Hypermobility (EDS/HSD) Clinic

Support for joint stability, movement and everyday activity

Hypermobility means that one or more joints move beyond the range usually expected. For many people this causes no problems, but for others it can be associated with joint pain, instability, repeated injuries, fatigue and difficulty managing everyday activity.

A hypermobility-focused physiotherapy programme looks at how your joints move, how well the surrounding muscles support them and how symptoms affect your daily life. Treatment usually focuses on improving strength, movement control, balance and physical capacity rather than simply trying to reduce flexibility.

Understanding EDS and HSD

Hypermobility spectrum disorders, or HSD, describe symptomatic joint hypermobility that can be associated with instability, pain and repeated injury. Hypermobile Ehlers-Danlos syndrome, or hEDS, is one of the Ehlers-Danlos syndromes and can also involve joint hypermobility alongside other symptoms.

Symptoms and their severity vary considerably. One person may mainly experience knee or shoulder instability, while another may have widespread pain, fatigue and difficulty maintaining normal activity.

Physiotherapy does not rely on one standard exercise programme. Rehabilitation needs to reflect the joints involved, current strength, physical capacity and the activities you need to manage.

When physiotherapy may help

An assessment may be useful if you experience:

• Joint pain associated with hypermobility
• Joints that frequently feel unstable
• Repeated sprains or strains
• Recurrent joint subluxations or dislocations
• Difficulty controlling movement
• Reduced balance or coordination
• Persistent muscle tension
• Fatigue during everyday activity
• Reduced strength
• Difficulty walking or using stairs
• Pain after relatively small amounts of activity
• Repeated flare-ups after exercise
• Difficulty returning to sport
• Reduced confidence following previous injuries
• Difficulty knowing how much exercise is appropriate
• Problems maintaining an exercise routine

The aim is not to stop your joints from being flexible. Rehabilitation focuses more on helping you control the movement you have and improving the support around your joints.

What happens during your first appointment?

Your first appointment begins with a discussion about your symptoms, medical history and how hypermobility affects your routine.

The physiotherapist may ask about:

• Which joints cause the most difficulty
• Previous sprains, dislocations or subluxations
• Pain and how it changes throughout the day
• Fatigue
• Activities that cause flare-ups
• Your current exercise level
• Work or study demands
• Previous rehabilitation
• Braces, supports or mobility aids you use
• Any existing EDS or HSD diagnosis
• Other health conditions
• What you would like to be able to do more comfortably

The physical assessment may look at:

• Joint movement
• Muscle strength
• Movement control
• Balance
• Coordination
• Walking
• Joint position awareness
• Everyday movements such as sitting, standing or using stairs
• Specific activities that regularly cause symptoms

The aim is to establish what your body currently manages well and where additional strength, control or physical capacity may be useful.

What treatment may include

Treatment is based on the individual assessment and can change as your strength and symptoms change.

Strengthening exercises

Strengthening is commonly used to improve the muscular support around hypermobile joints. Stronger muscles can help provide better control when joints move through larger ranges.

Exercises may begin at a relatively low level before gradually progressing.

The programme may include:

• Leg and hip strength
• Shoulder and upper-body strength
• Trunk and core control
• Calf and ankle strength
• Grip and wrist strength
• Whole-body conditioning

The exact exercises depend on which areas are causing difficulty.

Movement control

Being able to move a joint through a large range does not always mean that movement is well controlled.

Exercises may therefore focus on learning to move comfortably within a useful range rather than repeatedly reaching the end of the joint's available movement.

This can be particularly relevant during activities such as:

• Squatting
• Reaching
• Lifting
• Walking
• Running
• Using stairs
• Gym exercises

Balance and joint awareness

Some people with hypermobility find it harder to judge where a joint is positioned without looking at it.

Balance and joint-awareness exercises can help improve control and confidence during movement. These areas are commonly included in hypermobility rehabilitation.

Exercises may progress from simple standing activities towards more demanding movements depending on your goals.

Gradual physical conditioning

Pain, fatigue and repeated injuries can lead to long periods of reduced activity.

Over time, this can reduce strength and general fitness, making everyday tasks more physically demanding.

Rehabilitation may therefore include gradual cardiovascular and whole-body conditioning alongside exercises for individual joints.

Home exercise programme

You may receive a manageable programme to complete between appointments.

The programme should be realistic enough to continue consistently. Doing a smaller amount regularly is often more useful than completing a demanding programme occasionally and repeatedly triggering flare-ups.

Building joint stability

A common goal in hypermobility rehabilitation is improving the ability of muscles to support and control a joint.

This may be particularly relevant for areas such as the:

• Shoulders
• Knees
• Ankles
• Hips
• Wrists and hands
• Spine

Exercises are usually progressed gradually.

