Understanding Pain in Hypermobility: An Exercise Physiologist's Perspective
Many people with Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (hEDS) find that pain is rarely simple. It can shift to different parts of the body, change from day to day, and often does not match what scans or tests reveal. This can be frustrating for both the person in pain and the clinician trying to help.
Modern pain science no longer sees pain as just a result of tissue damage. Instead, we now understand that pain often comes from several systems working together, such as the muscles, nerves, and even the autonomic nervous system. This is especially important to consider in hypermobility.
As Exercise Physiologists, our job is not just to make muscles stronger. We also help improve the body’s overall capacity, movement efficiency, and resilience.
Why does pain occur in hypermobility?
Connective tissue in people with hypermobility is more elastic than that of the average person. While this allows greater flexibility, it also reduces passive joint stability.
As a result:
Muscles must work harder to stabilise joints.
Fatigue develops more quickly.
Movement patterns often become inefficient.
Repeated micro-loading can irritate tissues over time.
However, tissue overload is only one part of the picture, roughly three overlapping mechanisms.
1. Nociceptive Pain – Mechanical Overload
This is the "traditional" pain most people think about.
It occurs when muscles, tendons, ligaments or joints become overloaded or irritated.
Examples include:
Tendinopathy
Muscle strain
Joint irritation
Ligament stress
Mechanical neck or back pain
In hypermobility, joints often move beyond their optimal range. Because ligaments provide less passive support, muscles become the primary stabilisers. These muscles may remain active almost continuously, leading to fatigue and persistent aching.
Exercise Physiology Management
Exercise aims to improve the body's active stability through:
Progressive resistance training
Motor control exercises
Proprioceptive training
Functional strengthening
Load management
Gradual return to activity
The goal is not just to build stronger muscles. It helps the body control movement more efficiently.
2. Neuropathic Pain – Nerve Irritation
Some individuals experience pain that feels very different.
Symptoms may include:
Burning
Tingling
Electric shock sensations
Pins and needles
Altered sensation
This pain does not come directly from muscles or joints. Instead, it starts with irritated or sensitised nerves.
In hypermobility, excessive joint movement, muscle guarding, scar tissue, or prolonged postures may contribute to nerve irritation.
Exercise Physiology Management
Exercise interventions may include:
Neural mobility exercises (when appropriate)
Improving posture and movement efficiency
Reducing sustained compressive positions
Progressive strengthening
Optimising movement patterns
The goal is to lower stress on the nervous system and help the body work better overall.
3. Nociplastic Pain – An Overprotective Nervous System
One of the biggest developments in pain science over the past decade has been the recognition of nociplastic pain.
Unlike nociceptive or neuropathic pain, nociplastic pain is not driven primarily by ongoing tissue damage.
Instead, the nervous system becomes increasingly sensitive, causing normal movement or everyday activities to be interpreted as painful.
Common features include:
Widespread pain
Fatigue
Poor sleep
Brain fog
Heightened sensitivity to touch, noise or temperature
Pain that fluctuates significantly
This does not mean the pain is "psychological" or made up. The pain is very real, but the nervous system is being more protective than necessary.
Research shows that nociceptive, neuropathic and nociplastic mechanisms frequently overlap rather than occurring in isolation.
Exercise Physiology Management
Rather than pushing through pain, rehabilitation focuses on calming and retraining the nervous system through:
Graded exercise
Pacing strategies
Aerobic conditioning
Strength training
Education about pain
Sleep optimisation
Stress management
The goal is to slowly build up tolerance without causing repeated flare-ups.
Hypermobility Is More Than Flexible Joints
Research increasingly shows that many people with hEDS or HSD experience symptoms affecting multiple body systems.
These may include:
Autonomic dysfunction (such as POTS)
Gastrointestinal symptoms
Fatigue
Reduced exercise tolerance
Anxiety
Chronic pain
Mast cell-related symptoms (in some individuals)
Although these conditions often appear together, researchers are still studying why this happens and how they are connected. Current evidence suggests we should notice these overlaps, but not assume every person with hypermobility has all of them.
