Introduction

Joint hypermobility means that some or all of a person's joints have an unusually large range of movement.

People with hypermobility are particularly supple and able to move their limbs into positions others find impossible.

Joint hypermobility is what some people refer to as having "loose joints" or being "double-jointed".

Joint hypermobility syndrome

Many people with hypermobile joints don't have any problems, and some people – such as ballet dancers, gymnasts and musicians – may actually benefit from the increased flexibility.

However, some people with joint hypermobility can have a number of unpleasant symptoms as well, such as:

  • pain and stiffness in the joints and muscles
  • clicking joints
  • joints that dislocate (come out of the correct position) easily
  • fatigue (extreme tiredness)
  • recurrent injuries – such as sprains
  • digestive problems – such as constipation and irritable bowel syndrome (IBS)
  • dizziness and fainting
  • thin or stretchy skin

If hypermobility occurs alongside symptoms such as these, it is known as joint hypermobility syndrome (JHS).

Read more about the symptoms of joint hypermobility and diagnosing joint hypermobility.

What causes joint hypermobility?

Joint hypermobility is often hereditary (runs in families). One of the main causes is thought to be genetically determined changes to a type of protein called collagen.

Collagen is found throughout the body – for example, in skin and ligaments (the tough bands of connective tissue that link two bones together at a joint).

If collagen is weaker than it should be, tissues in the body will be fragile, which can make ligaments and joints loose and stretchy. As a result, the joints can extend further than usual.

JHS is widely thought to be a feature of an underlying condition affecting connective tissue called Ehlers-Danlos syndrome (EDS).

Read more about the causes of joint hypermobility.

Living with joint hypermobility

Most people with hypermobile joints won't experience any problems and won't require any medical treatment or support.

However, JHS can be very difficult to live with because it can cause such a wide range of symptoms.

People with JHS often benefit from a combination of controlled exercise and physiotherapy, as well as additional help to manage pain and make everyday tasks easier.

The nature of JHS means that you are at increased risk of injuries, such as dislocations and sprains. Managing the condition may therefore also involve treating short-term injuries as they arise, while following a long-term treatment plan to manage daily symptoms.

Read more about treating joint hypermobility.

Who is affected

Joint hypermobility is thought to be very common, particularly in children and young people. Some estimates suggest that around one in every five people in the UK may have hypermobile joints.

In many cases, the joints become stiffer with age, although joint hypermobility and its associated symptoms can continue into adult life.

It's not known how many people have JHS in the UK, as the condition is often not recognised or is misdiagnosed. It's thought to be more common in females than males, and less common in white people than those of other ethnic backgrounds.

Symptoms

Many people with joint hypermobility have few or no problems related to their increased range of movement.

Being hypermobile does not necessarily mean you will have any pain or difficulty. If you have symptoms, it is likely that you have joint hypermobility syndrome (JHS).

Symptoms of joint hypermobility syndrome

JHS can cause a wide range of symptoms, including:

  • pain and stiffness in the joints and muscles – particularly towards the end of the day and after physical activity
  • clicking joints
  • back and neck pain 
  • fatigue (extreme tiredness)
  • night pains – which can disrupt your sleep
  • poor co-ordination
  • recurrent joint dislocations – such as adislocated shoulder
  • recurrent soft tissue injuries – such as sprains and sports injuries

A person with JHS may also have a number of other symptoms related to weaknesses in the connective tissues throughout their body. Some of these symptoms are described below.

Digestive system problems

JHS can cause symptoms that affect your digestive system, because the muscles that squeeze food through your digestive system can weaken.

This can cause a range of problems, including:

  • gastro-oesophageal reflux disease (GORD) – where stomach acid leaks from your stomach to your gullet, causing symptoms such as heartburn
  • gastroparesis – where the stomach has difficulty emptying its contents into the small bowel, which can cause bloating and nausea
  • constipation
  • irritable bowel syndrome (IBS) – a disorder that affects the digestive system, causing tummy pain, diarrhoea and constipation

Postural orthostatic tachycardia syndrome (POTS) 

JHS can also cause abnormalities in the part of your nervous system that controls bodily functions you do not actively think about, such as the beating of your heart. This is known as your autonomic nervous system.

These abnormalities can cause problems when you stand up or sit in the same position for a while. Your blood pressure can drop to low levels, making you feel sick, dizzy and sweaty. You may also faint.

In some people, these abnormalities can lead to postural orthostatic tachycardia syndrome (POTS). POTS causes your pulse rate to increase rapidly within a few minutes of standing up. You may also experience:

  • dizziness or fainting
  • headaches
  • tummy upsets
  • sweating
  • a sensation of anxiety
  • purple puffy fingers and feet
  • a pounding or fluttering heart beat (heart palpitations)

Other problems

People with JHS may have other related conditions and further symptoms, including:

  • stress incontinence – a type of urinary incontinence that occurs because the pelvic floor muscles are too weak to prevent accidental urination
  • hernias – where an internal part of the body, such as an organ, pushes through a weakness in the muscle or surrounding tissue wall
  • in women, pelvic organ prolapse – where the organs inside the pelvis slip down from their normal position
  • varicose veins – swollen and enlarged veins, usually blue or dark purple
  • flat feet – where the inner part of your feet (the arch) is not raised off the ground when you stand
  • headaches
  • drooping eyelids
  • a tendency to bruise easily and develop stretch marks
  • thin or stretchy skin

Although a link is not entirely certain, it is thought that some people with JHS may be at an increased risk of developing osteoarthritis earlier in life than usual.

