Hypermobility Spectrum Disorder (HSD)
Hypermobility Spectrum Disorder (HSD) is a condition in which increased joint flexibility is associated with pain, instability or other musculoskeletal symptoms that affect daily life. While many people are naturally flexible without experiencing problems, HSD describes symptomatic joint hypermobility that requires assessment and appropriate management.
Although there is currently no cure, many people improve through education, targeted rehabilitation and personalised long-term management. At Rowan Health, we take a whole-person approach, assessing not only joint hypermobility but also pain, fatigue, movement patterns and associated conditions to develop an individualised support programme alongside your conventional medical care.
This information is intended for educational purposes and should not replace professional medical advice. If you have new, severe or worsening symptoms, always seek advice from your GP or specialist healthcare team.
KEY FACTS
✔ Medical name
Hypermobility Spectrum Disorder (HSD)
✔ Previously known as
Joint Hypermobility Syndrome (JHS), Benign Joint Hypermobility Syndrome (BJHS)
✔ What it affects
The joints, ligaments, tendons and surrounding soft tissues, primarily affecting the musculoskeletal system, although associated symptoms may involve other body systems.
✔ Common symptoms
Joint hypermobility, recurrent sprains, joint instability, chronic joint pain, muscle fatigue, poor proprioception, reduced exercise tolerance and repeated soft tissue injuries.
✔ Who can be affected?
HSD can affect children and adults of all ages. Many people have flexible joints without symptoms, but HSD is diagnosed when hypermobility is associated with pain, instability or functional impairment.
✔ How is it diagnosed?
HSD is diagnosed clinically using the 2017 International Classification. Assessment includes the Beighton Score, a history of joint hypermobility, exclusion of hypermobile Ehlers-Danlos Syndrome (hEDS) and other connective tissue disorders, confirmation of secondary musculoskeletal manifestations, and subtype allocation.
✔ Can it be treated?
Although there is no cure, most people benefit from education, progressive strengthening, physiotherapy, pain management and personalised rehabilitation programmes.
✔ Associated conditions
Some people also experience chronic pain, fatigue, orthostatic intolerance or POTS-type symptoms, gastrointestinal complaints, temporomandibular joint dysfunction and sleep disturbance. These associations should be assessed individually rather than assumed.
✔ When to seek urgent medical advice
Symptoms such as unexplained arterial or organ rupture, translucent skin, sudden severe chest pain, family history of sudden unexplained death or features suggestive of Marfan syndrome or vascular EDS require urgent specialist assessment rather than routine HSD management.
UNDERSTANDING THE CONDITION
Hypermobility Spectrum Disorder (HSD) is a condition affecting people whose joints move beyond the normal range and where this increased flexibility is associated with pain, instability or other musculoskeletal problems.
Having flexible joints alone does not mean someone has HSD. Joint hypermobility is relatively common and, for many people, causes no symptoms throughout life. HSD is diagnosed when hypermobility is accompanied by secondary musculoskeletal manifestations such as persistent pain, recurrent sprains, joint instability or repeated soft tissue injuries that affect everyday function.
The term Hypermobility Spectrum Disorder was introduced in 2017 as part of the International Classification of the Ehlers-Danlos Syndromes and related disorders. Before then, terms such as Joint Hypermobility Syndrome or Benign Joint Hypermobility Syndrome were used inconsistently. The new classification provides a clearer framework for distinguishing between asymptomatic joint hypermobility, HSD and hypermobile Ehlers-Danlos Syndrome (hEDS).
Importantly, HSD is not simply a milder form of Ehlers-Danlos Syndrome. It is a recognised diagnosis in its own right. Some people with HSD experience symptoms that are just as significant as those with hEDS, even though they do not meet the full international diagnostic criteria for hypermobile EDS. Management is often very similar, focusing on improving function, reducing pain and preventing recurrent injury rather than on the diagnostic label itself.
The 2017 framework also recognises four subtypes of HSD, based on the distribution of joint hypermobility:
Generalised HSD (G-HSD) – Hypermobility affecting multiple joints.
Historical HSD (H-HSD) – Previous generalised hypermobility that is no longer clearly present, often because joint flexibility decreases with age.
