Physical Therapy for Joint Hypermobility

Physical Therapy for Joint Hypermobility

Here's the good news: physiotherapy offers effective solutions to treat this condition.

What is joint hypermobility?

Joint hypermobility refers to a range of motion in the joints that is greater than^normal.¹ This condition affects approximately 10 to 30% of the general population, with a higher prevalence among women and^children.² The term "generalized hypermobility" is used when multiple joints are affected.

The diagnosis is based on the Beighton score, a standardized assessment system comprising nine flexibility tests. A score of 5 out of 9 or higher indicates^generalized hypermobility^.³ These tests assess, in particular, the ability to:

• Bend your thumb all the way to your wrist
• Extend your little finger beyond 90 degrees
• Over-extend your elbows and knees
• Touch the floor with your palms, legs straight

There is an important distinction between asymptomatic hypermobility and hypermobility spectrum disorders (HSD). In the latter case, hypermobility is accompanied by symptoms such as chronic pain, fatigue, and^joint instability^.⁴

Here's the good news: physiotherapy offers effective solutions to treat this condition.

How does physical therapy help with joint hypermobility?

Physical therapy is the cornerstone of treatment for^joint hypermobility.⁵ Unlike ligaments that are too loose—which cannot be “tightened”—physical therapy compensates for this laxity by strengthening the stabilizing muscles around the joints.

The mechanisms of action include strengthening the periarticular muscles to ensure stability, improving proprioception (the sense of joint position in space), and developing neuromuscular control to prevent excessive movement. Research shows that therapeutic exercises and motor training are effective in reducing pain and improving function in people with HSD and hypermobile Ehlers-Danlos syndrome (hEDS)⁶.

As physical therapists specializing in musculoskeletal rehabilitation, our approach focuses on restoring functional stability while taking into account the unique aspects of your condition. We use personalized treatment plans based on the latest evidence to help you return to an active life free from pain and limitations.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

What are the symptoms of joint hypermobility?

The symptoms of joint hypermobility vary greatly from person to person. Some people with hypermobility experience no symptoms at all, while others face significant challenges in their daily lives.

The most common musculoskeletal symptoms include chronic joint pain that worsens with activity, a feeling of instability or that the joint is “loose,” frequentsubluxations (partial dislocation of the joint), and recurrent sprains, even during^light activities.^⁷

In addition to joint issues, hypermobility may be accompanied by generalized fatigue and reduced stamina, positional dizziness (when standing up quickly), gastrointestinal problems, and sometimes sleep disturbances related to^pain.^⁸

It is important to note that the severity of symptoms does not always reflect the degree of hypermobility. Some people with severe hypermobility have few symptoms due to good muscle strength, while others with moderate hypermobility may experience significant pain.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

What physical therapy exercises are recommended for hypermobility?

The exercise program for joint hypermobility focuses on three key areas: muscle strengthening, proprioception, and neuromuscular control.

Targeted muscle strengthening

Strengthening exercises primarily target the stabilizing muscles around hypermobile joints. Research has demonstrated the effectiveness of eccentric strengthening (contracting the muscle as it lengthens) in improving^joint control. Priority areas often include strengthening the quadriceps and hamstrings for the knees, core stability exercises (deep abdominal muscles, back muscles) to protect the spine, and strengthening the rotator cuff for unstable shoulders.

Proprioceptive Exercises

Proprioception is often impaired in people with hypermobility. Balance and body awareness exercises help improve this function. These may include standing on one leg with eyes open and then closed, using unstable surfaces (balance cushion, wobble board), and performing slow, controlled movements with limited range of motion (to avoid hyperextension)¹⁰.

Neuromuscular control

These exercises teach the nervous system to activate the stabilizing muscles at the right moment. We focus on consciously activating the muscles before movement, coordination between different muscle groups, and the ability to hold a position without moving to the full^{range of motion11}.

Progression is key: start with simple exercises in a stable position, then gradually increase the complexity, load, and instability. The key is to maintain perfect control without ever forcing the joint into hyperextension.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

How long does physiotherapy treatment last?

The duration of physical therapy treatment for joint hypermobility varies depending on the severity of symptoms and individual goals. However, certain general timeframes are typically observed.

The initial intensive phase typically lasts 8 to 12 weeks. During this period, sessions are held 1 to 2 times a week, with a focus on learning proper exercise techniques and building^core strength^.¹³ This is when you will generally begin to notice the first improvements in pain relief and stability.