Causes

There are four factors that may contribute to joint hypermobility.

These are:

  • the structure of your collagen (a type of protein found in some types of tissue)
  • the shape of the ends of your bones
  • your muscle tone
  • your sense of your joint movements (proprioception)

These are explained in more detail below.

Collagen structure

Collagen is a type of protein found throughout your body – for example, in skin and ligaments. Ligaments are tough bands of connective tissue (fibres that support other tissues and organs in your body) that link two bones together at a joint. They strengthen the joint and limit its movement in certain directions.

If the structure of your collagen is altered, it may not be as strong, and the tissues that contain collagen will be fragile. This can lead to weakened or easily stretched ligaments.

Changes in the structure of your collagen are likely to be caused by changes to your genes. Genes are units of genetic material that you inherit from your parents. They contain instructions that tell your body how to work. If the instructions within the genes change, it can alter the structure of your collagen.

Shape of the bone ends

A joint is the junction between two bones. The shape of the bones determines how far you can move your limbs.

For example, your limbs will be more flexible if the socket that the bone moves around in, such as the shoulder or hip socket, is shallow.

Muscle tone

Children with joint hypermobility may have a degree of hypotonia (low muscle tone), which makes the muscles "floppy" and could mean the child is able to bend their joints more than usual.

Sense of joint movement

You should be able to sense the position and movement of your joints. For example, even with your eyes shut, you should know whether your arm is bent or straight. The medical term for this sense is "proprioception".

However, some people with joint hypermobility have an abnormal sense of joint movement and are able to sense when a joint is overstretched, giving them a wider range of movement.

Other conditions

In a small number of cases, joint hypermobility is associated with a more serious underlying condition. These are often inherited conditions, which parents pass to their children. 

Some conditions that can cause joint hypermobility are described below.

Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is the name for a group of uncommon conditions that affect connective tissues. There are four main types of EDS, most of which can affect the joints in some way.

Hypermobile EDS, previously known as EDS type III, is a form of the condition many experts now consider to be the same thing as joint hypermobility syndrome (JHS). This is the most common type of EDS and is estimated to affect around one in every 100 to 200 people.

Marfan syndrome

Like EDS, Marfan syndrome affects the body's connective tissues.

The condition can cause hypermobile joints in addition to a number of typical characteristics, such as being tall and having abnormally long and slender limbs, fingers and toes. It can also cause potentially serious problems affecting the heart and eyes.

Osteogenesis imperfecta

Osteogenesis imperfecta is a rare condition sometimes known as "brittle bone disease" because it causes fragile bones. Some forms of the condition can also cause joint hypermobility, along with a range of other problems.

Diagnosis

If your doctor thinks that you may have joint hypermobility, the Beighton score is often used as a quick test to assess the range of movement in some of your joints.

However, this cannot be used to confirm a diagnosis, because it is important to look at all the joints.

Your GP may also carry out blood tests and X-rays to rule out other conditions associated with joint pains, such as rheumatoid arthritis.

If you have other symptoms in addition to hypermobile joints, your GP may carry out a further assessment of your condition using the Brighton criteria, which can help determine if you have joint hypermobility syndrome (JHS).

The Beighton score

The Beighton score consists of a series of five tests, the results of which can add up to a total of nine points.

The score is worked out as follows:

  • one point if you can place your palms on the ground while standing with your legs straight 
  • one point for each elbow that bends backwards
  • one point for each knee that bends backwards
  • one point for each thumb that touches the forearm when bent backwards
  • one point for each little finger that bends backwards beyond 90 degrees

If your Beighton score is four or more, it is likely that you have joint hypermobility.

The Hypermobility Syndromes Association has images of the Beighton score tests, if you would like more information.

The Brighton criteria

The Brighton criteria take into account your Beighton score, but also consider other symptoms, such as joint pain and dislocated joints, and how long you have had them. There are major and minor Brighton criteria.

Major criteria

The major Brighton criteria are: 

  • having a Beighton score of four or more – either now or in the past
  • having joint pain for longer than three months in four or more joints

Minor criteria

The minor Brighton criteria are:

  • having a Beighton score of one to three, or having a Beighton score of zero to three if you are over 50 years of age
  • having joint pain for longer than three months up to three joints, back pain for longer than three months, or spondylosis (spinal arthritis) or spondylolisthesis (where a bone from the lower spine slips out of position)
  • dislocation or partial dislocation of more than one joint, or the same joint more than once
  • having three or more injuries to your soft tissues – such as tenosynovitis (inflammation of the protective layer surrounding a tendon) or bursitis (inflammation of a fluid-filled sac in a joint)
  • having particular physical characteristics called Marfanoid habitus – this includes being tall and slim and having long, slim fingers
  • having abnormal skin – such as thin and stretchy skin
  • having eye-related symptoms – such as droopy eyelids or short-sightedness
  • having swollen and enlarged veins (varicose veins), a hernia (when an internal part of the body pushes through a weakness in the surrounding tissue wall) or – in women – pelvic organ prolapse (where the organs inside the pelvis slip down from their normal position) 

According to the Brighton criteria, JHS may be diagnosed if you have:

  • two major criteria
  • one major criteria and two minor criteria
  • four minor criteria
  • two minor criteria and a close relative, such as a parent, who has been diagnosed with JHS

Assessing the impact of the condition

If you are diagnosed with JHS, it's important that your GP fully assesses the effect the condition is having.

