Hypermobility Changes the Rules: How We Approach EDS and Connective Tissue Disorders

If you have Ehlers-Danlos syndrome, a hypermobility spectrum disorder, or another condition affecting connective tissue, you may be understandably cautious about chiropractic care.

You should be.

Not because chiropractic care is automatically inappropriate for someone with hypermobility, but because your care shouldn't look exactly like everyone else's.

If a joint already moves excessively, our goal isn't to see how much farther we can move it.

If your body is using muscular tension to create stability, simply stretching every muscle that feels "tight" may not solve the problem.

And if you've spent years learning which positions your body tolerates and which ones it doesn't, we should listen to you before deciding what your body needs.

That's what being a safe place for patients with connective tissue disorders means to us.

It doesn't mean promising that nothing will ever hurt. It doesn't mean claiming that we specialize in every genetic or systemic disorder. And it certainly doesn't mean assuming every symptom you experience is caused by hypermobility.

It means taking the diagnosis seriously, taking the patient seriously, and adapting the care accordingly.

Hypermobility Doesn't Mean Every Joint Moves Well

This is probably the most important distinction to make.

Being hypermobile does not mean every joint in your body is moving appropriately all the time.

In fact, this is something we see clinically that can be confusing at first: a person can be globally hypermobile and still have a specific joint or region that isn't moving well.

Hypermobile joints can still become irritated. Muscles can guard. Movement patterns can change. One region may compensate for another. And sometimes a joint that normally has plenty of motion simply isn't moving normally today.

That matters because the answer isn't:

Never create motion in someone who is hypermobile.

It's:

Figure out where motion is actually needed — and where stability is needed more.

Those are very different approaches.

An Adjustment Is a Tool, Not the Goal

At Ascent, being in a chiropractic office doesn't mean every joint needs to be adjusted at every visit.

An adjustment is one tool available to us.

For someone with significant hypermobility or a connective tissue disorder, determining where not to create additional motion can be just as important as identifying an area where treatment may be useful.

That starts with an examination.

We want to know:

• Where do you have excessive motion?
• Where do you lack control?
• Is there a particular joint or direction that appears restricted?
• What movements reproduce your symptoms?
• How well can you stabilize the area?
• What happens when we load it?

If we identify an area that isn't moving well and an adjustment is appropriate, we can select the location, technique, and amount of force accordingly.

If a joint already has excessive motion and doesn't need more, we leave it alone.

Sometimes the right decision is to adjust.

Sometimes the right decision is not to.

Both require clinical judgment.

For hypermobile Ehlers-Danlos syndrome specifically, GeneReviews notes that chiropractic adjustment is not automatically contraindicated, but it should be performed in a way that avoids creating subluxation or dislocation.

That's a pretty good summary of how we think about it:

The diagnosis doesn't necessarily remove a tool from the toolbox.

It changes how thoughtfully we need to use it.

Flexible Doesn't Always Mean Mobile

Another thing we hear from hypermobile patients all the time is:

"I'm incredibly flexible, but I feel tight constantly."

That isn't necessarily contradictory.

Muscles contribute to joint stability. When a joint has a lot of passive motion, the surrounding muscles may have to work hard to control that motion. Muscles can become fatigued, sore, guarded, or overactive.

That can feel like tightness.

So if someone with hypermobility tells us their hamstrings, hip flexors, neck, or shoulders always feel tight, our first response isn't automatically:

Let's stretch it more.

We want to know why it feels tight.

There may absolutely be an area where mobility work is appropriate.

But sometimes the better answer is improved motor control.

Sometimes it's stability.

And very often, it's strength.

For Hypermobility, Stability and Strength Become the Priority

This is where our rehabilitation approach really starts to change.

For many musculoskeletal problems, restoring lost mobility is an important early goal.

But if you already have more range of motion than you can comfortably control, continually adding mobility doesn't address the bigger problem.

You don't necessarily need more range. You need more ownership of the range you already have.