Peripheral HSD (P-HSD) – Hypermobility mainly affecting the hands and feet.
Localised HSD (L-HSD) – Hypermobility affecting one joint or one group of joints.
These subtypes describe where hypermobility occurs, not how severe the condition is. Someone with Localised HSD affecting one joint may still experience significant pain and functional limitation.
COMMON SYMPTOMS
Hypermobility Spectrum Disorder can affect people in different ways. Some experience symptoms affecting only one or two joints, while others develop more widespread musculoskeletal problems over time. Symptoms often fluctuate, with periods of relative stability interrupted by flare-ups following injury, illness or increased physical activity.
Although HSD primarily affects the musculoskeletal system, some people also experience symptoms involving fatigue, balance, sleep or other body systems. These associated symptoms should be assessed individually rather than assumed to be part of HSD itself.
Joint Pain and Instability
The most common symptoms include persistent joint pain and a feeling that joints are unstable or "give way" during everyday activities.
People may experience:
Aching or painful joints
Recurrent sprains
Joint instability
Frequent subluxations or partial dislocations
Full joint dislocations
Pain after prolonged standing or walking
Joint clicking or popping
Repeated soft tissue injuries
Symptoms often affect the knees, shoulders, ankles, hips and wrists but may involve almost any joint.
Muscle Fatigue
Because the ligaments provide less passive stability, the muscles often need to work harder to control movement.
This increased muscular effort can lead to:
Muscle tiredness
Reduced exercise tolerance
Muscle aching
Slower recovery after activity
Early fatigue during routine daily tasks
Many people describe feeling physically exhausted despite performing activities that would not normally require significant effort.
Reduced Proprioception
Some people notice that they are naturally clumsy or frequently bump into objects.
This is thought to result from reduced proprioception—the body's ability to accurately detect joint position and movement.
Reduced proprioception may contribute to:
Poor balance
Frequent trips or falls
Difficulty judging joint position
Recurrent minor injuries
Reduced coordination
Although research continues, altered proprioception is recognised as one mechanism that may contribute to recurrent injury in people with HSD.
Recurrent Injuries
Repeated injuries are common because joints move beyond their most mechanically stable range.
Examples include:
Ligament sprains
Tendon irritation
Muscle strains
Shoulder instability
Ankle injuries
Knee instability
Overuse injuries
Some people experience repeated injuries despite maintaining good levels of fitness.
Fatigue
Fatigue is frequently reported by people living with HSD.
Several factors may contribute, including:
Increased muscular effort
Persistent pain
Poor sleep
Reduced physical conditioning
Associated conditions
Fatigue should always be assessed as part of a comprehensive clinical evaluation rather than being assumed to have a single cause.
Associated Symptoms
Although HSD is primarily a musculoskeletal condition, some people also experience symptoms that deserve further assessment.
These may include:
Dizziness when standing
Palpitations
Digestive symptoms
Jaw pain or clicking (TMJ dysfunction)
Sleep disturbance
Low mood or anxiety related to chronic symptoms
These associations do not occur in everyone and should not automatically be attributed to HSD. Instead, they should prompt appropriate screening and, where necessary, referral for further assessment.
CAUSES, MECHANISMS AND DIAGNOSIS
Why Does It Happen?
Hypermobility Spectrum Disorder develops because of differences in the body's connective tissues, particularly the structures responsible for supporting and stabilising joints.
Connective tissue is composed of proteins such as collagen and elastin, together with other structural components that provide strength, flexibility and resilience throughout the body. These tissues form ligaments, tendons, joint capsules, fascia and many other supporting structures.
For many people, increased joint flexibility simply reflects the normal variation seen within the population and never causes symptoms. HSD develops when this increased flexibility is accompanied by secondary musculoskeletal problems such as pain, instability or recurrent injury.
Unlike many other inherited connective tissue disorders, no single genetic cause has been identified for HSD. It remains a clinical diagnosis based on symptoms, examination findings and the exclusion of other connective tissue disorders, including hypermobile Ehlers-Danlos Syndrome (hEDS).
Current evidence suggests that symptoms arise through several interacting mechanisms rather than one single abnormality.
