Joint hypermobility seems to be one of those issues that is gaining awareness, and while it exists on a spectrum from that which causes no problems that that which is disabling, it is something that is all too easily overlooked. A new narrative review published in the Asia-Pacific Chiropractic Journal argues that when we do notice it, we may need to be focusing our care techniques and planning a little differently.
The paper, Joint Hypermobility in Chiropractic Practice: Spectrum, Recognition, Spinal and Extremity Laxity, and Evidence-Based Care by Henry Pollard, sets out a framework for recognising hypermobility, understanding where it sits on the spectrum of joint function, and adjusting care accordingly. Its central proposition is deceptively simple: “Hypermobility is not primarily a mobility problem. It is a stability problem.”
The review begins by separating two terms that are often used interchangeably. Joint laxity is described as “excessive passive movement within a joint due to reduced stiffness of supporting structures such as ligaments, capsules, or connective tissue restraints.” Pollard frames this as a structural concept; the passive restraints are simply doing less work, which means the muscles have to do more.
Joint hypermobility is “the ability of a joint to move beyond expected physiological limits, accounting for age, sex, and ethnicity.” Crucially, the paper notes it is “a clinical finding rather than a disease.” There are, of course, clinical findings like Ehlers-Danlos and its various subtypes, but hypermobility doesn’t always fit under that particular clinical heading. There can be other presentations of hypermobility that are not strictly ‘diseases’
That distinction matters. As Pollard puts it, “Hypermobility is not a diagnosis by itself. It is a physical trait. Its meaning depends on context.” A flexible dancer with no symptoms and a practice member with recurrent dislocations and diffuse chronic pain may both score highly on the same screening tool, but they are not presenting with the same problem.
How common is hypermobility? Honestly, we don’t know with any precision. A systematised review of screening tools noted that reported prevalence of generalised joint hypermobility ranges from 2% to 57% in general populations, and that there is “no Global consensus, or gold standard cut-off score that defines joint hypermobility.” That spread is notable in that it indicates that the variation is at least partly a measurement problem, not a population one.
Mobility as a spectrum
Rather than sorting joints into normal and abnormal, the Pollard review presents mobility as a continuum with three regions:
- Unstable hypermobility — motion exceeds normal limits alongside reduced connective tissue restraint and impaired neuromuscular control. Pollard notes that “patients often describe joints that feel unreliable.”
- Stable mobility — the healthy middle. Joints move freely but remain well supported by both passive structures and coordinated muscle control.
- Hypomobility — restricted motion, often linked to stiffness, protective guarding, or degenerative adaptation.
A poignant and clinically useful point is that these states coexist. “Hypermobile patients frequently develop stiff protective regions, especially in the spine. Excess motion in one segment may coexist with restriction in another.” The hypermobile practice member on your table may well present with a genuinely restricted, guarded region — and that region may be a compensation rather than the primary lesion.
This sits comfortably alongside how the Foundation understands vertebral subluxation: a diminished state of being, comprising reduced coherence, altered biomechanical function, altered neurological function and altered adaptability. In a hypermobile spine, the adaptability question becomes central. The review makes the same observation in different language: “In unstable hypermobile joints, the clinical problem is not a fixed displacement to correct. The problem is insufficient restraint and poor control.”
Where hypermobility becomes a syndrome
In a 2017 international classification of the Ehlers-Danlos syndromes and an accompanying framework paper clarified terminology that had been muddled for decades [2, 3] . Two categories are most relevant to chiropractic practice.
Hypermobility spectrum disorders (HSD) describe symptomatic hypermobility that does not meet criteria for hEDS. The review describes these as common in musculoskeletal practice, “often present with pain, instability, proprioceptive impairment, and reduced functional tolerance.”
Hypermobile Ehlers-Danlos syndrome (hEDS) sits at the more complex end, with broader systemic involvement — autonomic dysfunction, orthostatic intolerance, dizziness, syncope, exercise intolerance and fatigue among the features noted.
The human cost of missing these presentations appears to be substantial. A UK cross-sectional survey of more than 2,000 people with hEDS or HSD, conducted by researchers at the University of Edinburgh with Ehlers-Danlos Support UK and published in Disability and Rehabilitation, reported an average wait of approximately 19 to 21.7 years for diagnosis. Among respondents, 84% reported chronic pain, 74% reported partially dislocated joints, and only 13% reported access to a knowledgeable clinician. We would encourage readers to verify these figures against the primary paper before quoting them, but the direction of the finding is difficult to ignore: these practice members are spending decades in the system without being recognised.
