Physical Therapy Guide to Hypermobility Spectrum Disorders
Hypermobility spectrum disorders are conditions affecting the body’s ligaments and tendons. People with these conditions have hypermobile (“looser” than typical) joints. This joint looseness (laxity) and instability continues throughout their lifetime. HSDs can lead to long-term problems, such as chronic pain, unstable joints, and fatigue. This can cause people to limit their activities. Physical therapists help people with HSDs reduce their pain and increase joint stability and strength.
Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.
What Are Hypermobility Spectrum Disorders?
Hypermobility spectrum disorders are a group of conditions affecting the tissues that connect body parts. HSDs cause increased flexibility in joints throughout the body. People are born with HSDs, but the symptoms may not become apparent until later in life.
Some degree of joint hypermobility in children is typical. Joints gain stability as they mature. However, people with HSDs have joint looseness that persists throughout the life span. They may also have other musculoskeletal symptoms, such as:
- Chronic pain.
- Altered balance or sense of joint position (proprioception).
- Flat feet.
- Frequent injuries due to joint instability.
- Early onset osteoarthritis.
Symptoms of HSDs vary from person to person and can range from mild to severe. There are four different types of HSD. Their diagnosis depends on the body parts and joints affected. The types of HSD are:
Generalized. With G-HSD, most joints are hypermobile. Adults with HSD score 5 or greater out of 9 points, and children score 6 or greater out of 9 points on the Beighton scale,* a measure to specifically screen for joint hypermobility. They have at least two additional musculoskeletal (muscle, bone, joint, tissue) symptoms. These can include frequent joint dislocations, frequent ankle sprains, chronic joint pain, easy bruising, and early onset joint arthritis.
Peripheral. Joint looseness is predominantly found in a person’s hands and feet. They also have at least one other musculoskeletal symptom.
Localized. Excessive joint laxity is found in a small grouping of joints or in one particular area of the body. There are one or more musculoskeletal symptoms.
Historical. H-HSD is diagnosed later in life based on a self-report of generalized joint hypermobility. However, the person does not score high on the Beighton* scale. They have one or more musculoskeletal symptoms. They may also have a rheumatologic condition (inflammation).
*The Beighton scale assesses for hypermobility at nine different joints in the body with each joint scoring one point if excessive mobility is demonstrated on testing.
Another condition affecting joint hypermobility is hypermobile Ehlers-Danlos syndrome. hEDS can range from mild to severe. hEDS is a genetically linked, systemic syndrome that results in more severe and wide-ranging symptoms than HSD. With hEDS all connective tissues in the body, not just joints and ligaments, can be involved. Those with hEDS often have digestive and circulatory issues in addition to joint hypermobility. To be diagnosed with hEDS, a person must demonstrate an additional system involvement, in addition to hypermobile joints, and have a positive family history of the disease. hEDS is a specific “type” of EDS. “Ehlers-Danlos” is a group of 13 genetically linked connective tissue disorders. Depending on the specific genetic type, different tissues of the body are significantly affected or impaired. Not all those with EDS have joint hypermobility.
People with hypermobile joints should seek an evaluation by their physician or physical therapist.
How Does It Feel?
People with HSDs often report:
- Joint pain. Their joints hurt randomly or for longer periods of time with or without an injury.
- Loose joints (“double-jointed”). Frequent sprains, muscle strains, possible dislocations, and/or spinal problems occur.
- Decreased sense of joint position or alignment. Related balance problems can occur.
- Back pain (often with prolonged standing or sitting).
- Pelvic floor dysfunction. Trouble relaxing and coordinating the pelvic floor muscles. This can cause bowel or urine leakage problems.
- Frequent headaches.
- Chronic abdominal pain.
- Frequent joint popping.
- Flat feet and/or chronic foot pain.
- Easy bruising.
How Is It Diagnosed?
Hypermobility spectrum disorders are not genetic conditions. While people are born with HSD, they are not the result of an altered gene. Therefore, they cannot be diagnosed through genetic testing. They are diagnosed through a process of elimination. HSD diagnosis is based on the patient’s medical history and a physical exam. It is made after other conditions have been ruled out. In some states, a physical therapy diagnosis of the condition is sufficient for treatment. In other states, your physical therapist may also refer you to your PCP or an orthopedic specialist for additional evaluation.
How Can a Physical Therapist Help?
Physical therapy is vital for people with HSDs. Physical therapists offer strategies to help people reduce and/or manage pain and improve their:
- Joint stability and strength.
- Energy levels.
- Daily function.