These include:
Increased ligament laxity
Reduced passive joint stability
Greater muscular effort to control movement
Recurrent microtrauma
Altered proprioception
Progressive deconditioning following repeated injury
In some individuals, central sensitisation contributing to persistent pain
Understanding these mechanisms helps explain why treatment focuses on improving joint stability, movement patterns and long-term function rather than attempting to "correct" the underlying connective tissue itself.
Why Does Hypermobility Spectrum Disorder Cause Pain and Fatigue?
Many people with Hypermobility Spectrum Disorder ask the same question:
"If my joints are simply more flexible than average, why do I experience so much pain and fatigue?"
The answer lies in how the body maintains joint stability.
Joints rely on two complementary systems. The first is passive stability, provided by ligaments, joint capsules and other connective tissues. The second is active stability, where muscles continuously adjust their activity to control movement.
In people with HSD, the passive stabilising tissues are often more flexible than average. As a result, the muscles must work much harder to keep joints stable during everyday activities. Over time, this additional effort can lead to muscle fatigue, repeated minor injuries and persistent pain.
Increased Muscular Work
Normally, ligaments help prevent excessive movement and reduce the workload placed on muscles.
When joints are more mobile, muscles become the body's primary stabilisers. Every step, lift or change of position requires additional muscular control.
Although this compensation is highly effective, maintaining it throughout the day requires more energy than in people with greater passive joint stability.
This helps explain why activities such as standing, walking, carrying shopping or climbing stairs may become tiring much sooner than expected.
Repeated Micro-Injuries
Most people think of injuries as major events such as falls or sporting accidents.
In HSD, however, the body may experience many small episodes of excessive joint movement throughout the day.
These repeated minor strains can affect:
Ligaments
Tendons
Muscles
Joint capsules
Other soft tissues
Although each individual movement may seem insignificant, their cumulative effect can contribute to ongoing inflammation, pain and repeated soft tissue injuries.
Reduced Joint Position Sense
Healthy joints constantly send information to the brain about their position and movement.
This process, known as proprioception, allows the nervous system to make rapid adjustments that protect joints during movement.
In HSD, these signals may be less precise because the connective tissues containing specialised sensory receptors are more compliant.
As a result, the brain may receive less accurate information about joint position, increasing the risk of awkward movements, poor balance and repeated injuries.
Persistent Pain
Pain in HSD rarely has a single cause.
Instead, it often develops through several overlapping mechanisms.
These may include:
Repeated mechanical strain
Muscle overwork
Soft tissue injury
Joint instability
In some people, increased sensitivity of the nervous system following long-standing pain
This helps explain why two people with similar levels of joint hypermobility may experience very different levels of pain.
Why Fatigue Is So Common
Fatigue is one of the most common symptoms reported by people with HSD.
Rather than resulting from one single cause, it usually reflects the combined effects of:
Continuous muscular effort to stabilise joints
Persistent pain
Poor sleep caused by discomfort
Reduced physical conditioning following repeated injuries
Associated symptoms that may affect overall wellbeing
Understanding these different contributors helps explain why fatigue often persists even when routine blood tests are normal.
A Cycle That Can Develop Over Time
Without appropriate management, a cycle can gradually develop.
Joint instability may lead to pain, causing people to reduce their activity. Reduced activity can result in muscle weakness and deconditioning, making joints less stable and increasing the likelihood of further pain or injury.
Breaking this cycle is one of the main aims of treatment. Evidence suggests that carefully planned strengthening exercises, education and progressive rehabilitation can improve joint stability, reduce symptoms and help people regain confidence in movement.
How It Is Diagnosed
There is currently no blood test or genetic test that confirms Hypermobility Spectrum Disorder.
Instead, HSD is diagnosed through a detailed clinical assessment based on the 2017 International Classification of the Ehlers-Danlos Syndromes and related disorders. The assessment aims to confirm that joint hypermobility is present, determine whether it is responsible for the person's symptoms, and exclude other connective tissue disorders that require different management.
Medical History
Assessment begins with a detailed discussion of your symptoms and medical history.
Your clinician may ask about:
Joint pain and instability
Previous sprains or dislocations
Childhood flexibility
Family history of hypermobility or connective tissue disorders
Daily activities affected by your symptoms
Previous investigations or diagnoses
This information helps determine whether your symptoms are consistent with symptomatic joint hypermobility.
The Beighton Score
The Beighton Score is the most widely used screening tool for generalised joint hypermobility.
It assesses flexibility in nine movements involving the:
Little fingers
Thumbs
Elbows
Knees
Spine
Because joint flexibility naturally changes with age, different age-adjusted thresholds are used when interpreting the results.
Historical Hypermobility
Some people become less flexible as they get older or following injury.
If your current Beighton Score falls just below the diagnostic threshold, your clinician may ask questions about how flexible you were earlier in life.
For example, you may be asked whether you could:
Place your hands flat on the floor without bending your knees
Touch your thumb to your forearm
Perform the splits
Experience repeated shoulder or kneecap dislocations
Consider yourself "double-jointed"
These questions help identify Historical Hypermobility Spectrum Disorder (H-HSD) when appropriate.
Excluding Other Connective Tissue Disorders
One of the most important parts of assessment is ensuring that another connective tissue disorder is not responsible for your symptoms.
Your clinician will look for features that may suggest:
Hypermobile Ehlers-Danlos Syndrome (hEDS)
Vascular Ehlers-Danlos Syndrome
Marfan syndrome
Loeys-Dietz syndrome
Osteogenesis imperfecta
Other inherited connective tissue disorders
If these conditions are suspected, referral for specialist assessment may be recommended before confirming a diagnosis of HSD.
Identifying the Type of HSD
Once other diagnoses have been excluded, the pattern of joint hypermobility is classified as:
Generalised HSD
Historical HSD
Peripheral HSD
Localised HSD
This classification helps guide management but does not necessarily reflect the severity of symptoms.
HOW IS IT USUALLY MANAGED?
Management depends on the diagnosis, symptom severity, underlying mechanisms and each person's individual circumstances.
There is currently no treatment that can alter the underlying connective tissue differences responsible for Hypermobility Spectrum Disorder. Instead, management focuses on improving joint stability, reducing pain, preventing recurrent injuries and helping people maintain an active, independent lifestyle.
Treatment should always be individualised, as the pattern and severity of symptoms vary considerably between people. Most management plans combine education, rehabilitation and strategies to support long-term self-management.
Education and Self-Management
Understanding why symptoms occur is often the first step towards successful management.
Learning how joint hypermobility affects movement, recognising activities that increase joint strain, and developing practical strategies to reduce injury risk can improve confidence and support long-term symptom control.
Many people also benefit from learning how to balance activity with recovery, particularly during symptom flare-ups.
Physiotherapy and Progressive Strengthening
Current evidence supports physiotherapy and progressive strengthening exercises as the cornerstone of HSD management.
Rather than attempting to increase flexibility—which is usually unnecessary—rehabilitation focuses on improving muscle strength, movement control and joint stability.
Programmes are tailored to the individual's symptoms, affected joints and level of physical function, with gradual progression over time.
Research suggests that progressive strengthening can reduce pain, improve joint stability and increase confidence in movement when introduced appropriately.
Pain Management
Pain management depends on the underlying mechanisms contributing to symptoms.
For some people, pain mainly reflects repeated mechanical strain or joint instability. Others may also develop persistent pain associated with increased sensitivity of the nervous system following long-standing symptoms.
Management may include:
Activity modification
Targeted rehabilitation
Pain education
Appropriate use of medication where required
Referral to specialist pain services for complex cases
People with long-standing pain may benefit from a multidisciplinary approach that considers both the physical and functional impact of persistent symptoms.
Bracing and Orthotic Support
Some people benefit from temporary use of braces, splints, taping or orthotic devices.
These interventions may help during periods of increased symptoms or while rehabilitation is progressing, but they are generally considered supportive measures rather than long-term solutions.
Where possible, they should complement—rather than replace—an active strengthening programme.
Managing Associated Conditions
People with HSD may also experience symptoms affecting other aspects of their health.
