taking into account your stability, fatigue, and other health issues.

What are the symptoms of joint hypermobility?

Symptomatic hypermobility can cause joint pain, a feeling that the joint is loose, partial dislocations, and repeated sprains. A sprain is an injury to a ligament. Some people also experience fatigue or dizziness; other hypermobile individuals have no symptoms at all.

Joint pain may persist or worsen with certain activities. A subluxation is a partial dislocation of the joint; a shoulder dislocation is a complete dislocation. Sprains, including those of the lower back, can also recur.^{8, 5} These symptoms warrant an evaluation, even if they follow mild exertion.

Conditions related to hypermobility may also be accompanied by fatigue, reduced stamina, dizziness upon standing, digestive problems, and sleep disturbances.^{9, 5} Dizziness upon standing is not necessarily caused by inner-ear vertigo. Report these symptoms to your doctor so that the cause can be determined and treatment adjusted accordingly.

Pain intensity cannot be determined by flexibility alone. Some people who are very hypermobile have few symptoms, while others who are less hypermobile experience significant pain. The assessment also takes into account injuries, activities, fatigue, sleep, and other factors that influence how you feel.

A review of 18 studies found an increased risk of knee injuries among hypermobile individuals who participate in contact sports. It did not find a clear increase in ankle injuries.¹⁰ This does not guarantee the absence of ankle risk. Persistent pain also requires management that takes into account its variety and its impact on daily life.¹¹

What physical therapy exercises are recommended for hypermobility?

Exercises for hypermobility include muscle strengthening, balance exercises, and movement control exercises. They may include a modified chair rise, balance exercises near a support, and slow movements with resistance. The choice and difficulty level depend on which joints are painful and on your abilities.

Targeted muscle strengthening

Strength-training exercises target the muscles that support the joints. An eccentric contraction works the muscle as it lengthens—for example, when you slow down your descent into a chair. A 2014 review reported improvements from exercise, but found no convincing evidence that any specific type was better than another in the four available studies.¹² More recent research helps clarify certain options, without prescribing a single program.

Depending on your needs, the physical therapist will work on the quadriceps at the front of the thighs and the hamstrings at the back, the abdominal and back muscles for core strength, or the rotator cuff—a group of four muscles that help support and rotate the shoulder. The therapist will adjust the resistance and number of repetitions based on your control and recovery.

After an initial traumatic shoulder dislocation caused by an injury, greater laxity—that is, more play in the joint—is associated with a higher rate of recurrent instability.¹³ Follow-up takes this risk into account without predicting that another dislocation will occur.

Proprioceptive Exercises

Proprioception allows you to sense the position of a joint without looking at it. It may be less accurate in some people with hypermobility. Appropriate exercises can improve this perception and reduce pain.^{14, 15} One example is standing on one leg near a stable counter, using your hand for support if needed. A less stable surface or closing your eyes should only be added if the exercise remains under control and a fall can be prevented.

Neuromuscular control

Neuromuscular control exercises help improve muscle coordination during a movement. The physical therapist may have you practice climbing a step or performing a slow arm movement, and then adjust the speed or resistance. The goal is to improve your control over the movements needed for your daily activities, including their range of motion when appropriate.¹⁶

Progression begins with movements you can control. The load, duration, or difficulty is then increased based on your tolerance. It is not necessary to achieve perfect control or to permanently avoid any extension beyond the straight position. New pain, increased instability, or worsening symptoms require a reassessment of the exercise.

How long does physiotherapy treatment last?

Initial treatment for hypermobility often lasts several weeks or months, after which follow-up care is adjusted as needed. A review of six trials describes programs lasting 4 to 8 weeks. A trial described below tracks shoulder pain over a 16-week period. These time frames do not predict how long it will take you to recover.

In a preliminary physical therapy study, 29 participants were assigned to either counseling alone or counseling combined with six sessions over four months.¹⁷ This small trial primarily assessed the feasibility of a larger study. For shoulder conditions, a trial involving 100 adults who had experienced symptoms for at least three months compared two 16-week programs. The program with higher loads and more supervision improved scores on a questionnaire about shoulder-related symptoms and activities more than the one with lower loads. However, the average difference was below the threshold chosen for a considered significant improvement, and muscle soreness and headaches were more common.

