If you or someone you know has Hypermobility, it means that your joints can move more than most people’s. This can be a cool party trick, but it can also come with some challenges. Exploring Hypermobility treatments is essential for maintaining joint stability and overall well-being. Let’s talk about how to manage and treat Hypermobility to keep you feeling your best. An unfortunate misconception is that Symptomatic Joint Hypermobility always gets worse, and no treatments exist.

Understanding Hypermobility

Hypermobility means your joints are extra flexible. While this can be great for activities like dancing or gymnastics, it can also cause joint pain, fatigue, and injuries. Some people with Hypermobility may have a connective tissue disorder called Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). That’s why managing your overall health is important-it helps you handle symptoms and live life to the fullest.

Managing pain in Hypermobility, Hypermobility Spectrum Disorder and Hypermobile Ehlers-Danlos Syndrome (hEDS)

Working out your priorities for management or treatment depends entirely on what aspect or issues related to your Hypermobility are impacting your life the most. Consider the  Hypermobility Syndrome Symptom Wheel and identify which aspects you want to tackle first- I call it- “What do you think is the most life-impacting symptom we address today?” “Treating the treatable today.”

Education and support

Learning about Hypermobility and connecting with others who have similar experiences can be incredibly helpful if not the most important aspect of your care. “Knowledge is power”. Support groups, online forums, and educational resources can provide valuable information and encouragement. Please visit our list of Support groups for Hypermobility, HSD, EDS and related conditions.

Physiotherapy

Working with a physiotherapist who understands your Hypermobility is crucial. Physiotherapy provided by a Hypermobility aware physio can help you strengthen your muscles, improve your joint stability, posture, and teach you exercises to stop overworking guarding muscles whilst protecting your joints and enhance overall function. In our clinic I often use taping, bracing and posture aligning suits to assist provide feedback during exercise and strength sessions. The importance of an experienced Hypermobility or EDS Physiotherapist is crucial, as many patients report pain and injuries because of previous inappropriate Hypermobility treatments [1] [2].

Some of the therapies and techniques that are evidence based and that I have found successful to manage the many symptoms of Hypermobility include [3]:

• Manual therapies-care not to overstretch ligaments and joints is needed
• Specialised strengthening exercises- that focus on joint stabilisation, are low impact and POTS sensitive
• Breathing retraining with core engagement
• Movement and motor pattern retraining- creating the balance between recruiting muscles to support joints and not over-recruiting or guarding which causes pain.
• Muscle energy techniques
• Trigger point therapy
• Dry needling
• Pain and fatigue education
• Kinesiotaping or bracing
• Nerve stretches
• Posture, balance and proprioception training
• Pacing and calming therapies
• Gait, walking and functional rehabilitation
• Deep tissue and myofascial massage
• Heat and cold therapies
• Hydrotherapy
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Mobility aides
• General fitness and endurance

Where is my pain coming from?

If you’re dealing with pain, it needs to be understood and managed well.

Pain can come from lots of different places in the body and mind- and often, it’s a mix of a few causes coming together [4].

So, what’s “mixed pain”?

It’s when two or more types of pain are happening at the same time. For example, someone with Hypermobility might have sore joints from body damage or injuries (Nociceptive Pain), nerve pain from compression of nerves (Neuropathic Pain), pain sensitivity from a sensitised or over active nervous system (Nociplastic Pain), and increased pain because of life stresses, social demands, or clinician based trauma and invalidation, known as Psychological caused pain. All of that adds up to a very real and very complex pain experience for the individual.

The latest definitions of pain are more focused on the individual and personal experiences of pain rather than focusing wholly on tissue or bodily damage. The revised 2020 International Association for the Study of Pain (IASP) definition of pain is: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” [13]

So what are the types of “pain”?

1. Nociceptive Pain (Body Damage Pain)

This is the kind of pain you feel when something in your body is actually hurt, injured or inflamed. For example, if you cut your finger, twist your ankle, or have sore muscles – that’s nociceptive pain. It’s your body’s way of saying, “Hey, something’s wrong here!”