Your physical therapist will develop a personalized plan of care to treat your condition. Your treatment plan may include:
Muscle strengthening. Muscles provide stability to joints. Strength training is essential for pain management and injury prevention. Your physical therapist will design a program specific to your needs. They will work with you to increase the strength of key muscles. Strengthening the right muscles can help keep your joints stable and reduce your risk for injury.
Balance and joint awareness activities. Your physical therapist may work with you to improve your balance and coordination for sport-specific and everyday movements. This can help reduce the risk of injury and improve your joint stability.
Orthotics/taping/bracing. If a joint is too loose, you may need extra support to allow you to do some activities. Your physical therapist may provide joint taping, custom splinting, or bracing. They also may use these devices to help you support a joint while exercising. These techniques can reduce your risk for injury and allow you to do activities longer. Bracing and other supports are rarely recommended for use all the time. Rather, your physical therapist can recommend ways to safely support your daily activities.
Manual therapy. Pain is common with HSDs and similar conditions. Your physical therapist may apply gentle hands-on treatments (manual therapy) such as massage, joint mobilizations within appropriate ROM, and manual joint stability techniques (like taping, joint compression garments, and braces). These techniques can help reduce joint pain and discomfort while also helping to increase joint stability and joint awareness to help prevent further injury and pain.
Abdominal and pelvic floor strengthening. With HSDs and similar conditions, the muscles in your pelvic floor may be loose. This can cause pain or incontinence (leaking), and prolapse after a pregnancy. Prolapse occurs when an internal organ slips down into the pelvic area. HSD can also contribute to frequent constipation. A physical therapist who specializes in pelvic floor rehabilitation can address these concerns. Pelvic physical therapy may also help to address related chronic abdominal pain.
Patient education. Your physical therapist can help you better understand your condition. You can learn how it might be contributing to your pain and problems doing certain activities. They may educate you about the importance of proper hydration (drinking enough healthy fluids) and nutrition. Your physical therapist will help you develop strategies to manage your condition.
Pain management. Your physical therapist may provide resources and tools to manage pain, in addition to those listed above. These include but are not limited to:
- Gradual activity introduction.
- Compression socks.
- Finger or foot splints.
- Electrical stimulation.
Physical therapists are experts in prescribing pain-management techniques that reduce or eliminate the need for medication, including opioids.
Your physical therapist also may find that you need additional support. They may refer you to other health care providers who can support your specific needs.
Can This Injury or Condition Be Prevented?
Because hypermobility conditions are inherited, they cannot be prevented. Early detection and treatment (before pain develops) may help minimize pain or other impairments. This can enhance your long-term well-being.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat conditions such as HSDs. When seeking a provider you may want to consider:
A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedic or pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your, or your child’s, condition.
A physical therapist who is well-versed in the treatment of hypermobility, chronic pain, or other connective tissue disorders.
You can find physical therapists in your area with these credentials and clinical expertise on Find a PT, a tool built by the American Physical Therapy Association.
- General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family, friends, or other health care providers.
- Ask about the physical therapists' experience in helping people manage pain and hypermobile joint conditions when making an appointment.
Be prepared to describe your symptoms in as much detail as possible. Keep a journal of when you experience pain to help your physical therapist identify the best treatment options for you.
The APTA Academy of Pediatric Physical Therapy contributed to this consumer resource. It is for informational purposes only and is not intended to represent the position of APTA Pediatrics.
The American Physical Therapy Association believes consumers should have access to information to:
- Inform their health care decisions.
- Prepare them for their visit with a health care provider.
The following resources offer some of the best scientific evidence related to physical therapy treatment for hypermobility joint disorders. They report recent research and provide information on the standards of practice in the United States and internationally. They link to a PubMed* abstract (which may offer free access to the full text) or other resources. You can read them to learn more or bring a copy to your health care provider.
Ehlers Danlos Society. What Is EDS? Accessed October 16, 2023. https://www.ehlers-danlos.com/what-is-eds/.
Reychler G, De Backer M, Piraux E, et al. Physical therapy treatment of hypermobile Ehlers–Danlos syndrome: a systematic review. Am J Med Genet A. 2021;185(10):2986–2994. Article Summary on PubMed.
Castori M, Tinkle B, Levy H, et al. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet Part C Semin Med Genet. 2017;175(1):148–157. Article Summary on PubMed.
Castori M, Hakim A. Contemporary approach to joint hypermobility and related disorders. Curr Opin Pediatr. 2017;29(6):640–649. Article Summary on PubMed.
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 Part C Semin Med Genet. 2017;175(1):158–167. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information. PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.