For example, shoulder rehabilitation may begin with controlled movements before progressing towards lifting or overhead activity. Knee rehabilitation may move from basic strength exercises towards stairs, running or sport.

The goal is to prepare the joint for the movements it needs to manage in your actual routine.

Pain and hypermobility

Pain associated with hypermobility can behave differently from a straightforward new injury.

Some people experience pain in one or two joints, while others experience symptoms across several areas.

Muscles may also become tired or tense from repeatedly working to support joints that move through larger ranges.

Treatment may include:

• Strengthening
• Movement control
• Gradual activity
• Pacing
• Managing flare-ups
• Maintaining general fitness
• Practical changes to activities that repeatedly aggravate symptoms

The focus is usually on improving what your body can manage rather than repeatedly treating the painful area without addressing physical capacity.

Joint subluxations and dislocations

Some people with symptomatic hypermobility experience joints that partially or completely move out of their normal position.

The frequency and severity can vary significantly.

Rehabilitation may focus on:

• Strength around the affected joint
• Movement control
• Joint-position awareness
• Avoiding repeatedly forcing the joint into unstable positions
• Gradually preparing the joint for everyday activity
• Learning which movements tend to trigger instability

A new or significant dislocation should receive appropriate medical attention, particularly when there is severe pain, deformity, numbness or loss of normal movement.

Repeated instability may also require input from other healthcare professionals depending on the joint and severity.

Avoiding unnecessary end-range movement

People with hypermobility may naturally rest or exercise at the end of their available joint range.

For example, the knees may lock backwards while standing or the elbows may move beyond a neutral straight position.

Not every hypermobile movement is harmful, and there is no need to constantly worry about joint position.

However, if repeatedly moving or loading a joint at its end range contributes to pain or instability, rehabilitation may involve learning to control the joint within a more comfortable range.

The aim is better control rather than becoming rigid.

Fatigue and physical endurance

Fatigue can be an important part of HSD and hEDS for some people.

This can make exercise difficult because the amount you can manage may vary from day to day.

Rehabilitation may begin by identifying an activity level that is realistic to repeat.

This might involve adjusting:

• Walking distance
• Number of exercises
• Resistance
• Exercise duration
• Rest between activities
• Work or household tasks

Physical capacity can then be built gradually rather than repeatedly pushing to exhaustion.

Pacing activity

A common challenge is doing much more on a good day and then needing a long recovery period afterwards.

Pacing aims to create a more consistent level of activity.

For example, rather than completing a demanding task until pain or fatigue forces you to stop, the activity may initially be divided into smaller sections.

As tolerance improves, the amount you can manage can gradually increase.

The goal is not to avoid activity. It is to make activity easier to repeat and progress.

Managing flare-ups

Symptoms can fluctuate.

A flare-up may involve increased pain, fatigue, muscle tension or feelings of instability.

During these periods it may be useful to temporarily adjust your programme rather than either stopping completely or forcing yourself through the same level of activity.

A flare-up plan may involve:

• Temporarily reducing exercise intensity
• Using easier versions of exercises
• Continuing gentle movement
• Breaking activities into smaller amounts
• Allowing additional recovery
• Returning gradually to the previous programme

Progress can then continue once symptoms become more manageable.

Exercise does not need to be high impact

Exercise for hypermobility does not need to begin with running, jumping or heavy gym training.

Depending on your current ability, suitable starting points may include:

• Walking
• Controlled strength exercises
• Cycling
• Pool-based exercise
• Light gym exercises
• Balance work
• Pilates-style strengthening
• Low-impact cardiovascular activity

Lower-impact activity is often used when people are initially building strength and physical capacity.

Higher-impact exercise may still be possible for some people, but it should be introduced according to individual strength, control and symptoms.

Returning to the gym

Being hypermobile does not automatically mean that strength training should be avoided.

In fact, improving muscle strength can be an important part of managing symptomatic hypermobility.

Gym rehabilitation may initially focus on:

• Controlled technique
• Manageable resistance
• Joint position
• Gradual increases in load
• Avoiding unnecessary end-range loading where it causes symptoms
• Building consistency

Over time, exercises can become more demanding if your joints tolerate them well.

The aim is to build capacity rather than permanently limiting activity because of hypermobility.

Returning to running and sport

Sports place greater demands on joint stability, strength and coordination.

Before returning to higher-impact activity, rehabilitation may need to progress through:

• General strengthening
• Single-leg control
• Balance work
• Landing exercises
• Running
• Changes of direction
• Sport-specific movements

The progression depends on the sport and the joints involved.

Some people with HSD or hEDS participate successfully in demanding physical activities, while others need to modify how they exercise. The appropriate level is individual.

Walking and everyday mobility

Hypermobility can affect walking when pain, fatigue or instability is present.