At the one-year follow-up, the advantage in terms of the overall score was no longer clear. Some results regarding shoulder-related emotions remained favorable for high loads. These results support a structured progression, not an automatic transition to heavy weights.

After the initial sessions, the exercises can be continued at home, with reassessments as needed. Mobility can change with age, injuries, and training; therefore, hypermobility is not a fixed range of motion for life. However, certain genetic predispositions and symptoms may persist.¹⁸ The clinical guide on hEDS describes this variability. The frequency of appointments depends on your needs, such as after an injury or a change in symptoms.

A specific issue, such as instability between the skull and the upper neck, may require a medical evaluation and specially adapted exercises.¹⁹

The duration of treatment depends on the affected joints, pain, fatigue, other health issues, and your goals. The physical therapist also takes into account any barriers to exercise, such as a lack of energy or daily life constraints. Slow progress does not necessarily mean you are not trying hard enough.

Physical therapy aims to help you become more independent in choosing your activities and managing your symptoms. Some people need reassessments at various times; this does not mean that regular sessions will be necessary for the rest of your life.

Hypermobility and Ehlers-Danlos syndrome: What's the difference?

Hypermobility is a characteristic of movement, whereas HSD and hypermobile Ehlers-Danlos syndrome are diagnoses that take into account symptoms and other signs. hEDS is a condition—often inherited—that affects the tissues that support and connect the body’s structures, known as connective tissues. The difference is not simply a matter of greater flexibility or more severe pain.

Asymptomatic hypermobility may not require any treatment. You can continue your usual activities while being mindful of your comfort. If you experience pain, instability, or repeated injuries, you should seek an evaluation.

HSD can be diagnosed when hypermobility is accompanied by muscle or joint problems, after ruling out other causes. It does not meet the criteria for hEDS, but its symptoms can be just as severe and may require treatment.^{20, 1}

Hypermobile Ehlers-Danlos syndrome is diagnosed based on a set of clinical criteria revised in 2017, after growth has ceased.⁴ These criteria combine hypermobility, signs affecting other tissues, family history or certain complications, and the exclusion of other diseases. hEDS may be accompanied by more elastic skin, easy bruising, or digestive and circulatory problems. Its exact genetic cause is unknown; currently, no genetic test can confirm this diagnosis. However, a doctor may order tests to rule out other conditions.

hEDS can affect several bodily functions and may require consultations with various medical specialists. Other joint disorders may also occur alongside it.²¹ The doctor therefore looks for the causes of new symptoms rather than attributing everything to hypermobility.

The diagnosis guides medical management and preventive measures. In physical therapy, patients with either condition can benefit from strength training, movement control exercises, and guidance. The program takes all symptoms into account, not just ligaments or flexibility.

How can you prevent injuries caused by hypermobility?

Injury prevention aims to improve strength, gradually prepare for activities, and adjust movements that cause discomfort. These habits can help you better control your joints; they do not guarantee that you will not get injured.

Adjust positions that become uncomfortable

A position at the end of the range of motion, near the limit of movement, can be adjusted if it becomes uncomfortable. You can then keep your knee slightly bent, adjust how you rest your elbow, or switch to a “W” sitting position, with your legs folded to either side.²² These are temporary options, not a general prohibition against stretching the joints. The position alone does not prove that a ligament is damaged.

A small trial involving children and adolescents aged 7 to 16 with knee pain compared exercises performed up to the straight-leg position with exercises that involved greater knee extension. Pain decreased in both groups; some quality-of-life outcomes favored one group over the other. This study does not support recommending the same range of motion for everyone, especially after an injury or dislocation.

Regular preventive maintenance

A routine of strength and balance exercises helps maintain the abilities needed for daily activities. The muscle groups targeted and the frequency of exercise should be tailored to your needs; there is no need to treat asymptomatic hypermobility as if it were an injury. However, the risk may increase in certain situations, particularly in the knee during contact sports.¹⁰

Appropriate warm-up and cool-down

A gradual warm-up prepares the body for the movements involved in the activity—for example, walking before increasing your speed or starting with low resistance. A stiff muscle can sometimes benefit from gentle stretching, as explained in the Ehlers-Danlos Society’s physical therapy fact sheet. The physical therapist helps stretch stiff areas without putting additional strain on a joint that is already very mobile. It is not necessary to constantly strive for greater flexibility.