Why Exercise Is So Important
One of the strongest messages from current research is that exercise remains one of the most effective conservative treatments for hypermobility.
Appropriately prescribed exercise can improve:
Muscle strength
Joint stability
Balance
Proprioception
Functional capacity
Confidence with movement
Quality of life
Unlike medication, exercise helps address one of the main challenges of hypermobility: reduced active joint stability.
However, exercise needs to be individualised.
The goal is not to perform the hardest workout possible.
The aim is to build capacity while respecting what the body can handle right now.
Principles of Exercise for Hypermobility
Successful rehabilitation generally follows several key principles:
Start below the symptom threshold.
Beginning with manageable loads reduces flare-ups and improves consistency.
Progress gradually - Making small, steady improvements works better than suddenly increasing intensity. Resistance training helps muscles become better stabilisers.
Train movement quality - Learning efficient movement patterns reduces unnecessary tissue stress.
Build aerobic fitness - Improving cardiovascular fitness benefits pain, fatigue and autonomic regulation.
Monitor recovery - How you feel in the 24 to 48 hours after exercise gives helpful clues about whether the amount of exercise was right for you.
The Biopsychosocial Approach
Modern Exercise Physiology doesn't separate the body from the nervous system.
Pain is influenced by:
Tissue health
Muscle strength
Sleep
Stress
Fatigue
Previous pain experiences
Physical conditioning
Lifestyle factors
Instead of looking for one thing to "fix," rehabilitation aims to make the whole body more resilient.
That is why education, pacing, strength training, and behavioural strategies often lead to better long-term results than passive treatments alone.
Key Takeaway: Pain associated with hypermobility rarely has a single cause. It usually comes from a mix of mechanical loading, nervous system sensitivity, and lower physical capacity.
For Exercise Physiologists, this means treatment should focus on improving function rather than chasing pain alone.
The evidence continues to support:
Progressive resistance training
Motor control exercises
Balance and proprioceptive training
Aerobic conditioning
Education about pain
Individualised pacing and load management. Although research is still developing, one message is becoming clearer:ar:
Movement is still medicine, but it needs to be the right movement, in the right amount, at the right time.
Current Research
Systematic Reviews
Higo A, Palmer S, Liaghat B, et al. (2024).The Effectiveness of Conservative Interventions on Pain, Function and Quality of Life in Adults with Hypermobile Ehlers-Danlos Syndrome/Hypermobility Spectrum Disorders and Shoulder Symptoms: A Systematic Review. Archives of Rehabilitation Research and Clinical Translation.
Concluded that exercise-based rehabilitation is beneficial, but higher-quality studies are needed to determine optimal exercise type, dosage and progression.
Kaplan CM, Kelleher E, Irani A, et al. (2024).Deciphering Nociplastic Pain: Clinical Features, Risk Factors and Potential Mechanisms. Nature Reviews Neurology.
Describes nociplastic pain as a distinct pain mechanism that commonly overlaps with nociceptive and neuropathic pain, highlighting the need for multidimensional management.
Peebles KC, Jacobs C, Makaroff L, Pacey V. (2024).The Use and Effectiveness of Exercise for Managing Postural Orthostatic Tachycardia Syndrome in Young Adults with Joint Hypermobility and Related Conditions: A Scoping Review.
Supports exercise as a key intervention for improving orthostatic tolerance and physical function in people with POTS associated with hypermobility, while noting that programmes should be individualised.
Clark NL, Kainth GS, Johnson M, et al. (2024).Psychological Interventions to Improve Pain, Fatigue, Anxiety, Depression and Quality of Life in Children and Adults with Hypermobility Spectrum Disorders and Ehlers-Danlos Syndrome: A Systematic Review.
Found that combining psychological approaches with physical rehabilitation may improve pain, fatigue and quality of life, reinforcing a biopsychosocial model of care.