JHS can cause a wide range of symptoms (read more about the symptoms of joint hypermobility) and it's necessary to assess the effect of your symptoms on your quality of life to determine the treatment and support you need.

Read more about treating joint hypermobility.

Treatment

If you have joint hypermobility that doesn't cause any problems, treatment is not necessary.

However, you may need treatment and support if you have joint hypermobility syndrome (JHS), which causes a wide range of symptoms, including joint pain and digestive problems.

Some of the main treatments for JHS are outlined below.

Self care

There are some things you can do yourself that can help if you have JHS. These include:

  • ensuring you have a generally healthy lifestyle – including having a healthy diet and maintaining a healthy weight; this will help improve the strength of your joints and reduce the strain on them
  • adopting sleep hygiene measures if you have trouble sleeping – such as establishing fixed times for going to bed and waking up, trying to relax before going to bed, and maintaining a comfortable sleeping environment
  • staying as active as you can, but sticking to "low-impact" exercises, such as swimming or cycling to reduce strain on your joints
  • wearing comfortable and supportive footwear to support your ankles
  • applying heat – such as a hot water bottle or heat-rub cream – to soothe sore joints
  • if you have an injury from over-stretching, it helps to rest the joint and elevate it (for example, by propping it up on some pillows); you can also apply ice wrapped in a damp towel to the injured area

You may also find it useful to contact a support group. Both the Hypermobility Syndromes Association and Ehlers-Danlos Support UK have a network of local support groups where you can meet other people with JHS and Ehlers-Danlos syndrome (EDS).

Physiotherapy and exercise

Physiotherapy may help people with hypermobile joints in a number of ways. For example, it may help to:

  • reduce pain
  • improve muscle strength and fitness
  • improve posture
  • improve your sense of your body’s position and movement (proprioception)
  • correct the movement of individual joints

It's helpful to have a physiotherapist with knowledge of JHS, as some physiotherapy treatments can make symptoms worse.

A wide range of physiotherapy techniques can be used. You may be advised to follow an exercise programme that includes strength and balance training, special stretching techniques and advice about pacing.

Pacing involves balancing periods of activity with periods of rest. It means not overdoing it or pushing yourself beyond your limits, because if you do it could slow your long-term progress.

Occupational therapy

Occupational therapy aims to help you overcome difficulties in your everyday life caused by having JHS.

This may involve teaching you alternative ways of carrying out a certain task. For example, an occupational therapist can give you advice about  reducing the strain on your joints while using a computer or getting dressed.

Equipment may also be provided to make certain tasks easier. For example, special grips can make holding a pen easier and help improve handwriting.

An occupational therapist can also suggest ways to adapt your home to make moving around easier. For example, if using stairs is a problem, fitting special grab rails may be recommended.

Podiatry

For some people with JHS, flat feet can be a problem. If someone has flat feet, that person has no arch in the inner part of their feet, which can put a strain on nearby muscles and ligaments (tissue that connects bones together at a joint).

If you have problems with your feet, a podiatrist (a foot specialist) can recommend treatments such as special insoles to support your feet.

Painkillers

Medication can be used to manage the pain associated with JHS.

Painkillers available over the counter from pharmacies, such as paracetamol, can sometimes help. Your GP can also prescribe a medicine that contains both paracetamol and codeine, which is a stronger type of painkiller. Liquid paracetamol (such as Calpol) may be helpful for children with JHS.

Alternatively, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may help in some cases.

Painkillers and NSAIDs are also available as gels or sprays that can be applied directly onto painful joints.

Make sure you check the patient information leaflet that comes with your medicine before taking any over-the-counter medication, to make sure it is suitable for you.

Some people with JHS may find pain medication is not effective for them. There have been reports of local anaesthetic used during surgical procedures not having an effect on people with JHS. If you are having a procedure that requires anaesthesia, such as dental treatment, you may want to discuss the issue with your doctor or dentist beforehand. 

Pain management

If painkillers are not effective in reducing your pain, you may benefit from being referred to a pain specialist at a pain clinic. Staff at the clinic will be able to provide further advice and treatment.

For example, some people with JHS benefit from a pain management programme that incorporates a type of psychological therapy called cognitive behavioural therapy (CBT) when painkillers are not working.

Pain specialists can also provide stronger painkillers or medication used to specifically treat nerve (neuropathic) pain.

Treating specific problems

If you have any related conditions, these will often be treated in the same way as people without JHS.

For more information about the specific treatments for some of the problems associated with JHS, see: