Finding a PT Who Can Assess Ligament Laxity and Instability: What Hypermobility Patients Need to Know
- Dr. Kinsey Winter, PT, DPT
- 17 hours ago
- 7 min read
If you have hypermobility and you’ve been dealing with neck instability, upper cervical symptoms, or joint instability that no one has adequately assessed — the problem may not be that nothing is wrong. The problem may be that most physical therapists aren’t trained to find it.
Standard PT assessment evaluates strength, range of motion, movement patterns, and pain behavior. What it typically doesn’t include is hands-on assessment of ligament integrity — the kind of testing that identifies segment-specific instability and helps determine whether the passive restraint system at a given joint is actually doing its job.
For hypermobile patients, that gap is clinically significant.
Why This Matters for Hypermobility
In a hypermobile body, the ligaments and joint capsules that normally provide passive stability are more lax than average. This affects every joint — but it matters most in areas where passive stability is critical and where instability has the most systemic consequences.
The cervical spine, and particularly the craniocervical junction, is one of the highest-stakes areas in the hypermobile body. The ligaments at the base of the skull and upper neck support structures that affect the spinal cord, brainstem, cranial nerves, and vascular supply to the brain. When those ligaments are lax, the consequences can extend far beyond neck pain.
Understanding where instability exists — and how much — requires testing that most PTs simply aren’t trained to perform.
What Ligament Laxity Testing Actually Is
Ligament laxity testing assesses the integrity of specific passive restraint structures by applying controlled stress to a joint and evaluating the response. Unlike standard mobility assessment — which measures how far a joint moves — laxity testing evaluates whether the structures that should be limiting that movement are doing their job.
For hypermobile patients, this distinction matters enormously. A mobility test might show that a joint moves well. A laxity test asks whether that movement is controlled by the right structures — or whether passive restraints are absent or insufficient, leaving the muscular system as the only check on joint position.
This kind of testing requires advanced manual therapy training. It also requires clinical judgment about how much stress to apply in a body where normal limits don’t apply in the usual way.
Craniocervical Instability: What It Is and How It’s Assessed
Craniocervical instability (CCI) refers to excessive, uncontrolled movement at the craniocervical junction — the transition between the base of the skull and the upper cervical spine (C0–C1–C2). The ligaments at this junction — the alar ligaments, the transverse ligament, and the tectorial membrane — are responsible for limiting rotation, translation, and flexion at this critical interface.
When these ligaments are lax, the craniocervical junction can move beyond safe limits.
Common presentations include:
Occipital headaches or pressure at the base of the skull
Neck pain with a strong positional component
Dizziness, visual disturbances, or balance disruption
Brain fog that fluctuates with head position or load
Upper extremity tingling or numbness
POTS-like symptoms that worsen with upright posture
A sensation that the head feels too heavy for the neck to support
Important: A physical therapist cannot diagnose craniocervical instability. Formal diagnosis requires imaging — typically upright MRI or flexion-extension imaging — and evaluation by the appropriate specialist. What a trained PT can do is assess clinical signs of instability, support appropriate referral, and provide assessment data that informs the broader care team.
The clinical tests used in upper cervical instability assessment include:
Sharp-Purser test: Assesses atlantoaxial instability at C1–C2. The patient is seated with the cervical spine in slight flexion. The examiner applies a posterior glide to the head while stabilizing C2. A positive test is indicated by symptom reduction — the posterior glide repositions the atlas and reduces the neural or vascular irritation caused by instability.
Alar ligament stress tests: Assess the integrity of the alar ligaments, which limit contralateral rotation and ipsilateral lateral flexion at the craniocervical junction. Performed in both side-flexion and rotation planes.
Transverse ligament stress test: Specifically assesses the transverse ligament, which holds the dens of C2 in contact with C1.
Segment-specific shear testing below the craniocervical junction: Below C1–C2, anterior and posterior shear testing is performed at each cervical segment as tolerated. The degree of force is modified based on patient tolerance, symptom response, and clinical presentation. In hypermobile patients, a lax segment will often produce local or referred symptoms with minimal applied force — making attentiveness to symptom reproduction essential throughout.
These tests are performed as part of a full clinical picture, not in isolation. The pattern across tests — combined with patient history, symptom presentation, and response to assessment — guides clinical reasoning.
Instability Beyond the Craniocervical Junction
CCI receives the most attention — appropriately, given the severity of its potential consequences — but hypermobility-driven instability exists throughout the spine and into peripheral joints.
