Hypermobility

Asymptomatic hypermobility

Many people, particularly children, have hypermobile joints that cause no pain or functional limitation. This is considered a normal variant and does not require treatment, though monitoring during periods of growth is sometimes appropriate.

Hypermobility spectrum disorder (HSD)

HSD is the current internationally accepted term for symptomatic hypermobility that does not meet the diagnostic criteria for a defined connective tissue disorder. It replaces the older term "joint hypermobility syndrome (JHS)”. HSD is diagnosed when hypermobility causes symptoms, such as pain, instability, or fatigue, but a specific underlying condition, such as hEDS, cannot be confirmed.

Hypermobile Ehlers-Danlos syndrome (hEDS)

hEDS is the most common subtype of Ehlers-Danlos syndrome and is characterised by generalised joint hypermobility alongside specific clinical features including skin changes, joint instability, and a family history of the condition. The distinction between HSD and hEDS has important implications for management and genetic counselling.

Hypermobility associated with other conditions

A number of other conditions are associated with joint hypermobility and may need to be considered, including Marfan syndrome, osteogenesis imperfecta, and Down syndrome, all of which involve hypermobility as a feature alongside other significant clinical findings.

Symptoms vary considerably between individuals. Some people with hypermobile joints experience no difficulties, while others have presentations that significantly affect quality of life. Symptoms often fluctuate from day to day and may worsen with activity, fatigue, or hormonal changes.

Musculoskeletal symptoms include:

• joints that move beyond the normal range – for example, fingers that bend back further than usual, or elbows and knees that hyperextend

• joint pain, particularly after activity or prolonged standing or sitting

• joint stiffness, especially after rest or in the morning

• frequent sprains, strains, or partial dislocations (subluxations)

• joints that feel loose, unstable, or unreliable

• clicking, popping, or clunking in joints

• muscle pain and fatigue – the muscles work harder than usual to compensate for insufficient ligamentous support

Wider symptoms, more common in HSD and hEDS:

• chronic fatigue, often disproportionate to activity levels

• dizziness or palpitations on standing, related to autonomic nervous system involvement

• gastrointestinal symptoms including bloating and nausea

• Ssoft, stretchy, or easily bruised skin

• poor balance and coordination, due to reduced proprioception (the body's awareness of joint position)

• anxiety – this is increasingly recognised as having a neurobiological association with connective tissue hypermobility

Hypermobility is one of the most common musculoskeletal presentations in childhood and one of the most frequent reasons for referral to paediatric orthopaedics. It’s also frequently misunderstood — dismissed as growing pains, clumsiness, or anxiety — when in fact it reflects a genuine physical difference in connective tissue that merits proper assessment and support.

How hypermobility presents in children

Children with hypermobility may not describe their symptoms in the same way adults do.

Common presentations include:

• limb pain, particularly in the legs, often worse in the evenings or after activity, which is frequently attributed to growing pains

• reluctance to participate in physical activity, or tiring more quickly than peers

• clumsiness, frequent trips or falls, or poor coordination

• delayed walking or motor milestones in younger children

• joint injuries that seem disproportionate to the mechanism – a minor fall resulting in a significant sprain, for example

• complaints of pain that vary from day to day and are difficult to localise precisely

It’s important not to dismiss these symptoms. While many hypermobile children are entirely well and simply need reassurance and guidance, persistent pain, frequent injuries, or functional limitation, particularly if affecting school attendance or participation in sport, warrant specialist orthopaedic assessment.

The distinction between benign hypermobility and HSD or hEDS in children

Not all hypermobile children will develop symptomatic HSD or hEDS, but identifying those who are heading in that direction allows early intervention. Targeted physiotherapy and activity guidance at an early stage, before symptoms become entrenched, can substantially improve long-term outcomes.

Hypermobile children in sport and dance

Children involved in dance, gymnastics, or other flexibility-based activities are often hypermobile and may have been selected or encouraged, in part, because of their natural flexibility. While this can be an asset, training programmes should include adequate strength and stability work to protect developing joints. An experienced physiotherapist can advise on appropriate conditioning for hypermobile young athletes.

We welcome referrals for children and young athletes from age 4 upwards. If your child has persistent joint pain, is experiencing recurrent injuries, or you have concerns about their musculoskeletal health, early specialist review is recommended.

Hypermobility is caused by differences in the structure or composition of connective tissue, particularly increased elasticity in the collagen that forms ligaments and tendons. In the majority of cases, this has a genetic basis, meaning it tends to run in families.

Factors that influence hypermobility and symptom severity:

• genetics – the primary determinant; hypermobility tends to run in families, though its severity can vary considerably between family members

• age – joint flexibility is greatest in childhood and tends to decrease with age

• sex and hormonal influences – hypermobility is more prevalent in females; symptoms frequently fluctuate with the menstrual cycle, as oestrogen influences ligamentous laxity

• ethnicity – generalised hypermobility is more common in people of South Asian, Middle Eastern, and African backgrounds

• physical training – activities that specifically develop flexibility, such as gymnastics or dance, can increase the range of motion in hypermobile joints

Diagnosis of hypermobility begins with a thorough clinical assessment. At Welbeck, your consultant will take a detailed history and carry out a structured examination to assess the degree of hypermobility, identify any associated features, and determine whether further investigation is warranted.