Depending on individual needs, assessment or referral may be appropriate for:
Chronic pain
Fatigue
Orthostatic intolerance or POTS
Sleep disturbance
Gastrointestinal symptoms
Temporomandibular joint (TMJ) dysfunction
Anxiety or low mood related to living with a long-term condition
Identifying and managing these associated problems can significantly improve overall quality of life.
Lifestyle and Long-Term Health
Long-term management focuses on maintaining joint function while reducing the risk of future injury.
This may include:
Remaining physically active within individual tolerance
Building strength gradually
Maintaining a healthy body weight
Optimising sleep
Developing strategies to manage symptom flare-ups
Reviewing progress regularly and adapting rehabilitation when needed
Although symptoms may fluctuate over time, many people experience meaningful improvements in pain, function and confidence through consistent rehabilitation and ongoing self-management.
LIVING WELL WITH THE CONDITION
Impact on Daily Life
Living with HSD often means adapting to a body that requires greater muscular effort to perform everyday activities. While symptoms vary widely, many people describe living with recurrent injuries, unpredictable pain or fatigue that is not always visible to others.
For some, symptoms affect only one or two joints. For others, repeated instability may influence work, education, sport or family life.
Receiving a diagnosis can be reassuring, helping explain symptoms that may previously have seemed unrelated or difficult to understand. It can also provide a framework for developing practical strategies that improve function and reduce the risk of future injuries.
Although HSD is usually considered a long-term condition, many people improve considerably with appropriate rehabilitation. Building strength, improving movement control and understanding how to manage symptoms over time can help many people remain active and independent.
It is also important to recognise that symptoms may change over time. Joint flexibility often decreases with age, while pain or functional limitations may become more prominent. Regular review allows management strategies to evolve alongside changing needs.
HOW ROWAN HEALTH SUPPORTS YOU
At Rowan Health, we recognise that no two people with Hypermobility Spectrum Disorder experience exactly the same challenges. Our assessment therefore goes beyond measuring joint flexibility to understand how hypermobility affects your daily life, movement, pain, fatigue and long-term wellbeing.
Your initial assessment may include:
A detailed medical and symptom history
Assessment of joint hypermobility and stability
Review of previous injuries and recurrent sprains
Functional movement assessment
Screening for fatigue, chronic pain and associated symptoms
Identification of factors affecting work, sport and everyday activities
Discussion of your personal goals and priorities
Where appropriate, we may also consider associated symptoms such as dizziness on standing, digestive complaints, sleep difficulties or persistent widespread pain to determine whether further assessment or referral would be beneficial.
Following your assessment, we will develop a personalised care plan based on your individual presentation. Depending on your needs, this may combine education, rehabilitation strategies, lifestyle advice and selected evidence-informed integrative approaches alongside your conventional medical care. The focus is on improving function, supporting long-term self-management and helping you remain as active and independent as possible.
Because HSD is a long-term condition, support often involves regular review and adjustment of your management plan as your symptoms and goals evolve over time. This reflects the Rowan Health approach of treating the individual rather than simply the diagnosis.
When to Seek Medical Advice
Although Hypermobility Spectrum Disorder itself is not considered a life-threatening condition, some symptoms may indicate another connective tissue disorder or an unrelated medical emergency requiring prompt assessment.
Seek urgent medical advice if you experience:
Sudden severe chest, back or abdominal pain
Unexplained collapse or loss of consciousness
New weakness, numbness or difficulty speaking
Severe joint pain following significant trauma
An acutely swollen, hot or red joint associated with fever
Unexplained arterial, bowel or organ rupture
A family history of sudden unexplained death associated with connective tissue disorders
Certain physical features—including unusually thin translucent skin, marked cardiovascular abnormalities, very tall stature with long limbs, lens dislocation or other syndromic features—may suggest another inherited connective tissue disorder such as vascular Ehlers-Danlos syndrome, Marfan syndrome or Loeys-Dietz syndrome. These conditions require specialist assessment rather than routine HSD management.
If you experience severe or rapidly worsening symptoms, contact your GP, NHS 24 or emergency services as appropriate.
If your symptoms are severe, rapidly worsening or causing immediate concern, contact NHS 24 on 111. In a medical emergency, call 999 or attend your nearest Accident & Emergency department.
FAQs
Is Hypermobility Spectrum Disorder the same as being double-jointed?