After the initial phase, a long-term maintenance program is essential. The frequency of sessions gradually decreases (to every 2–4 weeks), but maintaining a regular home exercise routine becomes crucial. Since hypermobility is a permanent characteristic of your tissues, consistency in exercising is key to maintaining the gains^{you’ve achieved14}.

Factors that influence the duration of treatment include the number of affected joints, the presence of chronic pain, your adherence to the home exercise program, and your specific goals (returning to sports, performing daily activities without pain, etc.).

It is important to understand that physical therapy for hypermobility is not a one-time “cure,” but rather a process of learning how to manage your condition over the long term.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

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

There is often confusion between joint hypermobility, hypermobility spectrum disorders (HSD), and hypermobile Ehlers-Danlos syndrome (hEDS). Here are the key distinctions.

Benign joint hypermobility simply refers to excessive joint range of motion without any associated symptoms. People with this condition are often flexible and experience neither pain nor instability. No treatment is necessary unless symptoms develop.

Hypermobility spectrum disorders (HSD) occur when hypermobility is accompanied by musculoskeletal symptoms (pain, instability, fatigue) without meeting the strict criteria for^hEDS15. It is the most common diagnosis for symptomatic hypermobile individuals.

Hypermobile Ehlers-Danlos syndrome (hEDS) is a genetic connective tissue disorder with very specific diagnostic criteria established in^2017¹⁶. In addition to hypermobility, hEDS often involves systemic manifestations (hyperelastic skin, tissue fragility, and cardiovascular or gastrointestinal problems).

This distinction is important for prognosis and overall management, but the physical therapy approach remains similar: strengthening, stabilization, and education. Whether you have HSD or hEDS, the principles of treatment aim to compensate for ligament laxity through muscle strength.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

How can you prevent injuries caused by hypermobility?

Injury prevention for people with hypermobility relies on several complementary strategies that your physical therapist can teach you.

Avoid positions at the end of the range of motion

One of the golden rules is to never "lock" or hyperextend your joints. This means keeping your knees slightly bent rather than fully extended when standing, keeping your elbows in a neutral position rather than hyperextended, and avoiding sitting in a W-sitting position (with your legs folded to either side)^¹⁷. These extreme positions place excessive strain on already loose ligaments and increase the risk of pain and premature wear and tear.

Regular preventive maintenance

Maintaining a routine of strength and proprioception exercises is essential, even when you are not experiencing pain. It is recommended that you perform stabilization exercises 3 to 4 times a week, vary the types of exercises to engage different muscles, and include core strengthening in each^{session.¹⁸}

Appropriate warm-up and cool-down

Before any physical activity, a gradual warm-up is essential. It should include controlled dynamic movements (no excessive static stretching), activation of the stabilizing muscles, and a gradual build-up to the target intensity. Passive stretching at the end of the range of motion is generally not recommended for people with hypermobility, as it can worsen ligament laxity.

Paying attention to body language

Learning to recognize and heed your body’s warning signs is essential. If you feel unstable during an activity, reduce the intensity or modify the movement. Muscle fatigue increases the risk of injury: take regular breaks. Pain is a warning sign that should not be ignored: consult your physical therapist if it persists.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

Joint hypermobility and physical activity: Are they compatible?

Yes, joint hypermobility and physical activity are perfectly compatible, provided you adapt the type and intensity of your activities to your condition.

Recommended activities include swimming and aqua aerobics (buoyancy reduces stress on the joints), Pilates and adapted yoga with an instructor who is aware of your condition (avoid extreme positions), strength training with moderate weights and perfect form, and cycling with^proper ergonomic adjustments19.

Activities that should be modified or avoided include high-impact sports involving repeated jumping (which can be adapted with proper prior strengthening), activities requiring extreme flexibility (gymnastics, contortion), and ballistic or uncontrolled movements. This does not mean that these activities are prohibited, but rather that they require specific preparation and strict supervision.

The principles of safe physical activity for hypermobility include maintaining constant active control (never “collapsing” into a position), gradually increasing intensity and duration, listening to your body and adjusting accordingly, and combining cardiovascular, strength-training, and proprioceptive exercises.

With a well-designed exercise program and proper strength training, many hypermobile individuals engage in intense physical activities, including competitive sports. The key is proper preparation, monitoring, and recovery.

Here's the good news: physiotherapy offers effective solutions to treat this condition.