That's why rehabilitation for our hypermobile patients tends to place much more emphasis on things like proprioception, joint control, trunk stability, strength around vulnerable joints, good movement patterns, and progressively increasing the amount of load the body can tolerate.

The research supports that direction.

Exercise and rehabilitation are important components of managing hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders. Current recommendations emphasize strengthening, proprioception, movement control, and joint stability rather than simply increasing flexibility.

And ultimately, we want more than stability.

We want strength.

A body that can tolerate appropriate resistance, produce force, and control movement under load has more options than one that is simply being protected from movement.

Mobility → Stability → Strength → Power

Our rehabilitation framework at Ascent generally follows:

Mobility → Stability → Strength → Power

That sequence doesn't disappear for someone with hypermobility.

But the emphasis changes.

Mobility: Restore What Is Actually Missing

We still assess mobility first because, again, being hypermobile doesn't mean every joint moves appropriately.

There may be a legitimate restriction that needs to be addressed.

But we aren't trying to create range of motion just for the sake of creating range.

We restore the motion that's actually missing, preserve the motion that's useful, and avoid chasing additional range simply because we can.

Then we move on.

Stability: Control the Range You Have

Can you actively control your available range?

Can you maintain a joint position rather than simply falling into the end of it?

Can your trunk, hips, shoulders, and other stabilizing systems maintain position when movement occurs elsewhere?

Can you recognize where your body is in space?

That last question is particularly relevant because proprioception — our awareness of joint position and movement — can be impaired in people with hypermobility.

This is why early rehabilitation can sometimes look deceptively simple.

We're not just trying to make an exercise hard.

We're trying to make movement controlled.

Strength: Build Capacity

Once you can control a position, we want to know whether you can produce and tolerate force there.

This is where progressive resistance becomes increasingly important.

We want stronger muscles around vulnerable joints. We want better movement strategies. We want to progressively expose your body to the kinds of loads it needs to handle outside the clinic.

Strength isn't something we save for the very end of rehabilitation.

It's one of the primary tools we use to build capacity.

That could eventually mean squats, deadlifts, rows, presses, carries, sleds, single-leg exercises, or dozens of other movements depending on the person.

The exercise itself isn't the important part.

The important part is choosing an appropriate starting point and building from there.

Power: Prepare for Real Life

For some people, strength is enough.

For others, strength eventually needs to work quickly.

Running.

Jumping.

Skiing.

Mountain biking.

Playing a sport.

Catching yourself when you slip on an icy Anchorage sidewalk.

Those activities require more than being able to slowly control an exercise in the clinic.

They require your body to produce and absorb force quickly.

When appropriate for the individual, that's where power enters the progression.

The goal isn't simply to make a hypermobile person less symptomatic.

It's to help build a body that is strong, capable, and prepared for the things that person actually wants to do.

"Start Low and Go Slow" Doesn't Mean "Stay Weak"

The Ehlers-Danlos Society uses a helpful principle for exercise progression: start low and go slow.

We agree.

But there's an important second half to that idea:

You still progress.

Having Ehlers-Danlos syndrome, a hypermobility spectrum disorder, or another connective tissue condition doesn't mean we want you avoiding load forever.

Appropriate precaution helps us find a starting point from which we can progressively build.

Early rehabilitation may emphasize joint position, proprioception, bracing, and controlled movement.

Then resistance.

Then greater resistance.

Then increasingly complex movement.

And for the appropriate person, eventually running, jumping, skiing, lifting, throwing, or whatever else their life demands.

The available research on exercise and rehabilitation in EDS is still relatively limited, but systematic review evidence suggests that exercise and rehabilitation can improve physical and psychological outcomes. More and better research is still needed.

So we don't pretend there's one perfect "EDS exercise program."

There isn't.

The program needs to fit the person.

We Don't Confuse Precaution With Fragility

This distinction matters enormously to us.

We want to take connective tissue disorders seriously without teaching someone that their body is fragile.

Those are not the same thing.

Precaution might mean smaller increases in load.

It might mean spending longer developing control before progressing an exercise.

It might mean changing a movement because a particular joint doesn't tolerate it well.