2. Neuropathic Pain (Nerve Pain)

Neuropathic pain happens when there’s damage or disease affecting the body’s nerves that sense touch, temperature, and pain – even if there’s no injury to the skin or muscles in that area. In the simplest of terms, it’s pain caused by faulty wiring in the nervous system, so you might feel pain in places that look totally fine on the outside. It might feel like burning, tingling, numbness, or electric shocks. It can happen if nerves are damaged, compressed or irritated, like with sciatica or after shingles.

3. Nociplastic Pain (Pain with No Clear Injury)

This is pain that doesn’t come from obvious injury or nerve damage but the brain and body are still sending pain signals or the pain systems are not processing the pain well. It’s common in conditions like fibromyalgia, migraine or chronic widespread pain, where the pain system is extra sensitive, and widespread even though nothing appears to be “broken.” This does not mean that the pain is not real.

4. Biological Pain (The Body’s Natural Responses)

This is an umbrella term that includes all the physical stuff going on in the body – like inflammation, tight muscles, joint issues, hormones, and immune responses. For people with conditions like Hypermobility or Ehlers-Danlos Syndrome, their tissues and joints might cause this kind of ongoing, body-based pain.

5. Psychological Pain (The Brain’s Role)

Pain doesn’t just come from the body it is also processed and painful situations can live on, stored so to speak, in the brain. Things like stress, anxiety, depression, trauma, and past experiences can make pain worse or harder to deal with. This doesn’t mean the pain is “all in your head” – it just means the brain plays a powerful role in how pain is felt and processed [9].

Common causes of pain in Hypermobility

1. Joint Instability- because ligaments and joint capsules are hyperextensible/overly stretchy

• What it is: Joints that move too much or in ways they shouldn’t.
• Why it hurts: This can lead to subluxations (partial dislocations), full dislocations, or micro-injuries to surrounding tissues all made worse with further joint inflammation responses.
• Common areas: Shoulders, elbows, knees, hips, Jaw joints and fingers.

2. Muscle Overuse & Fatigue

• What it is: Muscles working overtime to compensate for unstable joints and trying to compensate by creating stability .
• Why it hurts: Constant effort to stabilise joints causes muscle tension, cramping, and fatigue.
• Additional: Can lead to trigger points, knots in muscles and chronic tightness.

3. Soft Tissue Injuries

• What it is: Damage to ligaments, tendons, and fascia from overstretching or micro-tears, e.g. sprains and strains
• Why it hurts: These tissues heal slowly and inefficiently in Hypermobility, leading to ongoing or recurrent pain.

4. Nervous System and Sensitisation pain

• What it is: The nervous system itself is not supported well because of deficits in the connective tissues so feedback is altered, and nerves can be trapped/compressed when lax joints move inefficiently. Also the nervous system can become more sensitive to pain over time, and due to the repeated injuries, to you physically, biologically, psychologically, socially and from clinician caused invalidation and traumatisation.
• Why it hurts: People can start to feel pain from things that shouldn’t normally hurt (called “central sensitisation”).
• Often linked with: Sciatica, Fibromyalgia, CSF leaks, nerve entrapments and pain syndromes.

5. Proprioception Issues

• What it is: Poor body awareness—your brain isn’t getting clear signals about many of your joints’ positions, this leads to bumping into things and tripping over easily
• Why it hurts: Leads to uncoordinated movement, joint strain, and overcompensation in other muscles.

6. Postural, Movement Patterns and Biomechanical Problems

• What it is: The way someone stands, moves, or sits may be altered and inefficient due to lax joints.
• Why it hurts: Leads to strain on certain muscles or joints over time, causing pain in the back, neck, feet, etc.

7. Fatigue and Poor Recovery

• What it is: Hypermobile people often experience more fatigue as their body’s work hard to support an upright posture and movement. People with Hypermobilty are also known to have sleep disorders.
• Why it hurts: Fatigue and poor sleep reduces tolerance to activity, lowers pain thresholds, and slows healing.

8. Comorbid Conditions

• Examples: Mast cell activation syndrome, dysautonomia (like POTS), anxiety, gastrointestinal issues, Fibromyalgia,.
• Why it hurts: These can contribute to widespread pain, headaches, abdominal pain, and general discomfort. Additionally, there are support structure deficiencies throughout your body, that are meant to hold your body organs, blood vessels, nerves, etc., and other tissues in place.

