Many people someone who is “double-jointed,” a person who can effortlessly bend their thumb back to their wrist, hyperextend their elbows and knees, or place their palms flat on the floor without bending their legs. While often seen as a fun “party trick” or a sign of natural gymnastic ability, for a significant number of people, this remarkable flexibility comes with a hidden and often misunderstood cost: chronic pain, joint instability, and debilitating fatigue. This trait, known medically as joint hypermobility, exists on a wide spectrum. For many, it is a benign and asymptomatic characteristic. For others, it is the defining feature of a complex and painful systemic condition, such as a Hypermobility Spectrum Disorder or Ehlers-Danlos syndrome. Understanding this distinction is the key to validating the real physical challenges that can accompany being “too flexible.”

Hypermobile joints, also known as joint hypermobility or being “double-jointed,” refer to joints that move beyond the normal range of motion with little effort. This extra flexibility is not due to strong muscles or dedicated stretching, but rather to the composition of the body’s connective tissue.

To understand this, it is helpful to use an analogy. Think of your joints as hinges on a door, held together and stabilized by strong, taut rubber bands, these are your ligaments and joint capsules. In most people, these “rubber bands” are firm and have limited give, allowing the hinge to open to a specific point and then stopping it securely. In a person with joint hypermobility, these rubber bands are much stretchier, like well-worn elastic. They allow the hinge to move far beyond its normal range, but they fail to provide the same firm, stable support. This can lead to “wobbly,” unstable joints that are more prone to injury.

It is crucial to understand that joint hypermobility exists on a spectrum:

• Asymptomatic Joint Hypermobility: This is the most common scenario. An individual is very flexible, can perform “party tricks,” but experiences no pain, dislocations, or other related symptoms. In this case, it is simply a physical trait, not a medical condition.
• Hypermobility Spectrum Disorders (HSD): This is a newer classification used for people who have symptomatic hypermobility meaning their joint laxity causes significant musculoskeletal problems like chronic pain, instability, and injuries but do not meet the full diagnostic criteria for another condition like Ehlers-Danlos syndrome (The Ehlers-Danlos Society, 2021).
• Hypermobile Ehlers-Danlos Syndrome (hEDS): This is a specific, heritable connective tissue disorder where generalized joint hypermobility is a primary feature, but it is also accompanied by a wider range of systemic issues, including soft, fragile skin, chronic pain, fatigue, and autonomic nervous system dysfunction. Today, many experts consider Joint Hypermobility Syndrome (JHS) and hEDS to be the same condition.

Hypermobile joints are typically caused by inherited differences in connective tissue. Connective tissue is the “fabric” of the body, providing strength, structure, and elasticity to everything from our skin and bones to our blood vessels and ligaments.

A key protein in this fabric is collagen. Collagen is the most abundant protein in the human body, acting as a crucial building block that gives tissues their strength and resilience. There are many different types of collagen, and their production is controlled by specific genes.

In individuals with joint hypermobility, it is believed there are variations or mutations in the genes that provide the instructions for making collagen and other related connective tissue proteins. These genetic variations cause collagen that is more pliable, extensible, and “stretchy” than normal. This leads to lax ligaments, tendons, and skin, which in turn results in the joints having a greater range of motion than is typical.

Patients often don’t realize that hypermobility isn’t just a neat party trick, it can come with long-term joint wear and chronic discomfort.

Hypermobile joints are mostly inherited. It is not caused by any lifestyle factor, diet, or activity. It is something a person is born with, encoded in their DNA.

• Genetics: The trait often runs in families. The most common inheritance pattern is autosomal dominant, which means that an individual only needs to inherit one copy of the responsible gene from one parent to have hypermobile joints. If a parent has the trait, there is a 50% chance they will pass it on to each of their children.
• Age: Children and adolescents are naturally more flexible than adults. Many people who are hypermobile in their youth become less so as they age and their connective tissues naturally stiffen.
• Gender: Joint hypermobility is generally more common in females than in males, which may be related to hormonal influences on connective tissue.
• Ethnicity: Some studies have shown that joint hypermobility is more prevalent in individuals of Asian and African descent compared to those of European descent.

Not everyone with hypermobile joints has symptoms. When symptoms do occur, it’s usually part of a hypermobility spectrum disorder (HSD) or hypermobile Ehlers-Danlos syndrome (hEDS).

The signs and symptoms can be broadly divided into two categories:

Musculoskeletal Symptoms (Related to the Joints and Muscles)

• Joint Instability: This is a core problem. Joints can feel wobbly, weak, or “not right.” This can lead to frequent joint subluxations (a partial dislocation where the joint slips out of place and then goes back in) or full dislocations. This is common in shoulders, kneecaps, and fingers.
• Chronic Pain: Widespread, chronic joint and muscle pain is a major feature. The pain is often deep and aching and can be difficult to pinpoint.
• Soft Tissue Injuries: Because the ligaments are too lax to stabilize the joints properly, the muscles have to work overtime. This can lead to a high rate of sprains, strains, tendonitis, and bursitis.
• Fatigue: Profound, debilitating fatigue is very common. This is partly because the body expends so much extra energy just to maintain posture and stabilize joints during everyday activities.
• Poor Proprioception: Proprioception is the body’s sense of its position in space. Many people with hypermobility have poor proprioception, meaning their brain doesn’t get clear signals about where their joints are. This can lead to clumsiness, poor balance, and difficulty with coordination.

