As a kid, you may have been the person who could fold in half. Touch the floor flat-palmed. Do the splits. But now you’re dealing with chronic pain, repeated injuries, and a nagging sense that your body just doesn’t work right. Even though you may not feel as flexible as an adult, here’s what’s actually going on.
Most runners and active adults assume that more flexibility equals better performance and lower injury risk. Yoga culture, youth sports coaches, and decades of “stretch before you run” advice have drilled this belief into us. But for a significant portion of the population — particularly those with joint hypermobility — the opposite is often true. Excessive range of motion is not a superpower. It’s a structural challenge that requires a fundamentally different approach to training, injury prevention, and rehabilitation.
What is Hypermobility, Exactly?
Hypermobility refers to joints that move beyond their normal range of motion. It’s not just about being “flexible” — it describes a situation where the passive restraints of a joint (ligaments, joint capsule, and the connective tissue that holds everything together) are more lax than average. This allows joints to move into ranges that the surrounding muscles and nerves weren’t designed to control well.
Clinicians typically screen for hypermobility using the Beighton Score. I personally don’t use that scale as much for adults, because adults tend to develop tightness to protect their joints from hypermobility. This is especially true for athletes who have learned to compensate for their athletic performance (e.g., a runner with tight hamstrings). I check for positive Beighton Score findings and perform hands-on assessment of the joints.
Hypermobility exists on a spectrum
Many people have some degree of joint laxity without any symptoms whatsoever. The presence of hypermobility alone doesn’t mean something is wrong. It’s when that hypermobility leads to pain, instability, repeated injury, or dysfunction in other body systems that it becomes clinically significant and warrants attention.
It’s important to distinguish between flexibility — which is about muscle extensibility — and hypermobility, which is about joint laxity. Again, you can be hypermobile without being particularly flexible in the traditional sense. Conversely, someone can have flexible hamstrings while still having hypomobile (tight) hips. These are related but distinct concepts.
EDS vs. Hypermobility Spectrum Disorder: What’s the Difference?
Ehlers-Danlos Syndrome (EDS) is a group of inherited connective tissue disorders caused by defects in how the body produces collagen — the protein that gives structure to skin, joints, blood vessels, and organs. There are 13 recognized subtypes, with hypermobile EDS (hEDS) being by far the most common. Importantly, there is currently no genetic test for hEDS; diagnosis is clinical, based on a detailed set of criteria established in 2017.
Hypermobility Spectrum Disorder (HSD) is a newer umbrella term for people who have symptomatic hypermobility but don’t meet the full diagnostic threshold for hEDS. This doesn’t mean they’re less affected. Many individuals with HSD experience significant pain, fatigue, and functional limitation. The distinction matters primarily for research and communication, but from a physical therapy standpoint, the treatment principles are nearly identical.
The diagnosis changes the name, not the approach. What both conditions share is this: the passive stabilizing structures of the joints — ligaments, joint capsule, connective tissue — cannot be relied upon to do their job. That means the body must compensate using active stabilizers: muscles. And if those muscles are weak, undertrained, or not firing at the right time, the joint is left exposed. Whether it’s hEDS or HSD, the foundation of treatment is always the same: building strength and neuromuscular control to compensate for what the ligaments can’t provide.
Why Hypermobility Raises Your Injury Risk
Hypermobile joints have more freedom of movement, but that freedom comes at a cost. Joints are designed to operate within a specific range in which the surrounding muscles can provide maximal control and force production. When a joint routinely moves beyond that range, extra strain is placed on the surrounding soft tissues (ligaments, joint capsule, tendons, muscle). The brain also starts to perceive a lack of safety within the joint and surrounding tissues. This can cause the muscles to tighten, putting the area at further risk of injury.
Proprioception is often impaired. Proprioception is your body’s ability to sense joint position in space — it’s the reason you can walk without looking at your feet. Research consistently shows that individuals with hypermobility have diminished proprioceptive acuity at the affected joints. This means their bodies are less accurate at sensing where a joint is and how fast it’s moving, which directly leads to poor joint protection during dynamic activities like running, changing direction, or landing from a jump. This can put athletes at greater risk of things like ankle sprains and ACL injuries.
End-range instability increases microtrauma. When a joint regularly reaches or exceeds its intended end range, the surrounding structures sustain repetitive stress that compounds over time. This shows up as chronic tendinopathy, stress reactions, repeated ankle sprains, patellofemoral pain, and hip and shoulder labral issues that never seem to fully resolve despite conservative care.
Protective muscle stiffness creates a secondary problem. When the brain detects joint instability, it responds by cranking up muscle tone or stiffness around that joint as a protective mechanism. This is helpful in the short term, but over months and years, it creates a pattern of chronic muscle guarding that feels like tightness. It is often mistaken for tightness in physical therapy and massage therapy. We’ll come back to this because it’s one of the most important and most misunderstood aspects of managing hypermobility.
Increased risk of dislocation. Those with more severe hypermobility may be at risk of acute and chronic dislocations and subluxations, particularly of the shoulder or patella.
It’s Not Just About Joints: Other Systems Affected
This is something that many of my hypermobile patients don’t realize (especially since most of my patients don’t realize they’re hypermobile): hypermobility, particularly hEDS and HSD, is not just a joint problem. Because the underlying issue is connective tissue quality, which is found throughout the body, multiple systems can be affected. Understanding this matters enormously for anyone trying to manage their symptoms holistically.
Other Systems Affected by hEDS and HSD
- Autonomic Nervous System – The part of our nervous system that controls our basic functions, such as breathing, heart rate, and blood pressure. People with hEDS and HSD can have dysregulated nervous systems, leading to POTS (postural orthostatic hypotension – “passing out”), dizziness, brain fog, and fatigue.
- Digestion – This can be related to the connective tissues of the digestive tract or the dysregulated autonomic nervous system.
- Skin – In more severe cases, skin may be prone to bruising or be slow to heal.
- Nervous System – The nervous system may be more sensitive to pain. This makes pain management more complex.
- Mental Health – Anxiety and depression occur at higher rates in the hypermobile population, partly due to the neurological overlap between anxiety and proprioceptive processing.
- Immune System – Mast Cell Activation Syndrome (MCAS) clusters with hEDS, causing allergic-type reactions, sensitivities to medications, foods, and environmental triggers.
For the runner or active adult with hypermobility, this systemic picture is a critical context. It explains why some patients have disproportionately high fatigue, why they take longer to recover between sessions, why their pain doesn’t always follow a predictable mechanical pattern, and why they may have tried everything and still feel like something is missing from their care.
As physical therapists working with this population, part of our role is to recognize these patterns and, where appropriate, coordinate with the appropriate medical providers. You are not “making it up.” These are real and complicated interconnected physiological processes.
Next week – PART TWO: How Injury Prevention and Rehab Looks Different for Someone With Hypermobility
Hypermobility is not a sentence to a life of pain and limitation. The runners and active adults we work with who have hEDS, HSD, and generalized hypermobility consistently make meaningful progress when they receive the right education, the right program, and the right support.
Understanding that your “tightness” may actually be protective weakness, that stretching more may be working against you, and that building strength is the most powerful lever you have — that understanding changes everything. It gives you a path forward that makes physiological sense and, more importantly, actually works.
Next week, we’ll talk about how you can work with your hypermobile body to make more meaningful progress in physical therapy and limit your risk of future injuries.
