5 Signs Your "Difficult" Ortho Patient May Be Hypermobile

If you have practiced orthopedic physical therapy for more than a few years, you already know this patient. The plan of care looks straightforward on paper. The diagnosis is correct. The interventions are appropriate. And yet progress stalls, or the patient gets worse before they get better, and you find yourself wondering if you are missing something.

You probably are. Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) are common, underrecognized, and very likely already in your caseload. Generalized joint hypermobility affects an estimated 10 to 20 percent of adults and up to 34 percent of children, and among patients presenting to rheumatology or pain clinics, roughly 37 to 39 percent screen positive for hypermobility.[1] These patients are most likely to show up first in an orthopedic or musculoskeletal PT clinic, not a specialist's office.[1]

Here are five signs worth paying attention to before you write your next plan of care.

Why Hypermobility Gets Missed in Ortho Practice

HSD and hEDS were reclassified in 2017, replacing older terms like Joint Hypermobility Syndrome and EDS-Hypermobility Type.[2][3] Diagnosis is still clinical, based on a combination of joint hypermobility, systemic features, and exclusion of other conditions, with no single lab test to confirm it.[3] That makes it easy to miss in a standard 45-minute ortho eval, especially when the referring diagnosis already seems to explain the symptoms.

Sign 1: The Recovery Timeline Doesn't Match the Injury

A grade 1 ankle sprain that should resolve in four to six weeks is still guarded and unstable at twelve. A rotator cuff strain responds to loading exactly as expected for two weeks, then plateaus or regresses. Patients with HSD and hEDS often report pain and even new injury with interventions that would be appropriate and well tolerated in a non-hypermobile patient.[2] If the tissue healing timeline and the clinical picture keep disagreeing with each other, hypermobility is worth ruling in or out.

Sign 2: A History of Recurrent Injuries in Unrelated Joints

One ankle sprain is an ankle sprain. A patient history that includes an ankle sprain two years ago, a shoulder subluxation last year, and patellofemoral pain now, with no single unifying biomechanical cause, is a pattern. Clinicians familiar with HSD and hEDS note that these patients commonly present across a wide variety of complaints, including ankle sprains, patellofemoral pain, shoulder instability, and neck pain, often without recognizing the connective tissue thread running through all of them.[1]

Sign 3: Standard Strengthening Protocols Provoke More Pain, Not Less

This is often the clearest clinical tell. A patient starts a conventional strengthening progression and instead of building tolerance, they report increased pain, fatigue, or a flare that takes days to settle. This is not a motivation or compliance problem. Patients with HSD and hEDS have reported pain and iatrogenic injury as a direct result of interventions that were not adapted for connective tissue laxity and proprioceptive deficits.[2] If your default progression is backfiring, it is a signal to slow down and reassess the underlying tissue and motor control picture rather than push harder.

Sign 4: Symptoms Show Up Outside the Joint

Connective tissue is not limited to joints, and neither are the symptoms. Patients with hEDS and HSD frequently report extra-articular findings alongside their musculoskeletal complaints, including fatigue, anxiety, orthostatic intolerance or lightheadedness, gastrointestinal symptoms, and pelvic or bladder dysfunction.[3] If a patient mentions any of these in the same breath as their shoulder pain, it is worth listening closely rather than filing it under unrelated.

Sign 5: Subtle Flexibility History, Even Without a Formal Beighton Score

Not every hypermobile patient will hyperextend their elbows in front of you. Ask about history instead of relying only on a snapshot exam. Could they touch their palms flat to the floor without bending their knees as a teenager? Did they do the splits without training for it? Did a shoulder or kneecap ever pop out and back in on its own? These are part of the standard five-part hypermobility questionnaire and can pick up a history of laxity that has since stiffened with age, which the Beighton score alone may miss.[4] Pair this with a current Beighton assessment for the fullest picture.

What This Means for Your Plan of Care

None of these five signs are diagnostic on their own. Together, they are a strong reason to slow down, ask a few more history questions, and consider adapting your approach before you repeat a protocol that already is not working. Recognizing HSD and hEDS earlier changes how you load tissue, how you dose manual therapy, and how you set expectations with the patient, and it can be the difference between a plan of care that finally makes sense to a patient who has heard "just strengthen it" one too many times.

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References

1. Russek LN. First, Do No Harm. Why You Should Identify Hypermobile Patients. JOSPT Blog. Published May 10, 2023. https://www.jospt.org/do/10.2519/jospt.blog.20230510/full/

2. Russek LN, Stott P, Simmonds J. Recognizing and Effectively Managing Hypermobility-Related Conditions. Phys Ther. 2019;99(9):1189-1200. doi:10.1093/ptj/pzz078

3. Yew KS, Kamps-Schmitt KA, Borge R. Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders. Am Fam Physician. 2021;103(8):481-492.

4. The Ehlers-Danlos Society. Assessing Joint Hypermobility. https://www.ehlers-danlos.com/assessing-joint-hypermobility/