It might mean choosing a different manual therapy technique.

It might mean occasionally taking a step backward when symptoms flare.

And sometimes it means deciding that a particular treatment simply isn't appropriate.

But the destination doesn't have to be perpetual rehabilitation.

For the right patient, the destination may be lifting weights, skiing, hiking, running, playing a sport, carrying kids, working a physical job, or simply trusting their body more during everyday life.

Your connective tissue disorder changes how we approach the process.

It doesn't mean we've stopped expecting your body to adapt.

You Know Your Body Better Than We Do

This may be the most important part of creating a genuinely safe environment for people with complex or chronic conditions.

You may have spent years learning your body.

You know:

"My shoulder doesn't like that position."

"My hip sometimes feels unstable here."

"That kind of stretching always makes me worse."

"My neck responds badly to that."

"This joint moves differently than the other one."

Those aren't inconveniences for us to work around.

They're information.

We bring clinical training, examination, biomechanics, and treatment options to the table.

You bring a lifetime of experience living in your body.

Good care requires both.

If something doesn't feel right, we want you to tell us.

If a particular technique has caused problems before, tell us.

If you're nervous about being adjusted, tell us.

If you don't want a particular treatment performed, we don't perform it.

There is no ego involved in changing the plan.

Our job isn't to convince you that our preferred treatment is the answer.

Our job is to figure out what you actually need.

Not All Connective Tissue Disorders Are the Same

This is also where we need to be careful with the word "hypermobility."

Ehlers-Danlos syndromes include multiple subtypes, and other heritable connective tissue disorders such as Marfan syndrome and Loeys-Dietz syndrome can involve considerations well beyond the musculoskeletal system.

Even within EDS, the precautions appropriate for someone with hypermobile EDS may be very different from those required for someone with vascular EDS.

That's why we don't want to reduce everything to:

"You're hypermobile, so here's the hypermobility program."

Your diagnosis matters.

Your medical history matters.

Your symptoms matter.

And sometimes the appropriate first step isn't chiropractic treatment or exercise at all.

Certain presentations warrant medical evaluation, imaging, genetic evaluation, or collaboration with another healthcare professional before we move forward.

Recognizing that isn't outside our model of care.

It's part of it.

Our job isn't to prove that every problem belongs in our office.

If someone else needs to be involved, we want them involved.

What Being a "Safe Space" Means to Us

We can't promise that any healthcare treatment or exercise program carries zero risk.

That's not what we mean by safe.

For us, safety is a process.

We ask questions before we make assumptions.

We examine before we treat.

We listen when you tell us something feels different.

We don't assume more mobility is always better.

We don't adjust a joint simply because you're in a chiropractic office.

We modify treatment when your condition calls for it.

We prioritize stability and control before adding significant load.

Then we build strength.

And when you're ready, we keep going.

We progress based on how you respond rather than where a generic protocol says you should be.

And when something falls outside our expertise, we'll tell you.

For people with Ehlers-Danlos syndrome, hypermobility spectrum disorders, and other connective tissue conditions, those details matter.

You don't need someone who's afraid to let you move.

And you don't need someone who ignores the reasons you require a little extra care.

You need someone willing to understand the difference.

Sources

Buryk-Iggers S, Mittal N, Santa Mina D, et al. Exercise and Rehabilitation in People With Ehlers-Danlos Syndrome: A Systematic Review. Archives of Rehabilitation Research and Clinical Translation. 2022;4(2):100189.

GeneReviews®. Hypermobile Ehlers-Danlos Syndrome. National Center for Biotechnology Information, U.S. National Library of Medicine.

The Ehlers-Danlos Society. Physical Therapy. Guidance regarding exercise, strengthening, movement control, stretching, joint instability, and manual therapy for EDS and HSD.

Russek LN, Simmonds J. The Evidence-Based Rationale for Physical Therapy Treatment of Children, Adolescents, and Adults Diagnosed With Joint Hypermobility Syndrome/Hypermobile Ehlers-Danlos Syndrome.

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