Systemic Symptoms (Beyond the Joints)

Because faulty connective tissue is found throughout the body, HSD and hEDS can cause a wide array of seemingly unrelated symptoms:

• Skin: The skin may be unusually soft, velvety, and slightly stretchy. Easy bruising is also very common.
• Autonomic Nervous System Dysfunction: Many individuals experience issues like Postural Orthostatic Tachycardia Syndrome (POTS), which causes dizziness, lightheadedness, and a rapid heart rate upon standing.
• Gastrointestinal Problems: Digestive issues are very common, including acid reflux, bloating, constipation, and symptoms that mimic Irritable Bowel Syndrome (IBS).
• Anxiety Disorders: There is a strong correlation between joint hypermobility and anxiety disorders. This may be related to autonomic dysfunction or the psychological stress of living with an unpredictable and painful condition (National Institutes of Health [NIH], 2017).

Diagnosis is clinical, based on physical exam, symptom history, and family history. Tools like Beighton Score measure joint flexibility.

The Beighton Score

The standard screening tool used to assess generalized joint hypermobility is the Beighton Score. This is a simple, 9-point test that measures the flexibility of specific joints:

1. Can you bend your little finger backward past 90 degrees? (1 point for each hand)
2. Can you bend your thumb forward to touch your forearm? (1 point for each hand)
3. Does your elbow bend backward more than 10 degrees? (1 point for each arm)
4. Does your knee bend backward more than 10 degrees? (1 point for each leg)
5. Can you place your palms flat on the floor with your knees straight? (1 point)

A score of 5 or higher in an adult (6 or higher in a child) is generally considered positive for generalized joint hypermobility.

Beyond the Score

It is critical to understand that the Beighton score alone does not diagnose a disorder; it only confirms the presence of hypermobility. To diagnose a condition like hEDS or HSD, a doctor uses a comprehensive set of criteria that includes the Beighton score plus an evaluation of the many other systemic symptoms, the extent of chronic pain, and a careful exclusion of other types of connective tissue disorders and autoimmune diseases.

There is no cure for hypermobile joints, but symptoms can be managed effectively through physiotherapy, lifestyle changes, and symptom control.

Physical Therapy: The Cornerstone of Management

This is the most important treatment for symptomatic hypermobility. However, it must be the right kind of physical therapy.

• The Goal is Stabilization, Not Stretching: The focus should be on strengthening the muscles around the joints. These muscles must be trained to act as “dynamic stabilizers” to do the job that the lax ligaments cannot.
• Improving Proprioception: Therapy includes exercises designed to improve the brain’s sense of joint position, which can reduce clumsiness and prevent injuries.
• Low-Impact Exercise: Activities like swimming, Pilates, and cycling are excellent for building muscle strength without stressing the joints.

Pain Management

• Activity Pacing: Learning to listen to your body and pace activities is crucial for managing both pain and fatigue.
• Bracing and Taping: Supportive braces or kinesiology tape can provide extra stability to vulnerable joints during certain activities.
• Medication: Over-the-counter pain relievers like acetaminophen or NSAIDs can be used for acute pain, but long-term management focuses on physical therapy rather than medication.

Managing Associated Symptoms

• For autonomic issues like POTS, management may include increasing fluid and salt intake and wearing compression garments.
• For anxiety and the psychological burden of chronic pain, counseling and cognitive-behavioral therapy (CBT) can be extremely helpful.
• It is also important for individuals to avoid “party tricks” and intentionally hyperextending their joints, as this can lead to injury and long-term joint damage.

Joint hypermobility is a common trait that exists on a vast spectrum. For most, being “double-jointed” is a harmless quirk. For a significant minority, however, it is the root of a chronic and painful condition that affects the entire body. The validation that comes from a proper diagnosis of a Hypermobility Spectrum Disorder or hEDS is a crucial first step, helping individuals understand that their symptoms of pain, instability, and fatigue are real and have a physical cause. While there is no cure, the prognosis for living well with hypermobility is excellent.

• Tinkle, B. T., Bird, H. A., Grahame, R., Lavallee, M., Levy, H. P., & Sillence, D. (2017). The lack of clinical diagnostic criteria for the hypermobile subtype of Ehlers–Danlos syndrome. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), 93–101. https://doi.org/10.1002/ajmg.c.31539
• The Ehlers-Danlos Society. (2021). What is HSD? Retrieved from https://www.ehlers-danlos.com/what-is-hsd/
• National Institutes of Health (NIH), Genetic and Rare Diseases Information Center (GARD). (2017). Joint hypermobility syndrome. Retrieved from https://rarediseases.info.nih.gov/diseases/10973/joint-hypermobility-syndrome