Paying attention to body language

Your symptoms and your control over the movement guide any adjustments. If the joint feels like it’s giving way, reduce the difficulty or modify the movement. Take breaks when fatigue makes it harder to control the movement. If pain increases, moves to a different area, or further limits your activities, you should reassess the program rather than push through it.

Joint hypermobility and physical activity: Are they compatible?

Physical activity is compatible with hypermobility as long as the exercises are tailored to your abilities and take into account the precautions associated with your diagnosis. We’ll work with you to choose the right activities; the presence of an unstable joint or another medical condition may require adjustments.

Swimming, aqua aerobics, cycling, and strength training may be appropriate depending on your symptoms. Water supports part of your body weight; bicycles can be adjusted to allow for comfortable pedaling. Pilates and yoga can also be adapted with a professional who is aware of your condition. The goal is to control your movements, not to constantly push your flexibility to the limit. In a small study of 18 people, eight weeks of home exercises improved pain, balance, and perception of knee position.²³ This study, which lacked a control group, does not prove that all these activities produce the same results.

Repeated jumping, contact sports, gymnastics, and rapid movements may require additional preparation or be discouraged if the joint remains unstable. The hEDS clinical guidelines recommend making decisions on a case-by-case basis. People with other forms of the condition, such as vascular Ehlers-Danlos syndrome, which weakens blood vessels, should take special precautions and follow the advice of their healthcare team.

To make progress, choose an activity you can tolerate, gradually increase its duration or difficulty, and allow time for recovery. Combine endurance, strength, and balance exercises as needed. If your symptoms worsen or you lose control, return to a level you can tolerate better and seek advice.

Some hypermobile people participate in intense or competitive sports. Their training takes into account previous injuries, their stability, their recovery, and other health issues. The choice of sport and intensity is discussed on an individual basis; flexibility alone does not determine everything.

When should joint pain be treated by a doctor?

A dislocated joint, an inability to walk or put weight on a limb, or severe pain following an injury requires evaluation in the emergency room. Don’t assume it’s just due to your hypermobility.

• Go to the emergency room if a joint is dislocated or if you are unable to walk or put weight on your leg, even if you haven't recently been injured.
• After a fall or injury, severe pain, tingling, or a loss of sensation around the joint also warrant this evaluation.
• Seek urgent medical attention if a painful joint is swollen and warm, or if the pain is accompanied by general malaise, fever, or sensations of heat, cold, or chills.

These guidelines follow the NHS recommendations on joint pain. For non-urgent symptoms, seek medical attention if the pain or swelling worsens, recurs frequently, interferes with sleep or daily activities, or if stiffness upon waking lasts longer than 30 minutes. Joint problems in children also warrant an evaluation.

References

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1. Castori M, Tinkle B, Levy H, Grahame R, Malfait F, Hakim A. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet C Semin Med Genet. 2017;175(1):148-157. (Back to sections: 1, 2, 3)
2. Remvig L, Jensen DV, Ward RC. Epidemiology of general joint hypermobility and the basis for the proposed criteria for benign joint hypermobility syndrome: a review of the literature. J Rheumatol. 2007;34(4):804-9. (Back to sections: 1, 2)
3. Beighton P, Solomon L, Soskolne CL. Joint mobility in an African population. Ann Rheum Dis. 1973;32(5):413-8. (Back to sections: 1, 2)
4. Malfait F, Francomano C, Byers P, Belmont J, Berglund B, Black J, et al. The 2017 International Classification of Ehlers-Danlos Syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):8-26. (Back to sections: 1, 2)
5. Yew KS, Kamps-Schmitt KA, Borge R. Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders. Am Fam Physician. 2021;103(8):481-492. (Back to sections: 1, 2, 3)
6. Engelbert RH, Juul-Kristensen B, Pacey V, de Wandele I, Smeenk S, Woinarosky N, et al. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers-Danlos syndrome. Am J Med Genet C Semin Med Genet. 2017;175(1):158-167. (Back to section: 1)
7. 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 section: 1)
8. Castori, M. Ehlers-Danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations. ISRN Dermatol. 2012;2012:751768. (Back to section: 1)
9. Chopra P, Tinkle B, Hamonet C, Brock I, Gompel A, Bulbena A, et al. Pain management in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):212-219. (Back to section: 1)
10. Pacey V, Nicholson LL, Adams RD, Munn J, Munns CF. Generalized joint hypermobility and risk of lower limb joint injury during sports: a systematic review with meta-analysis. Am J Sports Med. 2010;38(7):1487-97. (Back to sections: 1, 2)
11. 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)
12. Palmer S, Bailey S, Barker L, Barney L, Elliott A. The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review. Physiotherapy. 2014;100(3):220-7. (Back to section: 1)
13. 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)
14. Sahin N, Baskent A, Cakmak A, Salli A, Ugurlu H, Berker E. Evaluation of knee proprioception and the effects of proprioception exercises in patients with benign joint hypermobility syndrome. Rheumatol Int. 2008;28(10):995-1000. (Back to section: 1)
15. Daman M, Shiravani F, Hemmati L, Taghizadeh S. The effect of combined exercise therapy on knee proprioception, pain intensity, and quality of life in patients with hypermobility syndrome: A randomized clinical trial. J Bodyw Mov Ther. 2019;23(1):202-205. (Back to section: 1)
16. Tinkle BT. Symptomatic joint hypermobility. Best Pract Res Clin Rheumatol. 2020;34(3):101508. (Back to section: 1)
17. Palmer S, Cramp F, Clark E, Lewis R, Brookes S, Hollingworth W, et al. The feasibility of a randomized controlled trial of physical therapy for adults with joint hypermobility syndrome. Health Technol Assess. 2016;20(47):1-264. (Back to section: 1)
18. Carbonell-Bobadilla N, Rodríguez-Álvarez AA, Rojas-García G, Barragán-Garfias JA, Orrantia-Vertiz M, Rodríguez-Romo R. [Joint hypermobility syndrome]. Acta Ortop Mex. 2020;34(6):441-449. (Back to section: 1)
19. Russek LN, Block NP, Byrne E, Chalela S, Chan C, Comerford M, et al. Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations. Front Med (Lausanne). 2022;9:1072764. (Back to section: 1)
20. Tinkle B, Castori M, Berglund B, Cohen H, Grahame R, Kazkaz H, et al. Hypermobile Ehlers-Danlos syndrome (also known as Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome, hypermobility type): Clinical description and natural history. Am J Med Genet C Semin Med Genet. 2017;175(1):48-69. (Back to section: 1)
21. Rodgers KR, Gui J, Dinulos MB, Chou RC. Ehlers-Danlos syndrome, hypermobility type, is associated with rheumatic diseases. Sci Rep. 2017;7:39636. (Back to section: 1)
22. Scheper MC, Engelbert RH, Rameckers EA, Verbunt J, Remvig L, Juul-Kristensen B. Children with generalized joint hypermobility and musculoskeletal complaints: state of the art on diagnostics, clinical characteristics, and treatment. Biomed Res Int. 2013;2013:121054. (Back to section: 1)
23. Ferrell WR, Tennant N, Sturrock RD, Ashton L, Creed G, Brydson G, et al. Improvement in symptoms through enhanced proprioception in patients with joint hypermobility syndrome. Arthritis Rheum. 2004;50(10):3323-8. (Back to section: 1)
24. Rombaut L, Malfait F, De Wandele I, Mahieu N, Thijs Y, Segers P, et al. Muscle-tendon tissue properties in the hypermobility type of Ehlers-Danlos syndrome. Arthritis Care Res (Hoboken). 2012;64(5):766-72.
25. Juul-Kristensen B, Schmedling K, Rombaut L, Lund H, Engelbert RH. Measurement properties of clinical assessment methods for classifying generalized joint hypermobility—A systematic review. Am J Med Genet C Semin Med Genet. 2017;175(1):116-147.
26. Bloom L, Byers P, Francomano C, Tinkle B, Malfait F, Steering Committee of the International Consortium on the Ehlers-Danlos Syndromes. The International Consortium on the Ehlers-Danlos Syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):5-7.