At each level below C2, segment-specific shear testing can identify levels where passive restraint is insufficient. The thoracic spine, lumbar spine, and sacroiliac joints all carry passive stability responsibilities — and all can be assessed for laxity-driven instability in ways that standard PT evaluation doesn’t capture.
In peripheral joints — hips, knees, ankles, shoulders — standard ligament stress tests assess passive restraint integrity. For hypermobile patients, these findings are interpreted differently than in the general population: a positive finding reflects baseline laxity with clinical implications for loading, training, and rehabilitation approach, rather than indicating acute injury in the traditional sense.
The value of this assessment isn’t purely diagnostic. It creates a clinical map — a picture of where the passive system is insufficient and where the muscular system is compensating. That map directly informs treatment priorities.
Prolotherapy, PRP, and the Role of PT Assessment
Prolotherapy and platelet-rich plasma (PRP) injections are increasingly used in hypermobile patients to address ligament laxity — stimulating a healing response in the injected tissue with the goal of promoting passive stability over time.
For these interventions to be as effective as possible, it helps to know precisely which structures are lax before treatment, and to have an objective way to assess change afterward. A PT trained in laxity assessment becomes a meaningful part of the care team for patients pursuing regenerative injections.
Before injection: PT assessment documents which segments and structures demonstrate clinical laxity, providing a baseline that informs treatment targeting and establishes what clinical improvement should look like.
After injection: As prolotherapy or PRP takes effect over weeks to months, PT laxity assessment can track objective changes in segment stability. A segment that previously showed clinical instability on shear testing may demonstrate improved end-feel and reduced symptom reproduction as tissue responds to treatment — providing meaningful clinical feedback that patient-reported outcomes alone can’t capture.
During recovery: Regenerative injections create a window of active tissue remodeling. PT during and after this window focuses on building the active muscular stability that works in coordination with the improving passive system. A PT who understands both the injection process and hypermobility-specific loading principles can bridge this period far more effectively than a PT working from a standard protocol.
What to Look for in a PT
Not all physical therapists are trained to perform instability assessment or interpret findings in the context of hypermobility. Here’s what to look for:
Credentials that indicate relevant training:
COMT (Certified Orthopedic Manual Therapist): Advanced manual therapy training with extensive instruction in joint-specific assessment including stress and laxity testing
FAAOMPT (Fellow of the American Academy of Orthopedic Manual Physical Therapists): The highest manual therapy credential in the US; fellowship-level training includes advanced cervical and spinal assessment
SMT (Spinal Manipulative Therapist) or OMT fellowship training: Advanced spinal assessment and treatment training that includes upper cervical instability protocols
Questions to ask before booking:
Do you have experience assessing upper cervical instability in hypermobile patients?
Are you trained in cervical ligament stress testing — including alar ligament, transverse ligament, and segment-specific shear testing?
Do you have experience working with patients pursuing or recovering from prolotherapy or PRP?
Are you familiar with EDS and hypermobility spectrum disorders?
Red flags: A PT who has no familiarity with upper cervical stability testing, no experience with EDS patients, or who proposes a standard strengthening protocol without first mapping where instability exists — is not the right PT for this clinical picture.
How Flourish Approaches This
I hold both the COMT and SMT credentials — both of which include advanced training in cervical and spinal assessment, including the upper cervical stress testing described in this post. I also have hypermobility myself, which means I bring both clinical training and lived experience to this assessment.
When I evaluate a patient with suspected instability — whether at the craniocervical junction or throughout the spine — the assessment goes beyond what most PT evaluations include. Segment-specific shear testing, upper cervical ligament stress testing, and evaluation of the interaction between passive and active stability are all part of what I do at Flourish.
This is particularly relevant for patients pursuing or recovering from prolotherapy or PRP, where baseline laxity assessment and objective tracking of change over time adds meaningful clinical value to the care plan.
If you’ve been dealing with symptoms that suggest instability — upper cervical symptoms especially — and you haven’t had a thorough manual assessment, that may be the missing piece.
Related Reading
Free Resource
The “Is It Hypermobility?” self-assessment guide covers common signs of hypermobility spectrum disorders — including symptoms that often point to instability — written for patients who have been searching for answers.
Work With a PT Trained in Instability Assessment
Flourish Physical Therapy in Bellevue, WA specializes in hypermobility and EDS — including patients with complex instability presentations who haven’t had a thorough assessment elsewhere. Every session is 1:1 with Dr. Kinsey Winter, PT, DPT, COMT, SMT.
📍 Bellevue, WA | Hypermobility & EDS specialist | 1:1 | Cash-pay | Accepting new patients
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