Back Pain Doctor
Hypermobility Spectrum Disorder & hEDS
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Many people are flexible and have no trouble. When flexibility comes with pain, instability, fatigue or other symptoms, it may be hypermobility spectrum disorder, or hypermobile Ehlers-Danlos syndrome if the full 2017 criteria are met. Assessment focuses on the pattern of hypermobile joints, the Beighton score, the skin, any family history, and whether another connective tissue condition could explain the picture. Features such as fainting on standing, bowel or bladder symptoms and anxiety are asked about because they commonly travel with it.
There is no cure, and the evidence for specific treatments is limited. First-line care is usually education and a progressive strengthening, control and fitness programme kept up over months. In a 100-person trial, heavier full-range shoulder strengthening was safe in hypermobility spectrum disorder, so programmes do not need to stay light. Joint protection, pacing, sleep and a plan for flares. Some people also benefit from bracing or taping, occupational therapy and psychological support, and a coordinated, multidisciplinary approach is generally recommended. Medicines are chosen with easy bruising in mind.
The GP role is recognising the pattern, excluding other causes, coordinating allied health and specialist input and knowing when to refer, for example if vascular Ehlers-Danlos syndrome is a concern. Procedures such as needling, shockwave or injections are not treatments for hypermobility itself. The hypermobility, HSD and hEDS guide covers the diagnosis, the exercise evidence and how a long-term programme is built. This page is educational information only. Unusual flexibility with ongoing pain, repeated dislocations or fainting is worth seeing a GP about, and sudden severe chest, back or abdominal pain needs urgent care.
Common symptoms
- Joint pain, or joints that slip or dislocate without major injury
- Widespread aching and fatigue
- Easy bruising, soft or stretchy skin
- Light-headedness or a racing heart on standing
Evidence for twelve treatment options in hypermobility spectrum disorder & heds
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Mainstay, on limited evidence
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Exercise and physiotherapy are the mainstay in the AFP review, delivered as low-impact, low-resistance strengthening, proprioception and joint protection. The evidence is weaker than that suggests: a 2013 systematic review of four studies found no convincing evidence that exercise beat control or that one type was better (Palmer), and a 2021 review of six small trials (20 to 57 participants, 4 to 8 weeks) found improved pain and proprioception whatever the programme while noting that robust trials are missing (Reychler). A 21-person trial of two home shoulder programmes found both improved with no difference between them and no control arm (Spanhove), and compression garments added to physiotherapy improved some balance measures but not pain at 4 weeks in 36 people (Benistan). The largest trial randomised 100 adults with HSD and shoulder symptoms to 16 weeks of heavy full-range or light mid-range strengthening: function improved more with heavy loading at 16 weeks (174.5 points on WOSI, below the 252-point minimal important difference), with no serious adverse events but more transient soreness and headache, and the difference was not significant at one year (Liaghat, Br J Sports Med 2022 and 2024).
Pairing reviewed 2026-10-24.
Where it fits
The starting point: explanation, progressive strengthening through range (heavier loading is safe), control and fitness work, pacing and a flare plan, with physiotherapy or exercise physiology. The average benefit in trials is modest, and results depend on keeping it going for months.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Does not treat the condition
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Needling is not among the management options in the AFP review. The review notes that bleeding, bruising, poor response to local or regional anaesthesia and iatrogenic injury are common across Ehlers-Danlos forms, so invasive procedures need careful review.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Does not treat the condition
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Injection is not among the AFP management options. The review warns of bleeding, poor response to local anaesthetic and procedural injury across Ehlers-Danlos forms, and advises avoiding drugs that reduce platelet function where bruising is easy.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Does not treat the condition
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Vibration-based devices are not part of the management described in the sources reviewed, and no trial in hypermobility was identified.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Does not treat the condition
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Shockwave is not part of the management described in the sources reviewed, and no trial in hypermobility spectrum disorder or hEDS was identified. The tissue-fragility cautions in the AFP review apply.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Does not treat the condition
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Shockwave is not part of the management described in the sources reviewed, and no trial in hypermobility spectrum disorder or hEDS was identified.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Does not treat the condition
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Magnetotransduction therapy is not part of the management described in the sources reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Does not treat the condition
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Platelet-rich plasma is not part of the management described in the sources reviewed, and the review's cautions about bruising and procedural injury apply.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Does not treat the condition
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Prolotherapy is not part of the management described in the sources reviewed, and no trial in hypermobility spectrum disorder or hEDS was identified.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Wrong problem
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Hyaluronic acid is a treatment for osteoarthritis and is not part of the management described in the sources reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility. Coexisting osteoarthritis would be assessed separately.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Does not treat the condition
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Perineural injection is not part of the management described in the sources reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Does not treat the condition
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Hydrodissection addresses nerve entrapment and is not part of the management described in the sources reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
Is there a test for hEDS?
Does exercise help?
Are injections or procedures used?
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