Options for pain treatment

There are currently no comprehensive guidelines for managing chronic pain in EDS [5].

With this in mind it is then easier to understand why an individualised physiotherapy rehabilitation programme will be your treatment of choice. You can be reassured that when you are seen by a Hypermobility and/or Ehlers-Danlos aware health clinician they will help manage your pain. It is often found that the pain is slow to treat, and this should be emphasised at the start of your therapy programme. It is important to realise that the pain does not necessarily signify major damage or primary inflammatory arthritis but indicates soft tissue sprain- and strain-type injury, nerve pain or other Hypermobility related issues, often due to poor control of the joints and overwork of the muscles that are trying to provide support for lax ligaments.

There are many ways to address pain along with an individualised physiotherapy program, these include:

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS unit (Transcutaneous Electrical Nerve Stimulation) units are quite helpful for many of my patients. TENS is a small portable device that delivers mild electrical pulses through sticky padded electrodes placed on the skin.  These pulses work in two ways:

1. They can block pain signals from reaching your brain, so you feel less discomfort.
2. They help your body release endorphins, which are natural painkillers that make you feel better [6].

Many people use TENS units for back pain, arthritis, muscle soreness, and even nerve pain. It’s drug-free, easy to use at home, and can provide relief without side effects.  You can even use multiple TENS units at once to trat differing sites of pain, for instance to treat neck pain and knee pain.  TENS therapy can be particularly effective for managing muscle tension and joint pain associated with Hypermobility.

Supportive taping, bracing, orthotics and devices

If you’re dealing with pain taping, bracing, and orthotic inserts can help by stabilising your joints, reducing strain, and making movement easier [7].

• Taping can help guide your muscles and joints into better alignment, reducing pain and improving function.
• Braces provide extra support, preventing too much movement in a painful area while still allowing you to stay active.
• Orthotic inserts (special shoe insoles) can help take pressure off sore spots in your feet, knees, or even your back.

These tools don’t “cure” pain on their own, but they can make a big difference in managing discomfort and allowing you to move more comfortably. Using taping, braces, orthotics or body supports can help decrease muscle overactivation, stabilise your joints and prevent injuries [8]. Many patients have found these strategies extremely helpful to provide feedback about their body’s movements, manage pain and stabilise joints.

Dry needling

Thin needles are inserted into specific points in your muscles, known as trigger points or muscle knots. These points are often tender and can cause pain. The needles help to release tension in the muscles, improve blood flow, and reduce pain. This can also help improve your range of motion.

Heat or cold therapy

Applying heat or cold packs to painful areas can provide temporary relief. Heat can help relax muscles, while cold can reduce inflammation.

Sleep and nutrition adjustments

Reviewing what other body wide symptoms are adding to the pain and fatigue cycle is important. If you’re not sleeping from pain or discomfort or sleep apnoea this needs addressing. Making some changes to your daily routine can make a big difference. This might include pacing yourself during activities, taking breaks, relaxation or stretching more regularly, wearing braces and avoiding movements that put too much strain on your joints.

A note about exercise and strengthening

Regular, low-impact exercises like swimming, walking, bespoke strength training and stretching with Pilates or yoga can help keep your muscles strong and flexible without putting too much stress on your joints.  Being aware of potential Postural Orthostatic Tachycardia Syndrome (POTS) triggering movements and environments is also essential.

Prolotherapy

Prolotherapy, short for “proliferation therapy,” is an injection-based treatment used to manage musculoskeletal pain, particularly in cases involving joint instability or soft tissue injuries. It involves injecting a natural irritant – often a dextrose (sugar) solution – into the affected ligaments, tendons, or joints. The idea is to stimulate the body’s natural healing response by causing a mild, controlled inflammatory reaction, which encourages tissue repair and strengthens weakened areas over time. It’s commonly used for chronic pain related to Hypermobility, arthritis, or overuse injuries. While some patients report significant pain relief and improved joint stability, evidence on its effectiveness is still mixed, and it’s usually considered when other treatments haven’t helped.

