Flexible Joints – Hypermobility Syndrome

Some people’s joints are more flexible than the general population. In these people, joints such as wrist, knee, ankle, hip may bend and flex more than normal. Flexibility can be a feature that is noticed from childhood, or it can be at a level that is more vague and understood when special attention is paid. The ability of the joints to move more than normal degrees is called hypermobility. If the number of flexible joints is more than a certain value, it is called diffuse joint hypermobility.

If the flexibility or hypermobility of the joints does not cause any discomfort to the person, it is not considered a medical problem. For most people, being flexible does not cause complaints. It can even be an advantage in some sports like gymnastics, dancing and playing a musical instrument. But sometimes flexible joints can be associated with joint and muscle pain, frequent sprains or even dislocations of the joints. The presence of such complaints together with flexibility is defined as “hypermobility syndrome”. Another name is “Ehlers-Danlos syndrome type 3”.

To reiterate, widespread flexibility (hypermobility) in the joints and the fact that this situation causes complaints such as pain and susceptibility to sprains indicates joint hypermobility syndrome.

Who Gets Hypermobility Syndrome?

Elasticity may be caused by the genetic differences of the collagen fibers that make up the connective tissue or by the fact that the bones can move more due to the shallowness of the joint pit. The shallowness of the joint cavity causes excessive movement of several joints such as hips and shoulders. Diffuse hypermobility may be due to the difference in collagen fibers.

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Hypermobility may show familial inheritance. Women are generally more flexible than men. Collagen fibers forming the ligaments become more tightly bound to each other as age progresses. For this reason, the elderly are more hesitant than the young. Some people with hypermobile joints may find that as they get older, they can’t stretch as easily as they used to. Joint range of motion can be increased to a certain extent with exercise and training. For example, with yoga movements, the joints can be stretched.

Hypermobility may also develop due to another disease. The joints of people with Down syndrome are mostly flexible. This feature is also seen in other types of Marfan syndrome and Ehlers-Danlos syndrome.


There may be increased muscle pain, especially after exercise or heavy physical activity. Since the ligaments that hold the joints together are loose, more work falls on the muscles, which can lead to pain and injury. If there is damage to the joint, edema may occur and limitation of movement may develop until it heals. Foot and ankle pain are also common. Frequent ankle sprains may occur. Flat feet may also accompany it. Complaints increase with standing for a long time. Looseness of the ligaments holding the spine can cause neck, back and low back pain. If hypermobile joints are overstretched, the risk of dislocation is higher than normal, especially in the shoulder and kneecaps.

Skeletal muscles and joints may also be affected. Weakness in the muscles that move the bowels can lead to constipation, bloating and pain. Reflux (stomach acid to escape into the esophagus) can be seen. Weakness of the groin floor muscles can cause the problem of urinary incontinence called stress incontinence. Heart valves can also be affected by connective tissue elasticity; sometimes it does not cause any complaints, in some cases it can cause symptoms such as chest pain and palpitation. Blood pressure may be lower than normal, and when standing up quickly, blood pressure drops, palpitations, and fainting may occur.

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How Is It Diagnosed?

The diagnosis of hypermobility syndrome is made by questioning the complaints (taking a medical history) and physical examination. The Beighton score provides an assessment of the flexibility of the thumb/wrist, little finger, elbow, waist, and knee with some standard movements. A high Beighton score indicates hypermobility. There may also be hypermobility in different joints such as shoulders, neck, jaw, back, hip, ankle and foot that are not examined with this test. Along with a high Beighton score, pain in flexible joints, previous dislocations, injuries in structures such as muscles and tendons around the joint, and skin flexibility support the hypermobility syndrome.

Beighton Points

Beighton score can range from 0 to 9:

  • (1) Being able to touch the ground with the palms by bending from the waist without bending the knees (one point)
  • (2) More than 10 degrees of elbow backward flexion (hyperextension) (one point each side)
  • (3) Able to bend backwards more than 10 degrees (hyperextension) of the knees (one point for each side at each joint)
  • (4) Ability to flex the thumb until it touches the forearm (one point per side)
  • (5) Ability to bend the little finger backward more than 90 degrees (1 point for each side)

Brighton Criteria

The Brighton criteria can be used when deciding whether a person with flexible joints has joint hypermobility syndrome :

Major criteria:

  • Beighton score of 4 or higher
  • Joint pain affecting 4 or more joints and lasting longer than 3 months

Minor criteria:

  • Beighton score of 1, 2 or 3
  • Back pain or pain in one to three joints lasting more than 3 months or spinal spondylosis, spondylolysis, spondylolisthesis
  • Dislocation of more than one joint or more than one dislocation of a joint
  • 3 or more soft tissue problems (eg tendinitis, bursitis)
  • long slender body
  • Excessively supple skin, stretch marks, thin skin, or abnormal scarring
  • Low eyelids, myopia
  • Varicose veins, hernia, uterine or rectal prolapse
  • Mitral valve prolapse
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Diagnosis requires any of the following:

  • 2 major kriter
  • 1 major and two minor criteria
  • 4 minor criteria
  • 2 minor criteria and first degree relative EHS


Joint flexibility is not something that can be treated or changed. It is a structural feature of the body. However, if there are complaints due to excessive flexibility, these problems can be controlled with good planning of activities and physical therapy.

It is helpful to do muscle strengthening exercises in a controlled manner. It is important not to overdo it with strengthening exercises. Smaller weights can be used. Exercises should be done regularly. For some people, careful stretching may also be beneficial. It is recommended to learn the exercises under the supervision of a physiotherapist. If there is pain with any movement, the activity should not be persisted without determining the cause of the pain. Swimming is a safe and beneficial sport in which muscles can be developed without overloading the joints.

Various splints (wristbands, etc.) can be used to protect the joints while working or doing sports. This should be considered especially for joints that have developed dislocations before. Insoles that support the arch of the foot may be recommended. If the pain complaint is excessive, your doctor may prescribe pain medication for short-term use . Acupuncture and various physical therapy methods can also be effective in reducing complaints. Following healthy dietary recommendations can help normal development of connective tissue.

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