Hypermobility Disorders: The Diagnosis You Might Be Missing

“Can’t connect the issues… think connective tissue”

Ever had a patient with so many signs and symptoms that just don’t add up? Do you routinely consider hypermobility in your differentials?

Hypermobility can be one of the most challenging and fascinating presentations we see as physiotherapists, and it often goes under the radar. These patients often come to us after years of being misunderstood, misdiagnosed, or told that their symptoms are “just flexibility” or the result of anxiety. Yet, behind their mobility lies a complex interplay of connective tissue, autonomic, and neuromuscular factors that demand a nuanced approach.

In her Case Study, expert on hypermobility Taylor Goldberg takes us through how she identifies hypermobility, assesses for other contributing comorbidities, and ultimately manages the condition to help her patients achieve their goals. Hypermobility is a condition we are all likely to see in the clinic at some point, and it’s important that a) we don’t miss it and b) we’re confident in how to manage it! So with that said, Taylor’s Case Study is a must watch.  For now, this blog touches on some of the key aspects of hypermobility assessment.

If you want to see exactly how hypermobility expert Taylor Goldberg diagnoses and manages her patients, watch her full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

First, what is hypermobility?

There are three main types of patients you’ll see with hypermobility: ones who already know they have it, those who suspect it (likely due to the increasing attention on social media), or ones that have a bunch of symptoms and no idea they have hypermobility. Understanding which group your patient falls into changes how you communicate and what you focus on during assessment.

While hypermobile Ehlers-Danlos Syndrome (hEDS) might be the most commonly known, there are other types of hypermobility disorders to be aware of. See Taylor explain these types in this clip from her Case Study:

How is hEDS diagnosed?

Taylor’s case involved a 26-year-old female, a former gymnast who had been largely inactive for the past two years. She presented with severe neck pain, chronic fatigue, dizziness, recurrent subluxations, and an overall sense of physical weakness.

She described that no matter how hard she tried, she couldn’t build muscle and that exercise often left her wiped out for days. These factors raised Taylor’s suspicion of hEDS. Unlike all other hypermobility disorders, hEDS has no known genetic marker, which makes diagnosis entirely clinical. The process for diagnosing hEDS for this patient included completing a hEDS diagnostic criteria checklist, and referring the patient to a geneticist to test for and rule out all other forms of hypermobility.

Additional to this, other common comorbidities Taylor assessed for included:

1. Postural Orthostatic Tachycardia Syndrome (POTS): Often seen with dizziness, palpitations, or a racing heart when standing. This was confirmed in the patient via a tilt-table test.
2. Mast Cell Activation Syndrome (MCAS): Patients may report unexplained allergic-type symptoms or medication sensitivities. In this case, the patient was treated with over-the-counter medications which had a positive impact, indicating that MCAS was a likely comorbidity.
3. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Use the DSQ-PEM questionnaire for this. This was used to rule out ME/CFS for this patient.
4. Upper cervical instability: Occurs between C1-C2 or C1-the skull, which can compress the brainstem and cause chronic neck pain, dizziness, or a “heavy head” feeling. Should be ruled out in people with connective tissue disorder and neck symptoms. This was ruled out for Taylor’s patient through the subjective, as the patient’s neck pain was in the upper-trapezius and she did not report a heavy head feeling.
5. Anxiety: There is an overlap between anxiety and dysautonomia caused by conditions like POTS, so it’s important to explore whether symptoms like dizziness, breathlessness, or a racing heart occur in response to emotional stress or positional change. A simple question like “what position were you in when the symptoms occurred?” can help differentiate the two.

Objective assessment

Taylor completed a comprehensive assessment of the patient, a few key assessments included: full-body active range of motion (looking for hypermobility and guarding), single-leg stance with eyes closed (assessing proprioception), oculomotor assessment, and neurological assessments (due to the patient’s report of dizziness and neck pain – these tests were clear).

Taylor likes to assess compound and accessory movements, including movements that are important to the patient’s goals. See her explain what to look out for in some lower-limb compound movements in the below video from her Case Study:

Additionally, because the patient was reporting neck pain, she assessed a row with a triceps extension, looking at the quality of the movement and the patient’s ability to isolate the muscles; see her explain in the below clip from her Case Study:

Assessing these movements not only gives you an idea of the patient’s current function, but they also form the basis of your treatment planning.

Graded exercise is a core component of the intervention; however, it can be really tricky to understand just what and how much to do with these patients. Taylor uses a really useful traffic light system for movements and activities:

• Red: The movement/activity causes debilitating pain in the moment AND/OR pain lasts for 2 days or more = avoid it for now and build up to it in time.
• Yellow: The movement/activity causes pain which is not debilitating AND/OR pain lasts less than 2 days = we can try to modify this.
• Green: The movement/activity causes no pain/tolerable sensation = okay to do the movement/activity.

This approach helps patients reconnect with movement without fear while respecting their body’s thresholds. It turns symptom monitoring into an empowering tool rather than a source of frustration, and that’s often the key to sustained progress.

Wrapping up

Hypermobility is complex, multifaceted, and misunderstood, often leaving patients feeling alone in managing it. Let’s be clinicians who help patients with hypermobility feel empowered and supported!

With the right clinical lens, it becomes a fascinating puzzle rather than a mystery. From recognising red flags to differentiating between anxiety and dysautonomia, every piece of your assessment matters.

To see how an expert clinician brings all of this together in practice, from detailed assessment to pain strategy implementation, watch Taylor’s full Case Study. You’ll walk away with clear, evidence-informed strategies you can apply in the clinic tomorrow.