Psychology and Counselling

• For managing chronic illness and pain management: Psychological interventions and counselling can help you manage chronic illness, pain and co-occurring issues mood, sleep, and fatigue disorders, as well as common reports of negative feelings and poor emotional regulation in all types of Hypermobility syndromes and Ehlers-Danlos Syndrome [9].
• Anxiety and Depression: Techniques such as mindfulness and relaxation exercises can reduce anxiety and depression, which are common in people with Hypermobility.
• Coping Strategies: Therapy can provide you with coping strategies to deal with the emotional and psychological challenges of living with Hypermobility.
• Improving Quality of Life: Psychological support can improve your overall quality of life by addressing both the physical and emotional aspects of Hypermobility.

Exercise physiology

• Understanding pacing and exercise: Exercise physiologists can help you design personalised exercise programs to manage your fatigue whilst strengthening your muscles around your joints, providing better support and reducing the risk of post exertional fatigue.
• Increasing Stamina: Tailored exercise programs can help improve your stamina and general fitness, making daily activities easier and less tiring.
• Posture and Gait Training: Exercise physiologists can help you improve your posture and the way you walk, which can prevent further joint issues.

Other issues to consider when living with Hypermobility

Living with Hypermobility goes beyond joint flexibility and musculoskeletal concerns – it can affect multiple body systems, leading to a variety of complex and sometimes unexpected symptoms. Many individuals with Hypermobility experience issues beyond pain and instability, including difficulties with bladder and bowel function, dental health complications, pregnancy-related challenges, and autonomic dysfunctions like POTS.

Additionally, research continues to explore the links between Hypermobility and conditions such as neurodivergence and anxiety. Understanding these broader implications can help individuals and healthcare providers adopt a more comprehensive and proactive approach to management, ensuring a better quality of life.

In the article Living with Hypermobility: A practical guide, we explore some of these interconnected issues in more detail.

A note about medications in Hypermobility treatment

Your doctor might prescribe medications to help manage pain and inflammation. Always follow their advice, though being aware of the benefits and risks is important and letting them know if you have any allergies intolerances is crucial. Pain management in Hypermobility and hypermobile Ehlers-Danlos Syndrome (hEDS) can be quite complex. Medications are often not the first line of Hypermobility treatment due to several reasons:

• The Chronic Nature of Pain: Pain in Hypermobility and hEDS is often chronic and multifaceted, involving joint subluxations, muscle guarding and weakness, past negative clinician interactions, and issues with multi body systems as well as sleep, bladder and gut issues [10]. In Hypermobility pain can originate from tissue damage to muscles, ligaments and joints, as well as nerves and the nervous system, organs,  and other systems in the body. Pinpointing the exact cause of “the pain” can be a difficult task and medications alone may not address these underlying causes effectively.

Pain medications can be a double-edged sword, especially in conditions like Hypermobile Ehlers-Danlos Syndrome (hEDS) and other connective tissue disorders. Here’s a rundown of the risks and benefits:

Benefits:

1. Pain Relief: Medications like NSAIDs, acetaminophen, and opioids can provide significant relief from chronic pain, improving the quality of life.
2. Improved Functionality: By reducing pain, these medications can help individuals perform daily activities more comfortably.
3. Short-term Management: For acute pain episodes, medications can be very effective in providing quick relief.

Risks:

1. Side Effects: Many pain medications, such as NSAIDs and opioids, can have significant side effects, including gastrointestinal issues, which are already common in hypermobile and hEDS patients. While opioids carry risks of addiction, overdose, and other serious side effects [11].
2. Tolerance and Dependence: Long-term use of pain medications, especially opioids, can lead to tolerance (requiring higher doses for the same effect) and physical dependence.
3. Limited Research: There is a lack of extensive research on the long-term effectiveness and safety of these medications specifically for Hypermobility and hEDS and similar conditions. This makes it challenging to develop standardised Hypermobility treatment protocols.

Alternative Approaches:

Given these risks, non-pharmacological approaches like physical therapy, cognitive-behavioural therapy, and lifestyle modifications are often recommended as part of a comprehensive pain management plan.

It’s essential to work closely with healthcare professionals to weigh these risks and benefits and develop a personalised pain management strategy. If you want to dive deeper into this topic, you can find more detailed information here.