Recognising it in the room
The Pollard review is clear that recognition begins with history rather than examination. Practice members “often describe lifelong patterns rather than acute onset problems,” may recall being “double-jointed” as children, and may report recurrent sprains or dislocations with minimal trauma. Pain is often diffuse and shifting, and tendon complaints may not resolve with standard care.
On examination, the Beighton score remains the most widely used screening tool — nine manoeuvres assessing the fifth fingers, thumbs, elbows, knees and forward flexion of the spine. Commonly cited cut-offs are ≥5 for adults, ≥6 for pre-pubertal children, and ≥4 for adults over 50, though as noted above, consensus is imperfect.
Pollard is candid about its limits: “Beighton alone has limitations. It does not capture limb-specific instability, proprioception, or functional control deficits.” He suggests supplementing it with the five-point questionnaire — useful “particularly in adults who may have stiffened with age” — and limb-specific tools such as the Lower Limb Assessment Score.
The review also argues for including joint position sense and balance testing. That recommendation has reasonable support: a systematic review and meta-analysis pooling five studies and 254 participants, found significantly poorer lower limb joint position sense and threshold detection to movement in people with benign joint hypermobility syndrome, while findings in the upper limb were less clear [4].
What this means for how we adjust
The Pollard Review acknowledges that “manual therapy” can provide short-term symptomatic improvement through neurophysiological mechanisms. But he draws a firm line: “pain relief does not necessarily indicate improved stability. Manipulation/adjustment does not restore ligament stiffness or passive restraint.” In hypermobile and unstable joints, he suggests, “repeated end-range mobilisation may contribute to worsening irritability and functional decline over time.” [1]
Specific cautions are raised around suspected craniocervical instability, which the paper describes as “a major contraindication to high-velocity cervical manipulation/adjustment” warranting referral; around degenerative lumbar instability, where the review challenges the assumption that degeneration always produces stiffness; and around orthostatic intolerance and syncope.
Importantly, Pollard does not frame this as a retreat from chiropractic care. “This does not remove the Chiropractor’s role, it refines it.” Manual therapy may still be applied selectively to coexisting hypomobile regions or for symptom modulation within a kinetic chain approach — with the long-term emphasis shifting toward stabilisation and active rehabilitation.
Building stability rather than motion
The management recommendations centre on progressive strengthening, proprioceptive and sensorimotor retraining, motor control work, pacing, load management and education.
There is supporting evidence for parts of this. A randomised controlled trial followed 26 children aged 7–16 with joint hypermobility syndrome and knee pain through an eight-week supervised physiotherapy programme, and reported a mean 14.5 mm reduction in knee pain on a visual analogue scale (p=0.003) across both intervention arms, with improvements in thigh strength regardless of group allocation [5]. It is a small trial, and its findings should be read as suggestive rather than definitive.
On spinal motor control, the review draws on a well-known paper which found inefficient deep trunk stabilisation associated with low back pain [6]. The review is equally clear about what is not supported: passive-only care, and stretching programmes aimed at increasing flexibility in people who are already hypermobile.
What this means for chiropractic
This review does not overturn how we practise, and it does not claim to. Instead, it offers a clinical filter and a reminder to ask, before care planning, whether the presentation in front of us is one of restriction or one of insufficient control, because the two call for meaningfully different responses.
For chiropractors, the practical implication is that screening for hypermobility deserves a routine place in assessment, and that a high Beighton score should change the conversation rather than simply be noted. For practice members who have spent years being told their diffuse, shifting pain has no clear cause, being recognised may itself be significant.
This is a narrative review rather than original research. However, it provides a valuable and practical synthesises of existing literature and offers a way forward.
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References
- Pollard H. Joint Hypermobility in Chiropractic Practice: Spectrum, Recognition, Spinal and Extremity Laxity, and Evidence-Based Care. Asia-Pacific Chiropractic Journal. 2026;7.1:1–12. Available at: https://www.apcj.site/PollardJointHypermobility.pdf
- Malfait F, et al. The 2017 international classification of the Ehlers–Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. DOI: 10.1002/ajmg.c.31552
- Castori M, Tinkle B, Levy H, Grahame R, Malfait F, Hakim A. A framework for the classification of joint hypermobility and related conditions. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017;175:148–157. DOI: 10.1002/ajmg.c.31539
- Smith TO, Jerman E, Easton V, Bacon H, Armon K, Poland F, Macgregor AJ. Do people with benign joint hypermobility syndrome (BJHS) have reduced joint proprioception? A systematic review and meta-analysis. Rheumatology International. 2013;33(11):2709–16. DOI: 10.1007/s00296-013-2790-45
Pacey V, Tofts L, Adams RD, Munns CF, Nicholson LL. Exercise in children with joint hypermobility syndrome and knee pain: a randomised controlled trial comparing