Some people may find:

• Longer walks difficult
• Uneven surfaces tiring
• Stairs uncomfortable
• Standing for long periods difficult
• Ankles or knees becoming less stable when fatigued

Rehabilitation may include lower-limb strengthening, balance work and gradual increases in walking tolerance.

Where appropriate, footwear, supports or mobility aids may also be discussed as part of a wider management plan.

Braces, supports and taping

Some people use braces, supports or taping to help manage particular activities or unstable joints.

These may sometimes provide useful short-term support.

However, they are not automatically required for every hypermobile joint.

Where supports are used, it is often helpful to combine them with appropriate strengthening and movement rehabilitation rather than relying on external support alone.

The type of support required depends on the joint, symptoms and activity.

Manual therapy and stretching

People with hypermobility do not necessarily need more flexibility.

For this reason, repeated aggressive stretching is not usually the main focus of rehabilitation.

Some muscles may genuinely feel tight or uncomfortable, but this does not automatically mean they need to be stretched as far as possible.

Manual therapy may sometimes be used for pain or muscle tension, but it should be appropriate for the individual and generally sit alongside active rehabilitation.

The longer-term emphasis is usually on strength, control and function.

Work and study

Symptoms associated with hypermobility can affect both physically demanding jobs and desk-based work.

Difficulties may include:

• Prolonged sitting
• Prolonged standing
• Repetitive hand use
• Lifting and carrying
• Walking
• Fatigue
• Maintaining one position
• Repeated overhead activity

Rehabilitation may consider the specific demands of your work or study.

Rather than searching for one perfect posture, the focus may be on changing position regularly, building physical capacity and finding practical ways to manage demanding tasks.

Hypermobility and everyday life

The goal of rehabilitation does not have to be sport or exercise.

You may simply want to:

• Walk without repeatedly aggravating symptoms
• Carry shopping
• Play with your children
• Manage household tasks
• Sit through a working day
• Travel more comfortably
• Use stairs confidently
• Return to hobbies
• Spend less time recovering after activity

These everyday goals can be used to guide the rehabilitation programme.

Other symptoms and multidisciplinary care

HSD and hEDS can sometimes involve symptoms beyond the muscles and joints. Fatigue, headaches, gastrointestinal symptoms and autonomic problems are reported in people with HSD, and EDS can affect connective tissues throughout the body.

Physiotherapy mainly focuses on movement, strength and physical function.

Depending on your symptoms, care may also involve:

• Your GP
• Rheumatology
• Occupational therapy
• Podiatry
• Pain-management services
• Cardiology or autonomic specialists
• Gastroenterology
• Other relevant medical teams

The appropriate combination of services depends on the individual.

Physiotherapy and diagnosis

Physiotherapy can assess movement, strength, stability and physical function, but a physiotherapy appointment should not be presented as a way of confirming every type of Ehlers-Danlos syndrome.

If you already have a diagnosis, treatment can take that information into account.

If you suspect that you may have EDS or another connective-tissue condition, appropriate medical assessment may be recommended.

HSD and hEDS are related to symptomatic hypermobility, but Ehlers-Danlos syndromes include several different conditions with different medical considerations.

When further medical assessment may be needed

New symptoms should not automatically be assumed to be caused by hypermobility.

Further medical assessment may be appropriate if you experience:

• A significant new dislocation
• Sudden major loss of strength
• Persistent new numbness
• Significant unexplained swelling
• Severe pain following an injury
• New neurological symptoms
• Symptoms that are clearly different from your usual pattern
• Rapid or unexplained changes in your health

If concerns are identified during the physiotherapy assessment, further medical review may be recommended.

People with a diagnosed EDS subtype that carries specific medical precautions should follow the guidance of the specialist team involved in their care.

Treatment based on your goals

There is no single definition of successful hypermobility rehabilitation.

For one person, progress may mean returning to running. For another, it may mean completing a working day without a major flare-up afterwards.

Your goals may include:

• Improving joint stability
• Becoming stronger
• Walking further
• Reducing repeated injuries
• Managing fatigue
• Returning to the gym
• Returning to sport
• Improving balance
• Managing work more comfortably
• Becoming more confident with movement
• Managing flare-ups more effectively

Treatment can be built around these goals and adjusted as your abilities change.

Progress may take time

If symptoms have affected your activity for several years, strength and physical confidence may not return immediately.

Progress is often easier to recognise by looking at changes over several weeks rather than comparing one day with the next.

Useful signs of progress may include:

• Completing more activity
• Recovering more quickly
• Increasing exercise resistance
• Walking further
• Feeling more stable
• Experiencing fewer interruptions from minor injuries
• Managing work more comfortably
• Feeling more confident during movement

Pain levels are only one part of the picture.