The Beighton score

The most widely used clinical tool for assessing generalised hypermobility is the Beighton score. This nine-point scoring system tests flexibility at 5 sites: the little fingers, thumbs, elbows, knees, and trunk. A score of 4 or more out of 9 in adults, and 5 or more in children, suggests generalised hypermobility. However, it’s a screening tool rather than a diagnostic test – a high score without symptoms doesn’t constitute a diagnosis, and a lower score doesn’t exclude clinically significant localised hypermobility.

What your consultation at Welbeck will include:

• a full symptom history, including pain, fatigue, joint instability, and any systemic features

• family history, given the hereditary nature of connective tissue conditions

• Beighton score assessment and examination of specific symptomatic joints

• assessment of skin, proprioception, and other relevant clinical features

• in children, assessment of developmental history, motor milestones, and functional impact at school and in sport

Investigations

Hypermobility and HSD are diagnosed clinically. Investigations are used primarily to exclude other conditions or assess specific features, and may include blood tests, X-ray, MRI, or, in selected cases, genetic testing or specialist cardiovascular assessment.

Hypermobility itself cannot be prevented, as it’s largely genetically determined. However, the severity of symptoms and the risk of injury and long-term complications can be significantly influenced by early identification and proactive management.

The most effective steps are:

• recognising hypermobility early, particularly in children, and seeking appropriate assessment before symptoms become established

• strengthening the muscles around hypermobile joints, which is the single most effective way to improve stability and reduce pain

• avoiding activities that repeatedly push joints to their end range without adequate muscular support

• developing good proprioception through targeted neuromuscular training

• ensuring appropriate footwear, particularly in children with flat feet or hypermobile ankles

• for females, being aware that symptoms may fluctuate hormonally and planning activity accordingly

For many people, hypermobility causes mild or manageable symptoms. However, in those with more significant or symptomatic presentations, particularly where HSD or hEDS is present, the condition can have a substantial impact on daily life.

Possible complications include:

• recurrent joint injuries –sprains, subluxations, and dislocations that occur with minimal trauma and may take longer to heal

• chronic pain – persistent musculoskeletal pain affecting multiple joints

• chronic fatigue – often profound, and a major driver of reduced activity and social participation

• deconditioning – a cycle in which pain leads to reduced activity, which leads to further muscle weakness and joint instability

• psychological impact – chronic pain, diagnostic delay, and the often invisible nature of hypermobility-related conditions are associated with increased rates of anxiety and low mood

• in children – school avoidance, reduced participation in sport, and social isolation if symptoms are not identified and managed early

With appropriate, well-coordinated care, most people with hypermobility can achieve good symptom control and maintain an active life.

There’s no treatment that corrects the underlying connective tissue difference in hypermobility. The goal of management is therefore to reduce symptoms, improve joint stability, prevent injury, and support quality of life.

At Welbeck, your consultant will develop a personalised plan based on your individual presentation, age, and functional goals.

Physiotherapy and exercise rehabilitation

Physiotherapy is the cornerstone of hypermobility management and should be delivered by a physiotherapist with specific experience in connective tissue conditions.

A well-designed programme will include:

• muscle strengthening – particularly of the stabilising muscles closest to hypermobile joints

• proprioception and neuromuscular training – improving the body's awareness of joint position to reduce injury risk

• hydrotherapy – exercise in warm water reduces load on painful joints while enabling effective strengthening, and is particularly useful in more severely affected patients

• pacing strategies – learning to balance activity and rest to avoid the boom-and-bust cycle common in hypermobility

• postural training – improving alignment and reducing compensatory muscle tension

It’s important to note that stretching is not appropriate for hypermobile patients. Increasing range of motion in already unstable joints worsens symptoms – the focus must be on stability and strength.

Joint protection and supportive devices

Orthotic insoles, bracing, taping, and supportive footwear can all play a role in managing specific symptomatic joints, improving proprioceptive feedback, and protecting vulnerable areas during activity.

Pain management

Pain management should be tailored to the individual and may include simple analgesia for acute episodes, topical treatments for localised pain, and, in cases of chronic or widespread pain, referral to a pain specialist for more targeted approaches.

Multidisciplinary care

Complex presentations, particularly in patients with hEDS or significant systemic involvement, benefit from a coordinated multidisciplinary approach. At Welbeck, we can facilitate referral within our network to rheumatology, pain medicine, cardiology, and gastroenterology, as appropriate.

Surgical intervention

Surgery is rarely indicated for hypermobility and is generally avoided where possible, as hypermobile tissues may not hold repairs well and recovery can be prolonged. Where recurrent dislocation or structural joint damage requires surgical intervention, this will be planned carefully with full consideration of the underlying connective tissue context.

At Welbeck, our orthopaedic consultants have extensive experience in assessing and managing hypermobility across all ages – from young children presenting with joint pain and coordination difficulties, to adults who have lived with undiagnosed or undertreated symptoms for years.

We understand that hypermobility, particularly in its more complex presentations, is often a condition that patients have struggled to have taken seriously. Our approach is thorough, unhurried, and takes the full picture into account.

If you or your child are experiencing joint pain, frequent injuries, fatigue, or other symptoms that may be related to hypermobility, early specialist assessment can make a significant difference.

Our consultants are recognised by all major health insurance providers. We also offer care to self-paying patients. Get in touch today to book an appointment with one of our orthopaedic specialists.