References

1. Castori M, Tinkle B, Levy H, et al. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet C Semin Med Genet. 2017;175(1):148-157. doi:10.1002/ajmg.c.31539

1. Remvig L, Jensen DV, Ward RC. Epidemiology of general joint hypermobility and the basis for the proposed criteria for benign joint hypermobility syndrome. J Rheumatol. 2007;34(4):804-809.

1. Beighton P, Solomon L, Soskolne CL. Joint mobility in an African population. Ann Rheum Dis. 1973;32(5):413-418. doi:10.1136/ard.32.5.413

1. Malfait F, Francomano C, Byers P, et al. The 2017 International Classification of Ehlers-Danlos Syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):8-26. doi:10.1002/ajmg.c.31552

1. Engelbert RH, Juul-Kristensen B, Pacey V, 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. doi:10.1002/ajmg.c.31545

1. Simmonds JV, Herbland A, Hakim A, et al. Physical therapy interventions for generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome: a scoping review. Disabil Rehabil. 2023;45(21):3423-3443. doi:10.1080/09638288.2023.2208796

1. Castori M. Ehlers-Danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations. ISRN Dermatol. 2012;2012:751–768. doi:10.5402/2012/751768

1. Chopra P, Tinkle B, Hamonet C, et al. Pain management in Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):212-219. doi:10.1002/ajmg.c.31554

1. Palmer S, Cramp F, Clark E, et al. The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review. Physiotherapy. 2014;100(3):220-227. doi:10.1016/j.physio.2013.09.002

1. Sahin N, Baskent A, Cakmak A, et al. The effectiveness of physical therapy and rehabilitation programs in joint hypermobility syndrome. Disabil Rehabil. 2008;30(10):698-701. doi:10.1080/09638280701400330

1. Rombaut L, Malfait F, De Wandele I, et al. The muscle-tendon complex in Ehlers-Danlos syndrome. Am J Phys Med Rehabil. 2012;91(6):466-472. doi:10.1097/PHM.0b013e31824fa86d

1. Juul-Kristensen B, Schmedling K, Rombaut L, et al. Measurement properties of clinical assessment methods for classifying generalized joint hypermobility. Am J Med Genet C Semin Med Genet. 2017;175(1):116-147. doi:10.1002/ajmg.c.31540

1. Liaghat B, Ussing A, Petersen BH, et al. The feasibility of a randomized controlled trial of physical therapy for adults with joint hypermobility syndrome. Health Qual Life Outcomes. 2016;14:98. doi:10.1186/s12955-016-0496-6

1. Russek LN, Block SS, Byrne E, et al. Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: international expert consensus recommendations. Front Neurol. 2020;10:1305. doi:10.3389/fneur.2019.01305

1. Tinkle B, Castori M, Berglund B, 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. doi:10.1002/ajmg.c.31538

1. Malfait F, Francomano C, Byers P, et al. The 2017 International Classification of Ehlers-Danlos Syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):8-26. doi:10.1002/ajmg.c.31552

1. Scheper MC, Engelbert RH, Rameckers EA, et al. Children with generalized joint hypermobility and musculoskeletal complaints: current status of diagnostics, clinical characteristics, and treatment. Biomed Res Int. 2013;2013:121054. doi:10.1155/2013/121054

1. Pacey V, Nicholson LL, Adams RD, et al. Generalized joint hypermobility and risk of lower limb joint injury during sport: a systematic review with meta-analysis. Am J Sports Med. 2010;38(7):1487-1497. doi:10.1177/0363546509354406

1. Ferrell WR, Tennant N, Sturrock RD, et al. Improvement in symptoms through enhanced proprioception in patients with joint hypermobility syndrome. Arthritis Rheum. 2004;50(10):3323-3328. doi:10.1002/art.20582

1. Bloom L, Byers P, Francomano C, et al. The International Consortium on Ehlers-Danlos Syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):5-7. doi:10.1002/ajmg.c.31547

1. Palmer S, Bailey S, Barker L, et al. The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review. Physiotherapy. 2014;100(3):220-227. doi:10.1016/j.physio.2013.09.002

1. Palmer S, Cramp F, Clark E, et al. The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review. Physiotherapy. 2014;100(3):220-227. doi:10.1016/j.physio.2013.09.002

1. Simmonds JV, Herbland A, Hakim A, et al. Physical therapy interventions for generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome: a scoping review. Disabil Rehabil. 2023;45(21):3423-3443. doi:10.1080/09638288.2023.2208796