No. Many people naturally have flexible joints without experiencing any health problems. HSD is diagnosed when joint hypermobility is associated with pain, instability or other musculoskeletal symptoms that affect daily life.
Is HSD the same as Ehlers-Danlos Syndrome?
No.
Hypermobility Spectrum Disorder and hypermobile Ehlers-Danlos Syndrome (hEDS) are separate diagnoses within the 2017 international classification. Although they share many symptoms and are managed in similar ways, people with hEDS meet additional diagnostic criteria that are not present in HSD.
Can HSD get worse over time?
Symptoms can change over time.
Joint flexibility often decreases with age, but pain, weakness or reduced function may become more noticeable if muscles become deconditioned or repeated injuries occur. Regular review and appropriate rehabilitation can help maintain function.
Is there a cure?
There is currently no cure for HSD.
However, many people experience significant improvements through education, progressive strengthening, physiotherapy and personalised long-term management.
Should I avoid exercise?
Usually not.
Current evidence suggests that appropriately prescribed strengthening exercises are one of the most effective treatments for improving joint stability and reducing pain. Exercise programmes should be individualised and progressed gradually.
Why do I feel tired all the time?
Fatigue may result from the increased muscular effort required to stabilise hypermobile joints, together with persistent pain, disturbed sleep, reduced conditioning or associated conditions. A comprehensive assessment can help identify the factors contributing to fatigue.
Can HSD be associated with dizziness or digestive problems?
Some people with HSD also experience orthostatic intolerance, POTS-type symptoms, digestive complaints or sleep disturbance.
These conditions are recognised associations rather than features of HSD itself and should be assessed individually where appropriate.
How can Rowan Health help?
Our assessment considers how hypermobility affects your movement, pain, fatigue, function and quality of life. Following a comprehensive evaluation, we develop an individualised management plan designed to support your long-term health alongside your conventional medical care.
Sources & references
Castori M, Tinkle B, Levy H, Grahame R, Malfait F, Hakim A. A framework for the classification of joint hypermobility and related conditions. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017;175(1):148–157.
Malfait F, Francomano C, Byers P, et al. The 2017 International Classification of the Ehlers-Danlos Syndromes. American Journal of Medical Genetics Part C. 2017;175(1):8–26.
Malek S, Reinhold EJ, Pearce GS. The Beighton Score as a measure of generalised joint hypermobility. Rheumatology International. 2021.
Hakim AJ, Grahame R. A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain. International Journal of Clinical Practice. 2003.
Brittain E, Selfe J, Martin A, et al. Physical therapy interventions in generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome: a scoping review. Disability and Rehabilitation. 2024.
Liaghat B, Skou ST, Jørgensen U, et al. Heavy shoulder strengthening exercise in people with Hypermobility Spectrum Disorder and long-lasting shoulder symptoms. BMC Musculoskeletal Disorders. 2020.
Higo A, Palmer S, Liaghat B, Tallis J, Silvester L, Pearce G. The effectiveness of conservative interventions on pain, function and quality of life in adults with hEDS/HSD and shoulder symptoms: a systematic review. Archives of Rehabilitation Research and Clinical Translation. 2024.
The Ehlers-Danlos Society. Hypermobile Ehlers-Danlos Syndrome (hEDS) vs Hypermobility Spectrum Disorders (HSD): What's the Difference?
Association of Paediatric Chartered Physiotherapists. Hypermobility and Hypermobility Spectrum Disorder. 2024.
Clinical Review
Clinical content reviewed by
Rowan Health
Last reviewed:
28 July 2026
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Would You Like Personalised Support?
At Rowan Health, we look beyond joint flexibility to understand how hypermobility affects your movement, pain, fatigue and everyday life. Your assessment considers joint stability, previous injuries, functional limitations and associated symptoms to build a personalised picture of your health.
Following a comprehensive evaluation, we develop an individualised care plan tailored to your needs and goals. Depending on your presentation, support may combine education, rehabilitation strategies and selected evidence-informed integrative approaches alongside your conventional medical care.
Our aim is to help improve joint stability, reduce recurrent injuries, enhance function and support your long-term health and quality of life.