A note about surgery in Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders

In rare cases, surgery might be needed to repair damaged joints or tissues, this needs to be considered with great care as many specialists and surgeons are not aware of the unique needs and potential complications that can occur in people with Hypermobility and/or Ehlers-Danlos individuals when undergoing surgery [12]. For more information on surgical considerations see the article “What to talk to your doctor about before surgery.”

Surgery is usually only considered if all other Hypermobility treatments haven’t worked.

Living with Hypermobility can be challenging, but with the right  team of healthcare professionals and treatments, you can lead a full and active life. Remember to work closely with your healthcare team, listen to your body, and make adjustments as needed. You’re not alone in this journey, and there are plenty of resources and support available to help you along the way. It’s essential to work with a full multidisciplinary team of healthcare professionals to develop a comprehensive pain management plan tailored to individual needs.

References

[1] Russek, L. N., Stott, P., & Simmonds, J. (2019). Recognizing and effectively managing hypermobility-related conditions. Physical Therapy, 99(9), 1189–1200. https://doi.org/10.1093/ptj/pzz078

[2] Bovet C, Carison M, Taylor M. Quality of life, unmet needs, and iatrogenic injuries in rehabilitation of patients with Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome. Am J Med Genet A. 2016;170:2044–2051.

[3] Engelbert, R. H. H., Juul‐Kristensen, B., Pacey, V., de Wandele, I., Smeenk, S., Woinarosky, N., Sabo, S., Scheper, M. C., Russek, L., & Simmonds, J. V. (2017). The evidence‐based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos syndrome. American journal of medical genetics. Part C, Seminars in medical genetics, 175(1), 158-167. https://doi.org/10.1002/ajmg.c.31545

[4] Scheper, M. C., De Vries, J. E., Verbunt, J., & Engelbert, R. H. H. (2015). Chronic pain in hypermobility syndrome and ehlers-danlos syndrome (Hypermobility type): It is a challenge. Journal of Pain Research, 8(default), 591-601. https://doi.org/10.2147/JPR.S64251

[5] Whalen, K. C., & Crone, W. (2022). Multidisciplinary Approach to Treating Chronic Pain in Patients with Ehlers–Danlos Syndrome: Critically Appraised Topic. Journal of Pain Research, 15, 2893-2904. https://doi.org/10.2147/JPR.S377790

[6] Knight, D. (2022). Electrical Stimulation for Hypermobility Pain: Part 1. Mayo Clinic Connect. Retrieved from https://connect.mayoclinic.org/blog/ehlers-danlos-syndrome/newsfeed-post/electrical-stimulation-for-hypermobility-pain-part-1/

[7] Jessee, A. D., Gourley, M. M., & Valovich McLeod, T. C. (2012). Bracing and taping techniques and patellofemoral pain syndrome. Journal of Athletic Training, 47(3), 358-359. https://doi.org/10.4085/1062-6050-47.3.07

[8] Maarj, M., Pacey, V., Tofts, L., Clapham, M., & Coda, A. (2023). The Impact of Podiatric Intervention on the Quality of Life and Pain in Children and Adolescents with Hypermobility. International journal of environmental research and public health, 20(17), 6623. https://doi.org/10.3390/ijerph20176623

[9] Bulbena A, Baeza-Velasco C, Bulbena-Cabre A, et al. Psychiatric and psychological aspects in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):237-245.

[10] Chopra P, Tinkle B, Hamonet C, et al. Pain management in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017;175C:212-219.

[11] Arbuck DM. A fresh look at opioid antagonists in chronic pain management. Practical Pain Management. 2018;17(8).

[12] American Academy of Family Physicians. (2021). Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders. American Family Physician, 103(8), online Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders | AAFP

[13] Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, Keefe FJ, Mogil JS, Ringkamp M, Sluka KA, Song XJ, Stevens B, Sullivan MD, Tutelman PR, Ushida T, Vader K. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387; PMCID: PMC7680716.

[14] Carroll MB. Hypermobility spectrum disorders: A review. Rheumatol Immunol Res. 2023 Jul 22;4(2):60-68. doi: 10.2478/rir-2023-0010. PMID: 37637226; PMCID: PMC10457547.